Authors' reply

M Erceg¹, K Bečić²,  
¹ Department of Orthopedics, Clinical Hospital Center, Split, Croatia
² School of Medicine, University of Split, Split, Croatia

Correspondence Address:
Dr. K Bečić
School of Medicine, University of Split, Split
Croatia

Full Text

Sir,

We thank Sinha NK [1] for the comments on our article. [2] For the patient, we had two options 1) to create an osteosynthesis of the femur and to extract the loosened endoprosthesis (pending hip, Girdlestone excision arthroplasty-GEA) versus 2) implanting a partial cemented Austin Moore endoprosthesis with a big head and fix femur with two plates and screws. We opted for the latter and still think it was in the best interest of the patient. The fact that the patient is still mobile (20 years after the procedure) and can walk using a crutch, without pain and instability, never had a disclocation indicates that it was a good decision.

Sinha NK mention that the GEA procedure would be a better solution for this patient. The literature cited in the letter is both old and does not support the statement. In the first cited article (1976), the follow-up was 10 years and we fail to see a connection with our case. Half of the patients could walk with no aid or one stick". We presume that the remaning half could not walk without aid or a stick. The second citation has the average observation period after removal of the endoprosthesis of 5.2 years which is by no means long term. A conclusion in the second citation is that Girdlestone procedure is a "sensible rescue tehnique for infected hip prosthesis and in situation where reimplantation is technically impossible". In our case, the prosthesis was not infected and, because we did not have a revisional endoprosthesis, technically it was possible to implant a partial Austin Moore endoprosthesis. The next reference states that 81.5% of patients had deep infecion of the hip endoprosthesis, and Girdlestone procedure was the method of choice. There was no other option. The mean follow-up was 7 years. Our patient now walks for over 20 years. In another reference by Sinha NK, the follow-up was 37 months with the mean age of patients being 78.8 years. Our patient was 65-years-old at the point of surgery.

The letter also mentions that our patient (after 20 years) has protrusio acetabuli. This is correct. At the operation the patient had osseous floor defect of the acetabulum, but the head of the Austin Moore prosthesis was bigger then the osseous defect. It did not go deep and is still in the acetabulum. The letter also mentions that the range of movement (ROM) is small, as the picture 4 suggests. That is correct. At the age of 85, we do feel that ROM is likely adequate. A better ROM may be at the cost of prosthesis stability.

Sinha NK asks "What would have been the final outcome if the authors had chosen the first option and managed the pathological fracture of proximal femur with minimal hardware as needed?". The pathological fractures of the proximal femur could not be managed with minimal hardware, because the bone was thin and fractured at several places. It was thus necessary to put two plates and several screws. The decision to implant an Austin Moore prostheis with cement helps the stability of the upper femur. Girdlestone operation (GEA) is good temporary procedure for patients who have a infection of the hip. Young and active patients do not want to accept this procedure as a definitive outcome. [3] The satisfaction and functional results of the endoprosthesis are superior to Girdlestone operation, and it justifies the attempt at the conversion of Girdlestone situations with Total Hip Replacement, if technically possible in accordance with the patient's wishes and as allowed by his/her general health. [4],[5] Since we did not have revisional total hip endoprosthesis, we implanted a partial Austin Moore model. GEA is still a viable option to salvage irretrievably failed hips presenting technical difficulties in medically compromised patients. [6],[7] We remain convinced that the option we chose was in the best interest of the patient.

References