|Year : 2019 | Volume
| Issue : 1 | Page : 17-21
A technique for hip arthrodesis using a multiplanar external fixator and transarticular screws
Joshua N Speirs1, Djuro Petkovic2, John E Herzenberg3, Scott C Nelson1
1 Department of Orthopaedic Surgery, Loma Linda University, Loma Linda, California, USA
2 Illinois Bone and Joint Institute, Chicago, IL, USA
3 International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore, Maryland, USA
|Date of Web Publication||23-Aug-2019|
Dr. Joshua N Speirs
Department of Orthopaedic Surgery, Loma Linda University, 11406 Loma Linda Drive, Suite 213, Loma Linda, California 02354
Source of Support: None, Conflict of Interest: None
Background: To determine the clinical and radiographic results of hip arthrodesis using external with minimal internal fixation. Methods: A consecutive series of ten patients underwent hip arthrodesis using combined multi planar external fixation and transarticular screws. Operative parameters and radiographic and clinical results were retrospectively analyzed for each patient. Results: Mean estimated blood loss was 490 mL. At an average follow-up of 47.5 months, Harris Hip Score averaged 83.4. Mean postoperative measurements included anatomic axis hip adduction of 9°, hip flexion 22.2°, and leg length discrepancy 20.3 mm. Average adduction drift of 8.3° was noted after fixator removal. There were no nonunions. Conclusion: The described technique for hip arthrodesis reliably fused the hip in a favorable position requiring a less invasive approach with lower blood loss. Additional advantages include multiplanar stability, potential for hip position adjustment postoperatively and preservation of hip abductors; in case of future hip replacement.
Level of Evidence: This was a Level IV, case series.
Keywords: Adductor drift, hip arthrodesis, hip fusion, multiplanar external fixator
|How to cite this article:|
Speirs JN, Petkovic D, Herzenberg JE, Nelson SC. A technique for hip arthrodesis using a multiplanar external fixator and transarticular screws. J Limb Lengthen Reconstr 2019;5:17-21
|How to cite this URL:|
Speirs JN, Petkovic D, Herzenberg JE, Nelson SC. A technique for hip arthrodesis using a multiplanar external fixator and transarticular screws. J Limb Lengthen Reconstr [serial online] 2019 [cited 2019 Nov 18];5:17-21. Available from: http://www.jlimblengthrecon.org/text.asp?2019/5/1/17/265355
| Introduction|| |
A well-performed hip arthrodesis can provide pain relief and functional improvement in situ ations where other procedures do not offer good long-term solutions, especially in young patients. Hip arthrodesis is a salvage procedure and should only be performed after carefully considering alternatives and long-term goals of the patient. Hip arthrodesis is contraindicated in patients with bilateral hip disease, low back pain, and ipsilateral knee pain.
Alternatives to hip fusion should always be considered. Total hip arthroplasty (THA) offers reliable results with restoration of motion and relief of pain but commits young patients to a lifetime of wear particles and a high likelihood of needing revision surgery. In addition, THA may be complicated in patients with previous infection or in patients who are still growing. Pelvic support osteotomy has the advantage of maintaining hip motion; however, the procedure is more complex, and results are more variable than hip fusion. Social factors must also be considered, including lifestyle and access to medical resources. This is particularly important when working in resource-poor areas, where options for THA are limited, and the possibility for revision surgeries may be unavailable.
Various techniques have been described for hip fusion. Extra-articular techniques include various plating methods and external fixation., Transarticular procedures involve fixation across the joint, sometimes supplemented with spica cast or uniplanar external fixation.,, The purpose of this article is to describe a relatively simple and reproducible technique for hip arthrodesis that provides favorable results and preserves the abductors (allowing for possible future conversion to total hip arthroplasy,,) with less blood loss than other described techniques and without the need for postoperative casting.,,, We developed this method for use in resource-poor environments but have used it in the USA as well.
| Methods|| |
Approval for this study was obtained from the Institutional Review Board. Ten consecutive patients were retrospectively identified who had a hip arthrodesis performed between November 2007 and December 2012. Surgery was performed at three separate institutions in three different countries (Hôpital Adventiste d'Haiti (HAH –4 patients) in Port-au-Prince, Haiti; Cure Hospital in Santo Domingo, Dominican Republic (5 patients); Loma Linda University in Loma Linda, California (1 patient)). This was a consecutive series of all patients who had a hip arthrodesis performed by the Senior author (SCN); all were performed following the described technique.
The patient is placed supine on a radiolucent table without any bolsters to allow for accurate assessment of the hip position. A Smith Peterson approach is used. The rectus tendon is detached from its insertion on the anterior inferior iliac spine (AIIS). Adductor tenotomies are not usually needed. The capsule is opened, and the femoral head is dislocated. This is performed by extending, adducting, and externally rotating the hip with the aid of a bone hook beneath the lesser trochanter. The acetabulum is reamed to expose fresh bleeding bone using an acetabular reamer. If exposure is difficult, a smaller reamer or burr can be used. All cartilage is removed from the femoral head, which is then contoured to for a congruent fit within the acetabulum. Care is taken to preserve as much length as possible.
It is important to position the hip in 20°–25° of flexion. The position of the lumbar spine must be assessed when trying to estimate hip flexion. The lumbar spine should be a neutral position noted when a hand is held behind the lumbar spine. The hip should be placed in 0°–10° of external rotation. The necessary desired amount of abduction is added to minimize leg length discrepancy. The final position of the femoral shaft should not be abducted beyond 10° in relation to the pelvis. At the time of surgery, especially in the cases with larger leg length discrepancies, 4°–5° of additional abduction can be added to accommodate for adductor drift. This is discussed later in this report. This position is measured clinically and on fluoroscopic images with the aid of a sterile goniometer. Alternatively, a beanbag can be contoured preoperatively to hold the thigh and leg in the desired position. The hip joint is secured with one or two transarticular guide wires. The starting point for the guide wires is on the anterolateral aspect of the femoral neck, similar to the start point for slipped capital femoral epiphysis fixation [Figure 1]. The guide wire is directed toward the posterior superior quadrant of the acetabulum. This is an area that is considered a safe zone for acetabular component screws in THA. While maintaining the hip in the desired position, the external fixator is applied prior to placing the cannulated screws over the guide wires.
|Figure 1: Typical intraoperative photograph of a completed multiplanar external fixator. Including three half-pins in the femur, three to four half-pins in the pelvis, and in this case, a Sheffield ring external fixator|
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The Orthofix trauma fixator is used with a Sheffield ring to create a stable and multiplanar pelvic fixation that can be connected to femoral half-pin fixation. A total of three or four 6-mm hydroxyapatite-coated half pins are typically placed in the pelvis and three in the femur. The first pin is placed into the supraacetabular area. The fixator compression/distraction component is initially placed at mid position to allow for adjustments. A distal pin is placed in the femoral shaft. Two additional pins are added in the supraacetabular area and then two more in the femoral shaft. A half pin is inserted into the AIIS through a percutaneous incision adjacent to the anterior surgical wound. Predrilling is done with a solid 4.8 mm drill bit. A preliminary guide wire and cannulated 4.8 mm drill bit can alternatively be used for more accuracy. The four pelvic half pins are secured to the Sheffield rin, and the distal screw clamp is connected to the construct. The Orthofix trauma fixator has a universal ball joint, as well as a threaded distractor, which allows for adjustment of flexion, abduction, and rotation. Adjusting the position at this point is not advised unless the guide wires are withdrawn into the femoral head and then re-advanced when the desired position is obtained. The fixator is locked into position, which is confirmed radiographically. Partially threaded 6.5 or 7.3 mm cannulated screws are then placed across the joint to add compression [Figure 2]. Washers can be used if desired.
|Figure 2: Postoperative day 1. Radiograph showing the use of a multiplanar external fixator as well as at least one transarticular screw across the hip joint|
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The wound is then irrigated and if needed, autograft or allograft bone can be used to augment the fusion site. Wound closure is performed in a standard fashion.
Postoperatively patients are allowed to ambulate with crutches or a walker and are kept nonweight bearing on the operated extremity for at least 6 weeks. All patients should have postoperative plain films to confirm intraoperative measurements. We have performed postoperative adjustments of a few degrees to fine tune the amount of abduction and minimize leg length discrepancy. This is done by adjusting a compression/distraction device on the fixator while partially loosening the ball joints. Minor adjustments can be made on the fixator without losing joint compression. Caution must be exercised as this can cause small amounts of bending of the screws or screw creep in the cancellous supraacetabular bone. At this time, partial weight bearing is progressively advanced based upon radiographic healing, patient age, and patient size.
For each patient, hip flexion, rotation, abduction/adduction, and leg length discrepancy were examined, and the Harris Hip Score was calculated. Flexion and rotation were recorded using a handheld goniometer. The abduction/adduction was measured on initial postoperative radiograph and at final follow-up. The inferior portion of the sacroiliac joints was used to define the transverse pelvic line. Abduction or adduction is reported based on the anatomic axis of the femoral shaft in relation to a line perpendicular to the transverse pelvic line [Figure 3]. Leg length discrepancy was assessed on standing full leg-length films. Functional leg length discrepancy was assessed by placing blocks of known thickness under the shorter leg until the patient could comfortably bear weight equally on both legs. The fusion mass and position of the hip were also evaluated radiographically by cross-table lateral radiographs. Operative notes were reviewed for estimated blood loss.
|Figure 3: Results of normal, adducted, and abducted hip arthrodesis on alignment. Diagram showing the relationship between hip abduction and leg length discrepancy. (a) The first panel, the anatomic axis of each femur is in neutral rotation with respect to the pelvis. (b) The second panel, patient who's left femur is adducted 10° with respect to the femur, there is a functional 3 cm leg length discrepancy with the adducted leg functionally shorter. Conversely, (c) The third panel, the left leg is abducted 10° leading to a functional 3 cm lengthening of that leg (Copyright 2017, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore)|
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| Results|| |
A total of 10 patients underwent hip arthrodesis during the period from November 2007 to December 2012. The patients' mean age at time of surgery was 21.7 years (range 12–56). All but three patients were 12–15-year-old [Table 1]. The underlying etiology of the patients' hip pathologies included: trauma (4 patients, 2 had severe acetabular fractures which presented several months after injury), avascular necrosis after slipped capital femoral epiphysis (2 patients), septic arthritis resulting in severe arthrosis (2 patients), iatrogenic avascular necrosis after intramedullary nail placement (1 patient), and developmental dysplasia of the hip (1 patient). The mean estimated blood loss was 490 mL (range 200–1000 mL). The average follow-up was 47.5 months (range 4–92 months). Nine of the 10 patients were followed for a minimum of 2 years. Patient 2 was lost to follow-up after 4 months.
The average hip position in the coronal plane immediately after surgery was 1° adduction (range 6° adduction to 8° abduction). The average hip adduction at final follow-up was 9° adduction (range 2°–24° adduction). There was an average adduction drift of 8° (range 2° of abduction to 32° of adduction). The average hip was positioned in 22° of flexion at latest follow-up. The actual leg length discrepancy based on radiographs averaged 20 mm (range 0–57 mm). The external rotation of the affected legs averaged 8° (range 0°–20°). One patient developed a pseudarthrosis. He had a history of septic arthritis as a child and his postoperative period was complicated by infection requiring hardware removal. At final follow-up, this patient reported a hip score of 71 and refused revision surgery, as he was satisfied with his level of function.
At the final follow-up, all patients walked without the use of any assistive devices, and all patients reported significant improvement from their preoperative status and were satisfied with the results. Self-reported Harris Hip Scores averaged 83.4 (range 59–92). Of note, the maximum possible Harris Hip Score without motion in the hip is 95; scores between 80 and 90 are considered in the “good” range. Patients reported minimal limitations in their daily activities.
Two patients had suboptimal clinical results due to postoperative adduction drift. Patient 4, the oldest in the study, originally presented several months after a severe acetabular fracture that occurred in the 2010 Haiti earthquake. After hip fusion, 24° of hip adduction was noted at the final follow-up. Review of her records revealed that the fixator was removed prior to complete consolidation of the arthrodesis. She reported a Harris Hip Score of 59. Corrective surgery was offered but declined by the patient. THA was not an option due to economic limitations. Patient 7 incurred 18° of adduction drift after removal of the external fixation, resulting in a 4 cm functional leg length discrepancy. Her fixator was removed 97 days after initial surgery, and although the hip appeared to have fused on X-ray, it is suspected that the arthrodesis site had not sufficiently consolidated. Despite this deformity, she reported excellent clinical results, with a Harris Hip Score at last follow-up of 91. Excluding these two patients, the average position for the remaining eight patients was 5.6° of shaft adduction (range 2°–10°) and average adduction drift was 4.1° (range-2°–8°).
| Discussion|| |
According to Iobst and Stanitski hip arthrodesis techniques should include the following: (1) primary union of the fusion, (2) avoid postoperative casting, (3) minimize leg length discrepancy, (4) preserve ipsilateral knee motion, (5) achieve desired positioning of the fused hip, and (6) allow for future conversion to THA by preserving the hip abductors. The described technique successfully accomplishes each of these goals in addition to offering some other advantages. The procedure, as performed, involves less blood loss than any other described techniques found in the literature.,,, In addition, this technique allows for careful alignment of the hip joint, which has been shown to minimize painful sequelae and asymmetry. The easy to use multiplanar external fixation system allows for small adjustments of hip position even after surgery if needed. Schafroth et al. found that alignment of the hip fusion is key to preventing painful symptoms in the adjacent joints including the lower back, ipsilateral knee, and contralateral hip. Benaroch et al. found that patients fused in 20°–25°of flexion and with leg length discrepancies of <2 cm had significantly decreased rates of back pain, incidence of quadriceps deficiency, and abnormal gait.
Various other techniques for hip arthrodesis have been described in the literature. Matta used an extended Smith–Petersen approach to place a compression plate as well as transarticular lag screws. Schafroth et al. used a cobra plate with a trochanteric osteotomy; some patients required an additional subtrochanteric osteotomy to allow ideal positioning. This could also be performed using our technique, although in this series, we did not find it to be necessary. In some situations, the hip is already solidly fused. Many times, this is in a position of adduction, and the patient presents for leg length discrepancy. In these cases, a subtrochanteric osteotomy with a dynamic hip screw can provide adequate stability. If additional stability is needed, certainly external fixation could be of value. These described procedures either require more extensive surgical procedures or provide less secure fixation than the technique described in this article. Furthermore, they damage the abductors, which make subsequent total hip replacement more difficult. Another advantage of the described technique is that it provides rigid fixation without the use of a spica cast, which is required in some of the other less invasive hip fusion techniques.,
External fixation has been described previously as a method for securing hip fusions, including the use of uni- and multi-planar external fixators., Endo et al. described combining transarticular screws in combination with external fixation. They reported immediate mobilization of patient postoperatively and decreased complications due to earlier mobility and free range of motion of the knee and ankle. These studies report subjective pain relief and improved function postoperatively, but they do not report final hip position in all three planes. Our multiplanar external fixator configuration varies from the referenced studies by providing a more robust construct, allowing for improved postoperative mobility and more reliably maintaining joint position until fusion.
There are limitations to this study. First, the study is retrospective with the majority of the cases treated in an austere environment in the developing world. Moreover, this study includes a relatively heterogeneous patient population, with patients varying in age from 12 to 56 years with various etiologies of hip arthrosis. One of our patients was lost to follow-up after 4 months, a significant outlier. Two patients experienced excessive adduction drift. It is important to anticipate the tendency for adduction drift when performing hip fusion techniques where rigid fixation is not permanently left in place. The phenomenon of adduction drift has been reported by Fulkerson in a series of hip fusions performed with a variety of techniques. He found an average adduction drift of 9.5° in his series of 9 patients. Other studies have reported similar results. One can reduce the risk of excessive adduction secondary to adduction drift by adding hip abduction at the time of surgery and from our experience assuring that the arthrodesis site is completely consolidated prior to removal of the external fixator. Quantifying the exact amount of added abduction that is ideal to compensate for adduction drift has yet to be determined. If excessive adduction drift or significant limb length discrepancy does occur, a percutaneous femoral osteotomy prior to removal of the external fixator could be performed.
The strength of this series is the description of a reliable technique for hip arthrodesis by combining a stable multiplanar external fixation of the pelvis with transarticular fixation. In addition, this technique shows relatively low blood loss, spares abductor muscles, allows for early mobilization, and offers a high rate of fusion (90%) with good Harris Hip Scores. The majority of the patients in this series reported satisfaction with their surgical result and without significant limitations in their daily activity. This technique is an appropriate procedure for young patients and/or those in resource-deprived situations with severe painful hip arthrosis in whom other alternatives are not ideal.
Financial support and sponsorship
Conflicts of interest
Neither Joshua N. Speirs, MD; Djuro Petkovic, MD; Scott C. Nelson, MD authors have conflicts of interest to report. John E. Herzenberg, M, is a consultant for Smith Nephew, Orthofix, Orthopediatrics, and Nuvasive. There was no external source of funding for this research project.
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