Femoral Shortening Osteotomy Techniques in Total Hip Arthroplasty for Hartofilakidis Type C Developmental Hip Dysplasia: A 25-Year Single-Surgeon Series.

Abstract

Total hip arthroplasty (THA) for high-grade developmental dysplasia of the hip (DDH) is technically demanding, particularly when reconstruction of the true acetabulum requires substantial limb lengthening. Femoral shortening osteotomy is commonly necessary to facilitate safe reduction and minimize neurovascular complications. However, the optimal osteotomy level and technique are still debated. This was a retrospective case series of 117 THAs with femoral shortening osteotomy performed in 89 patients (28 bilateral) who had Hartofilakidis-type C DDH between 1997 and 2022 by a single surgeon. All acetabular components were implanted in the true anatomical position. There were five femoral osteotomy techniques that were employed based on anatomy and intraoperative findings: sequential proximal femoral resection with trochanteric osteotomy and distalization, subtrochanteric osteotomy (transverse and oblique), midshaft femoral osteotomy, and distal femoral osteotomy with valgus deformity correction. Outcomes included osteotomy union, leg-length restoration, rotational alignment, and neurological complications. Subtrochanteric osteotomy was the most performed technique (n = 58, 49.6%), followed by distal femoral osteotomy with valgus correction (n = 34, 29.1%), proximal femoral resection (n = 16, 13.7%), and midshaft osteotomy (n = 9, 7.7%). Radiographic union was achieved in all femoral osteotomies. There were three cases of greater trochanter non-union that occurred in the proximal femoral resection group. Mild femoral malrotation (less than 3 degrees) was observed in two oblique subtrochanteric osteotomies and did not require revision. Transient sciatic nerve palsy occurred in three patients (2.6%), all resolving within six months. There were no cases of femoral shaft fracture, implant loosening, or migration that were observed. Postoperative leg-length discrepancy was ≤ five mm in all patients. In our experience, transverse subtrochanteric osteotomy provided the most consistent results, combining effective control of rotation, high union rates, and preservation of metaphyseal bone, whereas alternative osteotomy levels remain useful in selected anatomical situations.