- Email: [email protected]
Endpoint: When revision arthroplasty is no longer an option
SE
M I N A R S I N
AR
T H R O P L A S T Y
27 (2016) 86–92
Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
Endpoint: When revision arthroplasty is no longer an option Bryan D. Haughom, MD, Aaron G. Rosenberg, MD, and Brian K. Park, MDn Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 201, Chicago, IL 60612
article info
abstract
Keywords:
The volume of revision total hip arthroplasty (THA) is increasing. While the tools to
total hip
address these complex patients have improved over recent decades, hip reconstructive
infection
surgeons will no-doubt be confronted with difficult cases, and the consideration of salvage
bone loss
procedures must be undertaken. In the face of significant medical comorbidities, chronic
resection arthroplasty
infection, soft tissue concerns, and bone loss there comes a time when the risk of revision, both in terms of complication as well as poor outcome, becomes untenable. This article reviews the research surrounding the salvage options following failed THA, namely amputation, arthrodesis, resection arthroplasty, and benign neglect. & 2016 Elsevier Inc. All rights reserved.
1.
Introduction
Recent epidemiological estimates indicate significant growth in the number of hip arthroplasties performed in the United States, with an estimated greater than 500,000 primary total hip replacements performed annually by the year 2020–2030 [1–4]. The observed increase in Total Hip Arthroplasty (THA) volume is partially explained by an expansion of the indications for hip replacement. Where once only the most debilitated patients were selected to undergo THA, the dramatic impact on quality of life has prompted many surgeons to broaden their indications for hip arthroplasty. At both ends of the spectrum, younger active and older lower demand patients are undergoing hip replacement. Furthermore, patients with more medical comorbidities are also receiving hip arthroplasties. These factors may help partially explain
not only the increase in volume, but also the associated increase in the observed and expected need for revision THAs in the future [3–5]. Current reports indicate more than 50,000 revision THAs are performed annually in this country, with projections indicating up to a 137% increase by the year 2030 [3–5]. While significant advancements in revision arthroplasty components instrumentation have facilitated the effectiveness of revision hip replacement, even in extremely challenging situations, there are times when repeated revision arthroplasty becomes contra-indicated. Although the restoration of function and the alleviation of pain remain central tenets of orthopaedic surgery, and in particular arthroplasty surgery, we, as surgeons must not forget the principal of primum nil nocere (“first, do no harm”). We must weigh the risks of revision hip arthroplasty in a poor host against the
Neither Dr. Haughom nor Dr. Park has any disclosures to declare. Dr. Rosenberg receives royalties, is a paid consultant and presenter for, and owns stock in Zimmer. Dr. Rosenberg sits on the editorial or governing board of, and receives royalties, financial or material support from Wolters Kluwer Health—Lippincott. No external funding or support was received for the preparation of this article. All work for this article was conducted at Rush University Medical Center. n Corresponding author. E-mail address: [email protected] (B.K. Park). http://dx.doi.org/10.1053/j.sart.2016.06.030 1045-4527/& 2016 Elsevier Inc. All rights reserved.
S
E M I N A R S I N
AR
T H R O P L A S T Y
potential benefits. In the face of significant medical comorbidities, chronic infection, soft tissue concerns, and bone loss there comes a time when the risk of revision, both in terms of complication as well as poor outcome, becomes untenable. Once this point is reached, a frank discussion with the patient must be undertaken outlining the potential treatment options. These treatment options include symptomatic treatment and benign neglect, amputation, arthrodesis, or resection arthroplasty. While none of these options are ideal, it is important to understand the literature behind each of these treatment options in order to best guide our choices and inform our patients.
2.
Is arthroplasty no longer an option?
While there are no true absolute contraindications to a revision hip arthroplasty, there are numerous relative contraindications which can be separated into several categories: medical comorbidities, soft tissue coverage concerns, poor bone stock, and chronic infection refractory to standard treatment. A number of studies in recent years have highlighted both modifiable and non-modifiable risk factors for complications and mortality in hip arthroplasty including advanced age, increased body mass as well as the presence of significant cardiac, pulmonary, renal, hepatic, and immune disease [6–20]. In fact, there now exist a number of risk calculators and prediction tools to help guide decisions and council patients [10,16]. Furthermore, we strongly encourage consultation with your medical colleagues to help determine an accurate risk assessment. While medical input is essential, it is only one of the factors that must be considered so in all but the most extreme settings, the decision to preclude a patient from revision surgery remains at the discretion of the surgeon. Despite improved metrics for diagnosis, as well as a better understanding of how to treat periprosthetic joint infections (PJI), they still represent the most significant biologic factors which may prevent successful revision. Periprosthetic joint infections remain an all-too-common cause of revision THA, with multiple reports demonstrating PJI to be the indication for revision in 15% of cases [5,21]. While many cases of chronic PJI can be successfully treated with a two-stage exchange, certain hosts (such as those with malnourishment, immunodeficiency, or obesity) and certain pathogens (e.g., resistant staphylococcal species) have been shown to be difficult to eradicate [22–26]. The vast majority of cases that fail two-stage exchange warrant reimplantation, however, recent reports evaluating repeat two-stage exchange show dismal outcomes. Kalra et al. evaluated 11 repeat two-stage exchanges from a single institution, and demonstrated a 64% recurrence rate [25]. In the appropriate patient, however, chronic antibiotic suppression has been shown to be an effective way to promote component retention and prevent repeat revision [27]. Other series demonstrate the efficacy of resection arthroplasty in eradicating infection in setting of a poor host or stubborn pathogen. Thus, refractory chronic infection is not inherently a reason to avoid revision or repeat revision surgery. However, surgeons and patients alike
27 (2016) 86–92
87
must understand their chances of success with revision surgery as well as their alternative options (e.g., chronic suppression, resection arthroplasty, etc.). Advances in cementless fixation revolutionized revision total hip arthroplasty, particularly in the setting of significant femoral and pelvic bone loss where reconstructions were once impossible (Fig. 1). Modern porous metal coatings and structural augments, as well as significant advances in component design (e.g., modular, tapered implants and total femoral replacement prostheses) now afford surgeons many more options than were once available. Furthermore, oncological prostheses as well as total femur replacements now exist in the armamentarium of the reconstructive surgeon to combat significant bone loss. Yet, despite these methods to deal with bone loss, surgeons are confronted with scenarios where reconstruction remains untenable. Although no true absolute contraindications exist with respect to bone loss, surgeons must consider the patient as a whole. One must consider the bone stock, the likelihood of operative success, patient medical comorbidities, and their overall functional level when deciding to reconstruct. For example, an elderly bed-bound patient with multiple significant medical comorbidities would not necessarily benefit from a complex revision, and might be better off with a resection arthroplasty. Ultimately these challenging treatment decisions must be undertaken with the collective input of the patient as well as our internal medicine colleagues. The soft tissue envelope surrounding the hip is substantial and forgiving. Despite the fact that flap coverage is rarely necessary, several varieties of flaps have been devised and reported in the literature [28–30]. The more pressing issue for hip surgeons relates to the health of the skin overlying the hip. In the setting of chronic infection or multiply operated hips, however, there may be issues with regards to obtaining reliable closure primarily. Thus consultation with a plastic surgeon may be advised. However, the majority of soft tissue concerns can be addressed and are rarely a true barrier to revision. Consideration should be given to potentially temporizing your revision until the health of the local tissues has improved (i.e., once an infection has cleared). Nevertheless, soft tissue coverage issues may require substantial surgical procedures (e.g., flaps), which may be ill advised in certain hosts.
3.
Symptomatic treatment/benign neglect
Symptomatic treatment and benign neglect remain viable options in certain clinical scenarios—namely in patients with chronic pain, chronic infections amenable to suppressive antibiotics, and those with unacceptable perioperative risk. In the case of chronic pain, without an impending fracture, patients can often be managed with medications. Furthermore, in the case of chronic infections that have proven refractory to standard treatment (e.g., two-stage exchange), several papers have illustrated the utility of chronic antibiotic suppression following a debridement and retention of components [27–33] ranging from 65% [33] to 86.2% [32]. And in the only comparative study on the topic, Siquiera et al. demonstrated a statistically significant benefit of chronic
88
SEM
I N A R S I N
A
R T H R O P L A S T Y
27 (2016) 86–92
Figure 1 – AP and lateral radiographs demonstrating periprosthetic and interprosthetic fractures treated with distal femoral replacement and plating. The interprosthetic fracture lead to a sagittal plane split, non-union and subsidence of the distal femoral prosthesis. Intraoperative comparison of lengths of the native femur and total femoral prosthesis. Post-operative X-ray demonstrating restoration of length and stability.
S
E M I N A R S I N
AR
T H R O P L A S T Y
suppression following surgical intervention for infection. They demonstrated a 68.5% success rate with antibiotic suppression compared with a 41.1% success rate without antibiotics [27]. To the authors' knowledge, no studies have evaluated the utility of antibiotic suppression in the absence of a surgical debridement. And finally, when a patient is being precluded from revision surgery for medical contraindications, the surgeon must consider whether these risks are potentially modifiable. If these modifiable risks factors are to improve, then the patient might become a reasonable operative candidate in the future.
4.
Amputation
Although rarely a tenable option from a patient's perspective, amputation serves as a viable terminal procedure when revision hip arthroplasty is no longer possible. While it is a rare outcome, three series have evaluated hip disarticulation for the treatment of severe bone loss, chronic refractory infection, and vascular injury [34–36]. Furthermore, one group reported a technique for tibia-hindfoot osteomusculocutaneous rotationplasty with calcaneopelvic arthrodesis [37]. It should be noted that these reports include a heterogeneous patient population, however, each of them includes a subset of failed hip arthroplasty patients. In the first series on the topic, Ford et al. described their experience with 4 patients, 1 of which had a prior THA complicated by periprosthetic fracture non-union, peroneal nerve palsy, and resultant equinus deformity, as well as an ankylosed varus knee [35]. The patient was noted to be walking with crutches and without the use of a prosthesis 7 weeks post-operatively. Similarly, Zalavras et al. recently presented their experience with a heterogeneous group of patients, including two chronically infected endoprostheses, who underwent hip disarticulation [36]. One death occurred in their series, though it was in a non-arthroplasty patient who presented with gas gangrene. And finally, in the largest series, Fenelon et al. presented their experience of 11 patients who underwent disarticulation for chronic refractory periprosthetic infection [34]. At the final follow-up, eight of the patients remain alive, 4 (50%) remained ambulatory, and 7 (88%) of them remained satisfied with their outcome. Peterson et al. detailed a technique to avoid hip disarticulation [37]. In their series of two patients, one of which had a failed THA, they describe their technique of rotating the lower leg and fusing the calcaneus to the pelvis in order to preserve length of the femur and facilitate the use of an above-knee amputation prosthesis. No larger series have described the outcomes of this rare procedure.
89
evolved to become a common treatment of rheumatic and osteoarthritic hip pathology over the early 20th century [38–40]. The advent of the THA has largely obviated the use of resection arthroplasty in modern orthopaedics other than its role in the treatment of the failed THA. In an era where revision options were limited, and our understanding of the correct treatment strategies of periprosthetic infections were in their infancy, the resection arthroplasty was not an uncommon treatment of the failed THA. Commonly referenced in the literature as a means of treating a periprosthetic infection, multiple reports have demonstrated greater than 90% rates of infection eradication [41–47]. Others have described the operation as a means of addressing aseptic failure, in particular in the setting of component loosening and loss of bone stock [48,49]. Relatively few series have documented patient satisfaction following resection arthroplasty for failed THA, however, outcomes are generally good, ranging between 70% and 100% [41–43,50]. These results must be taken cautiously, as much of the literature was generated prior to the development of modern revision techniques. With older and sicker patients undergoing revision THA today, the role of resection arthroplasty has changed and two recent reports analyzed resection arthroplasty for failed THA outcomes. Basu et al. reviewed their outcomes of 41 resection arthroplasties for failed THA. Chronic infection (60%) and recurrent dislocation (29%) represented the most common indications for resection arthroplasty. They found a high rate of mortality (41%) as well as significant functional impairment in survivors , with only 29% of patients able to ambulate without walking aids, 29% able to ambulate with the use of a walking aid, and 59% able to put on their own shoes and socks [51]. Malcolm et al. reported on 36 patients with resection arthroplasty for periprosthetic infection (68%), chronic dislocation (21%), and aseptic loosening (11%). They found high rates of major systemic (21%) and major local (13%) complications within 90-days. Four patients died within the 90-day post-operative period, high rates of mortality were observed at final follow-up (60% at 13 months) [52]. The findings of the Basu and Malcolm would suggest that outcomes are less optimal in current times, suggestive of the medically complex patients undergoing resection arthroplasty. Where once it was utilized for failed THA with compromised bone stock and recurrent dislocation, it is currently largely reserved for patients who have failed multiple two-stage exchanges for infection, patients whose medical status preclude large complex revisions, and the minimal or non-ambulator.
6. 5.
27 (2016) 86–92
Arthrodesis
Resection arthroplasty
First described by White in the mid-1800's as a treatment of septic arthritis of the hip, the resection arthroplasty has colloquially become known as the Girdlestone arthroplasty. Named after Gathorne Girdlestone, a British surgeon who utilized the procedure as a treatment of tuberculous arthritis and osteomyelitis of the hip, the Girdlestone arthroplasty
Although THA has revolutionized the care of hip arthritis, prior to THA arthrodesis remained the standard of care in the young patients with debilitating hip degeneration. (Fig. 2) As Callaghan showed in his seminal long-term follow-up study of young patients undergoing hip arthrodesis, the procedure can be extremely effective in eliminating hip pain. However, unfortunately high rates of back pain (60%), ipsilateral knee
90
SEM
I N A R S I N
A
R T H R O P L A S T Y
27 (2016) 86–92
Figure 2 – Hip arthrodesis is rarely performed now for failed THA. Modern techniques and technology make reconstruction possible in situations that were once unsalvageable. pain (60%), and contralateral hip (25%) were observed to develop at final follow-up [53]. It should be noted, however, that this series included no patients who had undergone prior arthroplasty. In fact, to our knowledge, only one article in the literature has evaluated post-arthroplasty hip arthrodesis [54]. In response to what Kostiuk et al. found to be “functionally poor” results in the “physiologically young patient” who underwent girdlestone for failed THA, he reported on hip arthrodesis as a viable alternative [54]. He evaluated 14 of his patients (13 men, average age 38 years) who underwent fusion following failed arthroplasty. On average, the patients had undergone 2.7 prior hip procedures, and half of his patients were revised for infection. Using a modified AO hip arthrodesis technique via a lateral approach and trochanteric osteotomy, the authors fused the hip in a position of slight flexion (151) and abduction (5–101). At an average 4.3 years follow-up 13 of 14 patients demonstrated bony union. The average leg length discrepancy reported was 4.6 cm and all patients were ambulatory, with three using a cane. All patients who fused were relieved of pain. The results of the Kostiuk series must interpreted carefully as surgeons of this era did not have the tools available that are now at the disposal of modern hip reconstructive surgeons. Thus, in the current era of hip reconstruction, this would seem an unlikely alternative, especially considering the substantial bone loss likely to be present given our improved instrumentation and much higher threshold to decline revision surgery.
7.
Conclusions
Total hip arthroplasties have revolutionized the care of the arthritic hip. This has led to more and more patients undergoing the operation, and subsequently higher rates of
revision surgery. Current estimates indicate revision THA will continue to rise in the coming years. The arthroplasty community is destined to be confronted with challenging revision scenarios involving poor hosts, significant bone loss, soft tissue concerns, and chronic infections. While revision surgery with THA is typically the preferred solution, surgeons must always weigh the risks and benefits of a demanding revision against the chances of success and the risks of complication. In these challenging scenarios, consideration should be given to the often seemingly less desirable options of benign neglect and symptomatic treatment, amputation, arthrodesis, and resection arthroplasty. Although the available literature is limited, it does demonstrate these options to be reasonable alternatives in the appropriate selected host.
re fe r en ces
[1] Brand RA. Biographical sketch: Sir John Charnley MD, 1911– 1982. Clinical Orthopaedics and Related Research 2010;468: 3147–8. [2] Culliford D, Maskell J, Judge A, Cooper C, Prieto-Alhambra D, Arden NK, et al. Future projections of total hip and knee arthroplasty in the UK: results from the UK Clinical Practice Research Datalink. Osteoarthritis and Cartilage/OARS, Osteoarthritis Research Society 2015;23:594–600. [3] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. The Journal of Bone and Joint Surgery. American Volume 2007;89:780–5. [4] Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. The Journal of Bone and Joint Surgery. American Volume 2014;96:624–30. [5] Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United
S
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
E M I N A R S I N
AR
T H R O P L A S T Y
States. The Journal of Bone and Joint Surgery. American Volume 2009;91:128–33. Belmont PJ Jr., Goodman GP, Hamilton W, Waterman BR, Bader JO, Schoenfeld AJ. Morbidity and mortality in the thirty-day period following total hip arthroplasty: risk factors and incidence. The Journal of Arthroplasty 2014;29:2025–30. Berstock JR, Beswick AD, Lenguerrand E, Whitehouse MR, Blom AW. Mortality after total hip replacement surgery: a systematic review. Bone Joint Research 2014;3:175–82. Cavanaugh PK, Chen AF, Rasouli MR, Post ZD, Orozco FR, Ong AC. Complications and mortality in chronic renal failure patients undergoing total joint arthroplasty: a comparison between dialysis and renal transplant patients. The Journal of Arthroplasty 2015. Courtney PM, Melnic CM, Gutsche J, Hume EL, Lee GC. Which patients need critical care intervention after total joint arthroplasty? A prospective study of factors associated with the need for intensive care following surgery. Bone Joint Journal 2015;97-B:1512–8. Edelstein AI, Kwasny MJ, Suleiman LI, Khakhkhar RH, Moore MA, Beal MD, et al. Can the American College of Surgeons risk calculator predict 30-day complications after knee and hip arthroplasty? The Journal of Arthroplasty 2015;30:5–10. Fang M, Noiseux N, Linson E, Cram P. The effect of advancing age on total joint replacement outcomes. Geriatric Orthopaedic Surgery and Rehabilitation 2015;6:173–9. Florschutz AV, Fagan RP, Matar WY, Sawyer RG, Berrios-Torres SI. Surgical site infection risk factors and risk stratification. The Journal of the American Academy of Orthopaedic Surgeons 2015;23(Suppl.):S8–11. Higuera CA, Elsharkawy K, Klika AK, Brocone M, Barsoum WK. Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clinical Orthopaedics and Related Research 2010;2011(469):1391–400. Illingworth KD, El Bitar YF, Banerjee D, Scaife SL, Saleh KJ. Inpatient mortality after primary total hip arthroplasty: analysis from the National Inpatient Sample database. The Journal of Arthroplasty 2015;30:369–73. Kirksey M, Chiu YL, Ma Y, Della Valle AG, Poultsides L, Gerner P, et al. Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998–2008. Anesthesia and Analgesia 2012;115:321–7. Manning DW, Edelstein AI, Alvi HM. Risk prediction tools for hip and knee arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons 2016;24:19–27. Miric A, Inacio MC, Kelly MP, Namba RS. Are nonagenarians too old for total hip arthroplasty? An Evaluation of morbidity and mortality within a total joint replacement registry. The Journal of Arthroplasty 2015;30:1324–7. Ponnusamy KE, Jain A, Thakkar SC, Sterling RS, Skolasky RL, Khanuja HS. Inpatient mortality and morbidity for dialysisdependent patients undergoing primary total hip or knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2015;97:1326–32. Tiberi JV 3rd, Hansen V, El-Abbadi N, Bedair H. Increased complication rates after hip and knee arthroplasty in patients with cirrhosis of the liver. Clinical Orthopaedics and Related Research 2014;472:2774–8. Ward DT, Metz LN, Horst PK, Kim HT, Kuo AC. Complications of morbid obesity in total joint arthroplasty: risk stratification based on BMI. The Journal of arthroplasty 2015;30:42–6. Kamath AF, Ong KL, Lau E, Chan V, Vail TP, Rubash HE, et al. Quantifying the Burden of Revision Total Joint Arthroplasty for Periprosthetic Infection. The Journal of Arthroplasty 2015;30:1492–7. Berend KR, Lombardi AV Jr, Morris MJ, Bergeson AG, Adams JB, Sneller MA. Two-stage treatment of hip periprosthetic joint
[23] [24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
27 (2016) 86–92
91
infection is associated with a high rate of infection control but high mortality. Clinical Orthopaedics and Related Research 2013;471:510–8. Cooper HJ, Della Valle CJ. The two-stage standard in revision total hip replacement. Bone Joint Journal 2013;95-B:84–7. Houdek MT, Wagner ER, Watts CD, Osmon DR, Hanssen AD, Lewallen DG, et al. Morbid obesity: a significant risk factor for failure of two-stage revision total hip arthroplasty for infection. The Journal of Bone and Joint Surgery. American Volume 2015;97:326–32. Kalra KP, Lin KK, Bozic KJ, Ries MD. Repeat 2-stage revision for recurrent infection of total hip arthroplasty. The Journal of Arthroplasty 2010;25:880–4. Odum SM, Fehring TK, Lombardi AV, Zmistowski BM, Brown NM, Luna JT, et al. Irrigation and debridement for periprosthetic infections: does the organism matter? The Journal of Arthroplasty 2011;26:114–8. Siqueira MB, Saleh A, Klika AK, O’Rourke C, Schmitt S, Higuera CA, et al. Chronic suppression of periprosthetic joint infections with oral antibiotics increases infection-free survivorship. The Journal of Bone and Joint Surgery. American Volume 2015;97:1220–32. d’Ettorre G, Marchetti F, Ceccarelli G, Gizzi F, Tierno F, Falcone M, et al. Surgical debridement with muscle flap transposition and systemic teicoplanin therapy for infected hip arthroplasty. Hip International 2010;20:255–7. Huang KC, Peng KT, Li YY, Tsai YH, Huang TJ, Hsu RW. Modified vastus lateralis flap in treating a difficult hip infection. The Journal of Trauma 2005;59:665–71. Windle BH, Stroup RT Jr, Beckenstein MS. The inferiorly based rectus abdominis island flap for the treatment of complex hip wounds. Plastic and Reconstructive Surgery 1996;98:99–102. Segreti J, Nelson JA, Trenholme GM. Prolonged suppressive antibiotic therapy for infected orthopedic prostheses. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America 1998;27:711–3. Rao N, Crossett LS, Sinha RK, Le Frock JL. Long-term suppression of infection in total joint arthroplasty. Clinical Orthopaedics and Related Research 2003;414:55–60. Barberan J, Aguilar L, Carroquino G, Gimenez MJ, Sanchez B, Martinez D, et al. Conservative treatment of staphylococcal prosthetic joint infections in elderly patients. The American Journal of Medicine 2006;119 [993.e7–993.e10]. Fenelon GC, Von Foerster G, Engelbrecht E. Disarticulation of the hip as a result of failed arthroplasty. A series of 11 cases. The Journal of Bone and Joint Surgery. British Volume 1980;62-B:441–6. Ford LT, Holder BK. Disarticulation for failed surgical procedures about the hip. Southern Medical Journal 1977;70: 1293–6. Zalavras CG, Rigopoulos N, Ahlmann E, Patzakis MJ. Hip disarticulation for severe lower extremity infections. Clinical Orthopaedics and Related Research 2009;467:1721–6. Peterson CA 2nd, Koch LD, Wood MB. Tibia-hindfoot osteomusculocutaneous rotationplasty with calcaneopelvic arthrodesis for extensive loss of bone from the proximal part of the femur. A report of two cases. The Journal of Bone and Joint Surgery. American Volume 1997;79:1504–9. Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. 1943. Clinical Orthopaedics and Related Research 2008;466:258–63. Gruca A. The treatment of quiescent tuberculosis of the hip joint by excision and “dynamic” osteotomy. The Journal of Bone and Joint Surgery. British Volume 1950;32-B:174–82. Lipscomb PR. Reconstructive surgery for bilateral hip-joint disease in the adult. The Journal of Bone and Joint Surgery. American Volume 1965;47:1–30.
92
SEM
I N A R S I N
A
R T H R O P L A S T Y
[41] Ballard WT, Lowry DA, Brand RA. Resection arthroplasty of the hip. The Journal of Arthroplasty 1995;10:772–9. [42] Bohler M, Salzer M. Girdlestone's modified resection arthroplasty. Orthopedics 1991;14:661–6. [43] Bourne RB, Hunter GA, Rorabeck CH, Macnab JJ. A six-year follow-up of infected total hip replacements managed by Girdlestone's arthroplasty. The Journal of Bone and Joint Surgery. British Volume 1984;66:340–3. [44] Grauer JD, Amstutz HC, O'Carroll PF, Dorey FJ. Resection arthroplasty of the hip. The Journal of Bone and Joint Surgery. American Volume 1989;71:669–78. [45] Haw CS, Gray DH. Excision arthroplasty of the hip. The Journal of Bone and Joint Surgery. British Volume 1976;58:44–7. [46] Herzog T, Link W, Engel S, Beck H. Resection arthroplasty: middle- and long-term results. Archives of Orthopaedic and Trauma Surgery 1989;108:279–81. [47] Pazzaglia UE, Ghisellini F, Ceffa R, Riccardi C, Ceciliani L. Evaluation of reimplant total hip prostheses and resection arthroplasty. Orthopedics 1988;11:1141–5. [48] Harris WH, White RE Jr. Resection arthroplasty for nonseptic failure of total hip arthroplasty. Clinical Orthopaedics and Related Research 1982;171:62–7.
27 (2016) 86–92
[49] Scalvi A, Campacci A, Marcer M, Cassini M, Guerra C, Ferraresi M, et al. Girdlestone arthroplasty for loosening of the total hip prosthesis: evaluation and results. La Chirurgia degli Organi di Movimento 1995;80:279–85. [50] Ahlgren SA, Gudmundsson G, Bartholdsson E. Function after removal of a septic total hip prosthesis. A survey of 27 Girdlestone hips. Acta Orthopaedica Scandinavica 1980;51: 541–5. [51] Basu I, Howes M, Jowett C, Levack B. Girdlestones excision arthroplasty: current update. International Journal of Surgery (London, England) 2011;9:310–3. [52] Malcolm TL, Gad BV, Elsharkawy KA, Higuera CA. Complication, survival, and reoperation rates following girdlestone resection arthroplasty. The Journal of Arthroplasty 2015;30: 1183–6. [53] Callaghan JJ, Brand RA, Pedersen DR. Hip arthrodesis. A longterm follow-up. The Journal of Bone and Joint Surgery. American Volume 1985;67:1328–35. [54] Kostuik J, Alexander D. Arthrodesis for failed arthroplasty of the hip. Clinical Orthopaedics and Related Research 1984;188:173–82.
M I N A R S I N
AR
T H R O P L A S T Y
27 (2016) 86–92
Available online at www.sciencedirect.com
www.elsevier.com/locate/semanthroplasty
Endpoint: When revision arthroplasty is no longer an option Bryan D. Haughom, MD, Aaron G. Rosenberg, MD, and Brian K. Park, MDn Department of Orthopaedic Surgery, Rush University Medical Center, 1611 W. Harrison St, Suite 201, Chicago, IL 60612
article info
abstract
Keywords:
The volume of revision total hip arthroplasty (THA) is increasing. While the tools to
total hip
address these complex patients have improved over recent decades, hip reconstructive
infection
surgeons will no-doubt be confronted with difficult cases, and the consideration of salvage
bone loss
procedures must be undertaken. In the face of significant medical comorbidities, chronic
resection arthroplasty
infection, soft tissue concerns, and bone loss there comes a time when the risk of revision, both in terms of complication as well as poor outcome, becomes untenable. This article reviews the research surrounding the salvage options following failed THA, namely amputation, arthrodesis, resection arthroplasty, and benign neglect. & 2016 Elsevier Inc. All rights reserved.
1.
Introduction
Recent epidemiological estimates indicate significant growth in the number of hip arthroplasties performed in the United States, with an estimated greater than 500,000 primary total hip replacements performed annually by the year 2020–2030 [1–4]. The observed increase in Total Hip Arthroplasty (THA) volume is partially explained by an expansion of the indications for hip replacement. Where once only the most debilitated patients were selected to undergo THA, the dramatic impact on quality of life has prompted many surgeons to broaden their indications for hip arthroplasty. At both ends of the spectrum, younger active and older lower demand patients are undergoing hip replacement. Furthermore, patients with more medical comorbidities are also receiving hip arthroplasties. These factors may help partially explain
not only the increase in volume, but also the associated increase in the observed and expected need for revision THAs in the future [3–5]. Current reports indicate more than 50,000 revision THAs are performed annually in this country, with projections indicating up to a 137% increase by the year 2030 [3–5]. While significant advancements in revision arthroplasty components instrumentation have facilitated the effectiveness of revision hip replacement, even in extremely challenging situations, there are times when repeated revision arthroplasty becomes contra-indicated. Although the restoration of function and the alleviation of pain remain central tenets of orthopaedic surgery, and in particular arthroplasty surgery, we, as surgeons must not forget the principal of primum nil nocere (“first, do no harm”). We must weigh the risks of revision hip arthroplasty in a poor host against the
Neither Dr. Haughom nor Dr. Park has any disclosures to declare. Dr. Rosenberg receives royalties, is a paid consultant and presenter for, and owns stock in Zimmer. Dr. Rosenberg sits on the editorial or governing board of, and receives royalties, financial or material support from Wolters Kluwer Health—Lippincott. No external funding or support was received for the preparation of this article. All work for this article was conducted at Rush University Medical Center. n Corresponding author. E-mail address: [email protected] (B.K. Park). http://dx.doi.org/10.1053/j.sart.2016.06.030 1045-4527/& 2016 Elsevier Inc. All rights reserved.
S
E M I N A R S I N
AR
T H R O P L A S T Y
potential benefits. In the face of significant medical comorbidities, chronic infection, soft tissue concerns, and bone loss there comes a time when the risk of revision, both in terms of complication as well as poor outcome, becomes untenable. Once this point is reached, a frank discussion with the patient must be undertaken outlining the potential treatment options. These treatment options include symptomatic treatment and benign neglect, amputation, arthrodesis, or resection arthroplasty. While none of these options are ideal, it is important to understand the literature behind each of these treatment options in order to best guide our choices and inform our patients.
2.
Is arthroplasty no longer an option?
While there are no true absolute contraindications to a revision hip arthroplasty, there are numerous relative contraindications which can be separated into several categories: medical comorbidities, soft tissue coverage concerns, poor bone stock, and chronic infection refractory to standard treatment. A number of studies in recent years have highlighted both modifiable and non-modifiable risk factors for complications and mortality in hip arthroplasty including advanced age, increased body mass as well as the presence of significant cardiac, pulmonary, renal, hepatic, and immune disease [6–20]. In fact, there now exist a number of risk calculators and prediction tools to help guide decisions and council patients [10,16]. Furthermore, we strongly encourage consultation with your medical colleagues to help determine an accurate risk assessment. While medical input is essential, it is only one of the factors that must be considered so in all but the most extreme settings, the decision to preclude a patient from revision surgery remains at the discretion of the surgeon. Despite improved metrics for diagnosis, as well as a better understanding of how to treat periprosthetic joint infections (PJI), they still represent the most significant biologic factors which may prevent successful revision. Periprosthetic joint infections remain an all-too-common cause of revision THA, with multiple reports demonstrating PJI to be the indication for revision in 15% of cases [5,21]. While many cases of chronic PJI can be successfully treated with a two-stage exchange, certain hosts (such as those with malnourishment, immunodeficiency, or obesity) and certain pathogens (e.g., resistant staphylococcal species) have been shown to be difficult to eradicate [22–26]. The vast majority of cases that fail two-stage exchange warrant reimplantation, however, recent reports evaluating repeat two-stage exchange show dismal outcomes. Kalra et al. evaluated 11 repeat two-stage exchanges from a single institution, and demonstrated a 64% recurrence rate [25]. In the appropriate patient, however, chronic antibiotic suppression has been shown to be an effective way to promote component retention and prevent repeat revision [27]. Other series demonstrate the efficacy of resection arthroplasty in eradicating infection in setting of a poor host or stubborn pathogen. Thus, refractory chronic infection is not inherently a reason to avoid revision or repeat revision surgery. However, surgeons and patients alike
27 (2016) 86–92
87
must understand their chances of success with revision surgery as well as their alternative options (e.g., chronic suppression, resection arthroplasty, etc.). Advances in cementless fixation revolutionized revision total hip arthroplasty, particularly in the setting of significant femoral and pelvic bone loss where reconstructions were once impossible (Fig. 1). Modern porous metal coatings and structural augments, as well as significant advances in component design (e.g., modular, tapered implants and total femoral replacement prostheses) now afford surgeons many more options than were once available. Furthermore, oncological prostheses as well as total femur replacements now exist in the armamentarium of the reconstructive surgeon to combat significant bone loss. Yet, despite these methods to deal with bone loss, surgeons are confronted with scenarios where reconstruction remains untenable. Although no true absolute contraindications exist with respect to bone loss, surgeons must consider the patient as a whole. One must consider the bone stock, the likelihood of operative success, patient medical comorbidities, and their overall functional level when deciding to reconstruct. For example, an elderly bed-bound patient with multiple significant medical comorbidities would not necessarily benefit from a complex revision, and might be better off with a resection arthroplasty. Ultimately these challenging treatment decisions must be undertaken with the collective input of the patient as well as our internal medicine colleagues. The soft tissue envelope surrounding the hip is substantial and forgiving. Despite the fact that flap coverage is rarely necessary, several varieties of flaps have been devised and reported in the literature [28–30]. The more pressing issue for hip surgeons relates to the health of the skin overlying the hip. In the setting of chronic infection or multiply operated hips, however, there may be issues with regards to obtaining reliable closure primarily. Thus consultation with a plastic surgeon may be advised. However, the majority of soft tissue concerns can be addressed and are rarely a true barrier to revision. Consideration should be given to potentially temporizing your revision until the health of the local tissues has improved (i.e., once an infection has cleared). Nevertheless, soft tissue coverage issues may require substantial surgical procedures (e.g., flaps), which may be ill advised in certain hosts.
3.
Symptomatic treatment/benign neglect
Symptomatic treatment and benign neglect remain viable options in certain clinical scenarios—namely in patients with chronic pain, chronic infections amenable to suppressive antibiotics, and those with unacceptable perioperative risk. In the case of chronic pain, without an impending fracture, patients can often be managed with medications. Furthermore, in the case of chronic infections that have proven refractory to standard treatment (e.g., two-stage exchange), several papers have illustrated the utility of chronic antibiotic suppression following a debridement and retention of components [27–33] ranging from 65% [33] to 86.2% [32]. And in the only comparative study on the topic, Siquiera et al. demonstrated a statistically significant benefit of chronic
88
SEM
I N A R S I N
A
R T H R O P L A S T Y
27 (2016) 86–92
Figure 1 – AP and lateral radiographs demonstrating periprosthetic and interprosthetic fractures treated with distal femoral replacement and plating. The interprosthetic fracture lead to a sagittal plane split, non-union and subsidence of the distal femoral prosthesis. Intraoperative comparison of lengths of the native femur and total femoral prosthesis. Post-operative X-ray demonstrating restoration of length and stability.
S
E M I N A R S I N
AR
T H R O P L A S T Y
suppression following surgical intervention for infection. They demonstrated a 68.5% success rate with antibiotic suppression compared with a 41.1% success rate without antibiotics [27]. To the authors' knowledge, no studies have evaluated the utility of antibiotic suppression in the absence of a surgical debridement. And finally, when a patient is being precluded from revision surgery for medical contraindications, the surgeon must consider whether these risks are potentially modifiable. If these modifiable risks factors are to improve, then the patient might become a reasonable operative candidate in the future.
4.
Amputation
Although rarely a tenable option from a patient's perspective, amputation serves as a viable terminal procedure when revision hip arthroplasty is no longer possible. While it is a rare outcome, three series have evaluated hip disarticulation for the treatment of severe bone loss, chronic refractory infection, and vascular injury [34–36]. Furthermore, one group reported a technique for tibia-hindfoot osteomusculocutaneous rotationplasty with calcaneopelvic arthrodesis [37]. It should be noted that these reports include a heterogeneous patient population, however, each of them includes a subset of failed hip arthroplasty patients. In the first series on the topic, Ford et al. described their experience with 4 patients, 1 of which had a prior THA complicated by periprosthetic fracture non-union, peroneal nerve palsy, and resultant equinus deformity, as well as an ankylosed varus knee [35]. The patient was noted to be walking with crutches and without the use of a prosthesis 7 weeks post-operatively. Similarly, Zalavras et al. recently presented their experience with a heterogeneous group of patients, including two chronically infected endoprostheses, who underwent hip disarticulation [36]. One death occurred in their series, though it was in a non-arthroplasty patient who presented with gas gangrene. And finally, in the largest series, Fenelon et al. presented their experience of 11 patients who underwent disarticulation for chronic refractory periprosthetic infection [34]. At the final follow-up, eight of the patients remain alive, 4 (50%) remained ambulatory, and 7 (88%) of them remained satisfied with their outcome. Peterson et al. detailed a technique to avoid hip disarticulation [37]. In their series of two patients, one of which had a failed THA, they describe their technique of rotating the lower leg and fusing the calcaneus to the pelvis in order to preserve length of the femur and facilitate the use of an above-knee amputation prosthesis. No larger series have described the outcomes of this rare procedure.
89
evolved to become a common treatment of rheumatic and osteoarthritic hip pathology over the early 20th century [38–40]. The advent of the THA has largely obviated the use of resection arthroplasty in modern orthopaedics other than its role in the treatment of the failed THA. In an era where revision options were limited, and our understanding of the correct treatment strategies of periprosthetic infections were in their infancy, the resection arthroplasty was not an uncommon treatment of the failed THA. Commonly referenced in the literature as a means of treating a periprosthetic infection, multiple reports have demonstrated greater than 90% rates of infection eradication [41–47]. Others have described the operation as a means of addressing aseptic failure, in particular in the setting of component loosening and loss of bone stock [48,49]. Relatively few series have documented patient satisfaction following resection arthroplasty for failed THA, however, outcomes are generally good, ranging between 70% and 100% [41–43,50]. These results must be taken cautiously, as much of the literature was generated prior to the development of modern revision techniques. With older and sicker patients undergoing revision THA today, the role of resection arthroplasty has changed and two recent reports analyzed resection arthroplasty for failed THA outcomes. Basu et al. reviewed their outcomes of 41 resection arthroplasties for failed THA. Chronic infection (60%) and recurrent dislocation (29%) represented the most common indications for resection arthroplasty. They found a high rate of mortality (41%) as well as significant functional impairment in survivors , with only 29% of patients able to ambulate without walking aids, 29% able to ambulate with the use of a walking aid, and 59% able to put on their own shoes and socks [51]. Malcolm et al. reported on 36 patients with resection arthroplasty for periprosthetic infection (68%), chronic dislocation (21%), and aseptic loosening (11%). They found high rates of major systemic (21%) and major local (13%) complications within 90-days. Four patients died within the 90-day post-operative period, high rates of mortality were observed at final follow-up (60% at 13 months) [52]. The findings of the Basu and Malcolm would suggest that outcomes are less optimal in current times, suggestive of the medically complex patients undergoing resection arthroplasty. Where once it was utilized for failed THA with compromised bone stock and recurrent dislocation, it is currently largely reserved for patients who have failed multiple two-stage exchanges for infection, patients whose medical status preclude large complex revisions, and the minimal or non-ambulator.
6. 5.
27 (2016) 86–92
Arthrodesis
Resection arthroplasty
First described by White in the mid-1800's as a treatment of septic arthritis of the hip, the resection arthroplasty has colloquially become known as the Girdlestone arthroplasty. Named after Gathorne Girdlestone, a British surgeon who utilized the procedure as a treatment of tuberculous arthritis and osteomyelitis of the hip, the Girdlestone arthroplasty
Although THA has revolutionized the care of hip arthritis, prior to THA arthrodesis remained the standard of care in the young patients with debilitating hip degeneration. (Fig. 2) As Callaghan showed in his seminal long-term follow-up study of young patients undergoing hip arthrodesis, the procedure can be extremely effective in eliminating hip pain. However, unfortunately high rates of back pain (60%), ipsilateral knee
90
SEM
I N A R S I N
A
R T H R O P L A S T Y
27 (2016) 86–92
Figure 2 – Hip arthrodesis is rarely performed now for failed THA. Modern techniques and technology make reconstruction possible in situations that were once unsalvageable. pain (60%), and contralateral hip (25%) were observed to develop at final follow-up [53]. It should be noted, however, that this series included no patients who had undergone prior arthroplasty. In fact, to our knowledge, only one article in the literature has evaluated post-arthroplasty hip arthrodesis [54]. In response to what Kostiuk et al. found to be “functionally poor” results in the “physiologically young patient” who underwent girdlestone for failed THA, he reported on hip arthrodesis as a viable alternative [54]. He evaluated 14 of his patients (13 men, average age 38 years) who underwent fusion following failed arthroplasty. On average, the patients had undergone 2.7 prior hip procedures, and half of his patients were revised for infection. Using a modified AO hip arthrodesis technique via a lateral approach and trochanteric osteotomy, the authors fused the hip in a position of slight flexion (151) and abduction (5–101). At an average 4.3 years follow-up 13 of 14 patients demonstrated bony union. The average leg length discrepancy reported was 4.6 cm and all patients were ambulatory, with three using a cane. All patients who fused were relieved of pain. The results of the Kostiuk series must interpreted carefully as surgeons of this era did not have the tools available that are now at the disposal of modern hip reconstructive surgeons. Thus, in the current era of hip reconstruction, this would seem an unlikely alternative, especially considering the substantial bone loss likely to be present given our improved instrumentation and much higher threshold to decline revision surgery.
7.
Conclusions
Total hip arthroplasties have revolutionized the care of the arthritic hip. This has led to more and more patients undergoing the operation, and subsequently higher rates of
revision surgery. Current estimates indicate revision THA will continue to rise in the coming years. The arthroplasty community is destined to be confronted with challenging revision scenarios involving poor hosts, significant bone loss, soft tissue concerns, and chronic infections. While revision surgery with THA is typically the preferred solution, surgeons must always weigh the risks and benefits of a demanding revision against the chances of success and the risks of complication. In these challenging scenarios, consideration should be given to the often seemingly less desirable options of benign neglect and symptomatic treatment, amputation, arthrodesis, and resection arthroplasty. Although the available literature is limited, it does demonstrate these options to be reasonable alternatives in the appropriate selected host.
re fe r en ces
[1] Brand RA. Biographical sketch: Sir John Charnley MD, 1911– 1982. Clinical Orthopaedics and Related Research 2010;468: 3147–8. [2] Culliford D, Maskell J, Judge A, Cooper C, Prieto-Alhambra D, Arden NK, et al. Future projections of total hip and knee arthroplasty in the UK: results from the UK Clinical Practice Research Datalink. Osteoarthritis and Cartilage/OARS, Osteoarthritis Research Society 2015;23:594–600. [3] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. The Journal of Bone and Joint Surgery. American Volume 2007;89:780–5. [4] Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. The Journal of Bone and Joint Surgery. American Volume 2014;96:624–30. [5] Bozic KJ, Kurtz SM, Lau E, Ong K, Vail TP, Berry DJ. The epidemiology of revision total hip arthroplasty in the United
S
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
[18]
[19]
[20]
[21]
[22]
E M I N A R S I N
AR
T H R O P L A S T Y
States. The Journal of Bone and Joint Surgery. American Volume 2009;91:128–33. Belmont PJ Jr., Goodman GP, Hamilton W, Waterman BR, Bader JO, Schoenfeld AJ. Morbidity and mortality in the thirty-day period following total hip arthroplasty: risk factors and incidence. The Journal of Arthroplasty 2014;29:2025–30. Berstock JR, Beswick AD, Lenguerrand E, Whitehouse MR, Blom AW. Mortality after total hip replacement surgery: a systematic review. Bone Joint Research 2014;3:175–82. Cavanaugh PK, Chen AF, Rasouli MR, Post ZD, Orozco FR, Ong AC. Complications and mortality in chronic renal failure patients undergoing total joint arthroplasty: a comparison between dialysis and renal transplant patients. The Journal of Arthroplasty 2015. Courtney PM, Melnic CM, Gutsche J, Hume EL, Lee GC. Which patients need critical care intervention after total joint arthroplasty? A prospective study of factors associated with the need for intensive care following surgery. Bone Joint Journal 2015;97-B:1512–8. Edelstein AI, Kwasny MJ, Suleiman LI, Khakhkhar RH, Moore MA, Beal MD, et al. Can the American College of Surgeons risk calculator predict 30-day complications after knee and hip arthroplasty? The Journal of Arthroplasty 2015;30:5–10. Fang M, Noiseux N, Linson E, Cram P. The effect of advancing age on total joint replacement outcomes. Geriatric Orthopaedic Surgery and Rehabilitation 2015;6:173–9. Florschutz AV, Fagan RP, Matar WY, Sawyer RG, Berrios-Torres SI. Surgical site infection risk factors and risk stratification. The Journal of the American Academy of Orthopaedic Surgeons 2015;23(Suppl.):S8–11. Higuera CA, Elsharkawy K, Klika AK, Brocone M, Barsoum WK. Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients. Clinical Orthopaedics and Related Research 2010;2011(469):1391–400. Illingworth KD, El Bitar YF, Banerjee D, Scaife SL, Saleh KJ. Inpatient mortality after primary total hip arthroplasty: analysis from the National Inpatient Sample database. The Journal of Arthroplasty 2015;30:369–73. Kirksey M, Chiu YL, Ma Y, Della Valle AG, Poultsides L, Gerner P, et al. Trends in in-hospital major morbidity and mortality after total joint arthroplasty: United States 1998–2008. Anesthesia and Analgesia 2012;115:321–7. Manning DW, Edelstein AI, Alvi HM. Risk prediction tools for hip and knee arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons 2016;24:19–27. Miric A, Inacio MC, Kelly MP, Namba RS. Are nonagenarians too old for total hip arthroplasty? An Evaluation of morbidity and mortality within a total joint replacement registry. The Journal of Arthroplasty 2015;30:1324–7. Ponnusamy KE, Jain A, Thakkar SC, Sterling RS, Skolasky RL, Khanuja HS. Inpatient mortality and morbidity for dialysisdependent patients undergoing primary total hip or knee arthroplasty. The Journal of Bone and Joint Surgery. American Volume 2015;97:1326–32. Tiberi JV 3rd, Hansen V, El-Abbadi N, Bedair H. Increased complication rates after hip and knee arthroplasty in patients with cirrhosis of the liver. Clinical Orthopaedics and Related Research 2014;472:2774–8. Ward DT, Metz LN, Horst PK, Kim HT, Kuo AC. Complications of morbid obesity in total joint arthroplasty: risk stratification based on BMI. The Journal of arthroplasty 2015;30:42–6. Kamath AF, Ong KL, Lau E, Chan V, Vail TP, Rubash HE, et al. Quantifying the Burden of Revision Total Joint Arthroplasty for Periprosthetic Infection. The Journal of Arthroplasty 2015;30:1492–7. Berend KR, Lombardi AV Jr, Morris MJ, Bergeson AG, Adams JB, Sneller MA. Two-stage treatment of hip periprosthetic joint
[23] [24]
[25]
[26]
[27]
[28]
[29]
[30]
[31]
[32]
[33]
[34]
[35]
[36]
[37]
[38]
[39]
[40]
27 (2016) 86–92
91
infection is associated with a high rate of infection control but high mortality. Clinical Orthopaedics and Related Research 2013;471:510–8. Cooper HJ, Della Valle CJ. The two-stage standard in revision total hip replacement. Bone Joint Journal 2013;95-B:84–7. Houdek MT, Wagner ER, Watts CD, Osmon DR, Hanssen AD, Lewallen DG, et al. Morbid obesity: a significant risk factor for failure of two-stage revision total hip arthroplasty for infection. The Journal of Bone and Joint Surgery. American Volume 2015;97:326–32. Kalra KP, Lin KK, Bozic KJ, Ries MD. Repeat 2-stage revision for recurrent infection of total hip arthroplasty. The Journal of Arthroplasty 2010;25:880–4. Odum SM, Fehring TK, Lombardi AV, Zmistowski BM, Brown NM, Luna JT, et al. Irrigation and debridement for periprosthetic infections: does the organism matter? The Journal of Arthroplasty 2011;26:114–8. Siqueira MB, Saleh A, Klika AK, O’Rourke C, Schmitt S, Higuera CA, et al. Chronic suppression of periprosthetic joint infections with oral antibiotics increases infection-free survivorship. The Journal of Bone and Joint Surgery. American Volume 2015;97:1220–32. d’Ettorre G, Marchetti F, Ceccarelli G, Gizzi F, Tierno F, Falcone M, et al. Surgical debridement with muscle flap transposition and systemic teicoplanin therapy for infected hip arthroplasty. Hip International 2010;20:255–7. Huang KC, Peng KT, Li YY, Tsai YH, Huang TJ, Hsu RW. Modified vastus lateralis flap in treating a difficult hip infection. The Journal of Trauma 2005;59:665–71. Windle BH, Stroup RT Jr, Beckenstein MS. The inferiorly based rectus abdominis island flap for the treatment of complex hip wounds. Plastic and Reconstructive Surgery 1996;98:99–102. Segreti J, Nelson JA, Trenholme GM. Prolonged suppressive antibiotic therapy for infected orthopedic prostheses. Clinical Infectious Diseases: An Official Publication of the Infectious Diseases Society of America 1998;27:711–3. Rao N, Crossett LS, Sinha RK, Le Frock JL. Long-term suppression of infection in total joint arthroplasty. Clinical Orthopaedics and Related Research 2003;414:55–60. Barberan J, Aguilar L, Carroquino G, Gimenez MJ, Sanchez B, Martinez D, et al. Conservative treatment of staphylococcal prosthetic joint infections in elderly patients. The American Journal of Medicine 2006;119 [993.e7–993.e10]. Fenelon GC, Von Foerster G, Engelbrecht E. Disarticulation of the hip as a result of failed arthroplasty. A series of 11 cases. The Journal of Bone and Joint Surgery. British Volume 1980;62-B:441–6. Ford LT, Holder BK. Disarticulation for failed surgical procedures about the hip. Southern Medical Journal 1977;70: 1293–6. Zalavras CG, Rigopoulos N, Ahlmann E, Patzakis MJ. Hip disarticulation for severe lower extremity infections. Clinical Orthopaedics and Related Research 2009;467:1721–6. Peterson CA 2nd, Koch LD, Wood MB. Tibia-hindfoot osteomusculocutaneous rotationplasty with calcaneopelvic arthrodesis for extensive loss of bone from the proximal part of the femur. A report of two cases. The Journal of Bone and Joint Surgery. American Volume 1997;79:1504–9. Girdlestone GR. Acute pyogenic arthritis of the hip: an operation giving free access and effective drainage. 1943. Clinical Orthopaedics and Related Research 2008;466:258–63. Gruca A. The treatment of quiescent tuberculosis of the hip joint by excision and “dynamic” osteotomy. The Journal of Bone and Joint Surgery. British Volume 1950;32-B:174–82. Lipscomb PR. Reconstructive surgery for bilateral hip-joint disease in the adult. The Journal of Bone and Joint Surgery. American Volume 1965;47:1–30.
92
SEM
I N A R S I N
A
R T H R O P L A S T Y
[41] Ballard WT, Lowry DA, Brand RA. Resection arthroplasty of the hip. The Journal of Arthroplasty 1995;10:772–9. [42] Bohler M, Salzer M. Girdlestone's modified resection arthroplasty. Orthopedics 1991;14:661–6. [43] Bourne RB, Hunter GA, Rorabeck CH, Macnab JJ. A six-year follow-up of infected total hip replacements managed by Girdlestone's arthroplasty. The Journal of Bone and Joint Surgery. British Volume 1984;66:340–3. [44] Grauer JD, Amstutz HC, O'Carroll PF, Dorey FJ. Resection arthroplasty of the hip. The Journal of Bone and Joint Surgery. American Volume 1989;71:669–78. [45] Haw CS, Gray DH. Excision arthroplasty of the hip. The Journal of Bone and Joint Surgery. British Volume 1976;58:44–7. [46] Herzog T, Link W, Engel S, Beck H. Resection arthroplasty: middle- and long-term results. Archives of Orthopaedic and Trauma Surgery 1989;108:279–81. [47] Pazzaglia UE, Ghisellini F, Ceffa R, Riccardi C, Ceciliani L. Evaluation of reimplant total hip prostheses and resection arthroplasty. Orthopedics 1988;11:1141–5. [48] Harris WH, White RE Jr. Resection arthroplasty for nonseptic failure of total hip arthroplasty. Clinical Orthopaedics and Related Research 1982;171:62–7.
27 (2016) 86–92
[49] Scalvi A, Campacci A, Marcer M, Cassini M, Guerra C, Ferraresi M, et al. Girdlestone arthroplasty for loosening of the total hip prosthesis: evaluation and results. La Chirurgia degli Organi di Movimento 1995;80:279–85. [50] Ahlgren SA, Gudmundsson G, Bartholdsson E. Function after removal of a septic total hip prosthesis. A survey of 27 Girdlestone hips. Acta Orthopaedica Scandinavica 1980;51: 541–5. [51] Basu I, Howes M, Jowett C, Levack B. Girdlestones excision arthroplasty: current update. International Journal of Surgery (London, England) 2011;9:310–3. [52] Malcolm TL, Gad BV, Elsharkawy KA, Higuera CA. Complication, survival, and reoperation rates following girdlestone resection arthroplasty. The Journal of Arthroplasty 2015;30: 1183–6. [53] Callaghan JJ, Brand RA, Pedersen DR. Hip arthrodesis. A longterm follow-up. The Journal of Bone and Joint Surgery. American Volume 1985;67:1328–35. [54] Kostuik J, Alexander D. Arthrodesis for failed arthroplasty of the hip. Clinical Orthopaedics and Related Research 1984;188:173–82.