Case Studies
Total joint replacement: total hip arthroplasty
Patient history
A painful hip made it increasingly difficult for this woman of 68 to perform activities of daily living. She had endured the pain for a number of years prior to her referral to us by her family doctor. With each passing year, the pain intensified while her ability to ambulate decreased.
Case description
Symptoms we observed included limping, trouble rotating the hip, shortened range of motion, and increased pain during weight-bearing. X-rays of her pelvis revealed loss of the joint space in her hip.
Diagnosis
Significant arthritis of the hip.
Treatment plan
We scheduled the patient for a total hip arthroplasty. A minimally invasive straight lateral approach to the hip from the decubitus position was employed; this entailed first creating a six-inch incision centered over the greater trochanter, opening the fascia latta and proceeding anterior-laterally to the hip joint in order to expose it. Next, the arthritic joint was dislocated anteriorly to expose the deteriorated femoral head and acetabulum. A cutting jig was applied to the femoral neck for a preoperatively templated cut. The arthritic femoral head was removed, giving greater exposure to the arthritic socket. Sequential reaming was initiated, then the acetabulum was taken down to bleeding bone and readied to be fitted with an appropriately sized titanium acetabular implant. The implant was press-fit into the bony pelvis and found to be intrinsically stable, but it was decided to add a screw for rotational fixation. Our attention then turned to the femoral side.
The medullary canal was prepared using a reamer followed by broaches, sequentially increasing in size. Bone stock was noted to be of good quality, so a cementless porous implant was utilized. A stem of correct size was press-fit into the bony canal. A highly polished metal ball was selected and placed on the end of the femoral stem, attaining a solid cold-weld fusion. The hip construct was reduced and range of motion checked, as were leg length and hip stability. The hip then was closed.
The surgery lasted 90 minutes. Within 12 hours, the patient was sitting upright in a chair and was half weight-bearing. The patient progressed to full weight bearing within two weeks. During that time, she used a walker and continued to do so until postoperative Week 6 when she began walking aided by a cane. The cane was discontinued at Week 9.
Outcome
Pain was substantially improved within a matter of days after surgery. By postoperative Week 9, the patient was limp-free. Full resumption of routine activities of daily living began at Week 12. The patient today is doing very well and is fully satisfied with her hip replacement.
Discussion
This procedure – with its high degree of predictability– is the “gold standard” for relief of pain caused by severely arthritic hip joints. However, contributing to the success of this case was the level of direct interaction between the patient and her orthopaedic surgeon from beginning to end. Moreover, care was delivered in strict accordance with American Board of Orthopaedic Surgery best-practices guidelines.
Case Studies
Total joint replacement: total hip arthroplasty
Patient history
A painful hip made it increasingly difficult for this woman of 68 to perform activities of daily living. She had endured the pain for a number of years prior to her referral to us by her family doctor. With each passing year, the pain intensified while her ability to ambulate decreased.
Case description
Symptoms we observed included limping, trouble rotating the hip, shortened range of motion, and increased pain during weight-bearing. X-rays of her pelvis revealed loss of the joint space in her hip.
Diagnosis
Significant arthritis of the hip.
Treatment plan
We scheduled the patient for a total hip arthroplasty. A minimally invasive straight lateral approach to the hip from the decubitus position was employed; this entailed first creating a six-inch incision centered over the greater trochanter, opening the fascia latta and proceeding anterior-laterally to the hip joint in order to expose it. Next, the arthritic joint was dislocated anteriorly to expose the deteriorated femoral head and acetabulum. A cutting jig was applied to the femoral neck for a preoperatively templated cut. The arthritic femoral head was removed, giving greater exposure to the arthritic socket. Sequential reaming was initiated, then the acetabulum was taken down to bleeding bone and readied to be fitted with an appropriately sized titanium acetabular implant. The implant was press-fit into the bony pelvis and found to be intrinsically stable, but it was decided to add a screw for rotational fixation. Our attention then turned to the femoral side.
The medullary canal was prepared using a reamer followed by broaches, sequentially increasing in size. Bone stock was noted to be of good quality, so a cementless porous implant was utilized. A stem of correct size was press-fit into the bony canal. A highly polished metal ball was selected and placed on the end of the femoral stem, attaining a solid cold-weld fusion. The hip construct was reduced and range of motion checked, as were leg length and hip stability. The hip then was closed.
The surgery lasted 90 minutes. Within 12 hours, the patient was sitting upright in a chair and was half weight-bearing. The patient progressed to full weight bearing within two weeks. During that time, she used a walker and continued to do so until postoperative Week 6 when she began walking aided by a cane. The cane was discontinued at Week 9.
Outcome
Pain was substantially improved within a matter of days after surgery. By postoperative Week 9, the patient was limp-free. Full resumption of routine activities of daily living began at Week 12. The patient today is doing very well and is fully satisfied with her hip replacement.
Discussion
This procedure – with its high degree of predictability– is the “gold standard” for relief of pain caused by severely arthritic hip joints. However, contributing to the success of this case was the level of direct interaction between the patient and her orthopaedic surgeon from beginning to end. Moreover, care was delivered in strict accordance with American Board of Orthopaedic Surgery best-practices guidelines.