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Painful Blinded Cup Arthroplasty in 61M with DDH
HPI
A 61-year-old male, married office worker presents with LEFT hip pain and leg length discrepancy. He has a history of left hip DDH treated as a child with hip spica casting. He underwent left femoral derotational osteotomy in 1969, which was complicated by S. aureus infection treated with I&D. He then had cup arthroplasty of the left hip in 1974, and left femoral lengthening in 2000. He did quite well with his left hip until ~ 2-3 years of progressively worsening pain and now wears a 1.5-inch (3.8 cm) shoe lift on his left. A comprehensive workup for infection was performed. Labs include an ESR of 2 and CRP of 3.2. Left hip aspiration revealed 260 WBC with 60% PMN, Negative Alpha defensin, and Cultures with NGTD at 21 days.
PMH
Past Medical History: Non-smoker, DDH-left, Hyperthyroidism, IBS, GERD, L distal femur chondrosarcoma Past Surgical History 1. s/p DFR, 2018 for L distal femur chondrosarcoma 2. L rev TKA for tibial component loosening 07/2020 3. Left hip resurfacing, derotational osteotomy, lengthening, RTHA, RTKA Allergies: Hydrocodone, Seasonal
PE
Positive Stinchfield’s test. Pain with log rolling of the left hip. Limited ROM. NVI. Left lower extremity is 5cm shorter than right.
1.
In addition to plain AP and LAT radiographs of the affected hip, would you obtain any further imaging to guide your treatment?
No - Current radiographs are sufficient
7%
22/296
Yes - additional x-ray views (aXR)
2%
8/296
Yes - CT pelvis (CT)
57%
171/296
Yes - MRI hip, metal subtracting (MRI)
7%
21/296
Yes- Bone scan
2%
6/296
Yes - aXR + CT
10%
31/296
Yes - aXR + MRI
0%
0/296
Yes - CT + MRI
3%
9/296
Yes - aXR + CT + MRI
1%
5/296
Yes - aXR + CT + MRI + Bone
2%
7/296
Outside my area of expertise - best if I don't vote
5%
16/296
2.
In addition to a clinical exam and preoperative labs (WBC, ESR, CRP), what additional studies would you get to rule out infection?
None - Clinical exam and preoperative labs (WBC, ESR, CRP) are sufficient
15%
43/275
Preoperative Aspiration Alone
19%
54/275
Arthroscopic Biopsy with Cultures (before Arthroplasty) Alone
3%
10/275
Intraoperative Studies (Cultures, Frozen Section) Alone
14%
40/275
Aspiration + Arthroscopic Biopsy
1%
5/275
Aspiration + Intraoperative Studies
34%
94/275
Arthroscopic Biopsy + Intraoperative Studies
1%
5/275
Aspiration + Arthroscopic Biopsy + Intraoperative Studies
3%
10/275
Outside my area of expertise - best if I don't vote
5%
14/275
3.
If you obtained an aspirate to rule out infection, either through needle aspiration or arthroscopic or open biopsy, would you send the sample for commercial molecular workup (DNA, RNA, Alpha Defensin) to rule out infection?
I would not obtain an aspirate to rule out infection.
6%
18/263
No - I would not send for commercial molecular workup (DNA, RNA) to rule out infection?
31%
84/263
Yes - Alpha Defensin Lateral Flow Test (Synovasure®)
40%
106/263
Yes - DNA PCR (MicroGenDX OrthoKEY PJI)
8%
22/263
Yes - Other Commercial Molecular Biology Test
2%
6/263
Yes - Synovasure® + MicroGenDX®
0%
0/263
Outside my area of expertise - best if I don't vote
10%
27/263
4.
If you choose Operative Treatment, what type of treatment would you perform?
I would not choose Operative management
0%
1/262
Revision Hip Resurfacing
1%
3/262
Conversion to Total Hip Arthroplasty (THA)
89%
235/262
Hip Arthroscopy
0%
1/262
Hip Arthrodesis
2%
6/262
Other
1%
3/262
Outside my area of expertise - best if I don't vote
4%
13/262
5.
If you choose to Convert to Total Hip Arthroplasty (THA), what components would you revise?
I would not choose to Convert to THA
2%
7/262
Revise Both Femoral and Acetabular Components
89%
234/262
Revise Femoral Component Only
3%
9/262
Revise Acetabular Component Only
0%
1/262
Outside my area of expertise - best if I don't vote
4%
11/262
6.
If you choose Conversion to Total Hip Arthroplasty (THA) and to revise both components, which approach would you use?
I would not choose conversion to THA
1%
4/259
Posterior (Posterolateral)
59%
155/259
Direct Lateral
17%
45/259
Anterolateral
11%
31/259
Direct Anterior
3%
10/259
Other
0%
1/259
Outside my area of expertise - best if I don't vote
5%
13/259
7.
If you choose Revision arthroplasty of the acetabular component, what reconstructive technique would you utilize?
I would not choose Revision Arthroplasty of the acetabular component only
3%
9/257
Large Hemispherical Cup with Screws +/- Augments
42%
108/257
Cup with Segmental Allograft
7%
19/257
Cage
1%
3/257
Cup + Cage +/- Augments
29%
77/257
Distraction Techniques with Augments
0%
1/257
Custom Triflange
7%
18/257
Outside my area of expertise - best if I don't vote e
8%
22/257
8.
If you choose Conversion to Total Hip Arthroplasty (THA) and to revise both components, would you cement your components?
I would not choose Revision Arthroplasty to THA
1%
4/254
No - I would Not cement either component
53%
136/254
Yes - Cement Femur Alone
22%
58/254
Yes - Cement Acetabulum Alone
4%
11/254
Yes - Cement Femur & Acetabulum
10%
27/254
Outside my area of expertise - best if I don't vote
7%
18/254
9.
If you choose Conversion to THA, what would be your goal to address his leg length discrepancy that currently requires a shoe lift?
I would not choose Conversion to THA
1%
3/253
Keep current length so patient remains 1.5 inch (3.8 inch) short
5%
13/253
Fix 100% of LLD so both legs equal length
20%
53/253
Lengthen by 0.5 inches (1.3 cm) leaving him 1 inch (2.5 cm) short
15%
40/253
Lengthen by 1 inch (2.5 cm) leaving him 0.5 inches (1.3 cm) short
50%
129/253
Outside my area of expertise - best if I don't vote
5%
15/253
10.
If you choose Conversion to Total Hip Arthroplasty (THA) and revise both components, what is your choice for the new bearing surface?
I would not choose Revision arthroplasty
1%
3/251
Metal head on Poly Cup
11%
30/251
Ceramic head on Poly Cup
46%
116/251
Metal Head on Metal Cup
0%
0/251
Ceramic Head on Ceramic Cup
4%
12/251
Dual Mobility (Poly head on Metal Cup)
29%
75/251
Outside my area of expertise - best if I don't vote
5%
15/251
11.
If you choose Conversion to Total Hip Arthroplasty (THA) and revise both components, what is your choice for the new bearing type and level of constraint?
I would not choose Conversion to Total Hip Arthroplasty (THA) and revise both components
2%
5/250
Standard Bearing
30%
75/250
Dual Mobility Bearing
54%
137/250
Constrained Liner
7%
19/250
Outside my area of expertise - best if I don't vote
5%
14/250
12.
If you choose Conversion to Total Hip Arthroplasty (THA) and to revise both components, what technology would you use to optimize the position of the components?
I would not choose conversion to THA
1%
4/250
None - Direct Visualization Alone
39%
99/250
Fluoroscopy (Fluoro) Alone
29%
74/250
Computer Assisted Navigation Alone (Nav)
3%
8/250
Robot-Assisted Navigation (Robot)
6%
15/250
Fluoro + Nav
7%
18/250
Fluoro + Robot
4%
12/250
Other Technology
1%
4/250
Outside my area of expertise - best if I don't vote
6%
16/250
13.
If you choose Conversion to THA with Computer Assisted Navigation Alone (Nav) or Robotics, what type would you use?
I would not choose Conversion to THA
2%
6/256
I would not use Computer Assisted Navigation Alone (Nav) or Robotics
47%
121/256
Imageless Computer Assisted Navigation (e.g., Naviswiss)
5%
13/256
Imageless Robotics (e.g., Rosa)
0%
2/256
Preop CT-Based Robotics (e.g., Mako)
20%
53/256
Fluoro-based Computer Assisted Navigation
7%
18/256
Other
3%
9/256
Outside of my area of expertise - best if I don't vote
13%
34/256
PROCEDURE #1
DOP: 5/3/2023
Conversion to hybrid total hip arthroplasty. Lower center of rotation closer to native acetabulum and use highly porous hemispherical cup, bone graft vs. superior augments if needed. Cemented stem for Dorr C bone and to control version, length, and offset
Intra-procedure P1
OUTCOMES
Post-procedure P1