Primary Hip Arthroplasty Case Title: Hemiresurfacing for Hip Osteonecrosis in Active Young Patients
Case Title: Hemiresurfacing for Hip Osteonecrosis in Active Young Patients
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Demographics
Age: 32 Sex: Male BMI: 29.1
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Relevant Past Medical History
Principal pathologies: Bilateral osteonecrosis of the femoral head.
Previous surgical procedures: None.
Medication: None.
Other: Important alkohol abuse—the patient drinks beer every day for many years.
History of presenting complaint: Right hip pain since December 2013 after a subchondral fracture of the femoral head. On December 12, 2014, he was submitted to hemiresurfacing arthroplasty with a cemented ReCap 50 mm from Biomet, since the chondral damage of acetabular cartilage was minimal and the labrum was intact (Figs. 4.1, 4.2 and 4.3). The postoperative course was very good and he returned to the horse riding with no pain. He works as a cowboy in the interlands of Brazil. After eight months, he started having pain in the left hip, and a CT demonstrated a subchondral fracture. On December 11, 2015, he was submitted to left hip hemiresurfacing arthroplasty with cemented ReCap 50 mm, and the acetabular cartilage and labrum were perfect. In both surgeries, he stayed in the hospital only for 48 h and started full weight bearing on the first day with a pair of crutches since the posterolateral approach was utilized.
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Clinical Examination
Symptoms: Important right (and later left) hip pain when walking and limping was visible.
Range of motion: Internal rotation = zero, flexion, external rotation, abduction, adduction, and extension with no abnormalities within normal range of motion.
Specific tests: Negative Trendelenburg.
Main disability: Minimal limping when walking.
Scoring if available: Analog pain rating scale = 4.
Neurovascular evaluation: Normal.
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Preoperative Radiological Assessment/Imaging
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Fig 4.1 Right femoral head with big cysts which were filled with Biomet cement from Switzerland
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Fig. 4.2 Minimal erosions on acetabular cartilage due to the subchondral fracture
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Fig. 4.3 Pelvis X-ray of second postoperatory day for hemiresurfacing arthroplasty of the right hip
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Preoperative Planning
Diagnosis: Our first thought was to implant a total hip arthroplasty, but, in exceptional cases of patients having a good acetabulum and no labral tear or labral detachment, we still prefer hemiresurfacing; although the outcomes of this type of arthroplasty are reported to be unpredictable, we still prefer to use this in certain cases with satisfactory results.
Possible treatment options: Hemiresurfacing or conventional total hip arthroplasty.
Chosen treatment method: Following consultation of the patient we choose the hemiresurfacing solution.
Selection of implants if applicable and rational: We have used Biomet and Conserve Plus femoral components which could be converted to total, so we do not use the original Conserve component since it cannot be converted to total in case of failure.
Expected difficulties: We start surgery by inserting the metal pin guide using an image intensifier without allowing the pin to cross the femoral head which can damage the acetabular cartilage. This surgery has to be done very carefully mainly when opening the capsule taking care not to damage the labrum. Never remove the fat pad, even if it is very inflamed, as it is usually seen in osteonecrosis. The severe synovitis of the foveal pad should be preserved and never be removed since we noticed that it works as a cushion or shock absorber and the patient has only a minimal discomfort.
Strategies to overcome difficulties: Patient selection is crucial. It is very important to explain to the patient that the duration of pain-free joint might not be long. If this is the case and when the patient is not satisfied, revision and conversion to a total resurfacing or a conventional total hip arthroplasty doing the osteotomy of the femoral neck are possible.
Templating: As we do not have resurfacings with increments of 1 mm anymore, always choose the smaller size, that is, in this case, we measure a 51 mm head and implant a 50 mm head in order to fit the acetabulum!
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Surgical Note
Patient’s position: Lateral.
Type of anesthesia: General.
Surgical approach: Posterolateral (MIS -max-imum incision surgery) with incision varying between 15 and 25 centimeters depending on the BMI).
Main steps: During the initial step we pass the guide pin through the skin with the aid of image intensifier trying to be in the middle of the femoral neck not allowing it to penetrate the femoral cartilage. Only after this start the skin incision;
this saves you time during surgery, less blood loss, and increase the precision of surgery.
Reconstruction techniques: It is important, if you can close the capsule, but sometimes we need to retrieve part of it and leave it open. It is very important to check if the labrum is not unturned when you reduce the femoral head back in the acetabulum. Check the total range of motion and feel in your fingers if there is no “entrapment of soft tissues”!
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Intraoperative Challenges
Challenges and solutions: Whether performing hemiresurfacing or total resurfacing is an intraoperative decision depending on the local conditions. It is always necessary to have a conventional prosthesis in case you do not have a good femoral head or you do not achieve a stable acetabulum resurfacing fixation since you cannot put screws, except in dysplastic hips. Although MRI and CT can give us explicit images, sometimes we are surprised with severe acetabular cartilage erosions which are not seen in these exams. In these cases we take a picture and show the patient later that hemiresurfacing was not possible.
Unanticipated problems and solution: As explained above, never start operation without having a conventional prosthesis available. It only happened once in our hands but it can happen, and we cannot ream the acetabulum more to insert a bigger resurfacing acetabulum.
Thorough description of decision-making, including the reason for the final decision: Young active patients with necrosis of the femoral head are ideal candidates for hemiresurfacing if well selected and prepared to live with eventual minimal pain after hemiresurfacing (some patients have some minimal discomfort but are satisfied with hemiresurfacing). This patient was so happy that we operated the other hip 1 year later. Note at 1-year post-op X-ray that there was new bone formation on medial calcar after 1 year (Figs. 4.4 and 4.5). The left hip had a substantial lateral cyst and was filled with cement which we believe will support the horse riding with no problems since the medial column was ok (Fig. 4.5).
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Postoperative Radiographs
(Figs. 4.3, 4.4, and 4.5)
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Fig. 4.4 Seven-month post-op right hip CT
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Fig. 4.5 One-year post-op right hip and one-day post-op left hip (which had a substantial lateral cyst)
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Postoperative Management
Chemoprophylaxis and anticoagulant treatment period: Aspirin 100 mg for 20 days, use of cefuroxime for 48 h, use of drain which was removed at 24 h, no blood transfusion necessary
Gait/limb loading until full loading: Use of a pair of crutches with full weigh bearing for 2–3 weeks maximum and one crutch contralateral side until limping stops
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Follow-Up and Complications
Report of postoperative complications and their management (i.e., recurrent dislocation): We needed to convert to a total hip resurfacing only a case of us since this 28-year-old young active male surfer refered considerable pain after walking more than two km. This patient had a lot of pain in the immediate postoperative period and is allergic to several anti-inflammatory drugs (usually our patients have no pain at all after total hip replacement using posterolateral approach with big incision—maximum incision surgery). We usually infiltrate the trauma with a topical anes-thetic solution made of 30 mg of Ketorolac and 1 mg of adrenaline in the muscles immediately before closure when using general anesthesia. If we use intradural anesthesia with morphine, we do not infiltrate locally the muscles with the above mentioned solution since anesthesia lasts for 24 h.
Scoring if available: Analog pain rating scale = 1.
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Discussion [92–94]
Advantages of the applied method: Hip resurfacing (HR) arthroplasty is a procedure that preserves bone and allows patients to return to a higher level of function with a longer prosthesis life compared with patients who receive a total hip arthroplasty (THA). It’s considered an alternative to THA in a selected group of patients who might potentially outlive a THA. During HR, the femoral neck is preserved, and the femoral head is shaped and capped with a metal device and short stem. The acetabulum is also lined with a specific metal device. We had the opportunity to visit professor Harlan Amstutz in 1993, 1995, and 1996 to see the wonderful lasting results of the hemiresurfacing prosthesis in young active athletes who continue to be active with hemiresurfacing.
Disadvantages of the method: Some patients may feel a certain discomfort, but it is acceptable. Close follow-up with annual X-rays is important.
Alternative evidence-based techniques for the case: Easy to revise if necessary.
Why is the chosen technique better for this case? The ideal patient is the one that withstands well pain (unfortunately there is no method to confirm if the patient will accept metal well on cartilage). Even for overweight patients or in the presence of an important subchondral fracture, the patient does not refer VAS score pain greater than 4, so we explained it was worthwhile to try. Indications and contraindications for your technique: A very careful surgical technique is mandatory in this surgery, retrieving the dead bone with arthroscopic curette, careful meticulous pulse lavage, placing a 3 mm hole in the femoral neck to aspirate the saline from pulse lavage which helps drying the bone before cementing is very important, and filling all cysts with finger pressuring cementation is
recommended.
Learning curve and how to manage complications: Do not remove fat from the fovea and leave the ligamentum teres (unless there is much ligamentum teres)—they act as shock absorbers. Never damage the labrum!
Level of evidence concerning the superiority of this method against others: We think it is a very good time saving method which can last more than 15 years as we were able to see many cases in the Joint Replacement Institute operated by professor Harlan Amstutz. People could not reproduce his results, probably because they are not being so meticulous, careful, and skilled as he was (he used to take 3 h to do a hemiresurfacing). We think hemiresurfacing has a place when a careful surgical technique is applied and the right patient selected.
