About Prof. Zhai Weimin
Prof. Zhai Weimin is a senior orthopedic surgeon at Ruijin Hospital, Shanghai Jiao Tong University School of Medicine. He specializes in total hip and knee replacement, with a focus on complex revision arthroplasty and sports-related joint injuries. He has performed over 5,000 joint replacement procedures.
Case Overview
A 58-year-old retired physical education teacher presented with two years of progressive left hip pain and limp, worsening over three months. Imaging confirmed ARCO Stage IV avascular necrosis of the left femoral head secondary to long-term high-dose corticosteroid use, complicated by osteoporosis and 1.5 cm limb length discrepancy. Prof. Zhai Weimin's team at Ruijin Hospital, Shanghai Jiao Tong University performed a minimally invasive direct anterior approach (DAMIS) total hip arthroplasty with intraoperative ICG fluorescence angiography to confirm acetabular and femoral bone perfusion. The patient was walking with a frame at 4 hours post-operatively, discharged on day 3, and achieved a Harris Hip Score of 92 (excellent) at 3 months. At one year, he had returned to light jogging.
Patient Background
- Age / Sex: 58-year-old male
- Chief Complaint: Left hip pain with limp for 2 years; worsening for 3 months
- Medical History: Long-term high-dose corticosteroid use 20 years prior for nephrotic syndrome (cumulative dose >10 g); no trauma; no alcohol use
- Occupation: Retired physical education teacher — high functional demands post-operatively
- Physical Exam: Left hip flexion limited to 90°; internal rotation 10°; positive FABER ("4" sign); positive Thomas test; left limb shortening ~1.5 cm
Pre-operative Workup
Imaging (X-ray + MRI + 3D CT)
- X-ray: Left femoral head collapse and flattening; joint space narrowing; trabecular disorganization — ARCO Stage IV
- 3D CT Reconstruction: Shallow anterior acetabular wall; proximal femoral medullary sclerosis; cortical thinning consistent with steroid-induced osteoporosis
- MRI: Positive crescent sign — subchondral fracture confirmed
- Bone Density (DEXA): T-score −2.8 (osteoporosis)
Digital Pre-operative Templating
- AI-assisted software used to predict implant sizing: cementless biological cup (52 mm diameter) + short-stem femoral component (femoral neck preserving)
- Surgical goals: restore limb length equality, reconstruct hip rotation center, achieve primary implant stability
Diagnosis & Surgical Strategy
Diagnosis: Left femoral head avascular necrosis (steroid-induced, ARCO Stage IV); secondary left hip osteoarthritis; osteoporosis.
Procedure: Minimally invasive direct anterior approach (DAMIS) total hip arthroplasty with intraoperative ICG fluorescence angiography.
Rationale for Anterior Approach
- Muscle-sparing: The DAMIS approach accesses the hip through the internervous plane between tensor fasciae latae and sartorius — no muscle or tendon is divided; posterior dislocation risk is near zero
- Precision positioning: Supine position allows intraoperative fluoroscopy for real-time cup anteversion and abduction angle verification
- Functional priority: For a former physical education teacher with high proprioceptive and strength demands, preserving the posterior soft tissue envelope is critical to long-term functional outcomes
Key Technologies
- Intraoperative ICG Fluorescence Angiography: IV ICG injected prior to final implant seating; near-infrared camera used to assess real-time perfusion of acetabular rim and proximal femur — particularly important in osteoporotic bone where vascularity may be compromised, predicting healing potential and infection risk
- Portable C-arm Navigation: Intraoperative fluoroscopy to confirm limb length restoration and hip center reconstruction
Operative Procedure
- Position & Setup: Supine on radiolucent operating table; both lower limbs prepped and draped for intraoperative length comparison; no traction table required
- Incision & Approach: Left anterolateral incision (~8 cm); blunt dissection through intermuscular plane; T-shaped capsulotomy; necrotic femoral head excised
Acetabular Preparation
- Thorough debridement of granulation tissue and osteophytes
- Sequential reaming from small to large diameter — incremental technique to avoid acetabular fracture in osteoporotic bone
- Trial cup confirmed: 40° abduction, 15° anteversion; excellent primary stability on impaction (clear resonant sound)
Femoral Preparation
- Canal preparation with short-stem trial; intraoperative fluoroscopy confirmed 1.5 cm limb length restoration
- Iliopsoas tendon released to prevent impingement
- Trial reduction: hip flexion >100°; no dislocation tendency in any position
ICG Fluorescence Verification
- IV ICG 2.5 mg injected; near-infrared imaging confirmed robust perfusion (bright green signal) at acetabular rim and proximal femur — no ischemic zones identified; bone viability confirmed prior to final implant seating
Implantation & Closure
- Ceramic-on-ceramic bearing surface selected (reduced wear debris — appropriate for relatively young, active patient)
- Wound irrigated; layered fascial and skin closure with cosmetic subcuticular suture
Operative Data
- Operative Time: 75 minutes (skin incision to closure)
- Estimated Blood Loss: ~150 mL
- Intraoperative Fluoroscopy: 3 exposures (minimal radiation)
Post-operative Recovery (ERAS Protocol)
- No Drain: Meticulous intraoperative hemostasis; local infiltration analgesia ("cocktail" technique) — no drain placed
- 4 Hours Post-op: Ambulating with walking frame — a hallmark advantage of the DAMIS anterior approach
- Multimodal Analgesia: NSAIDs-based protocol; opioid use minimized
Recovery Timeline
- Day 1: Hip ROM 90°; Harris Hip Score improved from 45 (pre-op) to 75
- Day 3: Walking frame replaced with single cane; discharged home
- Week 2: Wound healed; no erythema or swelling
- Week 6: Swimming and brisk walking resumed; X-ray confirmed implant position stable, no subsidence
Follow-up & Long-term Management
- 3 Months: X-ray confirmed osseointegration; Harris Hip Score 92 (excellent)
- 1 Year: No periprosthetic radiolucent lines; patient reported "forgetting he had a joint replacement"; light jogging resumed
- Osteoporosis Management: Ongoing bisphosphonate therapy + vitamin D supplementation to prevent periprosthetic fracture and support long-term implant longevity
Expert Commentary — Prof. Zhai Weimin
1. The Art of Approach Selection
With over 5,000 joint replacement procedures, I have performed every major approach to the hip. The choice of approach is not a matter of habit — it is a matter of matching the surgical corridor to the patient's anatomy, biology, and functional goals. For a 58-year-old former physical education teacher with intact posterior musculature and high activity expectations, the direct anterior approach was the only logical choice. No posterior capsule violation means near-zero dislocation risk. No gluteal muscle division means immediate weight-bearing and rapid proprioceptive recovery. The approach is the first surgical decision — and in this case, it determined everything that followed.
2. Precision in a Compromised Biological Environment
Steroid-induced osteonecrosis with concurrent osteoporosis is one of the most technically demanding scenarios in arthroplasty. The bone is simultaneously sclerotic in the medullary canal and fragile at the cortex — a combination that punishes aggressive reaming and rewards patience. The incremental acetabular preparation technique, the short-stem femoral component preserving proximal bone stock, and the ICG fluorescence confirmation of bone perfusion before final implant seating — each of these decisions was made with the patient's next 30 years in mind, not just the next 30 minutes. In osteoporotic arthroplasty, the surgeon's job is to preserve options for the future, not just solve the problem of today.
3. ERAS Is Not a Protocol — It Is a Philosophy
Walking at four hours after a total hip replacement is not a marketing claim. It is the direct consequence of every decision made before, during, and after the operation: the muscle-sparing approach, the multimodal analgesia, the absence of a drain, the early mobilization plan. When these elements are integrated deliberately, rapid recovery is not a goal — it is an outcome. This patient was discharged on day 3 and returned to jogging at one year. That is what modern orthopedic surgery should look like.
How CMCS Shanghai Coordinated This Case
China Medical Concierge Shanghai (CMCS) supported this patient's care pathway from initial overseas inquiry through one-year follow-up. Our coordination included:
- Pre-arrival X-ray and MRI image review and specialist referral to Prof. Zhai Weimin's orthopedic team at Ruijin Hospital
- Arrangement of 3D CT reconstruction, DEXA bone density scan, and digital pre-operative templating
- Bilingual interpretation during pre-operative consultation, including detailed discussion of approach options, implant selection, and osteoporosis management
- Surgical admission logistics, including hospital registration and accommodation support for accompanying family
- On-site medical interpretation throughout the hospitalization and ERAS recovery period
- Post-discharge coordination of physiotherapy referral, X-ray surveillance at 6 weeks and 3 months, and osteoporosis medication management
For international patients facing joint replacement surgery abroad, the combination of implant selection complexity, rehabilitation planning, and unfamiliar medical systems creates significant anxiety. CMCS exists to remove that barrier — ensuring patients access Shanghai's leading orthopedic expertise with every clinical and logistical detail managed from first contact to full recovery.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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