Bilateral hip ankylosis with HO

 Case refered by Dr. Mukesh Ladda from nagpur for opinion.
Please  give your views and comments

54yr male diabetic presented with bilateral stiff hip since one yr,slowly progressive to total stiffness since last six months.

History of septicemia with multiorgan failure one n half yr ago,recovered well but unable to stand or sit due to bilateral stiff hip.

His  question are as follows? My comments below are open to your valuable comments and views
1.Is THR only option?
With the sort of long standing Ankylosis the articular cartilage nutrition suffers and result in fibrous or bony ankyloisis. The question whether this was the result  of septic arthritis or due to neuraxial injury could be partly answered by ESR, CRP and intraop frozen section. Being a diabetic an HBAIC is advised. IF proven to be infected could consider girdlestone with local antibiotic delivery could be a choice before THR. If not A THR with the largest possible head to avoid dislocation

2.What will be the status of Abductors after removing HO?
 I would go dead lateral, split the TFL with anterior and posterior with bone slivers from the G. Troch. Do a neck ostetomy and remove the head, Ream or piece meal. After this the bone anterior and posterior can be removed  slowly exposing the bone subperiosteally and reove all the impinging bone. You want to watch for N/V damage  palpating vessels and preop MRI angio  if needed to asses where the vessels are embedded if needed. The all important homan's retractor, electroquatery  helps exposing the HO. The one similar case i did had a compartmental syndrome of thigh and femoral neurpraxia which recovered partially in 6 months. The contralateral hip was done 6 months later and laser was used toquarterise the bleeding bone to avoid compartmental syndrome. Those days we did not have any local thrombin delivery to stop bleeding if possible.

3.When should i do the second hip(gap between two THR)?
I would wait 3 to 6 months only for recovery
4.What are  the chances of recurrence? In my only experience of a bilateral case the xrays below the hip failed with a psuedo tumor due to MOM articulation with an XL head.

5.Radiothearphy protocol pre & post op?
My choice is radiation the morning before operation( experimental evidence in literature)

Below is a similar case I discussed before, So far I could trace only the preop and one post op at 3 months. will trace the entire series  in a few days once I get back to get the whole story.

Dr. Mojieb's Comments are added below

1- Would pre operative aspiration add value too to ascertain the possibility if this being post sepsis or not
2- Any role for Posterior Approach ???
That might give u a better opportunity of visualizing & protecting the hip abductors.The only issue will be, where to osteotomize the ankylosed  hip which I think u can do it a bit low , just above the lesser trochanter , this will help you retract the whole femur + abductors out of your way than ream away the acetabulum piece meal initially than as the landmark for the ant+ post columns become available u can place the Homan.

I like your idea about the neurovascular structure concern & the use if laser for bone cauterization
I personally have not used laser before but seems to be a great idea.

Asymmetric polywear in a tkr

I do not have the initial postop xrays taken at the time of index procedure done elsewhere. Hence, not sure whether improper balancing was one of the causes for  early  polywear ( 7 years)

 

 This was revised with legion revision system. The implants werte well fixed but the poly liner is not available anymore at least in india( FS knee) hence the total revision

lessons learned-Sequelae of open fracture talus with medial malleolus fracture

He has  pain on wt bearing with Varus hind foot and gross painful restriction of ankle movement. Varus of ankle can be partially corrected short of neutral.  Subtalar movemnts are terminally restricted but painless. Midfoot and tendons are normal.

1. Is this AVN with collapse.

2. Malunion with Sec OA

3. Investigations if any

4. what are the options

 we did an arthroscopic ankle fusion. the reasons and problems are discussed in the comments

Now after 3 months the ankle is solid fused has lateral pain from an abuting osteophyte or should one call it unionophyte. The disheartening xray is of .> 10 gegree varus which i feel i would  need correction thru a transfibular approach when symptoms arise. He is on a rocker heel slippers to simulate heel toe gait.

1.      He was referred for ankle replacement. We did a bone scan to rule out AVN and decided to do an arthroscopic ankle fusion as he was young and works as a electrician. I believe an ankle replacement at this age may not be a good idea. As his subtalar joints were relatively normal an ankle fusion was chosen. In view of his varus deformity we planned to open if the deformity was not corrected, By clearing the lateral gutter with Shaver and burr we could correct the varus and hence only the medial malleous screws were removed and percutaneous tibiotalar screws were inserted. Unfortunately one of the guide wires broke and intraop screening showed it to be intraosseous. However the postop xray showed the wire protruding into the sinus tarsi. I am hoping for an early fusion and hopefully no subtalar symptoms

Lessons learned.

1. Do not attempt arthroscopic fusion in the presence of varus deformity which is not passively correctable

2.My reason to attempt the same was due to the medial and lateral as well as anterior skin inscisions which would compromise wound healing as well as after taking out the lateral osteophyte i felt i corrcted the deformity refer xrays above which I know now was never a true AP

The Xrays below are refusion at  6 weeks postop. The fusion clinically feels solid. We have delayed wt bearing and left the foot unsupported inspite of bridging anteriorly and posteriorly as open fusions generally take 3 months to fuse.

Over all arthroscopic ankle fusions have above 95% fusion rates at 12 weeks. My personal series of 18 cases have all united execpt for 2 malunions both of which the indications were flawed due preop varus deformity as above which were only partilly corrected.

Price one pays for delayed revision in aseptic looseningr

This patient, a 44 year old rheumatoid lady underwent revision of rt hip in 2005  with MOM where in  we  advised revision of the lt. cup. Financial reasons or otherwise, she comes  7 years later with the cup migration. comments please. Her metal ions are fine. The xrays are in chronological order. Early revision could have saved much bone and made surgery easier.

1 

Would have loved to revise early without bone loss. Superiomedial migration suugest anterior column deAs the anterior column was compromised we could get good host bone with more than 70% contact with a jumbo trabecular cup and a wagner stem