Total hip arthroplasty for treating childhood infection sequelae

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Childhood hip infection may lead to a broad spectrum of residual deformities in the hip. Although total hip arthroplasty (THA) is the treatment of choice to eliminate pain and improve functions for end-stage osteoarthritis, THA in adult patients with childhood hip infection sequelae can be technically challenging because of the extensive and complex deformities. In addition, many surgeons hesitate to offer THA to patients with a history of childhood septic arthritis (SA) for fear of reactivating or recurrent infections. In this article, Youn-Soo Park from the Department of Orthopedic Surgery, Samsung Medical Center, Seoul, South Korea, updates us on the status of THA in patients with childhood infection sequelae in the hip joint—the surgical challenges, prognostic factors, and outcome.

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Youn-Soo Park

AO Recon Education Forum
Department of Orthopedic Surgery
Samsung Medical Center
Seoul, South Korea

Childhood septic arthritis

Septic arthritis can occur in patients of all ages, but because of the anatomical and physiological characteristics of joints in children, it is mostly found in young children [1]. It is a rare but serious, potentially devastating disease. In a prospective study, it was estimated at an incidence of 1:20,000 among the pediatric population in a region in South Africa [2], and others have estimated it at 1–5 cases per 100,000 in children in developed countries [1]. Correct diagnosis and timely treatment are important for good outcomes but can still result in residual deformities. Childhood hip infection sequelae are more common in poorer, less developed countries [1–3].

The onset of symptoms of SA can be joint swelling and/or sudden joint pain, malaise, a mild limp, inability to bear weight, or the recognition that a leg was not actively moving in an infant; there may or may not be fever at presentation [1, 2, 4, 5]. Staphylococcus aureus (S aureus) is the most frequently encountered pathogen, other organisms such as Streptococcus pneumoniae and Kingella kingae are also frequently found. The frequency of the pathogen can differ depending on the child's age and geographic location [1, 2, 4–6]. Previously in South Korea, for example, because of the prevalence of tuberculous infection in the population, tuberculous SA was commonly seen [7]. It is important to note that SA can happen without positive cultures, but when a positive culture was detected, it was associated with worse outcomes [4]. The hip joint is the most frequently affected site, followed by the knee joint, and multifocal sepsis is also not uncommon [2, 4, 5, 8].

Timely (within 5 days of the onset of symptoms) and aggressive antimicrobial therapy combined with surgical washout and/or arthrotomy are the best practice and are critical for good outcome [2, 4, 5]. Even then, patient-specific factors may still influence the outcome. Using multivariate analysis, Jeyanthi et al [4] showed that young age (< 4 years) and concomitant osteomyelitis were associated with a significantly higher risk of sequelae, and Wang et al [5] showed that SA with concomitant osteomyelitis and infection due to methicillin-resistant S aureus (as opposed to methicillin-sensitive S aureus) was associated with a significantly increased risk of sequelae [5].

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What to do with the long turnaround time of a microbiological culture test?

Several recent publications have pointed to the utility of real-time polymerase chain reaction (PCR) as a supplemental tool for rapid diagnosis of septic arthritis and identification of the infection organism. Such techniques may help with the reliable selection of appropriate antibiotics [1, 4].

Adult patients with hip infection sequelae

Patients with (childhood) infection sequelae may present with mechanical axis deviation, limb length discrepancy, distorted bony structure, and soft-tissue abnormalities [9, 11]. In severe cases, patients may have a dysplastic acetabulum, high dislocation, rudimentary proximal femur, and narrow femoral canal—ie, a total destruction of the hip (Figure 1); the soft tissue may present severe contracture of the joint capsule, weak abductor muscles, and scarred skin (Figure 2).

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Figure 1. Complete destruction of a hip joint by infection sequelae. A 41-year-old woman with septic hip sequelae. (a) High-riding hip center and femur with a narrow canal diameter on preoperative anteroposterior x-ray. (b) Severely deformed proximal femur missing its head viewed using three-dimensional computed tomography. (c) Total hip arthroplasty using modular stem with narrow diameter and small medial offset. Cerclage wiring was performed after extended trochanteric osteotomy and subtrochanteric shortening osteotomy. Figure reproduced under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted non-commercial use, distribution, and reproduction in any mediumwith proper citation.

A diagnosis of infection sequelae is usually based on the evidence of previous treatment for infection of the hip joint. Such evidence may include a history of medical and/or surgical treatments, radiographic features of previous infection (eg, arthrotomy scars), and/or clinical presentation (eg, presence of sinus drainage tract and atrophic abductor muscles, Figure 2) [3, 11].

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Figure 2. Soft-tissue signs of previous infection. A patient with severe infection sequelae showing (a) multiple scars of draining sinus and (b) contracted pericapsular structures and atrophic abductor muscles on the axial view of the preoperative magnetic resonance imaging. Figure reused under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted noncommercial use, distribution, and reproduction in any medium with proper citation.
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Is there a good classification system for infection sequelae of the hip?

Based on the initial damages and the radiological aspect at maturity, Choi et al [12] proposed a classification system for hip deformities after SA. Because the spectrum of deformities caused by SA in the hip can be quite broad and the intraoperative findings of the bony and soft-tissue structures often differ from patient to patient, a classification system is not particularly useful for preoperative planning. When a classification system is used, Park tells us, many find the commonly used Crowe classification for developmental dysplasia of the hip (DDH) just as useful as the Choi system [13, 14].

Challenges of total hip arthroplasty in treating infection sequelae

Although THA is the treatment of choice to relieve pain and improve quality of life in patients with childhood infection sequelae, it also presents some serious technical challenges with potentially increased chance of infection and complication [8, 9, 14, 15]. Given Youn-Soo Park's long years of handling these challenging THAs, we asked him how feasible it is to perform THAs in patients with severe deformation from infection sequelae. He told us, "THA in patients with severely deformed, high-dislocation hips is very complicated and difficult; 30–40 years ago, surgeons would not even try treating such patients with THAs. With the development of modern implants, many deformities can be handled more easily. For example, dysplastic stems and acetabular cups of different sizes are now available. These provide better fit for the deformed femurs and acetabula. The development of modular components and surgical techniques (such as subtrochanteric osteotomy) helps surgeons to correct rotational defects with better ease. In addition, the importance of the innovation in modern materials for liners should not be overlooked. The new ceramic and highly cross-linked polyethylene contributed to the development of thinner and more durable liners, which then contributed to improved survivorship of THAs—by reducing wear of the liners in comparison to the old polyethylene liners. Longer survivorship means fewer revisions, and this is extremely important for this patient population, who are oftentimes younger. Nowadays, THA in deformed hips is easier to perform and outcomes are better than before, but the procedure is still challenging." (For a description of surgical techniques in handling highly dislocated hips, see Part 1  and for a review of modular stems, see Part 3)

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THA in infection sequelae: Which approach is better?

The direct anterior approach for THA is all the rage these days. We asked Park if the anterior approach was a better approach for THA in hips with infection sequelae and he told us, "I usually use an anterolateral approach. There are two considerations: first, each surgeon may be more familiar with and better at one approach versus another, and second, each approach has its own advantages and disadvantages, so no approach is a generic best approach. Surgeons should decide on their own approach in performing a THA.

What is a suitable quiescent period to avoid reactivation of a previous infection?

Although an optimal quiescent period between the active infection and THA has not been well studied and is yet to be established, most of the available studies followed the 1991 publication by Kim [16] and considered a quiescent period of more than 10 years after infection resolution sufficiently long for THAs to be performed safely without fear of a reactivation of the previous infection [8]. Existing studies largely confirmed this practice [7, 9, 10, 17]. Even so, Park reminds our readers that due to complexity of such procedures, operation time can be longer than usual and there may be more loss of blood—both can lead to increased infection risk.

 

Childhood infection sequelae versus developmental dysplasia of the hip: a matched-pair study

Neglected or improperly treated DDH and childhood SA are the two most common causes of adult high hip dislocation. Total hip arthroplasty in these two patient populations is challenging and the same surgical principles and techniques are applied—both may require extensive soft-tissue release to ensure adequate exposure for proper implant insertion, reduction to the true acetabulum is the usual goal, and subtrochanteric osteotomy may be applied in case of leg lengthening more than 3–4 cm, to avoid neurovascular injuries (see Part 1) [13].

However, the deformities in patients with infection sequelae are usually more severe. In addition, due to the previous arthrotomy and draining of sinus tracks, patients with previous infection have more deformation in the major neurovascular structures and more severe adhesions surrounding the joints (Figure 3) [7, 11, 13, 18]. The result is that the soft-tissue release is more extensive in patients of the Choi type IV infection sequelae than in Crowe type IV DDH.

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Figure 3. Deformities from different etiologies. Choi type IV infantile septic arthritis sequelae (a) versus Crowe type IV developmental dysplasia of the hip (b). Preoperative anteroposterior x-rays contributed by Youn-Soo Park.
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Figure 4. Implant survivorship. At 10 years: Infection group: 83.6% (76.1–91.1); DDH group: 100% (P = .04). At 15 years: Infection group: 77.6% (68.6–86.6); DDH group: 85.1% (75.4– 94.8) (P = .04). Graph contributed by Youn-Soo Park.

Park et al [13] investigated if the clinical outcomes might be different for cementless THAs performed in patients with highly dislocated hips from different etiologies, ie, infection sequelae and DDH. The authors defined evidence of childhood infection based on treatment history and clinical or radiographic characteristics (eg, destruction of femoral head and neck, scars of sinus tracts or previous incisions for drainage). Sixty chronic, highly dislocated hips were divided into either the infection or the DDH group. The hips were matched 1:1 (25 patients in each group) using propensity scores generated by logistic regression and the resulting groups were comparable in preoperative demographics and leg length discrepancy (LLD: defined as the height difference of the parallel lines crossing the prominent points of the lesser trochanter and the lowest points of the teardrop) [13]. Comparing these two groups of patients followed up to a mean time of 12.3 years (range 5–22), statistical analyses determined that the infection group had overall less favorable outcomes: more blood loss, less correction in LLD, lower functional outcome as measured by the Harris hip score (HHS), UCLA Activity Score, more limping, and more surgical complications (Table 1). The survivorship was also statistically better in the DDH than in the infection group at 10 years, although at 15 years the statistical significance no longer existed (Figure 4).

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Table 1. Clinical outcome comparison between infection and DDH groups. DDH, developmental dysplasia of the hip; n, number of patients; SD, standard deviation. * The mean duration of follow-up was 12.3 (range 5–22) years. ** Abductor strength was evaluated using the manual muscle testing grading system in a lateral position.

Prognostic factors influencing outcomes of total hip arthroplasty in infection sequelae

Due to the low prevalence of infection sequelae and the necessity of long follow-ups, it is nearly impossible to conduct prospective studies on factors that could affect outcomes of THA in patients with childhood SA. Current best evidence is from a study on the functional outcomes after cementless THA in a cohort of patients (75 hips) with varying degree of deformities (Crowe types I–IV) from previous pyogenic or tuberculous infection followed up to a mean time of 5.8 years (range, 3–9 years); all patients had an infection quiescent period or more than 10 years [3].

Prognostic factors examined in this study were:

  1. Age at the onset of infection
  2. Degree of preoperative flexion contracture
  3. Hip fusion status
  4. LLD (measured as the difference in the distance from anterosuperior iliac spine to medial malleolus in affected and unaffected sides)
  5. Severity of acetabular deformity (according to the Crowe classification)
  6. Degree of femoral hypoplasia (based on the cortical width at the isthmus)

The authors determined that infection onset at an age younger than 5 years, fused hips, preoperative LLD greater than 1 inch (2.5 cm), severe acetabular dysplasia, and severe femoral hypoplasia were associated with poorer functional outcome as assessed by HHS [3].

It is perhaps worthwhile to mention that, in this group of patients treated with cementless stems made by different manufacturer and porous-coated, metal-backed modular cementless cup of varying sizes—all with conventional polyethylene liners—the overall mechanical loosening rate was 5.3% at a mean follow-up time of 5.8 years. All failures of acetabular components happened in patients with Crowe type IV hip dysplasia. Presumably, with the development of modern lines with more robust materials, improved outcome can be expected.

Conclusion

Total hip arthroplasty in dysplastic hips is very complicated and difficult, and deformities caused by high-grade hip infection sequalae are more prone to unfavorable outcomes than those caused by high-grade DDH. Various special surgical techniques have been developed for THA in severely dysplastic hips, and the invention of modular and other dysplastic stems are especially useful in managing these highly deformed hips. Given a sufficient infection quiescent period, reinfection is usually not a concern. With meticulous surgical planning, thorough knowledge in key technical difficulties and surgical principles, and the assistance of modular components, good mid-term outcomes and high implant survivorship can be achieved.

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Part 1 | Dysplastic high-riding hips

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Part 3 | Patients with skeletal dysplasia

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Additional AO resources

Access videos, tools, and other assets.

Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

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Seung Beom Han

Department of Orthopedics
Korea University Medical Center
Seoul, South Korea

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Seung-Jae Lim

Department of Orthopedic Surgery
Samsung Medical Center
Seoul, South Korea

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Youn-Soo Park

AO Recon Education Forum
Department of Orthopedic Surgery
Samsung Medical Center
Seoul, South Korea

This issue was written by Maio Chen, AO Innovation Translation Center, Clinical Science, Switzerland.

References

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