Clinical History, Examination and Blood Test Results

  • The 2nd workshop case is a 37-year old gentleman who presented with pain in his left hip limiting his mobility.

  • His medical background includes bilateral hip dysplasia, bilateral pes cavus, scoliosis and hereditary motor sensory neuropathy type 1 (HMSN1).

  • At the age of 20 he was treated for recurrent dislocation of the right hip with a valgus derotation femoral osteotomy and a Chiari osteotomy.

  • He received a number of osteotomies to the left acetabulum as a child.

  • At presentation, he was experiencing severe pain in his left hip and knee. This pain was constant, present at rest and exacerbated by movement. He reported significant clicking in the left hip on mobilisation.

  • On examination, internal and external rotation was almost impossible due to pain. Flexion was limited to 90 degrees.

  • Examination of the left knee was normal with a full ROM.


Imaging Results

PRE-OP RADIOGRAPH

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This pre-operative radiograph demonstrates destruction of the both the femoral heads with significant bilateral joint space narrowing. The previous femoral derotation valgus osteotomy and blade plate is seen on the right side. In the right acetabulum there is a threaded pin from the Chiari osteotomy and a broken drill bit. On the left there are two thin wires which are from a previous procedure in 1983.

 

Diagnosis

  • Complex developmental dysplasia of the left hip with secondary osteoarthritis.


Treatment operation 1

  • This patient required a left total hip replacement with a Pinnacle acetabular component and a CADCAM femoral component.


Imaging Outcomes Operation 1

POST-OP RADIOGRAPH

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This post-operative AP radiograph shows the Pinnacle acetabular component and CAD CAM custom femoral component in situ in the left hip.

 

Clinical History Continued

  • The patient represented in 2013 with pain and limited function in the right hip. He underwent removal of the ilium pins and right angle blade plate prior to a right total hip replacement.


Treatment operation 2

  • Right total hip replacement.

  • 42mm Deltamotion acetabular component with a 32mm -3 ceramic head.

  • CAD CAM stem was used. Implanted using a subtrochanteric trapezoidal osteotomy to correct for femoral deformity.

  • Cables required proximally and distally for a periprosthetic fracture.


Imaging Outcomes Operation 2

POST-OP RADIOGRAPH

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6-WEEK POST-OP RADIOGRAPH

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Bilateral hip replacements present. Here the acetabular cup is positioned well.

The acetabular component of the right THR has displaced at 6-weeks post-op, due to an osteoporotic fracture through the medial acetabular wall. The patient did not report any trauma or any sudden pain in the right hip between the procedure and follow-up at 6-weeks.

 

6-WEEK POST-OP CT

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This CT scan was required to design a new acetabular component for the patient (see treatment below).

 

Clinical history Continued

  • Failed right acetabular component due to osteoporotic fracture of the acetabulum requiring revision.


Treatment Operation 3

  • Single stage revision of the acetabular component only.

  • Custom made tri-flange implant was used – The CT above was used to design the implant.

  • 48mm acetabulum with a 38mm poly cemented liner.

  • 28mm femoral head (-3.5).


Imaging outcomes operation 3

POST-OP RADIOGRAPH

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1-YEAR POST-OP RADIOGRAPH

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A custom made tri-flange acetabular component was used to re-build this patients acetabulum. This procedure was done in 2013, and today a 3D printed component may have been utilised.

At one-year post operatively the tri-flange cup was well fixed and the previous osteotomy is showing callus formation.


Clinical Outcomes

  • The joint was stable and the patient reported no pain. They had an oxford hip score of 34 at one-year post op.


Learning Points

  • Custom tri-flange components are indicated for use when;

    • Previous reconstruction with a cage or porous metal augment has failed

    • Large contained defects ± discontinuity

    • Complex hips with multiple previous operations and insufficient bone stock

    • Paprosky 3A or 3B

  • Good outcomes are seen in patients with severe bone loss with or without discontinuity.