Published on 15 December 2025 Hip surgery
Primary total hip replacement in patients presenting multiple operations during childhood
Implanting a hip prosthesis in a patient who underwent several operations during childhood represents a true surgical challenge. Unlike a primary hip replacement on a non-operated hip, often considered a reliable and standard procedure, the multi-operated hip presents a modified, sometimes severely altered anatomy, making both planning and execution significantly more complex. At Inside the Hip in Lyon and Paris, management relies on precise three-dimensional analysis and the use of custom-made implants, essential for restoring optimal function despite long-standing sequelae.
The specific difficulties of multi-operated hips
Primary total hip replacement on a non-operated hip is a common intervention, considered reliable and feasible in most centers.
In contrast, certain childhood medical or surgical conditions make the procedure far more difficult and the outcomes more uncertain.
We regularly treat patients, sometimes young adults, who have a multi-operated hip dating back to childhood due to :
- developmental dysplasia of the hip (DDH)
- Legg–Calvé–Perthes disease
- childhood arthritis
- hip trauma
- or multiple past surgeries: pelvic osteotomy, femoral osteotomy, shelf procedure, capsular release, tendon section, etc
Often, no operative reports are available. Only several scars around the pelvis and femur, or even neurological sequelae, are observed.
A deeply altered anatomy
In these situations, patients present with highly atypical anatomy, including:
- pelvic tilt
- spinal deviation
- leg length discrepancy
- global atrophy of the gluteal and thigh musculature
Radiographs frequently show sequelae of previous pelvic or femoral surgeries, along with a markedly asymmetric hip architecture.
A thorough medical history, interview, and physical examination are therefore fundamental. They allow assessment of the spine, hips, lower limbs, passive and active mobility, and any muscular deficits (gluteus medius insufficiency or neurological involvement).
Which planning examinations are required?
When hip replacement is indicated, 2D planning is insufficient. It does not accurately reflect the true anatomy, particularly in the axial plane, nor the acetabular orientation, femoral anteversion, or retroversion.
A 3D CT scan is essential. It provides true-to-size analysis, three-dimensional reconstruction of the hip morphology, and evaluation of muscle trophicity (gluteal muscles, psoas). The presence of fatty degeneration is a poor prognostic factor for functional recovery.
In addition, a standing EOS scan helps evaluate lumbopelvic–femoral balance and lower-limb alignment abnormalities.
Subsequently, 3D CT planning allows:
- determining the optimal position, orientation, and diameter of the acetabular cup
- designing a custom-made femoral stem adapted to the intramedullary canal
- optimizing the prosthetic neck to adjust neck–shaft angle, anteversion, and medio-lateral offset
Objectives of hip prosthesis implantation in multi-operated hips
Implanting a hip prosthesis in this context must aim to :
- restore a functional anatomy
- remain realistic: a “perfect” hip is often a compromise
- minimize intraoperative complication risks
Choosing implants for multi-operated hips
These patients are often young, making it preferable to use a cementless implant, titanium bone fixation, and a ceramic-on-ceramic bearing surfaces, ensuring long-term absence of wear.
The surgical approach: a major consideration
We favor the muscle sparing direct anterior approach that preserves muscular structures. In multi-operated patients, any additional muscle section must be avoided, unlike what occurs with posterior or transgluteal approaches.
A technically complex surgery
The procedure is often demanding and requires:
- wide exposure
- joint release
- cup implantation according to the planned alignment (sometimes with dysplasia or bone grafting)
- implantation of the custom-made stem in strict accordance with the preoperative plan
At the end of surgery, the prosthetic ball is selected to properly balance the musculature.
Postoperative recovery is longer than for a standard primary hip replacement. A rehabilitation program of 4 to 6 months is required, focusing on restoring range of motion and lumbopelvic–femoral balance.
A new life for patients operated on since childhood
For these patients, often treated surgically from a very young age, the successful implantation of a hip prosthesis opens new possibilities — both in daily activities and in sports practice.
3D planning and custom-made prostheses are key to reassuring the patient, optimizing the procedure, and achieving the best possible surgical outcome.
