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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 2  |  Page : 117-121

Total hip arthroplasty for complex primary hips – A tertiary center experience


Department of Orthopaedics, ESIC Medical College and Hospital, Kolkata, West Bengal, India

Date of Submission24-Nov-2020
Date of Acceptance28-May-2021
Date of Web Publication27-Dec-2021

Correspondence Address:
Prof. Sanjay Keshkar
Department of Orthopaedics, ESIC Medical College and Hospital, Joka, Kolkata - 700 104, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_83_20

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  Abstract 


Background: Total hip arthroplasty (THA) surgery for complex primary hips are challenging not only for its technical difficulties but also for increased risk of complications, thus requiring detailed planning to ensure successful operation. This paper aims to present the pattern of complex primary hips presenting for total hip replacement and the challenges and complications. Materials and Methods: This was a retrospective study in which records of patients who had THA from 2015 to 2019 were analyzed for the demography, pattern of complex primary hip, and the surgical challenges and complications. Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years. Results: One hundred THAs were done during the study period, out of which 42 THAs in 29 patients (16 unilateral and 13 bilateral THAs) were of complex primary hip. Majority of them were of ankylosing spondylitis (38.1%) followed by posttraumatic avascular necrosis of femoral head (23.8%). The main difficulties were related to soft-tissue contracture, completely fused hip, and removal of hardware in old operated hip fracture. Postoperatively, majority of the patients had anemia (7 patients, 16.6%), followed by postoperative dislocation in 2 patients (4.7%). Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years, and the overall outcome was satisfactory in 95% of the patients. Conclusion: Complex THA is challenging and needs to assess properly and to be done meticulously. The surgical exposure and subsequent placement of components can be significant challenges in complex THA which can be tackled by using proper instrumentation and modular implants. With proper surgical technique, proper instrumentation, and proper implantation, one can expect good-to-excellent results even in complex THA.

Keywords: Arthroplasty, complex primary hip, total hip arthroplasty


How to cite this article:
Vidyarthi AR, Barman R, Kisku L, Akhtar MN, Keshkar S. Total hip arthroplasty for complex primary hips – A tertiary center experience. J Orthop Traumatol Rehabil 2021;13:117-21

How to cite this URL:
Vidyarthi AR, Barman R, Kisku L, Akhtar MN, Keshkar S. Total hip arthroplasty for complex primary hips – A tertiary center experience. J Orthop Traumatol Rehabil [serial online] 2021 [cited 2022 Jan 26];13:117-21. Available from: https://www.jotr.in/text.asp?2021/13/2/117/333572




  Introduction Top


Orthopedic surgeons are confronted with many hip pathology and trying their best to tackle them by preserving the hip. However, there are situations where one needs to sacrifice the hip and go for total hip arthroplasty (THA). It is the last but first option for individuals suffering from complex primary hip pathologies. Complex primary hip is a challenging hip in which one anticipates technical difficulties and complications right from its preoperative evaluation to peroperative, postoperative, and rehabilitation periods. These hips require meticulous planning and adequate preparation for THA to prevent/tackle the challenges and should be considered complex.[1],[2] A primary THA in patients with compromised bony or soft-tissue states (including but not limited to dysplastic hip, ankylosed hip, prior hip fracture, protrusio acetabuli, certain neuromuscular conditions, skeletal dysplasia, and previous bony procedures about the hip) has been described complex primary THA by Sathappan et al.[3] With increasing awareness, a number of complex hips, presenting to a tertiary institution for THA. This paper aims to present the pattern of complex primary hips presenting for THA and the challenges and complications.


  Materials and Methods Top


This was a retrospective study in which records of patients who had THA from 2015 to 2019 were analyzed for the demography, pattern of complex primary hip, and the challenges and complications. After proper diagnosis and evaluation, patients were planned for THA. Under regional/general anesthesia, patients were operated by posterior/lateral approach using the prosthetic component of the same company. The postoperative rehabilitation protocol remains same for all except for those who had some complication occurred like calcar split necessitating some modifications. Physical methods were insisted for prevention of deep venous thrombosis, but for comorbid and obese patients, Fragmin (enoxaparin) was used. Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years.


  Results Top


One hundred THAs were done during the study period, out of which 42 THAs in 29 patients (16 unilateral and 13 bilateral THAs) were of complex primary hip. The prevalence of complex primary THA was 42% in our study. As evident from demographic profile of patients [Table 1], 51.72% of the patients were male and 48.27% were female, with a male–female ratio almost 1:1. The age range from 20 to 70 years was analyzed, with a mean age of 46 years. In our series, we had different patterns of complex hips [Table 2], and majority of them were of ankylosing spondylitis (AS) (38.1%) followed by posttraumatic avascular necrosis (AVN) of femoral head (23.8%). Out of 42 cases, uncemented THA was done in 30 cases (71.4%) and 12 (28.6%) cases by cemented THA. We encountered various intraoperative problems for which instant solutions offered [Table 3]. The main difficulties were related to soft tissue contracture where extensive release required, completely fused hip where removal of head with creation of acetabulum was difficult and old operated hip fracture where removal of hardware was tricky and extra time taking for surgery. Removal of one case of cannulated cancellous screw (CCS) was very difficult and one case had intraoperative splinter of femoral shaft for which circlage wiring done. Postoperative complications were also noted and timely intervention offered [Table 4]. Majority of the patients had anemia (7 patients, 16.6%), followed by postoperative dislocation in 2 patients (4.7%).
Table 1: Demographic profile of patients who underwent complex primary total hip arthroplasty

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Table 2: Types of complex primary hips and their frequency

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Table 3: Intraoperative problems and their solutions in complex primary total hip arthroplasty

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Table 4: Postoperative problems with their solutions in complex primary total hip arthroplasty

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Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years. The preoperative Harris Hip Score ranged from 14 to 75, with a mean score of 41. There was a significant improvement at final follow-up (2 years postoperative) in Harris Hip Score of 80–100, with a mean of 94. Serial radiological evaluation up to 2-year follow-up showed no signs of loosening of prosthesis. There was no mortality recorded in our study. There was no significant infection recorded in our study. Only one patient had superficial wound infection which was managed by proper antibiotics and wound care. The overall outcome was satisfactory in 95%.


  Discussion Top


The prevalence of complex primary THA in our series is 42% which is comparable to another similar study.[1] Our mean age was close to that seen in another work.[4] In our series, the mean operative time (140 min) and mean intraoperative blood loss (1400 ml) are comparable with other studies.[5],[6],[7] The challenges encountered and possible solutions related to different complex hips of our series are discussed one by one.

Challenges of complex primary total hip arthroplasty in cases of ankylosed hip due to ankylosing spondylitis

In our series, majority of the cases were of AS with almost fused hip joints bilaterally. These cases were very challenging right from its preoperative evaluation. Degree of limb shortening, deformity, presence of a joint line, presence of greater trochanter, and hip abductor function should be properly assessed before THA.[8],[9],[10],[11],[12] Due to loss of range of motion of hip, surgical exposure and then dislocating the head of femur are difficult. In our series, we were able to dislocate all but four cases by gradual rocking movement of hip. Four cases of AS required an in situ femoral neck osteotomy by angling the saw blade in line with native acetabulum and leaving sufficient quantity of bone in ilium[13] and then piecemeal removal of head with subsequent reaming to create acetabulum. While reaming, it is difficult to identify the true acetabular cavity and was done by triangulating the three vital surgical landmarks: the obturator foramen inferiorly, the sciatic notch posteriorly, and the pubic bone anteriorly.[14] Femoral canal preparation was another problem one can face in these cases because of abnormal proximal femoral anatomy with a sclerotic femoral canal. One must be prepared to use modular implants to accommodate anatomical deficiencies or abnormalities. We faced such problem in almost all cases but managed by slow graduated rasping of canal and use of modular implant. Two cases had intraoperative minor calcar split which was managed by delayed weight-bearing. One must check the adductor tightness after completion of THA and percutaneous adductor tenotomy to be done, if adductor angle is >30°.[9] Almost all cases of AS required adductor tenotomy in our series. Bilateral cases [Figure 1] were done in two separate sittings with a minimum interval of 2 months.
Figure 1: Case of ankylosing spondylitis with preoperative radiograph showing bilateral ankylosed hip (a) and postoperative radiograph showing bilateral uncemented total hip arthroplasty (b)

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Challenges with avascular necrosis of femoral head with secondary arthritis

In our study, the second most common cases of complex hips were of AVN of heads of femurs. Majority of them had idiopathic AVN followed by posttrauma (hip fracture). None of our patients had pathology like sickle cell disease, as reported in other series.[15] These cases were associated with severe soft-tissue contractures, limb shortening, secondary early Osteoarthritis (OA) of hip, wandering acetabulum, subluxated head of femur, and narrow femoral canal. In these cases, dislocating the head was not the problem. AVN with wandering acetabulum [Figure 2] was tackled by using Jumbo shell. Shortening of limb was tackled by less cutting of neck. Femoral canal preparation and adductor tenotomy were done in similar manner, as done for the cases of AS.
Figure 2: Case of avascular necrosis with preoperative radiograph showing avascular necrosis of left femoral head with wandering acetabulum (a) and postoperative radiograph showing uncemented total hip arthroplasty using Jumbo Shell (b)

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Challenges with old neglected/operated hip fracture with or without hardware

In old neglected fracture neck femur cases, problems faced were mainly severe soft-tissue contractures and limb shortening and tackling them were not a problem. Duration of surgery and blood loss were more in these cases due to extensive Soft tissue release (STR). In old operated hip fractures, the hardware encountered in situ included CCSs – 2 cases, dynamic hip screw – 1 case, acetabular reconstruction plates – 1 case, and hemiarthroplasty components (Austin Moore prosthesis) – 1 case. All together five cases of hardware encountered in our series. These hardware had to be removed in the same stage surgery after which the total hip components were inserted. However they were associated with significantly longer procedures, more blood loss, presence of heterotrophic ossification, and increased risk of infection as mentioned in other studies.[16],[17] One case got splitter of proximal femur while rasping and was managed by wiring it [Figure 3]a and [Figure 3]b. One another case had absorbed neck managed by modular prosthesis for limb equalization [Figure 3]c and [Figure 3]d.
Figure 3: Two cases of old operated fracture neck femur with hardware (cannulated cancellous screws) in situ; Pre- and postoperative radiograph (a and b) showing splitter of proximal femur while rasping and was managed by wiring. Pre- and postoperative radiograph (c and d) showing absorbed neck managed by modular prosthesis for limb equalization

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Challenges with old acetabular fracture

The indications of THA in old acetabular fracture are (a) intra-articular comminution, (b) loss of the articular cartilage, (c) impaction of femoral head, and (d) impaction of acetabulum that involves 40% of the joint surface or weight-bearing region.[18] Two cases of old fracture of acetabular underwent THA in our series and had satisfactory result. One had impacted acetabulum due to malunion [Figure 4] and another one was operated case with acetabular plate in situ. The prognosis may be poor in these cases either due to thin and abnormal acetabulum or due to osteopenic bones.[19]
Figure 4: Preoperative radiograph (a) showing fracture acetabular floor (blue arrow) with incongruent hip and postoperative radiograph (b) of the same patient operated by cemented total hip arthroplasty with bone grafting showing impacted acetabulum due to malunion (Yellow arrow) but reasonably congruent hip

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Challenges with protrusio acetabuli

The main challenges in protrusio acetabuli are difficulty dislocating the hip and thin medial acetabular walls. Head should be removed in piecemeal after cutting the femoral necks in situ, and the hip center should be restored to within 10 mm of its anatomical location for improved cup survivorship.[20],[21] Peripheral reaming of the acetabulum is done to avoid medialisation, and low femoral neck resection with the use of increased medial offset is preferred to avoid excessive limb lengthening.[13] The cavitary defect behind the cup should be augmented with cancellous bone graft and impaction grafting techniques.[22] Protrusio cup can be used for better outcome as suggested in some reports.[1],[23] In our series, we had two cases of protrusio with one satisfactory result. In one another case, there was excessive medialisation and the outcome was poor [Figure 5].
Figure 5: Preoperative radiograph (a) showing bilateral protrusio acetabuli and postoperative radiograph (b) of total hip arthroplasty of left hip of the same patient showing excessive medialization and the outcome was poor

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Challenges with old unreduced dislocation of hip and other complex cases

The other complex cases, as shown in [Table 2], sometimes had a combination of features causing challenges intraoperatively. In order to reduce the dislocation, none of our patients had femoral shortening as reported by some workers.[24] Tight or absent medullary cavity was overcome by slow graduated rasping into the canal. Multiple acetabular cysts and defects were carefully curetted, reamed, and bone grafted (if needed) by using autogenous bone graft as there is none availability of allogenic bone graft (bone banks) in our center. Sometimes, conversion of Girdlestone arthroplasty is required as reported[25] but was not done on any of our patient. Patients with poor bone quality and absent/narrow medullary cavity are having high chances of calcar split during reaming and stem introduction. In this same group of patients, one may encounter difficulty locating the medullary cavity led to femoral perforation or even femoral splinter. Thus, some works have reported that intraoperative consideration of bone stock, quality, and method of component fixation may help minimize the risk of eccentric reaming, perforation or fracture of either the acetabulum or the femur, and loosening.[26] Patients with calcar split (two cases) and splinter (one case) were managed by cerclage wiring of the proximal femur and were advised delayed weight-bearing. The patients with femoral perforation can be managed by eventually locating the canal and bypassing it by the stem. None of our patients had femoral perforation.


  Conclusion Top


Complex THA is challenging and needs to assess properly and to be done meticulously. One must anticipate and avoid the challenging technical difficulties such as high incidence of intraoperative complications, increased operation time, and blood loss. The surgical exposure and subsequent placement of components can be significant challenges in complex THA which can be tackled by using proper instrumentation and modular implants. With proper surgical technique, proper instrumentation, and proper implantation, one can expect good-to-excellent results even in complex THA.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Sathappan SS, Strauss EJ, Ginat D, Upasani V, Di Cesare PE. Surgical challenges in complex primary total hip arthroplasty. Am J Orthop (Belle Mead NJ) 2007;36:534-41.  Back to cited text no. 3
    
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13.
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Nwadinigwe CU, Anyaehie UE, Ogbu DC, Muoghalu O. Orthopaedic complications of sickle cell disease: A review. Niger J Orthop Trauma 2011;10:81-8.  Back to cited text no. 15
    
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Weber M, Berry DJ, Harmsen WS. Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am 1998;80:1295-305.  Back to cited text no. 16
    
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Bayley JC, Christie MJ, Ewald FC, Kelley K. Long-term results of total hip arthroplasty in protrusio acetabuli. J Arthroplasty 1987;2:275-9.  Back to cited text no. 21
    
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25.
Alva A, Shetty M, Kumar V. Old unreduced traumatic anterior dislocation of the hip. BMJ Cas Rep 2013;2013:bcr2012008068.  Back to cited text no. 25
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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