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Modular Cementless Total Hip Arthroplasty for Hip Infection Sequelae

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Abstract

Childhood hip infection may produce significant anatomical deformations leading to the premature onset of secondary osteoarthritis. Total hip arthroplasty (THA) in these patient populations can be technically challenging and has been associated with high complication rates. This article reports the results of 58 cementless THAs with use of a modern implant design. The complication rate, including one recurrent infection, was relatively low. Cementless THA with use of a modular stem coupled with a metal-backed socket was found to be an effective and reliable treatment option for patients with the late sequelae of infective hip arthritis.

Infective hip arthritis can occur in any age group; however, if it occurs in young patients and if treatment has been delayed, infective hip arthritis may cause significant anatomical deformation of bony and soft tissue structures and lead to the premature onset of secondary osteoarthritis. Total hip arthroplasty (THA) in these patient populations poses special complications, especially in the presence of scarred soft tissue, leg-length discrepancy, a high-riding hip center, ankylosis, a dysplastic acetabulum with deficient bone stock, or femoral hypoplasia with a small canal. Previous experiences of THA in this subset of patients have been associated with relatively high complication rates, including intraoperative femoral fracture, recurrent infection, and mechanical loosening of component.^1-8 Although a few studies have reported low rates of infection recurrence following THA in patients with a long quiescent period after infection,^8-11 problems related to component fixation remain a major concern for relatively young patients with technically difficult THAs. The object of this study was to present the results of primary cementless THA, comprising a modular stem and a press-fit metal-backed socket, which was implanted between 1994 and 2000 in patients whose history and clinical and radiographic findings suggested late infection sequelae of the hip joint.

Materials and Methods

Between November 1994 and September 2000, the authors performed 58 primary THAs with the use of cementless modular prostheses in 58 patients with a history and clinical and radiographic findings suggestive of late infection sequelae of the hip joint. Diagnostic criteria included chronic hip pain in patients with clear evidence of a previous hip joint infection, such as medical or surgical treatment history and correlating radiographic or clinical features of a previous infection (eg, a previous arthrotomy scar or old draining-sinus scars) (Figure 1). The study subjects were comprised of 26 men (26 hips) and 32 women (32 hips), who had a mean age of 49.3 years (range: 24 to 67 years) at the time of the index arthroplasty. The mean age of patients at the time of infection onset was 8.3 years (range: 1 month to 16 years), and the mean time interval between initial infection contracture and primary arthroplasty was 35.2 years (range: 11 to 54 years). The mean duration of follow-up was 6.3 years (range: 4 to 10 years).

Total hip arthroplasty was performed only on patients who had been free of any sign or symptom of infection for >10 years before surgery. Preoperatively, a physical examination of the hip area was performed to detect any signs of inflammation, swelling, erythema, or localized tenderness. Laboratory investigations included a complete blood-cell count, erythrocyte sedimentation rate, and C-reactive protein levels. For patients suspicious of ongoing infection, a preoperative hip joint aspiration was additionally performed. Intraoperative smears and specimens were obtained to determine the presence of aerobic, anaerobic, and tubercle bacilli. Histopathological analysis was carried out using hematoxylin and eosin stained tissue samples to detect any evidence of bacterial or tuberculous infection. Analysis of patients’ history of infection and radiographic and physical findings indicated that hip pain was probably caused by tuberculous infection sequelae in 20 patients (34.5%) and by pyogenic infection sequelae in 38 patients (65.5%).

Figure 1: Photograph of the left hip of a 45-year-old woman who suffered infective hip arthritis when she was 3 years old. The photograph shows a previous arthrotomy scar and old draining-sinus scars (A). Radiograph (B) and three-dimensional computed tomographic images (C, D) showing complete resorption of the femoral head, a high-riding hip center, a dysplastic acetabulum with deficient bone stock, and a hypoplastic femur with a small canal diameter.

The senior author (YSP) performed all of the surgical procedures. Surgeries were performed through an anterolateral approach in 44 hips, the Smith-Peterson approach in five hips, a trochanteric osteotomy in six hips, and a subtrochanteric osteotomy in three hips. A porous-coated S-ROM modular stem (DePuy Orthopaedics Inc., Warsaw, Ind) was used in all hips. A metal-backed modular socket with an outer porous-coating was implanted without cement in all hips. In six hips with a relatively high degree of acetabular dysplasia and deficient bone stock, excessive medial wall reaming was performed and a smaller cup was used with a 22-mm diameter metal head and a polyethylene liner. The remaining 52 hips were implanted with a 28-mm diameter metal head and a polyethylene liner. Two acetabular components with <70% of the porous surface covered by host bone were fixed using a structural autogenous bone graft and screws without cement. All patients were allowed partial weight bearing on the second or third postoperative day, and full weight bearing after 4 to 6 weeks. A standard protocol of low-dose warfarin for thromboembolism prophylaxis was used selectively in high-risk patients. For postoperative antibiotics management, cephalosporin was administered 3 days intravenously, followed by oral route for 1 week.

Clinical evaluations consisted of Harris hip ratings¹² and a self-administered questionnaire that included items on pain and functional capabilities. Preoperative radiographic assessments of anatomical deformations for each hip were completed (Table). Using the system of Crowe et al,¹³ patients were classified into four groups on the basis of degree of hip dysplasia. To evaluate the degree of proximal femoral dysplasia in plain anteroposterior radiographs, assessments were made of the relative hypoplasia of the affected femoral isthmus by measuring the difference in cortical widths of affected and unaffected femoral canals at the isthmus, expressed with respect to a normal isthmus cortical width as a percentage. In five hips, the femoral canal was obliterated by a sequestrum as a consequence of concomitant infection at the proximal femur (Figure 2). Ten hips showed spontaneous fusion. For postoperative radiographic analysis, 6-week anteroposterior, frog-leg lateral, and cross-table lateral radiographs of surgically treated joints were considered to set the baseline. Acetabular components were considered unstable if a vertical or horizontal migration of >2 mm, a change of abduction angle of >2�, or a continuous radiolucent line wider than 2 mm was noted.¹⁴ Femoral components were considered unstable if pr ogressive subsidence exceeding 3 mm, any change in position, or a continuous radiolucent line wider than 2 mm was noted.¹⁵ Periprosthetic cystic or scalloped lesions exceeding 2 mm in diameter that had not been present on the immediate postoperative radiograph were defined as osteolytic.¹⁶ Radiographs were also evaluated for the presence of heterotopic bone and, when present, classified according to the system of Brooker et al.¹⁷

Figure 2: Radiograph and computed tomographic images showing severe hip destruction with femoral canal obliteration by a sequestrum.

Surgical Technique

Most patients underwent surgery in the lateral decubitus position, with a curvilinear lateral incision for anterolateral exposure. In fused or highly dislocated hips, the Smith-Peterson approach was often used. The hip joint capsule was exposed by dissecting the anterior bundle of the gluteus medius and minimus muscles. The capsule was incised, and the femoral head was exposed and dislocated for osteotomy. The joint capsule was dissected and followed to reach the true acetabulum. In all patients, total excision of the capsule, followed by iliopsoas tenotomy, was carried out. If the adductors were tight, then a subcutaneous adductor tenotomy was also performed through a separate small incision. In patients with persistent flexion deformity, rectus and sartorius (flexor) recession was also performed and, in those with rotational contracture, short external rotator release was performed, followed by gluteus maximus tenotomy. In all patients, an attempt was made to restore the normal hip joint center and to equalize leg length difference. In patients with exceptionally high-riding femurs, which were difficult to relocate, a femoral shortening procedure was performed (Figure 3).

Results

Clinical Results
The average Harris hip score improved from 49.5 points (range: 37 to 74 points) preoperatively to 89.2 points (range: 64 to 97 points) at the time of the latest follow-up. Of the 58 patients, 41 (70.7%) had an excellent result; 10 (17.2%), a good result; 6 (10.3%), a fair result; and one (1.7%), a poor result. Of the seven patients with a fair or poor result, four were explained by either socket loosening or infection recurrence, but the remaining three were not associated with hip arthroplasty. Thigh pain was absent in the majority of patients at the latest follow-up. Two patients (3.4%) reported mild thigh pain, which did not compromise normal activities. Twelve patients (20.7%) had a slight limp associated with abductor muscle weakness at the latest follow-up examination, but they did not require walking aids.

Figure 3: Treatment algorithm for THA in late sequelae of childhood hip infection.

Radiographic Results
According to the criteria for bone ingrowth described by Engh et al,¹⁵ 55 hips had radiographic evidence of a stable bone-ingrown acetabular component at the time of the latest follow-up. Three hips (5.2%) demonstrated progressive change in socket position with global radiolucency, which was considered definitively loose and required revision. No hip demonstrated radiographic evidence of progressive stem subsidence or a change in stem position. Periprosthetic osteolytic lesions were radiographically evident in three hips (5.2%) at the time of the latest follow-up. Of these, two had osteolytic lesions localized to Gruen zone I¹⁸; however, the remaining hip had excessive polyethylene wear and osteolysis and had to be treated by modular exchange of the acetabular liner and femoral head 6 years after the index arthroplasty (Figure 4). Radiographic evidence of heterotopic ossification was present in three hips (5.2%); two hips had Brooker grade I and one hip had Brooker grade II. Overall, the total mechanical failure rate was 6.9% (four of 58 hips). All four failed acetabular components were in patients with Crowe group III or IV hip dysplasia. Of these, two hips had received a structural autograft and screw fixations at the time of primary arthroplasty.

Reactivation of Infection
All preoperative laboratory investigations including a complete blood-cell count, erythrocyte sedimentation rate, and C-reactive protein levels were within normal limits. All intraoperative swab and tissue cultures and permanent histological sections were negative for tuberculous or bacterial infection. In one patient, mildly inflamed joint fluid was found in preoperative hip joint aspirate, but the patient’s blood count and sedimentation rate were normal. This patient underwent THA, and no sign of ongoing inflammation has been observed during follow-up. Infection recurred in one patient (1.3%) who originally had tuberculous hip arthritis. This patient subsequently underwent a Girdlestone hip operation. The interval between active infection and arthroplasty in this patient was 11 years.

Complications
Two linear femoral fractures occurred during stem insertion, both of which were treated with cerclage wirings and healed uneventfully. One Vancouver B1-type periprosthetic fracture occurred at the stem tip area 2 weeks after the index arthroplasty. The patient was successfully treated by open reduction and internal fixation, with retention of the stem. Other postoperative complications included transient s ciatic nerve palsy in one hip and deep vein thrombosis in another. During follow-up, no hip dislocated.

Figure 4: Preoperative radiograph (A) of a 52-year-old woman who suffered pyogenic hip arthritis at the age of 6 and developed a high-riding hip center. A smaller cup with a 22-mm diameter metal head and a polyethylene liner was implanted after excessive reaming of the medial wall. Postoperative radiograph showing the restoration of a normal hip joint center (B). Radiograph made 6 years after the index procedure shows near wear-through of the polyethylene liner with well-fixed acetabular and femoral components (C). Intraoperative photographs showing excessive wear and partial breakage of the polyethylene liner (D). The patient�s hip was treated by modular exchange of the acetabular liner and femoral head. Postoperative radiograph showing increased polyethylene thickness (E).

Discussion

It is difficult to differentiate old tuberculous sequelae from pyogenic sequelae of the hip. Although tuberculous sequelae and pyogenic sequelae of the hip may manifest different clinical features at the time of active infection, both types of infection tend to produce similar soft tissue scarring and bony structure destruction. Importantly, clinical results in this specific group of patients are not influenced by infection type, but rather are predominantly influenced by age at infection onset and the extent of preoperative anatomical deformation. Recent clinical studies on THA in patients with a history of childhood hip infection have shown t hat infection did not recur, providing that infection had been quiescent for >10 years prior to the index arthroplasty.^8,11 The findings support this observation because only one hip showed a reactivation of tuberculous infection, whereas no signs of recurrent infection were identified in the remaining 57 hips at the time of the latest follow-up.

The main consideration when performing THA in young patients with severe anatomical deformities was component fixation. Earlier series of THAs in these patient populations were associated with high complication and revision rates, which have been attributed to less optimal prostheses and materials, and poor surgical techniques.^1-3,5,19 The results of cementless THA with use of a press-fit metal-backed socket in combination with a modular stem design were satisfactory and showed significant improvements in terms of socket and stem fixation after a minimum of 4-years’ follow-up. In the present series, three acetabular components (5.2%) required revision because of aseptic loosening, and one hip (1.7%) with excessive polyethylene wear and osteolysis required modular exchange of the acetabular liner and femoral head. All four failed acetabular components were in patients with Crowe group III or IV hip dysplasia. Of these, two hips had received a structural autograft and screw fixations at the time of primary arthroplasty. This experience of acetabular failure with use of structural autograft has led to the use of a smaller acetabular cup with a 22-mm diameter head following excessive medial wall reaming in hips with severe acetabular dysplasia. During subsequent procedures, no additional acetabular component loosening has been observed. These findings correspond with the observations of Anderson and Harris,²⁰ who reported that stable fixation was achieved with the use of cementless acetabular components fixed with screws in hips with severe acetabular dysplasia, provided that at least 70% of the porous surface was covered by host bone.

Hypoplastic femur with a small proximal diameter secondary to undergrowth or destruction may limit the size and shape of a stem. Some authors have reported a high rate of revision due to mismatch of stem size with the canal,^1,3,8,19 and it has been suggested that poor initial stability is related to subsequent loosening. Kim¹⁹ observed a high rate of loosening (17%) for the Müller CDH femoral prosthesis (Protek, Berne, Switzerland) and attributed this to the use of small femoral stems in normal femoral canals. In the present study, with an average follow-up of 6.3 years, no radiologically loose stems were found. In addition, no complications related to the modularity of the stem were encountered. The authors expect that the loosening rate will remain low in the long-term, considering the characteristics of porous-coated implants, which tend to produce persistent initial fixation.

In the authors’ investigation, the complication rate, including one recurrent infection, was relatively low after THA in patients with secondary osteoarthritis due to late sequelae of infective hip arthritis. It seems likely that despite the anatomical deformations encountered, the improvements in surgical techniques and implant design were associated with encouraging clinical results. Modular cementless THA is an effective and reliable treatment option for these relatively young patients with severe anatomical deformities.

References

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Authors

Drs Lim and Park are from the Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.