Case history
Preoperative management
The patient is a 35-year-old male with no past medical history who
presented to our institution after sustaining a single GSW to the right
hip during a home invasion two weeks ago. He was undergone laparotomy
emergently and after stabilizing him, the patient sustained to our
center. Physical examination revealed an open ballistic wound to the
posterior hip and right sciatic nerve deficit. Radiographs (Fig. 1) and
computerized tomography (CT) scans (Fig. 2 and Fig. 3) of the pelvis and
hip were obtained, which demonstrated a comminuted fracture of the
femoral head, along with comminuted fracture of both acetabular columns.
Three-dimensional CT reconstruction images were acquired to further
characterize the femoral head and acetabular fracture fragments.
Associated injuries such as bowels and bladder were managed via general
surgery and urology services as well.
Operation
After discussing the risks and complications of operative treatment,
informed consent was obtained, and the patient was taken to the
operating room.
A kocher-langenbeck approach was used for exposure. We decided to
explore and neurolyse the sciatic nerve and use just a 3.5 mm
reconstruction posterior column buttress plate in order to do the total
hip arthroplasty (THA) after bone union along with irrigation and
debridement (Fig. 4).
After a year bone union was completed, and laboratory data showed no
evidence of infection. The pre-op harris hip score (HHS) was 22. In this
stage THA was done through lateral approach. After dislocating the hip
joint anteriorly, the hip was taken into a position of flexion,
adduction, and external rotation to deliver the femoral neck osteotomy
into the anterior aspect of the exposure and resecting the femoral head
residues. Then the acetabulum was prepared and a 52mm Zimmer Biomet
continuum cup was implanted with a 36 mm linear. The femoral canal was
prepared, and after trialing, a 16/225-mm Zimmer Biomet wagner SL
press-fit femoral stem was implanted with a metal Zimmer Biomet 36 mm
head and -3.5 mm neck length. The hip was then reduced with satisfactory
stability and soft-tissue tension were obtained. The exposure was then
closed in standard fashion. Standard radiographs were obtained
immediately after the operation (Fig. 5)
Postoperative care
He was made touch-down weight-bearing for 6 weeks and then allowed to
advance as tolerated. The physical therapy team was consulted
postoperatively for mobilization, and global hip precautions were
provided as this patient had a dual approach. No heterotopic
ossification prophylaxis was utilized. At one-year postoperatively, the
patient returned for a follow-up visit and Radiographs were obtained at
this time for routine monitoring and to confirm proper positioning of
hardware (Fig. 6). He had no complaints and the HHS was 74.