Case Study: Bilateral Total Hip Replacement in a 46-year-old female
with Bilateral Avascular Necrosis (AVN) of the Hip
A young female presented to our office with complaints of bilateral groin pain. The pain was constant and associated with stiffness. She didn’t recall any particular event leading to pain. She had the for the past three years which gradually worsened. She was a known patient if systemic lupus erythematosus with a history of prolonged steroid intake.
The pain was a dull throbbing in character located in the bilateral groin. There was radiation of the pain to both the knees on the inner side. The pain was moderate to severe in intensity. She experienced greater discomfort while going up and down the stairs. The pain was increased on bending, getting up from a chair and squatting.
She was employed as a security officer currently not working. She was diagnosed with systemic lupus erythematosus when she was a teenager and was on steroids on and off during flaring episodes. She was extremely distressed with the lack of activity secondary to pain.
She was an occasional smoker and consumed moderate alcohol socially. She was allergic to penicillin and shellfish. She was currently taking alendronate, simvastatin, and multivitamins. She previously had a right carpal tunnel release done six years ago.
On her physical examination, her gait was steady and coordinated. There was no wasting of the gluteal muscles or thighs. Both the shoulders, iliac spines, patella, and the malleolus were at the same level. There was no scoliosis or any exaggeration of the lumbar lordosis.
Both the anterior superior iliac spines were at the same level. There was no leg length discrepancy. The skin overlying both the groins was normal with no evidence of scar marks or sinus tracts. There was no swelling, erythema or local rise in temperature.
There was no broadening or thickening of the trochanters. Tenderness was present on the bilateral anterior joint line. The range of motion of the right hip was restricted in internal rotation. Flexion was present from 0 degrees to 120 degrees, extension 0 degrees to 5 degrees, adduction 0 degrees to 35 degrees, abduction from 0 degrees to 20 degrees. The rotation moments were painful.
The range of motion of the left hip was similarly restricted in the internal rotation and abduction. The straight leg raise test was positive bilaterally with pain in the groin anteriorly. The examination of the lower spine, bilateral ankles and knees were normal.
There was no distal neurological deficit. The bilateral lower extremity peripheral pulses were palpable and comparable. The power and sensory examination of the lower extremities was normal.
An X-ray was obtained which suggesting bilateral sclerosis of the head of femur and acetabulum changes. There were degenerative changes. An MRI of both hips was obtained.
Preoperative X-ray of the pelvis with both hips in anteroposterior view showing AVN of both hips.
Preoperative X-ray of the pelvis with both hips in the frog-legged lateral view showing AVN of both hips.
T1WI coronal section of MRI showing AVN hip.
T2WI coronal section of MRI showing AVN hip.
Axial sections of the T2WI and T1WI of MRI.
Hypointense areas were present on both T1WI and T2WI on both the head of the femur suggestive of sclerosis. Surrounding bone marrow edema was present and the bilateral necrotic area was approximately 70%.
After careful consideration of her medical conditions, she was advised bilateral total hip replacement for AVN. Risks, benefits, and alternatives were discussed with the patient at length. She agreed with the plan.
She underwent a bilateral total hip replacement. Her vitals remained stable postoperative. She had no distal neurological deficit. Pain medications were given to control post-op pain. Aspirin 325mg BID was prescribed for deep vein thrombosis prophylaxis.
The sutures were removed uneventfully. The wound was dry, clean and intact. She was compliant with hip precautions and physical therapy. On her subsequent follow-up visits, she had full range of motion. She was able to navigate without the support and reported no pain.
She was about to get back to her routine quickly and was back to her job in four months. She was extremely happy with the relief the surgery offered. She follows up as needed.
Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.