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Fused Hip with OA

Cases

Case report

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

	Xray 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

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J.F.M.Clough, Orthopaedic Surgeon, Kamloops, BC, Canada