Two early series that re-viewed the initial results of internal fixation reported fusion rates of 74% to 78%; surgical technique had the greatest influence on outcome.12,13 The overall l
Trang 1Total hip arthroplasty (THA) is the
standard of care for severe
osteo-arthritis (OA) of the hip, especially
in patients older than 50 years In
adolescents and young adults (16 to
30 years old), however, long-term
durability and the prospect of
mul-tiple revisions are a concern.1
Treat-ment should relieve symptoms yet
allow for as many options as
possi-ble in the future For early OA of
the hip, proximal femoral and
pelvic osteotomies preserve bone
stock and delay or even prevent
THA.2 However, disabled patients
with severe OA who desire to
re-turn to an active lifestyle also may
opt for a THA.3 Hip arthrodesis is
not generally perceived as a
favor-able alternative by surgeons or by
patients with severe OA because of
the dramatic and immediate relief
of pain and good functional results
of joint replacement Hip fusion is perceived as having functional out-comes inferior to those of THA
However, the long-term results of THA in this population have been disappointing, with revision rates of 33% to 45%.4-7 In these studies,4-7
active patients with unilateral hip disease secondary to osteonecrosis and OA had poorer results than did patients with inflammatory condi-tions
Long-term clinical data are insuf-ficient to assure prolonged sur-vivorship from newer techniques such as cementless fixation8or from implants utilizing alternate bear-ings The latter includes highly cross-linked polyethylenes,9 which
may reduce the extent of peripros-thetic bone loss and osteolysis induced by wear debris.10 The sur-geon is left with three choices: (1) delaying surgery by use of nonsur-gical modalities, such as a cane and medications; (2) performing a THA;
or (3) undertaking a bone-conserving procedure such as a hip arthrodesis
or osteotomy Delaying surgery relegates the patient to a more sedentary lifestyle A THA pro-vides reliable pain relief but puts the patient at risk for multiple revi-sion surgeries A hip arthrodesis, when done correctly, provides pain relief, enables an active lifestyle, and may permit later conversion, if in-dicated, to a THA with minimal morbidity Arthrodesis may be con-sidered as an option because of the long life expectancy of young pa-tients, the potential for failure of pri-mary hip replacement, and the increased risk and limited durability
of revision surgery
Dr Beaulé is Assistant Clinical Professor, Joint Replacement Institute at Orthopaedic Hospital, Los Angeles, CA Dr Matta is Clinical Pro-fessor, Department of Orthopaedic Surgery, University of Southern California, Los Angeles.
Dr Mast is Director, Bioregenerative Center, Northern Nevada Medical Center, Sparks, NV Reprint requests: Dr Beaulé, Joint Re-placement Institute at Orthopaedic Hospital,
2400 South Flower Street, Los Angeles, CA 90007.
Copyright 2002 by the American Academy of Orthopaedic Surgeons.
Abstract
The management of young adults with severe osteoarthritis of the hip
remains a problem because of the increased failure rates of total hip
arthro-plasty (THA) as well as the prospect of multiple revisions in this population.
Although hip arthrodesis is not perceived favorably as an alternative by most
orthopaedic surgeons or patients because of the presumption of less than
opti-mal functional outcomes, it is a viable technique, especially for younger
patients with a recent history of local infection and/or trauma With current
internal fixation techniques, a fusion rate >80% can be achieved with
maxi-mal preservation of bone stock Proper patient selection and optimaxi-mal
arthrodesis position (flexion of 20° to 30°, adduction of 5°, external rotation
of 5° to 10°, and limb-length discrepancy <2 cm) are essential for a
success-ful, long-term result Back and ipsilateral knee pain are the most common
complaints leading to secondary conversion of a hip fusion to a THA.
Symptoms improve markedly after conversion Survivorship of the
conver-sion THA is comparable to that of a primary THA when the patient is older
than 50 years of age and multiple surgical procedures have been avoided.
However, the procedure can be technically challenging and has a high risk of
postoperative complications.
J Am Acad Orthop Surg 2002;10:249-258
Paul E Beaulé, MD, FRCSC, Joel M Matta, MD, and Jeffrey W Mast, MD
Trang 2Results of Hip Arthrodesis
The initial reports of the results of
hip arthrodesis had short-term
follow-ups11 and focused mainly
on fusion rates with different
tech-niques (extra-articular versus
intra-articular, with or without internal
fixation) Indications included
tuberculosis in younger patients
and degenerative arthritis in older
patients Two early series that
re-viewed the initial results of internal
fixation reported fusion rates of 74%
to 78%; surgical technique had the
greatest influence on outcome.12,13
The overall long-term results of
hip arthrodesis (Table 1) depend on
proper surgical technique, adequate
hip positioning, minimal limb-length
discrepancy, and proper patient
selection When these factors are
favorable, incidence and onset of
pain in adjacent joints can be
signifi-cantly minimized, and most patients
are able to return to an active life,
including manual labor Female
patients tend to do as well as male
patients, with no reported difficulties
with childbirth However, the
sur-geon and the patient must be aware
of the limitations imposed by the
fused hip on activities of daily living
as well as sexual activity, particularly
when other joints become involved
The most important elements in the
assessment of hip arthrodesis are
functional outcome and the effect on
adjacent joints (contralateral hip,
ipsilateral knee, and lower back)
Function and Gait
Several authors14-17have reported satisfactory long-term function after hip arthrodesis, with most patients employed and able to walk more than 1 mile An average of 75% of patients reported adequate pain re-lief However, 32% experienced dif-ficulties with sexual activity, and more than 70% graded their activity
as below average for their age group, although female patients younger than 18 years of age fared better than older female patients
Two smaller series of young adults with long-term follow-up18,19also reported that most patients had ade-quate pain relief, were able to return
to work, and would consider a hip fusion again However, these pa-tients had difficulty putting on shoes and socks18and had some degree of sexual impairment.19
In a series of 40 Asian patients with hip fusion,1635 (87.5%) claimed that the arthrodesis limited bending during Japanese-style sitting Other common activities affected putting
on and taking off socks, standing, climbing stairs, and sexual activity
All patients returned to their previ-ous jobs, even those doing heavy labor.20
Ahlbäck and Lindahl21reviewed
35 patients with a minimum 2-year follow-up Gait was judged from an aesthetic standpoint only Sitting was based on the patient’s activities
of daily living Alignment in the frontal plane
(abduction/adduc-tion) had the greatest effect on gait because of its relationship to limb-length equality The patients with a hip fused in 40° of flexion, a contra-lateral hip with a flexion-extension arc ≥80°, and a lumbar spine with 40° of motion exhibited the best gait Gore et al22 provided a more detailed analysis of gait following unilateral hip fusion after reviewing
28 men (average age, 35 years) at 6 years A consistent gait dysrhythmia was observed secondary to a short-ened stance phase and prolonged swing phase for the fused hip com-pared with the mobile contralateral hip Patients also exhibited a slower gait velocity because of a shortened step length To substantially in-crease stride length, patients exhib-ited a greater than normal anterior pelvic tilt, which caused the lumbar spine to remain in varying degrees
of lordosis throughout the gait cycle The effective increase in lordosis and change in pelvic tilt resulted in the mobile hip having a greater flexion-extension excursion than normal Also, real inequality in limb length (shortening of the fused side) as well
as effective inequality (the hip po-sition in the frontal plane caused by adduction >10°) adversely affected walking performance The greater the inequality, the more irregular the forward progression, causing greater lateral motion of the head and trunk and a tendency to walk slower
A recent study by Karol et al23
confirmed the findings of Gore et
Table 1
Long-Term Results of Hip Arthrodesis
Trang 3al22that increased motion of the
lumbar spine and ipsilateral knee
had a negative effect on the gait of a
shortened, fused limb Average age
at the time of fusion in nine patients
was 13 years At an average
follow-up of 8 years, seven patients reported
earlier onset of back pain than in
other series The earlier onset of
back pain was thought to be due to
the younger age as well as higher
activity level of the patients Five
pa-tients had good to excellent results
Contralateral Mobile Hip
A review17of 125 patients (mean
age, 52 years) with fused hips at an
average 10-year follow-up revealed
that those whose mobile hips showed
a high probability of arthritic
deteri-oration24(ie, asymptomatic hip
dys-plasia) had an inferior functional
outcome and the lowest rate of
restored working capacity These
re-sults were thought to be secondary
to the added stresses placed on the
mobile hip during gait with a
unilat-eral fusion In another series,16
22.5% of patients with preexisting
osteoarthritic changes and/or a
diagnosis of developmental
dyspla-sia of the noninvolved hip had
pro-gression of disease
Ipsilateral Knee and Lower Back
Examining the knees of 200
pa-tients (mean age, 52 years) with
unilateral hip fusion at an average
follow-up of 22 years, Hauge25
noted radiographic evidence of
os-teoarthritic changes in 65% of
pa-tients, with 51% exhibiting genu
valgum Most (96%) demonstrated
some form of frontal or rotatory
in-stability, with more than 20% of the
majority complaining of knee pain
or instability No direct correlation
was made between position of the
fused hip and its potential effect on
the ipsilateral knee The
deteriora-tion and symptoms in the ipsilateral
knee were related to the rotational
strain placed on the knee during the
stance phase when, after the foot is
placed flat on the ground, the knee compensates for the increased trans-verse pelvic rotation These find-ings were similar to those of Spon-seller et al14and Callaghan et al,15
who reported that 57% to 61% of patients had pain in the lower back and ipsilateral knee A markedly higher incidence was noted in pa-tients with malpositioning of the fused hip (excessive abduction) In
an earlier study with an average follow-up of 4.4 years, Price and Lovell26 reported on 14 patients less than 15 years old This group had more favorable functional results, with only one patient com-plaining of ipsilateral knee pain
THA After Hip Arthrodesis
The primary indications for con-version of a hip fusion to THA are pain in the lumbar spine, ipsilateral knee, and contralateral hip The ability to alleviate the symptoms as well as provide a functional THA
at a later date is an important con-sideration when discussing the long-term outcome of a hip fusion with
a patient
Hardinge et al27reviewed 112 hips (104 patients) converted to THA after spontaneous or surgical fusion, excluding ankylosing spon-dylitis (Table 2) After an average of
25 years of fusion, the indications for conversion were pain in the lumbar spine (71% of patients), ipsilateral knee (48.1%), contralateral mobile hip (34%), and sound, fused hips with no evidence of spinal degenera-tion (9.8%) Limb-length discrepancy
>2 cm was present in 67% of pa-tients before conversion and in only 11.5% after THA Patients whose hips were fused before puberty had less improvement in hip muscle function because of underdevelop-ment of the greater trochanter Only 5% of patients were dissatisfied with their results Optimum scores on hip evaluation were not achieved
until 18 to 24 months after conver-sion Strathy and Fitzgerald28 re-ported on the long-term follow-up of
80 hips after conversion and identi-fied several risk factors for an early failure: surgical fusion (48.5% failure rate versus 5% when no previous surgery was done), more than two surgeries, and patient age of 50 years
or less at the time of conversion THA
In a more detailed analysis, Kilgus
et al29reported on 41 hips in 38 patients Sixty-eight percent were spontaneous fusions that had re-mained fused for an average of 33 years compared with an average of
18 years for the 32% that were surgi-cally fused A variety of total hip designs was used, including three surface arthroplasties At the time of conversion, 68% of patients com-plained of nonradicular and activity-related back pain, and 50% com-plained of loss of function from immobility or malposition of the fused hip Incidence of pain in the ipsilateral knee and fused hip was 42% and 16%, respectively, and 8%
in both the contralateral knee and hip The results demonstrated that
a higher percentage of patients ob-tained relief of back symptoms compared with relief of pain in the ipsilateral knee, fused hip, or con-tralateral knee and hip The range of motion was slightly less than that after primary THA Correction of limb-length discrepancy was an important element in overall patient satisfaction Interestingly, the UCLA hip function scores before and after THA were not significantly different, reflecting the high level of function preoperatively and the patients’ per-ception of a satisfactory result (ie, relief of back pain, correction of limb-length discrepancy) Only 33%
of patients used a less restrictive device (for example, a cane instead
of a crutch, or one crutch instead of two) for postoperative ambulation Postoperatively, patients continued
to improve functionally for up to 2 years The two most important
Trang 4fac-tors for postoperative abductor
mus-cle strength were preoperative
quali-ty and mechanical restoration of the
abductor lever arm The failure rate
of the THA at a mean follow-up of 7
years (range, 2 to 16.5 years) was 8%
for spontaneous fusion versus 23%
in the surgically fused hips Other
risk factors for earlier failure were
age less than 45 years at the time of
THA and patients with two or more
operations before conversion
Reikerås et al30reviewed 46
con-versions, with the indications for
sur-gery being pain in the lower back
and ipsilateral knee, as well as loss of
function from immobility or
malpo-sition of the fused hip Eighty-five
percent of patients were satisfied
with the outcome at a mean
follow-up of 8 years Poor results (eg,
pa-tients who used walking aids
post-operatively or had poor abductor
muscle function) were associated
with a long duration of fusion and
older age at the time of fusion The
common preoperative complaints of
the 37 women in the group were
dif-ficulties with sexual intercourse and
wetting the inside of the thigh
dur-ing urination, both probably second-ary to the excessive adduction of the fusion These problems resolved after conversion
Hamadouche et al31 reported on
45 hips after conversion, all done through a transtrochanteric approach, with a mean follow-up of 8.5 years
The indication for conversion was pain in the neighboring joints (ie, knee and lumbar spine) The only predictive factor of functional result with regard to the walking ability was the preoperative status of the gluteus muscles, which is best evalu-ated preoperatively by palpation of the contracting abductor muscles
Survivorship of hips that fused spontaneously (excluding ankylos-ing spondylitis) versus surgically was 94.6% versus 83.5% at 10 years (NS) Because abductor muscle con-traction is related to postoperative outcome,32 Hamadouche et al felt that conversion should not be done
if adequate abductor function is not present and the hip is in satisfactory position
Kreder et al33reviewed the com-plication rate of 40 conversions after
hip arthrodesis done with a variety
of surgical techniques during a 3-year period The conversions, which represented only 0.3% of the 12,952 THAs performed, had an overall complication rate of 45% compared with 11% for primary THA The re-vision and infection rates at 4 years were also much higher (10% for con-version versus 2% for primary THA
in each category) However, the database from which this informa-tion was collected did not include the type of fusion (surgical or spon-taneous), the number of prior surgi-cal interventions, or the type of prosthesis implanted
Overall, after THA for a fused hip, patients can expect relief of pain in adjacent joints (especially the back), marked correction of limb-length discrepancies, and im-proved mobility of the hip (although not as good as with a primary THA) Gait quality, as well as postopera-tive dependence on walking aids, is related to preoperative abductor muscle function More than half of patients require the use of walking aids after the conversion THA Full
Table 2
Long-Term Results of Conversion THA After Hip Arthrodesis
Improvement Complications Prior Mean Age Mean Age Survivorship Good and Back Knee Disloca- Infec-Surgical at Conver- at Follow-up at Follow-up Excellent Pain Pain tions tions
(112 hips)
Fitzgerald28
(80 hips)
(41 hips)
(46 hips)
et al31(45 hips)
Trang 5recovery may require up to 2 years
and be associated with a prolonged,
intensive physical therapy program
that should begin preoperatively
Survivorship of the prosthesis is
comparable to that of a primary
THA when multiple surgical
proce-dures have not been done before
conversion and if the patient is
older than 50 years of age at the
time of conversion34(Table 2) The
surgery is more technically
chal-lenging than a primary THA and is
associated with a higher infection
rate The high incidence of infection
after conversion to THA may reflect
the history of sepsis or tuberculosis
in many patients who have
under-gone fusion Although in some
studies27-31no infections were active
at the time of conversion, this
histo-ry is likely to affect the overall
infec-tion rate Only one study33has
attempted an assessment of the
rela-tive risk of infection of conversion
surgery compared with a primary
THA Although the higher rate of
complications should be carefully
considered and discussed with
patients before proceeding with the
conversion of a fused hip,
conver-sion remains the preferred method
to alleviate symptoms in adjacent
joints, especially if the fused hip had
been malpositioned
Hip Arthrodesis With
Contralateral THA and
Ipsilateral Knee
Replacement
Another approach to relieve pain is
replacement of symptomatic joints if
the hip is fused in the proper
posi-tion Garvin et al35 reported on 20
patients (23 arthroplasties), with
follow-up ranging from 2 to 15 years
Of the 14 replaced hips (patient age
at the time of arthroplasty, 31 to 75
years), only 10 were rated as good
to excellent The other patients
either needed revision surgery or
still had pain in the hip or lower
back Of the nine replaced knees (patient age, 45 to 81 years), seven were available for follow-up All required at least one postoperative manipulation, and two patients were not able to flex beyond 90°
The overall complication rate was 65% In another series36 of 16 total knee arthroplasties (TKAs) in pa-tients with an ipsilateral hip fusion, results in patients in whom the fused hip had been converted were comparable to those whose hips were fused in proper position
Rittmeister et al37reported on 18 patients with a fused hip Eleven had conversion THA only, four had conversion THA followed by ipsi-lateral TKA, and three had TKA alone ipsilateral to the fused hip Of the hips converted, 13 were avail-able for up (average
follow-up, 45 months; average age at con-version, 60.5 years) Eight patients required walking aids and had a positive Trendelenburg sign; eight had relief of back pain; and only two had relief of knee symptoms
The type of hip fusion (spontaneous versus surgical) and its duration did not affect the outcome The three patients with fused hips who had TKAs were dissatisfied with their results; poor range of motion was the predominant problem Of the four TKAs done after conversion of the fusion, two were rated as excel-lent and two, fair
All three studies35-37on the re-sults of TKA in the presence of a fused hip have reported a high com-plication rate with unpredictable outcome Thus, the only exception
to performing a TKA before con-verting the fused hip would be a patient with a satisfactorily posi-tioned hip in whom abductor mus-cle function was questionable In these patients, the results of THA are known to be inferior, with poor gait patterns and a decreased likeli-hood of adequate knee pain relief
If the hip is fused in a poor position and the patient has significant knee
pain, the conversion THA is prefer-able because of the notably inferior results of a TKA in that setting
Indications for Hip Arthrodesis
The ideal candidate for hip arthrod-esis is a young adult with severe monoarticular disease, especially posttraumatic, with high activity demands and without preexisting lumbar disease or ipsilateral knee or contralateral hip arthritis Other potential indications are a young patient in whom THA would be contraindicated or would carry a high complication rate (eg, with a his-tory of sepsis [Fig 1] or for salvage
of a multiply operated total hip) Patients with polyarticular arthritis
or with bilateral developmental dysplasia of the hips in which one hip is symptomatic should not be considered because of the high like-lihood of developing contralateral hip symptoms and degenerative changes
Assessment of Hip Position
The inherent inaccuracy of preopera-tive and intraoperapreopera-tive assessment of hip position in multiple planes has been a persistent impediment to at-tainment of optimal fusion position
Sagittal Plane (Flexion)
Gore et al22flexed the normal hip
to straighten the lumbar spine and measured the angle between the straightened lumbar spine and shaft
of the femur A comparison of clini-cal with radiologic measurements showed that radiology routinely measured more flexion, probably because of failure to flex the mobile hip sufficiently to flatten the lumbar spine completely At the time of fusion, the amount of flexion is sim-ply measured by the angle formed
by the horizontal table and femoral
Trang 6shaft Insufficient flexion will make
sitting extremely difficult, and
ex-cessive flexion will accentuate any
shortening of the leg and put
in-creased strain on the lumbar spine
Frontal Plane (Abduction and
Adduction)
In a neutral position, the
me-chanical axis is perpendicular to a
transverse axis through the pelvis
(through the inferior margins of
both sacroiliac joints) In this
posi-tion, the femoral shaft (anatomic)
axis has an average angle of 6° (5°
in men, 7° in women) adduction to
the vertical line representing the
mechanical axis (Fig 2) Flexion in
the hip joint appears on an
antero-posterior pelvic radiograph as an
increased abduction angle For
increasing flexion angles, the
dis-crepancy between actual and
radio-graphic measurements increases
and is usually 2° to 3° According to
Lindahl,38 adduction of 3° creates a
shortening of 1 cm, while abduction
of 3° leads to leg lengthening of 1
cm The apparent lengthening or
shortening of the limb is purely
functional and is the result of pelvic
obliquity imposed in the frontal
plane These two factors must be
verified when assessing hip position
intraoperatively
Longitudinal Plane (Rotation)
Rotation of the extremity is as-sessed visually by verifying patella and foot orientation to the level pelvis Excessive internal rotation will tend to cause the patient to con-tinually trip over the inturned foot
Excessive external rotation of the extremity will load the knee in flex-ion across the coronal plane, pro-ducing functional problems that cause disabling symptoms in a rela-tively short time.39 Slight exter-nal rotation is desired to facilitate putting on and taking off shoes as well as routine foot care
Limb Length
If leg lengths are equal preopera-tively, the actual removal of carti-lage as well as flexion of the hip will produce an acceptable shortening of
<2 cm Compensation for a preoper-ative discrepancy of 2 to 4 cm can be achieved by abducting the leg using Lindahl’s measurements.38 Exces-sive abduction should be avoided
For a discrepancy >4 cm, a two-stage procedure might be consid-ered because correction through limb abduction or adduction should
be limited to a 2-cm difference
Variations in abduction or adduc-tion >6° have a negative effect on the overall outcome of the fusion.21,22
The two-stage technique permits correction of limb lengths with inter-calary grafts or other lengthening techniques after the hip joint has been fused in its proper position
Recommended Optimal Positions
A review of the literature (Table 3) suggests the following as optimal positions for hip arthrodesis: 20° to 30° of flexion, 5° of adduction (ana-tomic axis to horizontal line through the pelvis), and 5° to 10° of external rotation In addition, leg shortening should be minimal (ie, limb lengths equalized within 1 to 1.5 cm) For the range of hip flexion, the activi-ties of the patient should be consid-ered For example, if the patient spends most of the time sitting at a desk, 30° of flexion might be the op-timum, while 20° is appropriate for
a manual laborer who stands most
of the time
Surgical Techniques
Although hip fusion may be an unfa-miliar operation to many recently trained surgeons, there are several techniques, each with specific
bene-Mechanical axis Transverse axis
Anatomic axis
Figure 2 Frontal plane alignment showing
the mechanical and anatomic axes.
Figure 1 A, Anteroposterior radiograph of a 35-year-old man 10 years after an acetabular
fracture that was malreduced and complicated by a deep wound infection B,
Antero-posterior radiograph 3 years after arthrodesis with anterior plate fixation.
Trang 7fits and limitations Hip
arthrode-sis11,39began with the development
of numerous techniques, many of
which required lengthy
postopera-tive immobilization and had high
rates of failure (up to 45%) The
double compression plate method of
Müller and, more recently, the cobra
head fixation plate11have provided
more viable alternatives In
choos-ing a technique, the surgeon must
consider later conversion to THA,
missing proximal femoral bone,
limb-length discrepancies, and the
presence of an active infection
Regardless of technique, if active
infection is present, arthrodesis
should be delayed until the infection
is quiescent (ie, normal laboratory
test results and no active drainage)
The most important factor for
suc-cess of hip arthrodesis is proper
positioning in the three planes
Cobra Head Plate Technique
Schneider is credited with
devel-oping the cobra head plate
tech-nique, which is widely used18,41,42
because of its reliable fusion rate
and avoidance of postoperative cast
immobilization.11 The technique
involves stripping the abductor
muscles from the iliac crest to
ac-commodate the cobra head of the
plate together with a pelvic
oste-otomy to enlarge the area of contact
between femur and pelvis Fusion
rates from 94% to 100% have been
reported.40
Beauchamp et al43 reported a modification of this technique in a series of 19 patients By contouring the plate to fit the contour of the pelvis and proximal femur, the pelvic osteotomy was eliminated
In addition, instead of stripping the abductors, the gluteus medius was detached with a bony block and replaced with a plate and screws at the level of its original attachment
All 19 patients achieved fusion
Other surgeons have adopted the technique.18 Stability of the implant
is achieved by loading the plate in tension and the bone in compres-sion Deficient bone stock is not uncommon, however, which can make the lateral tension band of the cobra head plate mechanically unsound (ie, with an increasing dis-tance between the plate and the loading axis, bending moments on the plate are increased) The strip-ping of the abductor muscles from the iliac wing also can negatively affect gait after THA conversion A technique that avoids the violation
of the abductor muscles would be preferable, especially if later conver-sion to THA is being considered
Anterior Plating Technique
The original motivation for the anterior approach was to create a technique that provides fixation to both the pelvis and femur while sparing the hip abductor muscles
In addition, with the patient supine
and the pelvis level during the surgery, positioning of the hip is facilitated Matta et al40reported a fusion rate of 83% in 12 patients using an anterior plating technique through a modified Smith-Petersen approach This technique allows placement of the plate along the pelvic brim immediately lateral to the sacroiliac joint and posterosu-perior iliac spine With the screws in-serted in an anteroposterior direction, excellent purchase is achieved in this area of thick bone, making this technique advantageous when there
is loss of acetabular or proximal femoral bone stock The insertion of
a lag screw from the trochanteric area through the supra-acetabular bone into the center of the femoral head provides additional compres-sion because of a lateral tencompres-sion band effect (Fig 3) As with other internal fixation techniques, no ex-ternal fixation (casting) is required unless the patient is expected to be noncompliant The anterior plating technique can also be effective in the presence of loss of bone stock (Fig 4) The patient is placed in the su-pine position on a standard fracture table or, optimally, on a Judet table.40
On a Judet table, the hip is placed in the desired position before prepar-ing the patient An intraoperative radiograph verifies the range of abduction-adduction The modified Smith-Petersen approach involves elevating the abdominal muscles from the iliac crest through their fascial attachment without violating the abductor musculature The dis-tal extension is within the tensor fascia muscular sheet, with detach-ment of both the sartorius and rec-tus femoris muscles To expose the femur, the vastus lateralis is elevated from a lateral to medial direction to avoid denervation With the hip joint exposed and denuded of carti-lage, the lag screw is inserted first, followed by the 12- to 14-hole low-contact broad dynamic compression plate Viewed anteriorly, the plate
Table 3
Recommended Positions for Hip Arthrodesis
Hip Lipscomb and Alhbäck and Gore Matta Karol
Position McCaslin12 Lindahl21 et al22 et al40 et al23
rotation
Add = adduction; abd = abduction
Trang 8has a 10° concave bend to match the
internal iliac fossa, a 50° convex
bend crossing the anterior
acetab-ular rim, and a 35° concavity in the
intertrochanteric area Usually the
plate is fixed to the pelvis first,
fol-lowed by a tensioning device
ap-plied to the distal end of the plate
The plate may have to be
undercon-toured to avoid increasing hip flexion
as the plate is being tensioned Iliac
crest bone graft from the inner table may be used if necessary Postop-eratively, patients are usually
restrict-ed to 30 pounds of weight-bearing for 8 to 10 weeks After 12 weeks, if radiographic consolidation is present, full weight-bearing is allowed
Double-Plating Technique
Double-plate fixation (Fig 5) is particularly appropriate with
diffi-cult situations such as unreduced dislocations, avascularity of bony surfaces, multiply operated hips, and poor patient compliance However, with significant limb-length discrep-ancy (>4 cm), the arthrodesis should
be individualized In these situa-tions, a two-stage arthrodesis is often done because the capability of hip positioning to correct significant limb-length discrepancies is limited
by the potential negative effect on adjacent joints (eg, increased abduc-tion associated with low back pain) The first stage is the preparation
of the head and the acetabulum for fusion, usually with local fixation and an intertrochanteric osteotomy
to remove the lever arm acting on the desired site of fusion In the sec-ond stage, 6 to 8 weeks later, the intertrochanteric area is stabilized
By removing the lever arm of the femur, the fusion site may heal with greater predictability.11 With the patient in the lateral position, a modified lateral approach is used; the gluteus medius and minimus muscles are elevated with a part of the greater trochanter The expo-sure is continued anteriorly in the plane between the sartorius and ten-sor, with the hip flexed and
exter-Figure 4 A, Anteroposterior radiograph of a 16-year-old male with a combined pelvic and femoral neck fracture He developed an
intra-articular infection of his left hip 6 months after injury Anteroposterior (B) and lateral (C) radiographs 8 months after arthrodesis The
patient maintained weight bearing as tolerated.
Figure 3 Anterior plating technique Anteroposterior (A) and lateral (B) views of the
pelvis with optimal position of plate and lateral lag screw.
Trang 9nally rotated The lateral plate
(broad 4.5 mm) is first applied and
contoured over the trochanteric bed
and placed anterior to the greater
sciatic notch and along the lateral
aspect of the femur The plate is
then secured proximally with a
ten-sion device applied distally After
removal of the anterior-inferior iliac
spine, the anterior plate (narrow 4.5
mm) is applied along the femoral
shaft, and a second tensioning
de-vice is applied with the plate fixed
proximally Both tensioning devices
are then tightened; the plates tend
to lift off the bone but are
reapproxi-mated with the insertion of screws
Postoperatively, patients are limited
to 30 pounds of weight-bearing for
8 to 12 weeks and allowed full
weight-bearing when consolidation
is evident on radiographs (Fig 6)
Summary
Arthrodesis is a treatment option for
young adults or adolescents with
unilateral hip disease, particularly in
the presence of recent infection and especially in the setting of failed pelvic or hip surgery for trauma
The ultimate goal for these patients
is a return to an active lifestyle, with minimal restrictions and an accept-able rate of long-term morbidity
Arthrodesis preserves bone stock and may provide pain relief for a significant period of time With proper patient selection and the hip
fused in an optimal position, the onset of notable pain in adjacent joints can be delayed for up to 25 years Current surgical techniques for fusion allow maximal preserva-tion of gluteus musculature, should conversion to THA eventually be considered In patients older than
50 years of age, survivorship of the conversion THA is nearly compara-ble to that of a primary THA
Figure 5 Double-plating technique Drawings show optimal position of the plates in anteroposterior (A) and lateral (B) views and after
reattachment of the greater trochanter (C).
Figure 6 A, Anteroposterior radiograph of a 16-year-old male with a painful dislocated
dysplastic hip B, Three years after fusion with the two-stage double-plating technique.
Frontal plane
30°
60°
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