Clinical History, Examination and Blood Test Results

  • Workshop 5 is a 76-year old gentleman who presented with indolent left hip worsening over 2-years.

  • He had a background of trauma to the left hip resulting in fracture requiring a left total hip replacement. This was a hybrid hip replacement (uncemented stem with a cemented socket). He made a good recovery from this procedure.

  • One year later he experienced pain from the left hip, requiring ibuprofen to control.

  • He presented to his local hospital one year later. At the time of presentation, some investigations demonstrated;

    • ESR of 27mm/H which was not abnormal for this patient

    • Radiograph demonstrating 10mm of stem subsidence between 1-year post-op and the time of presentation (roughly a year)

    • Culture negative hip aspiration

    • MRI spine demonstrating L2 stenosis

  • A year on he was referred to our service. On examination he had an antalgic short leg gait and was Trendelenburg test positive on the left side. He used a walking stick for mobilising. He only had 40% lumbar spine motion. Range of movement in the left hip was reduced due to pain. Sensation was reduced in all dermatomes of the left leg.

  • His pre-operative Oxford hip score was 18/48.

  • Investigations at this time demonstrated;

    • CRP of 3.6mg/L and an ESR of 19mm/H helping to rule out infection

  • CT SPECT demonstrating high uptake around the neck and tip of the implanted stem


Imaging Results

PRE-OP CT-SPECT

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PRE-OP BONE SCINTIGRAPHY

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This CT SPECT scan shows increased uptake of the tracer around the lesser trochanter and the tip of the femoral stem, a common radiological manifestation of aseptic loosening.

This bone scintigraphy scan demonstrates increased uptake of trace in the same areas as the SPECT CT adding to the suspicion of aseptic loosening.


Diagnosis

  • Loose left femoral stem requiring revision.


Treatment

This patient required revision of the left femoral component only. The acetabular component remained well fixed from the first procedure.

  • Intraoperatively;

    • Posterior approach

    • 4 stay sutures placed

    • Stem found to be loose, socket was well fixed

    • Stem removed

    • MP link stem 14 x 210mm with XXL body and medium 36mm ceramic head implanted

    • This achieved stability and a good length

    • Closure with vicryl, monocryl and glue


Imaging Outcomes

POST-OP RADIOGRAPHS

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This series of radiographs demonstrates the position of the MP Link stem post-operatively with the retained acetabular component.

 

Clinical Outcomes

  • Excellent patient outcome 1 year post surgery at the age of 88 years old. No support needed for walking distances of more than 1 mile.


Learning Points

  • CT spect shows which components loose, allowing retention of well fixed components if well positioned and no infection present

  • Revision surgery in octogenarians should not be refused due to age