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Fused Hip with OA knee

Case: Fused hip

Reported by Myles Clough, Orthopaedic Surgeon, Kamloops, BC, Canada


52 year old man on welfare presented with left knee pain in addition to back pain, moderate right hip and knee pain and profound depression.

He fell downstairs at the age of 18 months and sustained an injury to his left hip. After 2 years, at age 4 an operation on his left hip was performed with the intention of fusing it, taking bone from the left tibia. This was unsuccessful and he remained miserable and in pain throughout his childhood. At age 15 he was diagnosed as having Tuberculosis of the left hip and underwent two further procedures which did result in fusion of his left hip and some relief of pain. However his left leg was severely shortened.He developed back pain quite early and has been unable to work for the last 20 years. Also during this time he has developed left knee pain and osteoarthritis.

He has seen numerous orthopaedic surgeons and was told in 1985 that he "did not have enough muscle in the left hip area" to have a successful total joint replacement. In 1991 he was told that his knee symptoms might eventually require total joint replacement but that the chances of failure were high and that failure might be followed by left knee fusion or amputation. He is now so painful in the left knee that he has to use crutches although he does manage to look after himself.

Examination showed a depressed man, somewhat overweight walking on crutches with a stiff left hip and a severely shortened left leg. He walked on tiptoe on the left and the left knee has a valgus thrust when he bears weight on it. His spine is mobile but mildly tender and there is a scoliosis convex to the left. The left leg measures 14 cms less than the right from the iliac crest. Left thigh muscles are atrophied with quads circumference 10 cms less than the right. The left hip is fused in 35 degrees flexion.

Radiographs of lumbar spine, pelvis and L knee are shown below.


X-ray of the pelvis showing fusion and shortening of the left hip


Lateral of lumbar spine showing disk and facet joint degeneration


AP of L knee showing varus and OA

Questions

Ideally this man would require hip replacement, knee replacement and leg lengthening. Realistically he is not likely to get a wonderful result from any surgery. I have referred him to the "Complex Joint Clinic" as I  think they don't come much more complex, but am keenly interested in the best plan. Focusing on his need for pain relief what are the group's opinions on -

1. The chances of durable knee replacement with the hip remaining fused

2. Outcome of hip replacement surgery (assuming TB is "cured")

3. Some useful current investigations

4. Any other comments

Comments

From: Giorgos Savvides FRCS (drsavvid@spidernet.com.cy (mailto:%28drsavvid@spidernet.com.cy) )
Date: Thu 09 Apr 1998 - 20:24:19 BST

I apologise for not answering the questions in the form you put them 1, 2,3, and 4. All the possible solutions to this problem would be as follows:

1. Above or at the knee amputation, depending on the prosthetic facilities available. "Amputation can be one of the greatest and meanest operations in Surgery". This would eliminate the pain at the knee and would also eliminate the limb length discrepancy. It would not help his back pain and it would probably increase his chances of having a fracture of the Femur in the future.

If the patient is given to understand that the above would be the final solution to his problems, then one could, before resorting to amputation, try:

2 total knee arthroplasty. If the soft tissues around the knee are strong and the bone cuts are done with minimum removal of bone, this would last. Its endurance would not be affected by the immobile hip as any untoward
mechanical forces would probably break the extremely osteoporotic Femur before disrupting the artificial knee.

3 or in addition and later try total hip arthroplasty. The movement here would be beneficial to the back and also protect the Femur from untoward mechanical forces. The chances of a lasting arthoplasty at the hip are less than in the case of the knee: The bone stock and quality of the whole Left hemipelvis and the Femur is poor. The acetabulum would be
similar to what one finds in neglected coplete CDH (DDH). The upper Femur is of very poor bone and the absence of the trochanteric expansion would make the stem vulnerable to torsional strains. If one would attempt this operation one should cut the Femur below the 2nd screw (counting from below) to increase the protruding roof of the acetabulum. The cup should be of the CDH variety and should be placed in the original position of the acetabullum. Theoretically and with the appropriate soft tissue releases one could obtain 2-3 cm increase in length. In spite of a mechanically stable artificial joint this would still be vulnerable to dislocation due to the weak abductors (Positive Trendelemberg).

In case of failure of the total hip replacement artificial limb fitting would be more difficult as one would be left with a pseudarthrosis.

4 If after all these procedures the patient and his surgeons have appetite for further surgery he can be submitted to bone lengthening. This would have to be done at Tibial level and should be up to 10 cm, assuming that some length was procured at the total hip operation.
One of the indications for amputation is the "useless and the nuisance limb" and I would add the one that inspires unwise surgeons to long and lengthy procedures that may fail in the end ruining the already shattered (in this case he is depressed) psychology of the patient
Ref G.A. Appley: A system of Orthopaedics and Fractures. 1971

From: andrew clark (andrew@nbnet.nb.ca (mailto:%28andrew@nbnet.nb.ca) )
Date: Fri 10 Apr 1998 - 01:40:32 BST

It is with interest that I read your case report, as I have seen and operated on a number of similar cases with a diagnosis of remote sepsis that have done extremely well with surgical treatment.

Assuming that there is no evidence of infection, etc. and you are to proceed to surgery , the hip must be addressed first . This is due to inherent problems with limb alignment, and maintaining ROM after a TKR in the face of a stiff hip.

Preoperative assessment of bony architecture with a CT and soft tissue assessment with an MRI might be interesting, but I have not resorted to either.

Preoperatively, one of the most important considerations is whether there is evidence of active hip abduction or function of the tensor. This has been present even in one case I converted which had been fused for 45 years.

Patients are told that they will have a significant abductor lurch for up to 2 years, depending upon the quality of the muscle found at surgery. It also should be mentioned that the leg length discrepancy is often more apparent than real due to contractures of hip and knee.

I do these patients through a posterior approach, but perform an extensive adductor tenotomy in the supine position before final positioning laterally.

The usual recommendations are that a limb should be lengthened no more than 10%. Doing a fairly extensive sciatic nerve neurolysis from notch to beyond the gluteus insertion allows increased lengthening in such situations. I have no experience with SSEP's.

The obvious potential problem is with the condition of the abductors. Fortunately in most of these situations all of the multiple operations seem to have been done through an anterior approach which makes initial dissection posteriorly much easier. It also allows for identification of the posterior trailing edge of the abductors in many situations. On the other hand the final anterior release for the flexion contracture, which is aggravated by the lengthening, is more difficult. Ideally proximal femoral dissection should be done maintaining continuity of the abductor\ vastus sleeve. If this is precarious, then it can be reinforced with fascia lata or the tensor transferred directly into soft tissue repair. In some situations it is helpful to transfer the posterior fascia into the trailing edge of the abductors, simply to prevent the soft tissue sleeve from subluxing anteriorly.

Modular designs with prophylactic cerclage wiring or strut grafting to provide for further structural support and rotational stability for flutes, etc., works very well for the femur. The femur is cut as high as possible so that one can use a 0+ head to decrease the risk of dislocation and allow for further lengthening should a revision become necessary. It is unlikely the acetabulum will be much of a problem. This is placed in a more horizontal position if the abductors are poor due to the possibility of the hip resting in an adducted position. It might prove helpful to have available a constrained cup, though I have not found it necessary. Beware of soft cancellous bone. It makes the reaming simple, but the bone quality is poor. In elderly patients cementing in the cancellous bed is better than impaction of a press fit cup. I have experienced one intrapelvic protrusio with " final" seating of the cup. This has a way of making the day a little longer !

Post operatively, patients are braced depending upon the degree of abductor reconstruction that is required. Prone stretching exercises are done to work on the flexion contracture.

Many of these patients are actually fused in an adducted position leading to a valgus knee. These patients have to be told that their final limb alignment and knee position will be significantly affected by restoration of the hip to a neutral position. The knee is then done when the patient is able to demonstrate satisfactory flexion of the hip, so that it won't impede the knee rehab. If the opposite hip is the problem, I do this as the initial procedure during the same hospitalization.

I do not wish to sound cavalier in my approach to this problem, but I have found that this is one of the most gratifying procedures that we can do for patients in our specialty. We do have to remind ourselves and our patients that "there is no operation that can't make a patient worse", and that bad things can happen. Nevertheless in my experience the benefits far outweigh the risk and the patients quality of life is dramatically improved.
Andrew Clark MD, FRCS(C)
Moncton, New Brunswick, Canada

From: Rab Mollan (mollan@unite.co.uk (mailto:%28mollan@unite.co.uk))
Date: Thu 09 Apr 1998 - 23:02:34 BST

With some experience over the years of arthrodesis to THR, the greatest problem is not the surgery which usually is well indicated, but the psychological reaction to an "unstable" hip with poor muscle function. I always send my conversions to talk with two who have had it done so that they can understand the new feeling of a moving hip, which they interpret as unstable, and the problem of very poor musculature, which takes at least one year to build up.

Also, having an experience with chronic osteomyelitis and the need for joint replacement after destroyed, infected joints, the psychological problems increase with each operation. If this man is depressed before you begin, you have real problems ahead. You were quite right to send him to a team dealing with these problems on a regular basis.

From: Steve Krikler (steve.krikler@virgin.net (mailto:%28steve.krikler@virgin.net))
Date: Sat 11 Apr 1998 - 23:57:07 BST

One other note of caution:
In November I did the third revision on a man in his 50s. One of his previous approaches had been anterior (Smith-Peterson ish). I used a posterior approach and rebuilt the femur and acetabulum with impaction grafting. He had a few cm of shortening and was very keen to have this corrected. I got him just about back to length. I kept a careful watch on the sciatic nerve throughout, but he now has a femoral nerve palsy. I don't know if it was a retractor, my soft tissue releasing to regain length or just a traction injury. If your patient with a fused hip has weak abductors before you do his hip, and weak quads afterwards, I wouldn't be too optimistic about his knee function after TKR!

From: Raminder Singh (raminder@btinternet.com (mailto:%28raminder@btinternet.com))
Date: Sun 12 Apr 1998 - 00:15:13 BST

Is it mere coincidence that I too have seen a similarly aged fine gentleman who had a fusion to his tubercular hip in childhood. He too now has Osteoarthritis of the ipsilateral knee.

Our gentleman has led a very active lifestyle inspite of the shortening, though he has the occasional back problems. He has only recently started to have pain in his knee and was discovered to be having radiological evidence of osteoarthritis in his knee. His problems are surprisingly confined to the knee.

Remarkably the examination findings in our patient are nearly the same apart from him not being depressed and not having such a severe degree of muscle wasting.

Why do you want to do a THR on a fused hip joint that has not moved such a long time. As in our patient, I don't think the present complaint arises from the hip. Why interfere with the hip and cause any further complexities in the already difficult management.

Our patient is not too keen on the idea of limb lengthening in spite of a pronounced limp. He has managed remarkably well for the last forty years.

Our main concerns in our patient are:

1. Doing a knee replacement in a patient in which the biomechanics of the lower limb has changed. As I understand the fundamentals of replacing a knee is to have the axis of the hip, knee and the ankle aligned. With the hip flexed and adducted, how realistic is this goal going to be?
2. Will a abduction and extension osteotomy of the proximal femur realign the axes?
3. What are the long term results going to be like.

Does anyone on the list have experience on these sort of cases?
Raminder Singh
Specialist Registrar, Trauma and Orthopaedics,
Cambridge and East Anglia,
West Suffolk Hospital, Bury St. Edmunds, UK.

From: Myles Clough (mylesclough@shaw.ca (mailto:%28mylesclough@shaw.ca) )
Date: Mon 13 Apr 1998 - 17:41:41 BST

Raminder Singh wrote:
>
> Why do you want to do a THR on a fused hip joint that has not moved such a
> long time. As in our patient, I don't think the present complaint arises
> from the hip. Why interfere with the hip and cause any further complexities
> in the already difficult management.
>
My concerns is that the OA of the knee (and back) prove that intense and abnormal stresses are being applied to these areas. If normal joints don't stand up to these stresses I fear that anormal (artificial) joints won't either and that a TKR with a fused hip will fail by loosening very early. This concern could be answered if someone has experience with long term successful TKR with a fused hip; but so far I haven't heard from anyone with that experience.
> Our main concerns in our patient are;
>
> 1. Doing a knee replacement in a patient in which the biomechanics of the
> lower limb has changed. As I understand the fundamentals of replacing a knee
> is to have the axis of the hip, knee and the ankle aligned. With the hip
> flexed and adducted, how realistic is this goal going to be?
>
My question put another way
> 2. Will a abduction and extension osteotomy of the proximal femur realign
> the axes?
And be satisfactory in the long run with a TKR?
Myles Clough
Orthopaedic Surgeon, Kamloops, BC, Canada

From: Giorgos Savvides FRCS (drsavvid@spidernet.com.cy (mailto:%28drsavvid@spidernet.com.cy) )
Date: Tue 14 Apr 1998 - 18:24:06 BST

Myles Clough wrote:
"This concern could be answered if someone has experience with long term successful TKR with a fused hip; but so far I haven't heard from anyone with that experience."

This patient that I saw in my rooms yesterday is a 63 year old woman suffering for the last 40 years from rheumatoid arthritis. She had thr L hip 20 years ago and R tkr (Freeman with an all Polyethelene Tibial component) 8 years ago. I left the hospital six years ago and for that period I had not seen the patient.

When I saw her yesterday she had a bad Left knee, in varus and varus instability needing tkr. and a very bad R hip with protrusio and practically no movement from a position of 30 degrees fixed flexion. The Right knee
(Freeman tkr) had excellent collateral stability and it was painless. Its movements were dificult to asses due to the immobile hip but she had -5 extension and flexion to at least 90.

The xray of the R knee taken in some flexion AP showed no signs of losening. It is difficult to know for how long the R hip was immobile. If it was for more than 8 years it would have been operated before the knee. I estimate
it to have been in this condition for the last three years. Not long enough you may say for the knee to be affected. It may well be so.

But.... I know that in my repertoire and probably of others there are many cases of rheumatoid arthritis were the knee is done first and then the hip appears needing operation and being in a similar condition to the R hip of
this patient.

I apologise for the verbosity and I suggest that if any body wants to solve this problem by looking at cases (Theoretically and biomechanically there may still be a way of solving it) one should look at rheumatoid cases.

I would'nt dream adding to the KBs of this communication by attaching X-Rays. They are the X-Rays of the pelvis and detail R hip. I shall request Chris Oliver to "post them on the Edinburgh Web Page".
Giorgos Savvides

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