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Cementless total hip arthroplasty for adult patients with sequelae from childhood hip infection: A medium-term follow-up study
Journal Pre-proof Cementless total hip arthroplasty for adult patients with sequelae from childhood hip infection: A medium-term follow-up study Liang Zhang, MD, Yaming Chu, MD, Hongyi Shao, MD, Tao Bian, MD, Weiyi Li, MD, Yixin Zhou, MD PhD PII:
S0883-5403(20)30195-9
DOI:
https://doi.org/10.1016/j.arth.2020.02.034
Reference:
YARTH 57828
To appear in:
The Journal of Arthroplasty
Received Date: 18 November 2019 Revised Date:
4 February 2020
Accepted Date: 16 February 2020
Please cite this article as: Zhang L, Chu Y, Shao H, Bian T, Li W, Zhou Y, Cementless total hip arthroplasty for adult patients with sequelae from childhood hip infection: A medium-term follow-up study The Journal of Arthroplasty (2020), doi: https://doi.org/10.1016/j.arth.2020.02.034. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Cementless Total Hip Arthroplasty for Adult Patients with Sequelae from Childhood Hip Infection: A Medium-term Follow-up Study Liang Zhang MDa, Yaming Chu MDa, Hongyi Shao MDa, Tao Bian MDa, Weiyi Li MDb, Yixin Zhou MD PhDa,
a.
Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College
of Peking University, No.31 Xinjiekou East Street, Xicheng District, Beijing 100035, China b.
Department of Physical Therapy and Rehabilitation, Beijing Jishuitan Hospital, Fourth
Clinical College of Peking University, No.31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
Please address all correspondence to:
Yixin Zhou, MD, PhD Department of Orthopaedic Surgery Beijing Jishuitan Hospital, Fourth Clinical College of Peking University No.31 Xinjiekou East Street, Xicheng District, Beijing 100035 China Phone: 86-10-58516724, 86-13601019278 FAX: 86-10-58516724 Email: [email protected]
Emails of other authors: Liang Zhang, MD: [email protected] Yaming Chu, MD: [email protected] Hongyi Shao, MD: [email protected] Tao Bian, MD: [email protected] Weiyi Li, MD: [email protected]
1
Cementless total hip arthroplasty for adult patients with
2
sequelae from childhood hip infection:
3
A medium-term follow-up study
4
【Abstract】Objective To evaluate midterm clinical and radiographic results of total
5
hip arthroplasty(THAs) with cementless implants for adult patients with sequelae
6
from childhood hip infection. Methods Between 2002 and 2016, 165 patients (165
7
hips) who had a hip infection during childhood were treated with THAs with
8
cementless implants. The average duration of follow-up was 93.5 months (range,
9
26-206 months). Clinical results were evaluated via the Harris hip score (HHS) and
10
radiographic results were analyzed with postoperative serial x-rays. Results The
11
average HHS increased from 27 (range, 22-34) before surgery to 91 (range, 86-93) at
12
the latest follow-up examination (P < 0.001). At the latest follow-up evaluation, nine
13
cementless acetabular components demonstrated partial, nonprogressive
14
radiolucencies. No subsidence of more than 2 mm or evidence of a radiolucent line
15
was observed around the femoral components. Intraoperative periprosthetic fractures
16
occurred in 11 hips, including three acetabular fractures, two fractures of greater
17
trochanter, one femoral shaft fracture and five fractures of femoral calcar.
18
Postoperative complications included three cases of periprosthetic infection, one
19
episode of dislocation, one case of a femoral periprosthetic fracture, five cases of
20
sciatic nerve injury, one case of femoral nerve injury and one case of squeaking from
21
a ceramic bearing surface. Conclusions Cementless THA for adult patients with
22
sequelae from childhood hip infection presents significant technical challenges and a
23
relatively high complication rate. With meticulous surgical planning and anticipation
24
for the key technical challenges frequently encountered, the medium-term clinical and
25
radiographic results of THA in this setting were good with high implant survivorship
26
and patient satisfaction.
27
【Key words】Arthroplasty, hip infection, sequelae, cementless
28 29
Introduction
30
Total hip arthroplasty (THA) has been utilized to treat sequelae associated with
31
childhood hip infection for many years. However, the midterm and long-term
32
outcomes of THA in this young and active population remain controversial【1-6】. The
33
technical difficulties of THA in these patients are unique to a condition in which the
34
hip joint develops multi-planar deformities on both the acetabular and femoral sides
35
【7-9】. In addition to the young age of these patients and the presence of bone defects
36
and soft tissue scarring, THA is also often complicated by previous surgical
37
procedures performed during childhood【10-11】.
38
The aim of this study was to review the results of cementless THA for adult
39
patients with sequelae from previous childhood hip infection with an average
40
follow-up of 7.8 years. We hypothesized that THA for these patients may result in
41
pain relief, in addition to functional improvement, all while yielding high implant
42
survivorship and a low complication rate. The influence of the Crowe classification
43
grading on clinical outcomes of THA was also evaluated.
44 45 46 47
Materials and Methods Demographics A retrospective review was conducted of consecutive unilateral THAs performed to
48
treat patients diagnosed with sequelae from previous childhood hip infection between
49
January 2002 and December 2016 in 181 hips in 181 patients. At the most recent
50
follow-up examination, 165 hips (165 patients) were available for evaluation with an
51
average follow-up time of 93.5 months (range, 26-206 months) after surgery.
52
Approval of the local institutional review board and informed consent from all
53
participating patients were obtained for this retrospective study.
54
The average age of all patients was 9.6 years (range, 1-14 years) at the onset of the
55
index hip infection and 45.6 years (range, 18-79 years) at the time of THA. The
56
average interval between the initial infection and performing THA was 431.3 months
57
(96-816 months). According to the Crowe classification system【12】, all hips were
58
graded as type I (71cases), type II (53 cases), type III (24 cases) and type IV(17 cases).
59
The initial treatment was nonoperative in 112 hips (conservative treatment group) and
60
surgical intervention in 53 hips (surgical-treatment group), including joint
61
debridement and irrigation in 46 hips, arthrodesis in 4 hips, Girdlestone operation in 3
62
hips. Ankylosis of the hip before surgery was seen in 9 hips. Preoperative bone
63
defects were classified according to Paprosky criteria【13-14】. On the acetabular side,
64
there were 145 grade I acetabular defects and 20 grade II defects. On the femoral side,
65
there were 157 grade I femoral defects and 8 grade II defects.
66
Bacteriologic Evaluations
67
The classification of childhood hip infection was made on the basis of historical
68
records, clinical features, such as the presence of a draining sinus, and radiographic
69
findings. The type of infection microorganism was pyogenic in 81 patients (49%),
70
tuberculosis in 38 patients (23%) and unknown organisms in 46 patients (28%).
71
Among these 165 hips with childhood infection, 37 cases were confirmed with acute
72
hip sepsis. Meanwhile, 16 of 165 hips were seen with combined osteomyelitis of the
73
femur. Prior to arthroplasty, all patients were routinely evaluated with erythrocyte
74
sedimentation rate (ESR) and C-reactive protein (CRP) to elucidate whether an active
75
infection may be present. The ESR was elevated > 20 mm/h in 52 patients and the
76
CRP was elevated > 8 mg/L in 103 patients. Among them, only 3 patients had
77
elevated ESRs and CRPs. If an active hip infection was suspected prior to THA, a
78
technetium-99 bone scan was performed. Meanwhile, preoperative aspirations were
79
performed on 12 patients and the selection criteria include clinical and (or)
80
radiological suspicion of active infection and an elevated level of ESR and (or) CRP.
81
Intraoperatively, we cultured aspirates, smears, and excised specimens for growth
82
of aerobic, anaerobic, and tubercle bacilli. In cases with suspicious synovial fluid or
83
tissues, frozen section biopsies were performed during surgery. More than 5
84
polymorphonuclear leukocytes per high-power field in the frozen section specimen
85
are indicative of active infection. No case of active infection was detected in this
86
series. All patients received a systemic 2nd generation cephalosporin or vancomycin
87
for 2 to 5 days after the THA.
88
Surgical techniques and Prosthesis selection
89
A posterior surgical approach was performed in all hips. All acetabular components
90
were cementless and were implanted using a press-fit technique. The average
91
diameter of cups was 50.4 mm (range, 40 to 62 mm). In 5 hips with a shallow
92
acetabulum and poor acetabular coverage, the circumferential acetabular medial wall
93
osteotomy technique was utilized【15】. In 128 (77.6%) of 165 hips, cementless cups
94
were supplemented with 2 to 3 screws. Thirty-one hips had acetabular bone grafts; of
95
these, 23 had morcelized autografts and 8 received structural femoral head autografts.
96
All cementless stems were used to reconstruct the proximal femurs. In addition, we
97
implanted 61 modular S-ROM stems (DePuy, Warsaw). In 15 high dislocated hips
98
classified as Crowe Ⅳ, femoral transverse subtrochanteric shortening derotational
99
osteotomies were performed【16,17】. A ceramic-on-ceramic bearing surface was
100
utilized in 83 hips (50.3%), a ceramic-on-polyethylene bearing surface in 57 hips
101
(34.5%), and cobalt–chrome heads on a polyethylene bearing surface in 25 hips
102
(15.2%).
103
Clinical and radiographic evaluation
104
All patients were monitored clinically and radiographically on an outpatient basis at
105
3 and 6 months, as well as 1 year after surgery, and then biannually thereafter. For a
106
patient who missed outpatient appointment time, the observer who was responsible
107
for follow-up routinely got in touch with him all possible methods, including
108
telephone, E-mail, WeChat software at an interval of two weeks. Once this patient
109
failed to reply for three times, he will be regarded as a lost to follow-up (LTFU).
110
Clinical results were evaluated using the Harris hip score (HHS) system【18】by two
111
independent observers, who were not involved in performing the arthroplasties. The
112
HHS is based on the assessment of pain, function, deformity, and range of motion
113
(ROM). On the 100-point scale, a score of 90 points or more is defined as an excellent
114
outcome; 80 to 89 points, a good outcome; 70 to 79 points, a fair outcome; and 70
115
points or less, a poor outcome. Patient satisfaction was also evaluated using a
116
self-administered four-category scale (very satisfied, somewhat satisfied, somewhat
117
dissatisfied, and very dissatisfied).
118
Serial anteroposterior (AP) and translateral hip radiographs were examined for
119
evidence of radiolucencies, osteolysis or loosening of the prosthesis at the follow-up
120
visits. The bone-prosthesis interface was evaluated according to the zone system
121
described by Gruen et al【19】for the femoral side, and DeLee and Charnley【20】for
122
the acetabular side. Acetabular cup inclination angle and the anteversion angle were
123
measured by the method described by Widmer【21】. Loosening of the acetabular cup
124
was defined as a change of cup position exceeding 2 mm, a cup angle exceeding 3°,
125
or the detection of a radiolucent line thicker than 2 mm around a cup. Periprosthetic
126
cystic or scalloped lesions with a diameter of >2 mm that were not detected on
127
radiographs obtained immediately after the operation were defined as periprosthetic
128
osteolysis【22, 23】. Loosening of a cementless stem was defined as suggested by
129
Engh et al【24】. Bone union at the osteotomy site was assessed using postoperative
130
radiographs according to the method proposed by Masonis et al【25】. The formation
131
of postoperative heterotopic ossification (HO) was evaluated using the classification
132
described by Brooker et al【26】. Preoperative, postoperative, and the change in leg
133
length discrepancy (LLD) were recorded. The LLD is measured from the
134
inter-teardrop line to the midpoint of the lesser trochanter on both sides.
135
Statistical analysis
136
Data were statistically analyzed using SPSS software for Windows (version 18;
137
IBM, Armonk, NY, USA). Descriptive analyses for categorical variables were based
138
on percentages or frequencies and for continuous variables on mean and standard
139
deviation (SD) or median and quartile (25%-75%) if the data were skewed. The
140
preoperative and final follow-up HHS were compared using the Wilcoxon signed rank
141
test. The differences for the HHS between the conservative-treatment and
142
surgical-treatment groups were compared using the Mann-Whitney signed rank test.
143
The Kruskal-Wallis test was used to compare the HSS in the subgroups according to
144
the Crowe classification system. Significance was set at P<0.05, and tests were
145
2-tailed.
146 147
Results
148
Clinical assessment
149
The average HHS increased from 27 (range, 22-34) before surgery to 91 (range,
150
86-93) at the latest follow-up examination (P < 0.001). Results were excellent for 88
151
hips (53.33%), good for 54 (32.73%), fair for 20 (12.12%), and poor for 3 (1.82%).
152
The postoperative average HHS for the conservative-treatment and the
153
surgical-treatment groups increased from 26 (range, 20-34) and 28 (range, 24-34),
154
respectively, to 90 (range, 86-93) and 91 (range, 87-93) (P< 0.001), respectively.
155
However, there was no significant difference detected between groups regarding the
156
HHS at the latest follow-up examination (P> 0.05). We compared the HHS at the
157
latest follow-up examination among the four Crowe subgroups. The mean HHS
158
increased significantly from preoperative 26 (21-31) to 90 (86-93) at the latest
159
follow-up examination (P< 0.001) (Crowe I subgroup), from 27 (22-33) to 92 (88-95)
160
(P< 0.001) (Crowe II subgroup), from 30 (19-35) vs 89 (84-92) (P< 0.001) (Crowe III
161
subgroup) and from 34 (23-37) vs 93 (86-96) (P< 0.001) (Crowe IV subgroup),
162
respectively. However, no significant differences were observed between these
163
subgroups regarding the HHS at the latest follow-up examination (P> 0.05).
164
The patients who were very satisfied with the results of THA represented 105 hips
165
(63.64%), while those who were somewhat satisfied represented 49 hips (29.70%).
166
The patients who were somewhat dissatisfied with the results of THA represented 6
167
hips (3.64%) and those who were very dissatisfied represented 5 (3.03%) hips.
168
Radiographic results
169
Immediately after the THA, postoperative periacetabular gaps were observed in 17
170
hips (10.3%). Of these, 13 were less than 1 mm and the other 4 ranged from 1 to 2
171
mm. All but 5 of these gaps resolved during the initial 12 months after surgery.
172
At the latest follow-up evaluation, nine cementless acetabular components revealed
173
partial nonprogressive radiolucencies (three in zone I, three in zone I and II, three in
174
zone II and III, respectively). The average acetabular inclination angle was 39.0±7.2°
175
(range, 22.9-57.3°) and average anteversion angle was 17.8°±3.9° (range, 11.2-29.2°).
176
No cup was associated with evidence of marginal, retroacetabular or screw-related
177
osteolysis. At the latest follow-up visit, structural femoral head autograft appeared
178
partially resorbed, but well incorporated with the host bone. During the follow-up
179
period, bony union of the osteotomized medial acetabular wall and the femoral
180
subtrochanteric osteotomies was observed at an average of 4.4 months (range, 3.8-6.3
181
months) 【15】and 5.4 months (range, 4.8-6.3 months) after THA, respectively.
182
According to the Engh classification【24】, 137 stems showed stable bony ingrowth,
183
and 28 stems showed stable fibrous ingrowth at the latest follow-up examination. No
184
subsidence of more than 2 mm or radiolucent line was observed around the femoral
185
components.
186
The mean LLD decreased from 27.0 mm (range, 0.2-76.3 mm) preoperatively to
187
11.9 mm (range, -19.9-43.9 mm) postoperatively.
188
Complications
189
Intraoperative periprosthetic fractures occurred in 11 hips (3 hips with Crowe I, 5
190
hips with Crowe II, 3 hips with Crowe IV) including three acetabular fractures, two
191
fractures of the greater trochanter, one femoral shaft fracture and five fractures of the
192
femoral calcar. Two of these acetabular fractures were treated conservatively and cup
193
fixation was not compromised. The other acetabular fracture (Crowe IV) was
194
associated with the posterior column was considered an operative fracture that was
195
treated with open reduction and internal fixation. All femoral fractures were treated
196
with cerclage cabling and these healed uneventfully without signs of component
197
loosening.
198
Postoperative complications included three cases of periprosthetic infection, one
199
episode of dislocation, one periprosthetic femur fracture, five cases of sciatic nerve
200
injury, one case of femoral nerve injury and a case of squeaking from ceramic bearing
201
surfaces. The first periprosthetic infection occurred in a Crowe type III 43-year-old
202
male patient 3 years after THA. The interval between the childhood infection and
203
THA was 386 months and the patient had no history of surgery for his hip infection
204
during childhood. The infecting organism during childhood was unknown and it was
205
Staphylococcus aureus during the periprosthetic infection. The second case occurred
206
in a Crowe type II 22-year-old female patient one year after THA. The interval
207
between the childhood infection and THA was 182 months. The infecting organism
208
during childhood was Escherichia coli and it was Staphylococcus epidermidis during
209
the periprosthetic infection. The patient also had no history of surgery for hip
210
infection. Considering that the infecting organism was sensitive to antibiotics without
211
the characteristic of multi-drug resistance and the implants remained stable, both of
212
the two patients were successfully treated with surgical debridement with implant
213
retention. Fortunately, there was no recurrent of infection at the time of latest
214
follow-up. The third case with periprosthetic infection was seen 3 months after THA
215
in a Crowe type III 34-year-old male patient with an interval between the childhood
216
infection and THA of 230 months. The BMI before THA was only 19.2. The
217
preoperative level of ESR and CRP was 10 mm/h and 10 mg/L, respectively. So the
218
patient did not receive any technetium-99 bone scan or joint aspiration before THA.
219
The same organism, Mycobacterium tuberculosis, was isolated from the surgical
220
specimens at the time of debridement. The patient was treated with prosthesis removal
221
and antibiotic-loaded articulating cement spacers. Unfortunately, the reinfection
222
remained uncontrolled and the patient refused to receive any further revision surgery.
223
Two hips (Crowe II) with iatrogenic sciatic nerve injury had concomitant
224
periprosthetic fractures of the greater trochanter. One hip (Crowe IV) underwent a
225
subtrochanteric osteotomy and the length of the segmental resection was 3.0 cm. All
226
sciatic and femoral nerve injuries were treated with methylprednisolone and
227
mecobalamin injection, physiotherapy and dorsal extension orthosis (for sciatic nerve
228
injuries only). Among these sciatic nerve injuries, one case had a full recovery within
229
one year after THA, one had a partial recovery but another two cases did not
230
demonstrate any significant improvement in the sensory disturbance and foot drop.
231
The patient with a femoral nerve injury had a full recovery within three months after
232
THA.
233
Postoperative new-onset periprosthetic fracture, which occurred in one patient three
234
years after THA, was treated with open reduction and internal fixation and the
235
fracture healed without any further complication at the latest follow-up evaluation.
236
Postoperative dislocation, which occurred in one patient (Crowe IV) 8 weeks after
237
THA, was treated with closed reduction and there were no further events at the time
238
of the final follow-up examination. One complaint of asymptomatic squeaking
239
occurred with a ceramic-on-ceramic bearing surface.
240
After surgery, 33 hips (20%) demonstrated HO: Brooker class I in 27, class II in 4,
241
and class III in 2; there were no cases of class IV HO. Of these 33 hips, 20 hips were
242
of Crowe Type I, 6 of Type II, 4 of Type III and 3 of Type IV. No patient required
243
further surgery for HO.
244 245
Discussion
246
Adult patients diagnosed with end-stage osteoarthritis for sequelae from childhood
247
hip infection frequently manifest with severe anatomical deformities of the proximal
248
femur and acetabulum, as well as circumferential soft tissue and hence confer
249
considerable technical difficulties in performing THA. In the current study, we found
250
that although the reconstruction was technically demanding and complication rate was
251
relatively high, overall component survivorship was generally excellent with
252
encouraging clinical results and a high level of patient satisfaction.
253
The risk of reinfection should be considered seriously. Some authors have
254
emphasized that reinfection did not recur with THA, providing that infection had been
255
quiescent for more than 10 years【1-5】. Dudkiewicz et al【2】reported a group of
256
young patients with early coxarthrosis caused by septic hips in childhood, with an
257
average age of 19.1 years (range, 14-25) at the time of THA. No infection other than
258
one positive bone culture was noted after a mean follow-up of 8.1 years (range, 2-24).
259
The authors noted that the mean interval between the previous infection and the THA
260
was 15.2 years (range, 8-22). Kim et al【3】retrospectively analyzed 170 THAs that
261
were performed in patients with infection of the hip during childhood. All hips with a
262
quiescent period of more than ten years had no recurrence of infection. The remaining
263
two hips in one patient with a quiescent period of seven years had recurrence of the
264
infection. In our series, three cases of periprosthetic infection were confirmed during
265
the follow-up time period. The interval between the previous infection and subsequent
266
THA ranged from 182-386 months, respectively. Only in one of these cases were the
267
organisms the same organism and can be regarded as a reoccurrence of the childhood
268
infection. In this case, Mycobacterium tuberculosis was isolated from the surgical
269
specimens at the time of debridement, which matched the records for the childhood
270
organism.
271
Another important consideration when performing THA on these young, active
272
patients with severe anatomical deformities is component survivorship. Previous
273
reports have demonstrated relatively high revision and related complication rates,
274
such as osteolysis【1-3】. Fortunately, to date, none of the hips in our series required
275
revision for aseptic loosening and there are likely multiple potential explanations for
276
this. First, the follow-up period was relative short at an average of 93.5 months.
277
Second, all cups and stems that were implanted were cementless components. In
278
addition, we implanted 61 modular S-ROM stems for the cases with small and/or
279
straight medullary cavities, increased anteversion of proximal femur, or combined
280
subtrochanteric shortening derotational osteotomies【4, 27-29】. Third, there was a
281
comparably high percentage of ceramic bearing surfaces, with 50.3% of the hips
282
having a ceramic-on-ceramic bearing surface and 34.5% of the hips having a
283
ceramic-on-polyethylene bearing surface.
284
There is no disease-specific classification system for sequelae from childhood hip
285
infection. In fact, only Kim et al【3】have previously proposed a descriptive
286
radiographic system in their series. In this regard, the preoperative anatomic
287
deformity of the hip was retrospectively classified into three types. However,
288
differences between the subtypes were not discussed. In our series, we used the
289
Crowe classification system【11】,which plays a critical role in preoperative planning,
290
selection of operative technique and implants, and assessment of results for this case
291
series. We detected no significant differences between the Crowe subgroups regarding
292
the HHS at the latest follow-up examination. The THA reconstruction for cases with
293
Crowe III and IV in our series were still technically demanding both on the acetabular
294
and femoral sides. For instance, for hips in Crowe III and IV subgroup, the proportion
295
requiring a modular S-ROM stem was 58% (14/24) and 76% (13/17), respectively and
296
subtrochanteric shortening derotational osteotomies were performed in 15 hips.
297
Despite this, the incidence of intraoperative complications was relatively high.
298
Among 11 intraoperative periprosthetic fractures, 3 cases were in the Crowe IV
299
subgroup. A high percentage of postoperative complications were also observed in the
300
two subgroups, including one dislocation (Crowe IV), two periprosthetic infections
301
(Crowe III), three sciatic nerve injuries (2 cases with Crowe III and one case with
302
Crowe IV), and one femoral nerve injury (Crowe III).
303
There are several limitations to note in the present study. First, it was
304
retrospective with the inherent potential for inaccurate medical records and
305
information bias. Second, operations were performed by several surgeons that could
306
lead to diversity in implant choice. Third, because of a large time span of follow-up
307
duration with a maximum of 206 months, the identification of hip infection during
308
childhood by chart review (if obtained) and patient questionnaire may be
309
questionable.
310 311
In summary, cementless THA for adult patients with sequelae from childhood hip infection presents substantial technical challenges and a relatively high
312
complication rate. Despite this, it is possible that with meticulous surgical planning
313
and anticipation of key technical difficulties, the medium-term clinical and
314
radiographic results of THA can be good with high implant survivorship and a high
315
levels of patient satisfaction. Also, we emphasis the necessity of a comprehensive
316
screening system, including clinical, radiological, laboratory examination and
317
histological, bacteriological sampling evaluation, for maximizing the chances of
318
identifying residual microorganism.
319
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320
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12. Crowe JF, Mani VJ, Ranawat CS. Total hip replacement in congenital dislocation and dysplasia of the hip. J Bone Joint Surg Am 1979;61:15-23. 13. Paprosky WG, Magnus RE. Principles of bone grafting in revision total hip
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arthroplasty. Acetabular technique. Clin Orthop Relat Res 1994;147-155.
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14. Paprosky WG, Lawrence J, Cameron H. Femoral defect classification clinical
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89:1149-1154. 16. Wang D, Li LL, Wang HY, Pei FX, Zhou ZK. Long-Term Results of Cementless
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Total Hip Arthroplasty With Subtrochanteric Shortening Osteotomy in Crowe
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Type IV Developmental Dysplasia. J Arthroplasty 2017;32:1211-1219. doi:
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10.1016/j.arth.2016.11.005.
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17. Park KS, Yoon TR, Song EK, Seon JK, Lee KB. Total hip arthroplasty in high
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18. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures:
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evaluation. J Bone Joint Surg. 1969;51:737.
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19. Gruen TA, McNeice GM, Amstuts HC. “Modes of failure” of cemented stem-type
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femoral components: A radiographic analysis of loosening. Clin Orthop Relat Res
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370 371 372 373 374
20. Delee JG, Charnley J. Radiological demarcation of cemented sockets in total hip. Clin Orthop Relat Res 1976;121:20-32. 21. Widmer KH. A simplified method to determine acetabular cup anteversion from plain radiographs. J Arthroplasty 2004;19:387-390. 22. Joshi RP, Eftekhar NS, McMahon DJ, Nercessian OA. Osteolysis after Charnley
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primary low-friction arthroplasty. A comparison of two matched paired groups. J
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Bone Joint Surg Br 1998;80:585-590.
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23. Maloney WJ, Jasty M, Harris WH, Galante JO, Callaghan JJ. Endosteal erosion in
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association with stable uncemented femoral components. J Bone Joint Surg Am
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1990;72:1025-1034.
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24. Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic
381
fixation of porous-surfaced femoral components. Clin Orthop Relat Res
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1990;257:107-128.
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25. Masonis JL, Patel JV, Miu A, Bourne RB, McCalden R, Macdonald SJ, Rorabeck
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CH. Subtrochanteric shortening and derotational osteotomy in primary total hip
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389
Joint Surg Am 1973; 55:1629-1632.
390
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10.1016/j.arth.2018.01.041.
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Cementless hip arthroplasty and transverse shortening femoral osteotomy with
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the S-ROM stem for Crowe type IV developmental dysplasia. Eur J Orthop Surg
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Traumatol 2019 Feb 13. doi: 10.1007/s00590-019-02400-y.
398
29. Imbuldeniya AM, Walter WL, Zicat BA, Walter WK. Cementless total hip
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replacement without femoral osteotomy in patients with severe developmental
400
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401
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402
Acknowledgements: This work was supported by the Dengfeng Talent Training Program (DFL20190401).
TableⅠ ⅠPreoperative demographic and clinical data Variable
Data Group A
Data Group B
Total
Sex
78 men (47%)
87 women (53%)
165 patients
Side of the body affected
Left in 86 hips (52%)
Right in 79 hips (48%)
165 hips
Type of infection microorganism
pyogenic in 81 patients (49%)
tuberculosis in 38 patients (23%);
165 patients
unknown organisms in 46 patients (28%) Initial treatment
BMI Average age at the onset of index hip infection (yr) Average age at THA (yr) Average interval between initial sepsis and THA (mo) BMI=body mass index; THA = total hip arthroplasty.
conservative treatment in 112 patients (68%)
surgical treatment in 53 patients (32%)
24.0 (range, 16.2-35.4) 9.6 (range, 1-14) 45.6 (range, 18-79) 431.3 (96-816)
165 patients
Table 2 variables
Perioperative Complications Number of hips(percentage)
Intraoperative periprosthetic fractures
11(6.7%)
Postoperative periprosthetic fractures
1(0.6%)
Dislocation
1(0.6%)
Periprosthetic infection
3 (1.8%)
Femoral nerve injury
1 (0.6%)
Sciatic nerve injury
5 (3.0%)
Ceramic surface squeaking
1(0.6%)
Heterotopic ossification
33 (20%)
Fig. 1A–D. (A-B) A preoperative anteroposterior (AP) and lateral radiographs showing a unilateral osteoarthritis secondary to hip sepsis during childhood in a 41-year-old male who was initially treated by conservative method. (C) An AP radiograph made at second day after THA. (D) An AP radiograph made 3 months after THA showing heterotopic ossification (HO) with class
(white arrow) could be
observed around the less trochanter of left hip. (E) An AP radiograph made 3 years after THA showing a worsening HO with class island (class
(white arrow) and a new onset bone
) (yellow arrow) could be observed around the less trochanter and
greater trochanter of left hip, respectively. (F) An AP radiograph made 8 years after THA showing a further worsening of HO with class a new onset HO with class
around the less trochanter and
around the greater trochanter of left hip. The patient did
not receive any medication for the prevention of HO. At the latest follow-up visit, the patient complained of a mild limited deep squatting but was free of pain with a Harris hip score of 87.
Fig. 1-A
Fig. 1-B
Fig. 1-C
Fig. 1-E
Fig. 1-D
Fig. 1-F
S0883-5403(20)30195-9
DOI:
https://doi.org/10.1016/j.arth.2020.02.034
Reference:
YARTH 57828
To appear in:
The Journal of Arthroplasty
Received Date: 18 November 2019 Revised Date:
4 February 2020
Accepted Date: 16 February 2020
Please cite this article as: Zhang L, Chu Y, Shao H, Bian T, Li W, Zhou Y, Cementless total hip arthroplasty for adult patients with sequelae from childhood hip infection: A medium-term follow-up study The Journal of Arthroplasty (2020), doi: https://doi.org/10.1016/j.arth.2020.02.034. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Elsevier Inc. All rights reserved.
Cementless Total Hip Arthroplasty for Adult Patients with Sequelae from Childhood Hip Infection: A Medium-term Follow-up Study Liang Zhang MDa, Yaming Chu MDa, Hongyi Shao MDa, Tao Bian MDa, Weiyi Li MDb, Yixin Zhou MD PhDa,
a.
Department of Orthopaedic Surgery, Beijing Jishuitan Hospital, Fourth Clinical College
of Peking University, No.31 Xinjiekou East Street, Xicheng District, Beijing 100035, China b.
Department of Physical Therapy and Rehabilitation, Beijing Jishuitan Hospital, Fourth
Clinical College of Peking University, No.31 Xinjiekou East Street, Xicheng District, Beijing 100035, China
Please address all correspondence to:
Yixin Zhou, MD, PhD Department of Orthopaedic Surgery Beijing Jishuitan Hospital, Fourth Clinical College of Peking University No.31 Xinjiekou East Street, Xicheng District, Beijing 100035 China Phone: 86-10-58516724, 86-13601019278 FAX: 86-10-58516724 Email: [email protected]
Emails of other authors: Liang Zhang, MD: [email protected] Yaming Chu, MD: [email protected] Hongyi Shao, MD: [email protected] Tao Bian, MD: [email protected] Weiyi Li, MD: [email protected]
1
Cementless total hip arthroplasty for adult patients with
2
sequelae from childhood hip infection:
3
A medium-term follow-up study
4
【Abstract】Objective To evaluate midterm clinical and radiographic results of total
5
hip arthroplasty(THAs) with cementless implants for adult patients with sequelae
6
from childhood hip infection. Methods Between 2002 and 2016, 165 patients (165
7
hips) who had a hip infection during childhood were treated with THAs with
8
cementless implants. The average duration of follow-up was 93.5 months (range,
9
26-206 months). Clinical results were evaluated via the Harris hip score (HHS) and
10
radiographic results were analyzed with postoperative serial x-rays. Results The
11
average HHS increased from 27 (range, 22-34) before surgery to 91 (range, 86-93) at
12
the latest follow-up examination (P < 0.001). At the latest follow-up evaluation, nine
13
cementless acetabular components demonstrated partial, nonprogressive
14
radiolucencies. No subsidence of more than 2 mm or evidence of a radiolucent line
15
was observed around the femoral components. Intraoperative periprosthetic fractures
16
occurred in 11 hips, including three acetabular fractures, two fractures of greater
17
trochanter, one femoral shaft fracture and five fractures of femoral calcar.
18
Postoperative complications included three cases of periprosthetic infection, one
19
episode of dislocation, one case of a femoral periprosthetic fracture, five cases of
20
sciatic nerve injury, one case of femoral nerve injury and one case of squeaking from
21
a ceramic bearing surface. Conclusions Cementless THA for adult patients with
22
sequelae from childhood hip infection presents significant technical challenges and a
23
relatively high complication rate. With meticulous surgical planning and anticipation
24
for the key technical challenges frequently encountered, the medium-term clinical and
25
radiographic results of THA in this setting were good with high implant survivorship
26
and patient satisfaction.
27
【Key words】Arthroplasty, hip infection, sequelae, cementless
28 29
Introduction
30
Total hip arthroplasty (THA) has been utilized to treat sequelae associated with
31
childhood hip infection for many years. However, the midterm and long-term
32
outcomes of THA in this young and active population remain controversial【1-6】. The
33
technical difficulties of THA in these patients are unique to a condition in which the
34
hip joint develops multi-planar deformities on both the acetabular and femoral sides
35
【7-9】. In addition to the young age of these patients and the presence of bone defects
36
and soft tissue scarring, THA is also often complicated by previous surgical
37
procedures performed during childhood【10-11】.
38
The aim of this study was to review the results of cementless THA for adult
39
patients with sequelae from previous childhood hip infection with an average
40
follow-up of 7.8 years. We hypothesized that THA for these patients may result in
41
pain relief, in addition to functional improvement, all while yielding high implant
42
survivorship and a low complication rate. The influence of the Crowe classification
43
grading on clinical outcomes of THA was also evaluated.
44 45 46 47
Materials and Methods Demographics A retrospective review was conducted of consecutive unilateral THAs performed to
48
treat patients diagnosed with sequelae from previous childhood hip infection between
49
January 2002 and December 2016 in 181 hips in 181 patients. At the most recent
50
follow-up examination, 165 hips (165 patients) were available for evaluation with an
51
average follow-up time of 93.5 months (range, 26-206 months) after surgery.
52
Approval of the local institutional review board and informed consent from all
53
participating patients were obtained for this retrospective study.
54
The average age of all patients was 9.6 years (range, 1-14 years) at the onset of the
55
index hip infection and 45.6 years (range, 18-79 years) at the time of THA. The
56
average interval between the initial infection and performing THA was 431.3 months
57
(96-816 months). According to the Crowe classification system【12】, all hips were
58
graded as type I (71cases), type II (53 cases), type III (24 cases) and type IV(17 cases).
59
The initial treatment was nonoperative in 112 hips (conservative treatment group) and
60
surgical intervention in 53 hips (surgical-treatment group), including joint
61
debridement and irrigation in 46 hips, arthrodesis in 4 hips, Girdlestone operation in 3
62
hips. Ankylosis of the hip before surgery was seen in 9 hips. Preoperative bone
63
defects were classified according to Paprosky criteria【13-14】. On the acetabular side,
64
there were 145 grade I acetabular defects and 20 grade II defects. On the femoral side,
65
there were 157 grade I femoral defects and 8 grade II defects.
66
Bacteriologic Evaluations
67
The classification of childhood hip infection was made on the basis of historical
68
records, clinical features, such as the presence of a draining sinus, and radiographic
69
findings. The type of infection microorganism was pyogenic in 81 patients (49%),
70
tuberculosis in 38 patients (23%) and unknown organisms in 46 patients (28%).
71
Among these 165 hips with childhood infection, 37 cases were confirmed with acute
72
hip sepsis. Meanwhile, 16 of 165 hips were seen with combined osteomyelitis of the
73
femur. Prior to arthroplasty, all patients were routinely evaluated with erythrocyte
74
sedimentation rate (ESR) and C-reactive protein (CRP) to elucidate whether an active
75
infection may be present. The ESR was elevated > 20 mm/h in 52 patients and the
76
CRP was elevated > 8 mg/L in 103 patients. Among them, only 3 patients had
77
elevated ESRs and CRPs. If an active hip infection was suspected prior to THA, a
78
technetium-99 bone scan was performed. Meanwhile, preoperative aspirations were
79
performed on 12 patients and the selection criteria include clinical and (or)
80
radiological suspicion of active infection and an elevated level of ESR and (or) CRP.
81
Intraoperatively, we cultured aspirates, smears, and excised specimens for growth
82
of aerobic, anaerobic, and tubercle bacilli. In cases with suspicious synovial fluid or
83
tissues, frozen section biopsies were performed during surgery. More than 5
84
polymorphonuclear leukocytes per high-power field in the frozen section specimen
85
are indicative of active infection. No case of active infection was detected in this
86
series. All patients received a systemic 2nd generation cephalosporin or vancomycin
87
for 2 to 5 days after the THA.
88
Surgical techniques and Prosthesis selection
89
A posterior surgical approach was performed in all hips. All acetabular components
90
were cementless and were implanted using a press-fit technique. The average
91
diameter of cups was 50.4 mm (range, 40 to 62 mm). In 5 hips with a shallow
92
acetabulum and poor acetabular coverage, the circumferential acetabular medial wall
93
osteotomy technique was utilized【15】. In 128 (77.6%) of 165 hips, cementless cups
94
were supplemented with 2 to 3 screws. Thirty-one hips had acetabular bone grafts; of
95
these, 23 had morcelized autografts and 8 received structural femoral head autografts.
96
All cementless stems were used to reconstruct the proximal femurs. In addition, we
97
implanted 61 modular S-ROM stems (DePuy, Warsaw). In 15 high dislocated hips
98
classified as Crowe Ⅳ, femoral transverse subtrochanteric shortening derotational
99
osteotomies were performed【16,17】. A ceramic-on-ceramic bearing surface was
100
utilized in 83 hips (50.3%), a ceramic-on-polyethylene bearing surface in 57 hips
101
(34.5%), and cobalt–chrome heads on a polyethylene bearing surface in 25 hips
102
(15.2%).
103
Clinical and radiographic evaluation
104
All patients were monitored clinically and radiographically on an outpatient basis at
105
3 and 6 months, as well as 1 year after surgery, and then biannually thereafter. For a
106
patient who missed outpatient appointment time, the observer who was responsible
107
for follow-up routinely got in touch with him all possible methods, including
108
telephone, E-mail, WeChat software at an interval of two weeks. Once this patient
109
failed to reply for three times, he will be regarded as a lost to follow-up (LTFU).
110
Clinical results were evaluated using the Harris hip score (HHS) system【18】by two
111
independent observers, who were not involved in performing the arthroplasties. The
112
HHS is based on the assessment of pain, function, deformity, and range of motion
113
(ROM). On the 100-point scale, a score of 90 points or more is defined as an excellent
114
outcome; 80 to 89 points, a good outcome; 70 to 79 points, a fair outcome; and 70
115
points or less, a poor outcome. Patient satisfaction was also evaluated using a
116
self-administered four-category scale (very satisfied, somewhat satisfied, somewhat
117
dissatisfied, and very dissatisfied).
118
Serial anteroposterior (AP) and translateral hip radiographs were examined for
119
evidence of radiolucencies, osteolysis or loosening of the prosthesis at the follow-up
120
visits. The bone-prosthesis interface was evaluated according to the zone system
121
described by Gruen et al【19】for the femoral side, and DeLee and Charnley【20】for
122
the acetabular side. Acetabular cup inclination angle and the anteversion angle were
123
measured by the method described by Widmer【21】. Loosening of the acetabular cup
124
was defined as a change of cup position exceeding 2 mm, a cup angle exceeding 3°,
125
or the detection of a radiolucent line thicker than 2 mm around a cup. Periprosthetic
126
cystic or scalloped lesions with a diameter of >2 mm that were not detected on
127
radiographs obtained immediately after the operation were defined as periprosthetic
128
osteolysis【22, 23】. Loosening of a cementless stem was defined as suggested by
129
Engh et al【24】. Bone union at the osteotomy site was assessed using postoperative
130
radiographs according to the method proposed by Masonis et al【25】. The formation
131
of postoperative heterotopic ossification (HO) was evaluated using the classification
132
described by Brooker et al【26】. Preoperative, postoperative, and the change in leg
133
length discrepancy (LLD) were recorded. The LLD is measured from the
134
inter-teardrop line to the midpoint of the lesser trochanter on both sides.
135
Statistical analysis
136
Data were statistically analyzed using SPSS software for Windows (version 18;
137
IBM, Armonk, NY, USA). Descriptive analyses for categorical variables were based
138
on percentages or frequencies and for continuous variables on mean and standard
139
deviation (SD) or median and quartile (25%-75%) if the data were skewed. The
140
preoperative and final follow-up HHS were compared using the Wilcoxon signed rank
141
test. The differences for the HHS between the conservative-treatment and
142
surgical-treatment groups were compared using the Mann-Whitney signed rank test.
143
The Kruskal-Wallis test was used to compare the HSS in the subgroups according to
144
the Crowe classification system. Significance was set at P<0.05, and tests were
145
2-tailed.
146 147
Results
148
Clinical assessment
149
The average HHS increased from 27 (range, 22-34) before surgery to 91 (range,
150
86-93) at the latest follow-up examination (P < 0.001). Results were excellent for 88
151
hips (53.33%), good for 54 (32.73%), fair for 20 (12.12%), and poor for 3 (1.82%).
152
The postoperative average HHS for the conservative-treatment and the
153
surgical-treatment groups increased from 26 (range, 20-34) and 28 (range, 24-34),
154
respectively, to 90 (range, 86-93) and 91 (range, 87-93) (P< 0.001), respectively.
155
However, there was no significant difference detected between groups regarding the
156
HHS at the latest follow-up examination (P> 0.05). We compared the HHS at the
157
latest follow-up examination among the four Crowe subgroups. The mean HHS
158
increased significantly from preoperative 26 (21-31) to 90 (86-93) at the latest
159
follow-up examination (P< 0.001) (Crowe I subgroup), from 27 (22-33) to 92 (88-95)
160
(P< 0.001) (Crowe II subgroup), from 30 (19-35) vs 89 (84-92) (P< 0.001) (Crowe III
161
subgroup) and from 34 (23-37) vs 93 (86-96) (P< 0.001) (Crowe IV subgroup),
162
respectively. However, no significant differences were observed between these
163
subgroups regarding the HHS at the latest follow-up examination (P> 0.05).
164
The patients who were very satisfied with the results of THA represented 105 hips
165
(63.64%), while those who were somewhat satisfied represented 49 hips (29.70%).
166
The patients who were somewhat dissatisfied with the results of THA represented 6
167
hips (3.64%) and those who were very dissatisfied represented 5 (3.03%) hips.
168
Radiographic results
169
Immediately after the THA, postoperative periacetabular gaps were observed in 17
170
hips (10.3%). Of these, 13 were less than 1 mm and the other 4 ranged from 1 to 2
171
mm. All but 5 of these gaps resolved during the initial 12 months after surgery.
172
At the latest follow-up evaluation, nine cementless acetabular components revealed
173
partial nonprogressive radiolucencies (three in zone I, three in zone I and II, three in
174
zone II and III, respectively). The average acetabular inclination angle was 39.0±7.2°
175
(range, 22.9-57.3°) and average anteversion angle was 17.8°±3.9° (range, 11.2-29.2°).
176
No cup was associated with evidence of marginal, retroacetabular or screw-related
177
osteolysis. At the latest follow-up visit, structural femoral head autograft appeared
178
partially resorbed, but well incorporated with the host bone. During the follow-up
179
period, bony union of the osteotomized medial acetabular wall and the femoral
180
subtrochanteric osteotomies was observed at an average of 4.4 months (range, 3.8-6.3
181
months) 【15】and 5.4 months (range, 4.8-6.3 months) after THA, respectively.
182
According to the Engh classification【24】, 137 stems showed stable bony ingrowth,
183
and 28 stems showed stable fibrous ingrowth at the latest follow-up examination. No
184
subsidence of more than 2 mm or radiolucent line was observed around the femoral
185
components.
186
The mean LLD decreased from 27.0 mm (range, 0.2-76.3 mm) preoperatively to
187
11.9 mm (range, -19.9-43.9 mm) postoperatively.
188
Complications
189
Intraoperative periprosthetic fractures occurred in 11 hips (3 hips with Crowe I, 5
190
hips with Crowe II, 3 hips with Crowe IV) including three acetabular fractures, two
191
fractures of the greater trochanter, one femoral shaft fracture and five fractures of the
192
femoral calcar. Two of these acetabular fractures were treated conservatively and cup
193
fixation was not compromised. The other acetabular fracture (Crowe IV) was
194
associated with the posterior column was considered an operative fracture that was
195
treated with open reduction and internal fixation. All femoral fractures were treated
196
with cerclage cabling and these healed uneventfully without signs of component
197
loosening.
198
Postoperative complications included three cases of periprosthetic infection, one
199
episode of dislocation, one periprosthetic femur fracture, five cases of sciatic nerve
200
injury, one case of femoral nerve injury and a case of squeaking from ceramic bearing
201
surfaces. The first periprosthetic infection occurred in a Crowe type III 43-year-old
202
male patient 3 years after THA. The interval between the childhood infection and
203
THA was 386 months and the patient had no history of surgery for his hip infection
204
during childhood. The infecting organism during childhood was unknown and it was
205
Staphylococcus aureus during the periprosthetic infection. The second case occurred
206
in a Crowe type II 22-year-old female patient one year after THA. The interval
207
between the childhood infection and THA was 182 months. The infecting organism
208
during childhood was Escherichia coli and it was Staphylococcus epidermidis during
209
the periprosthetic infection. The patient also had no history of surgery for hip
210
infection. Considering that the infecting organism was sensitive to antibiotics without
211
the characteristic of multi-drug resistance and the implants remained stable, both of
212
the two patients were successfully treated with surgical debridement with implant
213
retention. Fortunately, there was no recurrent of infection at the time of latest
214
follow-up. The third case with periprosthetic infection was seen 3 months after THA
215
in a Crowe type III 34-year-old male patient with an interval between the childhood
216
infection and THA of 230 months. The BMI before THA was only 19.2. The
217
preoperative level of ESR and CRP was 10 mm/h and 10 mg/L, respectively. So the
218
patient did not receive any technetium-99 bone scan or joint aspiration before THA.
219
The same organism, Mycobacterium tuberculosis, was isolated from the surgical
220
specimens at the time of debridement. The patient was treated with prosthesis removal
221
and antibiotic-loaded articulating cement spacers. Unfortunately, the reinfection
222
remained uncontrolled and the patient refused to receive any further revision surgery.
223
Two hips (Crowe II) with iatrogenic sciatic nerve injury had concomitant
224
periprosthetic fractures of the greater trochanter. One hip (Crowe IV) underwent a
225
subtrochanteric osteotomy and the length of the segmental resection was 3.0 cm. All
226
sciatic and femoral nerve injuries were treated with methylprednisolone and
227
mecobalamin injection, physiotherapy and dorsal extension orthosis (for sciatic nerve
228
injuries only). Among these sciatic nerve injuries, one case had a full recovery within
229
one year after THA, one had a partial recovery but another two cases did not
230
demonstrate any significant improvement in the sensory disturbance and foot drop.
231
The patient with a femoral nerve injury had a full recovery within three months after
232
THA.
233
Postoperative new-onset periprosthetic fracture, which occurred in one patient three
234
years after THA, was treated with open reduction and internal fixation and the
235
fracture healed without any further complication at the latest follow-up evaluation.
236
Postoperative dislocation, which occurred in one patient (Crowe IV) 8 weeks after
237
THA, was treated with closed reduction and there were no further events at the time
238
of the final follow-up examination. One complaint of asymptomatic squeaking
239
occurred with a ceramic-on-ceramic bearing surface.
240
After surgery, 33 hips (20%) demonstrated HO: Brooker class I in 27, class II in 4,
241
and class III in 2; there were no cases of class IV HO. Of these 33 hips, 20 hips were
242
of Crowe Type I, 6 of Type II, 4 of Type III and 3 of Type IV. No patient required
243
further surgery for HO.
244 245
Discussion
246
Adult patients diagnosed with end-stage osteoarthritis for sequelae from childhood
247
hip infection frequently manifest with severe anatomical deformities of the proximal
248
femur and acetabulum, as well as circumferential soft tissue and hence confer
249
considerable technical difficulties in performing THA. In the current study, we found
250
that although the reconstruction was technically demanding and complication rate was
251
relatively high, overall component survivorship was generally excellent with
252
encouraging clinical results and a high level of patient satisfaction.
253
The risk of reinfection should be considered seriously. Some authors have
254
emphasized that reinfection did not recur with THA, providing that infection had been
255
quiescent for more than 10 years【1-5】. Dudkiewicz et al【2】reported a group of
256
young patients with early coxarthrosis caused by septic hips in childhood, with an
257
average age of 19.1 years (range, 14-25) at the time of THA. No infection other than
258
one positive bone culture was noted after a mean follow-up of 8.1 years (range, 2-24).
259
The authors noted that the mean interval between the previous infection and the THA
260
was 15.2 years (range, 8-22). Kim et al【3】retrospectively analyzed 170 THAs that
261
were performed in patients with infection of the hip during childhood. All hips with a
262
quiescent period of more than ten years had no recurrence of infection. The remaining
263
two hips in one patient with a quiescent period of seven years had recurrence of the
264
infection. In our series, three cases of periprosthetic infection were confirmed during
265
the follow-up time period. The interval between the previous infection and subsequent
266
THA ranged from 182-386 months, respectively. Only in one of these cases were the
267
organisms the same organism and can be regarded as a reoccurrence of the childhood
268
infection. In this case, Mycobacterium tuberculosis was isolated from the surgical
269
specimens at the time of debridement, which matched the records for the childhood
270
organism.
271
Another important consideration when performing THA on these young, active
272
patients with severe anatomical deformities is component survivorship. Previous
273
reports have demonstrated relatively high revision and related complication rates,
274
such as osteolysis【1-3】. Fortunately, to date, none of the hips in our series required
275
revision for aseptic loosening and there are likely multiple potential explanations for
276
this. First, the follow-up period was relative short at an average of 93.5 months.
277
Second, all cups and stems that were implanted were cementless components. In
278
addition, we implanted 61 modular S-ROM stems for the cases with small and/or
279
straight medullary cavities, increased anteversion of proximal femur, or combined
280
subtrochanteric shortening derotational osteotomies【4, 27-29】. Third, there was a
281
comparably high percentage of ceramic bearing surfaces, with 50.3% of the hips
282
having a ceramic-on-ceramic bearing surface and 34.5% of the hips having a
283
ceramic-on-polyethylene bearing surface.
284
There is no disease-specific classification system for sequelae from childhood hip
285
infection. In fact, only Kim et al【3】have previously proposed a descriptive
286
radiographic system in their series. In this regard, the preoperative anatomic
287
deformity of the hip was retrospectively classified into three types. However,
288
differences between the subtypes were not discussed. In our series, we used the
289
Crowe classification system【11】,which plays a critical role in preoperative planning,
290
selection of operative technique and implants, and assessment of results for this case
291
series. We detected no significant differences between the Crowe subgroups regarding
292
the HHS at the latest follow-up examination. The THA reconstruction for cases with
293
Crowe III and IV in our series were still technically demanding both on the acetabular
294
and femoral sides. For instance, for hips in Crowe III and IV subgroup, the proportion
295
requiring a modular S-ROM stem was 58% (14/24) and 76% (13/17), respectively and
296
subtrochanteric shortening derotational osteotomies were performed in 15 hips.
297
Despite this, the incidence of intraoperative complications was relatively high.
298
Among 11 intraoperative periprosthetic fractures, 3 cases were in the Crowe IV
299
subgroup. A high percentage of postoperative complications were also observed in the
300
two subgroups, including one dislocation (Crowe IV), two periprosthetic infections
301
(Crowe III), three sciatic nerve injuries (2 cases with Crowe III and one case with
302
Crowe IV), and one femoral nerve injury (Crowe III).
303
There are several limitations to note in the present study. First, it was
304
retrospective with the inherent potential for inaccurate medical records and
305
information bias. Second, operations were performed by several surgeons that could
306
lead to diversity in implant choice. Third, because of a large time span of follow-up
307
duration with a maximum of 206 months, the identification of hip infection during
308
childhood by chart review (if obtained) and patient questionnaire may be
309
questionable.
310 311
In summary, cementless THA for adult patients with sequelae from childhood hip infection presents substantial technical challenges and a relatively high
312
complication rate. Despite this, it is possible that with meticulous surgical planning
313
and anticipation of key technical difficulties, the medium-term clinical and
314
radiographic results of THA can be good with high implant survivorship and a high
315
levels of patient satisfaction. Also, we emphasis the necessity of a comprehensive
316
screening system, including clinical, radiological, laboratory examination and
317
histological, bacteriological sampling evaluation, for maximizing the chances of
318
identifying residual microorganism.
319
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Acknowledgements: This work was supported by the Dengfeng Talent Training Program (DFL20190401).
TableⅠ ⅠPreoperative demographic and clinical data Variable
Data Group A
Data Group B
Total
Sex
78 men (47%)
87 women (53%)
165 patients
Side of the body affected
Left in 86 hips (52%)
Right in 79 hips (48%)
165 hips
Type of infection microorganism
pyogenic in 81 patients (49%)
tuberculosis in 38 patients (23%);
165 patients
unknown organisms in 46 patients (28%) Initial treatment
BMI Average age at the onset of index hip infection (yr) Average age at THA (yr) Average interval between initial sepsis and THA (mo) BMI=body mass index; THA = total hip arthroplasty.
conservative treatment in 112 patients (68%)
surgical treatment in 53 patients (32%)
24.0 (range, 16.2-35.4) 9.6 (range, 1-14) 45.6 (range, 18-79) 431.3 (96-816)
165 patients
Table 2 variables
Perioperative Complications Number of hips(percentage)
Intraoperative periprosthetic fractures
11(6.7%)
Postoperative periprosthetic fractures
1(0.6%)
Dislocation
1(0.6%)
Periprosthetic infection
3 (1.8%)
Femoral nerve injury
1 (0.6%)
Sciatic nerve injury
5 (3.0%)
Ceramic surface squeaking
1(0.6%)
Heterotopic ossification
33 (20%)
Fig. 1A–D. (A-B) A preoperative anteroposterior (AP) and lateral radiographs showing a unilateral osteoarthritis secondary to hip sepsis during childhood in a 41-year-old male who was initially treated by conservative method. (C) An AP radiograph made at second day after THA. (D) An AP radiograph made 3 months after THA showing heterotopic ossification (HO) with class
(white arrow) could be
observed around the less trochanter of left hip. (E) An AP radiograph made 3 years after THA showing a worsening HO with class island (class
(white arrow) and a new onset bone
) (yellow arrow) could be observed around the less trochanter and
greater trochanter of left hip, respectively. (F) An AP radiograph made 8 years after THA showing a further worsening of HO with class a new onset HO with class
around the less trochanter and
around the greater trochanter of left hip. The patient did
not receive any medication for the prevention of HO. At the latest follow-up visit, the patient complained of a mild limited deep squatting but was free of pain with a Harris hip score of 87.
Fig. 1-A
Fig. 1-B
Fig. 1-C
Fig. 1-E
Fig. 1-D
Fig. 1-F