Hip fusion in young adults

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.

The Open Triradiate Cartilage: How Young Is Too Young for Total Hip Arthroplasty?

BACKGROUND

There is, to our knowledge, no published literature regarding primary total hip arthroplasty (THA) in pediatric patients with an open triradiate cartilage. The purpose of this study was to report the outcomes following primary THA in pediatric patients with open triradiate cartilage at a single intuition.

METHODS

Using a single institution's Total Joint Registry, 12 patients (13 hips) were identified as having undergone primary THA with open triradiate cartilage between the years of 2000 and 2019. The mean age and body mass index of this group were 13.1 years and 25.5 kg/m2, respectively. The cohort was composed of 10 males, and the mean follow up was 5.5 years. Indications for surgery, functional outcomes, and radiographic signs of stable fixation were analyzed.

RESULTS

The most common indication for surgery was avascular necrosis secondary to corticosteroid use (31%), followed by avascular necrosis after operative management of slipped capital femoral epiphysis (23%). The proportion of patients able to achieve independent, gait-aid free, ambulation improved from 23% to 100%. Mean postoperative Harris Hip Score was 92.3. All constructs were cementless, and bearing surfaces included ceramic-on-ceramic in 62% and ceramic on highly crosslinked polyethylene bearings in the remainder. Radiographic review at final follow up demonstrated osseointegration in 12 of 13 (92%) acetabular components. Although 1 patient experienced both acetabular component loosening and instability, on separate occasions, there were no incidences of infection, wound dehiscence, thromboembolic events, or failure secondary to wear.

CONCLUSIONS

In this study, THA in patients with an open triradiate cartilage yielded significant clinical improvement, low complication rates and good initial implant survivorship at early follow up. Awaiting closure of the triradiate cartilage for concerns of decreased fixation and implant survivorship may be unnecessary.

LEVEL OF EVIDENCE

Level IV-case series.

Links between the Hip and the Lumbar Spine (Hip Spine Syndrome) as they Relate to Clinical Decision Making for Patients with Lumbopelvic Pain

This narrative review focuses on the links between the hip and lumbar spine in the context of lumbopelvic pain. The literature regarding this topic is variable, found in many disciplines of care using different terminology. Collectively these inconsistencies add to the complexity of understanding the current evidence as it pertains to clinical practice. We have chosen to review studies that describe and assess overlapping pain distributions between the lumbar spine and hip, hip osteoarthritis and lumbopelvic pain, improvements in low back pain following hip arthroplasty, association of hip range of motion and lumbopelvic pain, and lumbopelvic motion and hip motion as they relate to low back pain and gender. The links between the hip and lumbar spine may provide the clinician important information to make decisions and recommendations for people presenting with the clinical symptom complex including lumbopelvic pain.

Salvage Procedures for Management of Prosthetic Joint Infection After Hip and Knee Replacements

Background:

The increasing load placed by joint replacement surgery on health care systems makes infection, even with the lowest rates, a serious concern that needs to be thoroughly studied and addressed using all possible measures.

Methods:

A comprehensive review of the current literature on salvage procedures for recurrent PJIs using PubMed, EMBASE and CINAHL has been conducted.

Results:

Prolonged suppressive antibiotic therapy (PSAT), resection arthroplasty and arthrodesis were the most common procedures performed. Suppressive antibiotic therapy is based on the use of well tolerated long term antibiotics in controlling sensitive organisms. Resection arthroplasty which should be reserved as a last resort provided more predictable outcomes in the hip whereas arthrodesis was associated with better outcomes in the knee. Various methods for arthrodesis including internal and external fixation have been described.

Conclusion:

Despite good union and infection control rates, all methods were associated with complications occasionally requiring further surgical interventions.

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

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

Total hip arthroplasty in teenagers: an alternative to hip arthrodesis

Debilitating arthritis in teenage patients is a complex problem with limited surgical options. Hip arthrodesis is unpopular amongst patients, and contemporary total hip arthroplasty (THA) may be a promising alternative. We report on the outcomes of THA in patients less than 20 years of age. All consecutive teenage patients undergoing THA at a tertiary referral centre were reviewed. Mean follow-up was 3.4 years (range 0.6-6.8) and 9 patients had at least 5 years follow-up. There were 51 THAs in 43 patients with a mean age of 17 years (range 12-19). The commonest indication was osteonecrosis (35 cases), mostly secondary to slipped upper femoral epiphysis (15 cases). Forty-six were uncemented and 5 were reverse hybrid THAs of which 7 were computer assisted design/manufacture (CADCAM) components. The commonest bearing surface used was ceramic on ceramic (40 cases). The survival rate was 96% and there were 2 complications. At latest follow-up, the mean Harris hip score was 90 (range 68-99) and UCLA activity score was 6 (range 4-9). Radiological analysis showed 2 patients with lucent lines around the acetabular component, but no signs of osteolysis or wear. We report good short to intermediate term survivorship and outcomes, and feel THA represents a valid alternative option to hip arthrodesis.

Less invasive fixation of an interthrocanteric fracture in an ankylosed hip with cannulated screws: a case report

A 68-year-old woman presented following a road accident with an undisplaced intertrochanteric fracture affecting an ankylosed hip and an ipsilateral calcaneal fracture. The interthrocanteric fracture was fixed with four 7.0 mm cannulated screws. The calcaneal fracture was fixed with K wires and immobilized in a plaster. Because of this combination of injuries, although she was allowed to mobilize non weight bearing from the first week, sitting and progressive weight bearing were not permitted for six weeks. Radiographs taken at the one year showed consolidation of the hip fracture without complications. Final functional indices showed an EQ-5D VAS score of 40, EQ-5D health state index adapted to Spanish value sets of 0.493 and an Oxford Hip Score of 31. Screw fixation of an undisplaced intertrochanteric fracture in an ankylosed hip may be sufficient in some instances provided the patient remains non weight bearing for long enough.

Intertrochanteric fracture of an arthrodesed hip

We report the case of a 74-year-old woman who sustained an intertrochanteric fracture of the femoral neck in a previously arthrodesed hip. The hip arthrodesis had been performed 53 years earlier to treat septic arthritis. The fracture was treated successfully using a double-plating technique with 4.5 mm titanium reconstruction plates.

Lumbar disc arthroplasty

Degenerative disc disease is the leading cause of pain and disability in adults in North America, and spinal fusion is the standard treatment. Despite this, it has been discussed among surgeons that (1) spinal fusion deserves reexamination in terms of its long-term consequences and benefits and (2) modern clinical research and development in disc arthroplasty strongly supports its emergence as an alternative. The ability to relieve pain by maintaining motion may be a critical factor in obtaining not only greater pain relief but in preventing adjacent segment degeneration. Early research in arthroplasty devices was promising but cut short. New knowledge in the functional anatomy and biomechanics of the spine has made possible the development of modern arthroplasty devices (eg, Charite Artificial Disc, ProDisc, Maverick device, FlexiCore device) of different constructions and materials (metal-on-plastic, metal-on-metal) and various ranges of motion/mobility that provide a basis for a classification of spinal mode and an assistance in implant selection. Current research also is confronting the critical obstacles of wear and tear and axial compression. Several devices currently are in clinical trials. A detailed review of their characteristics shows the exciting progress of a new treatment era of total disc replacement in spine-lumbar disc arthroplasty.

Why a mechanical disc?

Low back pain secondary to degenerative disc disease is an overwhelming and growing problem in the United States and Western countries. Most degenerative disc disease can be treated nonoperatively. There are, however, substantial numbers of patients who have not benefited from exhaustive nonoperative treatments and subsequently seek surgical solutions to their incapacitating back pain. Lumbar fusion for back pain and/or leg pain associated with degenerative disc disease is considered the gold standard by which other treatments are judged. A challenge to spinal fusion for degenerative disc disease is now being offered in the form of the artificial disc. The implantation of an artificial lumbar disc allows for maintenance or restoration of physiologic movement at affected segments. A major long-term complication of spinal fusion is degeneration of a disc adjacent to the fused segments. Theoretically, the maintenance of motion could minimize development of adjacent disc degeneration as seen with spinal fusion. It is interesting to note that fusion of the hip or knee is not considered a primary procedure, but fusion is a primary procedure for the lumbar spine. Four artificial lumbar discs are discussed in this article. Early results are promising in terms of clinical results and movement, but long-term follow-up clinical trials must be done in order to gain an accurate comparison with spinal fusion. Trials are currently ongoing. The clinical results up to now and the potential for maintaining lumbar mobility throughout life warrant continuation of this surgical procedure.

Historical review of cervical arthroplasty

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

Femoral neck fracture in an arthrodesed hip treated by a supracondylar intramedullary locked nail

We describe a case of a femoral neck fracture occurring 51 years after a hip arthrodesis. This rare lesion in an obese woman was treated with a straight supracondylar nail with proximal and distal locking inserted retrograde from the subtrochanteric area into the ileum. Full weight bearing was achieved within 1 week postoperatively, and union was present 3 months following the operation.

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.