Clinical History, Examination and Blood Test Results

  • Step 2 case 1 is a 39-year-old male who presented in 2013 with a 1 year history of a painful left hip replacement. He was born with bilateral developmental dysplasia of the hip (DDH) and underwent multiple operations up until the age of 18 on both of his hips. In 2000, he received a left hip replacement (ceramic-on-ceramic Furlong stem with a threaded acetabular cup). In 2001, he had a right hip replacement with the same implant type, but with a metal on polyethylene bearing.

  • Examination revealed a positive Trendelenburg test on the right side and negative on the left. He was walking with a stick. Straight leg raise on the left hand side was possible but restricted. Movements in both hips were restricted and rotation of the left hip was irritable

  • His Oxford hip score was 14/48

  • Blood CRP was less than 10 mg/L.

  • Injection of his left hip (preceeded by aspiration for microbiological culture) with bupivacaine local anaesthetic releaved his left hip pain for 24 hours.


Imaging Results

PRE-OP RADIOGRAPH

Click on the image for a closer look

This patients pre-revision anteroposterior (AP) radiograph showed well fixed and well positioned bilateral Furlong hip replacements with threaded cups. The left has a ceramic head and the right has a metallic head. There radiolucent area surrounding the left cup is artefact with no evidence of osteolysis.

The lateral view showed a slightly retroverted cup.

  • An MRI scan was taken and this revealed scar tissue surrounding the left hip.

  • CT Spect showed no evidence of loosening or infection and no evidence of lumbar spine or other pelvic pathology.


Diagnosis

  • Painful left ceramic on plastic furlong hip replacement secondary to synovitis.


Treatment

  • This patient’s left hip was revised in July 2014. The acetabular ceramic liner was found to be de-laminating and breaking up. There was synovitis so a synovectomy was performed and 5 tissue samples sent for extended microbiological culture. The threaded acetabular cup was explanted with minimal bone loss and replaced with a highly porous (Gription) pinnacle cup. The stem was retained and the head revised to a JRI Furlong ceramic head with titanium sleeve.

  • He developed pain in his right hip in December 2014 and underwent revision of the right hip in March 2015.


Imaging Outcomes

POST-OP RADIOGRAPH

Click on the image for a closer look

This anteroposterior radiograph shows bilateral highly porous hemispherical (Gription) pinnacle acetabular cups with ceramic-on-ceramic bearings. The two Furlong stems are both well fixed and well positioned.

 

Clinical Outcomes

  • The patient was happy with the overall outcome from his two revision operations.


Learning Points

  • Unexplained painful hip replacements need to be fully investigated, before revision is considered, with: blood inflammatory markers; hip aspiration for microbiological extended culture and injection of anaesethetic to confirm or refute the hip as the location for the pain; MARS MRI for soft tissue reactions and muscle damage; and CT Spect for loosening, infection and pain generators in the lumbar spine and pelvis. Additionally, consider blood cobalt and chromium levels when there are cobalt-chromium components (this may pick up taper corrosion).

  • Revision of ceramic on ceramic bearings should ideally use the same bearing type.

  • Obtain optimum equipment for removal of acetabular components to minimize bone loss.