Musculoskelet Surg DOI 10.1007/s12306-014-0342-z
ORIGINAL ARTICLE
Clinical and radiological short-term complications after singlestage bilateral uncemented total hip arthroplasty J. Lamo-Espinosa • S. Troncoso • A. Valentı´-Azca´rate P. Dı´az de Rada • J. R. Valentı´-Nı´n
•
Received: 16 June 2014 / Accepted: 14 November 2014 Ó Istituto Ortopedico Rizzoli 2014
Abstract Purpose Economic crisis time gives to efficient procedures an important role in healthy system. Total hip replacement is a common bilateral orthopedic procedure, but there exists an important controversy to perform it in single or two stages. Our aim is to report our clinical and radiological short-term complications of bilateral uncemented total hip arthroplasty in a single time. Materials and methods We have retrospectively reviewed the patients treated between 2000 and 2011 in our center by bilateral uncemented total hip replacement in a single time. We have reviewed the medical history and analyzed by age, diagnosis and ASA parameters related to the procedure, hospital stay, transfusion requirements and clinical complications. Radiological evaluation was made with anteroposterior hip radiograph evaluation (acetabular radiolucencies and stem migration). Functional assessment was carried out by the Merle D’Aubigne´ score. Results Seventeen patients with mean age of 47.4 (18–68) years were reviewed with a mean follow-up of 44.3 (6–172) months. ASA distribution: 29.4 % grade I; 52.9 % grade II and 17.6 % grade III. Merle´ D’Aubigne´ score improved from 11.01 to 16.45. Hospital stay was 6 days. Transfusion requirements were two hematic concentrates for each patient. Two external popliteal sciatic
J. Lamo-Espinosa (&) S. Troncoso A. Valentı´-Azca´rate J. R. Valentı´-Nı´n Orthopedic Surgery and Traumatology Department, Clı´nica Universidad de Navarra, Av. Pio XII, 36, 31008 Pamplona, Navarra, Spain e-mail:
[email protected];
[email protected] P. Dı´az de Rada Orthopedic Surgery and Traumatology Department, Hospital Reina Sofı´a, Tudela, Navarra, Spain
nerve neurapraxias fully recovered at follow-up. Radiological results showed one case of axial migration. Conclusions With proper patient selection and multidisciplinary team, the bilateral uncemented total hip arthroplasty in a single time has low complication rates. Our results could be used in the development of future randomized controlled trials or prospective cohort studies. Level of evidence IV. Keywords Bilateral arthroplasty Bilateral total hip prosthesis Uncemented total hip prosthesis Bilateral coxarthrosis
Introduction In 1971, Jaffe and Charnley reported the first case of bilateral total hip arthroplasty at a single time in the same patient [1]. Since then, until today the controversy between supporters of single- or two-stage procedures has been increasing. Bilateral hip disease is an often situation which could predict the necessity of bilateral total hip arthroplasty in the future. It is estimated that 10 % of patients who were undergoing total hip arthroplasty [2], the following year, will require the same procedure in the contralateral hip and 20 % in the following 5 years. Coxarthrosis is the most common diagnosis of total hip arthroplasty being bilateral in 42 % of patients. Many of the coxofemoral diseases that can lead to secondary coxarthrosis and indication of total hip arthroplasty are bilateral and can be present from an early age leading to an early osteoarthritis before the 50 years of age. In this kind of patients, the need for a bilateral arthroplasty is probable. The supporters of a single time bilateral
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procedure assume a lower risk and efficiency than twostage procedure [3], but this is not universally accepted. Some authors report some advantage in bilateral total hip arthroplasty in a single time. Anesthesic time reduced hospitalization stay and consequently lowered cost [4–9]. The supporters of two-stage procedure report the risk in patients undergoing bilateral surgery at single time, which is twice more than the two-stage procedure [10]. They also describe improvements in contralateral hip after the first intervention [11], less transfusions requirements and less neurological complications. Today’s economic difficulties give more value to efficient procedure. A frequent procedure such as total hip replacement should not be excluded from that aim. In this sense, our goal was to report our clinical and radiological short-term results and complications of bilateral uncemented total hip arthroplasty in a single time.
Materials and methods We have retrospectively reviewed patients who underwent uncemented bilateral total hip arthroplasty in single time between 2000 and 2011 in our center. Our inclusion criteria were patients who underwent bilateral total hip arthroplasty in single stage between the time referred. We have excluded cemented, partial and resurfacing bilateral hip arthroplasty to obtain a uniform sample for valid results and conclusions. During this time, we have indicated the single time procedure to patients with less than ASA III or those ASA III with controlled chronic disease, normal hemoglobin values without blood dyscrasias or hematologic disease and capacity to understand the postoperative protocol. Although cutoff age was not proposed, these criteria lead to relatively young patients (under 60 years). All participants provided written informed conset. All the surgeries were done by the senior author (JRV). In all the cases, the same surgical technique was performed with a Watson Jones modified approach in supine position under general anesthesia. Antibiotic prophylaxis with cefazolin 2 g (repeated doses of 1 g every 3 h from the start) was done. A final postoperative dose is given at 8 h after the last procedure. Separate surgical fields and instrumental’s tables between hips have been used. In all cases were implanted uncemented total hip prostheses (17 CLS Spottorno stemÒ (ZimmerÒ) and 10 expansive acetabular cups, 4 press-fit AllofitÒ (ZimmerÒ) without screws and 3 pressfit screwed AllofitÒ (ZimmerÒ)). Bearing surface distribution was: four ceramic–polyethylene and 13 metal–polyethylene. After the first hip surgery, the anesthesiologist team informs the surgical team the patient’s condition and the possibility of starting on the contralateral
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side. At the end of each intervention, two autotransfusion drainages (StrykerÒ) were placed (one intra-articular and one superficial to the fascia lata). Reinfusion was performed after 6 h of surgery. At 48 h, the drainages are removed. All patients received thromboprophylaxis with low molecular weight heparin (3500 UI Bemiparin HiborÒ) for 30 days, beginning after 6 h from the end of the second hip. All patients followed the same rehabilitation protocol: weight bearing is beginning at 24 h using walker initially and then British canes at 72 h. Short and frequent walk way are indicated. The last day in hospital, the patient is instructed to go up and down the stairs. All of these patients are supervised by a rehabilitation team and a nurse with orthopedic experience during hospital stay. One British cane is left at 6 weeks and the second one at 8 weeks after the surgery. All patients followed the same schedule reviews at 6 weeks, 3, 6 and 12 months. The age, sex, diagnosis, ASA score (American Society of Anesthesiologists), transfusion data, hospital stay and surgical and follow-up complications were collected from medical history. We have registered the surgical time and operating room data. Functional assessment of pain, mobility and ability to walk was done by the Merle D’Aubigne´ [12] scale before and at the end of follow-up by observers other than the operating surgeon. Radiologically, axial stem migration was assessed with Syngo system (SiemensÒ) by measuring the distance between the elbow of the stem and the apex of the trochanter major (Fig. 1). It was defined in millimeters by anteroposterior hip radiographies before weight bearing (24 h after procedure) and during the revision schedule defined previously [13, 14]. Acetabular component was evaluated with anteroposterior hip radiographies. Components mobilization or progressive radiolucencies lines were described using the De Lee and Charnley zones, comparing anteroposterior X-ray image before weight bearing (24 h after procedure) and during the revision schedule (13). The comparative study was done by the same investigator using the same software (Syngo System Siemens) minimizing possible bias. The presence of heterotopic ossifications was assessed by anteroposterior hip radiographs making a comparison between the presurgical study and during the revision schedule defined previously. They were classified using Brooker’s classification [15]. All patients underwent pre-intervention blood count, coagulation tests, Rh blood group and renal function tests. We reserve three blood units for each patient. The mean hemoglobin was 11.7 mg/dL. No presurgical blood transfusion was needed.
Musculoskelet Surg ´ Augbigne´ score data (right side) Table 2 Merle D
Fig. 1 Axial stem migration was assessed by measuring the distance between the elbow of the stem and the apex of the major trochanter Table 1 Demographic data Number of patients
17
Mean age (range)
47.4 (18–68)
ASA (American Society of Anesthesiologists score)
I: 5 (29.4 %) II: 9 (52.9 %) III: 3 (17.6 %)
Results Between 2000 and 2011, 20 patients underwent surgery for bilateral total hip prosthesis in single time. We have excluded three patients (one bilateral resurfacing, one cemented total hip prosthesis and one bipolar prosthesis). The average age of the patients was 47.4 years with age range from 18 to 68 years. Of the 17 patients, three were women and 14 were men. The ASA showed a distribution: grade I: 5 (29.4 %), grade II: 9 (52.9 %) and grade III: 3 (17.6 %). These ASA III cases were a patient with alcoholic liver disease in treatment with acenocoumarol (SintromÒ), a patient with bilateral hip fracture affected of Down’s syndrome and insulin-dependent diabetes mellitus and a patient with a history of prostate cancer with negative controls; Table 1). Mean patients’ follow-up was 44.3 months with a range from 6 months to 172 months.
Case
M-D Pre
M-D Post
Pain Pre
Mobility Pre
Gait Pre
Pain Post
Mobility Post
Gait Post
1
13
17
3
5
5
5
6
6
2
11
16
2
4
5
4
6
6
3
10
18
1
4
5
6
6
6
4
11
16
2
4
5
6
4
6
5
9
16
1
4
4
5
5
6
6
12
18
2
4
5
6
6
6
7 8
10 12
17 16
1 2
3 5
6 5
6 6
5 6
6 4
9
13
18
3
5
5
6
6
6
10
9
17
1
3
5
5
6
6
11
10
17
2
3
5
6
5
6
12
13
13
3
5
5
5
5
3
13
13
14
4
4
5
6
5
3
14
12
17
3
4
5
5
5
6
15
11
17
1
5
5
5
6
6
16
12
18
3
4
5
6
6
6
17
7
17
2
2
3
5
5
6
´ Augbigne´ score, Pre Preoperative value, Post Value at M-D Merle D the end of follow-up
The diagnosis that led to bilateral arthroplasty was primary osteoarthritis in six cases and secondary osteoarthritis in 10 (one spondyloepiphyseal dysplasia, three bilateral avascular necrosis, one bilateral hip epiphysiolysis, two congenital hip dysplasia and three Still’s disease). One affected by Down’s syndrome underwent surgery because of bilateral subcapital hip fracture. The mean Merle D’Aubigne´ score changed from 11 points preoperatively to 16.4 postoperatively. All parameters in this scale (pain, mobility and ability to walk) improved (Tables 2, 3). Patients were transfused with average of two RBCs during hospital stay. The average time of the patient in the operating room was 278 min (234–375) with an average of 102 min for each side (60–134). The mean hospital stay was 7 days. We observed one deep vein thrombosis case, a 37-yearold man with coxarthrosis secondary to epiphysiolysis in the childhood and ASA of 2. He was treated with low molecular weight heparin. He fully recovered, enjoying a normal life after a follow-up of 66 months. We must note two neurological complications (deep peroneal nerve paresis). The first case was a 27-year-old female wit congenital hip dislocation, and the second case was a 49-year-old female woman with Still’s disease. Both resolved spontaneously 8 and 12 weeks after surgery (Fig. 2). One patient had heterotopic ossification that did not require surgical treatment.
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No dislocation or infection has been registered. Radiographic evaluation showed one case of axial stem migration of 13 mm. A 44-year-old female affected by spondyloepiphyseal dysplasia was treated in childhood with left hip osteotomy. The bilateral hip arthroplasty
implants were a press-fit hip socket with screws and uncemented Spottorno stem in both hips. After 15-month follow-up, we observed the axial migration on the left hip. The patient did not report pain (Fig. 3). No acetabular aseptic mobilization or progressive radiolucencies were noted.
´ Augbigne´ score data (left side) Table 3 Merle D Case
M-D Pre
M-D Post
Pain Pre
Mobility Pre
Gait Pre
Pain Post
Mobility Post
Gait Post
1 2
11 10
16 18
2 2
4 3
5 5
5 6
5 6
6 6
3
11
18
1
5
5
6
6
6
4
11
16
2
4
5
6
4
6
5
11
16
1
5
5
5
5
6
6
12
17
3
4
5
5
6
6
7
12
17
3
4
5
6
5
5
8
12
14
2
5
5
6
6
4
9
13
18
3
5
5
6
6
6
10
10
17
1
4
5
5
6
6
11
9
17
2
2
5
6
5
6
12
10
13
1
4
5
4
6
3
13
12
14
3
3
5
6
5
3
14
12
17
3
4
5
5
6
6
15
12
17
2
5
5
5
6
6
16 17
12 10
18 17
3 3
4 4
5 3
6 6
6 5
6 6
´ Augbigne´ score, Pre Preoperative value, Post Value at M-D Merle D the end of follow-up
Fig. 2 A 49-year-old female woman with Still’s disease. The effort to recover the hip center rotation led to a temporal lesio´n of external ciatic popliteal nerve
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Discussion We report good clinical and radiological short-term results performing bilateral uncemented hip replacement at one same time. Some authors attribute a greater risk for the bilateral procedure [16, 17] because pulmonary complications. Berend [10] reports the risk in patients undergoing bilateral surgery at single time, which is twice more than the two-stage procedure. Years later, two meta-analysis with 2,063 and 1,819 patients report no significant differences [18, 19]. These studies include cemented and uncemented prostheses. Our study only includes uncemented hip arthroplasties. We have registered one case of deep vein thrombosis who recovered after treatment with low molecular weight heparin at high doses. Our results are consistent with a recent published report by Romagnoli [20]. There are few series involving only uncemented bilateral total hip arthroplasty [4, 21–23]. Some authors report some advantage in bilateral total hip arthroplasty in a single time. Anesthesic time reduced hospitalization stay and consequently lowered cost [5–9]. About the mean
Musculoskelet Surg Fig. 3 Axial stem migration of 13 mm. A 44-year-old female affected by spondyloepiphyseal dysplasia, treated in childhood with left hip osteotomy. After 15-month follow-up, we observed the axial migration on the left hip. The patient did not report pain
hospital stay in primary unilateral hip arthroplasty in our center is 6 days [24] with a cost about 300 euros per day. We have no seen an increased hospital stay in bilateral procedures, and consequently, we have reduced 6 days of hospital stay against the two-stage procedure. About uncemented total hip arthroplasty reports, Shih [4] only found differences in hospital stay (which was lower in the single time). Kim et al. [21] found no significant differences between groups, and Ritter [22] defends the single time as a safe and effective procedure. The uncemented unilateral total hip arthroplasty is a surgery with good results whose outcomes are difficult to improve. In our opinion to do not find differences between the single- and two-stage procedures is an advantage for the single time. Berend in 2007 [23] was the most critical to make the single-stage procedure because of greatest number of complications regarding unilateral procedure. To minimize the risk, we believe that the selection of patients is necessary. Our good outcomes are possible because of the selection of patient: mean age under 50, more than 80 % under ASA III and capacity to understand the postoperative protocol. The supporters of two-stage procedure found clinical improvements in contralateral hip after the first intervention [11]. We consider as bilateral surgical patients when conservative treatment has failed in advanced degrees of osteoarthritis. We do not expect significant clinical improvement attributable only to a better gait pattern after the first hip arthroplasty. In the other hand, the realization of single-stage surgery could correct limb length
discrepancy and lower extremity deformity secondary to coxopathy [2, 9]. According to previous reports, we report bigger transfusion requirements in single time bilateral procedure. Although we have not seen an increased clinical complication, we have to note that transfusion was always necessary. We think that patients with transfusion’s problems or those affected of hematologic disease must be considered an absolute contraindication in single time bilateral uncemented arthroplasty. The postoperative management of unilateral uncemented total hip arthroplasty requires partial weight bearing. In patients with a bilateral procedure at the same time, it is impossible to do. In the authors opinion, the critical point of the bilateral procedure is the degree of patient cooperation. Bilateral procedure cannot be generalized. In this situation with no partial weight bearing, one might expect, before doing the review, the possibility of stem migration secondary to the load. Following our early rehabilitation protocol at 24 h after surgery using walker initially and then with British canes, we found only one case of unilateral stem migration. A rigorous preoperative study is important. A small stem may lead a postoperative collapse. A good stem cortical contact is essential. The functional results in Merle D’aubigne´ scale show the effectiveness of the procedure. No differences were found with a previous publication of our group in unilateral cases [24].
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We must to note the high incidence of neurological complication (two hips of 34) when compared with unilateral series published by us in 2011 (1 of 189) [24]. We think that it is related to the pathogenesis of secondary osteoarthritis (one dysplasic hip dislocated (Crowe IV) and one Still’s disease with great joint deterioration). In this case, to restore the anatomical center of rotation of the hip implies an effort in the reduction, independent of whether it is a bilateral or unilateral procedure [25]. Macaulay et al. [26] report the importance to perform the bilateral arthroplasty in single time in centers with experience, good results in unilateral procedures and multidisciplinary team in making the decision. Berend 2005 reported after 1992 no mortality after the inclusion of internal medicine team in the perioperative time. We have incorporated a team of internal medicine to these patients. We recognize some potential limitations. The small number of postoperative complications (no dislocations or infections) and the good Merle´-Daugbigne´ results reported are due in part to the patient selection [27] and not only due to the small sample size or surgical position, as some authors have attributed [23]. The use of radiostereometric analysis (RSA) would have given a higher sensitivity in the analysis of radiographs for early implant migration [28], but the impossibility to have the necessary hardware to use this kind of analysis in our center made us to decline this option. The comparative study was done by the same investigator with the same software (Syngo System Siemens) minimizing possible bias. The sample included several preoperative diagnosis. It could be a bias. Our main complications are referred to uncommon diagnosis (Still disease and spondyloepiphyseal dysplasia). Primary osteoarthritis could be the most adequate indication for these procedures. It is well known that the Still disease and spondyloepiphyseal dysplasia have their own characteristics (bone quality, vascularization, bone shape, limb discrepancy) and a widely clinical presentation. We do not recommend bilateral single-stage procedure in that cases which we preoperatively considered to perform an additional surgical gesture (special implants, osteotomies, etc.) or revision surgery [29]. Another limitation of the study is the short follow-up. We consider that it does not affect the main aim of the study, which is the assessment of short-term complications. The authors believe that the potential difference between single and two stages should appear in the first year. After that, each prosthesis has an independent evolution as any single total hip arthroplasty. In summary, the bilateral uncemented total hip arthroplasty in single time is a safe and effective procedure with low complication rate in the short-term postoperative period. Proper patient selection, with an acceptable health
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status and capacity to cooperate in the immediate postoperative period and a fluent communication with a multidisciplinary team carries to functional results similar to those made unilaterally. The results of our investigation could be used in the development of future randomized controlled trials or prospective cohort studies. Conflict of interest
None.
Ethical standard The present study is in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
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