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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 12  |  Issue : 1  |  Page : 102-105

Complications following fracture neck of femur treated with austin moore hemiarthroplasty: A rare case report


Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh, India

Date of Submission01-Apr-2020
Date of Acceptance01-May-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Dr. Sameer Mittal
Department of Orthopaedics, AIIMS, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_18_20

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  Abstract 


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 Top


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.[1],[2] 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 Top


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].
Figure 1: Fracture neck of femur

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Figure 2: Operated with Austin Moore hemiarthroplasty

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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.
Figure 3: Dislocation of Austin Moore prosthesis

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Figure 4: Cemented hemiarthroplasty with Austin Moore prosthesis

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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 5: Fracture of the Austin Moore prosthesis

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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 7: Dislocated prosthesis with signs of infection

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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 Top


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.[3] In various studies, the most common intraoperative error identified during implantation of AMP was an inadequate length of the neck remnant.[4],[5],[6] 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.[7] 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.[8] 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%.[9] 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.[10] 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.[11],[12] 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.[13]


  Conclusion Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Emery RJ, Broughton NS, Desai K, Bulstrode CJ, Thomas TL. Bipolar hemiarthroplasty for subcapital fracture of the femoral neck. A prospective randomised trial of cemented Thompson and uncemented Moore stems. J Bone Joint Surg Br 1991;73:322-4.  Back to cited text no. 1
    
2.
Clayer M, Bruckner J. The outcome of Austin-Moore hemiarthroplasty for fracture of the femoral neck. Am J Orthop 1997;26:681-4.  Back to cited text no. 2
    
3.
Bhosale P, Suryawanshi A, Mittal A. Total hip arthroplasty for failed aseptic Austin Moore prosthesis. Indian J Orthop 2012;46:297-303.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Mue D, Yongu W, Mohammad H, Kortor J, Elachi I, Donwa J. Intra-operative implantation errors during hemiarthroplasty. J West Afr Coll Surg 2012;2:79-94.  Back to cited text no. 4
    
5.
Yau WP, Chiu KY. Critical radiological analysis after Austin Moore hemiarthroplasty. Injury 2004;35:1020-4.  Back to cited text no. 5
    
6.
Weinrauch P. Intraoperative error during implantation of the Austin Moore hemiarthroplasty. J Orthop Surg 2006;14:249-52.  Back to cited text no. 6
    
7.
Jones C, Briffa N, Jacob J, Hargrove R. The dislocated hip hemiarthroplasty: Current concepts of etiological factors and management. Open Orthop J 2017;11:1200-12.  Back to cited text no. 7
    
8.
Paprosky WG, Martin EL. Removal of well-fixed femoral and acetabular components. Am J Orthop (Belle Mead NJ) 2002;31:476-8.  Back to cited text no. 8
    
9.
Anagnostakos K, Fürst O, Kelm J. Antibiotic-impregnated PMMA hip spacers: Current status. Acta Orthop 2006;77:628-37.  Back to cited text no. 9
    
10.
Senthi S, Munro JT, Pitto RP. Infection in total hip replacement: Meta-analysis. Int Orthop 2011;35:253-60.  Back to cited text no. 10
    
11.
Parvizi J, Sim FH. Proximal femoral replacements with megaprostheses. Clin Orthop Relat Res 2004;420:169-75.  Back to cited text no. 11
    
12.
Sim FH, Chao EY. Hip salvage by proximal femoral replacement. J Bone Joint Surg Am 1981;63:1228-39.  Back to cited text no. 12
    
13.
Shih ST, Wang JW, Hsu CC. Proximal femoral megaprosthesis for failed total hip arthroplasty. Chang Gung Med J 2007;30:73-80.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]



 

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