|Year : 2020 | Volume
| Issue : 1 | Page : 102-105
Complications following fracture neck of femur treated with austin moore hemiarthroplasty: A rare case report
Alok Chandra Agrawal, Sameer Mittal, Harshal Sakale, Sandeep Kumar Yadav
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India
|Date of Submission||01-Apr-2020|
|Date of Acceptance||01-May-2020|
|Date of Web Publication||26-Jun-2020|
Dr. Sameer Mittal
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
Source of Support: None, Conflict of Interest: None
A 72-year-old male patient was operated by Austin Moore hemiarthroplasty for fracture neck of femur 6 years back who developed multiple complications. In this case, the patient developed dislocation of the hip joint following which the Austin Moore prosthesis got broken. During revision with bipolar hemiarthroplasty, the patient developed fracture of proximal femur which was poorly managed by K-wires and stainless steel wires. After some time, the patient developed dislocation of the bipolar prosthesis and signs of infection. We operated this patient with a two-stage revision. In the first stage following removal of all infected metalwork and debridement, we put antibiotic cement spacer, and after 4 weeks in the second stage, we did a total hip replacement with uncemented constrained proximal femoral modular reconstruction prosthesis. The case is being reported for its rare presentation in genuine management and successful outcome.
Keywords: Austin Moore hemiarthroplasty, complications, dislocation, elderly, fracture neck of femur
|How to cite this article:|
Agrawal AC, Mittal S, Sakale H, Yadav SK. Complications following fracture neck of femur treated with austin moore hemiarthroplasty: A rare case report. J Orthop Traumatol Rehabil 2020;12:102-5
|How to cite this URL:|
Agrawal AC, Mittal S, Sakale H, Yadav SK. Complications following fracture neck of femur treated with austin moore hemiarthroplasty: A rare case report. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2020 Sep 21];12:102-5. Available from: http://www.jotr.in/text.asp?2020/12/1/102/287710
| Introduction|| |
Austin Moore prosthesis (AMP) is being successfully used for a long time for the treatment of fracture neck of femur in elderly, medically unfit patients, and low-demand patients. In developing countries including India, it is frequently used in active patients also, which leads to complications such as implant loosening, sinking of implant due to resorption of neck, or acetabular erosions. Sometimes, the patient presents with broken implant too., In this case report, an old patient operated with Austin Moore hemiarthroplasty developed multiple complications and was treated with multiple salvage arthroplasties. The natural history of a series of inter-related complications is being presented.
| Case Report|| |
A 72-year-male patient had a history of fall on ground and developed pain in the right hip which was severe in intensity, and he was unable to bear weight on the right lower limb immediately after trauma. At presentation to a local orthopedic surgeon, he had no neurovascular deficit [Figure 1]. After preoperative fitness, he was operated with uncemented hemiarthroplasty with AMP [Figure 2].
One month later, he dislocated his operated hip with a loose prosthesis [Figure 3]. The same surgeon operated this time with a cemented hemiarthroplasty with the same AMP (a common practice in the developing world) [Figure 4] and open reduction of the dislocation.
Three years passed by, and the patient presented to the same surgeon with the AMP prosthesis broken [Figure 5]. He was operated with implant removal, cement removal, and revision cemented bipolar hemiarthroplasty. During this revision, proximal femoral fracture occurred which was poorly managed with wires [Figure 6].
|Figure 6: Revision cemented bipolar hemiarthroplasty with proximal femoral fracture, poorly managed with wires and dislocation of bipolar hemiarthroplasty|
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This patient again dislocated his hip [Figure 7] and presented to us. We were advised him with implant removal and conversion to total hip replacement (THR). The patient did not come for follow-up for 2 months and continued to walk on his dislocated hip. After 2 months, he presented with the same dislocated prosthesis, severe pain, discharge, erythema, and inability to walk. These were signs of infection [Figure 8].
|Figure 8: Removal of infected prosthesis and wires with all dead bones and antibiotic cement spacer in situ|
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The patient's blood investigation revealed that there was increased white blood cell count (15 × 103/μL), erythrocyte sedimentation rate (120 mm at the end of 1st hour), and C-reactive protein (73.5 mg/L). There was increased pain around the hip joint. The patient was planned for a two-stage debridement and revision hip arthroplasties. In the next step after debridement, infected prosthesis and wires with all dead bones were removed and antibiotic cement spacer was inserted. Skin traction was applied for keeping spacer in position [Figure 9]. The patient was called after 3 weeks and planned for spacer removal and definitive surgery. The spacer was removed and thorough debridement was done, and THR with uncemented constrained proximal femoral modular reconstruction prosthesis was done [Figure 10]. At 1-year follow-up, our patient is walking without pain or support and he is under treatment for osteoporosis too.
|Figure 9: X-ray Pelvis with both hips showing Total hip replacement with uncemented constrained proximal femoral modular reconstruction prosthesis|
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|Figure 10: X-ray Right hip with femur showing Total hip replacement with uncemented constrained proximal femoral modular reconstruction prosthesis|
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| Discussion|| |
Complications of Austin Moore hemiarthroplasty result due to multiple factors attributed to nonmodularity of AMP stem, inadequate lateralization of stem, poor interphase between metal and cartilage, calcar loading with poor Austin Moore fixation, implant bone instability, and poor soft-tissue balancing. In various studies, the most common intraoperative error identified during implantation of AMP was an inadequate length of the neck remnant.,, Short neck remnants have been associated with increased frequency of dislocation, residual thigh pain, limb shortening, prosthetic subsidence, and loosening necessitating early revision. When dislocation of hemiarthroplasty occurs, an initial attempt at closed reduction should be made. Patients should be warned of the possibility of further dislocations and the need for revision surgery. Bipolar articulations are more difficult to reduce than unipolar articulations, so the need for open reduction is more likely. Similarly, if radiographs demonstrate suboptimal implant positioning or acetabular dysplasia, open revision may be necessary. Revision options include conversion to THR or excision arthroplasty. This decision will clearly depend on the patient's mental state, premorbid mobility, and independence and their physiological reserve. Removal of well-fixed cement risks bone loss, cortical perforation, and fracture and is time-consuming and technically demanding. To remove sufficient cement to allow the insertion of an uncemented component often requires an extended trochanteric osteotomy or cortical window, which in turn demands long-stemmed distally fixed components. In this case, removal of cemented component was done by a general orthopedic surgeon and not a revision specialist. He operated without extended trochanteric osteotomy, and it resulted in a femoral fracture and bone loss, which was managed poorly by cerclage wiring. Two-stage revision for infected arthroplasties has been reported to produce the best results, with an infection eradication rate higher than 90%. The principles of two-stage revision are the removal of all prosthetic components, including cement, with radical debridement of infected tissue and bone. Local antibiotics, administered with the use of an antibiotic-loaded cement spacer, and systemic antibiotics are used in conjunction. Reimplantation is conducted at 6–12 weeks and may be altered depending on multiple factors. Several questions remain, particularly around the timing and the duration of antibiotic administration, the appropriate use of articulating spacers, and the timing of reimplantation. In this case a two stage procedure was carried out. In the first stage after thorough debridement and removal of all dead bone, antibiotic spacer was inserted. In the second stage after four weeks this antibiotic spacer was removed and definite surgery with a Limb preservation system was done. For a massive loss of bone stock on the proximal femur, the options of reconstruction are limited to megaprosthesis and allograft-prosthetic composite. Megaprosthesis is preferred to reconstruct the proximal femur in older and less active patients who had osteoporosis and severe bone deficiency in the proximal femur. Early mobilization and immediate full weight-bearing can be allowed if the megaprosthesis is successfully implanted., Shih et al. found satisfactory results of revision total hip arthroplasty with proximal femur megaprosthesis in 8 of the 12 patients at an average follow-up of 5.7 years.
| Conclusion|| |
The case is being reported due to the series of complications he underwent and how following scientific orthopedic principles the case was salvaged successfully.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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