Chiba Medical J. 98E：39-46， 2022
doi:10.20776/S03035476-98E-4-P39
〔 Case Report 〕
Jumpei Shoda1), Junichi Nakamura1), Shigeo Hagiwara1)
Yuya Kawarai1,2), Sumihisa Orita1,3), Yawara Eguchi1,4)
Kazuhide Inage1), Yasuhiro Shiga1,2), Yoshihiro Sakuma1,5)
and Seiji Ohtori1)
1) Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670.
2) Center for Advanced Joint Function and Reconstructive Spine Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8670.
3) Center for Frontier Medical Engineering (CFME), Chiba University, Chiba 263-8522.
4) Department of Orthopaedic Surgery, Center for Orthopaedic science medical innovation, Graduated School of Medicine, Chiba University, Chiba 260-8670.
5) Medical corporation Keisuikai Kanazawa Hospital, Yokohama 236-0021.
(Received February 11, 2022, Accepted March 24, 2022, Published August 10, 2022.)
【Background】 For patients with Parkinson’s disease, it is difficult to treat hip joint disorders because of postural abnormalities and muscle rigidity. Advances in spine surgery have led to an increase in the use of long-range fusion procedures, and their impact on pelvic alignment has been gaining attention. We report the case of a patient with Parkinson’s disease and spinal long fusion who required bilateral revision surgery for irreducible dislocation of total hip arthroplasties in rapidly destructive coxarthropathy.
【Case report】 A woman with severe Parkinson’s disease underwent spinal long-range fusion from Th3 to S for spinal deformity and lumbar spinal canal stenosis at 71 years of age. Three years later she developed severe right hip pain and difficulty walking due to progressive narrowing of the joint space due to posterior pelvic tilt (right Japanese Orthopaedic Association (JOA) score 21). The patient underwent right total hip arthroplasty via a direct anterior approach while supine on a traction table. Although the implant alignment was in a safe zone and intraoperative muscle tension was stable, the patient dislocated the hip anteriorly on the fourth postoperative day when transferring from a wheelchair to a bed. Manual reduction under general anesthesia was attempted but failed because of the muscle rigidity. Revision surgery was required on the seventh day after the initial surgery. She was able to walk with a cane and was discharged from the hospital. However, 6 months later, the contralateral left hip became painful and she needed a wheelchair again (left JOA score 19). By her strong request, we performed left total hip arthroplasty. However, one week after the surgery, she felt discomfort in her left hip joint when she was going to sit on the toilet, which caused the stem to sink and posterior twisting. Two days later, when she tried to put on her shoes, she dislocated posteriorly with a periprosthetic fracture. Revision surgery was required 2 weeks later. The patient was discharged home 2 months postoperatively and was able to walk alone 3 months postoperatively. Five years after surgery, both hips have recovered to the point where she can walk alone without pain and without redislocation, and she is highly satisfied with the outcome (JOA score: right 68, left 63).
【Conclusion】 Dislocation can occur even with appropriate implant placement. This is because the pelvic alignment changes with posture such as lying down, standing, and sitting. Especially in patients with spinal long fusion, immobility decreases and implant impingement is easy, and dislocation can occur both anteriorly and posteriorly. Additionally, in Parkinson’s disease, not only is it difficult to reduce intraoperatively due to muscle rigidity, but manual reduction is also difficult if the patient dislocates their hip after surgery, and open reduction may be necessary. Although the artificial hip joint of Parkinson’s disease is intractable, patient satisfaction is high.
Parkinson’s disease, spinal long fusion, rapidly destructive coxarthropathy, dislocation of total hip arthroplasty, revision surgery
In patients with Parkinson’s disease it is difficult to treat hip joint disorder because of postural abnormalities and muscle rigidity ［1］. Advances in spine surgery have led to an increase in the use of long-range fusion procedures, and their impact on pelvic alignment has been gaining attention ［2,3］. We report the case of a patient with Parkinson’s disease and spinal long fusion who required bilateral revision surgery for irreducible dislocation of total hip arthroplasties (THA) in rapidly destructive coxarthropathy.
A 74-year-old woman had a chief complaint of right hip pain. She also had severe Hoehn-Yahr Category III Parkinson’s disease that developed when she was 63 years old. There was nothing remarkable in her family history. She had been suffering from back pain since she was about 70 years old, and pain medication was ineffective. She underwent spinal surgery at the age of 71 because she had degenerative scoliosis and kyphosis at the 4th-5th lumbar level and lumbar spinal canal stenosis. Considering the Parkinson’s disease, she underwent a long range of fixation from her third thoracic vertebra to the ilium (Fig. 1). One year after her spine surgery, her right hip suffered from anterior thigh pain, making it difficult to put on her socks. She originally had a slight gait disturbance, but she became unable to walk because of the pain it caused (right side Japanese Orthopaedic Association (JOA) hip score, 21 points). Pain was reproduced when moving the right hip joint. X-ray imaging obtained when she was 64 years old showed a mild hip dysplasia with a centeredge angle of 16° with sufficient joint space (Fig. 2a). X-ray imaging immediately after spinal long fusion showed slight joint space narrowing with progressive posterior pelvic tilt (Fig. 2b). X-ray imaging when she was 74 years old showed destruction of the right hip with joint space disappearing and bone cysts both in the acetabulum and femoral head (Fig. 2c). Pelvic incidence was 41.6 degrees.
The diagnosis was right rapid destruction hip arthroplasty and THA was indicated. CT based threedimensional preoperative planning was performed, reproducing posterior pelvic tilt with ZedHip (Lexi) (Fig. 3). Considering the high risk of anterior dislocation due to posterior pelvic tilt, the anteversion of the cup was set from 5° to 10° smaller than the normal target angle of 15°. THA was performed via direct anterior approach with the patient supine on a traction table (Traction DAA), Lecure (Surgical Alliance and Calm Rana) ［4］. Implant information is as follows: cup: R3 diameter 48 mm (Smith & Nephew), insert: XLPE flat, stem: Profemur Z No. 3 (MicroPort Orthopedics), neck: straight S, head: Delta diameter 32 mm S (- 3.5 mm). The implant alignment was in a safe zone and intraoperative muscle tension was stable without a tendency to dislocate (Fig. 4). However, on the 4th day after surgery, she dislocated her hip anteriorly when she was transferred from a wheelchair to a bed (Fig. 5). Manual reduction under general anesthesia was attempted but was unsuccessful because the muscle tone around the hip was so strong that the dislocation could not be reduced. Revision surgery was required on the seventh day after the initial operation. For stability, the head length was changed from - 3.5 mm to + 0 mm and extended by 3.5 mm. She was able to walk with a cane and was discharged from the hospital.
However, 6 months later, her contralateral left hip became painful and she again needed a wheelchair (left side JOA hip score, 19 points, Fig. 6). By her strong request, we performed left THA via Traction DAA in a similar manner to that on the opposite side (Fig. 7). Implant information is as follows: cup: R3 diameter 48 mm (Smith & Nephew), insert: XLPE flat, stem: Profemur Z No. 2 (MicroPort Orthopedics), neck: straight S, head: delta diameter 32 mm M (+ 0 mm). However, one week after the surgery, she felt discomfort in her left hip joint when she was going to sit on the toilet, which caused the stem to sink and posterior twisting. Two days later, when she tried to put on her shoes, she dislocated her hip posteriorly with an incomplete periprosthetic fracture of the greater trochanter (Fig. 8). Revision surgery was required 2 weeks later. The stem was removed once, and metal cables were wrapped around the top and the bottom of the lesser trochanter to reduce and fix the fracture site (Fig. 9). The same stem was reinserted in an adjusted anterior version. Polyethylene was replaced with a 20°-elevated liner, which was turned 45° backward. The head length was changed from + 0 mm to + 3.5 mm and extended by 3.5 mm. Pelvic incidence was 39.0 degrees after the hip surgeries. The patient was discharged home 2 months postoperatively and was able to walk alone at 3 months postoperatively.
Five years after hip surgery, she can walk alone without pain and without redislocation, and she is highly satisfied with the outcome of bilateral THA (JOA hip score: right 68 points and left 63 points, Fig. 10).
Fig. 1 Spinal long fusion at 71 years old. (a) Anteroposterior simple X-ray image of the whole spine, (b) lateral simple X-ray image of the whole spine.
Fig. 2 Progress of deformity of the right hip joint. Anteroposterior simple X-ray image of the right hip shows an almost normal joint space at 64 years old (a) and narrowing at 71 years old (b). Joint space narrowing is obvious by 74 years old (c). Notice that the pelvic tilt progresses posteriorly.
Fig. 3 CT based three-dimensional preoperative planning. Pelvic tilt is reproduced from the preoperative X-ray imaging. (a) Anteroposterior image and (b) lateral image of right hip.
Fig. 4 X-ray image immediately after right primary total hip arthroplasty. (a) Anteroposterior view, (b) lateral view. Radiographic inclination was 34° and radiographic anteversion was 7° in cup alignment. Stem anteversion was 45° and the combined anteversion (cup anteversion + stem anteversion × 0.7) was 38.5°.
Fig. 5 Anterior dislocation at 4 days postoperatively. (a) Anteroposterior view, (b) lateral view.
Fig. 6 Progress of deformity of the left hip joint. Anteroposterior simple X-ray image of the right hip shows an almost normal joint space at 64 years old (a) and narrowing at 71 years old (b). Joint space narrowing is obvious 6 months after right hip surgery (c).
Fig. 7 X-ray image immediately after left primary total hip arthroplasty. (a) Anteroposterior view, (b) lateral view. Radiographic inclination was 35° and radiographic anteversion was 6° in cup alignment. Stem anteversion was 47° and the combined anteversion (cup anteversion + stem anteversion × 0.7) was 38.9°.
Fig. 8 Posterior dislocation at 9 days postoperatively. Simple X-ray image of anteroposterior view (a) and lateral view (b), computed tomography of axial image (c) and coronal image (d). Periprosthetic fracture is noted (Vancouver classification: type A, Baba’s classification: type 1A).
Fig. 9 X-ray image immediately after revision surgery of the left hip. Notice that the legs are stretched compared with Fig. 7. (a) Anteroposterior view, (b) lateral view.
Fig. 10 Follow-up X-ray image of bilateral revision total hip arthroplasty after 5 years. Notice the radiolucent line in zones 1, 8, 14 in both hips without sinking of the stem, osteolysis, or implant loosening. (a) Anteroposterior view, (b) right lateral view, (c) left lateral view.
The cause of revision surgery for THA in patients with Parkinson’s disease is periprosthetic fracture and dislocation ［5］. The dislocation rate after THA in patients with Parkinson’s disease varies from 0 to 37% according to the literature ［1,6,7］. This is much higher than the normal THA dislocation rate of from 0 to 3% ［4］. One reason for this is thought to be postural disturbance in Parkinson’s disease. Pelvic alignment changes with posture, such as lying down, standing, and sitting ［8］. Pelvic incidence is defined as the angle between a line perpendicular to the sacral plate at its midpoint and a line connecting this point to the femoral head axis. A large pelvic incidence corresponds to a pelvis with a horizontal sacrum and small iliac width; a small pelvic incidence indicates a pelvis with a vertical sacrum and a large iliac width. In general, the pelvic incidence is considered to be constant in individuals, but is increased with posterior fusion of the spine, and especially in cases with sacral fusion, it increases by an average of 5.9° ［2］. Considering the posterior tilt of the pelvis in the standing position, the right side had a small anterior opening angle of the cup, but was impinged posteriorly, resulting in anterior dislocation. On the left, the neck has become a posterior twist due to stem subsidence and a periprosthetic fracture. Normally the pelvis tilts backward from a standing position to a sitting position to avoid anterior impingement ［3］. But this did not occur due to long-range spinal fusion, resulting in anterior impingement and posterior dislocation. Therefore, these dislocations are unique to this case. This case suggests that the hip joint can be dislocated both anteriorly and posteriorly if the spinal alignment has a posterior pelvic tilt in the posterior bay and the mobility is lost due to long-range fixation. The second reason for a high complication rate is the ease at which patients can fall because of the balance disorder in Parkinson’s disease. In fact, in this case, the fall was repeated. A careful postoperative treatment protocol such as diligent monitoring by nurses is required to prevent early falls after surgery. Third, in patients with Parkinson’s disease, not only is it difficult to reduce the hip joint intraoperatively due to muscle rigidity ［1］, but manual reduction is also difficult if the hip is dislocated after surgery, and open reduction may be necessary. It is necessary to make patients aware of these problems by appropriate informed consent.
There are few reports discussing the relationship between pelvic incidence and hip disorders, but there are also reports that high pelvic incidence may lead to osteoarthritis of the hip ［9,10］. In this case, the joint space gradually narrowed, and 3 years later the joint was rapidly destroyed with severe hip pain (Figs. 2 and 6). Spine surgeons should be aware that hip joint disease occurs after spinal fusion.
Short-term and medium-term outcomes of THA for osteoarthritis with Parkinson’s disease were generally favorable ［6］. Pain was improved in 93% cases with Hoehn-Yahr classification I-IV and walking distance was extended. The present case was in a patient with severe Parkinson’s disease, and to preserve the muscle strength of the lower limbs as much as possible to regain walking ability, both initial THA and revision surgery were performed with minimally invasive surgery via Traction DAA, which is considered to have a lower dislocation rate than a posterior approach ［4］. Implant placement was appropriate; however, both hip joints were dislocated immediately after initial THA. Fortunately, the recovery after revision surgery was good, and walking ability was regained. Thus, total hip arthroplasty for Parkinson’s disease is intractable, but patient satisfaction is high, so we suggest that aggressive treatment may be considered.
JS and JN contributed to the concept and design of the study, and manuscript preparation. SH, YK, and YS2 contributed to acquisition of data. SO1, YE, KI, YS1 and SO2 revised the manuscript critically for important intellectual content. All authors read and approved the final manuscript.
The corresponding author, JN received JSPS KAKENHI Grant Number 17 K10954, Venture Business Laboratory in Chiba University, Hip Joint Foundation of Japan, and a research and development grant from Chiba Bank.
The corresponding author, JN is the chief executive officer of Calm Lana Inc. SO2 is an editorial board member of this journal. The other authors have no conflict of interests.
Written informed consent was obtained from the patient for publication of the present report. This is not human research. This is not animal research.
Not applicable.
We thank JAM Post (https://www.jamp.com/index.cfm) for English language editing.
Address correspondence to Dr. Junichi Nakamura.
Department of Orthopaedic Surgery,
Graduate School of Medicine, Chiba University,
1-8-1 Inohana, Chuou-Ku, Chiba 260-8670, Japan.
Phone: +81-43-222-7171.
Fax: +81-43-226-2116.
E-mail: njonedr@chiba-u.jp
