Introduction:

Total hip arthroplasty (THA) in Crowe-IV developmental dysplasia of the hip (DDH) presents a formidable surgical challenge due to severe proximal femoral deformity, distorted acetabular anatomy, and soft-tissue contractures. The complexity is amplified in patients with prior surgeries, where scarring and multiplanar deformity complicate reconstruction. We present the case of a 21-year-old female with a multiply operated hip and an unusual combination of 6 cm femoral lengthening, a grossly malrotated and angulated femur, and a dysplastic acetabulum, treated with THA using a modular SROM stem and corrective osteotomy.

Case Description:

The patient had undergone open reduction and varus derotation osteotomy at age 5, followed by a pelvic shortening osteotomy at age 15. Despite a true femoral lengthening of 6 cm, she presented with no apparent limb length discrepancy, creating a paradoxical biomechanical scenario. She had severe pain, limp, and functional limitation, unable to ambulate without discomfort and socially stigmatized due to her gait abnormality.

On evaluation, findings included:

Absence of femoral head with an up-ridden greater trochanter.

Severe proximal femoral deformity with approx. 70° angular malalignment and rotational abnormality.

Dysplastic true acetabulum with deficient anterior and superior walls.

Extensively scarred tissue planes from multiple prior procedures, complicating surgical dissection and exposure.

Surgical Technique:

Contrary to the conventional Crowe-IV sequence (femur preparation, acetabular reconstruction, followed by femoral shortening osteotomy to avoid nerve stretch), the unique pre-lengthened limb obviated the need for extensive soft-tissue releases (no adductor or gluteus maximus tenotomy required). Instead, the femur and acetabulum were prepared independently.

Acetabulum: Reamed to the true acetabular bed with careful medialization, addressing the challenges of a shallow, narrow cavity with deficient bone stock.

Femur: A modular SROM stem was selected for its versatility in version and offset control. A corrective osteotomy was performed both for alignment and controlled shortening, correcting the angular and rotational deformity while permitting canal preparation.

Reconstruction: The modularity allowed independent anteversion adjustment despite distorted proximal anatomy. Stable fixation was achieved without undue lengthening or neurovascular tension.

Discussion:

Key teaching points include:

In multiply operated Crowe-IV hips with prior lengthening, conventional soft-tissue releases may be unnecessary.

Extensive scar tissue requires meticulous dissection and influences surgical strategy.

Independent femoral and acetabular preparation may be advantageous in severe deformity.

Corrective osteotomy served the dual purpose of alignment and controlled shortening.

Modular stems provide critical intraoperative flexibility in offset and version correction.

Conclusion:

This case demonstrates that even in the most complex Crowe-IV dysplasia — compounded by multiple prior surgeries, extensive scarring, and severe femoral deformity — a tailored approach using modular stems and strategic osteotomy can achieve stable reconstruction and functional restoration. The principles highlighted here are directly applicable to surgeons confronting similar reconstructive dilemmas in young patients with dysplastic, multiply operated hips.