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Background Hip dysplasia is a condition where the acetabulum is too shallow to support the femoral head and is commonly considered a risk factor for hip osteoarthritis. The objective of this study was to develop a deep learning model to diagnose hip dysplasia from plain radiographs and classify dysplastic hips based on their severity. Methods We collected pelvic radiographs of 571 patients from two single-center cohorts and one multicenter cohort. The radiographs were split in half to create hip radiographs ( n  = 1022). One orthopaedic surgeon and one resident assessed the radiographs for hip dysplasia on either side. We used the center edge (CE) angle as the primary diagnostic criteria. Hips with a CE angle < 20°, 20° to 25°, and > 25° were labeled as dysplastic, borderline, and normal, respectively. The dysplastic hips were also classified with both Crowe and Hartofilakidis classification of dysplasia. The dataset was divided into train, validation, and test subsets using 80:10:10 split-ratio that were used to train two deep learning models to classify images into normal, borderline and (1) Crowe grade 1–4 or (2) Hartofilakidis grade 1–3. A pre-trained on Imagenet VGG16 convolutional neural network (CNN) was utilized by performing layer-wise fine-turning. Results Both models struggled with distinguishing between normal and borderline hips. However, achieved high accuracy (Model 1: 92.2% and Model 2: 83.3%) in distinguishing between normal/borderline vs. dysplastic hips. The overall accuracy of Model 1 was 68% and for Model 2 73.5%. Most misclassifications for the Crowe and Hartofilakidis classifications were +/- 1 class from the correct class. Conclusions This pilot study shows promising results that a deep learning model distinguish between normal and dysplastic hips with high accuracy. Future research and external validation are warranted regarding the ability of deep learning models to perform complex tasks such as identifying and classifying disorders using plain radiographs. Level of Evidence Diagnostic level IV

PurposeEarly osteoarthritis (OA) due to developmental dysplasia of the hip (DDH) is a known indication for total hip arthroplasty (THA). Though screening tools and joint-preserving procedures have been established successfully, there still is a relevant number of patients suffering DDH. Due to the lack of long-term outcome studies, we like to close this gap and present the results of a highly specialized center.MethodsThe study included 126 patients, who were treated in our institution with primary THA for DDH between January 1997 and December 2000. At the time of final follow-up, at a mean of 23 years postoperatively, 110 patients (121 hips) were clinically evaluated using the Harris-Hip Score. In addition, complication and surgical revision rates were assessed. We collected surgery-related data like implant choice and special surgical features such as autologous acetabular reconstruction or femoral osteotomies. Additionally, the severity of preoperative DDH was measured radiographically according to Crowe classification.ResultsThere were 91 female (83%) and 19 male (17%) patients with an average age of 51 ± 9.5 years (range 21–65) included. Mean follow-up was 23 ± 1.3 years (21–25), with a minimum of 21 years being necessary for inclusion. Using revision for any indication as primary endpoint, the Kaplan–Meier survivorship was 98.3% at 10 years and 81.8% at final follow-up. The overall revision rate was 18% (22 cases), which were split up as follows: 20 (17%) implant failures (loosened or broken components), one (1%) periprosthetic infection and one (1%) periprosthetic fracture. Regarding complications, we observed nine (7%) dislocations and one case (1%) with severe heterotopic ossification that required surgical excision. The mean Harris-Hip score at latest follow-up was 78 ± 14 points (32–95).ConclusionsThough implants and surgical techniques have improved over time, our results suggest THA in patients suffering DDH to be seriously challenging with relatively high overall complications in long-term observation and fair clinical outcome after 21 years postoperatively. There is evidence that prior osteotomy might be associated with a higher revision rate.

Purpose To compare AI-assisted 3D (AI-3D) preoperative planning versus two-dimensional (2D) X-ray preoperative planning for total hip arthroplasty (THA) using subgroup analyses (Crowe I–II vs. III–IV), and to examine associations between deformity severity and both planning accuracy and clinical outcomes via ordered trend analyses. Methods Single-centre retrospective cohort including 116 consecutive patients undergoing THA (May 2020–July 2023; AI-3D n  = 61; 2D X-ray n  = 55). Co-primary endpoints were exact implant size-match (cup/stem) and acetabular safe-zone attainment (Lewinnek/Callanan); Secondary endpoints included operative time, estimated blood loss, postoperative leg-length discrepancy (LLD), and 24-month functional scores—Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and pain on a visual analog scale (VAS)—plus implant survivorship. Analyses compared AI-3D versus 2D within prespecified Crowe subgroups; ordered trend tests across I–IV were performed in the pooled cohort. Results Overall comparisons showed that AI-3D demonstrated significantly higher accuracy in sizing prediction and acetabular cup positioning in this study: cup size-match 63.9% versus 41.8% ( P  = 0.017), stem size-match 65.6% versus 47.3% ( P  = 0.047), and Lewinnek/Callanan safe-zone attainment 91.8% versus 76.4% ( P  = 0.021); by contrast, operative time and blood loss did not differ significantly. Subgroup analyses suggested that this benefit was mainly confined to Crowe I–II, while in Crowe III–IV the differences were not significant. At the 24-month follow-up, HHS, WOMAC, VAS, and implant survivorship (≈ 98%) were comparable between groups. In trend analyses pooling both cohorts, cup match rates decreased as Crowe grade increased ( P  = 0.004), the extent of functional improvement (change in HHS (ΔHHS), change in WOMAC (ΔWOMAC)) rose with greater deformity severity (both P  ≤ 0.001), and safe-zone attainment remained high without a clear monotonic trend. Conclusions AI-3D preoperative planning provides measurable gains in implant sizing and acetabular cup positioning for THA, with benefits most evident in mild-to-moderate deformities (Crowe I–II). In severe deformities (Crowe III–IV), anatomical and reconstructive challenges appear to limit these advantages, emphasizing the continued importance of surgical expertise. Functional outcomes were comparable between AI-3D and conventional 2D planning. Overall, AI-3D may serve as a useful adjunct in complex cases, pending confirmation in larger multicentre and long-term studies.

Background High dislocation due to developmental dysplasia of the hip (DDH), classified as Crowe type III or IV, presents significant challenges in total hip arthroplasty (THA), particularly in preventing nerve complications while restoring leg length. Aim This study aimed to evaluate the clinical and radiographic outcomes of primary THA using an S‐ROM‐A modular stem with oblique subtrochanteric shortening osteotomy in patients with high hip dislocation; to identify the advantages, limitations, and possible countermeasures of this surgical approach. Patients and Methods Subjects were 45 hips (37 patients) with high hip dislocation (Crowe III/IV) treated by primary THA using an S‐ROM‐A stem, with femoral shortening osteotomy performed at our institution. Outcomes 3 years after surgery were examined in 100% of the subjects. Postoperative complications and functional and radiographic outcomes were investigated. Results The mean age at surgery was 65 years and the mean duration of postoperative follow‐up was 10.7 ± 3.4 years. There were no cases of postoperative infection, symptomatic pulmonary embolism, or neurological complications in the legs. Early postoperative dislocation occurred in two hips (4%, resolved conservatively) and osteotomy site nonunion in one hip (2%). Repeat surgery was required in only this case of nonunion (2%). The hip function score was significantly improved postoperatively. Leg lengthening after surgery was 0–56 mm (mean, 28 mm). Examination of radiographs revealed that it took 12 weeks for bone union at the osteotomy site in all hips except for the one hip with nonunion. No stem subsidence was found postoperatively, and “fixation by bone ingrowth” was achieved at the final follow‐up examination in all hips (100%), including the one that required repeat surgery. Conclusion THA using an S‐ROM‐A modular stem with oblique subtrochanteric shortening osteotomy provided favorable mid‐term outcomes in patients with Crowe III/IV DDH. No neurological complications occurred, and functional and radiographic improvements were substantial. Our method, which emphasizes intraoperative sciatic nerve palpation for individualized leg lengthening, may serve as a practical and safe alternative to more complex monitoring systems. Further research incorporating objective intraoperative monitoring may help standardize this approach. Intermediate functional and radiographic outcomes of the described method at final follow‐up were almost favorable, and there were no neurological complications. Reconstruction with S‐ROM modular stem combined with subtrochanteric shortening osteotomy in primary total hip arthroplasty (THA) for high hip dislocation is a useful surgical approach.

Background The purpose of this study was to investigate the relationship between the three dimensional (3D) femoral head displacement in patients with developmental dysplasia of the hip (DDH) and Crowe classification. Methods Retrospectively, CT scans of 60 DDH patients and 55 healthy demography-matched healthy control subjects were analyzed. Using the anterior pelvic plane a pelvic anatomic coordinate system was established. The center coordinates of the femoral heads of both the DDH patients and control subjects were quantified relative to the pelvic coordinate system and were mapped proportionally to a representative normal pelvis for comparison. Results In the anteroposterior (AP) direction, the center of the femoral head was significantly more anterior in the DDH patients (type I, II, and III, respectively45.0 ± 5.5, 42.9 ± 7.1, and 43.9 ± 4.6 mm) when compared to the controls (50.0 ± 5.2 mm) ( p  < 0.001 for all). In the medial-lateral (ML) direction, the center of the femoral head was significantly more lateral in the DDH patients (type I, II, and III =103.5 ± 8.6, 101.5 ± 6.6, 102.1 ± 11.2 mm) when compared to the controls (87.5 ± 5.1 mm) ( p  < 0.001 for all). In the superior-inferior (SI) direction, the center of the femoral head was significantly more proximal in the DDH patients (type I, II, and III =62.4 ± 7.3, 50.0 ± 6.3, and 43.2 ± 6.6 mm) when compared to the controls (66.0 ± 6.2 mm) ( p  < 0.001 for all). Conclusions The severity of DDH using the Crowe classification was related to the degree of the femoral head displacement in the SI direction, but not in the ML or AP directions. By assessing the 3D femoral head displacement in DDH patients, individualized component positioning might benefit surgical outcome.

Background A few previous studies have investigated patient satisfaction after total hip arthroplasty (THA) according to the degree of pelvic deformity. This study compared patient-reported outcomes after primary THA for Crowe types III, IV and I dysplasia. Methods This retrospective, single-center, single-surgeon case-control study included patients who underwent primary THA between 2008 and 2016. We sent postal questionnaires to 38 patients with Crowe type III and IV dysplasia. Among the questionnaire respondents, 23 patients, excluding those with a follow-up period of < 1 year, were enrolled as the H group. The control group included 46 patients with Crowe type I, matched for sex, age, body mass index and surgical approach. To investigate the influence of femoral shortening osteotomy, the H group was divided according to whether femoral shortening osteotomy was performed. Ten patients underwent THA with femoral shortening osteotomy (FO group), while 12 patients underwent THA without femoral shortening osteotomy (N-FO group). Patient demographics, mean follow-up period, surgical information, pre- and postoperative leg length discrepancy (LLD), and perioperative complications were investigated. Clinical evaluations were performed using the Japanese Orthopaedic Association (JOA) scores, 36-item short-form survey (SF-36), net promotor score (NPS), visual analogue scale (VAS), and questionnaires. The VAS and SF-36 scores were determined only at final follow-up. Results The H and control groups were not significantly different in the postoperative JOA scores and SF-36. In the H group, VAS at the final follow-up was significantly higher, and significantly more patients felt that postoperative rehabilitation was serious, expressing that they underwent THA for LLD correction. In addition, the VAS scores in the FO group was higher than those in the N-FO group. Postoperative LLD was significantly greater in the H group than in the control group. Each group had an NPS of > 50. Conclusion The postoperative VAS score was higher in Crowe type III and IV dysplasia than in Crowe type I dysplasia, but no significant differences were detected in the postoperative satisfaction, JOA score, and SF-36 score. These findings may help explain the effects of THA preoperatively to patients with Crowe type III and IV dysplasia. Level of evidence Therapeutic Level 3b.

Background The purpose of this study was to investigate the association between the severity of Developmental dysplasia of the hip (DDH) and the abnormality in pelvic incidence (PI). Methods This was a retrospective study analyzing 53 DDH patients and 53 non-DDH age-matched controls. Computed tomography images were used to construct three-dimensional pelvic model. The Crowe classification was used to classify the severity of DDH. The midpoint of the femoral head centers and sacral endplates were projected to the sagittal plane of the pelvis. The PI was defined as the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting this point to the axis of the femoral heads. Independent sample t-tests were used to compare the differences between the PI of DDH group and the non-DDH controls group. Kendall’s coefficient of concordance was used to determine the correlation between the severity of DDH and PI . Results Patients with DDH had a significantly ( p  = 0.041) higher PI than the non-DDH controls (DDH 47.6 ± 8.2°, normal 44.2 ± 8.8°). Crowe type I patients had a significantly ( p  = 0.038) higher PI (48.2 ± 7.6°) than the non-DDH controls. No significant difference between the PI in Crowe type II or III patients and the PI in non-DDH controls were found (Crowe type II, 50.2 ± 9.6°, p  = 0.073; Crowe type III, 43.8 ± 7.2°, p  = 0.930). No correlation was found between the severity of DDH and the PI (r = 0.091, p  = 0.222). Conclusions No correlation was found between the severity of DDH and the PI. The study confirmed that the PI in DDH (Crowe type I) group was higher than that of the non-DDH control group, while the PI does not correlate with the severity of DDH.

BackgroundThe purpose of this study is to investigate the inter- and intraobserver reliability of Crowe and Hartofilakidis classifications in the assessment of developmental dysplasia of the hip in adult patients.Materials and methodsTwo consultant orthopedic surgeons classified 141 dysplastic hips on 103 standard anterior–posterior pelvis radiographs according to the Crowe and Hartofilakidis classifications. Assessments were performed in random order by each observer on two separate occasions, at least 4 weeks apart. Kappa statistics were used to establish a relative level of agreement between observers for the two readings and between separate readings by the same observer.ResultsAt the first readings, interobserver reliability analysis revealed kappa coefficient of 0.71 for the Crowe classification and 0.54 for the Hartofilakidis classification. At the second reading, the kappa coefficient was 0.72 for the Crowe classification and 0.75 for the Hartofilakidis classification. Intraobserver reliability analysis revealed kappa coefficients of 0.71 for the Crowe and 0.80 for the Hartofilakidis classification for observer A, and 0.76 and 0.70 for observer B.ConclusionsIn conclusion, we have found substantial inter- and intraobserver agreement for Crowe classification and substantial to moderate agreement for Hartofilakidis classification in this study. Both classification systems assess the different aspects of developmental dysplasia of hip in adults. Each system has advantages and disadvantages. We suggest using both of these classifications together to increase the accuracy.

Objective The aim of this study was to determine whether the ratio between the femoral head diameter and pelvic height in a Chinese population is the same as that found in Westerners. Materials and methods Standard pelvic radiography was performed on a group of 187 Chinese adult subjects consisting of 81 males and 106 females with a mean age of 40 years (21–68 years). Femoral head diameter (vertical distance from the femoral head–neck junction to the highest point of the femoral head) and pelvic height (vertical distance from the highest point of the iliac crest to the edge of the ischial tuberosities) were measured. Results There were significant differences between males and females ( p  < 0.001), and between persons of high height versus low height ( p  = 0.011) and medium height ( p  = 0.039). There were no significant differences between persons of different age ( p  = 0.244), body mass index ( p  = 0.091), or between persons of low- and medium-height groups ( p  = 0.69). The overall mean ratio between the femoral head diameter and pelvic height was 0.215 (0.173–0.249) with a 95 % CI = 0.214–0.217. The mean ratios in males and females were 0.221 (0.194–0.249) and 0.211 (0.173–0.238), respectively. Conclusion The mean ratio in Chinese population was similar to the reported ratio in a western population (about 1:5). We suggest that Chinese surgeons may be able to use the Crowe classification to classify patients with hip dysplasia.