Hip Arthrodesis and Associated Problems

In the last 10 years, total prosthetic replacement has become the hip oper­ ation for many but not all surgeons. In our clinic the increasing frequency of TP has been paralleled by a reduction in the frequency of 10 and HA. For the experienced orthopaedic surgeon and hip surgeon, hip disease has so many facets that it could not possibly be tackled with one operation alone. Thus, HA seems recently to have won renewed recognition. It has once more become the procedure of choice in specific cases, possibly because of certain disadvantages and complications associated with TP which have somewhat tempered the original optimism. Currently, the risk of infection or loosening of the pros thesis is such that the operation cannot justifiably be recommended for patients under 55-60 years of age. In contrast with HA, in the majority of cases the results of TP or 10 are not fully predictable. The loss of joint motion is offset by two important advantages: -complete freedom from pain - full weight bearing is possible on the arthrodesed hip. On following up our HA operations from 1961 to 1971, we examined the development of the operative procedures in our clinic. We found that the range of indications had narrowed as stricter criteria were applied in choosing patients for operation. Adequate and precise operative tech­ niques were developed. We studied the biomechanics of the hip joint exten­ sively (effect of arthrodesis on the statics and dynamics of the hip joint and neighbouring joints).

I: General Aspects.- List of Abbreviations.- I. Historical Review.- II. Anatomy of the Hip Joint.- III. Biomechanics of Hip Arthrodesis and Internal Fixation: Kinetics and Elastometry.- 1 Introduction.- 2 Statics.- 2.1 Hip Joint and Lower Limb Skeleton.- 2.1.1 Standing on Both Legs.- 2.1.2 Standing on One Leg.- 2.2 Knee Joint.- 3 Kinetics.- 3.1 Introduction.- 3.2 Hip Joint and Lower Limb Skeleton.- 3.3 Pelvis and Lumbar Spine.- 3.3.1 Normal Conditions.- 3.3.2 Differences in the Coronal Plane.- 3.3.3 Differences in the Sagittal Plane.- 3.3.4 Knee Joint.- 3.3.5 The Contralateral Hip.- 4 Biomechanics of Individual Hip Arthrodeses.- 4.1 Introduction.- 4.2 Arthrodesis by Resection of the Joint Surfaces.- 4.3 Extra-articular Hip Arthrodeses.- 4.4 Hip Arthrodeses with Central Dislocation.- 4.5 Hip Arthrodesis with Pelvic Osteotomy.- 5 Biomechanics and Technique of Internal Fixation in Hip Arthrodesis.- 5.1 Introduction.- 5.2 Type I Hip Arthrodesis.- 5.2.1 Screw Fixation of the Iliofemoral Bridge Graft.- 5.2.2 Screw Fixation of the Proximal End of the Femur to the Pelvis.- 5.3 Type II Hip Arthrodesis.- 5.3.1 Buttress Plate.- 5.3.2 Compression Plate.- 5.4 Type III Hip Arthrodesis.- 5.5 Type IV Hip Arthrodesis.- 5.5.1 Correct Technique.- 5.5.2 Incorrect Technique.- 5.6 Hip Arthrodesis in the Presence of Infection.- 6 Elastometry.- 6.1 Introduction.- 6.2 Experimental Method.- 6.3 Results.- 6.3.1 Effects of Medial Displacement.- 6.3.2 Effects of Pretensioning of the Plate.- 6.3.3 Influence of Length of the Distal Screw.- 6.3.4 Hip Arthrodesis with Central Dislocation (Charnley).- 6.4 Evaluation of Experimental Results.- 6.5 Summary.- 7 Summary.- IV. General Indications for Hip Arthrodesis.- 1 Introduction.- 2 Diagnoses Leading to Hip Arthrodesis.- 3 General Considerations.- 3.1 Age.- 3.2 General Condition of Patient.- 3.3 Somatic Type.- 3.4 Sex.- 3.5 State of Joints Adjacent to the Arthrodesis.- 3.5.1 Lumbar Spine and Sacroiliac Joint.- 3.5.2 Ipsilateral Knee Joint.- 3.5.3 Contralateral Hip Joint.- 3.6 Occupation.- 3.7 Social Circumstances.- 3.8 Sport.- 3.9 Psychological Factors.- 4 Contraindications to Hip Arthrodesis.- 4.1 Relative Contraindications.- 4.2 Absolute Contraindications.- 5 Choice of Operation.- 6 Summary.- V. Operative Technique.- 1 Introduction.- 2 Preoperative Work-Up.- 2.1 Medical Examination.- 2.2 Radiological Examination.- 2.3 Orthopedic Investigation.- 3 Preparation for Operation.- 3.1 Anaesthesia.- 3.2 Positioning of the Patient.- 3.3 Draping.- 4 Operative Technique.- 4.1 Usual Operative Approach.- 4.2 Pelvic Osteotomy.- 4.3 Intertrochanteric Osteotomy.- 4.4 Wound Closure.- 5 Operative Technique: Particular Features of Different Arthrodesis Types.- 5.1 Type I Hip Arthrodesis.- 5.2 Type II Hip Arthrodesis.- 5.3 Type III Hip Arthrodesis.- 5.4 Type IV Hip Arthrodesis.- 5.5 Atypical Hip Arthrodeses.- 5.5.1 Hip Arthrodesis in the Presence of Infection.- 5.5.2 Arthrodesis of Girdlestone Hips or Similar Conditions.- 5.5.3 Arthrodesis of a High Dislocated Femoral Head.- 5.5.4 Hip Arthrodesis in Cases of Incomplete Painful Ankylosis of the Hip (Intertrochanteric Valgus Osteotomy).- 6 Corrective Osteotomies.- 6.1 Intertrochanteric Corrective Osteotomy.- 6.2 Supracondylar Corrective Osteotomy.- 6.2.1 Correction in Cases of Valgus Deformity.- 6.2.2 Correction in Cases of Varus Deformity.- 7 Summary.- VI. Summary of Part I (General Aspects).- II: Specific Problems and Case Material.- I. Evaluation of Case Material.- 1 Methods.- 2 Characteristics of Case Material.- 2.1 Sex.- 2.2 Age.- 2.3 Etiology.- 3 Types of Operation.- 3.1 Postoperative Course.- 3.1.1 Duration of Hospital Stay.- 3.1.2 Postoperative Cast Fixation.- 3.2 Intraoperative and Postoperative Complications.- 3.2.1 General Complications.- 3.2.2 Local Complications.- 3.2.3 Localised Operative Failures.- a) Pseudarthrosis.- b) Malposition.- c) Difference in Leg Length.- d) Nerve Damage.- e) Fatigue Fractures.- 3.3 Sociomedical Problems.- 3.3.1 Postoperative Fitness for Work.- 3.3.2 Disability.- 3.3.3 Independence of Patients with Hip Arthrodeses.- 3.4 Effect of Arthrodesis on the Contralateral Hip.- 3.5 Hip Arthrodesis and Back Complaints.- 3.6 Subjective Results.- II. Classification of Hip Arthrodeses by Indication.- 1 Hip Arthrodeses for Arthrosis of the Hip and Rheumatoid Arthritis.- 1.1 Arthrosis of the Hip.- 1.1.1 Introduction.- 1.1.2 Case Material.- 1.2 Rheumatoid Arthritis.- 1.2.1 Introduction.- 1.2.2 Case Material.- 2 Hip Arthrodeses in Cases of Hip Dysplasia.- 2.1 Introduction.- 2.2 Hip Arthrodeses for High Congenital Dislocation of the Hip.- 2.2.1 Increasing Leg Length by Hip Arthrodesis.- 2.2.2 Hip Arthrodesis for Arthrosis of the Secondary Acetabulum.- a) Hip Arthrodesis Following Angulation Osteotomy.- b) Hip Arthrodesis in the Presence of High Dislocation with Formation of a New Joint.- 2.3 Hip Arthrodeses for Varus Hip.- 3 Hip Arthrodeses for Post-traumatic Hip Disease.- 3.1 Introduction.- 3.2 Subsequent to Fractures of the Femoral Head.- 3.3 Posttraumatic Necrosis of the Femoral Head.- 3.4 Dislocation of the Hip with or without Fracture of the Acetabular Roof.- 3.5 Pelvic Fractures with Central Dislocation of the Hip.- 3.5.1 Case Material.- 3.6 Summary.- 4 Arthrodesis of Infected Hips.- 4.1 Introduction.- 4.2 Tuberculosis of the Hip.- 4.2.1 General Guide Lines.- 4.2.2 Case Material.- 4.3 Nontuberculitic Infections.- 4.3.1 Introduction.- 4.3.2 Case Material.- 5 Hip Arthrodesis for Necrosis of the Femoral Head.- 5.1 Introduction.- 5.2 Idiopathic Head Necrosis.- 5.2.1 Head Necrosis Alone.- 5.2.2 Head Necrosis with Subluxation of the Femoral Head.- 5.3 Femoral Head Necroses Subsequent to Orthopedic Operations.- 5.4 Post-traumatic Necrosis of the Head of the Femur.- 5.4.1 United Fracture.- 5.4.2 Pseudarthrosis Following Femoral Neck Fracture.- 5.4.3 Hip Arthrodesis as a Result of Inadequate or Incorrect Operative Technique.- 6 Hip Arthrodeses in Girdlestone Hip and Similar Conditions.- 6.1 Introduction.- 6.2 Girdlestone Hips.- 6.2.1 Subsequent to Prosthetic Replacement.- 6.2.2 Girdlestone Hip without Infection.- 6.2.3 Girdlestone Hip Following Clinically Eradicated Infection.- 6.3 Girdlestone-Hip-Like Conditions.- III. Hip Arthrodesis and Total Prosthesis.- 1 Introduction.- 2 Hip Arthrodesis Combined with Total Prosthesis on the Opposite Side.- 2.1 Statement of Problem.- 2.2 Case Material.- 2.3 Results.- 2.4 Case Material.- 3 Total Prosthesis Following Hip Arthrodesis.- 3.1 Introduction.- 3.2 Statement of Problem.- 3.2.1 Changes in the Musculature Following Hip Arthrodesis.- 3.2.2 Technical Difficulties at Operation.- 3.3 Indications.- 3.4 Case Material.- 3.5 Results.- 3.6 Case Material.- 4 Hip Arthrodesis Following Total Prosthesis.- 4.1 Introduction.- 4.2 Statement of Problem.- 4.2.1 Hip Arthrodesis Following Partial Prosthetic Replacement.- 4.2.2 Hip Arthrodesis Following Total Prosthesis.- 5 Summary.- IV. Complications.- 1 Introduction.- 2 Pseudarthrosis.- 2.1 Noninfected Pseudarthrosis.- 2.1.1 Stabilisation of the Pseudoarthrosis.- a) Compression Internal Fixation.- b) Bone Grafting.- 2.2 Infected Pseudoarthrosis.- 3 Malposition.- 4 Infections.- 4.1 Hematoma Considered as Potential Infection.- 4.2 Fresh Postoperative Infections.- 4.3 Quiescent Infection.- 5 Fatigue Fractures.- 5.1 Femoral Diaphyseal Fractures.- 5.1.1 Mechanism of Fatigue Fracture.- 5.1.2 Visualisation of Tension Lines Using Polarised Light.- 5.2 Femoral Neck fracture.- 5.3 Fractures Following Trauma.- 6 Dislocation of the Symphysis.- 7 Summary.- V. Summary of Part II (Specific Problems and Case Material).- References.