Total knee arthroplasty in patients with prior ipsilateral hip fusion

Total Knee Arthroplasty in Patients with Ipsilateral Hip Fusion: Technical Notes and Literature Review

Numerous studies report the success and outcomes of the total knee arthroplasty (TKA); however, few papers present patients with knee osteoarthritis and ipsilateral hip fusion. One controversy when treating patients requiring a TKA with prior ipsilateral hip fusion is whether to first perform a total hip arthroplasty (THA) of the fused hip, followed by the ipsilateral TKA, or to proceed with the TKA without replacing the hip; studies suggest that the position of the fused hip is a key factor when making this therapeutical decision. In addition, performing a TKA in patients with an ipsilateral fused hip may require modifications to the surgical technique generated by the lack of joint mobility in the hip. We identified 12 studies encompassing 30 patients with hip fusion and ipsilateral TKA in current orthopedic literature, but only six offered insights on patient positioning on the operating table during surgery. This study aims to review the current literature on patients with knee osteoarthritis and prior ipsilateral hip fusion and to present some technical considerations when performing a TKA on a 75-year-old patient with hip ankylosis who underwent a total ipsilateral knee arthroplasty in our clinic.

Hip fusion takedown with total knee and hip arthroplasty in a patient with end-stage chronic kidney disease - a case report and narrative literature review

Hip fusion takedown and conversion to [total hip replacement (THR)] is a technically demanding procedure related to a high risk of complications, however, in selected patients, it might be required before performing [total knee arthroplasty (TKA)]. Currently, there is no standard of care, and each case has to be considered individually. We describe a case of a 70-year-old male with left hip ankylosis and debilitating pain in the ipsilateral knee. We describe the justification and technical issues related to the management of this case, and the difficulties associated with performing those in a dialyzed patient. Based on our experience and available literature, we conclude that the patient has to be informed of possible complications and outcomes. Even the presence of serious comorbidity does not necessarily preclude such a procedure if the patient is in good condition and the successful outcome is highly probable.

Total Knee Arthroplasty in Patients With Prior Ipsilateral Hip Fusion: A Surgical Technique

BACKGROUND

In patients with severe osteoarthritis of the knee with prior ipsilateral hip fusion who require total knee arthroplasty (TKA), a controversial issue is whether to first convert the hip fusion to a total hip arthroplasty (THA) or to perform TKA without reconstruction of the hip. Also, immobility of the ipsilateral, fused hip adds significant technical challenge because the usual positioning of the leg requires modification in order to gain access needed for the TKA.

TECHNIQUE

In such cases, we position the patient with the knee suspended, similar to how we perform knee arthroscopy. In our experience, the ipsilateral knee has significant deformity and is best addressed with a constrained, hinged TKA.

RESULTS

In 3 patients with severe knee osteoarthritis with prior ipsilateral hip fusion-a 72-year-old man and a 79-year-old woman with hip arthrodesis due to posttraumatic arthritis and an 81-year-old woman with hip arthrodesis due to congenital dislocation of the hip-rotating-hinge knee prostheses were implanted due to severe knee instability. All 3 patients had satisfactory results, without complications, after follow-up of 1 to 5 years.

CONCLUSIONS

We obtained satisfactory results in the short and medium term without previously converting the hip arthrodesis to THA by positioning patients with the knee suspended, in a way similar to when knee arthroscopy is performed, and implanting rotating hinge TKAs due to severe preoperative knee instability.

Tibial Condyle Valgus Osteotomy for Ipsilateral Knee Osteoarthritis after Hip Arthrodesis

We report a case of tibial condylar valgus osteotomy (TCVO) for ipsilateral knee osteoarthritis (OA) after hip arthrodesis. A 58-year-old woman developed right purulent hip arthritis at one month of age and underwent right hip fusion at 16 years old. She visited our department at the age of 57 because her right knee joint pain worsened. The range of motion for her right knee was 80° and -5° of flexion and extension, respectively, and she experienced medial weight-bearing pain. A plain X-ray image showed that the right knee joint had end-stage knee OA with a bone defect inside the tibia, and the tibial plateau shape was the pagoda type. There was a marked instability in her right knee with a valgus of 9° and varus of 7° on stress photography. She underwent TCVO on her right knee and was allowed full load four weeks after surgery. Computed tomography imaging showed bone union nine months after surgery. Two years after the operation, there was no correction loss, and she could walk independently without pain. In general, total knee arthroplasty (TKA) is indicated for end-stage knee OA; however, there are problems, such as early loosening due to the increased mechanical load on the knee after hip OA. In this case, since a good course was obtained, TCVO is considered a treatment option for terminal knee OA after hip arthrodesis.

Surgical strategies in management of ankylosed bilateral hips and knees in crouched posture

A 26-year-old wheelchair-bound man was brought to our institute with progressive painful deformity of both lower limbs involving bilateral hip and knee for the past 5 years. The patient was wheelchair-bound for the past 18 months. He was only able to crawl to meet his locomotor demands. On examination, the patient was in a crouched posture with mild kyphosis at the thoracolumbar region and ankylosis of bilateral hip and knee in an unfavourable position. Radiological and serological evaluation diagnosed him to be a case of neglected ankylosing spondylosis. We planned for arthroplasty of the bilateral hip and knee for correcting his posture and to regain his locomotor ability. The severity of the deformity mandated extensive releases and the handling of neurovascular structures. Hence, a holistic treatment plan with various surgical strategies was devised to manage his deformities. The patient made a good recovery and regained his locomotor ability without any major complications at a 2-year follow-up.

Total Knee Arthroplasty with Prior Ipsilateral Hip Arthrodesis

Total knee arthroplasty (TKA) in the setting of previous hip fusion is rare with a paucity of evidence in the orthopaedic literature. Traditionally, TKA is performed supine, with the aid of knee-positioning devices allowing for hip flexion and range of motion of the knee to facilitate ease of surgical intervention. However, TKA using traditional positioning would not be possible in the presence of ipsilateral hip arthrodesis preventing hip motion. This case report describes a TKA performed for a 72-year-old woman with end-stage osteoarthritis of the right knee, ipsilateral hip arthrodesis, and leg-length discrepancy as the sequelae of slipped capital femoral epiphysis. We describe novel surgical positioning to be used to facilitate TKA in the absence of ipsilateral hip motion with bed modifications and the use of an extremity positioning device.

Total knee arthroplasty in a patient with ipsilateral hip ankylosis: A case report

RATIONALE

There is a large number of people that have knee degeneration in China. Total knee arthroplasty is one of the most effective methods of treatment in the later stages of the disease. However, there are challenges when performing total knee arthroplasty on patients with ipsilateral hip akylosis. So far, there are few reports on postoperative curative effect of total knee arthroplasty for these patients. This case report records how to perform total knee arthroplasty in a patient with ipsilateral hip ankylosis.

PATIENT CONCERNS

Due to ankylosing spondylitis, the flexion of the patient's hips are restricted in 10°, which leads to a limited ipsilateral knee flexion to 30° when she is in the supine position.

DIAGNOSES

Right knee osteoarthritis; right hip ankylosis.

INTERVENTIONS

We modified the traditional surgical position to allow easy exposure of the knee during surgery. After total knee arthroplasty, the patient was included in a planned training program, and was followed for 6 months.

OUTCOMES

The patient walked well without ambulation aid and achieved satisfactory knee joint function.

LESSONS

Conversion of a fused hip to a total hip arthroplasty does improve the quality of life of patients, but, given the high incidence of complications and more financial burden to the patient, we modified traditional surgical position of the patient to provide ideal surgical exposure of the knee. We hope that this case can be used as a reference for clinicians to deal with similar situations.

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.

Total knee arthroplasty in a patient with a fused ipsilateral hip

BACKGROUND

Many patients undergoing total knee replacement for joint degeneration may have cartilage wear in other joints and thus may already have had various other surgical procedures performed for these. To date, there is no data or description in the medical literature detailing how to perform a total knee replacement in a patient who previously underwent an ipsilateral hip fusion.

METHOD

We describe how this is done in a patient who had her ipsilateral hip fused in 30° of flexion. This presents a surgical challenge because the knee can only be flexed to 70° if done in the conventional supine position. This not only makes exposure more difficult but can also lead to complications including component malpositioning and extensor mechanism problems, such as patellar tendon rupture. We present this case study and describe, with the aid of a series of intra-operative photographs, how this can be performed, with special focus on patient positioning to optimize knee exposure in a patient with a previous hip fusion.

RESULTS

The modifications made during surgery allowed the knee replacement to be carried out uneventfully. The patient recovered well and was able to return to her usual activities.

CONCLUSION

We had to make various modifications to the intra-operative positioning in order to carry out the surgery. We hope these practical pointers will help clinicians faced with a similar situation in the future.

Total knee arthroplasty in patients with ipsilateral fused hip: a technical note

We report the surgical technique used to perform posterior-stabilized total knee arthroplasty (TKA) in two patients with a well positioned and functional hip arthrodesis. Intraoperatively, the operating table was placed in an increased Trendelenburg position. Episodically, we flexed the foot of the table by 90° to allow maximal knee flexion to facilitate exposure and bone cuts. We opted to resect the patella and tibia first to enable exposure, given the stiffness of the arthritic knee. One patient's medical condition prohibited complex conversion total hip arthroplasty (THA) prior to the TKA. The other patient's scarred soft tissues around the hip, due to chronic infection and multiple operations, made THA risky. The final outcome provided satisfactory results at a minimum of 2 years postoperatively. TKA can be successfully performed with adjustments of table position and modification of the sequence of surgical steps in patients with ipsilateral hip fusion.

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.

Hip arthrodesis in children: A review of 28 patients

BACKGROUND

The best method of treating intractable hip pain in an unsalvageable hip joint in a child is still a subject open to debate. We believe that hip arthrodesis in such patients provides a painless and stable hip for most activities of daily living in our challenging rural terrain. Therefore, we conducted this study to assess the functional ability of children with painful hip arthrosis treated by arthrodesis of the hip.

MATERIALS AND METHODS

A retrospective evaluation of 28 children (out of 35) who had an arthrodesis of the hip performed between 1994 and 2008 was carried out. The average age was 14 years, with 12 males and 16 females. There was involvement of the right hip in 13 and left in 15 cases. The average duration of follow-up was 4.87 years. The preferred position of the hip for arthrodesis was 20-30 degrees of flexion, neutral abduction-adduction, and neutral rotation, irrespective of the method of fixation.

RESULTS

The average duration of clinical and radiological arthrodesis was found to be 4 months (2-6 months). At the last follow-up, all patients were painfree and had good ambulatory capacity. The average Modified Harris Hip Score increased from 53 to 84 and the average post-surgical limb length discrepancy was 1.3 cm, which was well tolerated in all cases. Patients, however, had difficulty in squatting and had to modify their posture for foot care, putting on shoes, etc. Also, some patients complained of ipsilateral knee, contralateral hip, or low back pain with prolonged activity, but this was not severe enough to restrict activity except in one case that was known to have juvenile rheumatoid arthritis and needed ambulatory aid.

CONCLUSION

In an environment where pathology generally presents very late and often in a dramatic manner, where the patient's socioeconomic status, understanding, compliance, and the logistics of follow-up are consistently a challenge in management, hip arthrodesis has been an important procedure for our patient group, with good short-term results and promising midterm, and, hopefully, long-term prospects. In our series of patients, we have been successful in restoring painfree mobility.

Conversion of bilateral hip and knee ankylosis to total joint replacements

We present a 25-year-old patient with juvenile rheumatoid arthritis and ankylosis of both hips and both knees treated by staged bilateral hip and knee arthroplasty. She was followed up for 18 months. We discuss the pre-operative planning, surgical details and post-operative rehabilitation.

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.

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.

Total knee arthroplasty in a patient with rheumatoid arthritis and spontaneous fusion of the right hip

Abstract Bilateral total knee arthroplasty for a painful stiff knee was performed in a 50-year-old woman with rheumatoid arthritis who had spontaneous fusion of the right hip. Despite several manipulations, the range of motion of the right knee worsened. After total hip arthroplasty and ipsilateral knee revision, the right knee had a stable range motion of -15° to 75°. This case suggests that even if the ankylosed hip is in a good position, ipsilateral knee arthroplasty with a fused hip may result in a poorer range of motion than that after total hip arthroplasty.

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.