1. Introduction
Septic hip arthritis is the most common clinical inflammatory disease of the hip joint, caused by the pyogenic bacteria of high pathogenicity or Mycobacterium tuberculosis and the high pressure in the hip joint.[1,2] In addition to the special anatomical structure of the hip joint, children usually do not cooperate with physical examinations, complex of the hip innervation, the changeable symptoms, limited medical facilities in our country in the past, and making the situations serious and seriously affecting patient’s life quality.[3] Total hip arthroplasty (THA) has been recognized as the “gold standard” treatment for septic hip arthritis. As early as 1983, some scholars had been skilled in the treatment of adult septic hip arthritis with THA, achieving good results as reported.[4] However, due to the limitations of surgical technology and artificial hip prosthesis materials at that time, various complications such as chronic hip pain, prosthesis loosening, and infections were inevitable.
With the development of surgical technology and advancement of artificial hip prosthesis materials, efficacy of THA is gradually affirmed by orthopedic surgeons.[5] Even so, patients with sequelae of septic hip arthritis not only have serious soft tissue adhesions making exposure difficult, but also presenting residual bone deformities of various degrees. On 1 hand, these damages the quality of life seriously. On the other hand, it also brings challenges to the treatment with artificial prosthesis.[6] Therefore, in this study, we evaluated the clinical outcomes of THA for osteoarthritis secondary to septic hip arthritis.
2. Materials and Methods
2.1. Sample size calculation
According to sample size calculation formula: n = ta2PQ/d2, n is the sample size, P is the prevalence of osteoarthropathy secondary to septic hip arthritis, Q = 1-P, and d is the allowable error. a = 0.05, ta = 1.96. The minimum sample size is 80 cases.
2.2. Inclusion and exclusion criteria
Inclusion criteria: All patients in this study met the “Guidelines for the Diagnosis and Treatment of Osteoarthritis in China (2021 Edition)”[7] for the diagnosis of septic hip arthritis secondary to osteoarthropathy, and the patients were 18 years or older; The sequelae of hip arthritis, with severe clinical symptoms, indications for initial THA surgery; Severe proximal femoral deformities (such as: upper femoral trochanter or high straddling deformity, proximal femoral medulla Abnormal cavity morphology, such as medullary cavity atresia, thinning, angular torsion deformity, femoral neck shortening deformity with varus or valgus, and abnormal femoral anteversion angle, etc), it is difficult to correct with general techniques.
Exclusion criteria: Hip with nonstationary infection and severe preoperative gluteus medius dysfunction; Combined with severe basic medical diseases and difficult to tolerate surgery, coagulation dysfunction; Severe cardiovascular disease, hypertension, diabetes, tuberculosis, or patients with infectious diseases such as hepatitis B and syphilis.
2.3. General information
Finally, the medical records of 100 patients with osteoarthritis secondary to septic hip arthritis who received THA in our hospital from December 2010 to December 2021 were selected as the subject. Due to hospital transfer, epidemic of COVID-2019 and other reasons, ten cases were lost to follow-up and finally 90 cases were recorded. The study was reviewed and approved by the Ethics Committee of Hubei Provincial Hospital of Traditional Chinese Medicine. Informed consent was obtained from the patient.
2.4. THA procedures
2.4.1. Preoperative evaluation and management.
All patients received preoperative education and adopted standardized hospitalization and rehabilitation treatment plans. Rehabilitation treatments were all assisted by rehabilitation physicians and therapists at the Hubei Provincial Hospital of Traditional Chinese Medicine. All patients underwent the measurement of motion range of hip joint (preliminary estimation of hip joint damage) and the distance between the anterior superior iliac spine and medial malleolus (confirming the absolute length of the lower limbs and the difference between the 2 lower limbs). All patients underwent gluteus medius muscle strength examination, and it was confirmed that the gluteus medius muscle strength was grade 4 or above. Examination of blood routine, erythrocyte sedimentation rate, and C-reactive protein were carried out to rule out active infections. Pelvic anterior and upper femoral anterior and lateral X-rays were routinely checked, companied with the 3-dimensional computed tomography reconstruction examination and preventive use of antibiotics (Figs. 1–2).
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Figure 1.: Preoperative X-ray.
Figure 2.: preoperative squatting position.
2.4.2. Surgical methods.
The operations were performed by the same surgeon, and 1 of the surgeons was selected to describe the operation process in detail. The second-generation cephalosporin was instilled intravenously 30 minutes before the operation, tranexamic acid was injected intravenously 15 mg/kg at 10 minutes before the operation. All patients underwent general anesthesia, standard lateral position, posterolateral hip joint approach, and conventional posterolateral incision for easy exposure and femoral shaping. The images used in this study have been obtained with the patient’s consent.
Specific steps: Carve the skin and subcutaneous tissue layer by layer to fully expose the hip joint, and completely loosen the contracture synovium and scar granulation tissue around the hip joint. The range of relaxation includes: external rotator group, adductor muscle, iliopsoas muscle, iliotibial band, and gluteus maximus. The hip joint capsule has been exposed and the sciatic nerve is protected carefully. After enough exposure, the femoral neck is cut off and the femoral head is removed. (Fig. 3); The osteotomy line is obliquely from the pyriform fossa of the greater trochanter to the lateral cortical bone, the end point is 3 to 4 cm below the lesser trochanter. Along the osteotomy line, a long oblique bone piece with a length of 8 to 10 cm is made, and the width is the circumference of the proximal diaphysis. 1/2 of the diameter, the coronal plane retains the continuity and integrity of the gluteus medius, forming a structure of “muscles (gluteus minimums, gluteus medius)-bone muscle (lateral femoral muscle).” Push the osteotomy block forward to expose the acetabulum. The true acetabular position is determined according to the teardrops, Harris fossa and transverse acetabular ligament and other anatomical structures. Soft tissue in the acetabulum and osteophytes on the acetabular rim are removed. Acetabular file has been used to reverse pressure-fit filing, feasible autologous cancellous bone is implanted in the hip. The acetabular cup is placed in front of the acetabular socket. According to the initial stability of the acetabular cup implantation and the autogenous bone bed coverage of the acetabular cup, 1 to 2 cancellous screws are used to fix the acetabular cup without reinforcement. Structural bone graft support of the acetabulum, traction of the distal end of the osteotomy in the flexion and adduction and internal rotation position according to the soft tissue tension around the hip joint as well as the rotation center of the acetabulum, the length difference of the lower limbs, and also refer to the preoperative plan to decide whether to proceed with the femur shortening osteotomy. Diameter of the femoral medullary cavity is measured by computed tomography before operation. If the medullary cavity diameter was smaller than the smallest medullary cavity file diameter, 1 to 2 wires are needed to prewire the femoral shaft at the distal end of the osteotomy to avoid iatrogenic femoral fracture when the medullary cavity file is driven into the femoral medullary cavity (Fig. 4); Leaving the medullary cavity file in the medullary cavity, installing the head and neck trial model, and adjusting the anteversion angle of the femoral prosthesis according to the anterior inclination of the acetabular cup, resetting the hip joint, checking the tension of the sciatic nerve and surrounding soft tissue as well as the stability and mobility of the hip joint, and aim to make it clear whether a second osteotomy and further loosening of soft tissues are needed. With satisfied stability of the test model, the prosthesis and the femoral greater trochanter osteotomy block with internal slots are placed accordingly. Move the greater trochanter osteotomy block down to reconstruct the gluteus medius muscle tension, eccentricity and restore the anatomical shape of the medullary cavity of the proximal femur. 3 to 4 wires in small grooves for cerclage are adopted to fix the osteotomy block to prevent the wire from shifting and loosing. Autogenous bone grafts are used to fill the large gap at the osteotomy. Furthermore, certain dose of vancomycin is sprinkled around the incision to prevent possible infection (Fig. 5). A trial model of the femoral head is installed to reset the hip joint, to check the stability in all directions, dislocation tendency of the hip joint, and length of the lower limbs. With the above aspects confirmed, the femoral head prosthesis is placed. 1.0 g tranexamic acid that dissolved in 20 mL saline is injected into the joint cavity, followed by the incision closure; The drainage tube was clamped for 2 hours after the operation. The drainage tube can be removed on the second day after the operation if the drainage was < 60 mL at 24 hours after the operation. Leukocytes, erythrocyte sedimentation rate and C-reactive protein were monitored on after 1, 3, 5, and 7 days of the operation. Usually, intravenous use of second-generation cephalosporin lasts for 5 to 7 days, rivaroxaban anticoagulation for 2 weeks, oral celecoxib with 0.2 g twice a day for 4 weeks. Patients are allowed to experience fully weight-bearing 8 weeks after the operation and start squatting 3 months after the initial operation. The outpatient follow-up was performed at 6 weeks, 3, 6, 12 months, and every 1 year thereafter (Figs. 6,7).
Figure 3.: After femoral neck osteotomy (the left dashed triangle is the narrow femoral medullary cavity, and the right dashed circle is the acetabular side. It can be seen that the patient’s acetabular dysplasia is secondary, and the acetabular leukoplakia is in the shape of a “shallow disc”).
Figure 4.: Before reaming, the size of the smallest medullary cavity file should be compared according to the preoperative CT results. First, use a hand drill to ream the medulla, then circulate the wire 2cm below the osteotomy surface to avoid bursting, and then use a pendulum saw to split it vertically. End the femoral cortex to the steel wire, so as to achieve the purpose of controlling the direction and extent of iatrogenic fractures during the operation. CT = computed tomography.
Figure 5.: uses the single-strand steel wire cerclage technique, with 3-4 wires placed in the grooves respectively, and pay attention to protecting the muscles when scoring. The steel wire knot should be carefully twisted and fixed in a lower position to prevent the protrusion from irritating the surrounding soft tissues and causing pain.
Figure 6.: Postoperative X-ray.
Figure 7.: postoperative squatting position.
2.5. Follow-up
The functional evaluation of the hip joint after THA was carried out by using the Harris scoring system and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale, with a maximum score of 96 (20 points for pain, 8 points for stiffness, and 68 points for physical function). The Visual Analogue Scale (VAS) score was used to evaluate the degree of local pain. The Trendelenburg sign was used to assess the strength of the abductor muscles. The length of lower limbs was measured by measuring the distance from the anterior superior iliac spine to the tip of the medial malleolus.
2.6. Statistical methods
The data in this study were collected using Excel and reviewed by 2 physicians. The selected data are in accordance with the normal distribution. After the first author and corresponding author have entered the data into the computer system and proofread. SPSS 25.0 was used to perform statistical analysis. The measurement data were expressed by mean ± standard deviation and analyzed by using t-test, and the count data were expressed by n (%) and analyzed by using the χ2 test. The statistical P < .05 indicated that the difference was statistically significant.
3. Results
3.1. Comparison of general information
The general characteristics were presented in Table 1. The mean age of the male group was 45.64 ± 12.15 years and the female were 46.59 ± 13.74 years. The mean weight of the male group was 67.83 ± 1.32 kg and the female were 66.29 ± 1.66 kg. The male group had 0 case with KIM type I, 21 cases with KIM type II, and 24 cases with KIM type III. The female group had 0 case with KIM type I, 22 cases with KIM type II, and 23 cases with KIM type III. Baseline characteristics of the 2 groups are presented in Table 1. There were no significant differences in baseline variables between groups (P > .05).
Table 1 -
Comparison of general information between the 2 groups.
| Gender |
Weight (kg) |
Age (yr) |
KIM type |
| I |
II |
III |
| Male (n = 45) |
67.83 ± 1.32 |
45.64 ± 12.15 |
0 |
21 |
24 |
| Female (n = 45) |
66.29 ± 1.66 |
46.59 ± 13.74 |
0 |
22 |
23 |
|
χ
2
/t
|
0.506 |
1.635 |
0.045 |
|
P
|
.614 |
.106 |
.833 |
3.2. Analysis of operation status
90 patients were followed up. Results of the follow-up assessment showed that the mean OT was 1.78 ± 0.32 hour, the mean intraoperative BL was 586.62 ± 31.66 mL, the mean transfusion of RBC was 3.84 ± 0.75 U, 2 cases were positive, and 88 cases were negative for Trendelenburg sign (Table 2).
Table 2 -
Analysis of the operation status of the 2 groups of patients.
| Project |
Data |
| OT (h) |
1.78 ± 0.32 |
| Intraoperative BL (mL) |
586.62 ± 31.66 |
| Red blood cell transfusion (U) |
3.84 ± 0.75 |
| Trendelenburg sign |
Postoperative 2 (+) 88 (−) |
BL = blood loss, OT = operation time.
3.3. Comparison of efficacy
After treatment, the unequal length of the lower limbs and the postoperative VAS score were lower than that of the preoperative occasions. However, the WOMAC score, Harris score, and motion range of hip joint patients were higher than that of the preoperative. All the above showed statistical significance (P < .05, Table 3)
Table 3 -
Comparison of relevant scores and efficacy of pre- and postoperative.
| Variables |
Preoperative |
Postoperative |
t
|
P
|
| WOMAC |
28.78 ± 5.32 |
80.62 ± 13.66 |
−33.548 |
<.001 |
| Harris |
37.34 ± 11.25 |
86.26 ± 10.64 |
−29.971 |
<.001 |
| Unequal length of both lower limbs (cm) |
4.14 ± 1.18 |
0.62 ± 0.13 |
28.13 |
<.001 |
| VAS |
8.08 ± 2.12 |
4.32 ± 1.16 |
14.761 |
<.001 |
| Hip range of motion (˚) |
53.76 ± 12.37 |
128.24 ± 10.53 |
−43.459 |
<.001 |
VAS = visual analogue scale, WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index.
By the time of the last follow-up, no patients had deep infections, and all the incisions healed. One case suffered from transient sciatic nerve palsy and recovered completely after 6 weeks. Two cases developed intermuscular venous thrombosis. After a week of anticoagulation and symptomatic treatment, the symptoms improved significantly, and they discharged with reasonable functional exercise. No obvious thrombosis was found in the B-ultrasound after 1 month. Two patients experienced postoperative hip dislocation. One patient rehospitalized because of unreasonable exercises, which resulted in loosening of bone mass and prosthesis.
4. Discussion
Septic hip arthritis is a joint disease caused by direct infection of purulent bacteria. It is common in children and the elderly and the infirm. The pathogen is mainly staphylococcus aureus, and blood-borne infection is the most common route.[8] According to Gao et al, the glycans and glycosylation has gradually emerged in inflammation and other diseases.[9] As of now, it is unknown whether they are associated with the advance of septic hip arthritis and further studies are needed. Once septic hip arthritis occurred and were not treated in time, it may cause serious irreversible joint destruction and finally loss of joint function.[10] Patients often experience long-term hip discharge, protracted sinus tracts, are often accompanied by hip joint stiffness and limb shortening, and eventually lead to secondary hip arthritis, which seriously affect the patient’s quality of life.[11] Thus, patients hope to improve hip function and quality of life.
In this study, the mean preoperative VAS score was 8.08 ± 2.12, a relatively high score that makes the patients experienced long-term and serious pain. The obvious unequal lengths of lower limbs also result in inconvenience for these patients. Furthermore, the preoperative WOMAC score, Harris score, and motion range of hip joint were rather low. Thus, effective interventions are needed for these occasions. To a great extent, THA is the effective method for these patients. However, the risk of THA for such patients is relatively high, mainly including the continuous infection after THA since bacterial colonization lasts for a long time.[12] Another risk of THA is poor postoperative function of the hip joint due to the preoperative joint ankylosis and malformation.[13] The other is difficulty in carrying out THA due to repeated operations and severe scars, which may increase the risk of unsatisfied incision healing or nerve and vessel damage.[14] In this study, patients with sequelae of septic hip arthritis are mostly accompanied with various degrees of stiffness and shortening of the affected limb.
Commonly, placement of the acetabular prosthesis, control of the joint motion range and lower limbs length (gap < 2 cm) are quite important.[15] As we all know, for patients with dislocation, unequal length of lower limbs exceeding 4 cm, severe contracture of the soft tissue, obvious joint stiffness, and unbalance of the soft tissue during the operation are the main causes.[16] Moreover, the length of severely shortened limbs is closely related to the traction of nerves and blood vessels. It has been confirmed that the nerve damage caused by THA is greatly related to compression, traction and ischemia according to extensive researches focused on the etiology of nerve damage.[17] Therefore, much attention should be given to the protection of nerves and blood vessels when balancing the length of the limbs.[18] In this study, the shortened limbs were significantly improved after operations. Patient’s average changed length of the affected limbs was 4.6 cm, without nerve traction symptoms. The length difference between the lower extremities of the included patients was 4 cm or more, and they received preoperative traction for 3 days to facilitate the soft tissues to adapt to the extension of the limbs after operation.
At the same time, attention should be paid to completely loosen the soft tissue, remove the contracture joint capsule, loosen the surrounding muscles, cut off the external rotator group and part of the quadratus femoris, if necessary, partially loosen the iliopsoas muscle at the end point of the lesser trochanter, and free part of the sciatic nerve. Nerve tension can be detected during the operation.[19] If the tension were still severe after complete soft tissue loosening, the proximal femur reconstruction technique (osteotomy) can be performed first, but the forced reduction is not allowed to avoid sciatic nerve damage after surgery. Traction of the affected side skin is feasible after operation, as well as early functional exercise.[20] For patients in this study, the difference in the length of the lower extremities of most patients was > 4 cm, while the full length of the diseased sides before the operation are longer than that of the healthy sides. Therefore, not only the length of the limbs on both sides (the anterior superior iliac spine-the tip of the medial malleolus) should be measured before surgery, but also the flexibility of the lumbar spine, and tilt of the pelvis and compensation of the knee joint should be taken into account as well.[21] Most of the patients experienced structural tilt or scoliosis of the spine or pelvis, caused by the unequal length of the lower extremities. After balancing the length of the lower extremities, the condition of low back pain would gradually improve with the correction of the tilt of the pelvis.[22] However, for elderly patients with poor lumbar flexibility, it is easy to cause a new posture imbalance and aggravate the original low back pain after THA and full balance of the lower limbs. Therefore, for patients with sequelae of septic hip arthritis of different ages, the balance of lower limb length is often individualized.[23]
To solve this problem, the patients can be asked to increase the thickness of the sole of the shortened limb so as to find the most suitable length of the limb before operation. Meanwhile, combination of imaging data and the operation plan is of great importance. According to the above principles, the unequal length of lower limbs was significantly corrected in this study, and the VAS score of low back pain was significantly improved. In patients with sequelae of hip change and high dislocation of the femur, the knee joint often exhibits valgus deformity. If the acetabulum is reconstructed in the true acetabulum, the center of rotation of the acetabulum is moved inward, and increasing the tension of the iliotibial band and exacerbating knee valgus.[24] Using conventional femoral prosthetic stems instead of hip stems can just move the femoral shaft outwards and relax the iliotibial band to avoid the above problems.
In this study, the angulated bending deformity after the proximal femoral osteotomy was performed on the hip. Fusion of the hip resulted in the proximal femoral flexion hip adduction, internal rotation or abduction external rotation deformity, as well as the old femoral neck fracture, the greater trochanter, and was severely displaced upward and the medullary cavity deformity. In some patients with hip joint revision, due to osteolysis and stress shielding, the anatomical morphology of the proximal femur medullary cavity is abnormal and the greater trochanter is moved up obviously, and the femoral prosthetic stem is difficult to remove.[25] For patients with nonheavy acetabular deformity, ordinary prosthesis is placed at a conventional angle, and center of rotation can be better reconstructed. However, in patients with severe acetabular deformities, acetabular reconstruction is more complicated. In order to improve the containment of the acetabular prosthesis and maintain good stability of the prosthesis, there are 3 methods of treatment: using smaller acetabular inward and upward frustration, structural bone grafting on the posterior and upper side of the acetabular or metal pad.[26] These methods have their own advantages and disadvantages. It is relatively simple to deepen the acetabulum and use a smaller cup. For example, the polyethylene lining is thinner and easy to wear, and the small ball head also affects the stability of the hip joint. Choosing the 4th-generation ceramic prosthesis is not only wear-resistant, but also a relatively large ball head.[27] The bone graft can be autologous iliac bone or femoral head. The structural bone graft above the acetabulum increases the bone mass of the acetabulum. A larger diameter cup can be selected. However, the femoral head of such patients is often deformed, hardened and small, resulting in difficulty of the structural bone grafting and the higher risk of nonunion. In recent years, and the mid-term follow-up of the application of metal spacers in developmental dislocation of the hip and hip revision has achieved satisfactory results.
Needless to say, THA for osteoarthritis secondary to septic hip arthritis is much more complex than that in other surgeries of hip arthroplasty. When it refers to the operative complications, no perioperative death or other serious complications occurred. The mean OT was 1.78 ± 0.32 hour and the mean BL was only 586.62 ± 31.66 mL, the Trendelenburg sign was positive only in 2 cases. All in all, the THA for osteoarthritis secondary to septic hip arthritis is worthwhile with limited and controllable complications.
In our view, the results we have obtained in this study can be used for reference by clinicians, while certain limitations do exist. First, THA has a significant effect on osteoarthritis secondary to septic hip arthritis. Nevertheless, the included cases came from the same hospital thus the characteristics were poorly represented. Subjective as the exclusion and inclusion criteria are, it may result in biased results. Second, and this study is a single-center study without control. Hence, it is difficult to directly conclude that THA is superior to other surgical techniques. However, our clinical evaluation and imaging measurements are blinded, so the data are reliable and supportable to a great extent. Finally, the follow-up time was relatively short. In view of the good clinical results up to now, we will continue to follow-up the prosthesis survival rate and other objective indicators to evaluate the mid- and long-term outcomes of THA for treatment of septic hip arthritis.
To conclude, THA for osteoarthritis secondary to septic hip arthritis shows great results, which effectively relieve pain, improve joint mobility and patient’s life quality with limited and controllable complications. Meaningfully, this study may provide a certain reference value for surgeons as well as the medical care.
Author contributions
Conceptualization: Yongguo Liu, Jie Wang.
Data curation: Jie Wang.
Formal analysis: Yongguo Liu, Jie Wang.
Funding acquisition: Jie Wang.
Investigation: Xiguang Ye.
Methodology: Xiguang Ye, Yongguo Liu.
Project administration: Xiguang Ye.
Resources: Xiguang Ye.
Software: Jing Zeng, Yongguo Liu.
Supervision: Jing Zeng, Yongguo Liu.
Validation: Jing Zeng.
Visualization: Jing Zeng.
Writing – original draft: Jing Zeng.
Writing – review & editing: Jing Zeng.
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