The Journal of Arthroplasty xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Outcomes of Total Hip Arthroplasty in Spastic Patients Hassan Alosh, MD, Atul F. Kamath, MD, Keith D. Baldwin, MD/MPH, MaryAnn Keenan, MD, Gwo-Chin Lee, MD Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
a r t i c l e
i n f o
Article history: Received 11 February 2014 Accepted 6 March 2014 Available online xxxx Keywords: total hip arthroplasty spasticity upper motor neuron disease cerebral palsy
a b s t r a c t Patients with spasticity and hip arthritis can present challenges to treatment. This investigation evaluated the effectiveness and safety of THA in patients with upper motor neuron disease. Twenty-seven consecutive patients with history of cerebral palsy (CP) or acquired spasticity (AS) underwent 30 THAs for treatment of hip arthritis. They were followed for an average 2.5 years (range 2.1–12.1). Patients with CP were more likely to require hip adductor release and hip flexor lengthening at the time of THA. Statistically significant improvements were made in Harris Hip Scores, pain scores, range of motion, ambulatory status, and the use ambulatory-assistive devices. There were no dislocations in this group. Patients with spasticity can benefit from THA in terms of pain relief and improved mobility with relatively low complications. © 2014 Elsevier Inc. All rights reserved.
The prevalence of neurologic disorders in the general population is increasing. In the past 30 years, mortality from stroke has decreased by nearly 70% [1]. Meanwhile, its incidence in the young adult population has steadily increased, suggesting a longer lifetime burden of neurologic disease [2]. Greater longevity and functional status after a neurologic insult also means that these patients will have greater expectations for quality of life and mobility. Within the general population, the projected demand for total hip arthroplasty (THA) is estimated to increase by over 170% within the next 20 years, and the rate of revision THA is expected to double during this period [3]. This rapid rise will likely be mirrored in the people afflicted with neurologic disorders. Limited data exist regarding patient outcomes and perioperative protocols for the spastic patient undergoing primary THA. Furthermore, recognizing the broad spectrum of neurologic conditions, these patients may present with specific contractures and gait disturbances that needs to be carefully evaluated and considered during the preoperative and postoperative periods. Finally, concerns with hip instability, rehabilitation potential, and questions about realistic improvements in function following arthroplasty remain. Therefore the purposes of this study are to (1) evaluate the effectiveness and outcomes of patients with spasticity and coxarthrosis undergoing primary THA and (2) determine if differences exist among patients with cerebral palsy and those with acquired spasticity when undergoing THA.
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.03.005. Reprint requests: Gwo-chin Lee, MD, Department of Orthopaedic Surgery, Presbytarian Hospital, University of Pennsylvania, 51 N 39th St, 1 Cupp Building, Philadelphia, PA 19104.
Methods We retrospectively reviewed the medical records of 29 consecutive patients with spasticity who underwent primary THA by one of the senior authors (MAK or GCL) at our institution between 1993 and 2011. This study was approved and conducted according to the guidelines set forth by our institutional review board (IRB). All patients had a confirmed diagnosis of upper motor neuron (UMN) disorder including cerebral palsy (CP) or acquired causes such as traumatic brain injury (TBI), cerebrovascular accident (CVA), spinal cord injury (SCI), or multiple sclerosis (MS). Motor control was graded using a clinical scale [4]. In this scale, an extremity can be hypotonic (Grade 1) or rigid (Grade 2) without any volitional movement. The extremity may exhibit mass flexion or extension patterned movement. This can be reflexive (Grade 3) or volitional (Grade 4). Motor control can be selective with pattern overlay (Grade 5), meaning movement of the hip joint with minimal movement of the adjacent joints, or Grade 6 volitional, allowing movement of a single joint independent of movement in the adjacent joints. Motor strength was graded on a standard 0 to 5 scale, with 0/5 exhibiting no contraction, 3/5 demonstrating movement against gravity, and 5/5 exhibiting full motor strength. Preoperative Evaluation All patients were evaluated preoperatively and after surgery using a detailed, standardized format. Inclusion criteria included all patients between ages 25 and 80 with end-stage degenerative hip disease, an upper motor neuron disorder, and the ability to perform transfers and maintain an upright sitting posture. Patients with Grade 4 or greater motor control, in addition to Grade 3 or greater motor strength of the hip abductors and flexors, were deemed eligible for THA. Static
http://dx.doi.org/10.1016/j.arth.2014.03.005 0883-5403/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
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H. Alosh et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
deformities were differentiated from dynamic deformities with a pharmacologic block when necessary. Hip range of motion and deformity was determined with use of a goniometer before and after surgery. Fixed hip flexion and adduction contractures were determined preoperatively as described in previous studies [5,6]. Prior to surgery, patients and their families were extensively counseled and informed of the inherent risks of THA; in particular, infection, dislocation, neurologic injury, postoperative pulmonary and cardiac complications, and recurrent heterotopic ossification. Pain score were documented on 0–10 visual analogue scale. The use of assistive devices for ambulation was noted. Ambulatory status was also classified on a 0–5 scale: Level 0 (unable), 1 (nonfunctional), 2 (independent household), 3 (independent neighborhood), 4 (independent community), and 5 (normal). The modified Ashworth scale was used to classify spasticity via resistance to passive movement [7]. In this scale, 0 means no increase in tone, 1 means slight increase in tone, 2 means more marked increase in tone with the limb easily flexed, 3 means considerable increase in tone with difficult movement of the limb, and 4 is severe spasticity with a rigid limb. Antero-posterior radiographs of the pelvis and hip and cross-table lateral projections of the hip were obtained preoperatively to confirm degenerative disease and the presence of heterotopic ossification (HO). Patients with severe spasticity (Ashworth 3 or 4) were referred to the Physiatry service for selective pharmacologic blockade (either phenol or botulinum toxin). In this series, 14 patients (16 hips) who had Ashworth spasticity scores of 3 or greater and underwent pharmacological blockade procedures at a range of 2–3 weeks preoperatively. All patients who underwent these procedures improved their spasticity to an Ashworth score of 1 or 2 on the day of surgery. Improvements in range of motion was calculated by comparing the joint range of motion at last follow-up to the joint range of motion upon initial patient presentation prior to any selective injections. Data to compute Harris Hip Scores (HHS) was collected prospectively [8]. Surgical Technique All arthroplasties were performed using a standard posterolateral approach to the hip with the patient positioned in a lateral decubitus position. All patients underwent general anesthesia in order to achieve complete muscle paralysis. Uncemented, press-fit femoral and acetabular components were utilized in all patients. To minimize the effects of surgery in patients with muscle and gait dysfunction, the abductors were carefully protected. A modular femoral component was employed in cases of severe femur dysplasia (n = 3). Femoral head autograft or metallic augments were used to achieve adequate hip coverage in circumstances of acetabular dysplasia (n = 2). A constrained liner was used in two cases when abductor deficiency was encountered during THA. In all cases, the posterior hip capsule and short external rotators were repaired to minimize the risk of hip dislocation. Concomitant excision of heteropic bone (HO) was performed in 7 cases. These patients received a single dose of radiation up to postoperative day 3 and were given 75 mg indomethacin daily for an additional 4 weeks postoperatively to prophylax against recurrent heterotopic ossification. Additionally, soft tissue releases such as adductor tenotomy (n = 11) and iliopsoas lengthening (n = 6) were performed for patients with preoperative contractures. Patients with adduction contractures greater than 15° and flexion contractures greater than 30° under anesthesia underwent soft tissue release at the time of surgery. Patients with an equinovarus deformity of the foot (n = 6) had an Achilles lengthening and split tibialis anterior tendon transfer (SPLATT) performed preoperatively to achieve a plantigrade foot prior to THA. The median femoral component head size was 32 mm (range 22–32).
Postoperative Management Patients were managed aggressively with analgesics and muscle relaxants to minimize spasticity and maximize patient comfort during the postoperative period. A multidisciplinary approach including consultation with Physiatry and Pain Management was used in all cases. All patients in this series were placed in an abduction pillow and knee immobilizer postoperatively. Furthermore, patients with cognitive impairments and anticipated difficulty following hip precautions were placed in an abduction brace for a minimum of 6 weeks (n = 5). All patients were mobilized by physical therapy on postoperative day 1. All patients were discharged to a rehabilitation facility for additional physical and occupational therapies. Postoperative rehabilitation focused on strict maintenance of posterior hip precautions, achieving a stable gait pattern with a minimal degree of assistive devices, and stretching programs tailored to a patients prior or concomitant corrective procedures (eg, maintaining a plantargrade foot after a split tibialis tendon transfer). Furthermore, in coordination with the rehabilitation and the prosthetic services, necessary modifications to ambulatory-assistive devices were addressed in patients who also suffered from upper extremity spasticity and deformities. Follow-Up Data Patient medical records were reviewed for the major and minor outcomes of interest. Main outcomes of interest were improvement in ambulation status, subjective pain scores, and complications. Secondary outcomes included Harris Hip Scores, preoperative deformity, range of motion (ROM), and additional procedures performed during or in preparation for THA. Statistics Because the data were not normally distributed, the Wilcoxon Signed Rank test was used to determine significant differences in preoperative and postoperative ROM, pain scores, and Harris Hip Scores. In cases comparing proportions between the CP and AS cohorts, the chi-squared test with Yate's correction was used. Statistical significance was assigned at P ≤ 0.05. Statistics were performed used the Excel 2010 (Microsoft, Redmond, WA, USA) and STATA 11 (StataCorp, College Station, TX, USA) processors. Standard deviations are reported in parenthesis following mean values. Results A total of 29 patients with upper motor neuron disease and spasticity underwent 32 primary THAs. Two of these patients were lost to follow-up. The remaining 27 patients with 30 THAs were available for final analysis (Table 1). Among these patients etiology of spasticity was cerebral palsy in 12, traumatic brain injury in 9, cerebrovascular accident in 3, multiple sclerosis in 2, and spinal cord injury in 1 patient. Patients made statistically significant improvements in pain scores, Harris Hip scores, and range of motion following THA (Fig. 1). All patients rated their pain as severe preoperatively (visual analogue pain scale of 8 or greater). At last follow-up, 14 patients reported minimal hip pain (pain score b3), 11 reported mild to moderate hip pain (pain score N2 and b 7), and 3 severe hip pain (pain score of 7 or greater). Range of motion, with focus on hip flexion, abduction, and external rotation, all significantly improved following THA. Mean flexion improved from 83.3° to 101°, abduction improved from 14.2° to 36.8°, and external rotation increased from 8.1° to 19.2° (P b 0.01). Harris Hip Scores improved from a mean 15.0 (SD = 7.2, range 5–35) to a mean 67.3 (SD = 18.8, range 24–91), which was also statistically significant (P b 0.01).
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
H. Alosh et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx Table 1 Patient Demographics. Male Female Mean age Age range Mean follow-up Follow-up range Spasticity etiology Cerebral palsy Traumatic brain injury Cerebrovascular accident Multiple sclerosis Spinal cord injury Paralysis Hemiparesis Diplegia Quadriparesis Hip pathology Degenerative joint disease Avascular Necrosis Motor control Normal (grade 6) Selective (grade 5) Voltional synergistic(grade 4) Ashworth spasticity score Mean Range
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Table 2 Ambulatory-Assistive Devices Before and After THA. 12 patients (14 hips) 15 patients (16 hips) 48.6 years (12.2) 29.1–75.0 2.7 (2.5) 2.1–12.1 years 12 9 3 2 1 13 8 6 25 hips 5 hips 8 (0 CP, 8 AS) 15 (11 CP, 4 AS) 4 (1CP, 3 AS) 2.3 (1.2) 1–4
Mobility following surgery was improved in nearly all patients following THA. The mean ambulation score improved from a mean of 1.4 (1.1, range 1–4) to 3.0 (1.1, range 1–5) (P b 0.01). Prior to surgery, all patients required the use of an assistive device: 10 patients required use of a wheelchair, 13 used a walker, and 4 used a cane for ambulation. Postoperatively, 4 patients required use of a wheelchair, 10 ambulated with a walker, and 8 ambulated with a cane. Five of these patients did not require the use of an assistive device (Table 2). The degree of contractures encountered at the time of surgery differed between patients with congenital neurologic disorders (i.e. cerebral palsy (CP) compared to those with acquired spasticity (AS) (i.e stroke, brain injury, multiple sclerosis). Patients with CP trended toward a higher degrees of flexion and adduction contractures in comparison to those with AS (Table 3). Patients with CP required simultaneous adductor release more frequently compared to patients with AS at the time of THA (58% versus 22%, P = 0.10) and flexor lengthening was also performed at a higher rate (42% versus 5.5%, P = 0.05). Conversely, there was a trend for patients with AS to require excision of heterotopic bone compared to other patients. There were no dislocations in this series. The most common complication necessitating a return to the operating room was infection (Table 4). One patient required a resection arthroplasty
Preoperative assistive device Wheelchair/non-ambulator Walker Cane No device Postoperative assistive device Wheelchair/Non-ambulator Walker Cane No device
Cerebral Palsy
Acquired Spasticity
33% (4/12) 67% (8/12) 0% 0%
40% (6/15) 33% (5/15) 27% (4/15) 0%
17% (2/12) 33% (4/12) 42% (5/12) 8% (1/12)
13% 40% 20% 27%
(2/15) (6/15) (3/15) (4/15)
following a deep prosthesis infection. The prosthesis was believed to have been seeded by a decubitus ulcer that developed several months postoperatively. Three patients required superficial incision and drainage procedures for persistently draining wounds. At last follow-up, these patients were infection free with no other complications. One patient had an intraoperative calcar fracture managed successfully without any additional complications. Discussion As the life expectancy of patients with neurologic conditions increases, a greater number of patients with spasticity can be expected to present with symptomatic end-stage degenerative disease of the hip. Traditionally, Girdlestone resection arthroplasty has used to address the painful arthritic hip in the spastic patient [9]. While the procedure often yielded some improvements in pain, the functional recovery was often unpredictable. By shortening the affected limb and failing to address the imbalanced muscle forces across the hip joint, these patients often developed recurrent deformity and had continual difficulties with gait and ambulation. For today's patient with spasticity and degenerative hip disease, THA potentially affords the best opportunity for reducing pain and maintaining mobility. However, concerns with hip instability, poor rehabilitation potential and questions about the functional improvements that can be achieved following surgery persist. Data regarding outcomes following total hip arthroplasty in this patient population are limited. Also, there is also a lack of information with regard to arthroplasty in patients with acquired versus congenital neurologic disorders. Therefore the purpose of this study is to (1) evaluate the effectiveness and outcomes of patients with spasticity and coxarthrosis undergoing primary THA and (2) determine if differences exist among patients with cerebral palsy and those with acquired spasticity when undergoing THA. Our results show that patients with spasticity and coxarthrosis can benefit from THA. The patients in this series made predictable improvements in pain, ambulation status, and functional outcome scores. Previous investigations have usually reported adequate pain relief with THA among patients with cerebral palsy, but have not focused on functional and ambulatory status. One of the initial studies Table 3 Deformities and Corrective Measures in Cerebral Palsy Versus Acquired Spasticity.
Fig. 1. Preoperative and postoperative ROM, HHS, and pain scores.
Preoperative flexion contracture Range Preoperative adduction contracture Range Additional procedures Adductor release Flexor lengthening HO excision Split tibialis anterior transfer
Cerebral Palsy
Acquired
P-value
52.5 (25.6) 0–90 17.9 (13.4) 0–40
40 (37.4) 0–110 8.4 (15.4) 0–50
0.43
58% (7/12) 42% (5/12) 8% (1/12) 8% (1/12)
22% (4/18) 5.5% (1/18) 33% (6/18) 28% (5/18)
0.10 0.05 0.25 0.40
0.03
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
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Table 4 Complications. Cerebral Palsy
Acquired Spasticity
- Calcar fracture - Wound drainage requiring washout - Sacral decubitus ulcer (grade 3) - Recurrent HO requiring resection - Wound drainage requiring incision and - Prosthetic infection requiring drainage (2 cases) resection arthroplasty
of THA in patients with CP reported on a series of 19 hips between 1972 and 1986 [10]. The authors only used cemented implants and immobilized 16 patients in spica casts postoperatively. The authors reported the majority had pain relief and five patients regained the ability to walk. It is unclear whether the authors selected patients based on preoperative motor control and function. Another series of 16 patients with cerebral palsy undergoing THA reported that that 13 patients obtained good pain relief [11]. Consequently, in well-selected patients, THA can lead to improvements in pain and mobility in this patient population. This study also shows that the etiology of spasticity can be relevant when preparing for THA in the spastic patient. Patients with congenital neurologic conditions were more likely to require additional soft tissue releases at the time of arthroplasty compared to those with acquired spastic conditions. Patients with congenital conditions, such as those with cerebral palsy, present with lifelong history of hip dysplasia and contractures, whereas others, such as those with spasticity following a CVA, may experience hip pain and joint dysfunction as a relatively new process. Understanding the static and dynamic deformities these patients may present with is critical to the successful management of degenerative joint disease in the spastic patient. Nerve blocks are can be a useful adjunct, as they can serve a diagnostic function in establishing which deformities are dynamic, in addition to controlling spasticity postoperatively. In one case report, injection with botulinum toxin prior to total hip arthroplasty in a patient with cerebral palsy was reported with good results. The authors noted an improvement in preoperative hip adductor and flexion deformity, in addition to sustained pain relief and spasticity control for 8 weeks following the surgery [12]. Fixed hip contractures, of which the most common are hip adductor and flexor contractures, must be addressed intraoperatively. Hip adduction contractures affect balance and narrow the patient's base, in addition to contributing to an apparent leg length discrepancy. Hip and knee flexion contractures are often concurrent and should addressed with surgical release simultaneously, allowing a more natural and efficient gait pattern. Therefore, a detailed neuromuscular evaluation and addressing the deforming forces around the hip are important in maximizing gait function, mobility, and minimizing hip instability. Complications in this series included superficial and deep infections, recurrent HO requiring excision, and a decubitus ulcer. There were no dislocations in this series. Patients with neurologic diseases have historically been described as higher rates of hip instability [11]. Cognitive impairments and “at risk” resting leg positions secondary to persistent spasticity and contracture may contribute to his problem. Harris et al. [10] reported a series of 16 patients with cerebral palsy undergoing THA and as part of their protocol immobilized all patients postoperatively in a spica cast. The authors reported recurrent dislocations in two of their patients despite this precautionary measure. Additionally, Hernigou et al. [13] reported on a series of neurologically or cognitively impaired patients undergoing THA and found a 25% revision rate for dislocation when non-constrained components were used compared to 2% revision rate for dislocation when constrained liners were utilized. However, while some authors have advocated used of a primary constrained liner these high-risk patients, our results show that attention to both component position and soft tissue balance
through intraoperative releases can minimize the risk of dislocations without the use of constraint in most patients with spasticity. Weber and Cabanela [11], in their series of THAs among patients with cerebral palsy, reported no dislocations and recommended acetabular anteversion be increased to minimize the risk for instability. Consequently, the risk of instability following THA can be mitigated by careful patient selection, appropriate component position, and proper management of soft tissue contractures. The surgical approach to total hip arthroplasty in this population should permit flexibility to address the anticipated and unexpected challenges of the operation. We favored the posterior approach over the antero-lateral or direct lateral approach with attention to repair of the external rotators and capsule in our cases. While the posterior approach has been historically associated with higher dislocation rates, recent reports of augmented repairs of the posterior structures have decreased the rates of dislocation [14]. In addition, violation of the abductor musculature in a patient who is already neuromuscularly compromised may lead to residual muscle weakness which can interfere with gait or place the patient at risk for development of heterotopic ossification. The incidence of heterotopic ossification in all primary hip arthroplasties has been estimated to be over 20%, with cemented implants and the lateral approach being associated with greater rates [15]. Finally, there has been increasing recent interest in the direct anterior approach as a way to minimize instability in THA [16]. While a direct anterior approach can potentially minimize the risk for dislocation, it is not extensile, and does not allow for excision of heterotopic bone which can be present in patients with acquired spasticity. Our study has several limitations but also strengths. First, its main weakness is its relatively small sample size. This is partially a function of the rigorous preoperative criteria that were placed before a spastic patient would be considered eligible for THA. However, this also limits our ability to make definitive conclusions about the potential differences between patients with AS or CP undergoing primary THA. However, this study shows that in order to make predictable gains following THA, patients with spasticity should possess some degree of active motor control and have functional hip abductors. Furthermore, they should have enough cognitive capacity to participate in rehabilitation and avoid positioning themselves to be at risk for dislocation. Second, the results are limited by the retrospective and unmatched nature of the data. Many of these patients were referred to our institution for surgical management of their debilitating hip pain, and we had no patients with spasticity and severe hip arthritis who had opted out of undergoing THA (either non-operative or Girdlestone procedure) to serve as matched controls. Thus, this limits our ability to conclude that THA is superior to the other treatment modalities. However there are also several strengths. To our knowledge, this is one few studies focused exclusively on patients with spasticity undergoing THA. Additionally, our study is unique in that it quantifies both preoperatively and postoperatively the degree of spasticity, motor control, and ambulation following arthroplasty. Finally, our study compares THA in patient with acquired spasticity to others with patients with cerebral palsy. In summary, hip arthroplasty can afford patients with UMN disorders marked improvement in pain relief, function, and mobility. With the appropriate preoperative preparation, these patients demonstrated consistently improved outcomes on both objective and subjective measures. A comprehensive assessment of dynamic and static deformities must be included in the operative plan. Patients with cerebral palsy may present with more severe deformities and require tendon release or lengthening more frequently than those with acquired spasticity. With appropriate patient selection, planning, and a comprehensive team approach, hip arthroplasties can be performed safely and with low rates of instability even without the use of constrained liners.
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
H. Alosh et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
References 1. Rieks S, Willich SN, Mueller-Riemenschneider F. Trends in age-standardized and age-specific cerebrovascular mortality in germany between 1980 and 2009. Cerebrovasc Dis 2012;34(5–6):368. 2. Kissela BM, Khoury JC, Alwell K, et al. Age at stroke: temporal trends in stroke incidence in a large, biracial population. Neurology 2012 Oct 23;79(17):1781. 3. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007 Apr;89(4):780. 4. Keenan MA, McDaid P. Orthopedic interventions for the managment of limb deformities in upper motor neuron syndromes. Clinical evaluation and management of spasticity. Humana Press; 2002. p. 197–247. 5. Bartlett MD, Wolf LS, Shurtleff DB, et al. Hip flexion contractures: a comparison of measurement methods. Arch Phys Med Rehabil 1985 Sep;66(9):620. 6. Cibere J, Thorne A, Bellamy N, et al. Reliability of the hip examination in osteoarthritis: effect of standardization. Arthritis Rheum 2008 Mar 15;59(3):373. 7. Kaplan PE, Meridith J, Taft G, et al. Stroke and brachial plexus injury: a difficult problem. Arch Phys Med Rehabil 1977 Sep;58(9):415. 8. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation J Bone Joint Surg Am 1969 Jun;51(4):737.
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9. Baxter MP, D'Astous JL. Proximal femoral resection-interposition arthroplasty: salvage hip surgery for the severely disabled child with cerebral palsy. J Pediatr Orthop 1986 Dec;6(6):681. 10. Buly RL, Huo M, Root L, et al. Total hip arthroplasty in cerebral palsy. Long-term follow-up results. Clin Orthop Relat Res 1993 Nov;296:148. 11. Weber M, Cabanela ME. Total hip arthroplasty in patients with cerebral palsy. Orthopedics 1999 Apr;22(4):425. 12. Eibach S, Krug H, Lobsien E, et al. Preoperative treatment with botulinum toxin A before total hip arthroplasty in a patient with tetraspasticity: case report and review of literature. NeuroRehabilitation 2011;28(2):81. 13. Hernigou P, Filippini P, Flouzat-Lachaniette C-H, et al. Constrained liner in neurologic or cognitively impaired patients undergoing primary THA. Clin Orthop Relat Res 2010 Dec;468(12):3255. 14. White Jr RE, Forness TJ, Allman JK, et al. Effect of posterior capsular repair on early dislocation in primary total hip replacement. Clin Orthop Relat Res 2001 Dec;393:163. 15. Barbato M, D'Angelo E, Di Loreto G, et al. Adherence to routine use of pharmacological prophylaxis of heterotopic ossification after total hip arthroplasty: results from an Italian multicenter, prospective, observational survey. J Orthop Traumatol 2012 Jun;13(2):63. 16. Moskal JT, Capps SG, Scanelli JA. Anterior muscle sparing approach for total hip arthroplasty. World J Orthop 2013 Jan 18;4(1):12.
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
Contents lists available at ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Outcomes of Total Hip Arthroplasty in Spastic Patients Hassan Alosh, MD, Atul F. Kamath, MD, Keith D. Baldwin, MD/MPH, MaryAnn Keenan, MD, Gwo-Chin Lee, MD Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
a r t i c l e
i n f o
Article history: Received 11 February 2014 Accepted 6 March 2014 Available online xxxx Keywords: total hip arthroplasty spasticity upper motor neuron disease cerebral palsy
a b s t r a c t Patients with spasticity and hip arthritis can present challenges to treatment. This investigation evaluated the effectiveness and safety of THA in patients with upper motor neuron disease. Twenty-seven consecutive patients with history of cerebral palsy (CP) or acquired spasticity (AS) underwent 30 THAs for treatment of hip arthritis. They were followed for an average 2.5 years (range 2.1–12.1). Patients with CP were more likely to require hip adductor release and hip flexor lengthening at the time of THA. Statistically significant improvements were made in Harris Hip Scores, pain scores, range of motion, ambulatory status, and the use ambulatory-assistive devices. There were no dislocations in this group. Patients with spasticity can benefit from THA in terms of pain relief and improved mobility with relatively low complications. © 2014 Elsevier Inc. All rights reserved.
The prevalence of neurologic disorders in the general population is increasing. In the past 30 years, mortality from stroke has decreased by nearly 70% [1]. Meanwhile, its incidence in the young adult population has steadily increased, suggesting a longer lifetime burden of neurologic disease [2]. Greater longevity and functional status after a neurologic insult also means that these patients will have greater expectations for quality of life and mobility. Within the general population, the projected demand for total hip arthroplasty (THA) is estimated to increase by over 170% within the next 20 years, and the rate of revision THA is expected to double during this period [3]. This rapid rise will likely be mirrored in the people afflicted with neurologic disorders. Limited data exist regarding patient outcomes and perioperative protocols for the spastic patient undergoing primary THA. Furthermore, recognizing the broad spectrum of neurologic conditions, these patients may present with specific contractures and gait disturbances that needs to be carefully evaluated and considered during the preoperative and postoperative periods. Finally, concerns with hip instability, rehabilitation potential, and questions about realistic improvements in function following arthroplasty remain. Therefore the purposes of this study are to (1) evaluate the effectiveness and outcomes of patients with spasticity and coxarthrosis undergoing primary THA and (2) determine if differences exist among patients with cerebral palsy and those with acquired spasticity when undergoing THA.
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2014.03.005. Reprint requests: Gwo-chin Lee, MD, Department of Orthopaedic Surgery, Presbytarian Hospital, University of Pennsylvania, 51 N 39th St, 1 Cupp Building, Philadelphia, PA 19104.
Methods We retrospectively reviewed the medical records of 29 consecutive patients with spasticity who underwent primary THA by one of the senior authors (MAK or GCL) at our institution between 1993 and 2011. This study was approved and conducted according to the guidelines set forth by our institutional review board (IRB). All patients had a confirmed diagnosis of upper motor neuron (UMN) disorder including cerebral palsy (CP) or acquired causes such as traumatic brain injury (TBI), cerebrovascular accident (CVA), spinal cord injury (SCI), or multiple sclerosis (MS). Motor control was graded using a clinical scale [4]. In this scale, an extremity can be hypotonic (Grade 1) or rigid (Grade 2) without any volitional movement. The extremity may exhibit mass flexion or extension patterned movement. This can be reflexive (Grade 3) or volitional (Grade 4). Motor control can be selective with pattern overlay (Grade 5), meaning movement of the hip joint with minimal movement of the adjacent joints, or Grade 6 volitional, allowing movement of a single joint independent of movement in the adjacent joints. Motor strength was graded on a standard 0 to 5 scale, with 0/5 exhibiting no contraction, 3/5 demonstrating movement against gravity, and 5/5 exhibiting full motor strength. Preoperative Evaluation All patients were evaluated preoperatively and after surgery using a detailed, standardized format. Inclusion criteria included all patients between ages 25 and 80 with end-stage degenerative hip disease, an upper motor neuron disorder, and the ability to perform transfers and maintain an upright sitting posture. Patients with Grade 4 or greater motor control, in addition to Grade 3 or greater motor strength of the hip abductors and flexors, were deemed eligible for THA. Static
http://dx.doi.org/10.1016/j.arth.2014.03.005 0883-5403/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
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deformities were differentiated from dynamic deformities with a pharmacologic block when necessary. Hip range of motion and deformity was determined with use of a goniometer before and after surgery. Fixed hip flexion and adduction contractures were determined preoperatively as described in previous studies [5,6]. Prior to surgery, patients and their families were extensively counseled and informed of the inherent risks of THA; in particular, infection, dislocation, neurologic injury, postoperative pulmonary and cardiac complications, and recurrent heterotopic ossification. Pain score were documented on 0–10 visual analogue scale. The use of assistive devices for ambulation was noted. Ambulatory status was also classified on a 0–5 scale: Level 0 (unable), 1 (nonfunctional), 2 (independent household), 3 (independent neighborhood), 4 (independent community), and 5 (normal). The modified Ashworth scale was used to classify spasticity via resistance to passive movement [7]. In this scale, 0 means no increase in tone, 1 means slight increase in tone, 2 means more marked increase in tone with the limb easily flexed, 3 means considerable increase in tone with difficult movement of the limb, and 4 is severe spasticity with a rigid limb. Antero-posterior radiographs of the pelvis and hip and cross-table lateral projections of the hip were obtained preoperatively to confirm degenerative disease and the presence of heterotopic ossification (HO). Patients with severe spasticity (Ashworth 3 or 4) were referred to the Physiatry service for selective pharmacologic blockade (either phenol or botulinum toxin). In this series, 14 patients (16 hips) who had Ashworth spasticity scores of 3 or greater and underwent pharmacological blockade procedures at a range of 2–3 weeks preoperatively. All patients who underwent these procedures improved their spasticity to an Ashworth score of 1 or 2 on the day of surgery. Improvements in range of motion was calculated by comparing the joint range of motion at last follow-up to the joint range of motion upon initial patient presentation prior to any selective injections. Data to compute Harris Hip Scores (HHS) was collected prospectively [8]. Surgical Technique All arthroplasties were performed using a standard posterolateral approach to the hip with the patient positioned in a lateral decubitus position. All patients underwent general anesthesia in order to achieve complete muscle paralysis. Uncemented, press-fit femoral and acetabular components were utilized in all patients. To minimize the effects of surgery in patients with muscle and gait dysfunction, the abductors were carefully protected. A modular femoral component was employed in cases of severe femur dysplasia (n = 3). Femoral head autograft or metallic augments were used to achieve adequate hip coverage in circumstances of acetabular dysplasia (n = 2). A constrained liner was used in two cases when abductor deficiency was encountered during THA. In all cases, the posterior hip capsule and short external rotators were repaired to minimize the risk of hip dislocation. Concomitant excision of heteropic bone (HO) was performed in 7 cases. These patients received a single dose of radiation up to postoperative day 3 and were given 75 mg indomethacin daily for an additional 4 weeks postoperatively to prophylax against recurrent heterotopic ossification. Additionally, soft tissue releases such as adductor tenotomy (n = 11) and iliopsoas lengthening (n = 6) were performed for patients with preoperative contractures. Patients with adduction contractures greater than 15° and flexion contractures greater than 30° under anesthesia underwent soft tissue release at the time of surgery. Patients with an equinovarus deformity of the foot (n = 6) had an Achilles lengthening and split tibialis anterior tendon transfer (SPLATT) performed preoperatively to achieve a plantigrade foot prior to THA. The median femoral component head size was 32 mm (range 22–32).
Postoperative Management Patients were managed aggressively with analgesics and muscle relaxants to minimize spasticity and maximize patient comfort during the postoperative period. A multidisciplinary approach including consultation with Physiatry and Pain Management was used in all cases. All patients in this series were placed in an abduction pillow and knee immobilizer postoperatively. Furthermore, patients with cognitive impairments and anticipated difficulty following hip precautions were placed in an abduction brace for a minimum of 6 weeks (n = 5). All patients were mobilized by physical therapy on postoperative day 1. All patients were discharged to a rehabilitation facility for additional physical and occupational therapies. Postoperative rehabilitation focused on strict maintenance of posterior hip precautions, achieving a stable gait pattern with a minimal degree of assistive devices, and stretching programs tailored to a patients prior or concomitant corrective procedures (eg, maintaining a plantargrade foot after a split tibialis tendon transfer). Furthermore, in coordination with the rehabilitation and the prosthetic services, necessary modifications to ambulatory-assistive devices were addressed in patients who also suffered from upper extremity spasticity and deformities. Follow-Up Data Patient medical records were reviewed for the major and minor outcomes of interest. Main outcomes of interest were improvement in ambulation status, subjective pain scores, and complications. Secondary outcomes included Harris Hip Scores, preoperative deformity, range of motion (ROM), and additional procedures performed during or in preparation for THA. Statistics Because the data were not normally distributed, the Wilcoxon Signed Rank test was used to determine significant differences in preoperative and postoperative ROM, pain scores, and Harris Hip Scores. In cases comparing proportions between the CP and AS cohorts, the chi-squared test with Yate's correction was used. Statistical significance was assigned at P ≤ 0.05. Statistics were performed used the Excel 2010 (Microsoft, Redmond, WA, USA) and STATA 11 (StataCorp, College Station, TX, USA) processors. Standard deviations are reported in parenthesis following mean values. Results A total of 29 patients with upper motor neuron disease and spasticity underwent 32 primary THAs. Two of these patients were lost to follow-up. The remaining 27 patients with 30 THAs were available for final analysis (Table 1). Among these patients etiology of spasticity was cerebral palsy in 12, traumatic brain injury in 9, cerebrovascular accident in 3, multiple sclerosis in 2, and spinal cord injury in 1 patient. Patients made statistically significant improvements in pain scores, Harris Hip scores, and range of motion following THA (Fig. 1). All patients rated their pain as severe preoperatively (visual analogue pain scale of 8 or greater). At last follow-up, 14 patients reported minimal hip pain (pain score b3), 11 reported mild to moderate hip pain (pain score N2 and b 7), and 3 severe hip pain (pain score of 7 or greater). Range of motion, with focus on hip flexion, abduction, and external rotation, all significantly improved following THA. Mean flexion improved from 83.3° to 101°, abduction improved from 14.2° to 36.8°, and external rotation increased from 8.1° to 19.2° (P b 0.01). Harris Hip Scores improved from a mean 15.0 (SD = 7.2, range 5–35) to a mean 67.3 (SD = 18.8, range 24–91), which was also statistically significant (P b 0.01).
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
H. Alosh et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx Table 1 Patient Demographics. Male Female Mean age Age range Mean follow-up Follow-up range Spasticity etiology Cerebral palsy Traumatic brain injury Cerebrovascular accident Multiple sclerosis Spinal cord injury Paralysis Hemiparesis Diplegia Quadriparesis Hip pathology Degenerative joint disease Avascular Necrosis Motor control Normal (grade 6) Selective (grade 5) Voltional synergistic(grade 4) Ashworth spasticity score Mean Range
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Table 2 Ambulatory-Assistive Devices Before and After THA. 12 patients (14 hips) 15 patients (16 hips) 48.6 years (12.2) 29.1–75.0 2.7 (2.5) 2.1–12.1 years 12 9 3 2 1 13 8 6 25 hips 5 hips 8 (0 CP, 8 AS) 15 (11 CP, 4 AS) 4 (1CP, 3 AS) 2.3 (1.2) 1–4
Mobility following surgery was improved in nearly all patients following THA. The mean ambulation score improved from a mean of 1.4 (1.1, range 1–4) to 3.0 (1.1, range 1–5) (P b 0.01). Prior to surgery, all patients required the use of an assistive device: 10 patients required use of a wheelchair, 13 used a walker, and 4 used a cane for ambulation. Postoperatively, 4 patients required use of a wheelchair, 10 ambulated with a walker, and 8 ambulated with a cane. Five of these patients did not require the use of an assistive device (Table 2). The degree of contractures encountered at the time of surgery differed between patients with congenital neurologic disorders (i.e. cerebral palsy (CP) compared to those with acquired spasticity (AS) (i.e stroke, brain injury, multiple sclerosis). Patients with CP trended toward a higher degrees of flexion and adduction contractures in comparison to those with AS (Table 3). Patients with CP required simultaneous adductor release more frequently compared to patients with AS at the time of THA (58% versus 22%, P = 0.10) and flexor lengthening was also performed at a higher rate (42% versus 5.5%, P = 0.05). Conversely, there was a trend for patients with AS to require excision of heterotopic bone compared to other patients. There were no dislocations in this series. The most common complication necessitating a return to the operating room was infection (Table 4). One patient required a resection arthroplasty
Preoperative assistive device Wheelchair/non-ambulator Walker Cane No device Postoperative assistive device Wheelchair/Non-ambulator Walker Cane No device
Cerebral Palsy
Acquired Spasticity
33% (4/12) 67% (8/12) 0% 0%
40% (6/15) 33% (5/15) 27% (4/15) 0%
17% (2/12) 33% (4/12) 42% (5/12) 8% (1/12)
13% 40% 20% 27%
(2/15) (6/15) (3/15) (4/15)
following a deep prosthesis infection. The prosthesis was believed to have been seeded by a decubitus ulcer that developed several months postoperatively. Three patients required superficial incision and drainage procedures for persistently draining wounds. At last follow-up, these patients were infection free with no other complications. One patient had an intraoperative calcar fracture managed successfully without any additional complications. Discussion As the life expectancy of patients with neurologic conditions increases, a greater number of patients with spasticity can be expected to present with symptomatic end-stage degenerative disease of the hip. Traditionally, Girdlestone resection arthroplasty has used to address the painful arthritic hip in the spastic patient [9]. While the procedure often yielded some improvements in pain, the functional recovery was often unpredictable. By shortening the affected limb and failing to address the imbalanced muscle forces across the hip joint, these patients often developed recurrent deformity and had continual difficulties with gait and ambulation. For today's patient with spasticity and degenerative hip disease, THA potentially affords the best opportunity for reducing pain and maintaining mobility. However, concerns with hip instability, poor rehabilitation potential and questions about the functional improvements that can be achieved following surgery persist. Data regarding outcomes following total hip arthroplasty in this patient population are limited. Also, there is also a lack of information with regard to arthroplasty in patients with acquired versus congenital neurologic disorders. Therefore the purpose of this study is to (1) evaluate the effectiveness and outcomes of patients with spasticity and coxarthrosis undergoing primary THA and (2) determine if differences exist among patients with cerebral palsy and those with acquired spasticity when undergoing THA. Our results show that patients with spasticity and coxarthrosis can benefit from THA. The patients in this series made predictable improvements in pain, ambulation status, and functional outcome scores. Previous investigations have usually reported adequate pain relief with THA among patients with cerebral palsy, but have not focused on functional and ambulatory status. One of the initial studies Table 3 Deformities and Corrective Measures in Cerebral Palsy Versus Acquired Spasticity.
Fig. 1. Preoperative and postoperative ROM, HHS, and pain scores.
Preoperative flexion contracture Range Preoperative adduction contracture Range Additional procedures Adductor release Flexor lengthening HO excision Split tibialis anterior transfer
Cerebral Palsy
Acquired
P-value
52.5 (25.6) 0–90 17.9 (13.4) 0–40
40 (37.4) 0–110 8.4 (15.4) 0–50
0.43
58% (7/12) 42% (5/12) 8% (1/12) 8% (1/12)
22% (4/18) 5.5% (1/18) 33% (6/18) 28% (5/18)
0.10 0.05 0.25 0.40
0.03
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
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H. Alosh et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
Table 4 Complications. Cerebral Palsy
Acquired Spasticity
- Calcar fracture - Wound drainage requiring washout - Sacral decubitus ulcer (grade 3) - Recurrent HO requiring resection - Wound drainage requiring incision and - Prosthetic infection requiring drainage (2 cases) resection arthroplasty
of THA in patients with CP reported on a series of 19 hips between 1972 and 1986 [10]. The authors only used cemented implants and immobilized 16 patients in spica casts postoperatively. The authors reported the majority had pain relief and five patients regained the ability to walk. It is unclear whether the authors selected patients based on preoperative motor control and function. Another series of 16 patients with cerebral palsy undergoing THA reported that that 13 patients obtained good pain relief [11]. Consequently, in well-selected patients, THA can lead to improvements in pain and mobility in this patient population. This study also shows that the etiology of spasticity can be relevant when preparing for THA in the spastic patient. Patients with congenital neurologic conditions were more likely to require additional soft tissue releases at the time of arthroplasty compared to those with acquired spastic conditions. Patients with congenital conditions, such as those with cerebral palsy, present with lifelong history of hip dysplasia and contractures, whereas others, such as those with spasticity following a CVA, may experience hip pain and joint dysfunction as a relatively new process. Understanding the static and dynamic deformities these patients may present with is critical to the successful management of degenerative joint disease in the spastic patient. Nerve blocks are can be a useful adjunct, as they can serve a diagnostic function in establishing which deformities are dynamic, in addition to controlling spasticity postoperatively. In one case report, injection with botulinum toxin prior to total hip arthroplasty in a patient with cerebral palsy was reported with good results. The authors noted an improvement in preoperative hip adductor and flexion deformity, in addition to sustained pain relief and spasticity control for 8 weeks following the surgery [12]. Fixed hip contractures, of which the most common are hip adductor and flexor contractures, must be addressed intraoperatively. Hip adduction contractures affect balance and narrow the patient's base, in addition to contributing to an apparent leg length discrepancy. Hip and knee flexion contractures are often concurrent and should addressed with surgical release simultaneously, allowing a more natural and efficient gait pattern. Therefore, a detailed neuromuscular evaluation and addressing the deforming forces around the hip are important in maximizing gait function, mobility, and minimizing hip instability. Complications in this series included superficial and deep infections, recurrent HO requiring excision, and a decubitus ulcer. There were no dislocations in this series. Patients with neurologic diseases have historically been described as higher rates of hip instability [11]. Cognitive impairments and “at risk” resting leg positions secondary to persistent spasticity and contracture may contribute to his problem. Harris et al. [10] reported a series of 16 patients with cerebral palsy undergoing THA and as part of their protocol immobilized all patients postoperatively in a spica cast. The authors reported recurrent dislocations in two of their patients despite this precautionary measure. Additionally, Hernigou et al. [13] reported on a series of neurologically or cognitively impaired patients undergoing THA and found a 25% revision rate for dislocation when non-constrained components were used compared to 2% revision rate for dislocation when constrained liners were utilized. However, while some authors have advocated used of a primary constrained liner these high-risk patients, our results show that attention to both component position and soft tissue balance
through intraoperative releases can minimize the risk of dislocations without the use of constraint in most patients with spasticity. Weber and Cabanela [11], in their series of THAs among patients with cerebral palsy, reported no dislocations and recommended acetabular anteversion be increased to minimize the risk for instability. Consequently, the risk of instability following THA can be mitigated by careful patient selection, appropriate component position, and proper management of soft tissue contractures. The surgical approach to total hip arthroplasty in this population should permit flexibility to address the anticipated and unexpected challenges of the operation. We favored the posterior approach over the antero-lateral or direct lateral approach with attention to repair of the external rotators and capsule in our cases. While the posterior approach has been historically associated with higher dislocation rates, recent reports of augmented repairs of the posterior structures have decreased the rates of dislocation [14]. In addition, violation of the abductor musculature in a patient who is already neuromuscularly compromised may lead to residual muscle weakness which can interfere with gait or place the patient at risk for development of heterotopic ossification. The incidence of heterotopic ossification in all primary hip arthroplasties has been estimated to be over 20%, with cemented implants and the lateral approach being associated with greater rates [15]. Finally, there has been increasing recent interest in the direct anterior approach as a way to minimize instability in THA [16]. While a direct anterior approach can potentially minimize the risk for dislocation, it is not extensile, and does not allow for excision of heterotopic bone which can be present in patients with acquired spasticity. Our study has several limitations but also strengths. First, its main weakness is its relatively small sample size. This is partially a function of the rigorous preoperative criteria that were placed before a spastic patient would be considered eligible for THA. However, this also limits our ability to make definitive conclusions about the potential differences between patients with AS or CP undergoing primary THA. However, this study shows that in order to make predictable gains following THA, patients with spasticity should possess some degree of active motor control and have functional hip abductors. Furthermore, they should have enough cognitive capacity to participate in rehabilitation and avoid positioning themselves to be at risk for dislocation. Second, the results are limited by the retrospective and unmatched nature of the data. Many of these patients were referred to our institution for surgical management of their debilitating hip pain, and we had no patients with spasticity and severe hip arthritis who had opted out of undergoing THA (either non-operative or Girdlestone procedure) to serve as matched controls. Thus, this limits our ability to conclude that THA is superior to the other treatment modalities. However there are also several strengths. To our knowledge, this is one few studies focused exclusively on patients with spasticity undergoing THA. Additionally, our study is unique in that it quantifies both preoperatively and postoperatively the degree of spasticity, motor control, and ambulation following arthroplasty. Finally, our study compares THA in patient with acquired spasticity to others with patients with cerebral palsy. In summary, hip arthroplasty can afford patients with UMN disorders marked improvement in pain relief, function, and mobility. With the appropriate preoperative preparation, these patients demonstrated consistently improved outcomes on both objective and subjective measures. A comprehensive assessment of dynamic and static deformities must be included in the operative plan. Patients with cerebral palsy may present with more severe deformities and require tendon release or lengthening more frequently than those with acquired spasticity. With appropriate patient selection, planning, and a comprehensive team approach, hip arthroplasties can be performed safely and with low rates of instability even without the use of constrained liners.
Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
H. Alosh et al. / The Journal of Arthroplasty xxx (2014) xxx–xxx
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Please cite this article as: Alosh H, et al, Outcomes of Total Hip Arthroplasty in Spastic Patients, J Arthroplasty (2014), http://dx.doi.org/ 10.1016/j.arth.2014.03.005
