Results of Total hip arthroplasty after acetabular fractures

1. Results of Total hip arthroplasty after acetabular fractures Laurent Sedel Hopital Lariboisiere , University Denis Diderot (Paris) Forum institut Marcel Kerboull Paris 4/2/05

2. Technical difficulties • Special profiles : young age , unilateral • Difficult anatomy : acetabular mal union or even non union • + nerve problems • Sciatic • Gluteus medius • Hardware retrieval

3. 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

4. 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

5. First information : a primary hip can resume in excellent result Orthopaedic treatment Mr BAU..60 years Severe trauma . 1987

6. Right : screw in ring with Al/Al couple Left : cemented Bulky alumina+autograft

7. 12 years follow-up : 18A/18A

8. 50 years old man : initial treatment : traction . : acetabular non union 6 months 2 years follow-up : 18A

9. A primary total hip could be also very difficult 4 months Post-op 37 years old Untreated fracture of the acetabulum Sciatic palsy After 4 months 66 months No pain fully active Sciatic palsy recovered

10. 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

11. Mr M.. 56 years old Severe acetabular fracture one year before Bone bridge ankylosed 2 years

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

13. Bulky cemented Alumina socket 17 years later : pain free Every sports Had two kids Rated 18 A

14. Mr G.. 42 years Operated 3 years before : pain stiff Cerafit with al/al couple. Posterior wall reconstruction Aspect at 5 years : 16 C, fully active. But Sciatic nerve sequellae

15. Mrs Ma..24 years : suicide : osteosynthesis One year later : slight pain , stiff(60°) , some limp One year

16. Revision at 18 months : Cerafit with multicone Stem At 48 months : pain free , ROM 100° No limitation

17. Mr Cre 24 years Operated 2 years before : pain , stiff Sciatic palsy Per-op view

18. Reconstruction cementless socket And stem 10 months : 6;6,5

19. Mr R.. 21 years 5 years after osteotomy for malunion of the posterior wall Stiff , pain THR 1998 : Results at 55 months 18 A

20. 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 ORIF 64 were completely examined

22. Delay between fracture and total hip Non operated : 8 years Operated : 10 years 57 Al2O3/Al2O3 couple ( 8 cemented , 10 screwed in , 3 cerapress , 36 cerafit) 7 Al/PE

23. Sciatic palsies:20/64 14 post trauma (50% recovered) 4 post o.r.i.f. 2 post thr Gluteus medius palsy : at least 3? Sepsis : 7 / 64 4 post osteosynthesis 3 post THR ( 2 post conservative 1 post osteosynthesis)

24. 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

25. 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

26. Radiological results • Stem : 1 complete radiolucent line , 2 incomplete • Socket : 2 migration (screw in ) . 3 complete radiolucent lines (cemented)

27. 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

28. Survivorship regarding type of acetabulum • Cemented : 93% • Press fit : 96 % • Screw in : 70%

29. Gluteus palsy management : Sharrard procedure • Male , 57 years old operated 31 years before • Pain , stiff , complete gluteus medius palsy

32. Mrs B 28 years old 10 months after trauma

33. 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

34. Modern material permits long term strategy in young and active people Why don’t we perform a primary THR?

35. 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

36. Even a perfect surgery does not prevent from failures Paul Tornetta J.of American Academy of orthopedics surgeons February 01

37. What is a good result 1998 : stiff , pain , short 1978: mild pain limp one stick 50 years old 1977 Total hip 1 year follow-up

38. 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

39. Mr R…57 years. Car accident 09/00 15 days traction 04/00 11/00

40. Mr J.. 32 years Nov 03 Post op Nov 04

41. Jan 05

42. Mr F.. 32 years old Two columns Traction

43. 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 hip arthroplasty 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.

44. Merci