Total hip arthroplasty for correction of pelvic obliquity and leg length discrepancy in developmental dysplasia of hip

doi:10.3877/cma.j.issn.1674-134X.2026.03.005

Abstract

Abstract:

Objective

To evaluate the corrective effect of direct anterior approach total hip arthroplasty (DAA-THA) on leg length discrepancy (LLD) and pelvic obliquity (PO) in patients with developmental dysplasia of the hip (DDH), and to analyze the factors influencing improvement.

Methods

A retrospective analysis was conducted on 111 patients with DDH of Crowe typeⅠ-Ⅳ who underwent unilateral DAA-THA in Nanjing Drum Tower Hospital between January 2018 and June 2024. Inclusion criteria: radiologically confirmed DDH, primary unilateral DAA-THA, and complete imaging data. Patients with hip or lumbar surgery history, severe trauma, or other conditions affecting pelvic or lower limb alignment were excluded. The cohort included patients aged 42-84 years with a body mass index (BMI) of 18.7 to 34.0 kg/m²; 50 cases were left-sided (45.0%) and 61 were right-sided (55.0%). According to Crowe classification, 89 cases were type Ⅰ (80.2%), 15 cases of type Ⅱ (13.5%), five cases of type Ⅲ (4.5%), and two cases of type Ⅳ (1.8%). LLD, PO, and sacro-femoral-pubic (SFP) angle were measured on standardized anteroposterior pelvic radiographs. Data before and after operation were compared, and subgroup analyses were performed according to Crowe classification. Statistical analyses included paired t test, Mann-Whitney U test, and multivariate linear regression.

Results

All the patients were followed for 2.0 (0, 6.0) months. The mean age was (60±11) years, and mean body mass index (BMI) was (25±5) kg/m². Median disease duration was 84 (36, 120) months. After surgery, LLD decreased from 9.0 (5.3, 17.3) mm to 7.9 (3.6, 12.8) mm (Z=−3.874, P<0.001). PO decreased from 2.5 (1.7, 4.2)° to 2.3 (1.2, 4.2)° (Z=−2.294, P=0.022). The SFP angle increased from 62.0 (58.0, 64.9)° to 67.2 (63.1, 71.8)° (Z=−8.358, P<0.001). In subgroup analysis, the LLD change was 4.25 (−2.93, 8.70) mm in the patients of Crowe typeⅠ-Ⅱ and 11.73 (3.31, 29.60) mm in the patients of Crowe type Ⅲ-Ⅳ, while PO change was 0.40 (−1.00, 1.80)° in Crowe typeⅠ-Ⅱ and 1.90 (0.10, 2.70)° in Crowe type Ⅲ-Ⅳ, none of the difference was statistically significant (U=231.0, 263.0, both P>0.05). Multivariate regression showed that preoperative LLD was an independent predictor of LLD correction [β=0.867, 95% confidence interval (CI) (0.723, 1.010), P<0.001]. In the PO model, intraoperative blood loss [β=−0.104, 95% CI (−0.198, −0.010), P=0.030] and BMI [β=0.156, 95% CI (0.046, 0.266), P=0.006] were significant predictors. In the SFP model, preoperative SFP angle (β=−0.241, 95% CI (−0.428, 0.055), P=0.012) and Crowe classification [β=0.296, 95% CI (0.110, 0.481), P=0.002] were independently associated with improvement.

Conclusions

DAA-THA effectively improves LLD and sagittal pelvic alignment in DDH. However, correction of PO shows a improvement trend with no statistically significant difference. DDH of Crowe type Ⅲ-Ⅳ demonstrates greater improvement in SFP angle compared with Crowe typeⅠ-Ⅱ. Preoperative LLD is the primary predictor of LLD correction, while PO correction is influenced by preoperative PO, BMI, and intraoperative blood loss. SFP angle improvement is associated with preoperative SFP angle and Crowe classification. DAA-THA provides favorable short-term radiographic outcomes, but further large-scale studies with longer follow-up are required to confirm long-term efficacy.

Key words: Arthroplasty, replacement, hip, Developmental dysplasia of the hip, Leg length inequality, Pelvis

Peng Sun, Qiangqiang Li, Yu Zhang, Dongyang Chen, Qiang Jiang. Total hip arthroplasty for correction of pelvic obliquity and leg length discrepancy in developmental dysplasia of hip[J]. Chinese Journal of Joint Surgery(Electronic Edition), 2026, 20(03): 291-298.

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URL: https://zhgjwkzz.cma-cmc.com.cn/EN/10.3877/cma.j.issn.1674-134X.2026.03.005

https://zhgjwkzz.cma-cmc.com.cn/EN/Y2026/V20/I03/291

Figures/Tables 6

Figure 1 Anteroposterior radiographs of pelvis with DDH (developmental dysplasia of the hip) before and after the surgery. A is preoperative image showing marked displacement of the femoral head relative to the acetabulum, a large PO (pelvic obliquity) angle, and LLD (leg length discrepancy); B is postoperative image after successful DAA-THA (direct anterior approach total hip arthroplasty), demonstrating reduction of the femoral head into the acetabulum, decreased PO angle, and improvement of LLD

Table 1 Comparison of baseline characteristics between DDH patients of Crowe type Ⅰ-Ⅱ and type Ⅲ-Ⅳ

Crowe分型 Crowe type	例数 Number of cases	女/男 Female/male	年龄［岁，（ $x ¯$ ±s）］ Age（year）	BMI ［kg/m²，（ $x ¯$ ±s）］	病程［月，M（P₂₅，P₇₅）］ Disease duration（month）	LLD ［mm，（ $x ¯$ ±s）］	PO ［°，（ $x ¯$ ±s）］	SFP角［°，（ $x ¯$ ±s）］ SFP angle
Ⅰ～Ⅱ型	104	75/29	61±10	25±5	84（33，120）	13±11	4±6	61±5
Ⅲ～Ⅳ型	7	5/2	56±17	26±4	120（42，360）	31±19	5±4	60±5
统计值 Statistical values		χ²=0.002	t=1.017	t=-0.476	U=255.0	t=-3.895	t=-0.486	t=0.708
P值		＞0.05	＞0.05	＞0.05	＞0.05	＜0.001	＞0.05	＞0.05

Table 1 Comparison of baseline characteristics between DDH patients of Crowe type Ⅰ-Ⅱ and type Ⅲ-Ⅳ

Crowe分型 Crowe type	例数 Number of cases	女/男 Female/male	年龄［岁，（ $x ¯$ ±s）］ Age（year）	BMI ［kg/m²，（ $x ¯$ ±s）］	病程［月，M（P₂₅，P₇₅）］ Disease duration（month）	LLD ［mm，（ $x ¯$ ±s）］	PO ［°，（ $x ¯$ ±s）］	SFP角［°，（ $x ¯$ ±s）］ SFP angle
Ⅰ～Ⅱ型	104	75/29	61±10	25±5	84（33，120）	13±11	4±6	61±5
Ⅲ～Ⅳ型	7	5/2	56±17	26±4	120（42，360）	31±19	5±4	60±5
统计值 Statistical values		χ²=0.002	t=1.017	t=-0.476	U=255.0	t=-3.895	t=-0.486	t=0.708
P值		＞0.05	＞0.05	＞0.05	＞0.05	＜0.001	＞0.05	＞0.05

Table 2 Comparison of operative data between DDH patients of Crowe type Ⅰ-Ⅱ and type Ⅲ-Ⅳ

Crowe分型 Crowe type	例数 Number of cases	手术时间［min，M（P₂₅，P₇₅）］ Operation time	住院时长［d，M（P₂₅，P₇₅）］ Length of hospital stay	白蛋白［g/L，（ $x ¯$ ±s）］ Albumin
Crowe分型 Crowe type	例数 Number of cases	手术时间［min，M（P₂₅，P₇₅）］ Operation time	住院时长［d，M（P₂₅，P₇₅）］ Length of hospital stay	术前 Before operation	术后 After operation
Ⅰ～Ⅱ型	104	100.0（80.0，115.0）	7.0（6.0，9.0）	40.1±2.8	35.6±2.8
Ⅲ～Ⅳ型	7	135.0（95.0，172.5）	9.0（8.5，11.0）	39.7±1.6	32.7±3.4
统计值 Statistical values		U=233.50	U=179.00	t=0.58	t=1.81
P值		＞0.05	0.023	＞0.05	＞0.05
Crowe分型 Crowe type	例数 Number of cases	血红蛋白［g/L，（ $x ¯$ ±s）］ Hemoglobin		术后引流量［ml，M（P₂₅，P₇₅）］ Postoperative drainage	术中出血量［ml，M（P₂₅，P₇₅）］ Blood loss in surgery
Crowe分型 Crowe type	例数 Number of cases	术前 Before operation	术后 After operation	术后引流量［ml，M（P₂₅，P₇₅）］ Postoperative drainage	术中出血量［ml，M（P₂₅，P₇₅）］ Blood loss in surgery
Ⅰ～Ⅱ型	104	127.9±14.0	107.3±12.7	2.5（0，112.5）	150.0（150.0，200.0）
Ⅲ～Ⅳ型	7	129.1±16.0	98.6±11.9	0（0，45.0）	300.0（175.0，550.0）
统计值 Statistical values		t=-0.21	t=1.86	U=402.00	U=228.50
P值		＞0.05	＞0.05	＞0.05	＞0.05

Table 2 Comparison of operative data between DDH patients of Crowe type Ⅰ-Ⅱ and type Ⅲ-Ⅳ

Crowe分型 Crowe type	例数 Number of cases	手术时间［min，M（P₂₅，P₇₅）］ Operation time	住院时长［d，M（P₂₅，P₇₅）］ Length of hospital stay	白蛋白［g/L，（ $x ¯$ ±s）］ Albumin
Crowe分型 Crowe type	例数 Number of cases	手术时间［min，M（P₂₅，P₇₅）］ Operation time	住院时长［d，M（P₂₅，P₇₅）］ Length of hospital stay	术前 Before operation	术后 After operation
Ⅰ～Ⅱ型	104	100.0（80.0，115.0）	7.0（6.0，9.0）	40.1±2.8	35.6±2.8
Ⅲ～Ⅳ型	7	135.0（95.0，172.5）	9.0（8.5，11.0）	39.7±1.6	32.7±3.4
统计值 Statistical values		U=233.50	U=179.00	t=0.58	t=1.81
P值		＞0.05	0.023	＞0.05	＞0.05
Crowe分型 Crowe type	例数 Number of cases	血红蛋白［g/L，（ $x ¯$ ±s）］ Hemoglobin		术后引流量［ml，M（P₂₅，P₇₅）］ Postoperative drainage	术中出血量［ml，M（P₂₅，P₇₅）］ Blood loss in surgery
Crowe分型 Crowe type	例数 Number of cases	术前 Before operation	术后 After operation	术后引流量［ml，M（P₂₅，P₇₅）］ Postoperative drainage	术中出血量［ml，M（P₂₅，P₇₅）］ Blood loss in surgery
Ⅰ～Ⅱ型	104	127.9±14.0	107.3±12.7	2.5（0，112.5）	150.0（150.0，200.0）
Ⅲ～Ⅳ型	7	129.1±16.0	98.6±11.9	0（0，45.0）	300.0（175.0，550.0）
统计值 Statistical values		t=-0.21	t=1.86	U=402.00	U=228.50
P值		＞0.05	＞0.05	＞0.05	＞0.05

Table 3 Radiographic parameter improvement in the patients

时间点 Time points	LLD（mm）	PO（°）	SFP角（°） SFP angle
术前 before operation	9.0（5.3，17.3）	2.5（1.7，4.2）	62.0（58.0，64.9）
术后 After operation	7.9（3.6，12.8）	2.3（1.2，4.2）	67.2（63.1，71.8）
Z值	-3.874	-2.294	-8.358
P值	＜0.001	0.022	＜0.001

Table 4 Comparison of radiographic improvement between DDH patients of Crowe type Ⅰ-Ⅱ and type Ⅲ-Ⅳduring follow-up

Crowe分型 Crowe type	例数 Number of cases	随访时间［月，M（P₂₅，P₇₅）］ Follow-up（months）	LLD改善值［mm，M（P₂₅，P₇₅）］ LLD improvement	PO角改善值［°，M（P₂₅，P₇₅）］ PO improvement	SFP角改善值［°，（ $x ¯$ ±s）］ SFP improvement
Ⅰ～Ⅱ型	104	2.00（0，6.30）	4.25（-2.93，8.70）	0.40（-1.00，1.80）	5.60±4.37
Ⅲ～Ⅳ型	7	1.00（0，4.50）	11.73（3.31，29.60）	1.90（0.10，2.70）	12.44±4.17
统计值 Statistical value		U=384.5	U=231.0	U=263.0	t=-4.189
P值P value		＞0.05	＞0.05	＞0.05	0.004

Table 4 Comparison of radiographic improvement between DDH patients of Crowe type Ⅰ-Ⅱ and type Ⅲ-Ⅳduring follow-up

Crowe分型 Crowe type	例数 Number of cases	随访时间［月，M（P₂₅，P₇₅）］ Follow-up（months）	LLD改善值［mm，M（P₂₅，P₇₅）］ LLD improvement	PO角改善值［°，M（P₂₅，P₇₅）］ PO improvement	SFP角改善值［°，（ $x ¯$ ±s）］ SFP improvement
Ⅰ～Ⅱ型	104	2.00（0，6.30）	4.25（-2.93，8.70）	0.40（-1.00，1.80）	5.60±4.37
Ⅲ～Ⅳ型	7	1.00（0，4.50）	11.73（3.31，29.60）	1.90（0.10，2.70）	12.44±4.17
统计值 Statistical value		U=384.5	U=231.0	U=263.0	t=-4.189
P值P value		＞0.05	＞0.05	＞0.05	0.004

Table 5 Multivariate linear regression analysis of factors predicting correction outcomes in DDH patients

因变量 Dependent variable	预测变量 Predictor	β	95% CI	P值
LLD改善值（mm） LLD correction	术前LLD（mm） Preoperative LLD	0.867	（0.723，1.010）	＜0.001
PO角改善值（°） PO correction	术前PO角（°） Preoperative PO angle	0.797	（0.683，0.912）	＜0.001
	BMI（kg/m²） Body Mass Index	0.156	（0.046，0.266）	0.006
	术中出血量（ml） Intraoperative blood loss	-0.104	（-0.198，-0.010）	0.030
SFP角改善值（°） SFP correction	术前SFP角（°） Preoperative SFP angle	-0.241	（-0.428，-0.055）	0.012
	Crowe分型 Crowe classification	0.296	（0.110，0.481）	0.002

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