Figure 19.1
Preoperative radiographs showing no acetabular involvement
Management
After consultation, the patient was counseled that it would be best to proceed with a nonvascularized bone grafting as he preferred to delay THA by all means possible. Informed consent was obtained after discussing the risks and benefits of the planned procedures prior to surgery, including the risk of converting to a THA. Although the patient was aware that we would proceed bone grafting, she communicated that we may have to convert to a THA if we saw damage to the articular cartilage or signs of collapse not otherwise seen.
Bone Grafting
A 15-cm incision was made through an anterolateral approach, deepened it down through the skin and subcutaneous tissue and through the fascia lata. We took off the anterior 40% of the gluteus medius and minimus. We did a capsulectomy. When exposing the hip joint, we noticed there was significant degeneration of the femoral head with damage to the articular cartilage (see Fig. 19.2). At this time, we deemed grafting to be an insufficient treatment and elected to convert to a total hip replacement.
Figure 19.2
(a–d) Intraoperative examination of the right hip showing damage to the intra-articular cartilage
Total Hip Arthroplasty
We reamed the acetabulum and placed it in a press-fit construct. We took off the peripheral osteophytes and put in a neutral polyethylene liner. We then prepared the stem with the appropriate-sized stem and head combination. We achieved excellent stability and excellent leg length.
After careful irrigation, closure of the muscles, subcutaneous tissue, and skin was performed, and a sterile dressing was applied. The patient was then taken to the recovery room in stable condition.
Outcome
At her 14-week follow-up, she was pain-free and performing all her daily activities without difficulty. Radiographic evaluation showed a well-placed arthroplasty without evidence of osteolysis or loosening (See Fig. 19.3). On physical exam, the patient had minimal peri-incisional tenderness. She had five out of five muscular strengths and was neurovascularly intact at the lower extremities. The outcomes of THA in patients with ON are shown in Table 19.1.
Figure 19.3
Postoperative radiographs showing a well-placed implant with no signs of loosening or fracture
Table 19.1
Outcomes of THA in patients with osteonecrosis
Author, year | Case cohort | Cement vs. cementless | Number of cases | Number of controls | Mean follow-up, months (range) | Case mean HHS, points | Control mean HHS, points | Case implant survivorship, % | Control implant survivorship, % |
|---|---|---|---|---|---|---|---|---|---|
Graham et al. (2014) [1] | HIV | Cement | 43 | – | 42 (5–98) | 86 | – | 100 | – |
Issa et al. (2013) [2] | HIV | Cementless | 44 | 78 | 84 (48–132) | 85 | 87 | 95 | 96.5
Related posts: Systemic Lupus Erythematosus Patient Requiring THA
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 Complications of Uncemented Total Hip Arthroplasty: Success
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