1. Lower Limb Dept. HTO HCMC
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. U- shaped deformity, impossible supine position
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 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. Anesthesia method: spinal injection
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. PHYSICAL THERAPY PLAYS AN IMPORTANT ROLE FOR SUCCESS OF THA
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!