- Email: [email protected]
Total Hip Arthroplasty in a Patient with Contralateral Hemipelvectomy
The Journal of Arthroplasty Vol. 21 No. 5 2006
Case Report
Total Hip Arthroplasty in a Patient with Contralateral Hemipelvectomy Matthew R. Bong, MD, Kevin M. Kaplan, MD, and William L. Jaffe, MD
Abstract: Total hip arthroplasty has evolved in regard to surgical technique, implant design, and long-term survivorship over the last several decades with excellent clinical results. Owing to these improvements, indications for surgery have expanded to include a greater variety of patients. We present the case of a 62-year-old man who underwent total hip arthroplasty 39 years after contralateral hemipelvectomy. The importance of an appropriate preoperative plan in regard to patient positioning and postoperative protocol is addressed. Our patient was informed that data concerning his case would be submitted for publication. Key words: total hip arthroplasty, contralateral hemipelvectomy. n 2006 Elsevier Inc. All rights reserved.
Total hip arthroplasty (THA) has proven to be a dependable treatment for debilitating pain associated with degenerative joint disease of the hip, with at least 90% to 95% survivorship routinely encountered at 15 years [1]. Although good long-term results have been achieved in healthy patients with both lower extremities intact, there is a paucity of published data regarding THA in patients with ipsilateral or contralateral amputations [2]. We present the case of a 62-year-old man who underwent THA 39 years after contralateral hemipelvectomy.
Materials and Methods A 62-year-old man underwent left-sided hemipelvectomy at age 23 for radical resection of a recurrent fibrosarcoma of the left proximal thigh. Since the procedure, the patient achieved ambulation through the use of axillary crutches and declined the use of a prosthesis. The patient had no further local recurrence of his fibrosarcoma and no history of metastasis. After his hemipelvectomy, the patient had been employed as a barber and renovated apartments in his spare time. Four years before presentation, he developed progressively debilitating right-sided hip and groin pain. The pain significantly limited his ability to ambulate and led to his retirement from employment. The patient denied any back pain or radicular symptoms. The patient had no relief with the use of anti-inflammatory medication and activity modification. He had no medical problems and took no medications other than nonsteroidal anti-inflammatory drugs. The patient was healthy appearing and was able to ambulate with axillary crutches, but with significant right hip pain. He had well-healed
From the Department Orthopaedic Surgery, NYU/Hospital for Joint Diseases, New York, New York. Submitted March 8, 2005; accepted October 31, 2005. No benefits or funds were received in support of the study. Reprint requests: Kevin M. Kaplan, MD, Department Orthopaedic Surgery, NYU/Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003. n 2006 Elsevier Inc. All rights reserved. 0883-5403/06/1906-0004$32.00/0 doi:10.1016/j.arth.2005.10.015
762
Total Hip Arthroplasty in a Patient with Contralateral Hemipelvectomy ! Bong et al 763
precautions. The patient was able to ambulate independently with axillary crutches by postoperative day 4 and was discharged to home. At 2 weeks postoperatively, the patient’s wound was healthy appearing and the staples were removed. The patient was then seen at 6 weeks for a routine postoperative visit and stated at that time that he was quite satisfied with the procedure. The patient no longer experienced any pain in the hip or groin, had returned to active ambulation with his axillary crutches, and could perform an unassisted single leg stance. The patient’s wound was healed and the patient had achieved acceptable range of motion of the hip. Fig. 1. Anteroposterior radiograph of the pelvis demonstrating advanced osteoarthritic changes of the right hip and absence of the left hemipelvis.
incisions over his left hemipelvis. The patient had pain with passive range of motion of the right hip and limitation of internal rotation and abduction. The patient had a normal neurological and vascular examination. Radiographic evaluation of the right hip confirmed osteoarthritis with joint space narrowing and sclerosis (Fig. 1). There was no evidence of ipsilateral sacroiliac joint degenerative disease; however, there was some evidence of mild lumbar spondylosis. Because of the debilitating nature of his pain, the patient elected for THA. After obtaining informed consent, the patient was taken to the operating room. The patient was administered general anesthesia and placed in the lateral decubitus position and secured with multiple pillows. A bump was placed under the pelvis and pillows were placed under the leg to help prevent adduction of the right hemipelvis and lower extremity. A lateral hip incision was made and a posterior approach was used. An uncemented acetabular shell with two cancellous acetabular screws and an uncemented, proximally coated, femoral component were placed (Trident Hip System, Stryker, Kalamazoo, Mich). A ceramicon-ceramic bearing surface was chosen, using a 36-mm femoral head. A subfascial drain was placed before closure. A postoperative radiograph is presented in Fig. 2.
Discussion The benefits of THA are well established. The long-term results of THA in amputees are less clear. Salai et al [2] reported on 5 patients who underwent THA for treatment of a femoral neck fracture in a limb with a prior ipsilateral below knee amputation. The authors reported that all patients had returned to their prefracture functional status at an average 69-month follow-up. To our knowledge, the present case represents the first reported case of a patient successfully undergoing THA after contralateral hemipelvectomy. From a technical standpoint, the procedure did not vary much from THA done in patients with an intact pelvis. The major difference occurred in the setup. Because the contralateral hemipelvis is absent, the anterior inferior iliac spine of the intact hemipelvis was too low to use our usual lateral hip positioner and pillows had to be used to secure the
Results The patient tolerated the procedure well and had an uncomplicated hospital course. The patient was allowed full weight bearing with total hip
Fig. 2. Postoperative right hip radiograph showing placement of total hip components.
764 The Journal of Arthroplasty Vol. 21 No. 5 August 2006 patient. Poor positioning of the patient could lead to the intact hemipelvis being in an oblique position secondary to bending through the lower lumbar spine. This could lead to the acetabular component inadvertently being placed in too vertical of a position. If there is any question as to the position of the patient, an intraoperative radiograph with the patient in the lateral decubitus position can be obtained to determine the orientation of the hemipelvis. In this patient’s postoperative radiograph, the acetabular component appears to be more vertical than desired. However, during the surgery, the position of the sciatic notch was used to help obtain the proper abduction and anteversion and the patient’s hip was stable in all ranges of motion. The postoperative appearance may be secondary to the position of the patient’s hemipelvis and the fact that the contralateral pelvis is not present. Alternatively, one may consider placing the patient supine and performing the procedure through and anterior approach. This change would eliminate the issue of obliquity and may benefit the patient in regard to altered hip precautions. However, the issue of patient positioning may still present a problem if the contralateral side is not supported properly. In addition, most surgeons have performed numerous replacements using a single preferred approach and using an alternative less familiar approach may potentially increase the morbidity of the procedure. Choice of implant materials depends on numerous factors. In our patient, who was considered relatively young and active, the decision was made to use ceramic for its superior wear characteristics. With a ceramic implant, proper component
positioning is important to avoid catastrophic wear. However, as seen in this patient at over 1 year of follow-up, the hip is stable in all ranges of motion and the components show no evidence of failure. Postoperatively, the patient must be diligent in adhering to total hip precautions. This requires increased preoperative counseling by the surgeon. With no contralateral lower limb, there is no mechanical constraint to adduction of the operative hip and theoretically increases the risk of dislocation. Although not used in this case, a hip abduction orthosis may be helpful in the immediate postoperative period. However, this device may compromise the patient’s ability to ambulate. It stands to reason that patients who are ambulatory after hemipelvectomy would expose the remaining hip to increased loading and may be more prone to developing degenerative joint disease. In addition, as oncologic and trauma treatments continue to improve, patients are expected to live longer after hemipelvectomy. Because of this, orthopedic surgeons should be prepared to provide THA to patients with debilitating degenerative joint disease contralateral to a prior hemipelvectomy.
References 1. Rasquinha VJ, Dua V, Rodriguez JA, et al. Fifteen-year survivorship of a collarless, cemented, normalized femoral stem in primary hybrid total hip arthroplasty with a modified third-generation cement technique. J Arthroplasty 2003;18(7 Suppl 1):86. 2. Salai M, Amit Y, Chechik A, et al. Total hip arthroplasty in patients with below-knee amputations. J Arthroplasty 2000;15:999.
Case Report
Total Hip Arthroplasty in a Patient with Contralateral Hemipelvectomy Matthew R. Bong, MD, Kevin M. Kaplan, MD, and William L. Jaffe, MD
Abstract: Total hip arthroplasty has evolved in regard to surgical technique, implant design, and long-term survivorship over the last several decades with excellent clinical results. Owing to these improvements, indications for surgery have expanded to include a greater variety of patients. We present the case of a 62-year-old man who underwent total hip arthroplasty 39 years after contralateral hemipelvectomy. The importance of an appropriate preoperative plan in regard to patient positioning and postoperative protocol is addressed. Our patient was informed that data concerning his case would be submitted for publication. Key words: total hip arthroplasty, contralateral hemipelvectomy. n 2006 Elsevier Inc. All rights reserved.
Total hip arthroplasty (THA) has proven to be a dependable treatment for debilitating pain associated with degenerative joint disease of the hip, with at least 90% to 95% survivorship routinely encountered at 15 years [1]. Although good long-term results have been achieved in healthy patients with both lower extremities intact, there is a paucity of published data regarding THA in patients with ipsilateral or contralateral amputations [2]. We present the case of a 62-year-old man who underwent THA 39 years after contralateral hemipelvectomy.
Materials and Methods A 62-year-old man underwent left-sided hemipelvectomy at age 23 for radical resection of a recurrent fibrosarcoma of the left proximal thigh. Since the procedure, the patient achieved ambulation through the use of axillary crutches and declined the use of a prosthesis. The patient had no further local recurrence of his fibrosarcoma and no history of metastasis. After his hemipelvectomy, the patient had been employed as a barber and renovated apartments in his spare time. Four years before presentation, he developed progressively debilitating right-sided hip and groin pain. The pain significantly limited his ability to ambulate and led to his retirement from employment. The patient denied any back pain or radicular symptoms. The patient had no relief with the use of anti-inflammatory medication and activity modification. He had no medical problems and took no medications other than nonsteroidal anti-inflammatory drugs. The patient was healthy appearing and was able to ambulate with axillary crutches, but with significant right hip pain. He had well-healed
From the Department Orthopaedic Surgery, NYU/Hospital for Joint Diseases, New York, New York. Submitted March 8, 2005; accepted October 31, 2005. No benefits or funds were received in support of the study. Reprint requests: Kevin M. Kaplan, MD, Department Orthopaedic Surgery, NYU/Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003. n 2006 Elsevier Inc. All rights reserved. 0883-5403/06/1906-0004$32.00/0 doi:10.1016/j.arth.2005.10.015
762
Total Hip Arthroplasty in a Patient with Contralateral Hemipelvectomy ! Bong et al 763
precautions. The patient was able to ambulate independently with axillary crutches by postoperative day 4 and was discharged to home. At 2 weeks postoperatively, the patient’s wound was healthy appearing and the staples were removed. The patient was then seen at 6 weeks for a routine postoperative visit and stated at that time that he was quite satisfied with the procedure. The patient no longer experienced any pain in the hip or groin, had returned to active ambulation with his axillary crutches, and could perform an unassisted single leg stance. The patient’s wound was healed and the patient had achieved acceptable range of motion of the hip. Fig. 1. Anteroposterior radiograph of the pelvis demonstrating advanced osteoarthritic changes of the right hip and absence of the left hemipelvis.
incisions over his left hemipelvis. The patient had pain with passive range of motion of the right hip and limitation of internal rotation and abduction. The patient had a normal neurological and vascular examination. Radiographic evaluation of the right hip confirmed osteoarthritis with joint space narrowing and sclerosis (Fig. 1). There was no evidence of ipsilateral sacroiliac joint degenerative disease; however, there was some evidence of mild lumbar spondylosis. Because of the debilitating nature of his pain, the patient elected for THA. After obtaining informed consent, the patient was taken to the operating room. The patient was administered general anesthesia and placed in the lateral decubitus position and secured with multiple pillows. A bump was placed under the pelvis and pillows were placed under the leg to help prevent adduction of the right hemipelvis and lower extremity. A lateral hip incision was made and a posterior approach was used. An uncemented acetabular shell with two cancellous acetabular screws and an uncemented, proximally coated, femoral component were placed (Trident Hip System, Stryker, Kalamazoo, Mich). A ceramicon-ceramic bearing surface was chosen, using a 36-mm femoral head. A subfascial drain was placed before closure. A postoperative radiograph is presented in Fig. 2.
Discussion The benefits of THA are well established. The long-term results of THA in amputees are less clear. Salai et al [2] reported on 5 patients who underwent THA for treatment of a femoral neck fracture in a limb with a prior ipsilateral below knee amputation. The authors reported that all patients had returned to their prefracture functional status at an average 69-month follow-up. To our knowledge, the present case represents the first reported case of a patient successfully undergoing THA after contralateral hemipelvectomy. From a technical standpoint, the procedure did not vary much from THA done in patients with an intact pelvis. The major difference occurred in the setup. Because the contralateral hemipelvis is absent, the anterior inferior iliac spine of the intact hemipelvis was too low to use our usual lateral hip positioner and pillows had to be used to secure the
Results The patient tolerated the procedure well and had an uncomplicated hospital course. The patient was allowed full weight bearing with total hip
Fig. 2. Postoperative right hip radiograph showing placement of total hip components.
764 The Journal of Arthroplasty Vol. 21 No. 5 August 2006 patient. Poor positioning of the patient could lead to the intact hemipelvis being in an oblique position secondary to bending through the lower lumbar spine. This could lead to the acetabular component inadvertently being placed in too vertical of a position. If there is any question as to the position of the patient, an intraoperative radiograph with the patient in the lateral decubitus position can be obtained to determine the orientation of the hemipelvis. In this patient’s postoperative radiograph, the acetabular component appears to be more vertical than desired. However, during the surgery, the position of the sciatic notch was used to help obtain the proper abduction and anteversion and the patient’s hip was stable in all ranges of motion. The postoperative appearance may be secondary to the position of the patient’s hemipelvis and the fact that the contralateral pelvis is not present. Alternatively, one may consider placing the patient supine and performing the procedure through and anterior approach. This change would eliminate the issue of obliquity and may benefit the patient in regard to altered hip precautions. However, the issue of patient positioning may still present a problem if the contralateral side is not supported properly. In addition, most surgeons have performed numerous replacements using a single preferred approach and using an alternative less familiar approach may potentially increase the morbidity of the procedure. Choice of implant materials depends on numerous factors. In our patient, who was considered relatively young and active, the decision was made to use ceramic for its superior wear characteristics. With a ceramic implant, proper component
positioning is important to avoid catastrophic wear. However, as seen in this patient at over 1 year of follow-up, the hip is stable in all ranges of motion and the components show no evidence of failure. Postoperatively, the patient must be diligent in adhering to total hip precautions. This requires increased preoperative counseling by the surgeon. With no contralateral lower limb, there is no mechanical constraint to adduction of the operative hip and theoretically increases the risk of dislocation. Although not used in this case, a hip abduction orthosis may be helpful in the immediate postoperative period. However, this device may compromise the patient’s ability to ambulate. It stands to reason that patients who are ambulatory after hemipelvectomy would expose the remaining hip to increased loading and may be more prone to developing degenerative joint disease. In addition, as oncologic and trauma treatments continue to improve, patients are expected to live longer after hemipelvectomy. Because of this, orthopedic surgeons should be prepared to provide THA to patients with debilitating degenerative joint disease contralateral to a prior hemipelvectomy.
References 1. Rasquinha VJ, Dua V, Rodriguez JA, et al. Fifteen-year survivorship of a collarless, cemented, normalized femoral stem in primary hybrid total hip arthroplasty with a modified third-generation cement technique. J Arthroplasty 2003;18(7 Suppl 1):86. 2. Salai M, Amit Y, Chechik A, et al. Total hip arthroplasty in patients with below-knee amputations. J Arthroplasty 2000;15:999.