Results of Total hip arthroplasty after acetabular fractures
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Transcript of Results of Total hip arthroplasty after acetabular fractures
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