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

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.

Unusual presentation of recurrent subtrochanteric non-union in a patient with hip arthrodesis: A case report

This case report describes the management and therapeutic solution for the treatment of subtrochanteric non-union in a patient with hip arthrodesis. Two techniques can be used in the treatment of these non-unions: a closed intramedullary nailing or an open technique with plate, preferably carried out together with cortical bone graft. The surgical technique varies depending on the fixation method used for the initial treatment of the fracture and on the characteristics of the non-union. We report an unusual case of a patient who started her long clinical history more than 40 years ago with a septic arthritis of the hip healed in arthrodesis. 35 years later, after having undergone various surgeries, she fractured the proximal femur, which had to be operated seven times before reaching healing. Satisfactory outcomes were finally obtained. Arthrodesis proved to be the main cause of failed healing and of the recurrent non-union.

The Anatomical Course of the Lateral Femoral Cutaneous Nerve with Special Attention to the Anterior Approach to the Hip Joint

BACKGROUND

Injury to the lateral femoral cutaneous nerve (LFCN) is a risk during the operative anterior approach to the hip joint. Although several anatomical studies have described the proximal course of the nerve in relation to the anterior superior iliac spine (ASIS) and the inguinal ligament, the distal course of the LFCN in the proximal aspect of the thigh has not been sufficiently studied. The aim of this cadaveric study was to examine the branching pattern of the nerve, with special consideration to the anterior approach to the hip joint.

METHODS

Twenty-eight cadaveric hemipelves from 18 donors (10 paired and 8 unpaired specimens) were dissected. The LFCN branches were localized proximal to the inguinal ligament and traced distally into the area of the proximal aspect of the thigh. Distribution patterns of the nerve with respect to its relationship to the ASIS and the internervous plane of the anterior approach to the hip joint were recorded.

RESULTS

We found 3 different branching patterns of the LFCN: sartorius-type (in 36% of the specimens), characterized by a dominant anterior nerve branch coursing along the lateral border of the sartorius muscle with no, or only a thin, posterior branch; posterior-type (in 32%), characterized by a strong posterior nerve branch; and fan-type (in 32%), characterized by multiple spreading nerve branches of equal thickness. In 50% of the specimens, the LFCN divided into ≥2 branches superior to the inguinal ligament. Sixty-two percent of the LFCN branches entered the proximal aspect of the thigh medial to the ASIS; 27%, above; and 11%, lateral to the ASIS. The LFCN consistently coursed within the deep layer of the subcutaneous fat tissue.

CONCLUSIONS

Injury to branches of the LFCN cannot be avoided in approximately one-third of surgical dissections that use the anterior approach to the hip joint. To protect the anterior branch of the LFCN, the skin incision should be as lateral as possible. The posterior branch of the LFCN is most vulnerable in the proximal aspect of the anterior approach to the hip joint, where it can be expected to course within the deep layer of the subcutaneous tissue.

Potential Risk to the Superior Gluteal Nerve During the Anterior Approach to the Hip Joint: An Anatomical Study

BACKGROUND

The anterior approach to the hip joint is widely used in pediatric and adult orthopaedic surgery, including hip arthroplasty. Atrophy of the tensor fasciae latae muscle has been observed in some cases, despite the use of this internervous approach. We evaluated the nerve supply to the tensor fasciae latae and its potential risk for injury during the anterior approach to the hip joint.

METHODS

Cadaveric hemipelves (n = 19) from twelve human specimens were dissected. The course of the nerve branch to the tensor fasciae latae muscle, as it derives from the superior gluteal nerve, was studied in relation to the ascending branch of the lateral circumflex femoral artery where it enters the tensor fasciae latae.

RESULTS

The nerve supply to the tensor fasciae latae occurs in its proximal half by divisions of the inferior branch of the superior gluteal nerve. The nerve branches were regularly coursing in the deep surface on the medial border of the tensor fasciae latae muscle. In seventeen of nineteen cases, one or two nerve branches entered the tensor fasciae latae within 10 mm proximal to the entry point of the ascending branch of the lateral circumflex femoral artery.

CONCLUSIONS

Coagulation of the ascending branch of the lateral circumflex femoral artery and the placement of retractors during the anterior approach to the hip joint carry the potential risk for injury to the motor nerve branches supplying the tensor fasciae latae.

CLINICAL RELEVANCE

During the anterior approach, the ligation or coagulation of the ascending branch of the lateral circumflex femoral artery should not be performed too close to the point where it enters the tensor fasciae latae. The nerve branches to the tensor fasciae latae could also be compromised by the extensive use of retractors, broaching of the femur during hip arthroplasty, or the inappropriate proximal extension of the anterior approach.

Late-Onset Screw Migration into Iliac Vessels 21 years after Hip Arthrodesis

Iatrogenic injuries to the vascular system are a rare but serious complication of hip surgery. We report a case of an 83-year-old man who presented with intrapelvic migration of a screw into the space between the external iliac artery and vein 21 years after hip arthrodesis. The patient was treated with laparotomy, and the damaged artery was excised and sutured. This is the first case of a late vascular complication secondary to screw migration after hip arthrodesis.

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.

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.

[Minimally invasive anterior approach]

The minimally invasive direct anterior approach for total hip arthroplasty (THA) was first published in 1985. Since then the technique has been further improved and the indications have been extended. The approach utilizes the muscle gap between the tensor fasciae latae muscle on the lateral side and the sartorius muscle on the medial side. This muscle gap allows a direct and quick approach to the hip joint with good muscle preservation. During preparation of the femur the tensor fasciae latae muscle is at risk of being damaged. The lateral cutaneous nerve of the thigh (NCFL) and its branches are also in danger of being damaged during skin incision and dissection of the subcutaneous tissue. In this article the technique, risks and current clinical results of THA using the minimally invasive direct anterior approach are described. The results from the literature, as well as own results are compared to the traditional transgluteal lateral Bauer approach and discussed. Reviewing the literature, special attention has been given to the incidence of NCFL lesions, damage of the tensor fasciae latae muscle and positioning of the cup. Especially for the latter, the general view is hindered in the minimally invasive technique.

Hip arthrodesis in the pediatric population: where do we stand?

Reconstructive and salvage procedures have continued to evolve in orthopedic surgery with changing functional demands of the population as well as advances in implants and surgical techniques. What used to be popular or traditional care at some point may eventually become a thing of the past, and this is true as far as many orthopedic surgical procedures are concerned. Understanding the etiology, pathogenesis, and managing and postponing the destructive pathway of osteoarthritis (OA) has been the goal of orthopedists since the specialty began in the early part of 18^th century. Options of treating the severe sequelae of an arthritic joint have varied in different treatment eras. Management options have changed from a spectrum of non-treatment and slow suffering to muscle and soft-tissue releases, interposition arthroplasty and eventual extreme options like joint fusion or arthrodesis. The concept and advent of joint replacement surgery started a new era in the management of OA and was a dream come true in many ways. Mobility and stability are achieved together during the arthroplasty (joint replacement) that allowes the patient to maintain a good level of function. Arthroplasty certainly has its pros and cons as we have discovered in the past six decades. Pushing the envelope to younger population has its limitation in terms of longevity of the prosthesis, early loosening, need for repeated revisions that at some point may not be technically possible and risk of infection and disastrous consequences like PE and death associated with the gravity of the procedure. As infrequent as it is in today's clinical practice, arthrodesis of the hip joint has a role and remains a solid option for a well selected case.

The purpose of this review is to discuss the current indications in the pediatric population and outline surgical techniques for hip arthrodesis while pointing out limitations and shortcomings.

The history of the anterior approach to the hip

The anterior approach is a safe, reliable, and feasible technique for total hip arthroplasty, permitting optimal soft tissue preservation. Since Hueter first described this interval, many surgeons have approached the hip anteriorly to perform a myriad of surgical procedures. The anterior approach allows optimal muscle preservation, and it is a truly internervous approach to the hip. An understanding of the evolution of the anterior approach to the hip will help the orthopedic community understand these advantages and why so many have used this approach in the treatment of hip pathology and for the implantation total hip arthroplasty.

The use of a biplanar construct in pelvic external fixation

Inserting pins at a single location of the iliac crest temporarily provides an effective splint for emergency patients with pelvic ring fractures. For a longer application, however, this procedure frequently causes infection and pin loosening and does not effectively stabilize the pelvic construct. We presumed biplanar pelvic constructs may provide better stability than a uniplanar construct. Two patients were treated with inserting pins at the lateral side of the supra-acetabulum as well as the iliac crest. Postoperatively, they demonstrated significant improvement in pain relief. The biplanar pelvic constructs showed sufficient stability during the procedure and at the time of pin removal several months postoperatively. Another pinning location for pelvic external fixation is the anteroinferior iliac spine toward the posteroinferior iliac spine. Inserting pins from this spot and the iliac crest does not create a biplanar construct, since anatomically these pins share a similar plane. Thus, the biplanar method in which pins were introduced at the lateral side of the supra-acetabulum and at the iliac crest was selected. Despite the pins' application for several months, pin-site infection was not critical in our cases. We concluded that stability of the biplanar construct helped minimize pin-site infection.

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.

Preliminary assessment and treatment guidelines for hip disorders in young adults

The treatment of hip disorders in adolescents and young adults has evolved rapidly during the past decade because of enhanced understanding of prearthritic and early arthritic hip disease combined with improved diagnostic skills, better patient selection criteria, and refinements in alternative surgical procedures. Despite these advancements, the diverse clinical conditions and available surgical options highlight the need to develop optimal diagnostic and treatment guidelines for young patients with compromised hip function. Comprehensive care of young patients with hip disorders includes diverse surgical techniques such as arthroscopy, pelvic osteotomies, osteoplasty, femoral osteotomies, surgical dislocation, grafting procedures, arthrodesis, and prosthetic replacement. Optimal clinical results depend on the combination of careful patient selection and successful application of the appropriate surgical procedure. We outline general guidelines for the assessment and treatment of hip pain in young adult patients.

Hip arthrodesis: a procedure for the new millennium?

Advanced hip arthrosis in the young patient represents a difficult problem. Using currently available techniques, total hip arthroplasty (THA) in this patient population likely would result in multiple revision surgeries, usually at the expense of bone in the proximal femur and acetabulum. For noninflammatory, monoarticular hip arthritis, arthrodesis remains an excellent reconstruction option. Arthrodesis can provide pain relief and return to function in the majority of patients indicated for the procedure. Current techniques provide acceptable fusion rates. If possible, techniques that protect the abductor mechanism and limit deformity of the pelvis should be used. Patient education is an important part of the treatment process. The position of the limb is important to early satisfaction and durability of the fusion. Long-term difficulties after hip fusion are related to pain in contiguous joints. Conversion arthroplasty, if necessary, can result in favorable outcomes. Familiarity with the techniques and outcomes of hip arthrodesis are important for the hip surgeon to understand.

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.

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.