Case Study: Total Hip Replacement in a 65-year-old Male

with Avascular Necrosis of the Left Hip

A 65-year-old male presented to our office with complaints of left hip pain. The pain began 8 years ago but the patient didn’t recall any specific onset. Since the onset, the pain has worsened and the patient finds it difficult to walk and get up from sitting position. He reported consulting various doctors who told him that he has avascular necrosis. He was looking for surgical options for his hip pain.

The pain was described as moderate to severe in intensity located over the left groin which was constant. There was radiation to the left knee on activities such as walking and climbing stairs. The pain was described as a dull ache that would change to sharp on exacerbating activities. Recently he found it difficult to even tie his shoelaces. His current walking tolerance was less than a block.

The patient has previously tried treatment in the form of hip cortisone injections, NSAIDs, and physical therapy but with minimal relief. He was unable to squat and sit cross-legged. The patient was working as an accountant and his work involved frequent traveling, walking, climbing stairs and sitting for prolonged periods of time. The patient was unable to sleep comfortably at night.

He expressed dismay at his inability to work efficiently and being unable to do his daily activities. He was a past smoker (10 pack-years) and a social drinker. He denied any known drug allergies. His medical history included high blood pressure well-controlled with medications (amlodipine 10 mg). He previously had a cholecystectomy done 15 years ago. He denied any past history of trauma or surgeries around the hip.

The patient was using a cane for ambulation. His gait was antalgic with a reduced stance phase on the left side. Bilateral shoulders, anterior and posterior iliac spines, patella, and medial malleolus were at the same level. There was no evidence of scoliosis and exaggerated lumbar lordosis.

The skin overlying the left hip was normal with no scars or sinus tracts. On palpitation, there was left anterior hip joint line tenderness. There was no fullness or swelling in the left groin. There were no enlarged inguinal lymph nodes. The power and bulk of bilateral lower extremity muscles were intact.

The range of motion was not restricted but painful in internal rotation and abduction. There was no leg length discrepancy and no fixed deformities. The examination of the right hip revealed tenderness at the right greater trochanter suggesting bursitis. The examination of bilateral knees and ankles were normal.

There was no distal neurological deficit and power sensory examination of lower extremities was normal. There was no abnormality of the bladder, bowel function.
Imaging revealed osteoarthritic changes of the left hip with an AVN lesion that involves 60% of the femoral head. An MRI was obtained which revealed left femoral head avascular necrosis without overt subchondral collapse.

X-ray showing the AP view of the pelvis with both hip joints

X-ray showing the AP view of the pelvis with both hip joints.

X-ray showing the AP and frog-legged lateral views of the left hip jointX-ray showing the AP and frog-legged lateral views of the left hip joint - img 2

X-ray showing the AP and frog-legged lateral views of the left hip joint.

Considering the patient’s condition, and having exhausted conservative management, he was offered a left total hip replacement. Risks, benefits, and alternatives were discussed with the patient and his family at length. He agreed to go ahead with the surgery.

Operation: Left total hip arthroplasty.

Implant used: Acetabular shell 60 mm with a 6.5 mm x 30 mm cancellous screw, with ceramic femoral head 36 mm, 0-degree polyethylene with 127-degree neck angle hip stem.

Description of the procedure: The patient was brought to the operating room after obtaining informed consent and signing the correct surgical site. The risks, benefits, and alternatives were extensively discussed with the patient prior to the procedure. The patient was brought to the operating room and anesthesia was obtained by the anesthesiologist.

The patient was definitively positioned with the left hip up and the left hip was then draped and prepped in the usual sterile manner. The straight incision centered over the greater trochanter was used for the arthrotomy. Skin and subcutaneous tissues were then incised. The fascia was then divided.

The acetabulum was then exposed. The remainder of the labrum was then debrided. The acetabulum was reamed and the final shell was then placed into position in the correct abduction and anteversion.

The shell was then placed over the cup after the placement of the screw. Attention was then turned towards the femur. The remainder of the tissue on the undersurface of the greater trochanter was then removed. The femur was then sequentially broached and the final broach was left into position.

The trunnion was then placed over the shell and the head was then placed over the trunnion. The pre-robotic plan was used in the assessment of the height. The lesser trochanter to center distance was also measured preoperatively before making the neck resection and was also compared after placement of the trial component. The hip was then reduced and trialed through a full range of motion and the hip was stable in all physiological range of motion.

The hip was dislocated. Trial components were then removed. The final components were then placed into position. The hip was then reduced again. A thorough lavage was given. The posterior soft tissue structures were then tacked to the greater trochanter through transosseous tunnels. Thorough lavage was given.

The fascia was closed, cutaneous tissues were closed, subcutaneous tissues were closed. The skin was closed using staples. Sterile dressing was then applied over the wound and the patient was then transferred to the postoperative care unit in stable condition.

Postoperative X-ray of the pelvis showing AP and lateral views

Postoperative X-ray of the pelvis showing AP and lateral views.

The pathology report from the excised femoral head suggested degenerative disease with bone and marrow necrosis.

The recovery of the patient was excellent. The pain was managed with oxycodone and acetaminophen. An abduction pillow was used and hip precautions were explained to the patient. Aspirin 325mg BID was started for DVT (Deep vein thrombosis) prophylaxis. Sutures were removed on post-op day 14 uneventfully. There was no distal neurological deficit.

Home exercise program and physical therapy were initiated for gait training, fall prevention, strengthening age increasing range of motion. Weight-bearing was allowed as tolerated. After three months, the patient was back to his baseline activity. He had some returned to work and was very happy with the outcome.

Disclaimer – Patient’s name, age, sex, dates, events have been changed or modified to protect patient privacy.

Call Us Now!

4.9
Based on 93 reviews
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
Sam
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18
js_loader

My name is Dr. Suhirad Khokhar, and am an orthopaedic surgeon. I completed my MBBS (Bachelor of Medicine & Bachelor of Surgery) at Govt. Medical College, Patiala, India.

I specialize in musculoskeletal disorders and their management, and have personally approved of and written this content.

My profile page has all of my educational information, work experience, and all the pages on this site that I've contributed to.