TJA in Rare Conditions
Gunshot Wound to the Hip Resulting in a Femoral Head and Acetabulum Fracture Treated With Open Reduction and Internal Fixation and Bipolar HemiarthroplastyCombined fractures of the femoral head and acetabulum due to ballistic injuries are rare injuries, especially in the elderly. We present a case of a 70-year-old female who sustained a gunshot wound to the left hip, resulting in a comminuted femoral head fracture and posterior wall acetabular fracture. She was treated with open reduction and internal fixation of the acetabulum, as well as bipolar hemiarthroplasty for treatment of her femoral head fracture. At her 18-month follow-up visit, the patient was doing well and had no complaints.
Total Knee Arthroplasty With Patient-Specific Instrumentation to Correct Severe Valgus Deformity in a Patient With Hereditary Multiple ExostosesPatients with hereditary multiple exostosis develop several benign osseocartilaginous bulge lesions throughout the body. A 62-year-old woman presented for evaluation of worsening left knee valgus deformity, and left knee pain. She had been diagnosed with hereditary multiple exostosis at the age of 12 years. Radiographic evaluation of the left knee revealed exostoses that caused continuous bulges from cortical bone at the metaphyseal regions of the femur and tibia as well as extra-articular deformity.
Outcomes of Total Knee Arthroplasty in Patients With a Prior Contralateral Above-Knee Amputation: A Retrospective Review of a Nationwide DatabaseTotal knee arthroplasty (TKA) in patients with a prior contralateral above-knee amputation (AKA) is uncommon, with limited literature describing the outcomes. We used a national database to compare the outcomes of primary TKA in above-knee amputees and nonamputees.
Parsonage-Turner Syndrome and Closed-Incision Negative-Pressure Wound Therapy After Total Hip Arthroplasty in a Case of Marfan SyndromeNegative pressure wound therapy (NPWT) is a postoperative wound care method, which has recently become an ongoing field of research in hip and knee arthroplasty. We report the successful management of wound dehiscence and infection after THA in a case of Marfan syndrome by closed-incision negative-pressure wound therapy (ciNPWT). Our patient also developed a rare postoperative neurologic complication, that is, Parsonage-Turner syndrome (PTS). To our knowledge, this is the first report of PTS and ciNPWT use for SSI after THA in a Marfan patient.
Staged Bilateral Total Knee Arthroplasty for Neglected Blount Disease Using a Gap Balancing TechniqueBlount disease is an acquired, asymmetrical disorder of proximal tibial growth that results in a complex three-dimensional proximal tibial deformity, with tibial varus being the dominating feature. Although the exact pathophysiology is unknown, Blount disease is separated into 2 clinical variants, infantile and adolescent, based on the onset of symptoms occurring before or after the age of 10 years. If recognized and treated early, affected patients generally have a favorable prognosis; however, if neglected, it can lead to progressive malalignment and premature osteoarthritis.
Segmental Fractures of the Neck of Femur: Fix or Replace?Combined intracapsular and extracapsular fractures of the proximal femur—segmental fractures of neck of femur (SFNOF)—are rare and complex injuries. Literature regarding SFNOF is very limited; only one small retrospective study and 19 unique case reports have been described. We report the case of a 42-year-old man who suffered a compound subcapital femur fracture type Garden IV and an ipsilateral multifragmentary greater trochanter fracture from severe crush trauma. Neither the precise fracture constellation nor our management strategy, primary cemented total hip arthroplasty combined with tension band cerclage and triple K-wire trochanteric fixation, has been described in contemporary literature.
Complex Primary Total Knee Arthroplasty in a Patient with Achondroplasia, Osteoarthritis, and Severe Coronal InstabilityGenu varum in patients with achondroplasia is common and is often exacerbated by the associated generalized ligamentous laxity. Despite this, development of knee osteoarthritis is rare. There are only a few previously published case reports of total knee arthroplasty in this population. We present 2-year follow-up of a patient with achondroplasia who underwent staged bilateral primary total knee arthroplasties using hinged components. Technical considerations and careful preoperative planning are required in patients with achondroplasia given their small skeletal stature, metaphyseal deformities, and ligamentous laxity.
Bilateral Total Hip Arthroplasty in the Setting of Developmental Dysplasia of the Hip and Extreme Hip Flexion Requirements due to PhocomeliaPhocomelia is a rare congenital birth defect marked by hypoplastic or markedly absent limbs. Developmental dysplasia of the hip (DDH) is a congenital disorder with a failure of the native acetabulum to provide complete coverage over the femoral head. The secondary osteoarthritis that develops from DDH is technically challenging for orthopedic surgeons because of distorted anatomy. The present case describes the diagnosis of Crowe 3 DDH in a phocomelia patient with hyperflexion requirements who successfully underwent staged bilateral total hip arthroplasty via a direct anterior approach.
Spinopelvic Instability in Conversion Total Hip Arthroplasty: A Complicated Case of Loeys-Dietz SyndromeA 53-year-old patient with a history of Loeys-Dietz syndrome (LDS) presented with cutout after a right femoral neck fracture treated with a dynamic hip screw. This was treated with conversion total hip arthroplasty (THA), the second reported THA in a patient with LDS and the first in a post-traumatic reconstruction setting. The patient had 2 episodes of posterior hip dislocations within 2 weeks after the operation requiring a revision THA utilizing dual-mobility bearing to achieve stability. LDS is a connective-tissue disorder that is associated with joint hypermobility and spinal deformities, among other features.
Bilateral Posterior-Stabilized Total Knee Arthroplasty in a Patient With Osteopetrosis and Literature ReviewWe present a case report of a patient with osteopetrosis and refractory bilateral knees osteoarthritis who underwent bilateral total knee arthroplasties (TKAs). After conservative management has failed, surgical treatment with arthroplasty is an excellent alternative with satisfactory outcomes. TKA in patients with osteopetrosis has only been described in 6 other case studies, none of which underwent bilateral TKA. To perform this procedure, additional attention should be directed toward the presurgical planning because of the amplified difficulty of the procedure and the altered bone biology that increases the risks of intraoperative fractures and markedly extends the time of surgery.
Accelerometer-Based, Computer-Navigated Total Knee Arthroplasty to Correct a Complex Deformity in a Patient With Multiple Hereditary ExostosesAccelerometer-based computer-assisted navigation systems (ABCANSs) have been shown to improve alignment accuracy in total knee arthroplasty (TKA) and are effective in treating complex extra-articular deformity. We present an ABCANS-assisted TKA performed in a 68-year-old male with end-stage arthritis of the right knee, in the setting of a severe valgus deformity secondary to multiple hereditary exostoses.
Outcomes of Total Knee Arthroplasty with a Prior Contralateral Above-Knee Amputation: A Report of 10 CasesTotal knee arthroplasty (TKA) in the setting of a prior contralateral above-knee amputation (AKA) represents a rare scenario with limited reported outcomes. As such, it is difficult for surgeons to effectively counsel these patients relative to risks and expected outcomes after TKA. We report outcomes for a series of 10 such patients.
Long-Term Outcomes of the Knee and Hip Arthroplasties in Patients with AlkaptonuriaAlkaptonuria is a rare autosomal recessive metabolic disorder. It is characterized by the accumulation of homogentisic acid in the body due to a lack of enzymes that degrade it. Over time, it results in joint degeneration and eventually leads to ochronosis. Ochronosis refers to bluish-black discoloration of connective and other tissues within the body. In this study, we present 5 distinct cases diagnosed with alkaptonuria. They have undergone 8 total joint replacement surgeries (4 hips and 4 knees) within 8 years (2010-2018).
Rapidly Progressive Osteoarthritis and Acetabular Bone Loss Outcomes for Patients Undergoing Primary Total Hip ReplacementRapidly progressive osteoarthritis (RPO) is a rare condition which is poorly understood. Limited published literature is available. Reported here is a cohort of patients with RPO and acetabular bone loss who underwent primary THA. Risk factors, degree of acetabular bone loss and outcomes are presented. A typical case of RPO is described and investigations discussed. A retrospective audit was undertaken. 49 patients over an 18-year period were included. RPO patients were significantly older (P < 0.01) and had a lower BMI (P = 0.03).
Total Hip Arthroplasty for the Sequelae of Femoral Neck Fractures in the Pediatric PatientAlthough rare, total hip arthroplasty (THA) may be indicated in pediatric patients with degenerative changes of the hip joint after previous trauma. To illustrate management principles in this patient population, this study describes the case of a 15-year-old female who sustained bilateral femoral neck fractures after a generalized tonic-clonic seizure, an atypical, low-energy mechanism for this injury. These fractures were not diagnosed until 14 weeks after the seizure episode, at which point they had progressed to nonunion on the left side, malunion on the right side, and degenerative hip joint changes were developing bilaterally.
Drug-Induced Thrombocytopenia Secondary to Commonly Used Antibiotics in Total Joint ArthroplastyDrug-induced thrombocytopenia secondary to antibiotic exposure is a rare complication more commonly associated with other medications. In this review, we present a case of antibiotic-induced thrombocytopenia and discuss the clinical picture and approach to identifying the complication. With increasing use of antibiotics that may be associated with drug-induced thrombocytopenia in perioperative prophylaxis protocols, surgeons need to be cognizant of this cause of thrombocytopenia in the postoperative patient.
Total knee arthroplasty in hemophilia AHemophilia A is a rare genetic disorder involving a deficiency of clotting factor VIII. Coagulation factor replacement therapy has prolonged the life expectancy of patients with hemophilia, but recurrent hemarthrosis of major joints is often a common occurrence. Therefore, orthopaedic adult reconstructive surgeons increasingly encounter hemophilic arthropathy in young adults and consider treating with total joint arthroplasty. In this report, the authors describe a patient with hemophilia A and severe knee osteoarthritis, who was subsequently treated with primary total knee arthroplasty.
Total knee arthroplasty in osteogenesis imperfectaOsteogenesis imperfecta is a genetic disease resulting in abnormal collagen formation, with multiple clinical manifestations. Advancements in medical and surgical treatments have prolonged the life expectancy of these patients in recent decades. As a result, orthopedic surgeons are likely to be faced with the challenge of performing arthroplasty in these patients on a more frequent basis. Here, we describe a patient with osteogenesis imperfecta and subsequent severe osteoarthritis prompting primary total knee arthroplasty.
Femoral artery injury during total hip arthroplastyThere are an increasing number of vascular complications after hip replacement, some of which can be life-threatening. However, there are few reports of lower limb ischemic symptoms after undergoing an otherwise uncomplicated classic total hip replacement. We report a patient with low weight who developed postoperative limb ischemia resulting from blood clots caused by insertion of a Hohmann retractor close to small anterior acetabular osteophytes. Ultrasonography and angiography revealed her symptoms to be the result of femoral artery intimal injury with lower extremity arterial thrombosis, which led to pain, numbness, and decreased skin temperature.
Hip arthroplasty for osteonecrosis of the femoral head secondary to alcohol abuseAlthough the challenges of hip arthroplasty for avascular necrosis (AVN) are known, limited data exist to describe patient demographics and outcomes in the setting of AVN attributed to alcoholism. We retrospectively identified 43 patients (62 hips) who underwent primary hip arthroplasty between 1999 and 2016 for a diagnosis of AVN of the femoral head with a concomitant diagnosis of alcohol abuse and minimum follow-up of 2 years (mean, 8.6 years). The mean age was 51 years, predominantly male (88%), with a high rate of comorbidities.
Total knee replacement in patients with osteoarthritis and concomitant inveterate patellar dislocationThe inveterate patellar dislocation is an uncommon entity. The most frequent findings correspond to a misaligned valgus associated with lateral patellar dislocation. When severe knee osteoarthritis is present, total knee arthroplasty is an option, whether it is associated or not with realignment of the extensor apparatus. We present a review of published literature on correction of inveterate patellar dislocation associated with knee arthritis and our surgical technique with a case of inveterate patellar dislocation associated with tricompartmental knee osteoarthritis, in which a total knee arthroplasty was performed associated with proximal and distal realignment of the extensor apparatus.
Total knee arthroplasty in patients with multiple hereditary exostosesWe present a case report of a patient with severe valgus deformity of the right knee due to multiple hereditary exostoses (MHEs) treated with total knee arthroplasty (TKA). The surgical management of MHE affecting the knee encompasses exostoses resection, joint deformity rectification, and limb-length discrepancy alignment. On rare occasions, distraction osteogenesis and TKA have been used to correct valgus deformities of the knee. TKA in MHE patients with knee involvement has only been described in 6 cases.
Joint replacement surgery in homeless veteransTotal joint arthroplasty (TJA) in a homeless patient is generally considered contraindicated. Here, we report our known medical and social (housing and employment) results of homeless veterans who had TJA. Thirty-seven TJAs were performed on 33 homeless patients (31 men) at our hospital between November 2000 and March 2014. This was 1.2% of all TJAs. Average age was 54 years. Average hospital stay was 4.1 days. There were no major inpatient complications. Thirty-four cases had at least 1-year follow-up in any clinic within the Veterans Affairs health care system.
Total knee arthroplasty in a patient with hypofibrinogenemiaPatients with afibrinogenemia or hypofibrinogenemia present a unique challenge to the arthroplasty surgeon as fibrinogen is a key contributor to hemostasis. Patients with these disorders are known to have a higher risk for postsurgical bleeding complications. We present the case of a patient with hypofibrinogenemia who underwent an elective total knee arthroplasty. Our colleagues in hematology-oncology guided us initially to achieve and maintain appropriate fibrinogen levels in the early perioperative period.
Total joint arthroplasty in patients with chronic infectious liver diseaseThe opportunity for total joint arthroplasty (TJA) in patients with chronic infectious liver disease is rapidly expanding. This is the product of both superior survival of chronic hepatitis patients, evolving implant technologies, and improvement of techniques in TJA. Unfortunately, treating this group of patients is not without significant challenges that can stem from both intrahepatic and extrahepatic clinical manifestations. Moreover, many subclinical changes occur in this cohort that can alter hemostasis, wound healing, and infection risk even in the asymptomatic patient.
Total knee arthroplasty in multiple sclerosisWe present a case report of total knee arthroplasty complicated by spasticity and contractures in a patient with multiple sclerosis (MS). Four previous case reports in the literature describe adverse outcomes after total knee arthroplasty in persons with MS secondary to severe spasticity. Preoperative, intraoperative, and postoperative considerations for persons with MS, which may help to improve functional outcomes, are discussed. Prospective research is needed among persons with MS to help determine the timing and selection of persons for arthroplasty and to minimize complications related to spasticity.
Total knee arthroplasty in patients with extra-articular deformityMultiple acceptable options are available for the correction of distal femoral deformity associated with knee arthritis. The treatment modality should be chosen based on the extent of deformity and attention to preservation of the collateral ligaments. Surgical options range from osteotomy alone, arthroplasty with intra-articular correction, or arthroplasty with extra-articular correction. Different implant choices and fixation methods for the osteotomy possess advantages and disadvantages which need to be considered carefully.
Concomitant achondroplasia and developmental dysplasia of the hipAchondroplasia (ACH) is the most common form of hereditary dwarfism and presents with multiple musculoskeletal anomalies but is not normally associated with premature hip arthritis. Developmental dysplasia of the hip (DDH) is a spectrum of disease resulting in shallow acetabular depth and a propensity for chronic femoral subluxation or dislocation; it is among the most common causes of premature arthritis. This case report describes the diagnosis of symptomatic DDH in a patient with ACH and highlights difficulties of primary total hip arthroplasty (THA) as a treatment option.
Total knee arthroplasty in ochronosisAlkaptonuria is disorder of tyrosine metabolism due to deficiency of homogentisic oxidase characterized by excretion of homogentisic acid in urine, deposition of oxidized homogensitate pigments in connective tissues and articular cartilages (ochronosis). The result is dark pigmentation and weakening of the tissues resulting in chronic inflammation and osteoarthritis. Management of alkaptonuric ochronic osteoarthritis is usually symptomatic and replacements have comparable outcomes to osteoarthritis in patients without ochronosis.
Arthroplasty in organ transplant patientsThe number of solid organ transplants performed in the United States continues to increase annually as does survival after transplant. These unique patients are increasingly likely to present to arthroplasty surgeons for elective hip or knee replacement secondary to a vascular necrosis from chronic immunosuppression, or even age-related development of osteoarthritis. Transplant recipients have a well-documented increased risk of complications but also excellent pain relief and dramatic improvement in quality of life.