Rule out infection. If not there THA can only solve his problem

Dear Nitin Sunku,

The radiograph shows significant arthritis, joint destruction and protrusio acetabuli. I agree with Dr Raju Vaishya that total hip arthroplasty with lateralization of the cup to a normal position is likely to provide a predictable long-term solution.

regards

First choice should be THA. If infection is present then you should consider debridement and arthrodesis. In fact, in the past arthrodesis was preferred in similar young patients, especially those engaged with heavy physical work.

No doubt for THA

This case is elective for THA. As it's a post-traumatic arthrosis , once infection is ruled out, it's recommended  during the surgical approach to have the options for posterior wall reconstruction,  as bone graft and or trabecular augmentation. 

Good luck ,

Please send us the post op.  Images

Is it possible to have a CT scan of the Hip for better pre op. evaluation of this very interesting case?

I completely agree that further investigations would be necessary that only a plain film. It is mentioned that CT is done but there are no other images visible and looks like that no other investigations are done. I apologise if I am missing something. From the history it would be a good idea to find out what triggered the recent pain. Was it a mechanical strain or followed after a generalised illness? As it is not known the cause of his recent symptoms it would be a possibility for somebody to ask the question; do we need to do something? In the case that we answer this in such a way that indicates that; Yes we need to do something, then further things have to be answered. Infection has to be ruled out. Quality of bone has to be assessed. Also would be better to know what the patient wants to achieve and what is his occupation. Manual worker, for example, who will carry on digging trenches would be better with arthrodesis. A person on the other hand, who would be able to look after his condition because he is working in a shop/office could be advised to have a total hip with a complex augmentation at the acetabular part. I am sorry that I have not given to you a direction to one and only solution. I would be very much interested to see the outcome.

Most thinks are mentioned yet. I also agree that only THA can help. First Infection should be ruled out. A CT is needed to find out how the cup can be stabilized. It is a young patient so we have to consider further operations. Another problem may be the shortening of the leg. May be a first step can be osteotomy and extension to provide nerve palsy. Make sure that there is no infection and in a second step THA.

This patient should have a THA. The pelvis is caved in and the protrusio will cause the most problems because of offset in addition to shortening. I would use a cup-in-cup technique. A large trabecular metal cup deep and cement a second cup on top of the first cup. With computer navigation it is possible to place the second cup near the proper position despite the deformity. It is unlikely that one can safely restore all of the length during the first operation. I would use a modular revision stem so that when the soft tissues stretch out over the following 6month or year that one can go back and get the length safely.

A very interesting and challenging case. I would agree with most comments about THA assuming no infection. As Dr. Long has stated the protrusio is a significant problem. One should be as prepared as possible. I would suggest scans and having a model made prior to surgery for evaluation. You certainly do not want to be surprised during the case. Possible acetabular custom implants might make this reconstruction easier. Newer technology and 3_D printing are helpful. I would also have deep profile shells (+6mm) and lateral inserts along with Dual-mobility style available.

I also agree with Dr. Long on the use of modularity on the femoral side. Most of my experience is in the S-Rom Modular Stem which has stood the test of time and offers great flexibility in treating femoral offset and femoral version problems. However today there are a number of very good modular revision stems available. I have attached a couple of references.

Article Bilobed Oblong Porous Coated Acetabular Components in Revisi...

Conference Paper difiiicult-hip-replacement-surgery

Conference Paper REVISING THE DEFICIENT PROXIMAL FEMUR

Article Are Custom Triflange Acetabular Components Effective for Rec...

Article Can Dual Mobility Cups prevent Dislocation in All Situations...

Article Dual mobility acetabular components for revision THA

i agree with our professors that this patient candidate for THA but i think that cementless THR IS better and use the femoral head as a graft  for reconstruction of the acetabulum

Total Hip Arthroplasty associated with anti protusio cage Burch-Schneider 

There is no question that take down and conversion to THA is the procedure of choice. The femoral side is pretty straight forward with the exception of fine-tuning joint mechanics (leg length, femoral offset, and version orientation ).Excessive leg lengthening (greater than 2-3 cm) should be avoided to prevent sciatic nerve palsy. More than likely the patient will be left with deficient hip abductors muscles. After reconstruction of the socket I would consider a Dual-Mobility style acetabulum component and place the patient into a brace for 6-8 weeks post-op.

Reconstruction of the acetabulum is the challenge. It is important that the patient understand if his hip is functioning however painful there is a risk of his hip becoming  a nonfunctional unstable hip. Often these conversions go on to additional surgery as a result of hip instability.

Today there are a number of devices available to aid reconstruction of the acetabulum. The choice is left up to the experience and device selection of the surgeon. Doing a pre-operative scan and having a 3-D model available for review can reduce intra-operative complications. The key is having as many options available as possible. My stem of choice would be an S-Rom so you have some flexibility of version correction and cup would be a Dual-Mobility style with features for adjunct fixation.

Long-term results can provide improvements in patients symptoms and satisfaction however patient should be prepared for the real possibility of  the need for ambulatory support and a higher risk of acetabular loosening when compared to primary THA.

Good Luck

Tim