ÑOÃ HÖÕU THAÉNG, MD Lower Limb Dept. HTO HCMC

1. one-stage Bilateral total hip ARTHROPLASTY for the PATIENT of ankylosing spondylitis WITH sEVERE DEFORMITies ÑOÃ HÖÕU THAÉNG, MD Lower Limb Dept. HTO HCMC

2. MEDICAL RECORD • Nguyeãn Keá Phong, male, 45 y/o (1963) • IT • Ñaø laït - Laâm ñoàng • Reason of hospitalization: stiffness and deformities of spine and both hips

3. History • Progressive kyphosis since 18 y/o • Underwent correction surgery of spine at Binh Dan hospital 1 year later • Stiffness of both hips and whole spine with severe deformities since 23 y/o • Present situation: hard to walk, impossibly supine position

4. past history • Himself: Diabetes Mellitus • Family: good life

5. examination • General condition: slim, normal skin • Respiration: severe deformity of thorax, breathe abdominally, no dyspnea. Surgical scar #20cm at 11th-12th left intercostal space. • Cardio-vascular: normal, BP: 110/60 mmHg • GI: normal • Limited ROM of mandible

6. Musculoskeletal system • Cervical spine: Complete stiffness, kyphosis 300 • Thoraco-lumbar spine: Complete stiffness, kyphosis 900, right scoliosis 300 • Ilium: merge into lumbar spine, rotation

7. Musculoskeletal system Both hips: • Complete stiffness • Deformity in flexion 450, slight adduction

8. Musculoskeletal system • Knee joint: normal ROM • Shoulder joint and others: normal • Slight atrophy of gluteus & quadriceps • None of paralysis • None of impaired sensation

9. IMAGING U- shaped deformity, impossible supine position

10. X- rays Cervical spine

11. THORACO-LUMBAR SPINE

12. HIP JOINT

13. CT-SCAN

14. CT-SCAN

16. DIAGNOSIS ANKYLOSING ARTHRITIS OF BOTH HIPS IN THE PATIENT OF ANKYLOSING SPONDYLITIS WITH SEVERE DEFORMITY

17. INDICATION • BILATERAL THA • REDUCING KYPHOSIS & SCOLIOSIS GOAL:Improving mobility as well as recovering daily activities

18. Pre-op preparation INTERDEPARTMENTAL CONSULTATION: • Nutrition: balancing general condition • Endocrine: stable glycemia • ENT: support intubation when needed • Anesthesia

19. Pre-op preparation • Balancing general condition • Patient’s psychology • Physical therapy: Breathing exercise, exercise of knee’s motion and strengthening thigh’s muscle

20. CHALLENGE • ANESTHESIA’S METHOD: difficult, due to stiffness of spine and thorax, limited ROM of mandible • INTRA-OP&POST-OP POSITION: severe deformities of spine and ilium change anatomic landmarks, difficulty in orientation • AVOIDING INTRA-&POST-OP COMPLICATIONS: ARDS, bleeding, DVT, infection, pressure ulcer, dislocation…

21. OperatiON planS • Plan 1: femoral neck cutting, continued traction or spacer for 3 - 4 weeks then THA • Plan 2: two-stage THA apart ( 3-6 months) • Plan 3: one-stage bilateral THA • Anesthesia: epidural or inhaled

22. Preparing • Cementless THA prothesis • Intra-&post-op supporting instruments: pillow, Zimmer brace…

23. OPERATION Anesthesia method: spinal injection

24. OPERATION • PL approach for both sides, right side first • Right side: shell 52, head +0, stem 10 • Left side: shell 50, head +3, stem 10 • Leg lengths equal, ROM of both sides good, stable • Vacuum drainage postoperatively • Zimmer brace for both sides

25. OPERATION • Operative time: 3h 20m • Blood lost: 700ml • Blood transfusion: 1,5 unit • Prophylaxic antibiotic : Cefaxon 2g

26. POSTOPERATIon • Day 1: conscious, vital signs stable. Blood transfusion 4 units, antibiotic, analgesic, insulin • Day 2: better, withdraw drainage, blood transfusion 2.5 units • Day 3: transmit to spinal dept. • Day 4: Physical therapy

27. results

28. results Post-op Pre-op

29. results • 4th week post-op: • Walk without crutches, independence • ROM: good • No complications

31. DISCUSSION ANKYLOSING SPONDYLITIS: • Age: 20 - 40 • Male > female: 7 times (Van der Linden SM, 1985) • Result in stiffness and severe deformity • Accompanied disease: Cardio-vascular disease, respiration system, metabolism disorders

32. discussion INDICATION: • Complete stiffness of hip joint in bad position to recover biomechanics of hip joint and mobility • Create favourable conditions for spinal surgery

33. discussion

34. discussion • 133 cases THR 1995-2000 (Ñoã Höõu Thaéng): • Clinic diagnosis : • + Avascular necrosis of femoral head :45 • + OA :49 • + Old fracture of femoral neck :15 • + Fracture-dislocation of hip joint :04 • + Ankylosing spondylitis :07

35. discussion DIFFICULTIES: • Anesthesia method, intra-&post-op resuscitation • Changing anatomy landmarks, risk of implant mal-position • Accompanied: Cardio-vascular disease, diabetes…

36. discussion COMPLICATIONS: • Severe: bleeding, ARDS • Infection, DVT, pressure ulcer • Dislocation • Limb discrepancy • Osteo-myolitis

37. discussion TECHNIQUES: • One-stage or two-stage surgery (3-6 month apart) • Approach: PL approach, avoid bony resection of GT • Release soft tissues or shorten the femoral neck in case of severe contraction

38. discussion IMPLANT SELECTION: • Hybrid THA best option for ankylosing arthritis of hip joint • Cementless THA suitable for young patient with good-quality bone PHYSICAL THERAPY PLAYS AN IMPORTANT ROLE FOR SUCCESS OF THA

39. CONCLUSION A DIFFICULT AND RARE CASE: • Ankylosing Spondilitis with severe deformities of spine and both hips causing disability • Diabetes Mellitus accompanied • First case of bilateral THA at the same surgery in HTO • Good recovery: full-weight bearing after 4 weeks without post-op complications

40. CONCLUSION EXPERIENCES: • Thorough patient preparation • Plans for surgery and difficulties in intra- & post-operation • Instrument and implant preparation • Team works of Anesthesia, Internal medicine, Nutrition, ENT… • Physical therapy regime

41. Post-op x.rays of spine

42. Post-op spine surgery

43. Thank you!