Clinical Evaluation of 104 Hip Resection Arthroplasties After R e m o v a l of a Total Hip Prosthesis
P. G. M a r c h e t t i , M D , A. Toni, N. Baldini, M D , R. Binazzi, M D , L. D'Elia, M D , A. S u d a n e s e , MD, a n d M. Spinelli, M D
Abstract: Functional results of resection arthroplasty are currently considered
poor. In 104 hip prosthesis removals after either septic or aseptic loosening, pain, walking, joint motility, life style, and patient's opinion were evaluated. A satisfactory result was recorded in 72% of cases. Prognosis is poorer in patients who are young, have septic loosening, and have poor residual mobility. Resection arthroplasty should be considered a salvage procedure in cases of septic loosening and/or bone stock deficiency after a failed total hip arthroplasty. Key words: revision, resection, septic loosening, bone stock deficiency.
With the increasing popularity of total hip replacement as an effective procedure for the treatment of severely damaged joints, septic or aseptic loosening has progressively become a frequent pathologic entity. Reconstructive surgery is now widely accepted in aseptic loosening as the treatment of choice, at least in patients with satisfactory general conditions and good bone stock (19). However, considerable controversy still exists about the best procedure in cases of infected implants. Infection has long been considered a contraindication to a subsequent implant because of a high risk of recurrence (10), and resection arthroplasty has been routinely performed to eradicate completely the septic process. The result of this procedu[e is analogous to the pseudarthrosis proposed by Girdlestone, in 1943, for the treatment of septic hips (18). Some additional surgical operations suggested in case of severe disability after the Girdlestone procedure, such as support osteotomy
(2, 27) and trochanteric reconstruction (13, 15), appear of little value for improving hip function (31). Over the past few years, preliminary favorable results have been reported by several authors who performed a direct exchange on an infected implant (5, 7, 9, 11, 17, 21, 23, 24, 31). Functional results of this new approach seem to be better, compared with the highly disabling situation resulting from a simple resection arthroplasty (22, 31) (ie, an unstable hip with marked shortening and poor function). Such a discouraging picture contrasts with our experience. Only a few of our patients have required new hip reconstruction after removal of their loosened implant. This may be attributed to a relatively good acceptance of their actual status, similar to Calandruccio's observation (8). In addition, in many cases, bone stock deficiency contraindicates the implantation of a new prosthetic device. Moreover, longerterm follow-up studies of reimplantation surgery indicate an increasing failure rate (29). In reviewing the literature, we found surprisingly few papers on the results of Girdlestone pseudarthrosis after removal of a loose total hip prosthesi s (1, 3, 12, 14, 16, 20, 25, 30, 32). This may be due
From the Orthopedic Surgical Clinic, University of Bologna, lstituto Rizzoli, Bologna, Italy.
Reprint requests: P. G. Marchettio Clinica Ortopedica dell'Universith, Istituto Rizzoli,via Codivilla9, 40136 Bologna, Italy.
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The Journal of Arthroplasty Vol. 2 No. 1 March 1987
to reluctance of surgeons" to report and discuss disastrous failures of a prestigious and otherwise satisfactory procedure (16). Moreover, in these reports the patient's opinion was virtually never taken into account in evaluating final results. We describe our experience with a series of 123 patients who had 127 total hip prosthetic removals because of septic and aseptic loosening, to assess the advantages and disadvantages of this procedure in the face of the new developments of hip revision surgery.
Material and Methods At our institution, Girdlestone procedure was the only surgical treatment used for loosened implants until 1974, when we started revision surgery with cemented implants in aseptic cases. More recently, a decrease in cases of septic loosening and an improved confidence with cementless revision surgery ../ has significantly restricted our pracUce of excision arthroplasty. Between 1970 and 1983, 123 patients had a resection anhroplasty; in 4 cases surgery was bilateral, for a total of 127 loosened implant removals. All of the prostheses were cemented. The mean age of the patients was 60.4 _+ 9.5 years (range, 3081 years). Sixty-five percent of the patients were women and 35% were men. A minimum 6-month (maximum, 144-month) clinical and radiographic follow-up evaluation was carried out in 100 patients, 4 of whom had a bilateral pseudarthrosis. Therefore, the total number of hips considered in the present study is 104. Of these, 37 were aseptic. Of the remaining 67 cases with septic loosening, 23 (34%) showed evidence of infection immediately following the total hip replacement and postoperative period, and 42 (63%) displayed signs ofsubacute infection in the first 3 months; in 2 (3%), infection appeared much later. In 20 cases, previous attempts of simple surgical debridement had been unsuccessful. In aseptic cases, a new total hip replacement was considered unadvisable when there were poor general conditions or bone stock, deficiency. The surgical technique was different in septic and aseptic hips. In both, a wide exposure, together with particular care in dislocating the femur, was the rule. In addition, in septic cases either the cement or the granulation tissue was thoroughly excised, and antibiotic and antiseptic irrigations were performed. On the contrary, in aseptic cases complete cement removal was not considered mandatory. After surgery,
patients with septic hips were maintained in plaster for 4 - 6 weeks, with a continuous suction-irrigation system with antibiotics and antiseptic solutions for 20 days. In aseptic cases, the plaster was removed after 2 weeks. In both cases, load was then progressively allowed, at first with the aid of an ambulatory support and later with two crutches. A standing roentgenogram of the pelvis was routinely taken to adjust the heel elevation height. We believe that patients treated with a resection arthroplasty cannot be assessed with the usual parameters routinely applied to hip evaluation. In fact, shortening, altered posture, and hip muscular weakness are obvious consequences of this procedure. They may be considered more as a constant, rather than factors to be individually evaluated. The Chamley and Harris criteria for hip evaluation place considerable emphasis on pain, walking, everyday life, and joint motility, as well as on the patient's personal opinion of his or her present functional status. For this study, Charnley criteria were used to evaluate pain and joint motility and the Harris hip score was modified to assess the above-mentioned parameters (Table 1). The result was then evaluated as follows: excellent, 18 points; good, 16-17 points; fair, 13-15 points; and poor, less than 13 points. In addition, a radiographic evaluation was performed.
Table 1, Clinical Evaluation Score
Functional Parameters Pain
Gait Limp Supports
Distance
Life style Sitting
Wearing shoes
C l i m b i n g stairs
Public transportation Range of passive motion
Score 1-3 = unbearable 4, 5 = b e a r a b l e 6 = absent 0 1 0 1 2 0 1 2
= = = = = = = =
0 = 1 = 2 = 0 = 1 = 2 = 0 = 1 = 2 = 0 = 1 = 1, 2 3, 4 5, 6
severe slight bedridden two crutches one crutch bedridden c o n f i n e d to h o m e >300 meters unable only high chairs any chair unable difficult easy unable with supports without supports unable able = poor = fair = good
Resection Arthroplasty After THR
Results There were six intraoperative fractures of the femural shaft, which occurred only in septic loosenings (67 cases) due to a marked thinning of the cortex from septic lysis. Deep venous thrombosis occurred in three patients (2.4%). One patient (0.8%) died of pulmonary embolism 8 days after surgery. The patients were satisfied with the results in 77 cases (74%) and dissatisfied in 27 cases. Pain relief was almost complete in 32 cases (31%) and sarisfactory in 44 cases (42%). Twenty-eight patients (27%) complained of significant persistent pain. No patient had normal range of movement. Sixteen hips (15%) had good motility (5 points, according to Charnley) and 75 had fair motility (3-4 points). Thirteen hips (13%) were almost ankylosed. Life style comprises sitting, wearing shoes, climbing stairs, and using public transportation. As expected, none Of these was fully satisfactory (Fig. I). Shortening was less than 3 cm in 32 hips (32%); 3-5 cm in 54 (55%); and greater than 5 cm in 13 (13%). In 5 patients, no leg length discrepancy was reported. Limb posture was evaluated in 70 hips. The result was considered pathologic if residual adduction was
9
Marchetti et al.
39
greater than 15~ and exterrial rotation greater than 20 ~ Posture was satisfactory in 27 cases and unsatisfactory in 43 cases (61%). Nine of the 67 patients with septic loosening (13%) had a discharging sinus that lasted for 15-36 months after implant removal. In five cases, additional surgical debridement was performed after the resection arthroplasty. The clinical results were excellent in 13 patients (12%), good in 35 (34%), fair in 27 (26%), and poor in 29 (28%). The validity of our criteria are confirmed by the correspondence between objectively excellent, good, and fair results and patient's satisfaction and, conversely, between a poor score and patient's dissatisfaction. The quality of the results was also related to the following factors. 1. Age. The uniformity of age distribution (Fig. 2) allowed us to compare patients younger than and older than 60 years. Poor results occurred more often in younger patients; fair results were almost eqba!ly distributed; good and excellent results were more frequent in elderly patients (Fig. 3). A poor clinical result occurred in 1 of 3 cases in young patients but in only 1 of 10 in elderly patients. 2. Septic versus aseptic loosening. There were no 180. 98
O~ IZ
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70
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60
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o
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50 40 30 28
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Fig. 1, Life style evaluation after resection arthroplasty shows an overall unsatisfactory result. (A) Sitting. (B) Wearing shoes. (C) Climbing stairs. (D) Public transportation.
40
The Journal of Arthroplasty Vol. 2 No. 1 March 1987
69 o) 1-
,.:5
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Fig. 5. Relation between pain and joint motion. 70 ~0 I-"7" W
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cement (in aseptic cases) did not significantly affect clinical result.
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Discussion
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Fig. 3. Overall clinical results in patients by age. poor results in cases of aseptic loosening, and none of the septic loosenings were classified as excellent. Aseptic cases generally did well, with 55% classified as excellent or good and the remaining 45% as fair (Fig. 4). 3. Pain versus range of movement. There was a definite relation between intensity of pain and range of movement (Fig. 5). 4. Radiographic findings. The presence of heterotopic ossification, osteoporosis, osteolytic areas, irregular pseudarthrotic surfaces, or residual acrylic
CO I-71 I.d l-4
p4: Q. tL 0
9
SEPTIC LOOS
~
NON-SEPTIC LOOS
Fig. 4. Overall clinical results in septic versus aseptic loosening.
Loosening of a total hip prosthesis represents the failure of a generally gratifying procedure. Most cases of aseptic loosening can be effectively treated with reimplantation. In case of infection, this option should be limited to select patients, because of a high risk of recurrence of the infection. Moreover, in cases of severe bone stock deficiency, a new implant may be contraindicated. One alternative to a reconstructive procedure~is resection arthroplasty. Few authors have reported favorable results of resection arthroplasty after a failed total hip replacement. In our experience, the patient's functional status after resection arthroplasty is not as poor as generally reported (3, 12, 22, 23, 26, 30, 31). In fact, even if normal function cannot be achieved, pain is usually relieved, life style is only partially compromised, and, in septic cases, infection can be easily controlled with early removal of the prosthetic components, together with complete excision of inflamed tissues. Moreover, intraoperative blood loss (a major problem in these cases because of massive scar formation around loosened implants) is markedly limited. In some cases, delayed reconstructive surgery with a n e w total hip prosthesis may be indicated, particularly in younger patients with functionalIy poor results (33). Finally, it is important to maintain maxi m u m joint motility to limit the overgrowth of painful scar tissue. In summary, tesection arthroplasty is a salvage procedure for a failed implant; it should not be considered an elective operation. Our experience demonstrates that its main goals--pain relief and eradica-
Resection Arthroplasty After THR
tion of the i n f e c t i o n - - c a n be effectively achieved. On the contrary, revision arthroplasty is more difficult and uncertain, particularly for elderly patients with p o o r bone stock. In those cases, a n e w implant is seldom required by the patient w h o is reluctant to undergo further procedures, and, in most instances, a satisfactory functional level is achieved.
References 1. Ahlgren SA, Gudmundsson G, Bartholdsson E: Function after removal of a septic total hip prosthesis: a survey of 27 Girdlestone hips. Acta Orthop Scand 51:541, 1980 2. Batchelor JS: Excision of the femoral head and neck for ankylosis and arthritis of the hip. Postgrad Med J 24:241, 1948 3. Bittar ES, Petty W: Girdlestone arthroplasty for infected total hip arthroplasty. Clin Orthop 170:83, 1982 4. Boume RB, Hunter GA, Rorabeck CH, Macnab J J: A six-year follow-up of infected total hip replacements managed by Girdlestone's arthroplasty. J Bone Joint Surg 66B:340, 1984 5. Bucholz HW, Elson RA, Engelbrecht E et al: Management of deep infection of total hip replacement. J B'one Joint Surg 63B:342, 1981 6. Bucholz HW, Engelbrecht H: Infektionsprophylaxe und operative Behandlung der schleichenden tiefen Infektion bei der totalen Endoprothese. Chirurg 43:446, 1972 7. Bucholz HW, Engelbrecht E, Rottger Jet al: The management of deep infection involving joint implants. J Bone Joint Surg 61B:118, 1979 8. Calandruccio RA: Arthroplasty. p. 2297. In Edmonson AS, Crenshaw AH (eds): Campbell's Operative Orthopaedics. CV Mosby, St. Louis, 1980 9. Carlson AS, Josefsson G, Lindberg L: Revision with gentamicin-impregnated cement for deep infection in total hip arthroplasties. J Bone Joint Surg 60A: 1059, 1978 10. Chamley J: Acrylic Cement in Orthopaedic Surgery. Churchill Livingstone, Edinburgh, 1970 11. Cherney DL, Amstutz HC: Total hip replacement in the previously septic hip. J Bone Joint Surg 65A: 1256, 1983 12. Clegg J: The results of the pseudarthrosis after removal of an infected total hip prostesis. J Bone Joint Surg 59B:298, 1977 13. Colorma PC: The trocanteric reconstruction operation for ununited fractures of the upper end of the femur. J Bone Joint Surg 42B:5, 1960 14. Courtois B, Delarue P, le Saout J, le Nen G: Cinquante-neuf ablations de proth6ses de hanche: comparaison entre l'ablation simple et la coaptation. Rev Chir Orthop 68:523, 1982
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15. Coventry MD: Salvage of the painful hip prosthesis. J Bone Joint Surg 46A:200, 1964 16. de Morgues G: L'ablation simple des proth6ses totales de hanche. Rev Chir Orthop 61(suppl):ll0, 1975 17. Fremont-Smith P: Antibiotic management of septic total replacement: a therapeutic trial. In: The Hip. CV Mosby, St. Louis, 1974 18. Girdlestone GR: Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. Lancet 1:419, 1943 19. Harris WH: Revision surgery for failed, nonseptic total hip arthroplasty: the femoral side. Clin Orthop 170:8, 1982 20. Haw CS, Gray DH: Excision arthroplasty of the hip. J Bone Joint Surg 58B:44, 1976 21. Hunter G, Dandy D: The natural history of the patient with an infected total hip replacement. J Bone Joint Surg 59B:293, 1977 22. Jupiter J, Harris WH: Direct reimplantation of total hip replacements in septic hips in the adult, p. 29. In VH Frankel (ed): AAOS Instructional Course Lectures XXXI. CV Mosby, St. Louis, 1982 23. Jupiter JB, Karchmer AW, Lowell JD, Harris WH: Total hip arthroplasty in the treatment of adult hips with current or quiescent sepsis. J Bone Joint Surg 63A:194, 1981 24. Lindberg L, Carlsson A, Josefsson G: Use of antibiotic containing cement in total hip arthroplasty done in the presence of or after deep wound infection. In: The Hip. CV Mosby, St. Louis, 1977 25. Mallory TH: Excision arthroplasty with delayed wound closure for the infected total hip replacement. Clin Orthop 137:106, 1978 26. McElwaine JP, Colville J: Excision arthroplasty for infected total hip replacements. J Bone Joint Surg 66B:168, 1984 27. Milch H: The resection-angulation operation for hipjoint disabilities. J Bone Joint Surg 37A:699, 1955 28. Patterson FP, Brown CS: The McKee-Farrar total hip replacement: preliminary results and complications of 368 operations performed in five general hospitals. J Bone Joint Surg 54A:257, 1972 29. Pellicci PM, Wilson PD Jr, Sledge CB et al: Long-term results of revision total hip replacement: a follow-up report. J Bone Joint Surg 67A:513, 1985 30. Petty W, Goldsmith S: Resection arthroplasty following infected total hip arthroplasty. J Bone Joint Surg 62A:889, 1980 31. Wilson PD Jr, Aglietti P, Salvati EA: Subacute sepsis of the hip treated by antibiotics and cemented prosthesis. J Bone Joint Surg 56A:879, 1974 32. Wilson PD Jr, Amstutz HC, Czerniecki A et al: Total hip replacement with fLxation by acrylic cement: a preliminary study of 100 consecutive McKee-Farrar prosthetic replacements. J Bone Joint Surg 54A:207, 1972 33. Wilson MR, Fitzgerald RH Jr, Coventry MB: Reconstruction (delayed) by total hip arthroplasty after resection arthroplasty for infection, p. 149. In: The Hip. CV Mosby, St. Louis, 1978