|
Year |
2002 |
|---|---|
|
Question Number |
61 |
|
Category |
Hip and Knee Reconstruction |
Question
An otherwise healthy 65-year-old woman has incapacitating hip pain for which nonsurgical management has failed to provide relief. A radiograph is shown in figure 11. The next most appropriate step in treatment should consist of
1- bipolar hip arthroplasty
2- total hip arthroplasty
3- core decompression
4- fibula strut grafting
5- intertrochanteric flexion osteotomy
Figures
Answer (click for answer)
Preferred response: 2.
The radiograph shows stage IV AVN of the femoral head. AVN of the femoral head can be classified using the Ficat and Arlet staging system:
Stage 0: asymptomatic, normal radiograph
Stage I: mild or no symptoms, normal radiograph
Stage II: mild symptoms, density change seen on radiograph of femoral head (crescent sign)
Stage III: mild to moderate symptoms, loss of sphericity and collapse of femoral head on radiograph
Stage IV: moderate to severe symptoms, joint space narrowing and acetabular changes seen on radiograph
AVN presents more commonly in men, usually between the ages of 18 and 50. 50% have bilateral disease. Groin pain is the most common presenting symptom. Alcohol abuse, steroids, trauma and Gaucher’s disease are possible etiologic factors but about 20% of cases are idiopathic. Treatment of advanced AVN (stage III or IV) is total hip arthroplasty. In the first referenced article Taylor et al describe the results of 63 patients with advanced AVN treated with THA using an uncemented acetabular component and a cemented femoral stem. In their study they inserted 76 THAs in 63 patients with either stage III or stage IV AVN (later confirmed by histologic analysis). After a mean follow-up of 7.6 years they report a Harris Hip Score improvement from a preop mean of 29 +/- 14.7 to 94 +/- 6.8 postop. In the second referenced article Hartley et al report the clinical results of 55 THAs in 45 patients with a mean follow-up of 117 months. Ten patients underwent revision due to polyethylene wear, recurrent dislocation and deep infection. Of the 29 patients who did not have a revision the reported clinical results in this study were good to excellent. 79% were able to walk an unlimited distance, 83% had no limp, 93% had few or no functional limitations, 97% reported improved functional ability and 86% reported no or mild pain postoperatively.
Reference: 1) Taylor AH, Shannon M, Whitehouse SL, Lee MB, Learmonth ID: Harris Galante cementless acetabular replacement in avascular necrosis. J Bone Joint Surg Br 2001;83:177-182. 2) Hartley WT, McAuley JP, Culpepper WJ, Engh CA Jr, Engh CA Sr: Osteonecrosis of the femoral head treated with cementless total hip arthroplasty. J Bone Joint Surg Am 2000;82:1408-1413.