Arthrodesis and Resection Arthroplasty of the Hip

Key Points

Indications for arthrodesis of the hip include young active patients with arthritis in whom other forms of reconstruction will likely fail at an unacceptably high rate.
Surgical technique greatly influences outcome; sparing the abductor mechanism is key for later reconstruction.
The optimal position for hip fusion is 20 to 30 degrees of flexion, 5 to 7 degrees of adduction, and 5 to 10 degrees of external rotation, with shortening kept to a minimum.
Modern techniques quote a 78% to 83% fusion rate.
Conversion to total hip arthroplasty (THA) can have a favorable outcome, but rates of aseptic loosening, heterotopic ossification, and limp are higher than for primary THA.
Although rarely a primary indication, resection arthroplasty maintains its importance.
Modern resection preserves the femoral neck to preserve length for possible future reconstruction.
Resection with a capsular arthroplasty can be useful for young patients with developmental dysplasia of the hip.
Resection is a powerful treatment for infection about the hip joint.
The main goals are to relieve pain, restore some function, and eradicate infection.

Arthrodesis

Operative arthrodesis of the hip is defined by any method that effectively fuses the ilium and the proximal femur, eliminating the hip joint and its motion. Thus, arthrosis of the hip joint and accompanying pain are eliminated.

Hip arthrodesis was a commonly performed procedure in the United States up until other forms of motion-sparing, pain-relieving reconstruction became available. With the advent of hip arthroplasty, and the increasing durability and success rate of the procedure, with each decade the number of hip arthrodeses decreases. Unfortunately for some young patients, the durability of current components of total hip arthroplasty (THA) cannot compete with patients’ lifestyles, which often leads to revision. The success of modern components in patients younger than 50 years of age has been reported to be 87% at 10 years for uncemented Harris-Galante acetabular components, 95% at 7 years for Exeter cemented femoral components, and 90% for an uncemented grit-blasted, straight-tapered titanium femoral stem at 20 years. A recent review of patients less than 30 years old at the time of index THA demonstrates an overall revision rate of 18% at 10 years. Long-term results are expected to improve even further with improving bearing surfaces. Nevertheless, even with exceedingly favorable results, many patients younger than 50 years will need at least one revision THA in their lifetime.

Preoperative discussion with patients with end-stage arthrosis of the hip younger than 40 years must include discussions of the pros and cons of salvage procedures such as arthrodesis. Although surgeons’ enthusiasm for the procedure and patients’ acceptance of fusion may be low, hip arthrodesis may be an important consideration in a select patient population with end-stage arthrosis of the hip. A properly positioned fused hip joint can offer long-term pain relief and good function. Discussions between patient and physician with the patient's best interest in mind, combined with quality data, will continue to direct decision making.

Historical Perspective

In the United States in 1908, F. H. Albee first discussed arthrodesis of the hip for advanced arthrosis in 5 patients. Indications for the procedure in early reports included tuberculous hips in younger patients and unilateral osteoarthritis (OA) in older patients. Arthrodesis was first used for old congenital dislocation by Heusner, Lampugnani, and Albert as early as 1885, according to Nové-Josserand. In the early 1900s, many methods of extraarticular arthrodesis were described. Ghormley, in 1931, and Henderson, in 1933, described their techniques of arthrodesis, used chiefly in tuberculous hips.

Trumble, in 1932, and Brittain, in 1941, described techniques for ischiofemoral arthrodesis. Brittain's method of arthrodesis involved making a subtrochanteric osteotomy with special chisels and placing an autograft strut from the subtrochanteric osteotomy into the ischium. Patients were kept in plaster cast immobilization for 4 months postoperatively.

In 1938, Watson-Jones advocated internal fixation of the femoral head to the pelvis by a long Smith-Petersen nail. This technique was later refined and described in combination with iliac grafting. Watson-Jones reported in 1956 an incidence of 94% sound bone fusion in 120 patients who had arthrodesis of the hip for OA who had been observed for a minimum of 5 years. Immobilization in a double hip spica for at least 4 months was considered essential by these authors. Lange reported the largest series (500 patients) of the technique with 85% perfect results.

Thompson and Cholmeley, both in 1956, advocated routine subtrochanteric osteotomy for all patients having arthrodesis of the hip. Both Thompson and Cholmeley concluded that success occurred more frequently when the grafting operation was combined with or followed by osteotomy. Thompson noted a 90% rate of union in those patients having combined hip fusion and osteotomy against a prior 26% rate of union in patients in whom fusion was attempted without osteotomy for OA.

Charnley, in 1953, advocated central dislocation of the femoral head into a reamed acetabulum with or without any fixation and subsequently reported excellent or good results in 88% of 105 patients treated by this method. Even though many of his patients obtained a fibrous union, they were included in the 88% good results. Schneider applied the concepts of Charnley's arthrodesis and added the Cobra-headed plate arthrodesis.

These reports and others had relatively short follow-up and focused on fusion rates with different intraarticular and extraarticular techniques with and without internal fixation. Many reports required prolonged immobilization in a plaster cast for 6 weeks to 4 months to achieve fusion.

Callaghan and Sponseller were some of the first to report the long-term outcomes of patients with arthrodesis of the hip. Sponseller cited that 78% of patients were satisfied with the arthrodesis, and all were able to work; 57% had some low back pain, and 45% had knee discomfort. Only 13% had undergone THA on the arthrodesed hip. Callaghan retrospectively reviewed 28 patients with an average follow-up of 38 years after arthrodesis through various techniques. About 60% of patients had pain in the ipsilateral knee, with onset 23 years after arthrodesis, on average. Back pain was similar, with an average onset of 25 years after arthrodesis. Of these patients, 70% could walk farther than 1 mile. Based on their results, investigators believed that the optimal position for fusion was in approximately 5 degrees of adduction and 35 to 40 degrees of flexion. The authors concluded that a patient with an arthrodesis of the hip could function at a high level for many years and would be able to work at most occupations. Pain in the back and knee was a common sequela, especially at long-term follow-up. However, symptoms usually were not incapacitating and patients generally experienced their onset many years after the arthrodesis.

Indications/Contraindications

Indications

Monoarticular hip OA, especially in a very young, high-demand patient
History of unilateral septic arthritis of the hip with end-stage arthritis
Salvage of prior surgery (e.g., osteotomy)
Patients with contraindications to THA with end-stage disease
Muscular or neurologic deficiencies about the hip in the setting of end-stage arthrosis

Contraindications

Polyarticular arthritis
Rheumatoid arthritis
Active infection
Bilateral hip disease or dysplasia
Spondylosis
Radiographic knee arthritis
Knee instability
Notable concomitant spine pathology

Only after appropriate exhaustion of nonsurgical modalities—such as activity modification, antiinflammatories, and the use of assistive devices—should an operative salvage procedure such as fusion be entertained. A strong indication for arthrodesis of the hip is a young patient (generally defined as > 40 years of age) who is healthy with high demands (such as a heavy laborer) and end-stage monoarticular OA of the hip. Patients with neurologic or muscular abnormalities that would compromise the function of the abductor musculature after THA may also be better suited for arthrodesis.

Strong contraindications for arthrodesis of the hip include active infection, inflammatory arthritis such as rheumatoid arthritis or systemic lupus erythematosus, older patients with OA that can be managed with THA, and those with bilateral hip disease. Radiographs of the patient's lumbar spine, contralateral hip, and bilateral knees should be obtained. Although early changes in back and knee arthritis are not an absolute contraindication, various authors have reported poorer results, with spondylosis, gonarthrosis, and knee instability.

Other relative contraindications include patients who are not able to comply with postoperative rehabilitation and limited weight bearing, especially the obese. The patient's lifestyle must be taken into consideration. Those with a job or a desire for activity (such as climbing), sitting for long periods of time, and repetitive stooping or squatting may not be best served by arthrodesis. The patient's overall psychological condition should be assessed for tolerance of the procedure and rehabilitation.

Preoperative Planning

An important component of the preoperative plan is a precise and careful discussion of the options and expected functional outcome of the arthrodesis. The physician–patient relationship is very important in this situation for a positive outcome. Patients should be counseled that although the motion of the hip joint will be obliterated, they will be allowed to resume all activities. The reality of the salvage situation must be conveyed to enable the patient to have realistic and appropriate expectations after the procedure.

To help define the bony anatomy and any bony deformities that may be encountered at arthrodesis, enhanced radiographic evaluation is indicated. Routine standing anteroposterior (AP) pelvis, Judet, and AP and cross-table lateral views of the femur should be obtained. These films will allow the surgeon to assess leg length discrepancy, offset, rotation, and angular deformity. Additionally, the acetabular bone stock and points of fixation can be more readily assessed with Judet films. If the pelvic anatomy or bone deficiency is more complex, preoperative 3-dimensional computed tomography (CT) reconstructions of the pelvis and proximal femur may assist the surgeon in proper positioning and fixation of the arthrodesis.

Routine preoperative laboratory tests should be obtained. However, in addition, erythrocyte sedimentation rate, C-reactive protein, and complete blood count with differential are advised in patients with a history of infection. If any of these tests are abnormal, preoperative hip joint aspiration with cell count and culture will help rule out chronic infection. Patients with remote histories of inflammatory disease may have to be evaluated by a rheumatologist and may need to be reconsidered for fusion if active inflammatory disease is present.

Description of Technique(s)

Positioning of the Hip Arthrodesis

Positioning of the arthrodesis has been developed as a position of the limb that best accommodates normal activities of daily living. Patients with unilateral hip fusion walk with a gait that is somewhat slow, asymmetric, and arrhythmic. Compensation for absent hip motion is accomplished by increased transverse and sagittal rotation of the pelvis, increased motion in the sound hip, and increased flexion of the knee throughout the stance phase on the fused side. Positioning can have a large effect on the durability of the fusion and the joints adjacent to it. The optimal position of hip fusion is 5 to 7 degrees of adduction, 20 to 30 degrees of hip flexion, and 5 to 10 degrees of external rotation. Limb shortening is kept to a minimum. Gore and associates stated, “Relationships between the fusion position, certain physical traits, and walking performance suggest that the best gait can be expected in young patients who have free motion of the lumbar spine, the sound hip, and the knee on the side of fusion, and who have equal limb lengths and a hip fused in a position that includes excessive adduction.” It is important to note that Fulkerson found that in children with long-term follow-up, the fused hip can drift into excessive adduction over time. In these patients, it is advisable to fuse in neutral adduction. Activities that require hip flexion are most problematic for patients, who find that sitting in tight spaces such as airplanes is difficult. Additionally, simple activities of daily living are troublesome, such as donning and doffing socks and bending. Some women may have difficulty with sexual activity. For the operation to have a high likelihood of success, the patient must be willing to accept the limitations of the procedure and the surgeon must position the fusion in the most functional and durable position.

Techniques

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