THR teenager hip replacement after SUFE

[Josephine]

We also just had a CT scan done yesterday in the hopes that it will reveal enough healing in her femoral neck fracture to validate the removal of screws. If there is in fact enough "bonding" of the bones and we could get away with a minimally invasive procedure where the screws are removed, that would be ideal at this point. At least it might buy us a bit of time to allow Maya grow

You know, at this stage I could really use the dates of her two surgeries in order to offer a sensible reply here.

 

[Maya'sdad]

Hi Josephine, Maya's first surgery was on May 2, 2015. This was the emergency procedure following the automobile accident.

I've attached an x-ray of her first follow up visit after the initial surgery.

The second image attached was taken about two weeks after her second surgery,

and the last image is the most recent x-ray taken on 12-17-15

 

[Maya'sdad]

By the way, the date of the second surgery (osteotomy) was 8-5-15.
Thank you

 

[Josephine]

Thank you, those xrays are very informative and tell me a lot about how and why Maya has the problems she has now.

In this original xray, you can see that the screws are poorly placed as depicted by the red lines which show the optimum position.

(red arrow and blue circle ) not only is the fracture is not properly reduced but it is actually being held apart by the screws
(black arrow) and there is already movement around the screws as depicted by the shadows

Again, this blue arrow shows the total non-union of the fracture, the poor position of the screws (the red lines show where they should ideally be) and the protrusion of the screws through the top of the femoral head. This was inevitable because of their poor position to a point where there was very little bone stock holding them in place. And you can see how the head is tipped off the neck at an angle that meant bony union was impossible.

 

[Maya'sdad]

Thanks Josephine. That's what we were worried about. I think the real problems started with the first knucklehead surgeon. After the second surgery, the screws were set correctly right through the center of the neck and femoral head. For whatever reason, they migrated upwards. Based on what you see in these images, what do feel would be the best course of action at this stage?
Thank you in advance.
God Bless.

 

[Josephine]

After the second surgery, the screws were set correctly right through the center of the neck and femoral head. For whatever reason, they migrated upwards.

Actually that's an optical illusion. One of the xrays is a lateral view, from the side, and clearly shows the screws are badly placed. In the AP (back to front) view, it does look like they are better placed. And the screws didn't migrate upwards, the head moved and collapsed because it wasn't secure. That's what happens in cases like these, I'm afraid.

At this stage, you should keep her as much non-weight bearing as is possible. That's the only way to reduce the pain. But in the end, what she really needs is a hip replacement. Though there is one other option as a temporary fix to relieve the pain and that is a Girdlestone's operation. This may sound dramatic and extreme but it's a little used and very old procedure consisting of just removing the femoral head and leaving it until she can have the hip replacement. It won't require any bone cutting as the fracture is ununited and I would expect the femoral head to just lift out with a little division of some soft tissues. She would have a ghastly gait and need to use a pair of crutches but at least she would be about 90% pain free compared to now.

In years past, before the advent of the hip replacement, this was the only procedure available to people with badly arthritic hips!

This is what the end result would look like

 

[Maya'sdad]

Dear Josephine, it seems we need to fly you out to the US and have you move in with us
You have given us more information in the past few days than we have received in the previous nine plus months. On behalf of Maya and our entire family, thank you.
We expect to hear from Maya's surgeon in the next day or two with the results from last weeks CT. Hopefully this will help us determine what the best course of action will be.
Poor little Maya has been so strong and brave throughout this entire ordeal. As I am typing this, she is laughing hysterically while playing on her ipad. I wish for nothing more than to some day see her back on her feet doing the things she loves to do.
I will keep you all posted as we become more informed.
Thank you Josephine and the entire Bonesmart community.
God Bless!

 

[niknak79]

Hi again @Maya'sdad - just looking at those x-rays has made me so cross and so sad for wee Maya (and her family). Brings back some memories too (seeing the giant screws on an x-ray was quite alarming aged 8!).

Interestingly what Josephine suggested about the Girdlestone's operation is I think what was also suggested in my case when waiting for me to stop growing and get the THR. In my case they waited to see how long I could tolerate the pain for and if it became really intolerable before they were prepared to do the THR then the Girdlestone's op was the last resort. As it was I coped just about with the pain (under the excellent care of a specialist pain clinic using a combination of analgesics, TENS machine, acupuncture etc., and using crutches full time) until getting my new hip aged 19. My recovery after the THR was great. Back in those days you spent 2 weeks in hospital (not any more!) and then 3 months confined to not bending knee towards your chest more than 90 degrees, which meant I needed modifications made to my student digs (higher chairs, higher toilet etc.) but from memory I was off crutches pretty quickly and as soon as the three months was up I was riding a bike- something I hadn't been able to do since age 13.

Six months after the THR I led a SCUBA diving expedition to Malaysia for three months! It was amazing- it was like being given a new life. Pain almost completely disappeared within 12 weeks. Now 17 years later I am getting quite a bit of bother (which only really started a couple of years ago) - but possibly nothing to do with the hip, but rather the soft tissues around it (perhaps due to the number of surgeries I had as a child) (bursitis) and my back gives me some trouble. But the hip shows minimal wear so hoping to get a good few more years out of it yet! I am waiting for more PT and an MRI scan on the back to help figure out how to get the pain under control- the cortisone injection into the hip for the bursitis certainly has helped so after another one asap (previous one was 5 months ago).

I can honestly say having the THR was the best thing ever. To get mobility back and be almost completely free of pain was like a new lease of life.

No issues with infection, loosening or anything. Their biggest concern was likelihood of dislocation (I still remember my surgeon lecturing me about how to put on my wetsuit as he'd done a THR on a stunt man who had dislocated his putting on his wetsuit in the early months!). I had a fantastic surgeon who got a custom made joint constructed to fit my "funny femur" and really did everything he could I think to make the THR a success. He even timetabled the surgery to ensure I didn't miss term time at university!

Good luck with progressing Maya's case with her surgeon. Definitely sounds like something needs done quickly - it looks so sore :-(

 

[Josephine]

You have given us more information in the past few days than we have received in the previous nine plus months.

Well, you're lucky in that I've done so many fractured necks of femur in my early years as an operating theatre sister, that I became something of an expert on the subject! Then I took a job in charge of a department that did a lot of paediatric orthopaedic surgery and CDH and Perthes is naturally the major portion of that so the experience in NoFs just naturally transposed into it. I even lectured on the subjects quite a bit. So this and hip replacements have just come naturally to me and I am very, very pleased to still be able to make use of it at this age!

 

[Maya'sdad]

Thank you Josephine and Niknak79. Truly appreciate both of you sharing your knowledge and experiences.
At this point, we are still awaiting results form the CT (not real hopeful these will tell us much) to determine the next step. No question that Maya will require a third surgery, question is what type?
Do we again roll the dice on a revision? One in which the femoral neck and head is already displaying signs of AVN and has had six different screws inserted within the last 9 months, or a THR?

 

[Josephine]

Honestly, I cannot emphasise strongly enough that the only options are either a Girdlestone's or a THR.
If they start mentioning the word fusion (or arthrodesis) - which means to fix the hip so there is no movement - please be adamant when you say no! It's much, much harder to unpick a fusion than a Girdlestone to convert it to a hip replacement. I know as I've scrubbed for many!

 

[Maya'sdad]

A fusion was brought up as a possible option before and we all agreed we would not be heading down that path.
Guess we'll have to see how it plays out. Thank you for the info. Keep you all posted.
God Bless.

 

[Maya'sdad]

Update!
Ffter reviewing the CT scans, Maya's surgeon has made the following recommendations.
Please let me know your thoughts!
Thank you.

Maya's Dr...
"So the CT scan confirms much of what we were able to see on the xrays, i.e. 1) the screw tips have penetrated through the bone surface and appear to be penetrating into the joint, 2) there was some loss of alignment across the fracture site, 3) the osteotomy site appears well-healed. The amount of/lack of healing across the fracture site continues to be difficult to assess.
So my thoughts with the surgery are:
- removal of screws from the femoral head
- intraop evaluation of the fracture site
- revision fixation with new screws if fracture site does not appear fully healed
- consideration for removal of existing plate + screws
We can setup a time to talk soon – if you’d like. We can also continue to try to set up a meeting with Dr. XXXX (our hip replacement specialist)."

Your opinions and recommendations are most appreciated.

 

[niknak79]

@Maya'sdad I am just tagging @Josephine so that she sees your update from the CT scan results, as she will have the necessary expertise to help you. Interesting there is no mention of AVN in the Dr's notes? I am assuming (as a non specialist) that this could be good news if they think revision fixation of the fracture site is a possibility (I guess as they say that will depend on "intraop" look-see to see the current state of the fracture- which to me looked like it was actually being held apart by the first set of screws so no wonder it didn't heal). And she definitely needs the existing screws out asap!
Personally I would definitely push to see the hip replacement specialist also- just to give you as much info as possible on all options- especially for example if and when they would consider a THR as an option for Maya (i.e. would they need to wait until she has stopped growing and how would they assess when this has happened).
I do feel from my own experiences that trying to reduce the number of surgeries likely to be involved in restoring Maya's hip function (and alleviating pain) should be a key issue. The more surgeries the harder it is long term to fully recover in my opinion. But she is young and should heal fast with good care.
Thinking of you x

 

[Maya'sdad]

Thanks niknak. I truly appreciate your feedback. We hope to speak to her Dr today via phone conference. We are also hoping to move up our appt with the hip replacement specialist. Currently it's scheduled for 1-27 (the earliest we could get). Should have some additional info by days end.
Thanks much.

 

[Josephine]

The amount of/lack of healing across the fracture site continues to be difficult to assess - revision fixation with new screws if fracture site does not appear fully healed

I admire his optimism that an 8 month old fracture still has any chance of healing! I would think that to be highly unlikely. However, removal of those screws seems like a jolly good idea and may well give her some relief for the interim.

 

[Maya'sdad]

I'm thinking the same thing. However, could the screws simply be removed without doing anything else? If the fracture site has not healed properly what would hold everything together?
Thank you very much Josephine.
Cheers.

 

[Maya'sdad]

Dear Josephine, Maya's current surgeon is not certain if she qualifies for a THR since she currently has a plate with screws inserted into her femur. He feels the hip replacement specialist might want to have all the hardware removed and bones healed before THR is performed. He labeled this as staging. What is your opinion on this? If he is correct, it would mean that Maya would need one surgery to remove the hardware, and second (total of four surgeries) when her femur has healed to perform the THR.
I would truly value your input here. We are at whits end with this situation. I would hate to have to subject Maya to additional surgeries if they can be avoided.
Thank you in advance.
Sincerely,
Maya'sdad

 

[Josephine]

Maya's current surgeon is not certain if she qualifies for a THR since she currently has a plate with screws inserted into her femur.

Well, we already knew that!

He feels the hip replacement specialist might want to have all the hardware removed and bones healed before THR is performed.

Well, he might and he might not. It's his call really. I've scrubbed for both ways. But the really big screws that were put in first are gone and the present screws really aren't that big so wouldn't really pose a problem in my point of view. However, the screws in the plate do as they make a weakening of the shaft and also provide holes for the cement to ooze out of during surgery! All in all, I would recommend the staging and get those screws out so the hip surgeon has a solid femur to work with. Plus, since I would imagine much of her pain if from the screws ploughing up the acetabulum, at least she will be rid of that. Though the ununited fracture will still be painful but much less so.

I should also mention that the fractured head will not be totally unconstrained without the screws as there will be quite a bit of fibrous and scar tissue holding it in place. But there will still be a bit of movement, more like a wobble. How much pain this causes is anybody's guess - could be bad or could be mild, no-one can say until it's done.

 

[Maya'sdad]

Thank you so very much Josephine.
What your saying makes perfect sense.
The question I still have, if the plate and screws need to come out before THR, would it make sense to have the revision done at that time and hope for the best?