Management of radiation induced, bilateral Primary THA loosening with an aseptic Paprosky Type IIB acetabular defect and a contralateral septic Type IIIB acetabular defect: A case report and review of literature

Highlights

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  In conclusion, we have suggested some principles in treating patients with such a similar, difficult clinical presentation with Post-irradiation bilateral Primary THA loosening with an ipsilateral aseptic Paprosky Type IIB acetabular defect and a contralateral septic Type IIIB acetabular defect in a same patient.

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  Careful attention must be given to a patient’s medical history, especially if they have been previously treated with radiation to their pelvis for prior malignancy. Although further clinical studies are needed in this patient population, cementless fixation, particularly with tantalum trabecular metal provide stable long-term fixation and should be preferred over cemented implants.

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  In the face of an aseptic and contralateral septic loosening of THA components, careful staging of treatment is of utmost importance. Following initial management of the more urgent, septic hip with explant, antibiotic spacer implant, and continued intravenous antibiotic administration to eradicate infection, management of the contralateral aseptic hip can be addressed to better accommodate rehabilitation for the anticipated second-stage reconstruction.

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  Surgical dissection of post-irradiated hips can be difficult due to extensive fibrosis, scarring, and vascular friability. It can lead to extensive bleeding while negotiating surgical planes. This can be particularly treacherous if this is associated with persistent infection. It is always advisable to keep a Vascular surgeon on standby in such cases where bleeding complications may occur intraoperatively.

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  Although it is worthwhile to keep the Cup-cage/Triflange options in the surgical armamentarium in the case of severe bone loss (Paprosky Type IIIA and IIIB defects) the cup-in-cup technique (with augments and/or buttress’) is an option to achieve stable fixation and bridge to remaining native bone.

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  Trabecular augments can be used for tiding over segmental acetabular defects in these Paprosky type IIIB, pelvic discontinuity cases. It can also serve as another cementless adjuvant to the construct with potential for ingrowth and osseointegration.

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  Dual-mobility heads can serve additional benefit by providing a larger, more native sized head, a decreased chance of dislocation and higher range of motion.

Abstract

Introduction

Primary THA in an irradiated hip poses risk for early loosening and inadequate ingrowth.Adverse effects such as decreased vascularity and increased infection risk pose a threat.

Case presentation

Our patient was a case of post-irradiation (for cervical cancer) bilateral THA loosening causing aseptic acetabular loosening on one side and catastrophic septic loosening with a Paprosky type IIIB acetabular defect with pelvic discontinuity on the contralateral side.

Discussion

There have been various studies documenting deleterious effects of irradiation on osseointegration and provide a challenge for long-term implant stability in THA patients.

Conclusion

A meticulous treatment protocol with contemporary implant technology and staged bilateral stepwise management can lead to satisfactory clinical outcomes.This case report highlights on such specific nuances and principles.