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Date: April 2018 | Orthovasive Times 4

Case Study

THR in Polyarticular rheumatoid arthritis and bilateral fibrous ankylosed fused hip

Dr. Manish Shah

Dr. Manish Shah

(Author)

MBBS (1990)

MS (Orthopedics) (1993)

Co-Author

Dr.Varun Vyas

Case Vignette:

25 year old male patient with polyarticular rheumatoid arthritis and bilateral fibrous ankylosed fused hips was planned for a total hip replacement. He had malunited subtrochanteric fracture of left femur and was unable to stand or walk.

Pre-Op X-Rays:

Following are the X-Rays of First Pre_op Follow-up

Fig. 1. Both HIP Joints pre -op 08_10_2014
Fig.2. Pre-Op X-Ray Left Hip
Fig.3. Pre-Op X-Ray Left Hip
Fig.4. Pre -Op X-Ray LAT
Fig. 5. Pre -Op X-Ray LAT Left side

Case Discussion:

Patient was taken up for surgery for the right hip elsewhere. During surgery, acetabulum was overreamed by surgeon and fracture was happened which was fixed with plating and autograft from femoral head and THR was postponed by the operating surgeon.
The patient was referred for further management on 5th post operative day(08-10-17) with acetabulum plating with excision arthroplasty of right hip. Acetabular reconstruction with total hip was done on 16th October 2014.

To manage the defect in presence of the freshly placed plate and graft, cemented dual mobility cup was planned. A cemented dual mobility cup is a metal shell and hence provides the additional support needed in presence of a stable acetabular floor. Additional allograft and cemented dual mobility was performed to salvage the situation. The patient could walk with toe-touch weight bearing on the second post-operative day.

On the opposite side, osteotomy of the proximal femur with shortening was performed to correct the deformity and a dual mobility hip with a long stem was placed with autograft from the excised bone along with additional allograft.

Fig. 6. Post-Op X-Ray of Right Hip
Fig. 7. Post-Op X-Ray of Left Hip

Conclusion:

Cemented dual mobility cups in presence of a repaired acetabulum is a good salvage option. The metal shell of the cemented dual mobility acetabulum serves as a reinforcement ring and can be used with allograft, cement or screw-cement augmentation. The procedure is a cost effective salvage option. In a study by Haen TX et
al, 66 pateints of cemented dual mobility cups used in cases of acetabular defects without using any other reinforcement devices were followed for five years. These cups showed a 95% survival at five years.

Follow-up:

With proper surgical technique and good implant inventory, it is possible to do a primary complex varus unstable knee using a PS Stabilised prosthesis.

Fig. 8. Three years follow-up X-Ray
Fig. 9. Three years follow-up X-Ray Left Hip
Fig. 10. Three years follow-up X-Ray Right Hip

References:

Haen TX et al, Ortho trauma surg res 2015 Nov 2. pii: S1877-0568(15)00272-8