CASE IN POINT

NON UNION OF TOTAL HIP REPLACEMENT

The plaintiff had degenerative joint disease in her right hip and at first tried a conservative treatment path, attempting to relieve pan with physical therapy (Fig 1-1).

Fig 1-1 --- Click on Images to Enlarge
Her osteoarthritis with avascular necrosis worsened, so she went in for a total right hip replacement (Fig 1-2).
Fig 1-2
Postoperatively, she participated in a rehabilitation program, and a little over a year after the procedure, suffered some iliopsoas tendinitis/bursitis. Steroid shots provided some relief (Fig 1-3).
Fig 1-3
Twenty-two months after the initial procedure, she began having worsening right hip pain. Films showed subluxation (partial dislocation) of the acetabular cup, so she went in for a revision surgery to replace the loosened acetabular cup. During the procedure, the surgeon found that part of her acetabular liner had fractured and displaced, while the remaining acetabular liner remained in place. There was anteversion, but the surgeon believed it to be from the loosening of the component.

PLAINTIFF'S CLAIM:

The plaintiff's theory is that the cup was placed too far in anteversion (face of cup rotated to far anteriorly) by the surgeons in the first surgery. Her pain in the iliopsoas tendon region was a sign the cup was placed incorrectly. This misplacement caused her pain and eventually required her to have the cup replaced.

DEFENSE'S ARGUMENT:

The defense believed the initial placement of the cup was correct, but the cup did not develop enough ingrowth into the bone, which was the reason the cup loosened and anteverted. The defense experts believed the films over the 22-month period showed this. Pathology photos of the cup taken after its removal showed only about 25% bone grown on the surface of the cup. The revision surgery, performed by another surgeon, was successful.

VISUAL STRATEGY:

Collaborating with the defense attorneys and the expert physician, Illustrated Verdict created a visual strategy to help illustrate the hip anatomy and location of components in total hip replacement.

The first board showed the normal anatomy of the right hip. (Fig 4-1)

Fig 4-1

 

A second board showed the lateral approach to the hip joint during the first procedure. (Fig 4-2)

Fig 4-2
 

A set of illustrations outlined the initial total hip replacement. (Fig 4-3)

Fig 4-3
 

We used the post op film to show proper alignment of the components.
(Fig 4-4)

Fig 4-4
 

We colorized the films from two months and eight months post op to show that the components of the hip replacement continued to be well positioned. (Fig 4-5)

Fig 4-5
 

We also colorized films from approximately two years post op, when the studies started to show the movement of the acetabular component. (Fig 4-6)

Fig 4-6
 

Another board demonstrated the lack of bone growth into the acetabular cup, which was the reason it started to move and eventually become anteverted. (Fig 4-7)

Fig 4-7
 

Pathology photos also showed the lack of bone growth on the cup. (Fig 4-8)

Fig 4-8
 

The final board illustrated the difference between anteversion (cup rotated toward patient's front) and retroversion (cup rotated towards patient's back) and the relationship to the iliopsoas tendon. If the cup had been placed in anteversion, as the plaintiff claims, the iliopsoas would not have been affected anyway. (Fig 4-9)

Fig 4-9
 

The illustrations helped the defense successfully convey to the jury the following key points:

  • The cup was properly placed as seen in the films postoperatively.
  • The displacement of the cup did not happen until 22 months postoperatively
  • The claim by the plaintiff that the pain in the iliopsoas tendon was from the anteversion of the cup did not make sense, as an anteversion would have the cup move more posteriorly, away from the tendon.
  • The bone growth on the cup was not sufficient at only 25% to hold the cup in place and that is what caused it to move.

 

RESULT:
The jury found in favor of the defense.  

"Defense verdict, and the presentation was very helpful, thanks."

- Attorney Jack P. Shusted, German, Gallagher & Murtagh, P.C., Philadelphia, PA

 

 

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