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    ICJR CASES: Current Controversies in Total Hip Arthroplasty

    Total hip arthroplasty may have been dubbed the “operation of the century” by The Lancet, [1] but there are times that it is anything but a straightforward procedure.

    At Essential Hip Topics: Cradle to Grave, a collaboration of ICJR and the Mid-America Orthopaedic Association (MAOA), moderator Ronald E. Delanois, MD, challenged a panel of experienced joint replacement surgeons to review the radiographs, history, and physical examination findings for 6 difficult cases and share their thoughts on how they would manage these patients.

    RELATED: Insights on Challenging Total Hip Arthroplasty Cases

    The panel members for this discussion were Robert T. Trousdale, MD; Trevor G. Murray, MD; Ryan M. Nunley, MD; Michael A. Charters, MD; James A. Keeney, MD; and Carlos A. Higuera, MD. Here are the cases they considered:

    Case 1

    • 47-year-old female patient with chronic left hip pain
    • History of hip dysplasia with multiple surgeries on the left hip
    • Left open hip reduction in 1971 and 1972
    • Left femoral rotational osteotomy in 1972
    • Acetabuloplasty in 1973
    • Chiari osteotomy in 19878
    • Some pelvic obliquity
    • Does not use a shoe lift

    Case 2

    • 88-year-old male patient with increasing right hip/groin pain
    • Right total hip arthroplasty in 1991
    • Had stepped out of the shower the prior week and felt a “pop,” precipitating pain
    • Unable to ambulate
    • On examination, pain with range of motion of the left hip
    • Neurovascularly intact
    • Past surgical history significant for cardiac procedures, including triple coronary artery bypass graft surgery

    Case 3

    • 80-year-old male with elevated chromium and cobalt levels and deep, lateral pain in the left hip and buttocks
    • Left total hip arthroplasty performed in 2010
    • Multiple hip bursa injections for pain; no improvement
    • Antalgic gait and Trendelenburg to the left
    • Soft mass in the left hip
    • Left hip flexion 90°, full extension, internal rotation 5°, external rotation 10°, abduction 25°, adduction 10°
    • Pain with resisted abduction and flexion of the left hip
    • Negative straight leg raise, distal sensation intact to light touch, 2+ pulses

    Case 4

    • 83-year-old female patient with left hip pain from a fall
    • In the hospital for 29 days after the fall with hypertension urgency, urinary tract infection, and newly diagnosed dementia
    • Left total hip arthroplasty in 2007
    • Cannot bear weight since the fall
    • Does not want to use a walker

    Case 5

    • 70-year-old female patient
    • Left total hip arthroplasty in early 2018
    • Left hip pain since falling from a standing height
    • Cannot bear weight since the fall

    Case 6

    • 62-year-old male patient with left hip pain
    • Pelvic, femoral, and humeral fractures sustained in a motor vehicle accident at age 23
    • Failed open reduction and internal fixation of the femur fracture converted to total hip arthroplasty 1 year later
    • First revision for implant loosening 10 years later; second revision in 1999
    • Unbearable left groin/lateral hip pain for past 6 months
    • Severe limp with leg length discrepancy; right leg longer than left leg
    • Painful left hip motion on examination
    • FADIR, FABER, and resisted straight leg raise reproduce groin pain

    Click the image above to hear what the distinguished panel for this session had to say about these cases.

    Reference

    1. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007 Oct 27;370(9597):1508-19.