On-line CEUs

TIP OF THE MONTH: June/July 2007
Total Hip Arthroplasty: Case Presentation Using Metal on Metal Technology
Sean Conkle, OTC

In July 2004, a 43 year old white male, insulin dependant Athletic Trainer, presented to the office with ongoing bilateral hip pain, left greater than right, with increasing intensity over the last six months. The patient had complaints of difficulties getting into positions to perform stretching excersices on athletes and also performing activities of daily living.

According to his physical exam, this patient has limited range of motion, 85 degrees of flexion full extension, 20 degrees of external rotation, 20 degrees of internal rotation and 35 degrees of abduction. X-rays that were performed at that time (Figure 1) showed advanced degenerative changes of bilateral hips, left greater than right, with flattening of the superior lateral aspect of the left femoral head with acetabular osteophyte formation. At this time, the nature of the problem was described in detail to the patient and it was recommended that, due to the patient’s age and high demand profession, he proceed with conservative treatment to include NSAIDS and physical therapy for increased range of motion, as well as repeat radiographs to monitor progression.



In June 2006, the patient returned to the office stating that the pain in his left hip has been getting progressively worse, and now causing pain with ambulation. Upon examination, the patient has maintained his range of motion, and strength. The x-rays that were obtained revealed increased flattening of the superior aspect of the femoral head, with no cystic lesions identified, or evidence of petrusio. At this time surgical intervention was once again discussed with the patient. He was educated on the availability of new technology in hip replacements that utilize a metal on metal acetabular implant allowing for decreased wear characteristics. It was also explained to the patient that there were no long term studies of the effects of increased metal ION concentrations in blood and the associated risks.

After reviewing all information and options, the patient still decided to continue with conservative treatment. Once again in November 2006, the patient reported to the office stating that the pain in his left hip has increased significantly over the last couple of months to the point where he is having problems performing his activities of daily living.

Once again, continual conservative treatment options, verses surgical intervention that were discussed with the patient, the patient decided to proceed with a Total Hip Arthroplasty with metal on metal. Possible risks and complications were discussed at length, to include the possibility of revision hip arthroplasty (Figure 2).



In mid-December, the patient underwent Total Hip Arthroplasty utilizing the Depuy Summit Stem with a pinnacle sector 2 cup. The leg lengths were maintained and the patient had no complications post-operatively. He spent three days inpatient and was discharged from the hospital to outpatient therapy. On his post-operative visit, the patient had 80 degrees of flexion and 20 degrees of abduction. The patient reports he has no real “hip” pain, but minimal incision pain. The post-op films showed excellent alignment of prosthesis with good fixation (Figure 3).



In January 2007, the patient returned to the office stating that his pain level is 0 out of 10 and ambulated with normal gait. His range of motion is 90 degrees of flexion, 0 degrees of extension and with 35 degree of abduction, without any discomfort. The patient was released to modified duty at the work place with restrictions of no kneeling, bending, or squatting.

In late February, the patient returned to the office stating that he has no pain and has resumed regular activities of daily living. He states that for the first time in 4 years he is able to do everything he wants with no discomfort. He has 110 degrees of flexion with 45 degrees of external rotation, 20 degrees of internal rotation, with 45 degrees of abduction, without discomfort. Since undergoing Total Hip Arthroplasty patient has returned to the sidelines able to examine his athletes without discomfort, and states the he wishes he had undergone the procedure sooner so that he would not have gone through the pain he did over the past four years.

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