“Deborah is a very motivated 53 year old lady who has suffered with back pain and multiple joint problems since childhood. Her problems were a result of Ehlers-Danlos syndrome and development dysplasia of both hips.
She had a very successful hip replacement 10 years ago, but over the past year developed pain in the groin and thigh and was finding it difficult to get around when she arrived with us.”
Deborah underwent a battery of tests with us to find the cause of her problem. We knew that pain in the groin could point to a problem with the socket part of her hip replacement, and pain in the thigh could mean something wrong with the femoral stem. However, we were conscious that problems could be coming from her back.
We started by examining her and organising bloods tests and x-rays.
Her examination showed that she walked with a limp and the hip was irritable. Her blood tests were normal, making infection less likely.
Anteroposterior and lateral plain radiographs of the pelvis. The white arrow demonstrates thickening of the cortex of the bone suggesting loosening. The blue arrow demonstrates a lucent line around the implant near the top, which is often normal for this implant.
Due to the radiographic evidence of loosening, we organised a special type of scan called a SPECT CT. This involved an injection of a short-acting radio-active substance and then pictures being taken with a gamma camera at different time intervals over several hours. These were matched to a CT scan to give 3D information. This is very helpful for looking at areas of increased bone activity.
SPECT CT - This showed that whilst Deborah did have back problems (blue arrow), her hip really lit up (white arrow). Her bladder is in the centre of the image, showing the tracer ready to disappear from the body in her urine.
Deborah was diagnosed with a loose left sided femoral stem that required revision.
We knew that we had to get things just right for Deborah. She is young with high demands and her first hip replacement was done perfectly. We organised a CT scan to plan revision of her femoral stem so that we knew the expected implant sizes prior to surgery.
We knew that we needed to remove her existing stem with as little bone loss as possible. Just because something is ‘loose’ on a scan doesn’t mean it comes out easily! We were prepared to do a controlled break of her thigh bone (an extended trochanteric osteotomy) if the stem did not come out.
CT scan: Left-to-right, This demonstrates slices of bone from the front through to the back, giving the planned position for the new stem.
Deborah is a Jehovah’s Witness so prior to surgery we had discussed that she was not prepared to accept a blood transfusion. We organised to use a ‘cell saver’ which allows re-transfusion of her own blood without breaking the circuit. We could not have used this if we were worried about infection.
Anteroposterior and lateral plain radiographs taken after the procedure showing the femoral stem sat in the perfect position as planned.
EOS showing the patient sitting and standing with the CT planned femoral stem.
Surgery went to plan and the old stem came out easily. The new stem was inserted as per our pre-operative plan, and she was on her feet the next day.
Deborah bounced into clinic at 6 weeks after surgery and is doing very well. CT planning helped us to achieve a stable hip, maintain equal leg lengths, and do a quick operation with little blood loss.
Evidence for this treatment
In closer detail