THR in Neuroplogical Conditions

Written by Dr Josh Petterwood MBBS | Accredited Orthopaedic Registrar

Weekly Presentation – 5th March 2010

Introduction

  • Infrequently performed procedures
  • Little research
  • Complex conditions
  • Complex operations

Cerebral Palsy

  • Issues
    • Dysplasia/subluxation/osteoarthritis
    • Bony abnormalities
      • Coxa valga,
      • persistence of foetal anteversion,
      • superior subluxation
    • Secondary to muscle imbalance
      • Tight flexors/adductors overpower weak abductors/extensors
  • Evidence
    • 2 studies • 19pts • 16pts
    • 2 case reports
  • Results
    • Resection arthroplasty and arthrodesis mixed results
    • Theoretically THR
      • High risk of dislocation and aseptic loosening
  • Management
    • Custom implants,
    • constrained implants,
    • post op hip spicas,
    • concurrent tenotomies/botulinum
    • Multi-disciplinary approach

Parkinson’s

  • Epidemiology
    • Common disease – 1%
    Issues
    • Rigidity,
    • contractures,
    • bradykinesia,
    • tremor,
    • dystonia,
    • postural instability
  • Results
    • Hemiarthroplasty performed frequently
    • High mortality (up to 47% at 6/12)
    • High morbidity secondary to medical comorbidities
    • Little evidence regarding THR Parkinson’s
    • Scottish National Arthroplasty Registry
      • 2394 patients
      • Significantly lower dislocation rate
    • Weber et al
      • 107 pts – 93% pain relief – 26% medical complication
      • Did well early, then deteriorated

Poliomyelitis

  • Issues
    • Flaccid paralysis
    • Dysplasia,
    • subluxation,
    • osteopaenia,
    • contractures,
    • leg length discrepancy
  • Results
    • THR infrequently performed
    • Literature confined to case reports

CVA

  • Results
    • Scottish National Arthroplasty Registry
      • Desreased risk of dislocation
      • Increased risk of HO

Spinal Injury

  • Increased risk of HO
    • Radiation/indomethacin recommended
  • Increased dislocation risk in sitters eg. paraplegics

Charcot

  • Case reports only
  • Usually contraindicated Spinal Injury

Discussion

  • Older pts with Parkinson’s/CVA
    • Lower functional demand
    • Less chance of dislocation
    • Off-the-shelf, unconstrained implants
    • High incidence of medical comorbidity
  • Younger pts with CP/polio/spinal injury
    • Higher incidence of dislocation
    • High variability in anatomy
    • Constrained, modular implants

Take home message

  • Complex patients requiring
    • Individualised approach
    • Careful pre operative planning
      • Consideration of deforming forces across joint
  • Procedure
    • Templating
    • Modular prostheses
    • Constrained acetabular components
    • Soft tissue procedures/balancing
  • Multi-disciplinary approach
    • Pre and post op
  • Good outcomes achievable
    • Pain
    • Function

Powerpoint presentation