| From: Giorgos Savvides FRCS
(drsavvid@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
)
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)
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)
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)
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 inspite 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 ) 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 ) 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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