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Scientific Articles   |    
Evaluation of the Modified Albee Arthroplasty for Femoral Head Loss Secondary to Septic Arthritis in Young Children
Xue-dong Li, MD, PhD1; Bin Chen, MD1; Jun Fan, MD, PhD2; Chuang-yi Zheng, MD1; Dong-xin Liu, MD, PhD1; Hu Wang, MD, PhD1; Xue Xia, MD1; Shi-jun Ji, MD3; Shi-xin Du, MD, PhD1
1 Department of Orthopaedics, the 1st Affiliated Hospital, Medical College of Shantou University, 57 Chang Ping Road, Shantou, Guangdong 515041, China. E-mail address for S.-x. Du: dsx126333@sina.com.cn
2 Department of Burns, Medical College of Nanchang University, 603 Eight One Road, Nanchang, Jiangxi 330006, China
3 Department of Pediatric Orthopaedics, the Second Affiliated Hospital, China Medical University, 36 Shan Hao Road, Shenyang, Liaoning 110004, China
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

A commentary by Paul D. Sponseller, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at the 1st Affiliated Hospital, Medical College of Shantou University, Shantou, Guangdong, China

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jun 01;92(6):1370-1380. doi: 10.2106/JBJS.I.00201
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Abstract

Background: 

Surgical treatment options for femoral head deficiency in infants secondary to septic arthritis of the hip are varied and associated with uncertain long-term outcomes. The modified Albee arthroplasty has been considered an acceptable procedure; however, the long-term outcomes of this procedure have not been reported, to our knowledge. We evaluated the long-term outcomes of the modified Albee arthroplasty in young patients with severe sequelae of septic arthritis of the hip.

Methods: 

We retrospectively studied twenty-one children (twenty-one hips) in whom Choi type-IVB sequelae of septic arthritis of the hip had been treated with a modified Albee arthroplasty and six patients with the same sequelae who had been managed with simple observation. The Trendelenburg sign, pain, the range of motion, hip function, the Harris hip score, and limb-length discrepancy were assessed clinically. Remodeling of the femoral head, hip stability, and arthritic changes in the hip were evaluated radiographically.

Results: 

The twenty-one patients with the modified Albee arthroplasty were followed for an average of 121.2 ± 38.6 months and had better outcomes, in terms of the Trendelenburg sign, the Harris hip score, pain, the hip range of motion, and limb-length discrepancy, than the six patients who underwent simple observation. Patients who were two years of age or younger at the time of the arthroplasty exhibited a significantly less severe limb-length discrepancy and less loss of motion than those who were older than two at the time of the surgery. Furthermore, limb-length discrepancy was positively correlated and the range of motion of the hip and the Harris hip scores were negatively correlated with the patient's age at the time of the surgery, suggesting that early surgery in patients with severe sequelae of septic arthritis of the hip is associated with a better clinical outcome.

Conclusions: 

The modified Albee arthroplasty is a feasible and clinically useful procedure for the treatment of severe sequelae of septic arthritis of the hip, particularly in children who are two years of age or younger.

Level of Evidence: 

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Shi-xin Du, MD, PhD
    Posted on September 17, 2010
    Drs. Li and Du respond to Dr. Shah
    Department of Orthopaedics, 1st Affiliated Hospital, Medical College of Shantou University, China

    We appreciate the interest and thoughtful questions that Dr. Shah has made regarding our paper. We would attempt to address these questions as follows.

    In our retrospective study, we did not use the patients with additional procedures because our study includes only the evaluation of the results of those patients operated with modified Albee Arthroplasty for femoral head loss secondary to septic arthritis.

    Many treatment options have been proposed for the severe sequelae of septic arthritis of the hip, including simple observation, contralateral epiphysiodesis, hip arthrodesis, trochanteric arthroplasty, pelvic osteotomy, acetabuloplasty, femoral osteotomy, femoral head and neck reconstruction with a free vascularized iliac bone graft, and total hip arthroplasty (1-4). We believe the additional surgical procedures would improve the prognosis of the sequelae they are intended to treat. However, the indications and techniques best suited for reconstructive surgery for the severe sequelae of septic arthritis must be tailored to each patient. For example, trochanteric arthroplasty could stabilize the hip joint, decrease the abductor lurch, decrease leg length discrepancy, and create a better anatomic site for a total hip replacement. Disadvantages include decreased range of motion, increased chance of pain and degenerative arthritis, and unpredictable results (5).

    We have treated the severe sequelae of septic arthritis of the hip with modified Albee Arthroplasty since 1980. Initially, the pivotal role of the resection of the greater trochanter was not appreciated in our group. McCarthy suggested (6) the growth of the greater trochanter is divided equally between the appositional growth in the superior portion of the greater trochanter and growth in the metaphysis. In some Choi type IV patients, the femoral shaft length is maintained undisturbed by the activity of longitudinal growth of the greater trochanter (7). To acquire better limb length agreement with the growth of the greater trochanter, we have performed the Albee arthroplasty without removing the greater trochanter on three patients with Choi type IV deformity, two patients were lost on follow-up. Another is case 13 accepted for Albee arthroplasty at two years of age in 1982 (Figure 1).Three years after the arthroplasty, the epiphysis of the greater trochanter was obvious (Figure 2),and after 17 years follow-up, there was overgrowth of the greater trochanter in high position resulting in an impingement syndrome with the pelvic wall (Figure 3) which resulted in a Trendelenburg sign, pelvic instability and severe pain during physical exercise.


    Fig 1. Complete loss of the left femoral head and neck with pathologic dislocation (The radiograph was taken when the child was 2 years old).


    Fig 2. Three years after Albee arthroplasty of the hip, the epiphysis of the greater trochanter is obvious at the proximal lateral femur.


    Fig 3. Seventeen years and five months after Albee arthroplasty a nice femoral head shape remodeling from the inner fragment formed, but impingement syndrome resulted from overgrowth of the greater trochanter .Pain in the hip was severe, so further surgery was performed to relieve the pain, improve the limp and correct the Trendelenburg sign.

    In our paper, the criteria for evaluation of hip stability are as follows: a located hip joint must have good acetabular coverage of the femoral head, with a complete and concentrically reduced femoral head into the true acetabulum. In addition,the CE (center-edge) angles should be less than 20 degrees (the coverage of acetabulum on femoral head is decreased) producing a progressive anterolateral subluxation (8)See Figure 4B of our paper, where the subluxated hip is an unstable joint.

    Osteoarthritis in the hip will also decrease the range of motion (ROM). Direct damage by septic arthritis to the articular cartilage is common, as a result, the hip osteoarthritis is the most common sequelae of hip septic arthritis (9), and, if severe, partial or complete joint destruction may culminate in fibrous or bony ankylosis. Fibrous ankylosis may result in decreased ROM, and precedes the development of bony ankylosis, resulting in loss of joint mobility. In our paper, younger patients have a smaller load on the hip joint and less severe damage to the hip joint cartilage while older patients bear a heavier load, which increases the destruction of the hip joint cartilage . In our paper, osteoarthritis appeared in all patients by radiography, (see Figure 3C and Figure 4B of our paper). At present, there is no reliable means to evaluate the severity of the osteoarthritis except for hip range of motion, with abductor insufficiency manifested by an abductor lurch or a positive Trendelenberg sign.

    To avoid infection of Kirschner wires after fixation as skeletal traction, we applied 75% alcohol as disinfectant. As the most common complication is the breakage and migration of Kirschner wires into the hip joint, we avoided this by the application of a full hip spica cast.

    References

    1. Manzotti A, Rovetta L, Pullen C, Catagni MA. Treatment of the late sequelae of septic arthritis of the hip. Clin Orthop Relat Res. 2003;410:203-12.

    2. Cheng JC, Aguilar J, Leung PC. Hip reconstruction for femoral head loss from septic arthritis in children. A preliminary report. Clin Orthop Relat Res.1995;314:214-24.

    3. Van Tongel A, Fabry G. Epiphysiodesis of the greater trochanter in Legg-Calvé-Perthes disease: the importance of timing. Acta Orthop Belg. 2006;72:309-13.

    4. Lee DY, Choi IH, Chung CY, Ahn JH, Steel HH. Triple innominate osteotomy for hip stabilisation and transiliac leg lengthening after poliomyelitis. J Bone Joint Surg Br. 1993;75:858-64.

    5. Betz RR, Cooperman DR, Wopperer JM, Sutherland RD, White JJ Jr, Schaaf HW, Aschliman MR, Choi IH, Bowen JR, Gillespie R. Late sequelae of septic arthritis of the hip in infancy and childhood. J Pediatr Orthop. 1990;10(3):365-72.

    6. McCarthy JJ, Weiner DS. Greater trochanteric epiphysiodesis. Int Orthop. 2008;32:531-4.

    7. Morgan JD, Somerville EW. Normal and abnormal growth at the upper end of the femur. J Bone Joint Surg Br. 1960;42:264-72.

    8. Rab GT. Lateral acetabular rotation improves anterior hip subluxation. Clin Orthop Relat Res. 2007;456:170-5.

    9. Gao X, He RX, Yan SG. Total hip arthroplasty for patients with osteoarthritis secondary to hip pyogenic infection. Chin Med J (Engl). 2010;123:156-9.

    Hitesh H. Shah
    Posted on September 01, 2010
    Evaluation of the Modified Albee Arthroplasty
    Department of Orthopaedics, Kastruba Medical College, Manipal, India

    To the Editor:

    I read with interest the article entitled, “Evaluation of the Modified Albee Arthroplasty for Femoral Head Loss Secondary to Septic Arthritis in Young Children” (2010;92:1370-80), by Li et al. I must congratulate the authors for reporting excellent results for challenging sequelae in long term follow up. I would, however, raise couple of issues regarding this article.

    Why did the authors include only those children treated with the Albee arthroplasty without any additional surgery? We would like to know all the consecutive patients treated with the same procedure, as the results of the children without any additional surgeries would be far superior to the results of children with any additional surgeries. The authors mentioned that case 13 was treated with resection of greater trochanter in subsequent follow up, why is there disparity between these two statements? There were several problems and limitations with trochanteric arthroplasty like- gradual remodeling of proximal femur, abductor weakness and degenerative arthritis (1). We do not find any methods for evaluating the hip stability, remodeling of femoral head and acetabulum, remodeling of neck shaft angle and hip arthritis, power of hip abductors in this study. We would like to know about the exact follow-up protocol for the transarticular fixation, as there were several complications like infection, breakage or unusual migration related to transarticular fixation (2).

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Choi IH, Yoo WJ, Cho TJ, Chung CY. Operative reconstruction for septic arthritis of the hip. Orthop Clin North Am. 2006;37:173-83, vi.

    2. Marya KM, Yadav V, Rattan KN, Kundu ZS, Sangwan SS. Unusual K-wire migration. Indian J Pediatr. 2006;73:1107-8.

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