Results of Total hip arthroplasty after acetabular fractures

Laurent Sedel

Hopital Lariboisiere , University Denis Diderot (Paris)

Forum institut Marcel Kerboull Paris 4/2/05

Technical difficulties

• Special profiles : young age , unilateral

• Difficult anatomy : acetabular mal union or even non union

• + nerve problems– Sciatic– Gluteus medius

• Hardware retrieval

Which explains bad results with regular materials

– Romness and Lewallen JBJS .2B 90 : 52% acetabular loosening at 7 years

– Mears and Velyvis , JBJS A 82 Sept 00 : describes the technical difficulties

– Mears and Ward 96 : 36 cases : 58% loosening

– But few series and many short term follow-up

Two different situations

• Primary total hip– Socket reconstruction – Nerve management– But relatively easy surgery : less invasive

• Secondary after orif– Hardware retrieval– Nerve dissection– Infection risk

First information : a primary hip can resume in excellent result

Mr BAU..60 yearsSevere trauma . 1987

Orthopaedic treatment

Right : screw in ring with Al/Al couple Left : cemented

Bulky alumina+autograft

12 years follow-up : 18A/18A

50 years old man : initial treatment : traction . : acetabular non union

2 years follow-up : 18A

6 months

37 years old Untreated fracture of the acetabulumSciatic palsyAfter 4 months

Post-op4 months

66 monthsNo pain fully activeSciatic palsy recovered

A primary total hip could be also very difficult

But a total hip after ORIF is usually more difficult

• Nerve dissection• Hardware retrieval• Bone necrosis• Head badly dammaged cannot be used as a graft.• Acetabular grafting procedure : socket fixation• Muscle reconstruction

Mr M.. 56 years old Severe acetabular fracture one year before

ankylosed

Bone bridge

2 years

Mrs D.. 32 years : operated 2 years before Refered : pain , stiff

17 years later : pain freeEvery sportsHad two kidsRated 18 A

Bulky cemented Alumina socket

Mr G.. 42 years Operated 3 years before : pain stiffCerafit with al/al couple. Posterior wall reconstruction

Aspect at 5 years : 16 C, fully active. But Sciatic nerve sequellae

Mrs Ma..24 years : suicide : osteosynthesisOne year later : slight pain , stiff(60°) ,

some limp

One year

Revision at 18 months : Cerafit with multicone Stem

At 48 months : pain free , ROM 100°No limitation

Per-op view

Mr Cre 24 years Operated 2 years before : pain , stiff Sciatic palsy

Reconstruction cementless socketAnd stem

10 months : 6;6,5

Mr R.. 21 years 5 years after osteotomy for malunion of the posterior wallStiff , pain

THR 1998 : Results at 55 months 18 A

Since 1979 : 77 consecutive hips in 76 patients had a total hip For acetabular fracture_53 males , 23 females_Mean Age : 49 (16-78)_40 had had a conservative treatment_37 sustained previous ORIF64 were completely examined

Simple fractures 34

Posterior wall 19

Posterior colomn 6

Anterior wall 0

Anterior colomn 2

transverse 7

Complexe fractures 30

T shape 2

Posterior colomn and wall

6

T shape +Posterior wall 9

Two colomns 13

57 Al2O3/Al2O3 couple ( 8 cemented , 10 screwed in , 3 cerapress , 36 cerafit)

7 Al/PE

Delay between fracture and total hipNon operated : 8 years

Operated : 10 years

Sciatic palsies:20/6414 post trauma (50% recovered)4 post o.r.i.f.2 post thr

Sepsis : 7 / 644 post osteosynthesis3 post THR ( 2 post conservative1 post osteosynthesis)

Gluteus medius palsy : at least 3?

Results

• Lost to follow-up : 6 (3 from Algeria , one from Cameroun)

• 5 deceased from unrelated reasons

• Follow-up : from 6 months-20 years mean 5,5 years : 46 available

Results in 46 available

• Last PMA 16,1 (8-18)• 11 revisions

– 1 bipolar (septic) Girldestone– 9 socket loosening

• 2 septic• 6 aseptic (4 cemented , 2 screw in )

– 1 bipolar aseptic loosening

• No ceramic fracture

Radiological results

• Stem : 1 complete radiolucent line , 2 incomplete

• Socket : 2 migration (screw in ) . 3 complete radiolucent lines (cemented)

Survivorship

• Revision for any reasons : 74 % survival at 10 years (57% to 91%)

• Revision for aseptic loosening : 81 % at ten years

• Stem (aseptic revision ) 97% at 10 years

• Negative factors : screw in cup and overweight : p=0,03

Survivorship regarding type of acetabulum

• Cemented : 93%

• Press fit : 96 %

• Screw in : 70%

Gluteus palsy management : Sharrard procedure

• Male , 57 years old operated 31 years before– Pain , stiff , complete gluteus medius palsy

Mrs B 28 years old10 months after trauma

Discussion

• This is not a randomised study

• Lack of methodology

• But– Excellent results could be expected in THR

after primary conservative treatment– THR after ORIF is usually more difficult

Modern material permits long term strategy in young and active people

Why don’t we perform a primary THR?

O.R.I.F of complexe fracture of the acetabulum

• Difficult surgery– Extensive approach

– Neural damage (Sciatic , Gluteus medius, femoral)

– Infection

– Ossifications

– Head necrosis

– Acetabulum necrosis

• Resume in Secondary osteoarthritis

Even a perfect surgery does not prevent from failures

Paul Tornetta J.of American Academy of orthopedics surgeonsFebruary 01

50 years old 1977

1978: mild pain limp one stick

1998 : stiff , pain , short

Total hip 1 year follow-up

What is a good result

Current protocole

• Complete X rays and tomoscan appraisal of the fracture

• Traction for 3 weeks

• Rehab for 3 months

• Weight bearing at 6 to 8 weeks

• At 3 to 6 months : total hip if not tolerated

Mr R…57 years. Car accident

15 days traction04/00

09/00

11/00

Mr J.. 32 yearsNov 03

Post op Nov 04

Jan 05

Mr F.. 32 years oldTwo columnsTraction

Mears and Velyvis , J.Bone and Joint Surg. A 82 Sept 00 :

There is currently no convincing documented evidence that acute management With open reduction and internal fixation improves the success of a subsequent total hiparthroplasty performed for post traumatic arthritis.Ironically it has been our experience that the best late results of total hip arthroplasty after acetabular fracture have been documented when the arthroplasties were performed acutely.

Merci