Primary Hip Arthroplasty Case Title: Resurfacing Primary Hip Arthroplasty

1. Case Title: Resurfacing Primary Hip Arthroplasty

    

    

   1. Demographics

       

      Age: 52 years old

      Sex: Male

      BMI: 24.7

       

   2. Relevant Past Medical History

       

      Principal pathologies: Hypercholesterolemia.

      Previous surgical procedures: Ankle fracture in 1985, managed nonoperatively.

      Medication: Simvastatin 40 mg once daily.

      Other: Lives on the third floor flat without a lift and freely mobile.

      History of presenting complaint: A 10-year history of worsening bilateral hip pain. Pain is worse on the left side than the right. Unable to walk for time periods greater than 30 min due to groin pain and can no longer play squash.

       

   3. Clinical Examination

       

      Symptoms: Left groin pain with pain traveling down to thighs.

      Range of motion: Hip flexion to 95° with internal rotation limited to less than 15°. No external rotation of the hip with hip flexing into fixed internal rotation.

      Specific tests: Leg length discrepancy of 1.5 cm.

      Main Disability: Prior to hip pain was unable to play squash.

      Scoring if available: Harris Hip Score of 44 and WOMAC 46.7.

      Neurovascular Evaluation: Normal sensation in all lower limb dermatomes and pulses palpable at dorsalis pedis and posterior tibial arteries.

       

   4. Preoperative Radiological Assessment/and Imaging (Figs. 4.6 and 4.7)

       

   5. Preoperative Planning

       

      Diagnosis: Osteoarthritis (Figs. 4.6 and 4.7)

      Possible treatment options: (1) Birmingham Hip Resurfacing (Smith & Nephew, Andover, MA, USA), (2) uncemented total hip arthroplasty, and (3) cemented total hip arthroplasty

      Chosen treatment method: Hip resurfacing

       

       

       

       

      Fig. 4.6 AP pelvis

       

       

       

       

       

      Fig. 4.7 Lateral left hip

       

      Selection of implant if applicable and rational: Birmingham Hip Resurfacing because it is the best performing hip resurfacing implant on the UK National Joint Registry

      Expected difficulties: Femoral head bone stock deficiency due to severe osteoarthritis

      Strategies to overcome difficulties: Possibility of conversion to total hip arthroplasty if femoral head bone stock deficiency is present

       

   6. Templating (Fig. 4.8)

       

       

       

      Fig. 4.8 Legend for image—templating of left hip with use of TraumaCad software (Brainlab, Munich, Germany). A 62 mm cup with a 54 mm head was recommended. Note the avoidance of varus positioning

       

   7. Surgical Note

       

      Patient’s position: Lateral decubitus.

      Type of anesthesia: Spinal with sedation.

      Local periarticular injection.

      Surgical approach: Posterior approach.

      Main steps: A 15 cm incision made over the posterior aspect of the greater trochanter through the skin and fat. Fascia lata cut with the hip in slight abduction. Gluteus maximus was bluntly dissected. The sciatic nerve was identified and protected throughout. The piriformis tendon was identified and gluteus minimus and medius retracted anterosuperiorly using sharp Hohmann retractor. Piriformis tendon, short external rotators, and quadratus muscle with underlying capsule raised as a single flap posteriorly. Femoral head dislocated and delivered into the wound. Limited anterior capsulotomy may be necessary to achieve this. Centre line of implant template is determined as distance from the lesser trochanter by jig ruler, according to preoperative templating. The area of the posterior femur marked and collared alignment pin inserted with a drill, perpendicular to the neck of the femur. Long

      alignment jig set up, and stylus used to check femoral component positioning avoiding varus and neck impingement. When judged to be satisfactory regarding the lateral and coronal alignment, the guidewire is inserted. Guidewire overdrilled. Guide bar insertion over the guidewire. Recheck femoral component impingement. Sleeve cutter stop device placed over guide bar with corresponding head-neck template to prevent shoot through the sleeve cutter. Identify medial head-neck junction and summit of head marked. Plain cutter used to resect down to the identified level. Chamfer cutter used to shape the femoral head. Head trial placed over prepared bone and head subluxated anteriorly. This along with postero-inferior retractor allows wide exposure of the acetabulum.

      Acetabular preparation: Labrum resected and excised. Osteophytes are in the floor of the acetabulum and ligamentum teres resected. True acetabular floor identified. Reaming commenced at 46 mm, increasing in 2 mm increments. When sure of reaching the true acetabular floor, reaming increases in 1 mm, until press -fit fell is achieved by the reamer. Measurement is confirmed by trial cup size and also to confirm anterior coverage. Acetabular component positioned in the acetabular rim, at correct orientation to ensure splines are adjacent to the ischium and pubis and impacted onto the position. Osteophytes removed. A gauze swab is placed into the acetabulum, and the femur is prepared for cementation.

      The drill is used to form cement keyholes in the femoral head. Use of a taper drill to overream the central hole. Guide rod reinserted to recheck head-neck junction and mark depth of advancement of the femoral component. Pulse lavage and careful drying of the femoral head in preparation for cementing. Femoral component checked. Low viscosity cement prepared and poured into femoral component till 1/3 full and wet cement in contact with implant surface. Femoral component impacted onto head at 1 min. Excess cement removed. Rongeur used to resect any further osteophytes. Hip reduced with traction. The range of motion and the leg length equality confirmed on table (Figs. 4.9 and 4.10).

      Reconstruction technique: As described.

       

   8. Intraoperative Challenges

       

      Challenges and solutions: Careful assessment of the suitability of the patient for resurfacing. Larger incision utilized to ensure satisfactory placement of the implant. Careful dissection of the capsule to preserve retinacular blood supply of the femoral head. In the presence of small defects, cysts should be curetted to allow adequate cement interdigitation.

      Unanticipated problems and solutions: Notching of the femoral neck prevented by careful pre-op planning and meticulous operative technique. Varus position of acetabular component should be avoided.

       

   9. Postoperative Radiographs

      (Figs. 4.9 and 4.10)

       

       

       

      Fig. 4.9 AP pelvis. Left Birmingham Hip Resurfacing

       

       

       

       

      Fig. 4.10 Lateral left hip, Birmingham Hip Resurfacing in situ

   10. Postoperative Management

        

       Chemoprophylaxis and anticoagulant treatment period: The patient was placed on dalteparin, 5000 units subcutaneous, administered once daily. The thromboprophylaxis was given for 28 days. The patient was additionally given three doses of antibiotics in the immediate 24 h perioperatively. Gait/limb loading until full loading: The patient was permitted to fully weight bear

       postoperatively.

        

   11. Follow-Up and Complications

        

       No postoperative complications

       Scoring if available: Harris Hip Score of 96 and WOMAC 3.24

        

   12. Discussion

 

Advantages of the applied method: Hip resurfacing is a treatment option for the active younger patient, seeking surgery intending to returning to sport participation. Technically, the procedure offers the surgeon an opportunity to conserve proximal femoral bone stock. Other benefits include a lower rate of dislocation, owing to a larger diameter of the femoral head. Hip resurfacing arthroplasty was previously thought to offer improved proprioception but has been recently refuted according to Larkin [95]. There is also a proposed ease of revision. From the viewpoint of the patient, hip resurfacing has been demonstrated, by Daniel and colleagues [10], to permit those working in physically demanding occupations to return to work as well as a high proportion, 87% or greater, to return to “leisure time” sporting activities.

Disadvantages of the method: Drawbacks of the method include that it may be limited to a narrow cohort of patients, namely, male patients with larger femoral heads as suggested by registry data from both the Australian and UK registries. Female patients may be more at risk of fracture of the femoral neck secondary to osteoporosis. More recently, the disease of ARMD (adverse reaction to metal debris) has come to light. ARMD is a spectrum of soft tissue reac-

 

tions about the implant, which can cause local destruction of tissue, deep vein thrombosis, pain, and swelling. The incidence of this is unknown, but Pandit and colleagues estimate that this may occur in approximately 1% of all patients receiving metal-on-metal hip resurfacing within five years [96]. Risk factors for this include female sex and small component size [8]. Achieving accurate implant position is also essential to avoid failure as well as the risk of avascular necrosis of the femoral head and a limited inability of the technique to alter the patients offset or length.

Alternative evidence-based techniques for the case: Other techniques for this would be the use of an uncemented total hip arthroplasty using cross-linked polyethylene and ceramic or Oxinium head.

Why is the chosen technique better for this case? The patient is young and the keen sportsman. The technique will allow him to return to an active lifestyle.

Indications and contraindications for your technique: Indications include the younger, active patient with a larger femoral head.

Contraindications: Female patient with a smaller femoral head. Severely dysplastic hip secondary to DDH.

Learning curve and how to manage complications: A majority consensus (81%) from an international meeting in Ghent of notable surgeons suggested that surgeons ought to have 200 orthodox total hip replacements prior to embarking on hip resurfacing.

Level of evidence concerning the superiority of this method against others: Haddad and colleagues conducted a prospective cohort study comparing hip resurfacing to total hip arthroplasty [97]. The results are long-term findings (at ten years), and there was no loss to follow up. The study suggests improved function secondary to hip resurfacing. Other authors mirror the finding, but the follow-up is not as extensive.

ing versus total hip arthroplasty: a systematic review comparing standardized outcomes. Clin Orthop Relat Res. 2014;472:2217–30.

1. van Gerwen M, Shaerf DA, Veen RM. Hip resurfacing arthroplasty: a systematic review of functional outcome. Acta Orthop. 2010;81(4):680–3.

2. Grigoris P, Roberts P, Panousis K, Bosch H. The evolution of hip resurfacing arthroplasty. Orthop Clin North Am. 2005;36(2):125–34.

3. Corten K, SJ MD. Hip resurfacing Data from National Joint Registries What do They Tell us? What do they not tell us? Clin Orthop Relat Res. 2010;468:351–7.

4. Treacy RB, McBryde CW, Pynsent PB. Birmingham hip resurfacing arthroplasty. A minimum follow-up of five years. J Bone Joint Surg Br. 2005;87(2):167–70.

5. Back D, Dalziel R, Young D, Shimmin A. Early results of primary Birmingham hip resurfacings. An independent prospective study of the first 230 hips. J Bone Joint Surg Br. 2005;87(3):324–9.

6. Buergi ML, M. William L. Walter. Hip Resurfacing Arthroplasty The Australian Experience The Journal of Arthroplasty. 2007;22(7 Suppl):3.

7. Pandit H, Glyn-Jones S, Mc Lardy-Smith P, et al. Pseudotumours associated with metal-on-metal hip resurfacings. J Bone Joint Surg Br. 2008;90(7):847–51.

8. Coulter G, Young DA, Dalziel RE, Shimmin AJ. Birmingham hip resurfacing at a mean of ten years: results from an independent centre. J Bone Joint Surg Br. 2012;94(3):315–21.

9. Daniel J, Pradhan C, Ziaee H, Pynsent PB, McMinn DJ. Results of Birmingham hip resurfacing at 12 to 15 years: a single-surgeon series. Bone Joint J. 2014;96-B(10):1298–306.

10. Holland JP, Langton DJ, Hashmi M. Ten-year clinical, radiological and metal ion analysis of the Birmingham hip resurfacing: from a single, non-designer surgeon. J Bone Joint Surg Br. 2012;94(4):471–6.

11. Murray DW, Grammatopoulos G, Pandit H, Gundle R, Gill HS, Mc L-SP. The ten-year survival of the Birmingham hip resurfacing: an independent series. J Bone Joint Surg Br. 2012;94(9):1180–6.

12. Amstutz HC, Takamura KM, Le Duff MJ. The effect of patient selection and surgical technique on the results of conserve® plus hip resurfacing—3.5-to 14-year follow-up. Orthop Clin North Am. 2011;42(2):133–42.

13. Gareth H. Prosser, Piers J yates, David J wood, Stephen E graves, Richard N de Steiger, and Lisa N miller. Outcome of primary resurfacing hip replacement: evaluation of risk factors for early revision 12,093 replacements from the Australian joint registry. Acta Orthop. 2010;81(1):66–71.

14. Shimmin A, Beaulé PE, Campbell P. Metal-on-metal hip resurfacing arthroplasty. J Bone Joint SurgAm. 2008;90(3):637–54.

16. Johanson P-E, Fenstad AM, Furnes O, Garellick G,