Early Total Hip Replacement After Fractures of the Acetabulum
Introduction
Total hip replacement is an important option in the management of sequelae following fractures of the acetabulum to relieve pain and restore function. Delayed THA is usually performed for post-traumatic arthritis, chondrolysis or avascular necrosis after the fracture has healed, following nonoperative or surgical treatment.
As far as possible, this option should be reserved for elderly or older patients (Figs 31.1A and B).
Early or immediate total hip replacement after fractures of the acetabulum needs to be performed infrequently but can be a challenging operation. In this situation, the fracture fragments may not have healed enough to allow primary stability of the acetabular component to be obtained. The reconstructive option chosen should provide stable fixation of the fracture fragments and also allow implantation of a well functioning stable and satisfactory acetabular component, to prevent premature failure. However, the need for a precise anatomic reduction of the fracture is obviated so long as the overall shape of the acetabulum can be restored to allow socket fixation.
 |
Figures 31.1A and B: Delayed THA for secondary OA
459
31
 |
 |
 |
Total Hip Arthroplasty
Figure 31.2: Marginal impaction and comminution
Indications for Early THA
We have utilized this option mainly in elderly patients with comminuted fractures and osteoporotic bone. In younger patients, the emphasis should be on anatomic open reduction and internal fixation as far as possible. However, we have used total hip replacement as the primary option in isolated situations in young patients who have acetabular fractures with simultaneous femoral head and neck fracture where satisfactory repair is not possible.
The main indications for early THA after fractures of the acetabulum are as follows:
PATIENTS WITH ADVANCED AGE AND OSTEOPOROSIS WITH COMMINUTED FRACTURES
In such cases, open reduction and internal fixation may be difficult to achieve due to comminution and osteoporotic bone and may be associated with significant complications such as loss of fixation in porotic bone. Even if successful fixation is obtained, it may still not prevent inevitable THA in the near future due to severe articular cartilage injury or marginal impaction. Extensive marginal impaction of the acetabulum has been described as an indication (Fig. 31.2). In some cases where the shattering is extensive, it may be preferable to wait until early healing before THA (Figs 31.3 and 31.4).
 |
Figure 31.3: Extensive comminution
460
31
 |
 |
 |
Early Total Hip Replacement After Fractures of the Acetabulum
Figures 31.4A and B: (A) Early healing (B) THA after early healing preferred
 |
Figure 31.5: Extensive impaction and abrasive damage to the femoral head
INVOLVEMENT OF FEMORAL HEAD AND NECK
The pattern of fracture of the femoral head, especially when the femoral neck has also been fractured, usually precludes preservation of the femoral head. There may be additional femoral head impaction damage or damage due to abrasive loss of articular cartilage (Fig. 31.5). The femoral head may be fractured beyond repair (Figs 31.6 and 31.7).
DELAYED INITIAL REFERRAL WITH PERSISTENTLY SUBLUXED HEAD
The femoral head may be or persistently subluxed and at a higher risk of avascular necrosis. In such scenarios, the posterior wall fragment is often found to be quite thin and crushed and unsuitable for fixation, particularly when the age is advanced. In addition, the vascularity of the hip and viability of articular cartilage may be compromised (Figs 31.8 to 31.10).
In such cases, total hip arthroplasty is performed as primary treatment of the acetabular fracture. However, it must be appreciated that the joint reconstruction is likely to fail if the
461
31
|
|
 |
Total Hip Arthroplasty
Figure 31.6: Shattered femoral head and neck fracture in a young patient
 |
 |
Figure 31.7: After acute injury, THA performed on day 7 after surgery Figure 31.8: 82-year-old female, persistent
 |
subluxation at 12 weeks, ununited fracture, damaged head surface
 |
462
Figure 31.9: Crushed posterior wall, segmental defect in same patient as in Figure 31.8
Figure 31.10: After THA, same patient as in Figure 31.8
31
|
|
Early Total Hip Replacement After Fractures of the Acetabulum
fracture cannot be stabilized. In our experience, stable column fixation is mandatory for satisfactory THA reconstruction to be achieved. Similarly, the posterior and superior load bearing portion of the acetabulum must be reconstructed optimally to implant a stable socket. Preparing the acetabulum is usually the most technically challenging aspect of the operation. In rare occasions or borderline cases, one may need to go in for open reduction internal fixation of the native hip, but be prepared to convert to THA if extensive damage to the articular cartilage is discovered. In such cases, appropriate informed consent needs to be obtained.
Choice of Implants, Prostheses and Bone Grafts
The exact method of surgical technique used, particularly to achieve fixation of the fracture, will vary depending upon the type of the fracture, its location and comminution. Similarly, the bone grafting technique depends upon the type, size and location of the acetabular defect. We routinely use bone grafting in association with such procedures.
Although cementless fixation has been favoured by many authors, we have used cemented sockets for delayed total hip replacements after acetabular fractures combined with bone grafting for a number of years without increased mechanical failure rate and continue to prefer the same. We have therefore continued with their use in early total hip replacement. Earlier literature series with cement fixation showed inferior results largely attributed to inferior acetabular bone quality from deformity, nonunion, and sclerotic host bone combined with a young and active patient profile. Cementless fixation on the other hand provided
better results.
We believe that poor results traditionally reported with cemented sockets in the literature may be as a result of underestimating the bone loss and extent of defect, and consequent lack of bone grafting. Such cases need to be considered similar to revision situations and therefore appropriate bone grafting techniques need to be applied for good long-term results. (Figs 31.11A and B).
Specialized types of bilobed or oblong cups have been described for superior-lateral defects involving a segment of wall. We have no experience with these.
Large wall or column fragments are fixed with posterior column plates. Similarly, ununited fractures require stable fixation. Pelvic reinforcement cages/rings have been described in literature for unstable non-unions, pelvic discontinuity and major structural defects combined with structural and impaction bone graft. Cages have their own problems with loosening, breakage and dislocations apart from the technical difficulty of using some of the thicker designs which do not lend themselves to easy contouring.
 |
 |
Figures 31.11A and B: Bone grafts—structural autograft and impaction grafting
31
|
|
 |
 |
Total Hip Arthroplasty
Figure 31.12: Intraoperative pictures of same case as in figure 31.8. Ununited transverse fracture component, missing posterior superior wall, segmental defect
Figure 31.13: Structural femoral head autograft for posterior superior segmental defect, held with K-wire, and fixed with column plate which also stabilizes the nonunion
Our preference has been to use plating of the posterior column in these cases too, as this appears to provide a better biomechanical construct to obtain predictable healing of the fracture or nonunion ensuring longevity of the arthroplasty, when combined with bone grafting.
Nonunions are debrided and freshened to bleeding bone, and treated with stable fixation with posterior column plating, and bone grafting. Some authors have expressed concerns that application of a plate to the posterior column in the setting of nonunion may result in osteonecrosis of the fragment. We have not yet encountered this problem. The soft tissue attachments of bony fragments are meticulously preserved as far as possible.
Central bone defects involving the floor of the acetabulum, depending on size, can be addressed with impaction grafting or slices from a femoral head (Fig. 31.25). Large uncontained segmental defects involving the posterior wall and column are managed with structural autograft or allograft and a posterior plate (Figs 31.12 to 31.16).
In some cases, trabecular metal augments may be helpful. Major structural bone grafts may be resorbed and implants can break or loosen if the fracture does not unite. Concern has
31
|
|
 |
 |
 |
 |
Early Total Hip Replacement After Fractures of the Acetabulum
Figure 31.14: Reaming of the plated and fixed bone graft and acetabulum
Figure 31.15: Impaction grafting of floor and packing of graft into nonunion
 |
 |
Figure 31.16: Final cementation
31
|
|
been expressed that mobilization of displaced bony fragments could interrupt their blood supply. It may be possible to incorporate some of the fragments with other bone grafts.
Assessment
Total Hip Arthroplasty
PREOPERATIVE MEDICAL/ANESTHETIC ASSESSMENT
The surgery takes longer than routine primary THA and may be associated with intraoperative and perioperative medical and surgical complications in elderly patients. Aggressive medical work-up for optimization prior to surgery is essential. Early involvement of anesthetic and ICU colleagues is recommended. The patient must be thoroughly assessed for suitability for major surgical intervention from a medical and anesthetic point of view. Inferior vena cava filters prior to acetabular surgery may be considered for recent or concurrent venous thromboembolic events.
RADIOLOGICAL ASSESSMENT
Adequate imaging should be obtained. Our preference is to obtain following views as and where needed:
-
AP view of the pelvis
-
Judet views of the pelvis.
In most situations, these views are sufficient for planning. In more complex situations, severe deformities, or nonunions, additional radiographic studies with CT scans and 3D reconstructions where necessary may be obtained. Particular attention is given to study the fracture pattern and plan the fixation technique that will allow the satisfactory and unimpeded implantation of the THA. Also other pelvic injuries such as opposite acetabulum, pelvic ring injuries, deformities or nonunions need to be carefully considered.
Preoperative Planning
The patients are extensively counseled and appropriately consented. A thorough explanation of the risks and complications, possible options, and expected rehabilitation goes a long way in managing expectations. Meticulous planning is a prerequisite to smooth execution of the procedure. All the necessary equipment and implants should be available. An experienced theater team is invaluable. The surgical tactic should be rehearsed and the team should be familiarized with the steps and alternatives. Intraoperative radiology in theater may occasionally be needed.
Routine antibiotic and thromboembolic prophylaxis as per the unit policy is used. Mechanical VTE prophylaxis is used on the opposite leg. We prefer a low molecular weight heparin in the preoperative and early post-operative period and Warfarin for 3 months following surgery unless contraindicated. Cell salvage is routinely used. We have used inferior vena cava filters preoperatively where the patient has already had a known venous thromboembolic event during the current episode.
Surgical Technique
These cases demand that fixation of the fracture and implantation of the THA is performed in the same surgical episode. We prefer the Kocher-Langenbeck approach as it not only allows posterior column reduction and plating, and major bone grafting, but also allows total hip replacements at the same time (Fig. 31.17). Other authors have described the use of additional or alternative approaches such as an anterior approach for anterior column fixation, or for pelvic ring stabilization in combined injuries. Major displaced pelvic ring injuries may need to be stabilized prior to contemplating THA as a malaligned hemipelvis may result in suboptimal positioning of the acetabular component.
31
|
|
 |
 |
 |
Early Total Hip Replacement After Fractures of the Acetabulum
Figure 31.17: Lateral position, approach marked
Figure 31.18: Sciatic nerve
POSITIONING AND PREPARATION
The patient is positioned in the lateral decubitus position with appropriate padding of pressure areas. The surgical leg is draped free and any previous skeletal traction is usually removed. The draped leg is positioned at all times with the hip in extension and the knee in flexion. A well padded and sterile covered Mayo trolley can be used to support the leg and foot. This relaxes the sciatic nerve during surgery (Fig. 31.18). If there is any suspicion of infection, intraoperative specimens and samples can be collected for microbiology. In these cases, adequate preoperative work-up is mandatory.
SURGICAL APPROACH
The posterior K-L approach is developed. After dividing the fascia lata, the gluteus maximus is split along the length of the fibres. The gluteus maximus tendon is routinely divided from the femoral attachment to improve exposure and make it easier to visualize and protect the
31
|
|
sciatic nerve. Hemostasis is maintained meticulously. The sciatic nerve is carefully identified and mobilized from the scar tissue. The posterior edge of the gluteus medius tendon is identified and retracted. This allows the piriformis and anatomy of the short external rotators to be identified.
Total Hip Arthroplasty
BONY ANATOMY
In posterior wall or column fractures with displacement, this anatomy is often distorted. The wall fragments are identified. It is preferable to retain soft tissue attachments of the fragments until inspection is complete in case the decision is altered intraoperatively in favor of open reduction and internal fixation, and also where it may be possible to preserve some of the fragments as bone grafts. Our usual experience has been that the posterior wall fragment is compressed to a thin shell that is not suitable for fixation but can be morsellized as autograft.
SOFT TISSUE DISSECTION
The rotators are divided including the piriformis and short external rotators after placing stay sutures to facilitate later repair. The short external rotators are mobilized to the cotyloid groove and the ischial spine is identified if column fixation is necessary, as in an acetabular nonunion. The sciatic nerve remains protected by the short rotators. Any intact capsule is preserved and raised if possible as an inverted U-shaped broad flap to facilitate capsular repair after surgery. Releases are done anteriorly as necessary.
HIP DISLOCATION
Once this is done, the hip is dislocated and femoral head is inspected for cartilage loss, impaction fractures, loss of bony fragments, and the decision to proceed with THA is confirmed. The neck is resected. The head is preserved as autograft. Reamings are also preserved. Some additional autograft may be obtained from the femur if needed by preparing the canal early during the operation depending upon the design and philosophy of the stem used. In case of femoral head or neck fractures, the pieces may need to be removed from the acetabulum individually. Once the hip is dislocated, the neck is cut and the femoral head bone can be retained as autograft if the bone is of reasonable quality.
ACETABULAR EXPOSURE
The acetabulum is then exposed circumferentially and the area of the fracture, and bone loss is assessed. All fibrous tissue, scar tissue and necrotic bone are debrided until viable bleeding surfaces can be obtained. The column fracture may need stabilization prior to THA. This is similar to the situation of pelvic discontinuity in revision hip surgery.
The anterior column is also inspected. If anterior column stabilization is necessary, a column screw can be used. In our practice, if both columns are fractured with extensive comminution in the preoperative assessment, we prefer to wait for some healing to occur over 6-12 weeks following injury before performing THA. This allows the comminuted fragments, particularly medially and anteriorly, to heal and makes the technical reconstruction easier.
ASSESSMENT OF BONE LOSS
Defects can be classified according to one or more of various prevalent systems such as the AAOS system. They can be separated into cavitary or segmental, each of which can be further divided into peripheral or central. The superior and posterior segmental bone loss from a crushed wall piece is assessed. Such acetabular wall defects may coexist with column fractures or occur independently in posterior wall fractures. The medial wall is checked for central defects in the floor which can be managed with impacted bone graft, slices from the femoral head, with or without wire mesh. The most severe type is usually where the column is
31
|
|
 |
 |
 |
 |
Early Total Hip Replacement After Fractures of the Acetabulum
Figure 31.19: 65-year-old, male, same case as in Figure 31.23, crushed posterior superior wall fragment, acetabular articular cartilage damage, posterior superior large segmental defect
Figure 31.20: Femoral head autograft shaped over the defect. Posterior column plate supports and fixes the graft
fractured with bone loss, and there is pelvic discontinuity, or an ununited transverse type fracture of the acetabulum. We have seen nonunions in association with posterior wall fractures, and associated transverse fracture components (see Figs 31.12 to 31.16 and Figs 31.19 to 31.22).
REDUCTION AND STABILIZATION OF THE COLUMN FRACTURE
The columns are mobilized but as far as possible the soft tissue attachments are preserved. The deep scar tissue within the fracture surface is excised to mobilize both the superior and inferior acetabular column fragments. Although anatomic reduction is not absolutely essential, nevertheless correction of major deformity is required to optimize socket implantation. Standard acetabular reduction techniques are utilized. Occasionally, osteotomy of the ischial spine may be needed for derotation of the column.
A Schantz screw placed in the ischial tuberosity can help derotate the inferior fragment. Similarly pelvic reduction clamps can be used to achieve and provisionally hold the columns
31
|
|
 |
 |
 |
 |
Total Hip Arthroplasty
Figure 31.21: Reaming into the graft and reaming of the acetabulum, impaction grafting of floor
Figure 31.22: Plate and screw fixation of the re-shaped graft to reconstruct defect, socket ready for cementation
until plate fixation is achieved. Pelvic reduction clamps over cortical screws can be used to reduce displaced fractures and hold them while plating is performed. Similarly intraoperative traction may be required and can be applied manually or using an AO femoral distractor. Where there is no other segmental piece of the acetabular wall missing, column stabilization using contoured curved pelvic reconstruction plate is performed. On some occasions, two plates may be necessary to achieve good rotational stability.
In case of mildly displaced nonunions, bone grafting with autograft is performed in the freshened debrided defect prior to fixation. If the nonunions are widely separated, we prefer to mobilize and reduce and realign them prior to bone grafting to improve the deformity and restore the anatomy. Failure to reduce and approximate a displaced nonunion may put the arthroplasty at risk of premature failure. Once the columns have been fixed, the surgeon can proceed with the arthroplasty.
31
|
|
Early Total Hip Replacement After Fractures of the Acetabulum
31
 |
Figure 31.23: 65-year-old male, preoperative X-ray, early PE, needed IVC filter, subluxed femoral head at 4 weeks, see intraoperative images in Figure 31.20 to 31.22
Figure 31.24: After structural bone grafting, impaction grafting, cemented THA at 4 weeks, same patient as in Figures 31.20 to 31.23
SEQUENCE—FIXATION, REAMING AND GRAFTING
The surgeon has to tailor the technique to suit the exact problem as required. Once the columns have been stably fixed, and where there is no segmental defect, the acetabulum is prepared by reaming to accept the definitive acetabular component. A trial component is used to finalize the size of the definitive socket. We believe in bone conservation and therefore reaming is restricted to getting a bleeding surface of bone. Often in a comminuted fracture, loose pieces of cartilage, debris, fibrous tissue and nonviable pieces of bone may need to be discarded to get a fresh bleeding surface of cancellous bone. The peripheral subchondral bone is preserved where possible. Trial cups of various sizes are used to plan the size of the definite component. We do not ream beyond the size of the natural acetabulum as far as possible.
Where there is a segmental defect to reconstruct, some reaming can be performed at this stage to freshen the floor of the acetabulum to bleeding surface and some reaming is performed after fixation of the bone graft to achieve the final shape and preparation. Also, if impaction grafting is planned, then the floor of the acetabulum or a central defect needs to be bone grafted before fixing the structural graft.
Various different surgical techniques can be used for grafting of contained or uncontained bone defects or for ununited fractures. Small contained and cavitary defects can be addressed with impaction grafting using autograft from the resected femoral head. Larger defects can be managed either with structural autograft from the femoral head or trabecular metal augments. Our preference is to use bone graft in younger patients. This can be secured using supplementary lag screws, or with a posterior plate as described later. Cementless cups have been preferred with femoral head autograft in literature.
DEALING WITH CENTRAL/FLOOR SEGMENTAL BONE DEFECTS
Usually such defects arise from the fractures involving the quadrilateral plate. When there is a defect in the medial floor, then impaction grafting is performed prior to stabilizing the structural bone graft. Combined defects tend to be more difficult to deal with. We prefer to use slices of the femoral bone graft to plug large central defects rather than wire mesh. This technique is similar to the one described for protrusio hip reconstruction using bone graft. Slices of femoral head are cut using the saw and impacted after laying them over the defect
|
|
 |
 |
 |
Total Hip Arthroplasty
Figure 31.25: Slices/wafers of bone for packing into central segmental defect or protrusio cavitary defect
until sufficient thickness has been achieved. The slices are usually thin enough to mould and conform to the acetabular floor and this conformity can be improved by using a dome pusher. This achieves stable graft bed in our experience. An alternative is to use wire mesh with or without peripheral screws (Fig. 31.25).
PREPARATION OF BONE GRAFT CHIPS FOR IMPACTION
We prefer to prepare bone graft for impaction using manual techniques as described by the Nijmegen/Exeter groups rather than a bone mill. All cartilage is removed from the femoral head. Soft tissue is similarly excised. If the patient’s own femoral head is of good quality we prefer that to an allograft. Where the bone is crushed or very osteoporotic, a fresh frozen allograft from the bone bank is preferred. The chip size is usually between 5-7 mm and we routinely wash the graft. Impaction grafting is performed using sequential impactors to achieve the desired effect avoiding the graft bed from becoming too thick to promote adequate revascularization and osseo-integration. A small segmental defect can be dealt with by the use of a rim mesh (Figs 31.11 and 31.25).
DEALING WITH POSTEROSUPERIOR SEGMENTAL BONE LOSS IN ACETABULAR WALL
In such cases, the displaced posterior and superior piece of the acetabular wall is usually held by scar tissue. The bone piece is usually very osteoporotic and often crushed. If there are good soft tissue attachments then the cartilage can be denuded and it may be possible to incorporate the remnant in the reconstruction. If the piece is crushed or necrotic, it is discarded and reconstructed (see Figs 31.9 to 31.16 and 31.19 to 31.24).
Our preference is to use femoral head autograft or allograft as described below. For an isolated superior segmental defect, screw fixation should suffice. However, when the defect is posterior then it will be subjected to significant mechanical forces during mobilization, and such defects need femoral head autograft stabilized with posterior column plates. Also when the column is additionally fractured, the plate can be contoured to stabilize the columns as well as buttress the femoral head bone graft posterosuperiorly. Elderly patients can be managed with trabecular metal augments in selected defects. Early results from augments appear encouraging but long-term results are needed.
The acetabular bed is freshened using reamers or curettes. The femoral head autograft can be debulked to avoid prominence, and shaped to match the corresponding surface of the host acetabulum by placing the femoral head in the superior and posterior defect and moving it around until best fit is obtained. This is held with provisional Kirschner wires. If
31
|
|
autograft reamings are available, they can be placed between the allograft and host bone to fill up any slight voids from the mismatch. Then definitive fixation can be achieved by using partially threaded cancellous screws with a washer. This technique has been previously described to reconstruct dysplastic hips and used successfully in our institution for a number of years.
Early Total Hip Replacement After Fractures of the Acetabulum
If the defect is quite posterior, then we prefer to use a posterior column plate to support and buttress the posterior surface of the structural femoral bone graft. Once the femoral graft has been adequately and stably fixed, it is shaped using reamers and the acetabulum is prepared for cementation.
NONUNION
A minimally displaced nonunion can be fixed in situ after freshening surfaces and autogenous bone grafting. More displaced nonunions need to be mobilized, reduced and fixed with plate prior to impaction grafting of the ununited fracture gap. We prefer to use a posterior column plate to achieve stable fixation. Obliquely oriented nonunions may be amenable to fixation with a cable passed from inside the pelvis. This technique can be associated with intrapelvic injury and requires experience (Figs 31.26 to 31.28).
 |
 |
Figure 31.26: 65-year-old, massive, conservatively treated fracture, painful nonunion at 4 months, loss of joint space, incongruent head
Figure 31.27: Early THA, reduction and plate fixation with bone grafting of freshened nonunion
 |
Figure 31.28: Follow-up 2 years, healed fracture
31
|
|
FINAL ACETABULAR PREPARATION AND SOCKET CEMENTATION
Total Hip Arthroplasty
The acetabulum is then prepared by sequential reaming to accept the acetabular component. This technique describes the use of cemented sockets which is our preference, especially in elderly, but also in the younger patients. The aim is to place the cup into the prepared acetabulum so that it has full bony cover. To improve cement fixation, 6 mm holes are drilled into the periphery of the acetabulum, particularly at the superior aspect. A flanged acetabular cup is useful since it provides extra fixation around the rim of the socket. (see previous described series).
Any pulse lavage of the acetabulum has to be performed prior to impaction grafting. Once bone has been impacted, a dry surface has to be maintained for cementation. We use contemporary cementation techniques using pressurization and the final flanged acetabular component is implanted into satisfactory anteversion and inclination.
The stem is implanted in usual fashion as per the preference of the surgeon. Attention is given to achieving appropriate leg lengths and a stable hip.
CLOSURE
The wound is washed. Transosseous repair of the capsule and rotators is performed using thick non-absorbable Ethibond sutures using trochanteric drill holes. The gluteus maximus tendon is repaired. The sciatic nerve is checked again. A deep drain is left deep to the deep fascia and a superficial drain additionally if required. Routine wound closure is performed.
Results
In a recent meta-analysis, Giannoudis et al reported that conversion total hip arthroplasty (THA) was performed for the treatment of post-fracture complications in 8.5% of the cases within 2 years after initial management. Mears et al noted a bimodal distribution for conversion THA between 6 months and 2 years, and another peak was noted at greater than 10 years after injury. Their overall reported incidence of conversion THA at 5 years was 11%.
Mears et al reported their results in selected patients with acetabular fractures treated with acute THA. Their indications for the acute arthroplasty included intra-articular comminution, full-thickness abrasive loss of the articular cartilage, impaction of the femoral head, and impaction of the acetabulum that involved >40% of the joint surface and included the weight-bearing region. At the time of the latest follow-up, they reported that none of the cups were loose or revised for mechanical loosening out of the 57 patients who underwent this procedure. They concluded that in selected patients with a displaced acetabular fracture that had a low likelihood of a favorable outcome after fracture treatment, an acute total hip arthroplasty may provide an alternative means to achieve a painless, mobile hip. They also recommended that the complex operations were best performed by a surgical team with substantial experience with both acetabular trauma and hip arthroplasty.
Pitfalls and Problems
Extreme osteoporosis may make fixation quite difficult. The surgeon should be familiar with various different fixation strategies to deal with complex situations. In some cases, we would recommend doing the procedure in two stages. The first stage consists of fixing the fracture and bone grafting. The second stage would involve implantation of a THA. We have used this successfully in a small number of cases. The sciatic nerve has to be carefully protected throughout the surgery as described. Intraoperative monitoring may be available in some centers. Heterotopic ossification is a known problem. Occasional torrential intraoperative bleeding may be encountered during mobilization of the nonunion or the columns. The surgeon should be familiar with the anatomy and methods of achieving hemostasis. In very
31
|
|
severe intrapelvic protrusio of the femoral head, preoperative vascular studies and availability of a vascular surgeon has to be considered.
Postoperative Regime
Early Total Hip Replacement After Fractures of the Acetabulum
We continue intravenous antibiotics as per our unit’s policy for 48 hours. Indomethacin is prescribed for 6 weeks to prevent heterotopic ossification. The patients are mobilized on the second or third postoperative day. We usually prefer to avoid weightbearing on the affected side for up to 6-8 weeks followed by progressive weightbearing. However, the regime may need to be modified in elderly patients who may be at additional risk of falling in which case early weightbearing may be allowed. For this reason, good stable fixation of the fracture is required to permit early weightbearing. Follow-up radiographs are done to monitor healing of the fracture and incorporation of the bone graft. Physiotherapy input is provided as required. Mechanical prophylaxis is used for 6 weeks and chemical prophylaxis with Warfarin for 3 months.
Summary
This operation is technically challenging, but it can provide excellent clinical outcome. We continue to prefer cemented sockets with bone grafting. This approach to the problem avoids two major surgical procedures in elderly and gives good functional outcome. The technique continues to evolve and we continue to monitor our long-term results of this philosophy.
Bibliography
-
Bellabarba C, Berger R, Bentley CD, et al. Cementless acetabular reconstruction after acetabular fracture. J Bone Joint Surg Am 2001;83:868-76.
-
Berry DJ, Halasy M. Uncemented acetabular components for arthritis after acetabular fracture. Clin Orthop 2002;405:164-7.
-
Berry DJ. Total hip arthroplasty following acetabular fracture. Orthopaedics 1999;22:837-9.
-
Giannoudis PV, Grotz MRW, Papakostidis C, et al. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 2005;87B:1-9.
-
Hamer AJ, Stockley I. Acetabular fracture treated by primary hip arthroplasty. Injury, 1994;25(6):399-400.
-
Huo MH, Solberg BD, Zatorski LE, et al. Total hip replacements done without cement after acetabular fractures: A 4- to 8-year follow-up study. J Arthroplasty 1999;14:827-31.
-
John B Catalano, Christopher T Born. Total hip arthroplasty after acetabular fracture treated initially with open reduction and internal fixation. Operative Techniques in Orthopaedics 1997;7(3):250-5.
-
Matthew L Jimenez, Marvin Tile, Richard S Schenk. Total hip replacement after acetabular fracture. Orthopedic Clinics of North America, 1997;28(3):435-46.
-
Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: Indicators of outcome. Clin Orthop 2003;407:173-86.
-
Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures. 2-12 year results. J Bone Joint Surg Am 2002;84(1).
-
Mears DC, Velyvis JH. Primary total hip arthroplasty after acetabular fracture. J Bone Joint Surg 2000;82:1328.
-
Philip Hirst, Max Esser, John CM Murphy, Kevin Hardinge. Bone Grafting For Protrusio Acetabuli During Total Hip Replacement: a review of the Wrightington method in 61 Hips. From the Center for Hip Surgery, Wrightington. J Bone Joint Surgery 1987;69-B(2).
-
Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. Long-term results. J Bone Joint Surg Br 1990;72:761-4.
-
Sermon P, Broos P Vanderschot. Total hip replacement for acetabular fractures. Results in 121 patients operated between 1983 and 2003. Injury, Int J Care Injured 2008;39;914-21.
-
Weber M, Berry DJ, Harmsen S. Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am 1998;80:1295-1305.