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Unusual way of loosened total hip arthroplasty treatment with an Austin Moore endoprosthesis
M Erceg1, K Becic2,
1 Department of Orthopaedics, Clinical Hospital Centre Split, Split, Croatia
2 School of Medicine, University of Split, Split, Croatia
Correspondence Address:
K Becic
School of Medicine, University of Split, Split
Croatia
Abstract
A 65-year-old female patient with aseptic loosening of total cemented hip endoprosthesis and pathologic fracture of the femur at the level of the stem of endoprosthesis was presented. As no appropriate endoprosthesis was available due to the war in Croatia and war priority, the problem was managed by femur osteosynthesis and implantation of a partial Austin Moore hip endoprosthesis. The endoprosthesis is still functioning well (for 20 years).To the best of the author«SQ»s knowledge, nobody has ever treated problem like this using this alternative, an unconventional method, with an Austin Moore endoprosthesis.
How to cite this article:
Erceg M, Becic K. Unusual way of loosened total hip arthroplasty treatment with an Austin Moore endoprosthesis.J Postgrad Med 2014;60:81-83
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How to cite this URL:
Erceg M, Becic K. Unusual way of loosened total hip arthroplasty treatment with an Austin Moore endoprosthesis. J Postgrad Med [serial online] 2014 [cited 2023 Sep 23 ];60:81-83
Available from: https://www.jpgmonline.com/text.asp?2014/60/1/81/128823 |
Full Text
Introduction
Aseptic loosening of the endoprosthesis is certainly the most important late post-grafting complication. Osteolysis may occur both at the junction between the bone and cement and at distant sites as well as in cementless endoprosthesis. A great amount of plastic debris formed by friction of the prostheses head against the plastic acetabular wear is considered primarily responsible for the occurrence of osteolysis. [1],[2],[3],[4]
Aseptic loosening of the endoprosthesis results in painful limping progressing to complete immobility. Fractures of the impaired bone may occur even without any major trauma. Replacement is best achieved by a revision of previously cemented long-stem hip endoprosthesis whereas recently cement-free replacement has been given preference, usually by bone grafts femoral and acetabular components. [5],[6],[7] But in some situations, such as a war, the case must be dealt with by using an alternative, sometimes unconventional method.
Case Report
A 65-year-old female patient with loosened hip endoprosthesis and femur fracture was transported to our Department in 1993. The X-ray image showed aseptic loosening of the total cemented hip endoprosthesis and pathologic fracture of the femur at the stem level. What was seen is a strong osteolysis of the bone around the endoprosthesis, but also distally of the endoprosthesis [Figure 1].{Figure 1}
During war time in Croatia, technical resources were inadequate because the supply of the endoprostheses was not a priority. [8] The patient underwent surgery, managing the problem, in an unusual way. A partial Austin Moore endoprosthesis was implanted and cemented using two plates with screws. In later years the newly formed osseous floor of the acetabulum was observed whereas femoral osteolysis disappeared [Figure 2].{Figure 2}
The endoprosthesis is still functioning for 20 years now; the patient uses a crutch and orthopedic shoe. There is no new osteolysis of the femur, and the places of the old osteolytic lesions disappeared [Figure 3] and [Figure 4]. Osteolytic lesion of the acetabular floor is because of mechanical reason.{Figure 3}{Figure 4}
Discussion
The patient had all signs of aseptic loosening of the hip endoprosthesis with big femur osteolysis around the bone cement along the stem but there was also a big osteolytic lesion (4 × 2.5 cm) more distally [Figure 1]. Acetabular segment of the endoprosthesis together with the bone cement was cranially shifted and inversed, i. e. mobile, with pronounced periarticular ossifications and osseous floor of the acetabulum missing (not seen in [Figure 1]). The femoral fracture was located between the medium and the lower third of the endoprosthesis stem.
A revised endoprosthesis with an extremely long stem and massive bone grafts were obviously required for successful management of this problem. No such endoprosthesis and bone grafts from an adequate bone bank were available.
Implantation of the primary total hip cemented endoprosthesis and plates with screws was considered but the acetabular floor was completely free from bone and the cavity of the acetabulum was large. The osseous defect of the acetabular floor was so large that the new primary plastic acetabulum would almost sink into the pelvis. Direct contact between the cement and soft tissues of the pelvis had to be prevented, where authors had their own unfavorable experience. [9] It was not possible to graft a common plastic acetabulum without the availability of a bone bank and meshwork or ring.
Thus, two outcomes are possible: 1. to create the osteosynthesis of the femur and leaving the hip without endoprosthesis (pending hip); or 2. to implant a partial Austin Moore endoprosthesis with the largest head, cemented to prevent its sinking into the calcarless femur with fixation of the fragments by plates and screws. The second variant was chosen and the largest available Austin Moore endoprosthesis was implanted [Figure 2]. The head of the partial endoprosthesis filled the entire bone defect of the acetabulum, still being large enough to remain in the place within the acetabulum. The clinical and radiologic control examination showed an appropriate position and function of the endoprosthesis. The X-ray obtained later showed the acetabulum to have formed a 0.5 cm wide osseous floor [Figure 2]. Upon the removal of the plastic acetabulum there were no new sites of osteolysis, whereas the previous ones were considerably reduced or disappeared. Thus, supporting the theory of polyethylene debris rather than the bone cement, to be responsible for osteolysis. [1],[2],[3]
Twenty years after the procedure (age of 85) the patient is still mobile; she walks with a crutch and orthopedic shoe and is satisfied with her situation. On the X-ray there is no osteolysis on the femur bone, since there is no more plastic acetabulum in the region. The bone defect of the acetabular floor is of mechanical reason (metal head and pelvic bone) [Figure 3] and [Figure 4], but the head of the endoprosthesis is stabile in acetabulum. There is no reason to do any more surgical procedures with this patient.
To the best of author's knowledge, this was the first case of implantation of an Austin Moore endoprosthesis after loosening the cemented hip endoprosthesis and femur fracture.
The procedure described is, by no means recommended as a therapy because revised endoprostheses and bone banks are generally available. However, this could be an interesting case how physicians dealt with it in a war situation, when such a situation required alternative and acceptable solutions.
References
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