The Story

'“Umar attended my clinic aged 39 with a 1-year history of a very painful left hip. He had a clinical history of bilateral developmental dysplasia of the hip which was treated with multiple operations to try and form a native acetabulum. By the age of 26 he required bilateral total hip replacements. On the left he had a ceramic on ceramic THR with a Furlong stem and a threaded acetabular cup and on the right he had a metal on polyethylene THR with the same components. These operations had been very successful for Umar up until this point.”


The Investigation

On clinical examination, Umar had a positive Trendelenburg test on the left hand side. He was able to mobilise with the aid of a stick. Raising his legs straight up off of the couch was possible but uncomfortable on both sides. His range of movement was restricted on both sides and rotation of the left hip was particularly irritable.

His Oxford Hip Score was 14/48 on the left hand side.

His blood CRP was <10mg/L helping to rule out infection.

A left hip aspiration and extended microbiological culture further helped to rule out an infection.

A bupivicaine local anaesthetic hip injection (into the left hip at the time of aspiration) helped to relieve his pain for 24-hours.


the evidence

Anteroposterior plain radiograph demonstrates 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.

Lateral plain radiograph of the left hip showing a slightly retroverted cup.

  • Images being chased by ROB

  • 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.


The Diagnosis

Umar was diagnosed with a painful left ceramic-on-plastic Furlong hip replacement secondary to synovitis.


The plan

We knew we would have to operate on both hips, however as the left was causing Umar more issues at this time, we decided to revise the left hip joint first, followed by the right after a period of recovery. We aimed to use a highly porous hemispherical cup while retaining the well fixed stems.


The operation

Umar’s left hip was revised first. Intraoperatively, the acetabular ceramic liner was found to be de-laminating and breaking up. Additionally, 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.

We revised the right hip about 9-months later using a very similar procedure.


The Outcome

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

 

Level of function to be checked by ROB and documented here!


The Verdict

To be completed by PROF

The previous learning points were as follows:

  • 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.


Evidence for this treatment

  • Needed


In closer detail

  • Needed


Related cases…

  • Needed