Total hip arthroplasty after excision arthroplasty: indications and limits

Functional outcome of total hip arthroplasty in tubercular hip arthritis: A prospective study

Background

Total hip arthroplasty (THA) is a well-established procedure to cure tubercular hip arthritis in patients with healed tuberculosis while its role in active tuberculosis is still debatable. The aim of the study is to investigate the functional outcomes of THA in active tuberculosis with advanced hip arthritis. The reactivation of tuberculosis and complications postoperatively has also been assessed.

Materials and methods

The current open-ended prospective cohort study was carried out at a tertiary center from 2018 to 2020. Twenty patients of active tubercular hip arthritis (8 females and 12 males) were taken with a follow-up period ranging from 1 year to 3 years, with a mean of 14 months.Biochemical investigations were done both preoperatively and postoperatively. Preoperative anti-tubercular therapy (ATT) regimen was administered, as per standard norms, to patients for a minimum period of 6 weeks, and postoperatively for 6 months-12 months. Postero-lateral and Hardinge approaches were employed in all cases. Clinical and radiological parameters were assessed and functional outcomes were evaluated using the Harris Hip score (HHS).

Results

The mean age of patients was 37.6 ± 11.38 years. Biochemical parameters were also found to improve postoperatively (p < 0.0001). The mean flexion, extension, abduction, external and internal rotation were found to increase postoperatively (p < 0.001). The mean flexion deformity in the preoperative period was 12.35 ± 4.716, whereas none of the patients had flexion deformities post operatively. The mean shortening was 2.12 ± 0.60 and 1 ± 0 at preoperative and postoperative respectively. The Total hip arthroplasty implant was found stable in all patients. The mean Harris score increased subsequently throughout the follow-up interval and differences were statistically significant (p < 0.0001). None of the patients had reactivation of tuberculosis infection postoperatively.

Conclusion

Total hip arthroplasty is a reliable option to treat active advanced tubercular hip arthritis and gives good functional outcome with proper preoperative and postoperative ATT regimen.

Total hip arthroplasty in active and advanced tubercular arthritis: a systematic review of the current evidence

STUDY DESIGN

Systematic review.

INTRODUCTION

Total hip arthroplasty (THA) is a well-acknowledged surgical intervention to restore a painless and mobile joint in patients with osteoarticular tubercular arthritis of the hip joint. However, there is still substantial uncertainty about the ideal management, clinical and functional outcomes following THA undertaken in patients with acute Mycobacterium tuberculosis (TB) hip infections.

AIM OF THE STUDY

To undertake a systematic review and evaluate existing literature on patients undergoing THA for acute mycobacterium tuberculosis arthritis of the hip.

METHODS

A systematic review of electronic databases of PubMed, EMBASE, Scopus, Web of Science and Cochrane Library was performed on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search focused on "arthroplasty in cases with tuberculosis of hip joint" since inception of databases until July 2023. Data on patient demographics, clinical characteristics, treatment administered, surgical interventions and outcome, as reported in the included studies, were recorded. Median (range) and mean (standard deviation) were used to summarise the data for continuous variables (as reported in the original studies); and frequency/percentage was employed for categorical variables. Available data on Harris hip scores and complications were statistically pooled using random-effects meta-analysis or fixed-effect meta-analysis, as appropriate RESULTS: Among a total of 1695 articles, 15 papers were selected for qualitative summarisation and 12 reporting relevant data were included for proportional meta-analysis. A total of 303 patients (mean age: 34 to 52 years; mean follow-up: 2.5 to 10.5 years) were included in our systematic review. In a majority of included studies, postero-lateral approach and non-cemented prosthesis were employed. Fourteen studies described a single-staged procedure in the absence of sinus, abscess and tubercular infection syndrome (TIS). All surgeries were performed under cover of prolonged course of multi-drug anti-tubercular regimen. The mean Harris hip score (HHS) at final follow-up was 91.36 [95% confidence interval (CI): 89.56-93.16; I2:90.44%; p<0.001]. There were 30 complications amongst 174 (9.9%) patients (95% CI: 0.06-0.13; p=0.14; I2=0%).

CONCLUSION

THA is a safe and effective surgical intervention in patients with active and advanced TB arthritis of hip. It is recommended that the surgery be performed under cover of multi-drug anti-tubercular regimen. In patients with active sinus tracts, abscesses and TIS, surgery may be accomplished in a multi-staged manner. The clinical (range of motion, deformity correction, walking ability and pain scores), radiological (evidence of radiological reactivation and implant incorporation) and function outcome (as assessed by HHS) significantly improve after THA in these patients.

Is hip resection arthroplasty a successful definitive treatment?

Purpose

Hip resection arthroplasty as a definitive treatment is an uncommon indication, although still in use selectively. This study evaluates a cohort of patients who have undergone hip resection arthroplasty surgery indicated as a definitive treatment, in order to assess the rate of re-operation, the rate of infection, and the mortality rates.

Methods

We conducted a retrospective, observational, descriptive analysis of a cohort of patients who had undergone a hip resection arthroplasty intended as a definitive treatment, in two University Hospitals from 1994 to 2020. The exclusion criteria were the implantation of a hip cement spacer, or a temporary hip resection arthroplasty in patients undergoing a two-staged surgical approach. We found 26 cases of hip resection arthroplasty. We recorded the indications for a definitive hip resection arthroplasty, the outcomes and complications, and analyzed the success of the hip resection arthroplasty as a definitive surgery using a Kaplan-Meier curve.

Results

Seven cases (26.9%) required a re-operation after the hip resection arthroplasty, four cases for persistent hip infection, and in the three remaining a conversion to a total hip arthroplasty was re-considered due to a good medical evolution and non-tolerance to the low functional outcome. The mortality rate was 61.5% (27 days-20 years), with a 19.2% mortality rate in the first 5 years. All the cases that required another surgery after the hip resection arthroplasty were re-operated within the first 18 months.

Conclusion

Unfortunately, hip resection arthroplasty continues to show elevated re-operation rate and early mortality rate, as well as low functional outcomes. Two-staged hip revision arthroplasty is the surgical treatment of choice in patients suffering from a periprosthetic joint infection, however we believe that hip resection arthroplasty should be considered in fragile patients, who have endured multiple revision surgeries, or their comorbidities make them unfit from further surgeries.

Revision arthroplasty with megaprosthesis after Girdlestone procedure for periprosthetic joint infection as an option in massive acetabular and femoral bone defects

Background and aim:

To evaluate the clinical outcomes of patients treated with Girdlestone procedure (GP) or excision arthroplasty (EA) for periprosthetic infection with massive bone defects and undergoing revision arthroplasty.

Methods:

All patients treated with EA or GP for hip periprosthetic infection between 2014 and 2017 and sustaining revision arthroplasty (RA) were included in the study. Patients with less than 24 months of follow-up or less than 12 months between GP or EA and RA were excluded. Any sign of implant mobilization or periprosthetic fracture was assessed through X-ray. Patients were evaluated with D’aubigne-Postel hip score before RA and at the last follow-up. Mann-Whitney U test was used to assess differences between pre-RA surgery and last follow-up. P value was set as <0.05.

Results:

Twelve patients meet the inclusion criteria (mean follow-up 58+/-9.72 months). No radiographic sign of implant mobilization or periprosthetic fracture was reported. A significant difference was found for each parameter of the D’Aubigne-Postel score (p < 0.0001); none of the patients reached more than fair results in the absolute hip score. The difference between pre and post-operative global status showed a fair improvement. A significant difference was found for leg length discrepancy between pre and post RA (p<0.0001).

Conclusions:

Conversion from EA or GP to RA in patients suffering from massive acetabular and femur defects is challenging; conversion procedure is able to reduce patients’ disability and to improve walking ability. (www.actabiomedica.it)

Restoration of the hip geometry after two-stage exchange with intermediate resection arthroplasty for periprosthetic joint infection

Two-stage exchange with intermediate resection arthroplasty (RA) is a well-established surgical procedure in the treatment of chronic periprosthetic joint infection (PJI), whereby a higher failure rate of final hip geometry restoration due to tissue contraction is controversially discussed. The aim was to evaluate radiographic changes of hip geometry parameters during PJI treatment and to determine the impact of the intermediate RA on the final joint restoration after reimplantation of a total hip arthroplasty (reTHA). Radiographic parameters (leg length (LL), femoral offset (FO), horizontal/vertical acetabular center of rotation distance (h/vCORD)) of 47 patients (mean age: 64.1 years) were measured on standard radiographs of the pelvis and compared between four different stages during PJI treatment (pre-replacement status (preTHA), primary total hip arthroplasty (pTHA), RA and reTHA). The RA duration (mean: 10.9 months) and the number of reoperations during this period (mean: n = 2.0) as well as their impact on hip geometry restoration were evaluated. Between preTHA and pTHA/reTHA an equivalent restoration was measured regarding the FO (p < 0.001/p < 0.001) and hCORD (p = 0.016/p < 0.001), but not regarding the LL and vCORD. In contrast, analysis revealed no influence of RA and an equivalent reconstruction of LL (p = 0.003), FO (p < 0.001), v/hCORD (p = 0.039/p = 0.035) at reTHA compared to pTHA. Furthermore, RA duration (p = 0.053) and the number of reoperations after RA (p = 0.134) had no impact on radiographic hip geometry restoration. The two-stage exchange with intermediate RA does not alter the preexisting hip joint parameters, whereby a good restoration of the final hip geometry, independent of the duration or the number of reoperations, can be achieved.

Resection Arthroplasty Compared With Total Hip Arthroplasty in Treating Chronic Hip Pain of Patients With a History of Substance Abuse

BACKGROUND

Retrospective comparison of surgical management of severe hip pain in patients with a history of substance abuse treated by modified Girdlestone resection arthroplasty (RA) vs delayed total hip arthroplasty (THA) following yearlong sobriety pathway.

METHODS

Patients were identified using charts, current procedural terminology (CPT) code query, and THA sobriety pathway registry. The primary outcome was adequate pain control following surgery, defined as visual analog scale ≤ 5 or verbal description of "moderate" or lower pain. RA patients with infectious arthritis were analyzed separately. The secondary outcome was the level of mobility after surgery.

RESULTS

In the THA pathway, 15 of 28 (53.6%) proved sobriety, 11 (39.3%) underwent THA, and 9 (32.1%) achieved adequate pain control (median 77 days). After RA, 19 (76%) achieved adequate pain control (median 119.5 days). Preoperative infection did not significantly affect time to pain control after RA (P = .94). Time to adequate pain control was not significantly different between RA and THA patients (P = .19). Three patients (30%) experienced improved level of mobility after THA and 7 (70%) experienced no change. After RA, 7 patients (29.1%) experienced improved level of mobility, 3 (13.6%) lost mobility, and 14 (63.6%) experienced no change. Three RA patients were later converted to THA without complication.

CONCLUSION

Yearlong sobriety pathway leading to THA leads to successful pain control in less than one-third of enrolled patients. Compared to delayed THA, RA enables more patients with substance abuse to be treated sooner and results in successful reduction of pain in a similar proportion of patients. RA may be an effective pain-reducing procedure for these patients.

Total hip replacement in tuberculosis of hip: A systematic review

Total hip replacement (THR) in patients with tuberculous arthritis of the hip is controversial. The timing of surgery, type of prosthesis, reactivation of the disease, high complication rates and the long-term survival of the reconstruction are the major conc erns. There is little information regarding this concern in the literature. We conducted a systematic review of published studies on Total Hip Replacement in patients with Tuberculosis of the hip. A search of Pubmed and Google Scholar database articles published between January 2000 and July 2017 was performed. Thirteen articles were identified, comprising 226 patients. The mean follow-up was 5.48 years. Antituberculosis treatment was given for atleast 2 weeks pre-operatively and continued post-operatively for between six and 18 months after THR. Three patients had reactivation of infection. At the final follow-up, the mean Harris hip score was 89.98. Total Hip Replacement in tuberculosis of hip is safe and efficient way to save the joint function. The most important factors to achieve success include the accurate diagnosis, efficient pre- and postoperative anti-tuberculosis therapy, thorough debridement, two stage procedure for patients with sinus(es).

Two-stage total hip arthroplasty for patients with advanced active tuberculosis of the hip

Background

Treatment of advanced active tuberculosis (TB) of the hip is confronted with great challenges. Although one-stage total hip arthroplasty (THA) is considered as a safe procedure for most patients by some authors, there are still exceptions. The purpose of this paper was to investigate the feasibility and effectiveness of two-stage THA for selected patients with advanced active TB of the hip.

Methods

Nine consecutive patients with advanced active tuberculous arthritis of the hip were reviewed in this study. Out of these nine patients, the hips of five were destroyed extensively with difficulties of thorough debridement at one operation, and the hips of the other four were detected of sinus tracts. Nine patients received the two-stage total hip arthroplasty (THA) protocol and the perioperative antituberculous medication between January 2008 and December 2013. During the first stage, a debridement was carried out after at least 2 weeks of antituberculous chemotherapy to remove abscesses and infected and necrotic tissues as thoroughly as possible, followed by antituberculous chemotherapy for a minimum of 3 months (average 4.2 months). During the second stage, hip prosthesis was implanted if the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) were normal and the wound was well healed. Antituberculous chemotherapy was continued for 6–9 months postoperatively to constitute a total duration of a minimum of 12 months after the first operation. The patients were then evaluated based on the reactivation of infection, the Harris hip score system, X-ray, ESR, and CRP.

Results

The average follow-up was 40 months (range, 18–72 months). No reactivation of TB or superimposed infection was observed in all patients. The ESR and CRP returned to the normal level with no liver injury. The average Harris hip score was increased from 35 (range, 15–55) preoperatively to 91.5 (range, 83–97) at the final follow-up. The X-ray film showed no prosthesis shift or loosening.

Conclusions

Two-stage THA is an alternative treatment option for patients with advanced active tuberculosis of the hip under some difficult conditions. The hip with sinus tracts or destroyed extensively with difficulties of thorough debridement at one operation may be regarded as indications.

Clinical outcome following conversion of Girdlestone's resection arthroplasty to total hip replacement: a retrospective matched case-control study

A total of 31 patients, (20 women, 11 men; mean age 62.5 years old; 23 to 81), who underwent conversion of a Girdlestone resection-arthroplasty (RA) to a total hip replacement (THR) were compared with 93 patients, (60 women, 33 men; mean age 63.4 years old; 20 to 89), who had revision THR surgery for aseptic loosening in a retrospective matched case-control study. Age, gender and the extent of the pre-operative bone defect were similar in all patients. Mean follow-up was 9.3 years (5 to 18). Pre-operative function and range of movement were better in the control group (p = 0.01 and 0.003, respectively) and pre-operative leg length discrepancy (LLD) was greater in the RA group (p < 0.001). The post-operative clinical outcome was similar in both groups except for mean post-operative LLD, which was greater in the study group (p = 0.003). There was a significant interaction effect for LLD in the study group (p < 0.001). A two-way analysis of variance showed that clinical outcome depended on patient age (patients older than 70 years old had worse pre-operative pain, p = 0.017) or bone defect (patients with a large acetabular bone defect had higher LLD, p = 0.006, worse post-operative function p = 0.009 and range of movement, p = 0.005), irrespective of the group. Despite major acetabular and femoral bone defects requiring complex surgical reconstruction techniques, THR after RA shows a clinical outcome similar to those obtained in aseptic revision surgery for hips with similar sized bone defects.

Atraumatic posterior dislocation of the native hip: an unusual presentation of septic arthritis

We present a case of chronic posterior hip dislocation after severe joint destruction following septic arthritis. In the absence of trauma, infection must be considered in the differential diagnosis of a dislocated joint particularly in patients with risk factors such as intravenous drug abuse and immune compromise. Excision arthroplasty of the hip was performed with good pain relief and functional outcomes. This is an excellent temporary or permanent solution in managing such complex cases although alternative management options are discussed.