A 64 yrs old female was admitted on 21/06/2013 for Pain in left hip since March 2013(3 and ½ months). She also complained of inability to walk since 15 days. Patient was operated for FRACTURE NECK OF FEMUR 6yrs back and was alright for 2 yrs. After that vague pain started in her left Hip. Clinically left lower limb was short. Active straight leg test not possible. Movements of hip painful and limited. The recent X-Ray showed Dislocation of Hip Lt. Side. Planned for revision hip surgery.
Left hip was explored. There was no glutei muscle seen. The entire area was filled with ALVAL fluid. Acetabular Cup was removed with less difficulty. The coral stem was also removed. The upper one third of femur was Avascular. The further procedure was deferred for allowing the soft tissue to resolve. The entire ALVAL tissue was curetted as much as possible. So the surgery was not preceded.
During the second stage procedure, Revision hip with constrained hip system was done.
There are ongoing concerns regarding metal wear debris following the use of metal-on-metal (MoM) bearings for hip surface and total arthroplasty. A Type IV Hypersensitivity reaction to MoM articulations has previously been identified (aseptic lymphocyte dominated vasculitis associated lesion, ALVAL) but little is known of its incidence, diagnosis or management. Persisting groin pain in MoM patients may be undiagnosed ALVAL.
ALVAL- (Aseptic Lymphocyte Dominated Vasculitis Associated Lesion) is a medical reaction triggered by a soft tissue reaction in the body causing pain and inflammation and, where present, has affected some patients with metal on metal implants
Metallosis, another known complication is a medical condition resulting from a build-up of metallic debris in the surrounding soft tissue of the body. It has been reported that Metallosis can occur in patients with metal transplants and that these metal particles have been strongly linked to tissue damage, tumours, including Pseudo-tumours (an accumulated mass of inflamed tissue formed as a reaction to an irritant), high metal ion blood counts and blood poisoning.
ALVAL and Metallosis, when present in patients who had received metal on metal hip replacements are thought to be caused by incorrect placement of certain hip components in the patient, causing additional wear on these components. The hip resurfacing device functions as a metal bearing made of high carbon, cobalt and chromium alloys. If a patient is fitted with one of these implants, and the components are not aligned properly, then this malalignment of the bearing results in much more wear in that area, potentially causing a high- metal ion level as the debris and particles ( generated from the friction and wear of the metal components against one another) are released into the patient’s blood stream.
Current-generation MOM implants are made of cobalt-chromium alloys. A few authors have reported on an unusual mode of failure of these implants that is associated with a localized hypersensitivity reaction and immunologic response to metal wear debris: aseptic lymphocytic vasculitis associated lesion (ALVAL). The reported presenting features of ALVAL include early postoperative groin pain, radiographic loosening and osteolysis, recurrent dislocations, and periprosthetic fractures.
This is a single case reporting of a 64 years old female who was admitted for pain in her left hip since 3 and ½ months. She also complained of inability to walk since 15 days. Patient had a fall before 6 years and was diagnosed to have Fracture Neck of Femur. She was advised for Total Hip Metal on Metal prosthesis. She was operated with the same 6 years back. Initial 2 years after surgery she was completely alright doing all her routine activities. After 2 years she started to experience some vague pain over her operated hip. Initially the pain was vague but it increased progressively with days. She managed the pain with some analgesics and continued her routine activities.
Recently since 3 and ½ months she complaints of severe pain in her Left hip (old operated hip) followed by inability to walk since 15 days. On examination the Left Lower limb was shortened. The Active straight leg test was not possible. Greater trochanter was prominent on palpation. Range of movements was painfully restricted.
Clinical and radiological examination revealed Posterior dislocation of hip, loosening of the Cup & Osteolysis of the superior part of acetabulum and lateral cortex. So Decided to explore and proceed for revision hip.
Stage 1 Procedure:
Under SA, with pt. in Rt. Lateral position with Lt. hip facing up, the hip was exposed by lateral approach.
There was no muscle tissue, namely the glutei which was found necrosed and fibrosed. The necrosed tissue was brittle and greyish in colour. The same was excised as much as possible.
The upper end of the femur was not having any muscle attachment and it was avascular.
The trochanteric region was curetted which was filled with necrotic tissue. The head was removed from the stem. It was not shiny.
The acetabulum was covered with thick whitish fibrous tissue which was not bleeding on cut. The granulation and fibrous tissue was cleared and cup exposed. There was erosion of Acetabular wall superiorly. It was tapped out gently and removed. The granulation tissue was curetted out till it started oozing in the floor of acetabulum.
The fibrous tissue was excised as much as possible. The upper end of the femur was osteotomized in form of window and stem was removed. There was no bleeding in the medullary canal. A portion of the bone was taken for biopsy. Good wash was given and the window was closed with stainless steel wire. Wound closed in layers with DT. Foam traction was given. Curetted material from acetabulum and gluteal region was sent for
- Culture sensitivity
- Histo pathological examination
Fig.3 Glutei found necrosed & fibrosed which is brittle & Fig.4 Upper end of femur without any muscle attachment
Greyish white in colour (ALVAL) and found Avascular
Fig.5 Fibrosed being excised as much as possible Fig.6 Removed MOM Prosthesis
Fig.7 X-ray taken after Stage 1 procedure
Reasons for 2 Stage procedure:
The entire hip area was occupied by greyish brittle soft tissue (ALVAL Lesion). No delineation of the soft tissue namely the gluteus medius and the rotators. The entire muscles are necrosed.
As the earlier clinical, radiological and lab investigation do not reveal any evidence of infection, the materials were sent for to conform,
- No infection.
- Evidence of metal arthrosis (ALVAL).
The upper third of the femur was found Avascular.
So the surgery was not preceded.
The patient after the Stage 1 procedure was put on foam traction allowing soft tissues to resolve.
Fig.8 Histo pathological Report Fig.9 Microbiological Report
Now, as there is no evidence of infection, both culture and Histo pathological study and it is decided to revise the surgery with
- Constrained acetabulum.
- Proximal femur reconstruction.
- Solution to prevent loosening or rotation of stem.
Stage 2 Procedure:
Under GA, with Patient in Right lateral position with Left hip facing up, with the same incision left hip region was exposed. The upper end of femur looks better than what it was earlier. The acetabulum was cleaned & reamed up to 48mm. 48 shell was driven home with good version & 40 degrees abduction. The cup fixation was augmented with 3 screws. Trail liner was fixed & was found satisfactory.
Femur- The Greater Trochanter absent. Having Lesser Trochanter as a land mark, the femoral canal was reamed up to 14.5. The trail 15 stem with Calcar trial reduction was done with 0 size head. It was stable & satisfactory.
Hip dislocated. The trial stem removed & fixed with 15 size solution stem. 0 size trial head as fixed to the solution stem & hip reduced & found hip was stable. The trail liner was removed & replaced with constrained liner and it was stable. The selected 28 size head was fixed to the stem.
The augmenting liner was held to the neck. The liner was well cleaned. The groove in the constrained liner was cleaned & found satisfactory. The hip is reduced & keeping the head & neck perpendicular to the cup it was tapped nicely so that the head was driven in. Now the head is in good place. The augmenting ring was driven in to the groove of the liner. It was holding nicely. Hip movements tested & are stable. The window of the upper end of femur was placed back and held with S.S wire. Wound wash was given. The soft tissue was double breasted over the prosthesis. The rest of the wound is closed in layers with DT.
Fig.10 Upper end of Femur with good vascularity Fig.11 Constrained acetabulum in place
Fig.12 Upper end of femur reconstructed and trail fitting done Fig.13 Femoral implant in place with constrained
Fig.14 Fitting of the selected Constrained Hip system Fig.15 Revised THA
Fig. 16 X-ray taken immediately after second stage Procedure
After the second stage procedure, patient was very comfortable with minimal pain and improved. Patient retained the abduction and adduction movements. Active mobilization of Non- weight bearing walking with walker was started on the 3rd post operative day. Alternate day dressing of the wound was done. The wound seemed very healthy. With all the above improvement it was decided to discharge the patient on the 7th day after dressing.
On the 7th day, there was slight ooze from the postero-lateral aspect of the wound. Immediately 2 sutures were removed and the ooze was cleaned. Good wound wash was given. Dressing was done. The ooze seemed to be serous discharge. It was sent for culture and sensitivity. The stay of the patient in the hospital was prolonged. The reports came out negative for any growth. It was proved to be serous discharge, probably because of the reaction of the soft tissues to the Metal. Everyday dressing was done. The surrounding wound healed well, but wound gaping was present in the postero-lateral aspect and serous discharge continued to ooze out.
Apart from the serous discharge, the patient recovered very well. She was comfortable with minimal pain. She was able to do Non- weight bearing walking with walker. On the 14th day post operatively, all the sutures were removed and patient was decided to be discharged from the hospital. The surrounding wound was very healthy. But still everyday dressing was done at home. She was reviewed periodically at the hospital and the serous discharge was sent to lab for culture and sensitivity periodically.
After 1 month postoperatively, the patient was called for review. Serous discharge has reduced to about 50% when compared to the earlier condition. Patient was made to do weight bearing walking with walker. She was very comfortable walking without any pain. Her movements over her hip and knee were restored. Continuous follow-up of the patient was done. Patient at present is very comfortable.