operative management is difficult because of difficult exposure , altered anatomy of soft tissue structures , hypoplastic femoral medullary canal and shallow and atypical acetabulum filled with soft tissues . femoral head is up - ridden with contracted abductors which resists reduction of femoral head into acetabulum . altered anatomy of neurovascular structures also pose a risk of being injured during surgery . here we are presenting a case of bilateral total hip arthroplasty in 20 years old female with developmental dysplasia of hip and sharing our experience of its operative management . we concluded from this case study that total hip arthroplasty in developmental dysplasia of hip is technically demanding but gives good functional and clinical result . for getting functionally good result contracted soft tissues around joint developmental dysplasia of hip is a spectrum of developmental disorders of hip in which acetabulum is dysplastic and it presents in different forms in different ages . ligament laxity , breech position in utero and primary acetabular dysplasia has been suggested as etiological factors . if hip remains dislocated for a long time , fatty tissue ( pulviner ) thickens in the depth of acetabulum , ligamentum teres elongates and thickens and capsule gets stretched out and become very loose . a completely dislocated hip usually causes symptoms much later than a subluxated hip and in some individual it never becomes painful . crowe et al   devised a popular classification to grade the severity of developmental dysplasia of hip which ranges from type one ( superior migration of head < 50%of its diameter ) to type four ( > 100% superior migration ) . type four ( as is the case in this patient ) has worst functional outcome . in cases of untreated developmental dysplasia of hip in adults , total hip arthroplasty ( tha ) is a challenging surgery . acetabular reconstruction is traditionally done with cemented or uncemented cup with or without structural bone grafting . femoral head is up - ridden and femoral canal will also be hypo - plastic . joint capsule will be contracted which hampers the sufficient exposure of the joint and mobilization of femur . this can be done by , careful dissection of soft tissues and release of capsule attached to the proximal femur , pi - crusting of abductors to gain length and if needed sub - trochanteric shortening of femur . we are reporting this case for the good result we obtained with proper operative technique . a 20 years old female presented to us with history of difficulty in walking since childhood and pain in both hips for last two years . she had been suffering from these problems since childhood but had not taken any definitive treatment . on all hip movements were painfully restricted and extension , adduction and rotational movements were not possible . 3 centimeters shortening was present on left side . on radiological examination x - ray pelvis with both hips ap view [ fig.1 ] revealed proximally migrated dysplastic head of femur with dysplastic shallow empty acetabulum . the length of subtrochantric osteotomy was determined so that it would not lengthen the leg more than 3 cm to prevent sciatic nerve stretching . all necessary investigations were done and anesthetic clearance was taken . patient was planned for bilateral uncemented tha in two stages . patient was positioned in lateral position . hip joint was approached by a postero - lateral incision over posterior aspect of greater trochanter curved over buttock . it should be kept in mind , that femoral neuro - vascular bundle and sciatic nerve may not be present at usual anatomic positions . after splitting gluteus maximus , acetabulum was cleared of fibrous tissues and progressively large reamers were used to enlarge the shallow acetabulum . using power reamer it was shaped spherical and a trial implant was used to determine the coverage of the cup . ischial and pubic bone were exposed proximally along with tear drop to get a clear idea of available bone stock . acetabulum was stable and well seated per - op with coverage of more than 90% [ fig.2 ] . osteotomized segment was vertically splitted and used to re - enforce osteotomy site as a cortical strut graft . excessive ante version of femoral neck was corrected by placing the prosthesis eccentrically in the medullary canal . to facilitate the reduction the prosthetic joint than can be reduced without undue tension [ fig.5 ] . left hip was reconstructed using similar technique after two weeks [ fig . we used acetabular cup ( stryker ) 44 mm ( both side ) , head ( smith nephew ) 28 mm ( metal , both side ) and femoral stem ( smith nephew ) size ten on right side and size nine on left side . x - rays at four months follow - up showed good stable implants with good callus formation at the osteotomy sites [ fig . 4 months follow - up x - ray showing good callus formation at osteotomy site . in untreated developmental dysplasia of hip , concentric reduction of prosthetic hip is technically demanding . cup coverage and restoration of normal hip biomechanics remain the most important issues . a wide range of prostheses should be available to choose one which is best suited for hypoplastic bones . although , russoti and harris have postulated that a proximal position of acetabulum is an acceptable alternative   on the contrary , pagnano et al . have found high rate of loosening of prosthetic components with proximal position   bone stock is also deficient proximally and restoration of normal hip biomechanics is difficult . with reconstruction of acetabulum at anatomical site , we did subtrochanteric osteotomy in this case and osteotomized segment was vertically splitted and used to re - enforced osteotomy site as a cortical strut graft . reikeraas et al   obtained 96% good to excellent results with simple transverse osteotomy and fixation with porous coated stem . a subtrochanteric osteotomy along with modular stem allows for correction of excessive femoral anteversion as well as concentric reduction and also safeguards neurovascular structures against traction injury . many authors   have shown satisfactory results with use of cemented stem in dysplastic femora . keeping the young age of our patient and hypoplastic femoral canal in mind , we used uncemented modular stem in hope for better fixation and longer life of implant . . anatomical reduction of prosthetic components can be possible only after lengthening of shortened abductors . in this case structural bone grafting is traditionally done in acetabular reconstruction to reinforce deficient supero - lateral aspect . in this patient we obtained > 90% acetabular cup coverage on both sides [ fig 3 ] without structural bone grafting . have reported high failure rates in long term with use of structural graft and recommended its use only as a last resort . acetabular reconstruction has high failure rate if graft covers a large proportion of the cup . although some authors have reported satisfactory results using structural bone graft [ 10 , 11 ] . leela c. biant et al   reported excellent results in crowe type three and four dysplastic hips at 10 years follow up using s - rom stem . we think that whenever bone stock permits cementless cup fixed with screws without structural bone grafting gives good result . total hip arthroplasty in untreated developmental dysplasia of hip is a technically demanding procedure and anatomical reconstruction of hip joint requires experience and technical support to provide pain free functionally good hip . preoperative planning regarding acetabular position , proper prosthesis selection and adequate soft tissue dissection especially tight abductors and flexors are keys to success in these difficult cases .
introductionmanagement of developmental dysplasia of hip in adult is challenging problem . 
 management protocols are not well defined in terms of operative technique . 
 patient may present very late . 
 usually they consult orthopaedic surgeons when osteoarthritic changes set in , leading to pain . 
 operative management is difficult because of difficult exposure , altered anatomy of soft tissue structures , hypoplastic femoral medullary canal and shallow and atypical acetabulum filled with soft tissues . 
 femoral head is up - ridden with contracted abductors which resists reduction of femoral head into acetabulum . altered anatomy of neurovascular structures also pose a risk of being injured during surgery.case reporthere we are presenting a case of bilateral total hip arthroplasty in 20 years old female with developmental dysplasia of hip and sharing our experience of its operative management.conclusionwe concluded from this case study that total hip arthroplasty in developmental dysplasia of hip is technically demanding but gives good functional and clinical result . for getting functionally good result contracted soft tissues around joint 
 need special attention .