THR in Osteoporotic Acetabular Fractures

Hazem Abdel-Azeem, M.DProfessor of Orthopaedic SurgeryCairo University

In most Arab countries, life expectancy has increased in the past two decades.

- In 1980-1985, the average life expectancy was 58 years for men and 61.3 years for women.

- Currently, it is 71 for females & 73for females

• Distribution of the Arab population by broad age groups, 1980-2050

In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The

incidence of elderly patients with acetabular fractures increased by 2.4-fold between the

first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001).

Matta et al…2010

Fractures are characterised by

• Displacement of the anterior column(64% )• Separate quadrilateral-plate component

(50.8% )• Roof impaction (40%) in the anterior

fractures, and• Comminution (44%) • Marginal impaction (38%) in posterior-wall

fractures.

Epidemiology : Hip region injuries incidence in elderlies

• In elderly, the incidence of proximal femur, pelvic and acetabular fracture has been expressed by the ratio 60:10:1

• Therefore, the fractures of the Acetabulum may be missed due to directed attention towards other hip fractures

60

10

1

Low energy trauma cases are commonly misdiagnosed initially as fracture of fracture neck femur

• Some times fracture neck femur and femoral neck are combined

Study Series : 62 hips in 61 patients

• Cases 51 males 10 females• Age avarage 68 years ( Yougest 55,Oldest 72)• Bone quality

– Normal or osteopaenic 24 cases– Osteoporotic 28 cases– Severely osteoporotic 10 cases

Mechanism of Injury

• Moderate or low energy injuries in osteoporosis ( fall on to the greater trochanter) n= 29 cases

• High energy trauma as in normal bone n=32

• Study :– Clinical examination , fitness for surgery– Imaging Radiography and CT studies– Classification with modification– Densitometry when needed– Duplex for the leg vessels ( A & V ) when needed– Anticoagulation– Operative or conservative– End of follow up is either fracture healing or THR

Recorded types are– Isolated :

• Ant wall 3 • Ant col without comminution 6• Ant col with comminution 10• Post wall without comminution 7• Post wall with comminution 5• Post col without comminution 5• Post col with comminution 2• Transverse fr 0

Cases Classification :

– Combined :• T fracture 0• Transverse with pos wall 0• Ant with post hemitransverse 12• Post col with post wall without comminution 2• Post col with post wall with comminution 2• Associated both col without comminution 4 • Associated both col with comminution 4

Radiological study

Recorded problems : – Articular impaction 6– Dislocation of the hip 13– Comminuted Anterior or

posterior-wall fractures 17– Injury to the femoral head 7– Presence of OA 16

Treatment Goals

• To obtain painless mobile stable life lasting hip

• To get ambulant patient with less pain as soon as possible

• To avoid 2nd go surgery• To avoid DVT & thromboembolism and

other recumbancy complications

For the sake of treatment line choice and preoperative planning

The different types are divided into groups

according to bone quality and hip condition

• Cases of normal bone Quality

• Cases of associated hip osteoarthrosis

• Cases of poor bone quality (osteoporosis & osteomalacia )

• Cases with intra articular traumatic insult :– depressed fracture or– Pipkin’s fracture

Bone Quality : Hip join clinical condition :

• Cases of normal bone Quality

• Cases of associated hip osteoarthrosis

• Cases of poor bone quality (osteoporosis & osteomalacia )

• Cases with intra articular traumatic insult :– depressed fracture or– Pipkin’s fracture

Bone Quality : Hip join clinical condition :

Conservative Treatment n=3

Indications• All non displaced

fractures• Minimally displaced (less

than 2 mm)• Displaced low anterior

column, low transverse or low T- fracture

• Unfit patients

Conservative Treatment

• In all studies also in ours; poor results have been recorded in at least 30% of patients treated conservatively...!!!

Operative treatment

Indications• Displaced fractures• Unstable fractures• Associated traumatic

insult to the femoral head• Associated proximal

femoral fracture• Depressed fragment• Associated osteoarthritis

Surgical Treatment Options

In young adult

• Anatomic Reduction And Internal Fixation

In geriatric age

• Three Possibilities are there1st - To achieve anatomical

reduction and internal fixation

( n= 33 )

IF NOT

2nd - Acute THR ( n=16 )

IF NOT

3rd – Delayed THR ( n= 8 )

Considering the first option :

Reconstruction of the acetabulum anatomically by open reduction and internal fixation

Geriatric Pt does not differ from young

Obstacles are Comminution and Osteoporotic bad quality bone

Other difficulties are - unrecognition of fracture

patterns - severe comminution - depressed fractures - erosion of articular surfaces- associated Pipkin's fracture - or fractures of the proximal

femur

Intraoperative Technical Consideration we Adopted :

• Use only one approach• Minimize the operative

time (less than 4 hrs)• Use 4.5 plates and

4.5/6.5 screws• Use plates and don’t

rely on lag screws alone• Handle the vessels with

care ( It breaks)

Results of 1st group ( n 33 )

• Anatomical reduction 21• Fair reduction ( gap or

step < 5 mm ) 9• Poor reduction 3

• 2years follow up :- Lost 7- OA 11- good 15

Option 2 Acute THR ( n=16 )

• Is used when reconstruction by ORIF is impossible

( n= 11 )• Also in associated :

– Pipkin's fracture

( n = 2 )– Hip AO ( n= 3 )

Option 2 THR

• Open reduction& int fixation primarily

• Anatomical reduction is not needed

• Internal fixation should be by plate and screws

• Column screw is inadequate

• Wrong to use the metal back of the acetabular cup as circular plate to fix the fracture

Anterior plating then THR

Association with Pipkin's

Fracture acetabulum with hip OA

ACUTE BIL FR ACETABULUM CASE : Male 68 ys

Results of Acute THR

• Plate fixation+ THR ( n=5 )• Plate Fixation + Graft + THR ( n= 7 ) • Screw fixation + Graft + THR ( n = 3 )• Reconstruction ring + Graft + THR ( n = 1 )

Results of Acute THR

• Post operative :– Dislocation 6– DVT 3– Pulmonary showers 2– External iliac A

Thrombosis 1

• 2 years Follow up :- Lost 3- Loosened cup 3- Hip pain 2 - Doing well 8

Option 3 Delayed THR ( n = 8 )

• Is considered a salvage of unsatisfactory result after conservative treatment

• Segmental and cavitary acetabular defects usually result after neglected acetabular fractures and should be grafted

Option 3 Delayed THR

• However , leaving the patient in bed or traction followed by late arthroplasty may lead to significant complications as well as failure of arthroplasty

Delayed THR Results

• Grafting + THR ( n=2 )• Plate + Graft + THR ( n= 5 ) • Reconstruction ring ( n = 1 )

Delayed THR Results

• Post operative complications :- Dislocation 3- DVT 2- Pulmonary Embolism 1

• 2 Years Follow up :– Lost 1– Loosening of cup 3– Pain 2– Doing well 2

In conclusion

• Treatment of acetabular fracture in geriatric age group posses challenges that are not always seen in the younger age group

• This is due to comminution , osteoporosis and high incidence of thrombo embolic problems

• Letournel classification is used in this study• Letournel classical types were not always produced as

he described , some comminution was commonly there due to osteoporosis

Conclusion

• Displaced acetabular fractures + good bone stock → ORIF

• Acute THR depends on rigid fixation to build a solid base for placement of the total hip– Anatomic reduction is the not needed– Never use the prosthetic shell as a “hemispherical

plate”– Always use the traditional plates and screws and not

reconstruction rings– Anticoagulation

Conclusion• Late arthroplasty is used for failed treatment

cases , the acetabulum must be reduced ,fixed and grafted before cup application

Thank you