Barrack, Robert L.

Butler, R. Allen

Hsu, Joseph R.

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Washington University School of MedicineDigital Commons@BeckerOpen Access Publications2-1-2006Use of an Ilizarov apparatus to perform closedreduction of a chronic proximal dislocationfollowing total hip arthroplasty: A case reportR. Allen ButlerTulane University School of MedicineJoseph R. HsuWilliam Beaumont Army Medical CenterRobert L. BarrackWashington University School of Medicine in St. LouisFollow this and additional works at: http://digitalcommons.wustl.edu/open_access_pubsPart of the Medicine and Health Sciences CommonsThis Open Access Publication is brought to you for free and open access by Digital Commons@Becker. It has been accepted for inclusion in OpenAccess Publications by an authorized administrator of Digital Commons@Becker. For more information, please contact engeszer@wustl.edu.Recommended CitationButler, R. Allen; Hsu, Joseph R.; and Barrack, Robert L., ,"Use of an Ilizarov apparatus to perform closed reduction of a chronicproximal dislocation following total hip arthroplasty: A case report." The Journal of Bone and Joint Surgery.88,2. 411-414. (2006).http://digitalcommons.wustl.edu/open_access_pubs/1114COPYRIGHT © 2006 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED411Use of an Ilizarov Apparatus to Perform Closed Reduction of a Chronic Proximal Dislocation Following Total Hip ArthroplastyA CASE REPORTBY R. ALLEN BUTLER, MD, JOSEPH R. HSU, MD, AND ROBERT L. BARRACK, MDInvestigation performed at Tulane University Health Sciences Center, New Orleans, Louisiana islocation remains a major early perioperative com-plication of total hip arthroplasty, with a prevalenceof 3.9% within the first six months as reported in a re-view of 58,521 patients in the Medicare population1. While theliterature abounds with options for the treatment of recurrentdislocation after total hip arthroplasty, we are not aware of anyreport on the treatment of chronic proximal dislocation aftertotal hip arthroplasty. We report the case of a patient in whomthis complication was successfully treated with gradual closedreduction with use of an Ilizarov distraction technique. Thepatient was informed that data concerning this case would besubmitted for publication.Case Reportforty-six-year-old man was involved in a motor-vehicle ac-cident in 1997 and sustained a right posterior wall acetab-ular fracture with peroneal nerve palsy that was treated withopen reduction and internal fixation. Degenerative joint diseasesubsequently developed, and the patient underwent right totalhip arthroplasty. Postoperatively, the hip dislocated multipletimes and revision total hip arthroplasty was recommended bythe original treating physician. The revision procedure waspostponed on a number of occasions, and the patient was thenlost to follow-up.The patient presented to our facility six years later forevaluation of chronic proximal dislocation at the site of theright total hip arthroplasty. The initial radiographic evaluationrevealed the right total hip replacement to be dislocated posteri-orly, resulting in 10 cm of shortening (Fig. 1). Other than theperoneal nerve palsy, motor and sensory function were intact inthe involved extremity. The patient had chronic pain in the but-tock and a severe Trendelenburg gait, and he walked with use ofa crutch and a 7.5-cm shoe-lift. The pain was worse withweight-bearing but was also moderate to severe with sitting.The treatment options that were discussed with the pa-tient included resection arthroplasty, revision surgery with re-sidual limb-length discrepancy, and soft-tissue lengtheningwith use of an external fixator, possibly followed by revisionsurgery. After discussion of the risks and benefits of each op-tion, the patient opted for the lengthening procedure.The patient was taken to the operating room, where aspanning Ilizarov device was placed over the right hip (Fig.2). The patient was placed in the lateral decubitus position toallow complete access to the pelvis. The anterior superior il-iac spine and the posterior superior iliac spine were palpatedto ensure safe passage of transosseous tensioned wires. Tran-sosseous wires were placed in an anterior-to-posterior direc-tion within the ilium. The starting point for the wires wasDAFig. 1Anteroposterior radiograph demonstrating 10 cm of shortening.412 THE JOU R N A L OF BO N E & JO I N T SU RG ER Y ·  JB JS .ORGVOLU M E 88-A ·  NU M B ER 2 ·  FE B R UA R Y 2006US E OF A N ILI Z A ROV APPA R AT U S TO PE R F O R M CL OS E D RE DU C T I O N OF A CH RON I C PROX IM AL DI S LO C A T I O N FOL LOW I NG THAjust proximal to the anterior superior iliac spine. The wireswere driven between the tables of the ilium with a wire-driver. Once the posterolateral cortex of the iliac wing waspierced with the wire, the wire was advanced manually bygentle tapping. Care was taken to ensure that the trajectoryof the wire was lateral to the posterior inferior iliac spine.This technique was adapted from observations made at theKurgan Institute, Russia, by one of the authors (J.R.H.).Since these tensioned wires were oriented at 90° to the dis-traction force, they were very resistant to loosening. Thewire fixation was reinforced by half-pins that were placedalong the iliac crest and in the anterior inferior iliac spine.The use of hydroxyapatite-coated half-pins added to their re-sistance to loosening. Tapered, blunt-tipped half-pins wereused to facilitate their placement between the tables of the il-iac wing. The cortex of the iliac crest was predrilled througha stab incision. The path of the half-pins was not predrilled,to ensure that the cortices of the ilium remained intact. Thehalf-pins were then placed into the pilot hole in the crest andwere gently driven into the ilium for approximately 5 mmwith use of a mallet. At this point, we turned the half-pinswithout applying axial pressure in order to draw them be-tween the tables of the ilium. Fixation in the femur was ac-complished with three half-pins that were placed as fardistally on the femur as possible to avoid contamination ofthe prosthesis from a possible pin-track infection. Further-more, distal pin placement avoided the creation of a stress-riser in the diaphyseal bone adjacent to the femoral stem.The patient was started on a lengthening regimen at arate of 4 mm per day on the first postoperative day. The pa-tient was managed with enoxaparin postoperatively and wastransferred to a rehabilitation unit on the second postopera-tive day to continue lengthening.Two complications occurred during the lengtheningprocess. Approximately three weeks after the placement ofthe Ilizarov frame, the patient presented to the emergencyroom complaining of shortness of breath and pleuritic chestpain. He was diagnosed with a pulmonary embolism andwas admitted for treatment. Duplex Doppler imaging ofboth lower extremities failed to reveal any evidence of deep-vein thrombosis. Heparin therapy was started, and a venacava filter was placed. Additional thromboprophylaxis wasprovided with a coumadin protocol and, after six days, thepatient was transferred back to the rehabilitation unit. Twoweeks later, the patient was seen in clinic and it was notedthat the frame had angulated at the proximal joint, causingone of the half-rings to impinge on the soft tissues of theright buttock. The patient was taken to the operating room.With the patient under anesthesia, the frame was derotatedand diagonal supports and “cross-links” were added to thehip-spanning frame to counteract the torsional forces on thelong vertical struts of the apparatus. Intraoperative radio-graphs that were made after revision of the frame showed thehead of the femoral component to be at the level of the supe-rior edge of the acetabular component. Postoperatively, theframe was lengthened at a rate of 4 mm per day for sevendays. At this point, six weeks after the initial surgical proce-dure, radiographs showed the head of the femoral compo-nent to be reduced in the acetabulum. The patient was takento the operating room the following day. The Ilizarov appa-ratus was removed, and the patient wore an abduction bracefor three days. The patient was then managed with a hippantaloon spica cast that ended proximal to the knee joint tofacilitate walking.The hip pantaloon spica case was maintained for eightweeks, after which time the patient was allowed to bear weightas tolerated and physical therapy was begun. The patient re-turned for follow-up two years later. He was able to walk with-out assistive devices and had a mild limp due to the residualperoneal nerve palsy from the initial injury. Radiographsmade at that time showed that the total hip replacement re-mained reduced (Fig. 3). In spite of a trochanteric nonunion,he had had a minimal Trendelenburg sign and could resistgravity in side-lying abduction.Discussionhe use of external fixation for lengthening before totalhip arthroplasty in patients with developmental dyspla-TFig. 2Postoperative appearance of the Ilizarov device, placed with the patient in the lateral decubitus position, with transos-seous wires proximally and half-pins distally.413 THE JOU R N A L OF BO N E & JO I N T SU RG ER Y ·  JB JS .ORGVOLU M E 88-A ·  NU M B ER 2 ·  FE B R UA R Y 2006US E OF A N ILI Z A ROV APPA R AT U S TO PE R F O R M CL OS E D RE DU C T I O N OF A CH RON I C PROX IM AL DI S LO C A T I O N FOL LOW I NG THAsia of the hip has been described2,3. However, we found no re-ports describing the use of external fixation to reduce achronic dislocation after total hip arthroplasty. In the case ofour patient, the components were well aligned and well fixedand therefore avoiding component revision was a priority. Arapid rate of distraction (4 mm per day) was used becausewe were returning the neurovascular structures to their nor-mal anatomic length. However, concern should remain asneurologic compromise can still occur, especially toward theend of the lengthening period, because of long-standingscarring of the nerves and adjacent soft tissues. The patientshould be educated with regard to the signs of neural irrita-tion. If such signs develop, the distraction should be slowedor even temporarily halted.We believe that the use of the anterior-to-posteriortransosseous wires in the ilium are important to the successof forceful distraction across the hip. On the basis of our ex-perience in similar cases, we believe that fixation with half-pins alone is associated with rapid loosening. In cases such asthe one described in the present report, in which large forcesmust be generated to overcome scarring and soft-tissue con-tracture, the tensioned wires oriented at 90° to the force vec-tor are essential. Obviously, experience with the use oftransosseous wires and knowledge of the anatomy are crucialto the safe employment of this technique.While complications such as pulmonary embolism andpin-track infection can occur in association with the use ofthis method, the very difficult case described in the present re-port was treated successfully. A much higher level of functionwas restored, equal limb lengths were restored, and an openprocedure was avoided. We believe that gradual distractionwith an external fixator is a viable option for the treatment ofchronic dislocation following total hip arthroplasty. R. Allen Butler, MDDepartment of Orthopaedic Surgery, Tulane University School of Medi-cine, 1430 Tulane Avenue, SL-32, New Orleans, LA 70112. E-mail address for R.A. Butler: allenbutler1@cox.netJoseph R. Hsu, MDDepartment of Orthopaedic Surgery, William Beaumont Army Medical Center, 5005 North Piedras Street, El Paso, TX 79920. E-mail address for J.R. Hsu: joe.hsu@us.army.milRobert L. Barrack, MDDepartment of Orthopaedic Surgery, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8233, St. Louis, MO 63110. E-mail address for R.L. Barrack: barrackr@wustl.eduThe authors did not receive grants or outside funding in support of their research for or preparation of this manuscript. They did not receive pay-ments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.doi:10.2106/JBJS.E.00529Fig. 3Radiograph, made two years after removal of the brace, demonstrating maintenance of reduction of the total hip implant and equal limb lengths.414 THE JOU R N A L OF BO N E & JO I N T SU RG ER Y ·  JB JS .ORGVOLU M E 88-A ·  NU M B ER 2 ·  FE B R UA R Y 2006US E OF A N ILI Z A ROV APPA R AT U S TO PE R F O R M CL OS E D RE DU C T I O N OF A CH RON I C PROX IM AL DI S LO C A T I O N FOL LOW I NG THAReferences1. Phillips CB, Barrett JA, Losina E, Mahomed NN, Lingard EA, Guadagnoli E, Baron JA, Harris WH, Poss R, Katz JN. Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement. J Bone Joint Surg Am. 2003;85:20-6.2. Symeonides PP, Pournaras J, Petsatodes G, Christoforides J, Hatzokos I, Pantazis E. Total hip arthroplasty in neglected congenital dislocation of the hip. Clin Orthop Relat Res. 1997;341:55-61.3. Lai KA, Shen WJ, Huang LW, Chen MY. Cementless total hip arthroplasty and limb-length equalization in patients with unilateral Crowe type-IV hip dislocation. J Bone Joint Surg Am. 2005;87:339-45.

Use of an Ilizarov apparatus to perform closed reduction of a chronic proximal dislocation following total hip arthroplasty: A case report

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Use of an Ilizarov apparatus to perform closed reduction of a chronic proximal dislocation following total hip arthroplasty: A case report

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