• Users Online: 48
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 30  |  Issue : 2  |  Page : 62-66

Extended trochanteric osteotomy for recurrent dislocation in primary total hip replacement-A case report


1 Orthopaedic Department, Woodland Multi speciality Hospital, Kolkata, India
2 Dept. of Orthopaedic Surgery, Murshidabad Medical College, W.B, India

Date of Submission26-Jun-2022
Date of Acceptance12-Aug-2022
Date of Web Publication24-Dec-2022

Correspondence Address:
Dr. Abhijit Bandyopadhyay
Orthopaedic Department, Woodland Multi speciality Hospital, Kolkata
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijors.ijors_8_22

Rights and Permissions
  Abstract 

Dislocation after primary total hip replacement (THR) elicits significant morbidity and also affects the quality of life. Various patients and surgery related factors are the predictors of dislocation. The present case describes with six major prior surgeries for dislocation with a long cemented stem as a major reason. After complete evaluation, our plan was extended trochanteric osteotomy for cement removal followed by distal fit interlocked long stem, use of constrained acetabular liner and a larger head. At 5th post-operative day, patient had good functional outcome and no radiographic evidence of complications.

Keywords: Constrained acetabular liner, extended trochanteric osteotomy, reef system, revision arthroplasty


How to cite this article:
Bandyopadhyay A, Kumar S. Extended trochanteric osteotomy for recurrent dislocation in primary total hip replacement-A case report. Int J Orthop Surg 2022;30:62-6

How to cite this URL:
Bandyopadhyay A, Kumar S. Extended trochanteric osteotomy for recurrent dislocation in primary total hip replacement-A case report. Int J Orthop Surg [serial online] 2022 [cited 2023 Feb 9];30:62-6. Available from: https://www.ijos.in/text.asp?2022/30/2/62/365204




  Introduction Top


Total hip replacement (THR) is the routinely performed surgical intervention for the management of pain and disability as a result of diseases of hip joint such as osteoarthritis.[1],[2] Although, it elicits increased success rate, in some cases the failure in primary replacement occurs. The revision post primary total hip replacement occurs with the clinical indication such as aseptic loosening, joint dislocation, infection at the prosthetic joint site, peri prosthetic fractures and adverse effects as a result of multiple operative intervention.[3] Previous studies indicate the incidence of dislocation after primary THR ranges between 1–21% and after revision THR is 9–21%.[4] In the cases of primary THR, 2/3rd of dislocation can be treated by conservative methods and 1/3rd requires surgical correction. Majority of the prosthetic dislocations are posterior and nearly 70% of dislocations in hip arthroplasty occur in 1st month. However, the dislocation after 4–5 months is primarily due to the muscular imbalance especially the abductor mechanism and malposition of the components.[5] Recurrent dislocations generally require surgical correction and dislocation rates are higher in revision THR. The various surgical procedures reported in the literature are correction of hardware malposition, converting the head to larger size, using constrained implant/using elevated liners and trochanteric advancement.[6] We report an unusual case of a long-standing recurrent total hip replacement presenting in one year after index surgery.


  Case Report Top


We present here a 39 years old male patient who meets with an accident in 2013 April and suffers from head injury and right sided pelvic injury. After primary management at local hospital he was taken to a medical college and then to a Private hospital where he was diagnosed as posterior dislocation of hip with undisplaced acetabular fracture [Figure 1]. He was then treated with closed reduction and traction [Figure 2]. At the end of 3 weeks patient again suffered from severe pain in the hip joint and they lost their faith here at private hospital and shifted the patient to an another private hospital where they did acetabular fixation. But pain was not reduced and patient was unsatisfied and was unable to walk. Patient’s family member then opted for other hospital for treatment. There patient was offered standard cemented modular bipolar prosthesis as part of his treatment [Figure 3]. But on 1st post-operative day dislocation was noticed in the ward [Figure 4]. On the next day patient was taken to operation theatre where open reduction was done. Patient was made to walk on third postoperative day following which patient noticed severe pain. After that patient lost his faith in the operating surgeon and they decided to shift to other hospital.
Figure 1: Radiograph of Left hip fracture dislocation

Click here to view
Figure 2: Radiograph of Acetabular fixation

Click here to view
Figure 3: Radiograph of cemented Modular bipolar prosthesis

Click here to view
Figure 4: Radiograph showing the dislocation after cemented modular bipolar prosthesis

Click here to view


The whole process nearly took one month and the surgeon found the cemented bipolar prosthesis to be dislocated [Figure 5]. Surgical team this time planned to remove the implant and change into an uncemented long stem total hip replacement and the period was September 2013 [Figure 6]
Figure 5: Radiograph confirmation of cemented bipolar prosthesis dislocation

Click here to view
Figure 6: Radiograph of uncemented long stem total hip replacement

Click here to view


Patient was in good condition for 10 months. After that suddenly he noticed pain and difficulty in walking and so he went to the concern hospital for check-up where the basic investigations and X rays were normal. With antibiotics pain subsided and patient was persuaded and sent back to his hometown. But very next day the prosthesis got dislocated [Figure 7]. Then the patient was admitted to the same hospital where the implant was removed and was revised to long stem cemented total hip arthroplasty [Figure 8] and the period was September 2014. After 2 weeks the patient returned to home and was apparently well for a month and was able to walk without pain.
Figure 7: Radiograph showing the dislocation of uncemented long stem total hip replacement

Click here to view
Figure 8: Radiograph of long stem cemented total hip revision arthroplasty

Click here to view


But in October 2014 the patient had dislocation of the prosthesis [Figure 9]. In this condition the patient was admitted to our hospital. Through history was taken and clinically examined. CT scan was done with 3D reconstruction to observe acetabular wall deficiency, version and inclination of acetabular component and the femoral stem. He was thoroughly investigated to overruled t he infection and was planned and prepared for a massive revision total hip arthroplasty. Our plan was to remove the implant with minimum bone loss, to do a distal fit interlocked long stem (DePuy Synthes REEF™), to use a constrained acetabular liner and a larger head.
Figure 9: Radiograph showing dislocation of long stem cemented total hip revision arthroplasty

Click here to view


Patient was operated, extended trochanteric osteotomy was done, implants as well the cement was completely removed [Figures 10], (11) and (12). Acetabulum was completely checked for any deficiency and tight fit Acetabular shell was applied fixed with 2 screws. Constrained liner was applied. Femoral canal was prepared and Reef stem was applied and distally locked. ETO was repaired with SS wire. Trial reduction was done and to our satisfaction and stability was checked. Larger head of 36 mm was applied.
Figure 10: CT scan showing dislocation of long stem cemented total hip revision arthroplasty

Click here to view
Figure 11: Extended trochanteric osteotomy

Click here to view
Figure 12: Removal of Implants

Click here to view


Post-operative period was uneventful. Patient was discharged on 5th postoperative day, stitches were removed on 14th day. Postoperative X-ray was good [Figure 13] and [Figure 14]. After 7 years patient is walking normally and regularly performing his daily duties.
Figure 13: Removal of cements

Click here to view
Figure 14: Post-operative radiograph showing the complete fixation

Click here to view



  Discussion Top


Recurrent dislocation of hip prosthesis is a devastating problem for the surgeon as well the patient. So there is a need of customized management strategy which suits the patient. Mounting patient related factors are associated with elevated risk of dislocation such as older age, abnormal BMI, low socioeconomic status, addictive disorders and specific comorbidities. Previous spinal fusion and hip surgeries, THR for avascular necrosis, rheumatoid and inflammatory arthritis were the significant predictors for dislocation.[4]

In our case the dislocation of THR was recurrent so surgery was the mainstay of treatment. Further the integrity of acetabulum was checked so posterior approach was preferred in spite of the fact the posterior approach has more chances of dislocation. Per operatively we found loosely fitted long cemented stem and incorrect version of acetabular cup which were the major reasons for dislocation. Based on the above findings we did extended trochanteric osteotomy for complete removal of cement mantle. Removal of the cement is the vital and challenging part of the revision surgery. With the help of ETO, the cement and the restrictor was removed under our direct vision. ETO gives a wide exposure and avoid the iatrogenic fractures and bone loss. Previous study done by Park et al.[7] showed that the stem subsidence and cortical perforation rate is significantly higher in non-ETO patients as compared to ETO patients. Luo et al.[8] showed significant outcome using extended trochanteric osteotomy in high congenital hip dislocation. In this study, ETO of 8 cm to 12 cm yielded marked exposure of acetabulum and the femur, reporting a 100% union rate with excellent clinical outcome. Further, after 6 previous surgeries there was always a chance of proximal femoral bony deficiencies and osteopenia. So, distal fit fully HA coated long stem which can be interlocked to provide initial stability made by Depuy Synthes called Reef stem was chosen. To reduce the chances of dislocation, constrained liner was used, though it has longevity issues but we were comfortable with it. Increasing the femoral head size to 36 also reduces the chance of dislocation.


  Conclusion Top


Recurrent dislocation of hip arthroplasty is always challenging and there is no clear cut mandate or any established treatment protocol. Further, the risk factors have to be analysed and it is also essential to check the position of implant in safe zone. The treatment has to be customised after detail study of the patients.

Acknowledgements

Nil

Declaration of patient consent

Written informed consent to participate in the study was collected from the patient. Patient was informed that data concerning the case would be submitted for publication and he agreed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Berry DJ, Harmsen WS, Cabanela ME, Morrey BF. Twenty-five-year survivorship of two thousand consecutive primary charnley total hip replacements: Factors affecting survivorship of acetabular and femoral components. J Bone Joint Surg Am 2002;84:171-7.  Back to cited text no. 1
    
2.
Söderman P, Malchau H, Herberts P. Outcome after total hip arthroplasty: Part I. General health evaluation in relation to definition of failure in the swedish national total hip arthoplasty register. Acta Orthop Scand 2000;71:354-9.  Back to cited text no. 2
    
3.
Dargel J, Oppermann J, Brüggemann GP, Eysel P. Dislocation following total hip replacement. Dtsch Arztebl Int 2014;111: 884-90.  Back to cited text no. 3
    
4.
Kunutsor SK, Barrett MC, Beswick AD, Judge A, Blom AW, Wylde V, et al. Risk factors for dislocation after primary total hip replacement: Meta-analysis of 125 studies involving approximately five million hip replacements. Lancet Rheumatol 2019;1:e111-21.  Back to cited text no. 4
    
5.
Dawson-Amoah K, Raszewski J, Duplantier N, Waddell BS. Dislocation of the hip: A review of types, causes, and treatment. Ochsner J 2018;18:242-52.  Back to cited text no. 5
    
6.
Lu Y, Xiao H, Xue F. Causes of and treatment options for dislocation following total hip arthroplasty. Exp Ther Med 2019;18:1715-22.  Back to cited text no. 6
    
7.
Park YS, Moon YW, Lim SJ. Revision total hip arthroplasty using a fluted and tapered modular distal fixation stem with and without extended trochanteric osteotomy. J Arthroplasty 2007;22:993-9.  Back to cited text no. 7
    
8.
Luo Z, Chen M, Hu F, Ni Z, Ji X, Zhang X, et al. Cementless total hip arthroplasty with extended sliding trochanteric osteotomy for high congenital hip dislocation: A retrospective study. Medicine (Baltimore) 2017;96:e6581.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed136    
    Printed10    
    Emailed0    
    PDF Downloaded17    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]