Endoprosthesis in paraplegics with periarticular ossi cation of the hip

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1 (2003) 41, 29 ± 33 ã 2003 Interntionl Society All rights reserved 1362 ± 4393/03 $ Originl Article Endoprosthesis in prplegics with perirticulr ossi ction of the hip SWJ Becker*,1,KRoÈ hl 1 nd F Weidt 1 1 Centre for Spinl Injuries, BG Trum Centre, Hlle Sle, Germny Study design: Clinicl study. Ojectives: To evlute indictions of hip endoprosthesis in perirticulr ossi ctions. Setting: A Injury Centre in Germny. Methods: Clinicl exmintion, X-ry control. Results: Surgery of perirticulr ossi ction (prosteorthropthy, POA) either involves simple resection of the ossi ction or removl of the hip. The ltter hs n impct on the sitting posture with concomitnt incresed pressure sore risk. Nevertheless the hip is iomechniclly importnt in prplegics. We re investigting the outcome of totl hip replcement (THR) in ptients with nkylosis due to perirticulr ossi ction. Six hip replcement cses seen in follow-up of up to 24 months showed no loosening, with good moility of the joint. We follow strict periopertive POA prophylxis, which resulted in ech cse reporting only slight recurrence (Brooker 1 ± 2) without ny loss of functionl moility. Conclusion: In nkylotic hips with moility/socil/hygenic prolems we fvour hip replcement in cses with osteorthritis or high risk of osteoporotic frcture. A replcement of the joint should e preferred to Girdlestone opertion. (2003) 41, 29 ± 33. doi: /sj.sc Keywords: perirticulr ossi ction; hip endoprosthesis; joint replcement; spinl cord injury Introduction Prosteorthropthy (POA) is one of the most mysterious nd disling complictions fter pr- or tetrplegi. The fct tht its origin is still not entirely known is re ected y the di erent synonyms of this disese: perirticulr ossi ction, myositis circumscript, neurorthropthy, prrticulr osteom, nkylosing pelvospondylitis nd neurogen romyopthy. However, the clinicl course is uniform; once the ossi ction is complete, the result is totl nkylosis of the joint. This reduces the cpility of multion signi cntly. 1 In the cse of ossi ction of the lower extremities, the ptient runs n incresed risk of pressure sores nd UTI ecuse of hygienic di culties/ctheteristion prolems. 2,3 Mteril nd methods We performed clinicl study of prplegic ptients with POA, to oserve the outcome of hip preserving nd replcing opertive procedures. The ptients were evluted pre-nd postopertively t 6 month intervls with X-rys nd clinicl exmintion, including pssive ROM (rnge of motion (see Tle 1)). *Correspondence: SWJ Becker, Centre for Spinl Injuries, Berufsgenossenschftliche Kliniken Bergmnnstrost Merseurger Str. 165, D Hlle/Sle, Germny In joint preserving procedures, we removed the POA vi n nterior or lterl incision. In joint replcing procedures, we removed the POA nd implnted cemented totl hip prosthesis with semi cptive cup. The preopertive choice of hip preserving nd removing procedures is sed upon the moility of the joint, hence in cses with moility 4508 exion we generlly try to preserve the joint. Surgicl technique All of the treted cses showed severe (grde 4 POA fter Brooker) of the hip (see Tle 1). The loclistion of the POA ws on the nterior, lterl nd posterior spect of the joint. We therefore performed douleincision technique, with the ptient in supine position. The nterior incision ws used to identify the vessel/nerve undle nd to dissect the POA long the rectus femoris muscle. After completion of the nterior resection, stndrd lterl pproch with muscle identifying technique (prtil resection of medil glutel muscle, identifying nd deinsertion of miniml glutel muscle) ws performed followed y POA resection nd stndrd THR implnttion. The opertion ws completed with seprte reinsertion of the miniml nd medil glutel muscles. In order to void recurrence to POA we treted ll cses with

2 30 Endoprosthesis in prplegics with perirticulr ossifiction of the hip Tle 1 Age (yers)/ Sex Ptients nd outcome ASIA Time of opertion fter primry injury (months) POA pre-op POA t follow-up ROM exion pre-op ROM exion t follow-up Follow-up (months) 23, mle C , mle B ± , mle D , mle D , mle B , mle B preopertive rdition of 6 Gry nd postopertive 6 weeks course of NSAIDS (indomethcin). Results Between 1998 nd 2000 we treted 144 ptients with cute pr- or tetrplegi. Out of these, 19 ptients showed POA of the hip. No cses received POA prophylxis fter the injury. Twelve cses were e ectively treted with physiotherpy due to POA5grde II fter Brooker. 4 In those cses n opertive procedure ws voided. However, seven ptients did not respond to physiotherpy nd developed complete joint nkylosis with grde 4 ossi ction fter Brooker within 6 months of the injury. All of the ptients were prplegics. A simple resection of the POA ws performed in two cses. Two ptients showed ilterl ossi ction; in one of those cses we performed simple excision of the POA on one side nd implnted prosthesis on the contrlterl side (see Figure 1,). Overll we implnted n ipsilterl prosthesis in four cses, nd ilterl prosthesis in one cse (see Figure 2,). All ptients received the periopertive prophylxis s mentioned ove. The men ge of the THR group ws 39.4 yers (23 ± 57 yers) of the POA group 38 J. Interestingly ll ptients were mle. The follow-up period ws 6 ± 24 months, the results of the THR group re shown in Tle 1. The ROM of the hip joint ws stisfctory in ll cses, without gross deteriortion t follow-up. Both ptients with simple POA resection showed 908 exion t follow-up (12 nd 24 months). In the cse with ilterl ossi ction nd unilterl prosthesis the ROM of the prosthetic joint (1008) ws slightly etter thn tht of the preserved joint (908) on follow-up. Both groups showed no di erence in the recurrence of POA, nd in no cses, cused loss of moility. No post-op infections occurred, no prosthetic loosening ws seen on follow-up. All cses reported full moilistion in wheelchir, without hygienic prolems or pressure sores nd were furthermore le to e moilised in stnding frme. Discussion Perirticulr ossi ctions in prplegics occur most often in the hip joint. 5 Severe (grde 4) ossi ction of Figure 1 () Mle, 23 yers, prplegi ASIA B, ilterl POA grde 4 fter Brooker (rrows), pre-opertion. () Sme ptient fter resection right hip, THR left hip X-ry, 6 months fter THR the hip is fortuntely rre nding, 6 s is lso shown in our study, ut nevertheless hs n importnt negtive in uence on the rehilittion of prplegic ptient. The hip is typiclly xed in externl rottion nd slight exion. The degree of the exion might vry, leving the ptient sometimes unle to use wheel-

3 Endoprosthesis in prplegics with perirticulr ossifiction of the hip 31 Figure 2 () Mle, 52 yers, prplegi ASIA D, left side cetulr frcture, ut ilterl POA grde 4 fter Brooker (rrows). () Sme ptient fter ilterl THR, X-ry 1 yer fter opertion chir. However, multiple studies hve shown tht impired ROM of the hip cuses distured sitting posture nd therefore n incresed risk of pressure sores. 1±3 Therefore it is importnt to moilise the joint to increse ROM, so the min gol should e the moilistion of the hip. This tretment regime is not restricted to the hip lone, ll joints pro t from either soft tissue relese or resection of the ossi ction. To rech this gol, joint replcements of other joints my e helpful nd necessry. In our study (see Tle 1), ve out of six cses showed exion ROM of less thn 108 nd no rottion or /dduction cpcity, s such those ptients did hve totl nkylotic joint (see Figure 2,). The surgicl tretment of POA cn e restricted to removl of the POA nd prophylctic mesures. But one hs to consider tht nkylosis nd ossi ction re lwys enhncing locl osteoporosis ecuse the xed joint most often does not llow norml wheelchir or stnding frme moilistion. Thus, the locl osteoporosis is considerly incresed. This my led to severe osteoporosis of the hed of femur, which my not tolerte weight ering once the `protective' ossi ction is removed. On the other hnd, locl excision my dmge the lood supply to the hed of the femur. To void the osteonecrosis, it is therefore dvisle to dissect the tissue crefully nd locte the circum ex femorl vessels. As descried y Rossier, 6 the POA is lwys extrrticulr, ut my e ttched to the cpsule of the hip. Therefore it my e di cult to preserve the cpsule of the hip joint. It my lso e di cult to de ne the order of the POA, resulting in n occsionl injury to the neck of the femur with consecutive incresed frcture risk. Sometimes the preopertive X-rys give clue out the osteoporosis of the hed of the femur. If in ny dout, the hip joint cn e explored surgiclly nd the degree of the osteoporosis ssessed intropertively. In cses in which we decided intropertively on the implnttion of prosthesis, the hed turned out to e totlly osteoporotic with severe suchondrl osteolysis nd preservtion of just the outer surfce of the hed. This sitution cn e compred to lloon lled with liquid surrounded y thin outer surfce. Regrding the two incision technique, the generl lterl pproch does not ect ny muscle which my lter e needed to cover pressure sore. The incision is crefully chosen so it will not split or dmge the tensor fscie lte muscle. Should defect of the greter trochnter develop lter on, this muscle cn still e used. Also the lterl vstus muscle is spred nd cn e used lter on. The nterior incision my dmge the rectus nterior, however, this muscle is in generl not used for p procedures. So why should we not perform simple resection of the joint without implnttion of prosthesis? First of ll, we hve to consider the muscle forces round the hip. If pr- or tetrplegic ptient is su ering from spsticity, the muscle forces re dislocting the femur crnilly nd dorslly, s seen typiclly in dysplstic hips. 7 Furthermore, the muscle forces of the dductors will cuse n dduction, nd s consequence, the ptient will develop locl pressure points, either lterlly over the greter trochnter, or dorslly. Further di erences of hip resection etween wlking nd prplegic ptient hve to e considered. In Girdlestone sitution on wlking person, the mjor im of the physiotherpy tretment is to centrlise the femur whilst preserving rnge of motion, so tht the femur is creting neorthrosis with the cetulr roof. In cses with femorl neck frcture, centrlistion does not occur, ecuse the necrotic frgment will impir centrlistion of the femur. In those cses either THR or n excision of

4 32 Endoprosthesis in prplegics with perirticulr ossifiction of the hip this frgment my e performed. The postopertive physiotherpy is supported y externl rces to centrlise the femur. In wheelchir ound ptient these rces cnnot e pplied. The sitting posture in the wheelchir, with oth legs in dduction, is dislocting the femur lterlly, resulting gin in pressure sores. This condition cn e compred to neglected femorl neck frctures with consecutive disloction of the femorl hed (see Figure 3 ± c). The hip prosthesis is centrlising the joint whilst llowing n optiml rnge of motion. Becuse we use semicptive cup, the risk of disloction my e reduced. Our limited ptient numer is of course not su cient to provide hrd dt, nd this pproch hs to e vlidted in severl yers whether to e superior to THR without semi-cptive cups. Nevertheless we recommend to strictly follow the postopertive tretment rules of THR, voiding rottionl nd dduction mnoeuvres until the sixth postopertive week. Intropertive lood loss is minor concern in our opinion, if we compre our results etween simple removl of the POA nd removl+implnttion of THR. Blood loss of course occurs during simple POA resection, n verge of 2100 mls hve een descried. 3 We re routinely using cell-sver during the opertion. In our study, the lood loss in cses with POA resection ws on verge 3000 mls with 700 mls retrnsfused, in cses with THR 3375 mls with 770 mls retrnsfused. Postopertive lood loss is minly due to the lrge open spongiose one res cused y the removl of the POA. In cemented totl hip, the dditionl open spongiose surfce of the femorl shft nd the cetulum is closed with c Figure 3 Mle, 41 yers, prplegi ASIA A. () Frctured neck of femur (rrow) nd disloction of the left hip. () Note dduction of leg nd protrusion of proximl femur lterlly in supine position (rrow), clofen pump (*). (c) Recurrent pressure sores grde 5 (Dniel/Seiler) left hip

5 Endoprosthesis in prplegics with perirticulr ossifiction of the hip 33 cement nd is not the reson for n incresed postopertive lood loss. The only mjor di erence is the opertion time, which is longer in cses with comined POA resection nd THR (220 min compred to 180 min in cses with simple resection). All of our ptients pro ted from the intervention. The ptients with simple resection showed good postopertive ROM, which cn e compred to long-term study showing good results fter POA resection regrding sitting posture nd ROM. 2,8 We cnnot compre our results in the prosthetic group, ecuse so fr no studies out the outcome of primry THR fter POA in prplegics hve een pulished. Severl studies focused on THR in ptients with cererl plsy 9,10 nd showed disloction risk of 10 ± 26%, loosening risk of 5 ± 20% nd risk of POA recurrence of 53 ± 58%. However, semi cptive cups were not used in those studies, so we should expect improved disloction rtes in our series. In our group, no loosening ws seen fter still limited follow-up. We expect loosening rtes to e higher thn in nonconstrined prosthesis in wlking ptients, ut we do not think higher loosening rte should dominte the decision on totl hip replcement in prplegic ptients. However, even if long-term study eventully shows higher loosening risk, either revision cn e performed or the prosthesis cn e explnted, leving the ptient in the sme sitution s fter primry hip resection, ut hving so fr pro ted from the ene ts of good sitting posture nd lower pressure sore risk. We furthermore recommend periopertive POA prophylxis. The ene t of indomethcin nd singledose rdiotherpy is widely known, 11 recently oth therpies lso hve proven to e of ene t in prophylxis of prplegic ptients. 12,13 A pre-opertive rdition should e performed on the sme dy s the opertion. This precution is reducing the leeding complictions ecuse of rective vsodilttion 8 h fter rdition. It is therefore dvisle to perform the opertion well efore this time limit. In our study ll cses showed recurrence of POA grde 1 or 2 fter Brooker, however this recurrence did not chnge the functionl outcome. This cn e compred to the ove nmed studies, which showed high recurrence risk, ut no signi cnt impct on the ROM. The rdition is performed nteriorly so s to void skin necrosis either lterlly or dorslly with consecutive risk of pressure sores s descried y Speed. 3 Until now we still lck n optiml prophylxis to void POA fter trum. Therefore the surgicl tretment remins necessry ut chllenging. Although ech cse hs to e ssessed individully, we feel tht n ggressive tretment with THR is indicted, even in young ptients (see Figure 1,), in order to void the consequences of Girdlestone sitution. Even Girdlestone sitution might e reversed to prosthesis, ut once pressure sore hs invded the joint nd cused infection, the tretment options regrding implnttion of prosthesis re very limited. In conclusion we recommend the use of totl hip replcement, s well estlished method in orthopedics, in pr- or qudriplegic ptients to void further complictions nd loss of independence. References 1 RoÈ hl K, Weidt F, Becker S. Behndlungsstrtgien heterotoper Ossi ktionen der oeren ExtremitÈ ten ei RuÈ ckenmrkverletzten. Trum Berufskrnkh 2000; 2: 358 ± Suro JV, Grrison SJ. Heterotopic Ossi ction: Dignosis nd mngement, current concept nd controversies. J Med 1999; 22: 273 ± Speed J. Heterotopic Ossi ction. emedicine Journl, 2001, Volume 2, Numer 6. 4 Brooker AF et l. Ectopic ossi ction following totl hip replcement. Incidence nd method of clssi ction. J Bone Joint Surg Am 1973; 55: 1629 ± Gerner HJ. Die QuerschnittlÈhmung. Berlin: Blckwell Wissenschft, 1992; p Rossier AB et l. Current fcts of pr-osteo-rthropthy (POA). Prplegi 1973; 11: 38 ± Becker S et l. Biomechnicl spects in femorl osteotomies for hip dysplsi in dults. J Bone Joint Surg Br 1998; 80 (Suppl): B1 ± B9. 8 Meiners T, Ael R, Bohm V, Gerner HJ. Resection of heterotopic ossi ction of the hip in spinl cord injured ptients. 1997; 35: 443 ± Root L, Goss JR, Mendes J. The tretment of the pinful hip in cererl plsy y totl hip replcement of hip rthrodesis. J Bone Joint Surg Am 1986; 68: 590 ± Buly RL et l. Totl hip rthroplsty in cererl plsy. Long-term follow-up results. Clin Orthop 1993; 296: 148 ± Hofmnn et l. Generl short-term indomethcin prophylxis to prevent heterotopic ossi ction in totl hip rthroplsty. Orthopedics 1999; 22: 207 ± Bnovc K, Willims J, Ptrick L, Hni Y. Prevention of heterotopic ossi ction fter spinl cord injury with indomethcin. 2001; 39: 370 ± Sutter-Bihl ML, Hultenschmidt B, Lieermeister E, Nnssy A. Frctionted nd single-dose rdiotherpy for heterotopic one formtion in ptients with spinl cord injury. A phse-i/ii study. Strhlenther Onkol 2001; 177: 200 ± 205.