Complications associated with total hip arthroplasty in four large nondomestic felids

CASE DESCRIPTION A 9-year-old 37-kg sexually intact male snow leopard (Panthera uncia) with no history of lameness but radiographic evidence of right femoral subluxation and flattening of both femoral heads, 2 juvenile (< 1 year old) 25-kg sexually intact male cheetahs (Acinoynx jubatus) with unilateral hind limb lameness resulting from trauma, and an 11-year-old 110-kg sexually intact female Amur tiger (Panthera tigris altaica) with a 2-year history of left hip joint osteoarthritis were examined. CLINICAL FINDINGS No clinically relevant clinical findings other than hip joint problems were identified. All 4 felids underwent staged bilateral (snow leopard) or unilateral (cheetahs and tiger [Panthera tigris]) total hip arthroplasty (THA). TREATMENT AND OUTCOME In the snow leopard, both femoral THA components were found to be luxated 1 year after surgery. Treatment consisted of autogenous corticocancellous rib graft augmentation of the dorsal acetabular rims and synthetic suture capsulorrhaphies. The snow leopard lived for an additional 4 years with no additional THA-related complications. In the other 3 animals, catastrophic complications (luxation in the cheetahs and femoral fracture in the tiger) occurred shortly after THA. The THA implants were removed, and excision arthroplasty was performed. Long-term outcomes were good in all 3. CLINICAL RELEVANCE Findings underscore the challenges associated with THA in large nondomestic felids. Given the high risk for early catastrophic failure as a result of luxation or fracture, plans must be made and resources must be available in case revision surgery or implant removal with excision arthroplasty becomes necessary.

Deep infection after hip hemiarthroplasty: risk factors for infection and outcome of treatments

Aims Deep surgical site infection (SSI) remains an unsolved problem after hip fracture. Debridement, antibiotic, and implant retention (DAIR) has become a mainstream treatment in elective periprosthetic joint infection; however, evidence for DAIR after infected hip hemiarthroplaty is limited. Methods Patients who underwent a hemiarthroplasty between March 2007 and August 2018 were reviewed. Multivariable binary logistic regression was performed to identify and adjust for risk factors for SSI, and to identify factors predicting a successful DAIR at one year. Results A total of 3,966 patients were identified. The overall rate of SSI was 1.7% (51 patients (1.3%) with deep SSI, and 18 (0.45%) with superficial SSI). In all, 50 patients underwent revision surgery for infection (43 with DAIR, and seven with excision arthroplasty). After adjustment for other variables, only concurrent urinary tract infection (odds ratio (OR) 2.78, 95% confidence interval (CI) 1.57 to 4.92; p < 0.001) and increasing delay to theatre for treatment of the fracture (OR 1.31 per day, 95% CI 1.12 to 1.52; p < 0.001) were predictors of developing a SSI, while a cemented arthroplasty was protective (OR 0.54, 95% CI 0.31 to 0.96; p = 0.031). In all, nine patients (20.9%) were alive at one year with a functioning hemiarthroplasty following DAIR, 20 (46.5%) required multiple surgical debridements after an initial DAIR, and 18 were converted to an excision arthroplasty due to persistent infection, with six were alive at one year. The culture of any gram-negative organism reduced success rates to 12.5% (no cases were successful with methicillin-resistant Staphylococcus aureus or Pseudomonas infection). Favourable organisms included Citrobacter and Proteus (100% cure rate). The all-cause mortality at one year after deep SSI was 55.87% versus 24.9% without deep infection. Conclusion Deep infection remains a devastating complication regardless of the treatment strategy employed. Success rates of DAIR are poor compared to total hip arthroplasty, and should be reserved for favourable organisms in patients able to tolerate multiple surgical procedures. Cite this article: Bone Jt Open 2021;2(11):958–965.

A 6-Month-Old Neglected Obturator Inferior Variety of Anterior Hip Dislocation in A Young Male Managed with an Intermediary Salvage Measure Without the Need for Osteotomy or Excision Arthroplasty with A Resultant Ambulatory Natural Hip – A Case Report

Introduction: Among all the traumatic hip dislocations, anterior hip dislocation is a rarity in which the obturator inferior variety is one of the rarest to be documented [1]. Here we present to you the case of our patient, a 35-year-old male with a six month neglected obturator variety of anterior hip dislocation treated by salvage procedure of open reduction without the need for intertrochanteric osteotomy and resultant preserved natural hip for ambulation as an intermediary procedure. Case Report: Mr. SH a 35-year-old male had a fall from 15 feet in his village and was treated by a local quack, Meanwhile the patient continued to experience pain and difficulty walking and after an ordeal of nearly 6 months during the lockdown period in coronavirus disease pandemic, showed up in our emergency room and was diagnosed with an obturator type anterior hip dislocation for which we carried out open reduction aided with Murphys skid through an anterolateral approach and stabilization using two Steinman pins and further immobilization by Thomas splint for a period of 15 days, which was done after confirmation of intact head vascularity under general anesthesia after which gradual mobilization was initiated. 3 months post operative, now patient is ambulatory with stick support with no deformity, no pain and with early radiological features of avascular necrosis (AVN) for which Total Hip Replacement (THR) is planned at a later date. Conclusion: Utilisation of salvage procedures and moreover those with minimal operative complications will result in better, natural long-term intermediary measure outcome with a resultant delay in joint replacement procedure which is in the better interest of the patient. Keywords: Anterior hip dislocation, open reduction, obturator inferior type, neglected dislocation, Anterolateral approach.

Neglected reactive arthritis complicated by bilateral hip and temporomandibular joints ankylosis after a suspected tetanus infection: a case report

Background Reactive arthritis had been reported to occur after various vaccinations, including the tetanus toxoid vaccine; here, we report a case of ankylosing arthropathy suggested to be a complication of missed neglected reactive arthritis after tetanus infection. Case presentation A healthy 20-year-old woman presented with subtrochanteric right femoral fracture; imaging studies showed bilateral ankylosed hip, kyphoscoliosis, bilateral fused temporomandibular joints, and normal sacroiliac joints bilaterally. Laboratory investigations for a rheumatic or autoimmune disease were all within normal ranges. Detailed history revealed admission of the patient to an ICU unit (1 year before the trauma) for a month as she was diagnosed as having tetanus infection, after which she was unable to walk or feed herself. At the final follow-up, the patient started walking with a moderate limb after having a series of surgeries including femoral fracture fixation, temporomandibular joint excision arthroplasty, and bilateral total hip arthroplasty. Conclusion Unusual complications after tetanus infection can occur in the form of joint ankylosis, which could be presented after prolonged immobilization possibly due to improper management of reactive arthritis.

Dual-mobility bearings in complex revision hip arthroplasty

Background: Revision total hip arthroplasty (rTHA) is associated with an increased dislocation risk. Dual-mobility (DM) bearings have been used to address this issue. Such constructs offer increased range of motion and enhanced stability whilst avoiding some issues associated with fully-constrained devices. DM bearings have been used in our unit since 2013. Methods: All rTHA cases since 2013 were reviewed using the following criteria: (1) use of a DM bearing; (2) extensive soft tissue or bone loss resulting from ARMD, infection or multiple revisions, or requiring custom or megaprosthetic reconstruction; (3) minimum 2-month follow-up. Results: 52 cases were identified with a median of 2 previous operations (range 1–6) and mean follow-up of 14 (2–41) months. The Novae-Stick component was used in 50 cases, the Avantage in 2 and the Trident MDM in 1 case. 19 required acetabular reconstruction using trabecular metal and four required custom acetabular components. 19 required femoral reconstruction with a proximal or total femoral replacement. Postoperatively, 8 patients (15.4%) sustained a dislocation at a mean of 1.6 (range 1–3) months. 3 (5.8%) requiring re-revision. 1 required excision arthroplasty and 2 a constrained liner, 1 of which went on to have further instability. There were no intraprosthetic dislocations. Conclusions: Dual-mobility components are a viable option in the complex rTHA setting. Early dislocations can occur but the rate of instability is acceptable in this high-risk group.

Treatment of Ventral Hip Luxation in a Puppy

A Three months of age, 4.5 kg, female mixed (cross) breed presented to our clinic with complaint of the left hind leg lameness. In the clinical, radiographic and ultrasonographic examination, ventral hip luxation was diagnosed. Based on the examination findings which indicated the case was chronic, surgical treatment was decided. Hip joint was exposed firstly by craniodorsal approach. Flattened and full acetabulum, fractured greater trochanter, ruptured gluteal muscle attachment and irreparably broken joint capsule were determined. Excision arthroplasty was performed by ventral approach. Greater Trochanter was attached to its position by an L shape Steinman pin using craniodorsal approach. Then, a drill hole was created on the greater trochanter, and a screw was inserted to dorsal acetabular rim. A synthetic suture passed through the hole was tied to the screw in a figure of eight mode. Postoperative antibiotics and anti-inflammatory drugs were used. Physiotherapy such as swimming and massage treatments was proposed following skin sutures removal. In the 4th week control postoperatively, the dog began to use the operated leg effectively despite the moderate quadriceps’ contracture. The contracture was mostly resolved 12th week by continuing physiotherapy.

Traumatic joint luxations in cats: Reduce, repair, replace, remove

Practical relevance: Traumatic joint luxations are usually associated with significant trauma and there may be concomitant systemic injury. Joints are unstable as a result of injury to one or more supporting structures and the clinician should aim to determine which structures are damaged with physical examination, diagnostic imaging and careful assessment under sedation/anaesthesia. The aim is to reduce the joint back to its anatomical position, and then to maintain this through repair of damaged structures. However, where this is not possible, replacement or removal (arthrodesis/excision arthroplasty) of the joint remain viable options. Clinical challenges: Owing to the small size of feline joints and the severity of damage often seen, surgical management of these cases can be challenging. The first priority is to ensure the patient is systemically well before embarking on any specific surgical treatment of a luxated joint. Cats also present challenges in the postoperative period and a lack of patient and owner compliance can be detrimental to postoperative outcomes. Aims: This article aims to help the reader diagnose joint luxations and to assist decision-making with an overview of the management and treatment options available. Evidence base: There are a number of original articles and textbook chapters in the literature covering aspects of different joint luxations, particularly for the more common luxations. This article draws on information from key feline research and, where necessary, extrapolates from relevant canine research. The authors also offer practical guidance based on their own clinical experience.