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Journal of Pediatric Orthopaedics 21:130134 2001 Lippincott Williams & Wilkins, Inc.

, Philadelphia

Current Issues
Edited by Carl L. Stanitski, M.D.

Hip Arthrodesis: Revisited

Christopher A. Iobst, M.D. and Carl L. Stanitski, M.D.
Advanced, unilateral hip disease in an active, otherwise healthy, adolescent presents a challenging problem for orthopaedic management. Although arthrodesis of the hip is performed less frequently now than in the past, it remains an effective treatment choice for monoarticular hip disease in young patients. Hip arthrodesis can provide complete pain relief and allow strenuous activity in patients too young for replacement arthroplasty. Unfortunately, temporal and cultural changes, including exposure to people (usually older) who have had excellent outcomes from total hip arthroplasty, have increased the expectations of patients (31). Consequently, hip arthrodesis has become a relatively unpopular treatment choice among patients and surgeons. Despite technical advances in total hip arthroplasty, including the use of noncemented components, hip replacements are not currently known to last without revisions for 30 to 40 years in vigorous, active individuals. Hip arthrodesis, conversely, can provide a durable, functionally satisfying alternative to arthroplasty and allows young patients with severe unilateral hip disease to lead productive lives. Lagrange of France is credited with performing the first hip arthrodesis on a 16-year-old girl in 1886 (6). His attempt at wire fixation failed, and a pseudarthrosis developed (26). Nevertheless, his pioneering approach served, with modifications, as the procedure of choice for half a century for painful conditions of the hip joint, especially at a time when tuberculitic and pyogenic arthritis were prevalent. In 1908, Albee (2) performed the first hip arthrodesis in the United States. Subsequent authors advocated numerous techniques ranging from extraarticular fusion with iliofemoral bone grafts (usually for tuberculous or septic sequelae) to intraarticular fusion with postoperative immobilization in a cast (25). Internal fixation was introduced during the 1930s to 1950s (van Nes, Burns, Watson-Jones, Kuntscher) in an effort to increase stability, decrease the rate of pseudarthrosis, maintain the position of fusion, and mobilize the patient more rapidly (11). All these methods required prolonged immobilization in bed or in a cast, and pseudarthrosis rates remained disturbingly high (647%) (11). Farkas,
Address correspondence to Dr. Carl L. Stanitski, Department of Orthopaedic Surgery, Medical University of South Carolina, 96 Jonathan Lucas St., Suite 708, Charleston, SC 29425, U.S.A. From the Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, South Carolina, U.S.A.

in 1939 (13), first described the addition of a subtrochanteric osteotomy to the arthrodesis in an attempt to decrease the rate of nonunion by eliminating the long femoral lever arm, thereby reducing tension across the fusion site. Charnley (9) attempted to achieve greater bone contact and stability with central dislocation and internal compression fixation in 1953. Modern techniques of hip arthrodesis began with Schneiders introduction of the Cobra-head plate in 1966 (30). This revolution in internal fixation techniques provided surgeons with a more secure and reliable arthrodesis technique that required minimal external immobilization and allowed earlier patient mobilization. Current techniques using internal or external fixation allow precise positioning of the hip, preservation of bone stock, early weight bearing, and have very low rates (010%) of nonunion (26). Numerous surgical techniques of arthrodesis exist today, but the superiority of any particular technique has not been demonstrated. All methods of fixation have the same goals: (a) primary union of the arthrodesis within a reasonable time; (b) avoid postoperative casting; (c) minimize inequality of leg lengths; (d) preserve knee motion; (e) achieve proper position of the fused hip; and (f) facilitate potential future conversion to total hip arthroplasty by retaining the hip abductors (28). Four basic techniques are mentioned in the recent literature. The most commonly described technique uses the Cobrahead plate, which can be placed laterally or anteriorly and follows established principles of stable internal fixation and tension-band compression at the site of hip arthrodesis (18,24). Its major advantages are that it allows precise positioning of the hip, has high rates of union, and diminishes the need for postoperative immobilization. Critics of the Cobra plate note the necessity of extensive soft tissue dissection, especially the detachment of the abductor muscles, which may have an adverse effect on later conversion to a total hip arthroplasty (29). Murrell and Fitch (26) described a technique that reattaches the greater trochanter to the Cobra plate in an effort to preserve the hip abductors. Klemme et al. (18) noted that adolescents at or above the 90th percentile for their age-determined weight were at a significant risk for pseudarthrosis when arthrodesis was attempted with the Cobra plate. The Cobra plate, despite some limitations, remains a reliable choice for achieving a solid, painless fusion in most adolescents (Fig. 1). 130



FIG. 1. A 14-year-old boy with avascular necrosis of his femoral head secondary to an acute slipped capital femoral epiphysis. An arthrodesis was performed using a Cobra plate and an anterior pelvic reconstruction plate. Note that the abductor position is maintained.

A second technique uses an external fixator to achieve arthrodesis. This method does not disturb the anatomy of the proximal femur, which facilitates conversion to a total hip arthroplasty in the future, if necessary. It also allows precise positioning of the hip and lets the patient remain ambulatory while using the external fixator. However, external fixator patients hips tend to drift into slight adduction, and the surgeon should plan the arthrodesis accordingly (33). A third method, the Thompson technique (28), internally fixes an autogenous iliac bone graft onlay anteriorly over the pubic ramus and femoral head and neck. This method uses an intertrochanteric osteotomy to facilitate proper positioning of the hip and to reduce forces across the hip by decreasing the long lever arm of the femur. Whereas this osteotomy promotes fusion, it theoretically makes later conversion to a total hip arthroplasty more difficult by altering the alignment of the proximal femur. The fourth technique uses internal fixation techniques such as the dynamic hip screw or retrograde cancellous screws placed across the joint to achieve a compression arthrodesis. These techniques use familiar surgical approaches with limited exposure and do not disturb the hip

abductors. Bone stock is preserved, and strong compression across the fusion is possible. Femoral osteotomy is not required. Bone graft can be placed in the acetabulum to make up voids created by an avascular femoral head (Fig. 2). The ideal candidate for hip arthrodesis is an adolescent or young adult with incapacitating unilateral hip disease unresponsive to nonoperative measures. Physical examination should concentrate on evaluation of the lower back, contralateral hip, and ipsilateral knee. Pain or disability in any of these areas may be a relative contraindication to arthrodesis. Normal range of motion of the ipsilateral knee and ankle, contralateral hip, and lumbar spine is necessary for compensatory mechanisms of gait required by the arthrodesed hip. The patient should be free from systemic conditions limiting physical activity (i.e., juvenile rheumatoid arthritis) and have a normal life expectancy. The ideal position of hip arthrodesis is a subject of debate. The position of fusion recently recommended is 20 to 30 degrees of flexion, neutral abductionadduction (up to 5 degrees of adduction), and neutral internal external rotation (or slight external rotation) (27). Although most surgeons would agree with these parameters, the literature has wide-ranging recommendations (1,3,5,7,11,15,25,29,31). The amount of flexion is important to facilitate comfortable gait and sitting. Ewald et al. (12) found that hips fused in approximately 30 degrees of flexion had a normal energy expenditure with walking at a comfortable speed. Gore et al. (15) revealed that patients with a hip fused in 38 to 57 degrees of flexion tended to walk with smoother forward progression than did those with hips fused in greater or lesser amounts of flexion. Liechtis (21) biomechanical analysis suggests that fusing the hip in 15 to 25 degrees of flexion would produce the best conditions for walking and climbing stairs. The amount of flexion of the hip

FIG. 2. A 14-year-old boy with avascular necrosis of his femoral head. An arthrodesis was performed using a 150-degree dynamic hip screw and 7.3-mm cannulated screws. No change was done to the abductor mechanism.

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CURRENT ISSUES ational level was rarely a problem (31). In another longterm follow-up (average, 35 years), 71% of patients could walk more than 1 mile (7). Fulkersons 1977 review (14) of nine pediatric patients undergoing hip arthrodesis stressed the excellent functional results at an average of 9 years after surgery. It is important to remember that these results represent patients who were fused with old techniques, and even more impressive outcomes can be expected from modern fusion methods. Early reports of hip arthrodesis had a 15 to 30% pseudarthrosis rate, which has decreased with current techniques to approximately 0 to 10% (26). With regard to the potential problems in joints adjacent to the fused hip, long-term studies indicated that secondary symptoms did not develop until an average of 20 to 25 years after arthrodesis, and these symptoms were usually not debilitating (7,31). Pain in the lower back is the most common reported symptom after fusion. Callaghan et al. and Sponseller et al. (7,31), in long-term follow-up studies, have an incidence of back pain close to 60%, which is similar to the rate of back pain in the nonarthrodesed working man. Although one study reported the onset of low-back pain as early as 6.6 years after surgery (3), Liechti found a 49% improvement in low-back complaints after hip arthrodesis in patients seen 4 to 5 years after surgery (21). In patients who did develop low-back pain severe enough to require hip arthroplasty intervention, studies show that take-down of the arthrodesis and conversion to total joint arthroplasty relieves the back pain in most patients (4,17). Ipsilateral knee disorders are the second most common finding after hip arthrodesis and may ultimately cause more problems than low-back pain. Collateral ligamentous laxity was often seen in the ipsilateral knee but was not found to be functionally significant (31). A knee-pain incidence of 8 to 57% was noted in studies with adequate follow-up. Up to 20% of these patients required operative intervention to control disabling pain (3). The changes in gait pattern after hip arthrodesis have been studied. Not surprisingly, overall walking speed is decreased (11). On the basis of oxygen-consumption calculations, gait is 53% as efficient as normal (11). Gore et al. (15) demonstrated that increased transverse rotation of the pelvis, increased motion of the opposite hip (particularly full extension), and continuous flexion of the ipsilateral knee during stance phase of gait were required to compensate for a fused hip. Gore et al. stated that the best gait can be expected in young patients with a supple lumbar spine which allows pelvic tilt, with normal hip motion on the sound side, normal knee motion on the side of the fusion, minimum limb length inequality, and a fusion position in which excessive adduction is avoided. The data on outcomes after total hip replacement in young patients with rheumatoid arthritis or other collagen diseases show satisfactory results, probably because they have a compromised general level of activity (28). In young, healthy, and active patients, the outcome data on hip-replacement arthroplasty is dismal. Chandler et al.

appears to be linked to the development of back pain, but the data are contradictory. Callaghan et al. (7) found that patients without back pain at long-term follow-up tended to have a more flexed hip position and recommended a fusion in 35 to 40 degrees of flexion. This is supported by the work of Roberts and Fetto (29), who found that patients fused in 30 degrees of flexion had less back pain than did those fused in 20 degrees of flexion. Benaroch et al. (3) demonstrated that, in their series, patients whose hips were fused at approximately 20 degrees rather than 30 degrees of flexion had lower incidences of back pain. The literatures recommendations on the amount of abductionadduction is not much clearer. According to the calculations of Lindahl (22), as little as 3 degrees to either side of the midline can cause a 1-cm change in leg length, which underscores the critical importance of obtaining a precise arthrodesis. Because abduction of the hip has been shown to cause more knee varus deformity, increased ipsilateral knee and back pain, and more severe radiographic changes in the knee, most authors agree that abduction should be avoided (3,5,7,11,31). Some authors still support an abducted position because it can decrease a leg-length discrepancy and allows maximal bone contact between the femoral head and acetabulum (25). Price et al. (28), Fulkerson (14), and Benaroch et al. (3) also demonstrated a progressive drift of the fused hip into slight adduction in the skeletally immature patient and consequently recommended fusing in slight abduction (1 2 degrees) to compensate for this occurrence. Whereas Carter and Wickstrom (15) advocated fusion in 5 to 10 degrees of adduction to prevent nonunion, most authors agree with a recent assessment that neutral abductionadduction is sufficient (3,11,27). Patients with hips fused in 10 degrees of adduction or less tended to walk faster and to show less irregularity in forward progression (15). Rotation position is much less controversial. Internal rotation should be avoided to prevent interference with the opposite limb during gait. External rotation is important because it helps the patients to put on their shoes. Ahlbach and Lindahls (1) recommendation of up to 20 degrees of external rotation may be extreme, but ranges between 0 and 10 degrees are often quoted in the literature (3,11,27). Precise hip attitude has enormous importance during fusion surgery. Proper patient positioning and intraoperative radiographs are advised to check hip fusion alignment. Despite being a potentially unpopular treatment choice, hip arthrodesis has a long-standing, successful track record of providing patients with a durable, stable, essentially painless hip joint that allows an active, productive life. Long-term follow-up of hip arthrodesis (average, 38 years) shows that 78% of patients were satisfied with the result (31). All of the patients in this study were able to work, and 34% could not think of any significant limitation of activity caused by arthrodesis. The patients considered their overall activity levels similar to those of their peer group. This is best demonstrated by the finding that, although the ability to compete seriously in most sports was impaired, participation on a recreJ Pediatr Orthop, Vol. 21, No. 1, 2001

CURRENT ISSUES (8) reported a 23% revision rate and an additional 30% with progressive loosening of the prosthesis at 5-year follow-up. Dorr et al. (10) reported on 81 patients who had 108 primary total hip arthroplasties when they were younger than 45 years, and found rates of failure of 22% at 5 years and 28% at 5 to 10 years. Charnley (9) stated that loosening occurs in approximately 40% of people younger than 40 years who undergo total hip arthroplasty for unilateral osteoarthritis of the hip. Klassen (19) showed there was a greater than 50% failure rate in young people undergoing total hip arthroplasty. With newer implant designs and fixation methods, the rates of failure may be reduced. Despite this, for otherwise normal, active, young patients, repeated revisions seem inevitable over a span of 20 to 30 years of use. Total hip arthroplasty may be considered in a child with sequelae of collagen vascular disease or rheumatoid arthritis, but hip arthrodesis should be the primary procedure of choice in young healthy patients with unilateral hip disease in the year 2000. Although good long-term results can be obtained with hip arthrodesis, the possibility of future conversion to a total hip arthroplasty should be considered when planning a hip arthrodesis (5). The conversion of a hip arthrodesis to a replacement arthroplasty is technically more difficult than a primary hip arthroplasty performed for more common indications. The patient will have distorted anatomy from previous surgery, and the joint space cannot be used as a landmark (17). A critical element in determining favorable results is the condition of the hip abductor musculature. One author (20) suggested that hip conversion may actually compromise gait because of difficulty powering the newly mobile hip with weak abductors, requiring walking aids in patients who did not require them before the operation. Kilgus et al. (17) found that postoperative function of the abductor muscles depended on the preoperative quality of the muscles and on the accuracy of the biomechanical restoration. They found that postoperative strength of the muscles of the hip improved for 2 years or more in most patients, with decreased dependence on supports for walking. This information reinforces the importance of maintaining anatomic abductor positioning at the time of arthrodesis. The main indication for converting a hip arthrodesis to a total hip arthroplasty is pain in adjacent joints. The literature demonstrates that conversion to a total hip arthroplasty generally has favorable results. Lubahn et al. (23) noted that pain relief was achieved in 12 of 13 patients with pain in the lower back, four of four patients with pain in the ipsilateral knee, and seven of 10 patients with pain in the contralateral hip after conversion. Hardinge et al. (16) reported that 54 of 74 patients had complete relief of pain in lumbar spine, and a further five were very much improved after conversion. Brewster et al. (4) reported 31 of 33 patients had complete relief of their preoperative pain, which included pain in the hip, back, and knee. At 1 year after surgery, 28 of the 33 patients required no support for walking and said they could walk an unlimited distance. Functionally, although


motion of the hip remains somewhat restricted compared with the range that can be expected after primary hip arthroplasty (average, 7587 degrees flexion) (4,17), patients have improved ability to go up and down stairs, the ability to tie shoes and put on socks, an increase in leg length (average, 2.9 cm), and an increase in the period of sitting in comfort (4). Strathy and Fitzgerald (32) reported a 48% failure rate at 10 years after conversion to total hip arthroplasty and contradicted good results reported by others. They thought that their results may have been limited because they represent surgical techniques and prosthetic components available between 1970 and 1974. With modern implants and surgical techniques, these dismal results should certainly improve. In general, conversion of a hip arthrodesis to a total hip arthroplasty should have favorable outcomes. Most patients are satisfied with their conversion procedure because of relief of pain in the back, knee, and hip, improved mobility of the hip, and improvement of leglength discrepancy (17). If the arthrodesis does not significantly compromise the regional anatomy, conversion should not pose significant technical difficulty for the surgeon. In summary, advanced, destructive, unilateral hip disease in the active adolescent remains a difficult problem to treat. Because of the many reservations regarding hip replacement in young, healthy adults, it is necessary to consider options that relieve pain and retain function, especially if conversion to total hip arthroplasty is possible at a later date. Hip arthrodesis is such an option (11). If the patient is carefully selected and adequately counseled before surgery, especially about the 9 to 12 months needed for gait normalization, and modern techniques of arthrodesis are used, a high success rate can be expected. Christopher A. Iobst, M.D. Carl L. Stanitski, M.D. Medical University of South Carolina Charleston, South Carolina, U.S.A. REFERENCES
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