Clinical History, Examination and Blood Test Results

  • Step 4 case 1 is a 74-year-old male who presented with inability to cope with his long standing left hip girdlestone. He had a primary left hip replacement (THR) in 1999 which was complicated by early, recurrent dislocation. Revision was done after only a few weeks. He later developed infection with a sinus which was managed non-operatively for 16 years, using antibiotic suppression. In 2015 the infection flared up so he underwent a Girdlestone procedure to remove the implant as part of a two stage revision for infection. However, the surgeon was reluctant to proceed to the 2nd stage due to the size of the acetabular defect together with long history of infection so he referred the patient to our team.

  • Examination revealed an antalgic and trendelenberg gait, using two crutches and a left shoe raise. He was able to abduct and straight leg raise on the left side.

  • Blood CRP was 10mg/L and ESR was 33mm/Hr. He had a white cell count of 10x109 per litre. A tissue biopsy of the left hip was was negative for infection. MRI excluded osteomyelitis.


Imaging Results

PRE-OP RADIOGRAPH

Click on the image for a closer look

This radiograph shows an anteroposterior (AP) radiograph of the pelvis. You can see a left sided Girdlestone procedure causing significant left sided leg length discrepancy.

This shows a closer view of the left hip with a Girdlestone. You can see there is chronic remodelling of the left acetabulum with a reasonable bone stock.


Diagnosis

  • This patient was diagnosed with a non-infected Girdlestone suitable for a second stage revision. There was a superior acetabular defect.


Treatment

ANATOMIC RESTORATION SOCKET

Click on the image for a closer look

A Stryker Anatomic Restoration Socket was used to reconstruct this patient hip, as seen in the image above.

 
  • This patient underwent the second stage of their revision in March 2017.

  • Key surgical steps

    • Posterior approach

    • 5 hip capsule samples sent for extended microbiological culture.

    • Socket reamed to 67mm to accommodate a 68mm left Anatomic Restoration socket which has an eccentric centre of hip rotation.

    • 5 screws with very good hold

    • Dual mobility liner

    • Stability and leg length testing

    • Wash


Imaging Outcomes

POST-OP RADIOGRAPH

Click on the image for a closer look

AP radiograph of both hips two days post-operatively showed a well-positioned jumbo cup with 5 screws and appropriate restoration of hip centre of rotation (medially and inferiorly). 

 

Clinical Outcomes

  • This patient was discharged but unfortunately went on to have a non-ST elevated myocardial infarction (NSTEMI) after discharge. He recovered well with the use of cardiac stenting.

  • His walking has improved substantially. 


Learning Points

  • Acetabular defects can be treated with jumbo cups that have an eccentric centre of rotation instead of complicated augments.