Primary Hip Arthroplasty Case Title: Hybrid Primary Total Hip Arthroplasty

1. Case Title: Hybrid Primary Total Hip Arthroplasty

    

    

   1. Demographics

       

      Age: 86 Sex: Female BMI: 25

       

   2. Relevant Past Medical History

       

      Principal pathologies: Gorham’s ‘vanishing bone’ disease, osteoarthritis, hypertension, asthma, type 2 diabetes mellitus, psoriasis and gastro-oesophageal reflux disease.

      Previous surgical procedures: Left hybrid total hip replacement in May 2006 and a hysterectomy in 1988.

      Medication: Ciclosporin, metformin 500 mg BD, lansoprazole 15 mg OM, felodipine 2.5 mg OD, perindopril 8 mg OM, alendronic acid 70 mg weekly, adcal-D3 1.25 g OM, QVAR 50 mcg BD, rivaroxaban 10 mg OD, salbutamol

      200 mcg prn, tramadol 50 mg BD and paracetamol 1 gm QDS.

      History of presenting complaint: Right-sided groin and buttock pain with radiation up to the knee. She has night pain and rest pain. The pain is worse on weight-bearing, and her walking distance is now limited to a few yards. She takes

      paracetamol and tramadol. Over the last 3 months, her pain has become significantly worse. She has difficulty putting on socks and shoes. She struggles to get in and out of bed and to get up from a chair. She has had a left hybrid total hip arthroplasty nine years ago and is extremely happy with the outcome of the surgery.

       

   3. Clinical Examination

       

      Symptoms: The patient has a significant pain from the movement of her right hip and mobilizes with an antalgic and Trendelenburg gait.

      Range of motion: The patient’s range of motion of her right hip joint is hip flexion 80°, abduction 10°, adduction 5°, internal rotation 0° and external rotation 5°.

      Specific tests: Thomas test demonstrates 20° fixed flexion deformity as well as positive Trendelenburg test.

      Main disability: Patient could only mobilize a few yards (even so with great difficulty).

      Neurovascular evaluation: The right lower limb was neurovascularly intact.

       

   4. Preoperative Radiological Assessment/Imaging (Figs. 3.19, 3.20, and 3.21)

       

       

       

      Fig. 3.19 Anteroposterior pelvis radiograph showing osteoarthritis of the right hip with Gorham’s ‘vanishing bone’ disease affecting the left ischium

       

       

       

       

       

      Fig. 3.20 Lateral radiograph of the right hip

       

       

       

       

      Fig. 3.21 Templating of the right hip with hybrid arthroplasty

       

   5. Preoperative Planning

       

      Diagnosis: Osteoarthritis of the right hip (Figs. 3.19 and 3.20).

      Possible treatment options: (1) Hybrid primary total hip arthroplasty. (2) Cemented primary total hip arthroplasty. (3) Uncemented primary total hip arthroplasty.

      Chosen treatment method: Hybrid primary total hip arthroplasty.

      Selection of implants if applicable and rational: Uncemented porous-coated acetabular com-

      ponent, cross-linked polyethylene (XLPE) liner, oxidized zirconium femoral head and cemented femoral component.

      Expected difficulties: (1) Osteoporotic bone with a risk of intraoperative fracture. (2) Varus neck-shaft angle predisposing to leg length discrepancy.

      Strategies to overcome difficulties: (1) Gentle controlled hip dislocation after adequate capsular release. (2) Low neck cut and use of high-offset femoral component.

      Templating: Templated as shown in Fig. 3.21.

       

   6. Surgical Note

       

      Patient’s position: Lateral decubitus.

      Type of anaesthesia: Spinal anaesthetic.

      Surgical approach: Posterior approach.

      Main steps: A standard posterior approach to the hip. Incision through fascia lata. Gluteus maximus fibres were split proximally. Gluteus medius and minimus are retracted supero-medially to expose short external rotators. The sciatic nerve was identified and protected throughout. The leg was internally rotated to place the short external rotators on a stretch. Short external rotators were detached close to femoral insertion. Capsule and short external rotators were detached as one layer. The hip was dislocated gently with internal rotation. Using the osteotomy guide, the femoral neck was oste-otomized, and the femoral head was excised. Then, the acetabulum was exposed circumferen-tially. The transverse acetabulum ligament was identified. The acetabulum was reamed to its true floor. A trial acetabular cup was inserted. Following this, a definitive porous-coated acetabular component was inserted with good anterior coverage and 5° more closure than her native anatomy, and in her own anteversion, parallel to the transverse acetabular ligament. Two postero-superior screws were inserted. The acetabular osteophytes were removed. XLPE liner was inserted. With the knee flexed at 90°, the medullary canal was opened at the transected neck with a box chisel, aiming posteriorly and laterally. A blunt medullary reamer was then inserted to open up the canal. The femur was broached to the

       

      appropriate stem size, and following which the broach handle was removed, leaving the broach within the medullary canal, and a calcar reamer was used to ream the calcar level with the broach. A high-offset trial neck and appropriate femoral head were then used, and the hip was reduced. The hip was assessed for soft tissue tension, leg length as well as stability. The femoral component was cemented using fourth-generation cementing technique. The definitive femoral head was inserted after retrialling. The hip joint was reduced. The joint was lavaged. The short external rotators and the capsule were repaired with transosseous sutures to the greater trochanter. A layered closure was performed and a sterile dressing was applied to the wound (Figs. 3.22 and 3.23).

       

   7. Intraoperative Challenges

       

      Challenges and solutions: As described in preoperative planning and surgical note.

      Unanticipated problems and solutions: No unanticipated problems were identified in this case. Thorough description of decision-making, including the reason for the final decision: As

      described in the discussion below.

       

   8. Postoperative Radiographs

      (Figs. 3.22 and 3.23)

       

       

       

       

      Fig. 3.22 Postoperative anteroposterior pelvis radiograph

       

       

       

       

      Fig. 3.23 Postoperative lateral right hip radiograph

       

   9. Postoperative Management

       

      Chemoprophylaxis and anticoagulant treatment period: T.E.D anti-embolism stockings, foot pumps and dalteparin 5000 IU for 35 days.

      Gait/limb loading until full loading: Early mobilization to achieve full weight-bearing status as soon as possible.

       

   10. Follow-Up and Complications

        

       There have been no complications with both her hybrid total hip replacements. The left total hip arthroplasty was performed nine years ago, and the right total hip arthroplasty was performed 2 months ago.

        

   11. Discussion

 

Advantages of the applied method: Gorham’s disease, otherwise known as ‘vanishing bone’ disease, is characterized by destruction of osseous matrix and proliferation of vascular structure, resulting in bone absorption and destruction. There have only been approximately 200 reported cases since it was first described by Gorham in 1838 [40]. Due to its rarity, there has not been a clear consensus on the treatment and management of this disease as it is often individualized [40]. Apart from this case, we have been aware of nine other reports of total or partial hip arthroplasty in Gorham’s disease [40]. From the literature, aseptic loosening of cemented acetabular components remains a significant complication resulting in

 

revision surgery [41]. For the same reason, we opted to use an uncemented porous-coated acetabular component to promote osteointegration. The advantage of a cemented femoral stem, in this case, was to achieve adequate fixation in osteoporotic bone, allowing the patient to start full weight-bearing immediately. Additionally, with modern cementing techniques, outcomes of cemented femoral stems have improved [42].

Disadvantages of the method: Disadvantage of using an uncemented acetabular component is the risk of intraoperative acetabular fracture on insertion [43]. Disadvantages of the cemented femoral stem are potential aseptic loosening and cement-related embolism [44].

Alternative evidence-based techniques for the case: An alternative technique for this case, as described in other case reports, is cemented primary total hip arthroplasty.

Why is the chosen technique better for this case? The patient had a successful outcome with the same technique on the opposite hip and hence the decision to reproduce it on the current symptomatic side.

Indications and contraindications for your technique: Indications for hybrid total hip replacement, in this case, are the osteoporotic femur, patient’s age and comorbidities. Contraindications are young, fit and active patients with adequate bone stock.

Learning curve and how to manage complications: Standard routine and reproducible technique used to minimize complications.

Level of evidence concerning the superiority of this method against others: As discussed above.