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Total hip arthroplasty is the end-stage treatment option for adults with developmental dysplasia of the hip (DDH). The dysplastic acetabulum and proximal femur and the surrounding soft-tissue pathology present a challenge for surgeons. Patients with Crowe type IV DDH have a false acetabulum on the ilium and a hypoplastic and shallow true acetabulum invaded by fibroadipose tissue. The acetabular component should be placed in the same orientation as the true acetabulum, restoring the center of rotation.

This video describes the surgical steps for minimally invasive total hip arthroplasty via the direct anterior approach in a 57-year-old woman with Crowe type IV DDH. The patient complained of a severe limp, 3.5 cm of right limb shortening, and severe right hip functional limitations. Total hip arthroplasty was performed on a traction table with perineal support, which allowed for guided limb positioning. An abundant amount of soft tissue covered the false acetabulum, and hypertrophy of the psoas tendon, capsule, ligamentum teres, and labrum was observed. Extensive capsulotomy and soft-tissue release were crucial before acetabular cup positioning. Cup placement in the true acetabulum was possible via a three-dimensionally-printed, small, uncemented acetabular cup that was stabilized with the use of extra screws. Given that the limb-length discrepancy was less than 4 cm, a regular, short femoral stem was used. The postoperative protocol consisted of partial weight bearing, with full weight bearing initiated at 6 weeks postoperatively.

Total hip arthroplasty is a challenge in patients with Crowe type IV DDH. Complex anatomy dictates the surgical techniques to achieve a mechanically stable and functional implant. The anterior approach is a safe and effective method for exposure of bone and soft-tissue pathology, allowing for the management of DDH.