Long term results of arthrodesis for severe osteoarthritis of the hip in young adults

Changes of the coronal lumbar-pelvic-femoral alignment after conversion total hip arthroplasty in patients with unilateral ankylosed hip

To elucidate the changes in coronal lumbar-pelvic-femoral alignment after conversion total hip arthroplasty (THA) in patients with unilateral ankylosed hip. A retrospective radiologic study of 48 patients (48 hips) with unilateral hip arthrodesis who underwent conversion THA was conducted. Cobb's angle of lumbar scoliosis (LS), the pelvic obliquity (PO) angle, and the hip adduction angle (HAA) on standing anterior-posterior spine-pelvis-hip radiographs were measured before and after THA. The differences of LS, PO, and HAA before and after THA were defined as ΔLS, ΔPO, and ΔHAA, respectively. A paired samples t-test or the Wilcoxon signed-rank test were used to compare the absolute values of the LS, PO, and HAA between preoperative and postoperative groups. The Pearson's correlation coefficient (r) or Spearman's correlation coefficient (ρ) was calculated to assess the relationship between ΔLS, ΔPO, and ΔHAA and possible associated factors. Significant differences were found in the preoperative LS (mean, 10.8° vs. 8.2°, p = 0.004), PO (median, 6.8° vs. 2.0°, p < 0.001), and HAA (median, 10.0° vs. 6.0°, p = 0.003). ΔLS was correlated with the preoperative LS (ρ =  - 0.621, p < 0.001), PO (ρ =  - 0.580, p < 0.001), and HAA (ρ =  - 0.467, p < 0.001). ΔPO was correlated with the preoperative LS (r =  - 0.596, p < 0.001), PO (ρ =  - 0.892, p < 0.001), and HAA (ρ =  - 0.728, p < 0.001). ΔHAA was correlated with the preoperative LS (r =  - 0.583, p < 0.001), PO (ρ =  - 0.751, p < 0.001), and HAA (ρ =  - 0.824, p < 0.001). LS, PO, and HAA were significantly improved after conversion THA. Greater improvement in LS, PO, and HAA can be expected in patients with larger preoperative LS, PO, and HAA values.

Hip arthrodesis in children : a review of 26 cases with a mean of 20 years' follow-up

AIMS

To examine the long-term outcome of arthrodesis of the hip undertaken in a paediatric population in treating painful arthritis of the hip. In our patient population, most of whom live rurally in hilly terrain and have limited healthcare access and resources, hip arthrodesis has been an important surgical option for the monoarticular painful hip in a child.

METHODS

A follow-up investigation was undertaken on a cohort of 28 children previously reported at a mean of 4.8 years. The present study looked at 26 patients who had an arthrodesis of the hip as a child at a mean follow-up of 20 years (15 to 29).

RESULTS

The mean Harris Hip Score (HHS) increased from 39.60 (SD 11.06) preoperatively to 81.02 (SD 8.86; p = 0.041) at final review. At latest follow-up, the HHS was found to be excellent in four patients (15%), good in 11 (42%), and fair in 11 (42%). A total of 16 patients (62%) reported mild low back pain, five (19%) had moderate pain, and five (19%) patients had no back pain. Mild ipsilateral knee pain was reported by 19 (73%), moderate pain by one (4%), and no pain by six (23%) patients. Mild contralateral hip pain was reported by ten patients (38%), and no pain by 16 (62%). The 36-Item Short Form Health Survey scores were very good in four patients (15%), good in 18 (70%), and poor in four (15%), with a mean score of 70.92 (SD 12.65). Of 13 female patients who had given birth, 12 did so with uncomplicated vaginal delivery. All patients had to modify their posture for toileting, putting on lower body clothes, foot care, and putting on shoes.

CONCLUSION

Our results show that with hip arthrodesis, most patients have relatively good function at long-term follow-up, although some pain is experienced in adjacent joints, and modification in some activities of daily living is common.Cite this article: Bone Joint J 2022;104-B(9):1089-1094.

Treatment Options for End-Stage Hip Disease in Adolescents: To Replace, Fuse, or Reconstruct?

INTRODUCTION

This paper aims to review the indications criteria for the surgical treatment of adolescents with hip osteoarthritis and summarize the contemporary techniques that orthopaedic surgeons can apply for hip reconstruction.

DISCUSSION

Hip osteoarthritis remains a concerning burden to North American society. While the rate of total hip replacement (THR) in younger patients has increased in the last decades, younger patients may have a higher risk of revision hip replacement because of their increased level of activity and expected patient longevity compared with the elderly. Increased demand for multiple revision surgeries is a concern for the adolescent patient. Although in general THR has been increasingly recommended for the treatment of end-stage osteoarthritis secondary to pediatric hip disorders, hip arthrodesis remains a beneficial alternative for the treatment of severe hip disease secondary to infection and for patients who desire to engage in a very active lifestyle. Hip preservation procedures are ideally performed in the prearthritic stage or in hips with minimal degeneration to preserve the joint and achieve the most optimal outcomes. However, adolescents and young adults with moderate and rarely advanced arthritis may benefit from surgical treatment using hip preservation techniques.

CONCLUSIONS

Treatment of adolescents with pain and dysfunction because of end-stage hip disease is challenging and controversial. THR and arthrodesis are the 2 principal alternatives. However, in particular circumstances, hip reconstruction may be recommended.

Early to medium-term outcomes of uncemented ceramic-bearing total hip arthroplasty in teenagers for paediatric hip conditions

AIMS

Despite advances in the treatment of paediatric hip disease, adolescent and young adult patients can develop early onset end-stage osteoarthritis. The aims of this study were to address the indications and medium-term outcomes for total hip arthroplasty (THA) with ceramic bearings for teenage patients.

METHODS

Surgery was performed by a single surgeon working in the paediatric orthopaedic unit of a tertiary referral hospital. Databases were interrogated from 2003 to 2017 for all teenage patients undergoing THA with a minimum 2.3 year follow-up. Data capture included patient demographics, the underlying hip pathology, number of previous surgeries, and THA prostheses used. Institutional ethical approval was granted to contact patients for prospective clinical outcomes and obtain up-to-date radiographs. In total, 60 primary hips were implanted in 51 patients (35 female, 16 male) with nine bilateral cases. The mean age was 16.7 years (12 to 19) and mean follow-up was 9.3 years (2.3 to 16.8).

RESULTS

The most common indication for teenage hip arthroplasty was avascular necrosis secondary to slipped upper femoral epiphysis (31%; n = 16). Overall, 64% of patients (n = 33) had undergone multiple previous operations. The survival at follow-up was 97%; two patients required revision for aseptic loosening (one femoral stem, one acetabular component). Both patients had fused hips noted at the time of arthroplasty. A further two patients had radiolucent lines but were asymptomatic. At latest follow-up the mean Oxford Hip Score was 44 (31 to 48) and a Visual Analogue Scale measurement of 1.5, indicating satisfactory function.

CONCLUSION

Operating on this cohort can be complicated by multiple previous surgeries and distorted anatomy, which in some cases require custom-made prostheses. We have demonstrated a good outcome with low revision rate in this complex group of patients. Cite this article: Bone Joint J 2020;102-B(11):1491-1496.

Low back pain and radiographic severity as predictors in hip osteoarthritis patients receiving steroid injection therapy

INTRODUCTION

We investigated the effects of lower back pain (LBP) on measures of pain, disability, and function in highly symptomatic hip OA patients receiving intra-articular steroid injection (IASI) therapy. We also investigated the effect of radiographic severity of hip OA for comparison to LBP.

METHODS

97 consenting subjects with symptomatic hip OA presenting for IASI were evaluated at baseline, assessed over an 8-week period, and followed at least 1 year later for new arthroplasty. At baseline and 8 weeks follow-up patient demographics, presence/absence of back pain, physical function tests, a single anteroposterior pelvis x-ray, and subjective scores of pain, stiffness and function (VAS and WOMAC) were collected. We also followed which subjects proceeded to obtain total hip arthroplasty in the examined hip.

RESULTS

Cohorts with LBP reported significantly worse scores for all of VAS pain and WOMAC questionnaires but showed no difference in ROM and were not more likely to proceed to arthroplasty. Cohorts with severe radiographic OA had significantly worsened scores for stiffness (χ² = 6.74, p = 0.009), decreased ROM (p < 0.01), and were more likely to proceed to arthroplasty (χ² = 9.79, p = 0.044).

DISCUSSION

Back pain has a substantial effect on clinical parameters relevant to assessment of severity of hip OA, especially self-reported pain and function. This finding highlights LBP as a significant confounding factor in hip OA patient assessments and will inform future studies to determine the most effective treatment strategies for hip OA patients.

Total knee arthroplasty in patients with prior ipsilateral hip arthrodesis

Only a few articles based on the management of symptomatic knee osteoarthritis in patients with prior ipsilateral hip arthrodesis have been reported, and there are no clear criteria for the best treatment option [to carry out a total knee arthroplasty (TKA)-or to take down the hip fusion and conversion to a total hip arthroplasty-THA, and after that to carry out the TKA]. We report two cases, a 72-year-old male who underwent a left hip arthrodesis at 28 because of a trauma and a 51-year-old woman who underwent a left hip arthrodesis at 9 years because of a congenital dislocation. They presented severe ipsilateral symptomatic knee osteoarthritis. Once the cases were studied and the two therapeutic possibilities were evaluated, we decided to perform TKA. Currently, both patients have no pain, a stable knee with good range of motion and without aseptic loosening radiologic criteria.

The Choice Between Total Hip Arthroplasty and Arthrodesis in Adolescent Patients: A Survey of Orthopedic Surgeons

For adolescent patients with end-stage hip disease, the choice between total hip arthroplasty (THA) and arthrodesis is complex; the clinical evidence is not definitive, and there are difficult trade-offs between clear short-term benefits from THA and uncertain long-term risks. We surveyed nearly 700 members of the Pediatric Orthopedic Society of North America and the American Association of Hip and Knee Surgeons. Respondents chose between a recommendation of THA or arthrodesis in four clinical vignettes. A clear majority of surgeons recommended THA in two of the vignettes, however opinion was somewhat divided in one vignette (overweight adolescent) and deeply divided in another (adolescent destined for manual labor job). Across all vignettes, recommendations varied systematically according to surgeons' age and their attitudes regarding tradeoffs between life stages.

Hip arthrodesis with the anterolateral plate: an innovating technique for an orphaned procedure

BACKGROUND

In developing countries hip osteoarthritis constitutes a major public health issue as it is highly prevalent in all age ranges of population, including the young. It often remains untreated because of the low accessibility of total hip prostheses. Hip arthrodesis still represents a major treatment option, but, for several reasons which are discussed in this paper, is nowadays infrequently performed. By means of reporting the results of a new simple technique, using a self-devised plate, the relevancy of hip arthrodesis in this particular environment is emphasized.

METHODS AND FINDINGS

Our series included 35 patients with painful hip osteoarthritis who underwent a hip fusion with the anterolateral arthrodesis plate. Two of them had a concurrent femoral osteotomy for correction of a vicious position of the limb and another patient had a femoral diaphysis osteotomy and placement of a Wagner elongating device in order to proceed with a limb lengthening by callotasis. The follow-up period averaged 16,9 months (9 to 34). All hips, except two, achieved solid fusion between 6 and 15 months after surgery. One failure of fusion was in the oldest patient, who presented a loosening of plate and screws due to an advanced degree of osteoporosis; the other was in a young patient who admitted having walked on his leg too soon. Patient satisfaction was high. We concluded that this technique is reliable and effective.

CONCLUSIONS

The results of this study should convince the hesitant surgeon and patient to consider hip arthrodesis an acceptable treatment option for disabling hip arthritis, compared to no treatment at all.

Conversion of hip fusion to total hip replacement

Hip arthrodesis remains a viable surgical technique in well selected patients, typically the young manual labourer with isolated unilateral hip disease. Despite this, its popularity with patients and surgeons has decreased due to the evolution of hip replacement, and is seldom chosen by young adult patients today. The surgeon is more likely to encounter a patient who requests conversion to total hip replacement (THR). The most common indications are a painful pseudarthrosis, back pain, ipsilateral knee pain or contralateral hip pain. Occasionally the patient will request conversion because of difficulty with activities of daily living, body image and perceived cosmesis. The technique of conversion and a discussion of the results are presented.

Cite this article: Bone Joint J 2013;95-B, Supple A:114–19.

Arthrodesis of the hip and conversion to total hip arthroplasty: a systematic review

A systematic review of the literature was performed in order to evaluate the outcomes following arthrodesis of the hip and subsequent conversion to total hip arthroplasty. Eight studies regarding primary hip arthrodesis evaluating 249 hips revealed variable union rates (37.5%-100%) and patient satisfaction rates (69%-100%). Adjacent joint pain was commonly seen in the lower back (up to 75%) and ipsilateral knee (up to 57%) and complications were reported in 8.4%. Eleven studies regarding conversion arthroplasty evaluating 579 patients revealed inconsistent results regarding relief of pain. Complications were seen in up to 54%, most commonly due to mechanical failure, deep infection and nerve palsy. Whilst hip arthrodesis can provide pain relief and patient satisfaction, conversion arthroplasty is associated with an unacceptably high complication rate.

Gait findings in the adolescent subject with a stiff hip

BACKGROUND

Adolescent subjects with severe unilateral hip disease are often stiff and painful yet have limited surgical options. Although hip fusion has been used successfully to minimize pain, acquired gait compensations after arthrodesis are factors felt to lead to knee and back pain over time. However, these gait compensations may already be present in a person with a stiff hip. The purpose of this study was to describe the quantitative gait findings of the adolescent subject with a unilateral stiff hip and to determine whether these findings are similar to those of subjects presenting after arthrodesis.

METHODS

This study was a retrospective review of 6 subjects seen in a motion analysis laboratory between 2005 and 2009 (age 13 to 17 y). All adolescents had been referred to the motion analysis laboratory for a routine clinical gait study. Subjects were selected for this study based on kinematic sagittal plane hip motion found to be < 25 degrees (mean 16.2 degrees). Diagnoses included: Legg-Calvé-Perthes (3) and hip avascular necrosis (3).

RESULTS

Compared with laboratory-based normative data, the following findings were significant: increased arc of trunk and pelvic motion (sagittal, coronal); involved side--decreased arc of hip and knee motion (sagittal), decreased peak hip abduction in swing; contralateral side--increased arc of hip and knee motion (sagittal); and increased peak hip abduction in swing.

CONCLUSIONS

Gait compensations in multiple planes and joints were identified in adolescent subjects with a unilateral stiff hip. These compensations are necessary for these subjects to generate forward progression in gait and are similar to deviations found after hip arthrodesis. Subjects with a stiff hip may already be at risk to develop pain and/or arthrosis in adjacent motion segments due to these obligatory gait characteristics. Hip fusion may not increase these risks (in this patient population) since the compensations are already present and requisite, but may provide an opportunity to decrease pain and improve function.

LEVEL OF EVIDENCE

Level IV, Case Series.

Identification and treatment of infected total hip arthroplasty

Periprosthetic joint infection (PJI) in the hip following prosthetic joint placement is a devastating outcome of an otherwise often successful surgical treatment (total-hip arthroplasty). Management of PJI is dependent upon accurate diagnosis and successful treatment, both of which are challenging. Recently, great strides have been made in improving the diagnosis of PJI, which has no 'gold standard' diagnostic tool. Proper diagnosis is essential as untreated or undetected PJI can quickly lead to biofilm formation on the implant surface depending upon the infecting organism. Upon complete biofilm formation, successful treatment requires prosthetic resection with immediate or delayed reimplantation. Even with the most aggressive surgical treatment, PJI eradication currently has a success rate of approximately 80%. Unfortunately, technologies to improve the local delivery of antibiotics are not expected to be available in the near future.

Is total hip arthroplasty after hip arthrodesis as good as primary arthroplasty?

BACKGROUND

Conversion of hip arthrodesis to a THA reportedly provides a reasonable solution, improving function, reducing back and knee pain, and slowing degeneration of neighboring joints associated with a hip fusion. Patients generally are satisfied with conversion despite the fact that range of mobility, muscle strength, leg-length discrepancy (LLD), persistence of limp, and need for assistive walking aids generally are worse than those for conventional primary THA.

QUESTIONS/PURPOSES

We compared THA after hip arthrodesis and primary THA to determine whether these procedures would be associated with similar functional scores, maintenance of scores with time, complications and failures, survivorship of the arthroplasty, and patient satisfaction.

PATIENTS AND METHODS

We retrospectively matched 48 patients undergoing conversion of a fused hip to a THA between January 1980 and January 2000, with 50 patients receiving a primary THA during the same period. We prospectively followed all patients between January 2000 and January 2010. The changes in function and pain after THA were compared between the two cohorts using the Harris hip score (HHS) and the Rosser Index Matrix (RIM). The Oxford hip score (OHS) and the SF-36 also were used to assess quality of life (QOL) during followup. Complications were collected and survivorship of the THA was evaluated. Patient satisfaction was assessed using the Robertsson and Dunbar questionnaire. The minimum followup was 10 years (mean, 17 years; range, 10-29 years).

RESULTS

At last followup, hip function and health-related QOL were similar for patients having conversion of hip arthrodesis to THA and for patients having a routine THA. Scores diminished overall in the two groups between 2000 and 2010, but without a difference for the HHS, RIM QOL, and OHS in the study cohort. The rate of complications, THA survival, and patient satisfaction were similar in both groups.

CONCLUSIONS

Conversion of hip arthrodesis to a THA provides substantial improvement of hip function and health-related QOL, with an acceptable rate of complications, good expectancy of survival for the arthroplasty, and high level of patient satisfaction comparable to those of primary THA.

LEVEL OF EVIDENCE

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Total hip arthroplasty after hip joint ankylosis

BACKGROUND

Back pain and knee pain are typical secondary degeneration symptoms after hip ankylosis. Take down of hip ankylosis and implantation of a total hip arthroplasty (THA) is believed to be a promising treatment option.

METHODS

A total of 22 hip ankylosis patients [15 men, mean age 53.7 years (range 30-72 years); 7 women, mean age 50.8 years (range 42-61 years)] underwent THA during 1980-2000 after spontaneous (n = 10) or surgical (n = 12) fusion of the hip joint. The mean duration of ankylosis prior to THA was 32.5 years (range 2-61 years).

RESULTS

At the mean follow-up of 13.2 years (range 2-19 years), the Harris hip score averaged 84.9 points (range 70.1-99.0 points). All patients (100%) confirmed that they would undergo conversion surgery again. Aseptic loosening of two stems (one cemented, one cementless; 9.5%) and two deep infections (9.5%) required revision surgery.

CONCLUSIONS

THA is a promising option for treatment of secondary long-term hip ankylosis sequelae. A conversion operation after spontaneous ankylosis provides better functional outcome than after surgical fusion. However, full function with complete pain relief and a negative Trendelenburg sign might be not attainable in all cases.

The long-term fate of the hip arthrodesis: does it remain a valid procedure for selected cases in the 21st century?

Even in current orthopaedic practice, some cases are still not suitable candidates for hip replacement and hip fusion remains the only option in these highly selected patients. In this retrospective study we describe the long-term clinical outcome, quality of life and radiological evaluation of all adjacent joints in a cohort of 47 hip fusions. The main objective of our study was to show the long-term effects of a fusion. Thirty patients were analysed after an average of 18.2 years (range 6.2–30.5 years) with a mean SMFA of 31.2 (range 9–70). The VAS for pain for the fused hip was an average 1.9 (range 0–8), for the contralateral hip 2.0 (0–8), for the ipsilateral knee 2.0 (0–8), for the contralateral knee 1.8 (0–8) and for the lower back 3.6 (0–8). Average walking distance was 115 minutes (range 10–unlimited). Although the hip arthrodesis has lost popularity, it still is an option for the young patient with severe hip disorders, while leaving the possibility to perform a THA at a later stage. If the arthrodesis is performed with an optimal alignment of the leg, complaints from the adjacent joints are minimal, even in the long-term, and an acceptable quality of life can be obtained. We believe that in highly selected cases a hip fusion, even in current practice, is still a valid option.

Ergebnisse und Erfahrungen der Remobilisation von H�ftarthrodesen

INTRODUCTION

With the predictably good outcome of total hip arthroplasty today (THA), hip arthrodesis currently has limited indications. Over the long term, however, most patients develop secondary degenerative arthritis in the spine, contralateral hip, and ipsilateral knee due to overloading. The deteriorating condition of these joints eventually causes the onset of pain, which often requires conversion of a fused hip to a THA. The results and experiences of conversions of a hip arthrodesis into a THA are reported.

INTRODUCTION

Between 1 January 1985 and 31 December 2001 conversion of a previously performed arthrodesis of the hip to THA was carried out in a total of 45 patients; 34 patients could be followed up after the conversion to THA after a mean of 77.5 months (min.: 24, max.: 208). The primary indications for the conversion were low back pain (n=21) and ipsilateral knee pain (n=13).

RESULTS

The mean age at the time of THA was 75.3 years (min.: 32, max.: 74). The mean time interval between the arthrodesis and the conversion to THA was 30.4 years (min.: 5, max.: 66). Of 34 hips, 29 (85%) were either pain free or had minimal pain. Complications included one persisting sciatic nerve palsy, two superficial infections, two periprosthetic fractures, and two heterotopic ossifications IV degrees with one recurrence of ankylosis and one marked reduction of motion. Revision arthroplasty was performed in four hips. Postoperatively 7 patients showed no limping, 11 showed a slight limp, and 17 a pronounced limp. Recurrent dislocations occurred in one patient.

CONCLUSION

We conclude that this operation can lead to satisfactory results even after a long duration of the arthrodesis. There is a high rate of complications after conversion of a hip arthrodesis to a total hip arthroplasty. These issues must be carefully considered and discussed with the patient before any conversion procedure.

Historical review of cervical arthroplasty

Early attempts at spinal arthroplasty in the 1950s yielded limited success. A revival of this procedure occurred in the 1980s and became a realistic treatment option in the 1990s. Both lumbar and cervical arthroplasties have been introduced in the US since 2000 for randomized, prospective studies in accordance with the Food and Drug Administration (FDA) investigational device exemption provisions. In June 2004 the first lumbar arthroplasty device was approved by the FDA for use in the US. It is likely that cervical arthroplasty will soon follow and may be available for widespread use as early as 2006. In this paper the authors review the historical development of cervical arthroplasty.

Gait adaptations in patients with longstanding hip fusion

PURPOSE

To examine the long-term effects of hip arthrodesis in terms of gait adaptations.

METHODS

Motion analysis was performed on 9 patients who underwent unilateral hip arthrodesis between 1979 and 1991. A standard clinical gait analysis 3-dimensional model for the lower limb was used to calculate the effect of the fused hip on walking, compared with the contralateral normal hip.

RESULTS

Significant (p<0.05) gait adaptations noted in the fused side were, compensatory hip hiking during the swing-phase, a 24% reduction in hip adduction moment, a 37% decrease in genu-varus moment, 80% reduced hip power, and excessive pelvic tilt.

CONCLUSION

It appears that the excess pelvic tilt observed was to achieve relative hip extension via increased relative lumbar lordosis, while the decreased coronal plane moments of the hip and knee observed were to reduce joint loading on the affected side.

Hip arthrodesis: current indications and techniques

The management of young adults with severe osteoarthritis of the hip remains a problem because of the increased failure rates of total hip arthroplasty (THA) as well as the prospect of multiple revisions in this population. Although hip arthrodesis is not perceived favorably as an alternative by most orthopaedic surgeons or patients because of the presumption of less than optimal functional outcomes, it is a viable technique, especially for younger patients with a recent history of local infection and/or trauma. With current internal fixation techniques, a fusion rate >80% can be achieved with maximal preservation of bone stock. Proper patient selection and optimal arthrodesis position (flexion of 20 degrees to 30 degrees, adduction of 5 degrees, external rotation of 5 degrees to 10 degrees, and limb-length discrepancy <2 cm) are essential for a successful, long-term result. Back and ipsilateral knee pain are the most common complaints leading to secondary conversion of a hip fusion to a THA. Symptoms improve markedly after conversion. Survivorship of the conversion THA is comparable to that of a primary THA when the patient is older than 50 years of age and multiple surgical procedures have been avoided. However, the procedure can be technically challenging and has a high risk of postoperative complications.

Hip and knee replacement after longstanding hip arthrodesis

This study determined whether patients with severe knee disease below a hip arthrodesis can be treated successfully with total knee replacement alone or whether such patients require total hip arthroplasty followed by knee replacement. Eighteen patients who had hip arthrodesis for a mean of 33 years underwent total hip replacement alone, total knee replacement alone, or a combination of both. The Harris hip score improved from a mean of 55.3 to a mean of 86.9 points at 45 months after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 33 to a mean of 78 points in patients who had total knee replacement after total hip arthroplasty. The Hospital for Special Surgery knee score improved from a mean of 35 to a mean of 44 points in patients having total knee replacement alone below a hip arthrodesis. The followup after total knee replacement averaged 53 months. These data suggest that a knee replacement alone in a patient with a fused hip is unlikely to provide a satisfactory result. Patients with severe knee disease below hip arthrodesis require total hip arthroplasty followed by knee replacement. This applies even when severe osteoarthritis of the knee is the primary complaint.

Arthrodesis of the hip joint using an external fixator

Arthrodesis of the hip has been plagued by high rates of nonunion, and by complications associated with prolonged cast immobilization. To prevent these problems, we devised a procedure for hip arthrodesis using an external fixator in combination with internal fixation at the fusion site. We have treated nine patients with this technique. All of the arthrodeses were solidly united without wound infections at the most recent follow-up. Patients were able to leave their hospital bed and walk on the affected limb with a cane shortly after surgery. This was possible because the external fixator was low in profile, as it was applied from the anterosuperior iliac spine to the femoral shaft, and provided rigid stabilization of the arthrodesis. The technique resulted in a reduction in the period of bed rest, immediate postoperative mobilization, shorter periods of hospitalization, no limitation in the range of knee and ankle motion, improvement in the patient's ability to carry out the personal hygiene, and fewer complications.

Hip fusion through an anterior approach with the use of a ventral plate

A new technique to achieve a reliable fusion of the hip joint through an anterior approach with use of a ventral low contact dynamic compression plate and a lateral 6.5 mm lag screw is presented in detail. The advantages of this technique are that the approach does not jeopardize the vascularity of the femoral head, that the fixation on the pelvic side uses the strong bone stock of the sciatic buttress, and that the hip abductor muscles and greater trochanter are preserved. The authors also present the indications and the results of their experience with 12 patients. The followup period averaged 24.8 months (range, 10-42 months). Ten patients (83%) achieved a solid fusion by radiologic and clinical criteria. Although a moderately symptomatic nonunion developed in 1 patient, another patient went on to a painful nonunion to whom another attempt for fusion has been recommended. According to the hip score of Merle d'Aubigné and Postel, the average figures for pain and ambulation increased from 3.2 points to 5.0 points and from 2.7 points to 4.5 points, respectively, after surgery. Six of the 12 patients regained the ability to work in their former jobs or in new occupations. Eight patients felt no or minor restrictions in doing their former sports activities. Patient satisfaction was high with a majority reporting minor discomfort mainly around the fused hip.

Hip fusion in young adults

Hip arthrodesis remains an option for treatment of severe arthritis in young persons resulting primarily from osteonecrosis, congenital dysplasia, and joint sepsis. The authors reviewed six patients who underwent fusions as young adults (average age: 30.8 years) with an average follow-up period of 11.7 years. Solid arthrodesis without infection was noted in all cases. Patients who worked returned to prior employment without limitation. All patients complained of symptomatic low back pain and felt ambulation was limited by ipsilateral knee pain. Five of six noted impaired sexual function; although childbearing was not affected in one case. Four of six were satisfied with the operation, but only three of six would undergo it again given the alternative of total joint arthroplasty.

Intermediate follow-up of a simple method of hip arthrodesis in adolescent patients

Thirteen male patients (average age, 15.6 years) underwent intraarticular hip arthrodesis for unilateral disabling hip disease. Follow-up averaged 6.6 years. Seven patients had excellent or good Harris hip scores. Ten patients had low back pain, and seven patients had knee pain on the side of the fused hip. Limb-length discrepancy averaged 3.7 cm. A progressive hip adduction drift (average, 7 degrees) occurred during follow-up. Patients whose hips were fused in a position of 20-25 degrees flexion and whose limb-length discrepancies were < 2 cm had significantly lower incidences of back pain. Cybex muscle testing revealed significantly decreased quadriceps strength (29%) on the hip-fusion side. Gait laboratory analysis demonstrated decreased velocity, stride length, and cadence. There were two mildly symptomatic nonunions. Based on these results, we recommend that the hip fusion be positioned in 20 degrees flexion and 0 degree abduction. The joint must be completely debrided down to viable bone to maximize chances for union. Maintaining a limb-length discrepancy of < 2 cm is essential to minimize the incidence of low back pain, quadriceps deficiency, and abnormal gait parameters.