Complications of Uncemented Total Hip Arthroplasty: Success

Figure 21.1

Anteroposterior radiograph of the left hip before the core decompression. There is good articular space and no evidence of collapse of the femoral head

Figure 21.2

Lateral radiograph of the left hip before the core decompression. There is good articular space and no indication of femoral head collapse

Management

The patient underwent bilateral core decompression in June 1994. An 11 mm drill was inserted in to the lesion under fluoroscopy, followed by partial coring of the lesion with a curette which was then taken through the same incision. Postoperatively, the patient was wheelchair bound and allowed only bathroom transfers for 6 weeks with advanced weight bearing over the following 4 weeks. Pathology confirmed the diagnosis of osteonecrosis in both femoral heads.

Outcome Bilateral Core Decompression

The patient recovered from both procedures uneventfully. At 3 months postoperatively, she complained only of slight pain in the right hip while the left hip was pain free. Thereafter, she started full weight bearing as tolerated. Approximately 5 months after the procedures, she started dancing and complained thereafter of severe pain in the right hip. The patient was promptly evaluated and found to have collapse with subchondral fracture of the femoral head in the right hip (Fig. 21.3).

Figure 21.3

Anteroposterior radiograph of the right hip after the core decompression demonstrating collapse of the femoral head and a subchondral fracture

She was placed on crutches with significant improvement of her pain, to the point that after 2 weeks they pain resolved. Then, weight bearing was restarted as tolerated up to full weight bearing. For several years, the patient complained only intermittently from pain in the right hip (moderate at most) but overall she did well and lived a completely normal life; including dancing. Nine years after the core decompressions, she remained pain free with a normal gait and flexion of 120° in both hips. Internal rotation on the right side was 10° and 40° on the left side. Thirteen years after both procedures, the patient was happy with the results and only had mild periodic pain without need for pain medications. Twenty years after the bilateral core decompression, in 2014, the patient complained of pain in the right hip; this pain was progressively worse for the last 6 years. The pain in the right hip was worsened by standing and by long periods of activity, and it was improved by walking. There were no flexion contractures bilaterally. Flexion was 90° on the right side and 100° on the left, internal rotation was 0° (right) and 35° (left), external rotation was 30° (right) and 45° (left), abduction was 20° (right) and 45° (left), and adduction was 10° on the right side and 45° on the left hip. The right hip radiographs demonstrated complete collapse of the femoral head, joint space was bone on bone, subchondral sclerosis on both the femur and acetabular side, and clear femoral head deformity from previous collapse (Figs. 21.4 and 21.5). The patient decided 20 years after the core decompression to finally undergo a right total hip arthroplasty.

Figure 21.4

Anteroposterior radiograph of the pelvis demonstrating collapse of the femoral head and arthrosis of the right hip 20 years after the core decompression. The left hip shows no signs of collapse, and it also shows good preservation of the articular space (20 years after the core decompression)

Figure 21.5

Lateral radiograph of the right hip demonstrating loss of articular space 20 years after the core decompression

Outcome

Postoperatively, the patient evolved uneventfully. Six months after surgery, she was able to walk without limitations and to go up the stairs normally holding to the rail. She is currently satisfied with the surgery and performs her routine daily life activities successfully and without any limitations (Figs. 21.6 and 21.7).