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

Functional Improvement and Patient Satisfaction Following Conversion of Fused Hip to Total Hip Arthroplasty

BACKGROUND

This study aimed to determine the clinical outcomes, predictors of suboptimal functional improvement, and factors influencing patient satisfaction following conversion of a fused hip to total hip arthroplasty (THA).

METHODS

A retrospective analysis of clinical and radiographic data was performed on 83 patients (83 hips) who underwent fused hip conversion to THA. Implant survival and predictors of poor functional outcome (Harris hip score < 70) were analyzed. In addition, factors associated with patient dissatisfaction (visual analog scale < 25th percentile) were analyzed in 63 patients (63 hips) who completed a patient-reported outcome measures questionnaire.

RESULTS

The median Harris hip score improved from 55 (range, 18 to 77) to 78 (range, 36 to 100) at a mean follow-up of 10.2 ± 4.8 years (P < .001). Implant survival was 97.4% at 10 years and 91.3% at 20 years, with any revision as the endpoint. Multivariate analysis identified preoperative reliance on mobility aids as an independent predictor of poor functional outcome (P = .021). There were 48 of 63 patients (76%) satisfied (satisfaction visual analog scale ≥80) with the operated hip. Demographics and preoperative/postoperative clinical data did not differ between satisfied and unsatisfied patients. Among the patient-reported outcome measures, the Forgotten Joint Score-12 emerged as an independent discriminator of patient satisfaction.

CONCLUSIONS

Conversion of a fused hip to THA provides functional improvement, favorable implant survival, and high patient satisfaction. However, patients dependent on mobility aids may experience suboptimal functional recovery, underscoring the need for careful preoperative counseling and patient selection.

Long-term outcomes of converting fused hips to total hip arthroplasty are satisfactory: a systematic review and meta-analysis

Background

Although conversion arthroplasty of fused hips can relieve pain and provide patient satisfaction, long-term outcomes of total hip arthroplasty (THA) after hip fusion remain a subject of debate. This meta-analysis aimed to assess the effectiveness of THA for fused hips over a long period with concerns over potential complications.

Methods

A systematic search of five databases from 2000 until 2023 identified English studies evaluating THA for fused hips with at least 100 months of follow-up. Meta-analyses were conducted using random-effect models via the comprehensive meta-analysis software. Sensitivity analysis, in-depth meta-regression, Egger's test, and the trim-and-fill method were performed appropriately.

Results

The meta-analysis assessed 790 patients and 889 hips with a mean follow-up of 11 years. At the final follow-up, the mean Harris Hip Score (HHS) and leg length discrepancy (LLD) improved by 34.755 and 2.3 cm from the baseline, respectively. Regarding survival of hip fusion conversion to THA, most studies (88.8%) reported a 5-year implant survival rate of at least 90%, and the 15-year and 20-year implant survival rates, ranged between 80-90% and 70-90%, respectively. Subjective dissatisfaction with the conversion of hip fusion to THA was only 5.3%. Composite rates of revision, instability, and aseptic loosening were 13.6%, 3.8%, and 8.8%, respectively.

Conclusions

Conversion of fused hips to THA results in favourable long-term outcomes regarding HHS, LLD, survival rates, and subjective satisfaction, leading to improved quality of life in properly selected patients. However, the presence of complications should be considered when evaluating the overall success of the procedure.

Hip arthrodesis conversion to dual mobility total hip arthroplasty in a young adult using a custom-made highly-porous titanium monobloc cup: A case report

INTRODUCTION

Conversion of hip arthrodesis to total hip arthroplasty (THA) is an effective but challenging procedure to restore hip functionality and improve quality of life. Herein, a case of arthrodesis takedown to a dual mobility THA with a custom-made 3D-printed cup.

PRESENTATION OF CASE

Due to higher risk of instability and loosening for the altered and atrophic anatomy, a custom-made highly-porous titanium dual mobility monobloc cup has been used for a cementless conversion THA in 31-year-old patient with hip arthrodesis. At 3-year follow-up clinical and radiographic results were excellent with the custom-made implant found stable and well osseointegrated.

DISCUSSION

To the best of our knowledge, this is the first case of arthrodesis conversion to THA with custom-made highly-porous dual mobility cup in a young adult. The dual mobility construct helped reducing the risk of dislocation, while the highly-porous structure reduced the risk of aseptic loosening.

CONCLUSION

The use of cementless highly-porous dual mobility implant in complex cases young patients is supported.

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.

Conversion of a Fused or Ankylosed Hip to Total Hip Arthroplasty: Is the Direct Anterior Approach in the Lateral Decubitus Position an Ideal Solution?

Background

Total hip arthroplasty (THA) using the direct anterior approach (DAA) is becoming increasingly popular due to its potential benefits over the posterolateral approach (PLA). However, few studies have compared the efficacies of these two surgical approaches in hip fusion treatment. This study compared early clinical direct anterior and posterolateral THA outcomes in hip fusion treatment.

Methods

Here, 127 hips (65 DAA, 62 PLA) were retrospectively evaluated. Early postoperative functional outcomes of DAA and PLA groups were assessed using Harris score and Oxford Hip Score (OHS) and standard anteroposterior hip radiographs. Surgical characteristics, perioperative results, and complications within 6 months postoperatively were recorded.

Results

Though baseline values were similar, Harris and OHS scores were better in the DAA group than in the PLA group at 1 and 3 months postoperatively. The average cup anteversion angle was significantly greater in the DAA group than in the PLA group (12.7° vs. 11.1°). More hips undergoing DAA were successfully orientated in both inclination and anteversion angles (46 vs. 32). Early postoperative hip function predictors were preoperative fused hip position, surgical approach, and range of motion. DAA was associated with reduced postoperative blood loss and shorter hospital stays. Furthermore, 14 vs. 8 complications occurred in the DAA vs. PLA group. Lateral femoral cutaneous nerve injuries were observed in eight hips (12.3%) of the DAA group.

Conclusion

For fused or ankylosed hips, THA using DAA in the lateral decubitus position may result in excellent prosthesis positioning and faster postoperative recovery throughout early follow-up vs. PLA.

Use of Imageless Navigation in the Conversion of Hip Fusion to Total Hip Arthroplasty

Conversion of hip arthrodesis to total hip arthroplasty is associated with significant challenges, including accurate restoration of leg length and proper orientation of the acetabular component. Computer-assisted navigation provides real-time data on these parameters that may be a useful augment during hip fusion takedown surgery. Here, we present the case of a 64-year-old woman who presented with symptoms related to a left hip arthrodesis. The patient underwent a left-sided hip arthrodesis takedown and conversion to a total hip arthroplasty (THA). Due to the altered anatomical architecture of the fused hip, imageless navigation was used to assist with the conversion to THA. This case demonstrates that in complex hip arthroplasty procedures, where anatomical morphology is altered, navigation technology can be beneficial in addressing the challenges of achieving optimal placement of acetabular components and establishing appropriate leg length and offset.

Review of complications, functional outcome, and long-term survival following conversion of hip fusion to total hip arthroplasty

AIMS

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

METHODS

A total of 39 hip fusion conversions to THA were undertaken in 38 patients by a single surgeon employing a consistent surgical technique and uncemented implants. Parameters assessed included Harris Hip Score (HHS) for function, range of motion (ROM), leg length discrepancy (LLD), satisfaction, and use of walking aid. Radiographs were reviewed for loosening, subsidence, and heterotopic ossification (HO). Postoperative complications and implant survival were assessed.

RESULTS

At mean 12.2 years (2 to 24) follow-up, HHS improved from mean 34.2 (20.8 to 60.5) to 75 (53.6 to 94.0; p < 0.001). Mean postoperative ROM was flexion 77° (50° to 95°), abduction 30° (10° to 40°), adduction 20° (5° to 25°), internal rotation 18° (2° to 30°), and external rotation 17° (5° to 30°). LLD improved from mean -3.36 cm (0 to 8) to postoperative mean -1.14 cm (0 to 4; p < 0.001). Postoperatively, 26 patients (68.4%) required the use of a walking aid. Complications included one (2.5%) dislocation, two (5.1%) partial sciatic nerve injuries, one (2.5%) deep periprosthetic joint infection, two instances of (5.1%) acetabular component aseptic loosening, two (5.1%) periprosthetic fractures, and ten instances of HO (40%), of which three (7.7%) were functionally limiting and required excision. Kaplan-Meier Survival was 97.1% (95% confidence interval (CI) 91.4% to 100%) at ten years and 88.2% (95% CI 70.96 to 100) at 15 years with implant revision for aseptic loosening as endpoint and 81.7% (95% CI 70.9% to 98.0%) at ten years and 74.2% (95% CI 55.6 to 92.8) at 15 years follow-up with implant revision for all cause failure as endpoint.

CONCLUSION

The use of an optimal and consistent surgical technique and cementless implants can result in significant functional improvement, low complication rates, long-term implant survival, and high patient satisfaction following conversion of hip fusion to THA. The possibility of requiring a walking aid should be discussed with the patient before surgery. Cite this article: Bone Joint J 2021;103-B(7 Supple B):129-134.

Conversion of Hip Arthrodesis Using Robotic Arm Technology

Recent advancements in computer-assisted surgery have led to a renewed interest in robotic-assisted hip arthroplasty. This technology assists with component position which is especially useful in prior trauma or dysplasia cases. We present a case of a surgical hip fusion conversion to total hip arthroplasty with the use of robotic-assisted technology. Enhanced preoperative planning with the ability to manipulate implant position before execution can be invaluable during complex procedures. Further research is warranted before revision cases using computerized navigation systems becomes more prevalent.

Conversion of Fused Hip to Total Hip Arthroplasty: Long-Term Clinical and Radiological Outcomes

BACKGROUND

Despite promising results at the mid-term followup, several aspects of conversion of the fused hip to total hip arthroplasty (THA) remain controversial. The aim of this study was to evaluate clinical and radiological outcomes with a minimum 5-year followup in patients who underwent conversion of the fused hip to THA.

METHODS

Fifty-seven patients (59 hips) were evaluated. The Harris Hip Score (HHS), range of motion (ROM), and the Visual Analogue Scale (VAS) were used to assess hip function and low back pain. Subjective satisfaction with surgery and the presence of the Trendelenburg sign was also evaluated. Radiological assessment was performed pre- and postoperatively to evaluate loosening and heterotopic ossification (HO).

RESULTS

After a mean followup of 13.0 ± 6.2 years, HHS and VAS significantly improved from 46.0 ± 16.7 to 80.8 ± 18.8 and from 4.4 ± 1.5 to 2.1 ± 1.4 (both P < .001), respectively. Twenty-three patients (40.4%) had a positive Trendelenburg sign, and HOs were found in 29 cases (49.1%). An overall 29.8% complication rate was noted. Smoking habits and rheumatoid arthritis were predictive of Trendelenburg sign (P = .046 and P = .038, respectively). Implant survival rate as the end point was 98.7 ± 1.3% at 5 years, 92.4 ± 3.3% at 10 years, 82.1 ± 5.7% at 15 years, and 73.4 ± 8.0% at 20 and 25 years. A worse cumulative implant survival rate was noted in patients who underwent previous hip surgery, defined as any hip operation before fusion (P = .005).

CONCLUSION

Conversion of the fused hip to hip arthroplasty provides high levels of hip functionality and satisfaction with surgery at long-term followup. An implant survival rate higher than 70% can be expected 25 years postoperatively.

Patient-reported outcomes following primary total hip arthroplasty in Crowe type III or IV developmental dysplasia are comparable to those in Crowe type I: a case-control study of 96 hips with intermediate-term follow-up

BACKGROUND

A few previous studies have investigated patient satisfaction after total hip arthroplasty (THA) according to the degree of pelvic deformity. This study compared patient-reported outcomes after primary THA for Crowe types III, IV and I dysplasia.

METHODS

This retrospective, single-center, single-surgeon case-control study included patients who underwent primary THA between 2008 and 2016. We sent postal questionnaires to 38 patients with Crowe type III and IV dysplasia. Among the questionnaire respondents, 23 patients, excluding those with a follow-up period of < 1 year, were enrolled as the H group. The control group included 46 patients with Crowe type I, matched for sex, age, body mass index and surgical approach. To investigate the influence of femoral shortening osteotomy, the H group was divided according to whether femoral shortening osteotomy was performed. Ten patients underwent THA with femoral shortening osteotomy (FO group), while 12 patients underwent THA without femoral shortening osteotomy (N-FO group). Patient demographics, mean follow-up period, surgical information, pre- and postoperative leg length discrepancy (LLD), and perioperative complications were investigated. Clinical evaluations were performed using the Japanese Orthopaedic Association (JOA) scores, 36-item short-form survey (SF-36), net promotor score (NPS), visual analogue scale (VAS), and questionnaires. The VAS and SF-36 scores were determined only at final follow-up.

RESULTS

The H and control groups were not significantly different in the postoperative JOA scores and SF-36. In the H group, VAS at the final follow-up was significantly higher, and significantly more patients felt that postoperative rehabilitation was serious, expressing that they underwent THA for LLD correction. In addition, the VAS scores in the FO group was higher than those in the N-FO group. Postoperative LLD was significantly greater in the H group than in the control group. Each group had an NPS of > 50.

CONCLUSION

The postoperative VAS score was higher in Crowe type III and IV dysplasia than in Crowe type I dysplasia, but no significant differences were detected in the postoperative satisfaction, JOA score, and SF-36 score. These findings may help explain the effects of THA preoperatively to patients with Crowe type III and IV dysplasia.

LEVEL OF EVIDENCE

Therapeutic Level 3b.

Total Hip Arthroplasty for Ankylosis Requiring Rotational Rectus Femoris Flap and Skin Graft for Wound Closure

We present a case report of a 51-year-old Ghanaian immigrant who underwent total hip arthroplasty in the setting of spontaneous ankylosis of unknown etiology. The increase in offset of the patient's limb through reconstruction, in combination with severe soft-tissue atrophy of the lower extremity, resulted in a soft-tissue defect that could not be closed primarily. This ultimately required a rectus femoris rotational flap and skin grafting for coverage. We describe the surgical technique used for conversion of an ankylosed hip to total hip arthroplasty, as well as the technique for management of a large proximal thigh soft-tissue defect with rectus femoris muscle flap coverage.

Long-term results of cementless total hip arthroplasty for the treatment of ankylosed hip

PURPOSE

The purpose of this study was to report the long-term results of total hip arthroplasty (THA) for the treatment of ankylosed hip.

METHODS

Twenty-nine consecutive THAs were performed in 26 patients. The mean age of the patients at the time of the operation was 43.3 years (range, 19-69 years). We used cementless fixation in all hips and the mean duration of follow-up was 10.1 years (range, 4.5-20 years). Radiological evaluation of components, osteolysis, radiolucent lines and loosening were assessed. The Harris Hip Score (HHS), range of motion (ROM), limb-length discrepancy and walking capacity with or without any support were used preoperatively and at final follow-up for clinical evaluation. Survivorship analysis was conducted using the Kaplan-Meier method using second revision for any reason as the endpoint.

RESULTS

The mean HHS was 85.6 (range, 55-98) points and mean ROM was 110.5° for flexion. The mean limb-length discrepancy improved from 4.1 cm to 1.1 cm. Positive Trendelenburg sign was recorded in 31% of the patients and 24% of patients needed any support for walking postoperatively. We observed surgical complications related to abductor arm in 25% of the patients. Radiolucency on the acetabular side was seen on one or more zones in 15 patients (16 hips). One aseptic acetabular component loosening was observed. On the femoral side, 11 patients demonstrated non-progressive radiolucent lines and osteolysis around the stem was seen in four hips but there was no aseptic stem loosening. The Kaplan-Meier survival rate considering revision for any reason as the endpoint was 81.5%, for aseptic loosening 91.3%, for a worst-case scenario of 66.4% at 10 years.

CONCLUSION

Cementless fixation showed good to excellent results at 10 years. Preoperative and postoperative abductor status of the patient is critical for patient satisfaction.

Hip-Spine Syndrome: The Coronal Alignment of the Lumbar Spine and Pelvis in Patients with Ankylosed Hips

Introduction

Fixed abduction and/or adduction deformities of the hip joint may cause pelvic obliquity with subsequent development of secondary lumbar scoliosis. However, the relationships between the magnitude of a fixed angle (either abduction or adduction) of the hip and the direction of pelvic tilt and lumbar scoliosis remain unclear. The purpose of this study was to investigate the coronal alignment of the lumbar spine and pelvis in patients with ankylosed hips.

Methods

A total of 56 patients were analyzed, including 17 males and 39 females, with an average age of 65 years (range: 45 to 80 years). Regarding the coronal spinopelvic alignment, the following parameters were measured: the degree of lumbar scoliosis (LS; Cobb angle), pelvic obliquity (PO), and ankylosed hip angle (AHA). The PO and AHA were defined as the angle between the inter-teardrop line and a horizontal line, respectively, and the long axis of the femur on the side of the ankylosed hip. For each parameter, correlations between the parameters were evaluated using a regression analysis. A P value of <0.05 was considered significant.

Results

Positive linear correlations were observed between the AHA and direction of the PO angles (r = 0.831, p<0.01), the AHA and direction of the LS angles (r = 0.770, p<0.01), and the directions of the PO and LS angles (r = 0.832, p<0.01).

Conclusions

This study provides evidence to suggest that, in patients with ankylosed hips, the abduction position is positively correlated with the downward PO and the convexity of the LS toward the AH side. In contrast, the adduction position is positively correlated with these results on the opposite side.

Risk Factors and Treatment Options for Failure of a Two-Stage Exchange

PURPOSE OF REVIEW

Although a two-stage exchange revision is reported to have a high success rate, this strategy may fail as a treatment for prosthetic joint infection (PJI). When it does, resection arthroplasty, arthrodesis, amputation, and chronic antibiotic suppression may play a role. The purpose of this review is to determine which are the main risk factors for a two-stage exchange failure and to analyze the indications and results of resection arthroplasty, arthrodesis, amputation, and antibiotic chronic suppression for PJI.

RECENT FINDINGS

Recent literature demonstrates that the main risk factors for a two-stage exchange failure are as follows: hemodialysis, obesity, multiple previous procedures, diabetes mellitus, corticosteroid therapy, hypoalbuminemia, immunosuppression, rheumatological conditions, coagulation disorders, and infection due to multidrug-resistant (MDR) bacteria or fungal species. Regarding microorganisms, besides Staphylococcus aureus, Streptococcus spp., Enterobacteriaceae species such as Klebsiella pneumoniae and Enterobacter sp., Pseudomonas aeruginosa, or Acinetobacter baumannii, and fungus including Candida sp. are also considered risk factors for a two-stage exchange failure. Resection arthroplasty, arthrodesis, and amputation have a limited role. Chronic suppression is an option for high-risk patients or unfeasible reconstruction. In summary, we report the main risk factors for a two-stage exchange failure and alternative procedures when it occurs. Future research on patient-specific risk factors for a two-stage exchange may aid surgical decision-making and optimization of outcomes.

Total hip arthroplasty following arthrodesis: a single-center experience of 17 patients

Purpose

We aimed to present our experience with total hip arthroplasty in patients with previous hip arthrodesis.

Patients and methods

This was a retrospective study, in which clinical and radiological outcomes of total hip arthroplasty performed in 17 patients (mean age 54.2±8.5 years; age range 33–68 years; female to male ratio 10/7) with previous arthrodesis in our clinic between 2001 and 2014 were reviewed. Patients were followed up for 6.7±2.8 years (range 3–12 years) after the operation and evaluated for ipsilateral knee pain, range of motion, walking capacity, and leg-length discrepancy. The clinical outcome was assessed by the Harris Hip Score.

Results

The outcome of arthroplasty was good or excellent in 14 of 17 patients (82.3%), fair in two patients (11.8%), and failure in one patient (5.9%). The Harris Hip Score increased to 79.8±9.8 postoperatively from a preoperative score of 40.9±10.1 (p<0.01). Pain-free hip was obtained in 15 patients (88.2%), and range of motion was 88°. Fourteen patients (82.4%) reported a significant decrease in back pain, and 11 patients (64.7%) in ipsilateral knee pain. Ten patients (58.8%) were able to walk normally, five patients (29.4%) walked with slight Trendelenburg gait without support, and two patients (11.8%) with severe Trendelenburg gait using arm rests. The mean leg-length discrepancy was 1.1 cm (range 0–3 cm). The complications were peroneal nerve palsy (n=3), superficial wound infection (n=3), hip dislocation (n=2), and heterotopic ossification (n=3).

Conclusion

If it is well planned, conversion of hip arthrodesis to total hip arthroplasty is a successful and safe procedure, which increases patients’ functionality.

Long-term results of custom cementless-stem total hip arthroplasty performed in hip fusion

INTRODUCTION

Due to complex anatomical considerations, results of cementless-stem total hip arthroplasty (THA) in hip fusion remain controversial compared with conventional THA. We therefore aimed to analyse 3D anatomy of the fused hip based on pre-operative computed tomography (CT) scans, functional outcomes based on the Harris Hip Score (HHS) and the Hip Disability and Osteoarthritis Outcome Score (HOOS), modifications of hip anatomy based on post-operative standardised radiography, and determine complication rate and long-term survival based on Kaplan-Meier analysis.

METHODS

We retrospectively studied 23 hips that underwent conversion of a fused hip to THA using a 3D CT scan-based custom titanium (Ti alloy hypoxyapetite (HA)-coated stem. The mean follow-up was 15 (9-22) years. Femur anteversion ranged from -29° to 80°.

RESULTS

HHS improved from 59 to 89 points and average range of motion (ROM) was 88° for flexion. Back pain decreased in 62%, and knee pain decreased in 42%. The mean post-operative leg-length discrepancy was 7.8 mm. No intra-operative complications occurred. One aseptic stem loosening for mechanical failure was observed. The Kaplan-Meier survivorship considering revision for any reasons as the end point was 95.6% [95% confidence interval (CI) 92.4-98.8] at 15 years.

CONCLUSION

Custom cementless stems may be an interesting solution to address the particular anatomical features of hip fusion at the time of THA, with an excellent survival rate at 15 years.

Hip fusion takedown to a total hip arthroplasty-is it worth it? A systematic review

INTRODUCTION

Patients with surgically or spontaneously fused hips are often dissatisfied with their overall function and the debilitating effect on adjacent joints. Therefore, in properly selected patients, hip fusion-takedown and conversion to total hip arthroplasty (THA) can result in improved function and decreased pain. We aimed to (1) evaluate the indications for conversion, (2) evaluate the clinical outcomes, (3) analyze the overall complications, and (4) identify the overall satisfaction following the procedure.

METHODS

A systematic and comprehensive literature search was performed to analyze studies evaluating conversion of hip fusion to THA. After reviewing 3,882 studies, 27 total studies (1,104 hips) met our inclusion/exclusion criteria and were included in our final analysis. A weighted mean of rates was determined for each complication, including infection, instability, loosening, nerve-related, abductor-related, venous thrombotic event, and revision.

RESULTS

The study population consisted of 53.2% male and 46.8% female subjects. The mean age at time of conversion was 52 years (range 36-65 years), the mean time until follow-up was 9.2 years (range 2.5-17.3), and the mean duration of arthrodesis was 27.7 years (range 11-40.2). As measured by Harris Hip Score, overall clinical outcomes improved from 58.1 points (range 42.4-70 points) pre-operatively to 80.0 (range 62-93.5) post-operatively. The specific complication rates were 5.3% (range 0-43.6%) for infection, 2.6% (range 0-15.4%) for instability, 6.2% (range 0-17.2%) for loosening, 4.7% (range 0-13%) for nerve-related complications, 13.1% (range 0-87%) for abductor-related complications, and 1.2% (range 0-13%) for venous thrombotic events. The revision rate was 12.0% (range 0-43.6%).

CONCLUSION

Takedown of a fused-hip can be a challenging procedure. Although patients can benefit functionally, both patients and surgeons need to be aware of the complications and increased risk of further revision procedures, which should be an important part of the pre-operative discussion.

Conversion of hip fusion to total hip arthroplasty: clinical, radiological outcomes and complications in 40 hips

OBJECTIVE

The purpose of this retrospective study is to report the clinical and radiological outcome of total hip arthroplasty in patients with previous hip arthrodesis.

PATIENTS AND METHODS

We retrospectively reviewed 28 (40 hips) prospectively followed patients in whom ankylosed hips were converted to total hip arthroplasty (THA) between 2010 and 2014 in our institution. The average age at the time of the conversion operation was 40.8 ± 9.8 years (range 24-62). The ankylosis had lasted 20.4 ± 13.0 years (range 3-56) before conversion surgery. The etiology of the ankylosis was septic arthritis in 10 (25%), post-traumatic hip osteoarthritis in 8 (20%), developmental hip dysplasia in 6 (15%), rheumatoid arthritis in 6 (15%), primary osteoarthritis in 5 (12.5%) and ankylosing spondylitis in 5 (12.5%) hips. The indications for arthroplasty were intractable low back pain in 14 (50%), hip pain in 24 (85.7%), and ipsilateral knee pain in 19 (67.8%) patients. Harris Hip Score (HHS) was used to rate the clinical results before and after the surgery. Radiographic evaluations included component malposition and loosening. All complications during the study period were recorded.

RESULTS

The mean follow-up period was 39.9 ± 10.6 months (range 24-60). The mean preoperative HHS was 33.3 ± 8.6 (range 18-50) and the mean HHS at the final follow-up was 74.9 ± 8.6 (range 52-97). There was a statistically significant increase in HHS (p = 0.0001). HHS was excellent in 1, good in 6, fair in 14 and poor in 7 patients. Increase in HHS was lower than 20 points in one patient (18 points), and one patient required two-staged exchange procedure due to deep infection. Thus, according to our success criteria (increase in HHS more than 20 points, radiographically stable implant, and no further surgical reconstruction), 92.8% (26/28) of patients had benefit from the surgery. Trendelenburg sign was positive in 12 hips. There was limb length inequality in 11 patients (mean 0.5 cm, range 1-3 cm). No patients had heterotopic ossification, sciatic nerve palsy or dislocation. There were five intra-operative fractures of the greater trochanter that were treated with cable wiring. One patient had trochanteric avulsion injury and was treated with trochanteric grip and cables. One patient (2.5%) had deep infection one year after the conversion THA and was treated with two-staged exchange procedure.

CONCLUSION

Conversion hip arthroplasty is an effective treatment method which provides functional recovery and patient satisfaction. However, a proper surgical technique and planning is necessary to minimize the complications.

Modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov external fixator as a salvage method in the management of severely infected total hip replacement

BACKGROUND

Resection arthroplasty or hip arthrodesis after total hip replacement (THR) can be used to salvage the limb in case with deep infection and severe bone loss. The Ilizarov fixator provides stability, axial correction, weight-bearing and good fusion rates.

MATERIALS AND METHODS

We retrospectively assessed the outcomes of 37 patients with severe periprosthetic infection after THR treated between 1999 and 2011. The treatment included implant removal, debridement and a modified Girdestone arthroplasty (29 cases) or hip arthrodesis (seven cases) using the Ilizarov fixator. The Ilizarov fixation continued from 45 to 50 days in the modified arthroplasty group and 90 days in the arthrodesis group. One case was treated using the conventional resection arthroplasty bilaterally.

RESULTS

Eighteen months after treatment, infection control was seen in 97.3% cases. Six hips were fused as one patient died in this group. Limb length discrepancy (LLD) averaged 5.5 cm. The Harris hip score ranged from 35 to 92 points. Hip joint motion ranged from 10° to 30° in the modified arthroplasty group. All subjects could walk independently or using support aids. No subluxation or LLD progression was observed.

CONCLUSION

The modified Girdlestone arthroplasty and hip arthrodesis using the Ilizarov apparatus results in sufficient ability for ambulation and good infection control in cases of failed THR associated with severe infection.

Anterior approach for total hip arthroplasty conversion of hip fusion

PURPOSE

Hip fusion conversion has shown mixed results, in particular a higher rate of failure than primary total hip replacement. Conversion is usually carried out by a lateral approach.

METHODS

We reported a series of 37 hip fusion conversions performed by an anterior approach. Clinical and radiographic outcomes of this unusual approach were reported at eight years of follow up.

RESULTS

At eight years of follow up, survivorship was 86. 6 % (IC 95 %: 62.4-95.7 %). Sixteen patients reported good relief of the pre-operative back spine or knee pain. PMA score was significantly improved. Two implant aseptic loosenings needing revision surgery were reported.

CONCLUSION

The anterior approach seemed to be as good as the other hip approaches for hip fusion conversion to total hip replacement.

A Report on Three Consecutive Cases using Computer Tomography 3D Preoperative Planning for Conversion of Arthrodesed Hips to Total Hip Replacements

BACKGROUND

Conversion of an arthrodesed hip to a total hip arthroplasty (THA) is a technically demanding procedure with high complication rates. One important issue is that determining the amount of correction for a leg length discrepancy (LLD) can be difficult at the planning stage.

QUESTIONS/PURPOSES

The aim of this study is to assess the reliable use of computer tomography (CT)-based three-dimensional (3D) preoperative planning for the conversion of arthrodesed hips to THAs.

PATIENTS AND METHODS

CT-based preoperative 3D planning was used to convert three arthrodesed hips to THAs. The efficacy of the planning was evaluated with postoperative radiographic measurements involving the amount of correction for LLD, position of components, difference between targeted and actual values, and ratio of the moment arms. The clinical assessment was performed with the Japanese Orthopaedic Association (JOA) hip score before and after THA.

RESULTS

The mean amount of LLD correction and median LLD after THA were 16 mm (range, 15-17 mm) and 4 mm (range, 1-10 mm), respectively. The components were implanted close to the positions recommended by the preoperative simulation. The ratio of the moment arms indicated that the converted hips were reconstructed in a biomechanically correct manner. The implants for the conversion to THA were successfully positioned with respect to anatomy and functional outcome. The median JOA hip score improved from 50 points (range, 30-66 points) preoperatively to 79 points (range, 72-86 points) at the latest follow-up.

CONCLUSIONS

CT-based preoperative 3D planning could be a powerful guidance tool for conversion of arthrodesed hips to THAs.

Ceramic on ceramic hip arthroplasty in fused hips

BACKGROUND

Most literature in the field of total hip arthroplasty (THA) for fused hips, until date has reported the results of using metal on polyethylene and ceramic on polyethylene bearings. Results of THA using ceramic on ceramic (CoC) bearings in fused hips have not been published in literature. This study reports the results of cementless THA using CoC articulation perfomed in fused hips.

MATERIALS AND METHODS

Twenty-three patients (25 hips) with fused hips underwent conversion to THA using CoC bearings and were followed up for a mean 5.4 years. The conventional posterolateral approach was used in 15 hips, a modified two incision technique in 7 hips and a direct lateral approach with greater trochanteric osteotomy in 3 hips. Postoperatively, range of motion exercises were encouraged after 2-3 days of bed rest and subsequent gradual weight bearing using crutches was begun.

RESULTS

Mean Harris hip score improved from 42.4 to 84.2 and mean leg lengthening of 36.6 mm was achieved. In the average 5.4 years (range 2.8-9.1 years) followup there were no cases with osteolysis around acetabular cup and femoral stem. In this study, there was no case of ceramic fracture. There was one case of squeaking.

CONCLUSION

This study suggests that cementless THA performed for fused hips with CoC bearings can provide good early clinical results.

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.

Conversion of arthrodesis to total hip arthroplasty: clinical outcome, complications, and prognostic factors of 21 consecutive cases

BACKGROUND

Although the results of hip arthrodesis compare favorably with those of total hip arthroplasty (THA) in younger patients, long-term consequences such as osteoarthritis of the neighboring joints may necessitate conversion of the arthrodesis to THA.

QUESTIONS/PURPOSES

The purpose of the present study is to assess mid-term clinical outcome and self-perceived improvement in patients who underwent conversion at our department. Secondary aims were incidence of complications and association between patient characteristics and characteristics of the fusions with the outcome of the procedure.

PATIENTS AND METHODS

The study sample comprised 21 cases in 20 patients. Minimum follow-up was 3 years (mean, 8 ± 6.5 years) in 20 cases. Thirteen patients had surgical hip fusions and 7 (8 hips) had nonsurgical fusions. Mean age at the time of conversion was 58.5 years.

RESULTS

Nineteen out of 21 cases had functioning implants at the latest follow-up visit. According to the Merle d'Aubigné scale, outcome was considered excellent, very good, or good in 15 cases. Lower back pain was reduced in all patients. All but two patients were satisfied after the conversion. The main complications observed included incomplete removal of bone block, intra-operative fractures, dislocation and damage to the femoral artery. Time to conversion and type of fusion had no significant correlation with the clinical outcome.

CONCLUSIONS

Conversion THA is a challenging but successful procedure according to the mid-term clinical outcome observed. Our study suggests that, prognostic factors should be used with caution when establishing indications and post-surgical expectations.

Complex primary total hip arthroplasty

Although total hip arthroplasty is now a classic procedure that is well controlled by orthopedic surgeons, some cases remain complex. Difficulties may be due to co-morbidities: obesity, skin problems, muscular problems, a history of neurological disease or associated morphological bone deformities. Obese patients must be informed of their specific risks and a surgical approach must be used that obtains maximum exposure. Healing of incisions is not a particular problem, but adhesions must be assessed. Neurological diseases may require tenotomy and the use of implants that limit instability. Specific techniques or implants are necessary to respect hip biomechanics (offset, neck-shaft angle) in case of a large lever arm or coxa vara. In case of arthrodesis, before THA can be performed, the risk of infection must be specifically evaluated if the etiology is infection, and the strength of the gluteal muscles must be determined. Congenital hip dysplasia presents three problems: the position and coverage of the cup, placement of a specific or custom made femoral stem, with an osteotomy if necessary, and finally lowering the femoral head into the cup by freeing the soft tissues or a shortening osteotomy. Acetabular dysplasia should not be underestimated in the presence of significant bone defect (BD), and reconstruction with a bone graft can be proposed. Sequelae from acetabular fractures presents a problem of associated BD. Internal fixation hardware is rarely an obstacle but the surgical approach should take this into account. Treatment of acetabular protrusio should restore a normal center of rotation, and prevent recurrent progressive protrusion. The use of bone grafts and reinforcement rings are indispensible. Femoral deformities may be congenital or secondary to trauma or osteotomy. They must be evaluated to restore hip biomechanics that are as close to normal as possible. Fixation of implants should restore anteversion, length and the lever arm. Most problems that can make THA a difficult procedure may be anticipated with proper understanding of the case and thorough preoperative planning.