332 © 2014 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd
VIDEO OF ORTHOPAEDIC TECHNIQUE
Total Hip Arthroplasty in Congenital Hip Dysplasia Ru-jie Zhuang, MD, Guan-jun Chen, MM Department of Orthopaedics, Zhejiang Chinese Medical Hospital, Hangzhou, China
Introduction owadays, total hip arthroplasty (THA) is frequently performed for serious hip diseases such as osteonecrosis of the femoral head, osteoarthritis of the hip, developed dysplasia of the hip1 and failed internal fixation of femoral neck fractures. In our hospital, more than 1000 patients with hip diseases of average age 71 years (range, 45–82 years) underwent THA last year. During these elderly patients’ hospitalizations, we had to face many difficulties because of comorbidities such as cardiovascular and respiratory diseases2. We have found that preoperative preparation and postoperative rehabilitation exercise are as important as the surgery itself in the elderly patients.
N
Case Presentation 67-year-old man presented with right hip pain for 30 years. He had not received a diagnosis or any effective treatment during these years and presented to our hospital for treatment. About 9 months previously, his local hospital had congenital hip dysplasia based on his typical medical history and imaging studies. On examination, we found that the right lower limb was 2 cm shorter than the contra-lateral limb. He had limitations of motion in flexion, extension, pronation and supination and difficulty in walking and the Patrick sign was positive. We detected no comorbidities. According to Crowe’s classification, his right hip was stage II. After discussion with the patient and his family, we agreed that THA was the optimal treatment3. The size of the required hip prosthesis was determined with a template preoperatively. After deep vein catheterization and induction of general anesthesia, a posterior-lateral approach was performed with the patient in a left lateral position. After identifying the greater trochanter of the femur, a longitudinal incision about 12 cm long with the greater trochanter as the center was made. An electrotome was then used to separate the skin, subcutaneous fascia, fat and muscle layer by layer, thus exposing the hip joint. After the capsule and other soft tissue had been excised, the femoral neck was clearly visible. Care was taken to ensure that 1.5 cm of bone in the femoral calcar was retained above the lesser trochanter, after
A
which the femoral head was removed with an osteotome. The femoral head was deformed and necrotic surface cartilage was attached to it. After removing the head, most of the soft tissue around the acetabulum, such as the capsule and labrum, was cleared to obtain a sufficiently clear view to allow enough reaming of the cartilage and inner cortex for cancellous bone to be visible. At this point, a suitably sized acetabular cup was chosen. To prevent subsequent dislocation, an anteversion angle of 10° to 15° and abduction angle of 35° to 40° was aimed for. The proximal femur was reamed with an intramedullary awl and intramedullary files that progressively increased in size until the femoral medullary space had been adequately prepared for the prosthesis. A suitably sized femoral stem prosthesis was then chosen and the head installed. Next, the hip joint was tested for any possibility of dislocation or length discrepancy, including performing flexion, extension, pronation and supination to ensure that dislocation would not occur. The external muscle groups were sutured carefully to prevent postoperative dislocation and the incision sutured layer by layer to ensure there was no dead space. Two days later, the patient was encouraged to walk by a sports-medicine physician. Because the patient was elderly, the chief orthopaedist and nurse would pay close attention to the patient’s cardiorespiratory function to prevent pulmonary embolism. Discussion lderly patients with congenital hip dysplasia often have comorbidities such as cardiovascular and respiratory diseases and other medical conditions. Therefore, before performing THA, we should ensure that the patient has no contraindications to surgery. Second, planning of the operation is extremely important. In China, the patients choose the type of hip prosthesis depending on the cost and the anticipated survival time. In this case, a ceramics–ceramic hip prosthesis was the best choice because the patient’s age. During the procedure, the reaming of the acetabulum is crucial to the success of the operation. It must be reamed until enough cartilage and inner cortex have been removed for cancellous bone to be visible4. The correct angles of the acetabulum are crucial to successful THA. Generally, an anteversion angle of 10° to 15°
E
Address for correspondence Ru-jie Zhuang, MD, Department of Orthopaedics, Zhejiang Chinese Medical Hospital, Hangzhou, China 310006 Tel: 0086-013867120008; Fax: 0086-571-87068001; Email: [email protected]
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Orthopaedic Surgery 2014;6:332–333 • DOI: 10.1111/os.12141
333 Orthopaedic Surgery Volume 6 · Number 4 · November, 2014
and an abduction angle 35° to 40° will prevent occurrence of dislocation. This requires that the surgeon have sufficient expertise, which can only be acquired by having clinical experience of more than 300 THAs. The proximal femur needs to be reamed with an intramedullary awl and progressively larger intramedullary files until the femoral medullary space has been adequately prepared for the prosthesis. Care must be taken to ensure that the proximal femur is not broken by the intramedullary awl. Finally, the size of the femoral stem prosthesis chosen should be such as will maintain joint stability and limb length. Postoperatively, pulmonary embolism is the most serious potential complication5. The chief orthopaedist and nurses should pay close attention to the patient’s cardiorespiratory function, including using a pneumatic pump and
THA for Congenital Hip Dysplasia
administering rivaroxaban 10 mg daily from 12 hours after completion of surgery. After THA, rehabilitation exercises are important. These patients should be encouraged to begin progressive ambulation and muscle strength exercises by the sports-medicine physician. This hard work maximizes the chance of THA for congenital hip dysplasia being successful and the patients achieving a good recovery. Video Image dditional video images may be found in the online version of this article. Visit http://onlinelibrary.wiley.com/doi/10.1111/os. 12141/suppinfo
A
References 1. Hasegawa Y, Iwase T, Kanoh T, Seki T, Matsuoka A. Total hip arthroplasty for Crowe type IV developmental dysplasia. J Arthroplasty, 2012, 27: 1629–1635. 2. Kieffer WK, Dawe EJ, Lindisfarne EA, Rogers BA, Nicol S, Stott PM. The results of total hip arthroplasty for fractured neck of femur in octogenarians. J Arthroplasty, 2014, 29: 601–604. 3. Kim YH, Kim JS. Total hip arthroplasty in adult patients who had developmental dysplasia of the hip. J Arthroplasty, 2005, 20: 1029–1036.
4. Pagkalos J, Chaudary MI, Davis ET. Navigating the reaming of the acetabular cavity in total hip arthroplasty: does it improve implantation accuracy? J Arthroplasty, 2014, 29: 1749–1752. 5. Jones MD, Parry MC, Whitehouse MR, Blom AW. Early death following primary total hip arthroplasty. J Arthroplasty, 2014, 29: 1625–1628.
VIDEO OF ORTHOPAEDIC TECHNIQUE
Total Hip Arthroplasty in Congenital Hip Dysplasia Ru-jie Zhuang, MD, Guan-jun Chen, MM Department of Orthopaedics, Zhejiang Chinese Medical Hospital, Hangzhou, China
Introduction owadays, total hip arthroplasty (THA) is frequently performed for serious hip diseases such as osteonecrosis of the femoral head, osteoarthritis of the hip, developed dysplasia of the hip1 and failed internal fixation of femoral neck fractures. In our hospital, more than 1000 patients with hip diseases of average age 71 years (range, 45–82 years) underwent THA last year. During these elderly patients’ hospitalizations, we had to face many difficulties because of comorbidities such as cardiovascular and respiratory diseases2. We have found that preoperative preparation and postoperative rehabilitation exercise are as important as the surgery itself in the elderly patients.
N
Case Presentation 67-year-old man presented with right hip pain for 30 years. He had not received a diagnosis or any effective treatment during these years and presented to our hospital for treatment. About 9 months previously, his local hospital had congenital hip dysplasia based on his typical medical history and imaging studies. On examination, we found that the right lower limb was 2 cm shorter than the contra-lateral limb. He had limitations of motion in flexion, extension, pronation and supination and difficulty in walking and the Patrick sign was positive. We detected no comorbidities. According to Crowe’s classification, his right hip was stage II. After discussion with the patient and his family, we agreed that THA was the optimal treatment3. The size of the required hip prosthesis was determined with a template preoperatively. After deep vein catheterization and induction of general anesthesia, a posterior-lateral approach was performed with the patient in a left lateral position. After identifying the greater trochanter of the femur, a longitudinal incision about 12 cm long with the greater trochanter as the center was made. An electrotome was then used to separate the skin, subcutaneous fascia, fat and muscle layer by layer, thus exposing the hip joint. After the capsule and other soft tissue had been excised, the femoral neck was clearly visible. Care was taken to ensure that 1.5 cm of bone in the femoral calcar was retained above the lesser trochanter, after
A
which the femoral head was removed with an osteotome. The femoral head was deformed and necrotic surface cartilage was attached to it. After removing the head, most of the soft tissue around the acetabulum, such as the capsule and labrum, was cleared to obtain a sufficiently clear view to allow enough reaming of the cartilage and inner cortex for cancellous bone to be visible. At this point, a suitably sized acetabular cup was chosen. To prevent subsequent dislocation, an anteversion angle of 10° to 15° and abduction angle of 35° to 40° was aimed for. The proximal femur was reamed with an intramedullary awl and intramedullary files that progressively increased in size until the femoral medullary space had been adequately prepared for the prosthesis. A suitably sized femoral stem prosthesis was then chosen and the head installed. Next, the hip joint was tested for any possibility of dislocation or length discrepancy, including performing flexion, extension, pronation and supination to ensure that dislocation would not occur. The external muscle groups were sutured carefully to prevent postoperative dislocation and the incision sutured layer by layer to ensure there was no dead space. Two days later, the patient was encouraged to walk by a sports-medicine physician. Because the patient was elderly, the chief orthopaedist and nurse would pay close attention to the patient’s cardiorespiratory function to prevent pulmonary embolism. Discussion lderly patients with congenital hip dysplasia often have comorbidities such as cardiovascular and respiratory diseases and other medical conditions. Therefore, before performing THA, we should ensure that the patient has no contraindications to surgery. Second, planning of the operation is extremely important. In China, the patients choose the type of hip prosthesis depending on the cost and the anticipated survival time. In this case, a ceramics–ceramic hip prosthesis was the best choice because the patient’s age. During the procedure, the reaming of the acetabulum is crucial to the success of the operation. It must be reamed until enough cartilage and inner cortex have been removed for cancellous bone to be visible4. The correct angles of the acetabulum are crucial to successful THA. Generally, an anteversion angle of 10° to 15°
E
Address for correspondence Ru-jie Zhuang, MD, Department of Orthopaedics, Zhejiang Chinese Medical Hospital, Hangzhou, China 310006 Tel: 0086-013867120008; Fax: 0086-571-87068001; Email: [email protected]
bs_bs_banner
Orthopaedic Surgery 2014;6:332–333 • DOI: 10.1111/os.12141
333 Orthopaedic Surgery Volume 6 · Number 4 · November, 2014
and an abduction angle 35° to 40° will prevent occurrence of dislocation. This requires that the surgeon have sufficient expertise, which can only be acquired by having clinical experience of more than 300 THAs. The proximal femur needs to be reamed with an intramedullary awl and progressively larger intramedullary files until the femoral medullary space has been adequately prepared for the prosthesis. Care must be taken to ensure that the proximal femur is not broken by the intramedullary awl. Finally, the size of the femoral stem prosthesis chosen should be such as will maintain joint stability and limb length. Postoperatively, pulmonary embolism is the most serious potential complication5. The chief orthopaedist and nurses should pay close attention to the patient’s cardiorespiratory function, including using a pneumatic pump and
THA for Congenital Hip Dysplasia
administering rivaroxaban 10 mg daily from 12 hours after completion of surgery. After THA, rehabilitation exercises are important. These patients should be encouraged to begin progressive ambulation and muscle strength exercises by the sports-medicine physician. This hard work maximizes the chance of THA for congenital hip dysplasia being successful and the patients achieving a good recovery. Video Image dditional video images may be found in the online version of this article. Visit http://onlinelibrary.wiley.com/doi/10.1111/os. 12141/suppinfo
A
References 1. Hasegawa Y, Iwase T, Kanoh T, Seki T, Matsuoka A. Total hip arthroplasty for Crowe type IV developmental dysplasia. J Arthroplasty, 2012, 27: 1629–1635. 2. Kieffer WK, Dawe EJ, Lindisfarne EA, Rogers BA, Nicol S, Stott PM. The results of total hip arthroplasty for fractured neck of femur in octogenarians. J Arthroplasty, 2014, 29: 601–604. 3. Kim YH, Kim JS. Total hip arthroplasty in adult patients who had developmental dysplasia of the hip. J Arthroplasty, 2005, 20: 1029–1036.
4. Pagkalos J, Chaudary MI, Davis ET. Navigating the reaming of the acetabular cavity in total hip arthroplasty: does it improve implantation accuracy? J Arthroplasty, 2014, 29: 1749–1752. 5. Jones MD, Parry MC, Whitehouse MR, Blom AW. Early death following primary total hip arthroplasty. J Arthroplasty, 2014, 29: 1625–1628.
