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Revision and Bilateral Hip Replacement - Denise Kavanaugh
Denise Kavanaugh is a trooper in more ways than one. The veteran St. Louis police officer had battled breast cancer years ago and was back on active duty when she was hit by a parcel truck in a road accident.
“I broke my pelvis in about eight places,” says Kavanaugh. “It took me 30 days just to recover from that.”
Kavanaugh ultimately had to retire on disability after 15 years in local law enforcement. Chronic pain and a lasting limp led her to undergo primary hip replacement surgery on her left side in 2010 at a hospital not in the BJC system. “I was in a lot of pain and I kept losing my balance and falling,” she says. “I was just so unsteady that I had to do something.”
But Kavanaugh says even after the initial hip replacement, the pain and discomfort remained constant. More than 60 physical therapy sessions failed to alleviate the pain. “I ended up using a walker or a cane just to get around,” Kavanaugh recalls. “I couldn’t walk independently at all without some type of support.”
In late 2011, Kavanaugh came to Washington University School of Medicine for a second opinion. Initial x-rays here found that Kavanaugh’s replacement joint did not have the proper offset and not in proper alignment.
“When the offset is not properly restored at the time of hip replacement, it can lead to improper tension on the hip abductor muscles, which can make them weak,” says orthopaedic surgeon Ryan Nunley, MD, a joint preservation and replacement specialist. “The hip abductors are the most important muscles following a posterior approach to hip replacement, so when they are weak and not functioning properly, it can lead to a high risk of dislocations and chronic limp.”
Complicating matters was the fact the Kavanaugh’s left leg was several centimeters shorter than the right leg following the initial hip replacement. The leg discrepancy also aggravated the hip abductor muscles and stressed the new joint.
After extensive evaluation, Nunley recommended revision hip replacement. “In order for us to adjust her leg length and offset issues, we had to remove her original implants and replace them with a new ball and socket,” Nunley explains. “The new implants used a larger femoral head (ball on top of the thigh bone). We also replaced the old acetabular socket with a new one made of titanium. Several screws kept the new joint supported in the correct position until bone growth occurred and stabilized the joint.”
Nunley says the challenging part of revision hip replacement is that the soft tissues surrounding the area have some elasticity, which varies greatly from patient to patient depending upon factors such as age, gender, and reasons for the initial hip problem. Adequate tension on the hip abductors must be maintained to keep the hip from dislocating and to minimize limping.
“I felt the difference right away when I got up in the hospital following Dr Nunley's surgery,” says Kavanaugh. “It didn’t hurt anymore. I was just so happy that the pain was gone.”
Because of the extensive revision, her left leg actually became slightly longer than her right.
“The leg length discrepancy happens because we have to lengthen the limb to restore adequate tension on the hip abductors,” says Nunley. “If patients undergo hip replacement only on one side, we can correct that discrepancy with the use of orthotics. In Ms. Kavanaugh’s case, she had degenerative arthritis in both of her hips and she underwent a second total hip replacement on her right side in December. In that procedure, we evened out the limb length discrepancy so that she now completely level again.”
“He did such a good job at eliminating the pain in my hips,” says Kavanaugh. “I have complete faith in Dr. Nunley. He is so careful and precise; I know I’ll feel completely better soon.”
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