Stabilization of an acetabular fracture with cables for acute total hip arthroplasty

Acetabulum fractures in elderly patients: A review

Fractures of the acetabulum in elderly patients were often caused by low energy trauma. Fractures involving anterior column are more common and often associated with impaction and comminution. Osteoporosis further complicates the management. Percutaneous fracture fixation has low morbidity but it is a technically demanding procedure. Open reduction and fracture fixation is done with or without simultaneous total hip replacement. Delayed total hip replacement is considered in posttraumatic arthritis patients. Patients with minimal displaced fractures, associated both-column fractures with secondary congruence of joint and patients who are medically unfit for surgery can be managed non-operatively. Whatever be the method of management, these elderly patients should be mobilised as early as possible.

A Review on Management of Insufficiency Fractures of the Pelvis and Acetabulum

"Insufficiency fractures of the pelvis and acetabulum are occurring at increasing rates. Osteoporosis is the most prevalent risk fracture. Diagnosis begins with plain radiographs followed by advanced imaging with computed tomography and/or MRI. Pelvic ring fragility injuries are classified by the Fragility fractures of the pelvis system. Elderly acetabular fractures may be classified by the Letournel system. Management of these injuries is primarily nonoperative with early immobilization when allowed by fracture characteristics. When warranted, percutaneous fixation and open reduction internal fixation are options for both. Both acute and delayed total hip arthroplasty are options for acetabular fractures."

Open reduction and internal fixation alone versus open reduction and internal fixation plus total hip arthroplasty for displaced acetabular fractures in patients older than 60 years: A prospective clinical trial

INTRODUCTION

The optimal treatment of elderly patients with an acetabular fracture is unknown. We conducted a prospective clinical trial to compare functional outcomes and reoperation rates in patients older than 60 years with acetabular fracture treated with open reduction and internal fixation (ORIF) alone versus ORIF plus concomitant total hip arthroplasty (ORIF + THA). Our hypothesis was that patients who had ORIF + THA would have better patient reported outcomes and lower reoperation rates postoperatively.

METHODS

Inclusion criteria were patients older than 60 years with acetabular fracture plus at least one of three fracture characteristics: dome impaction, femoral head fracture, or posterior wall component. Eligible patients were operative candidates based on fracture displacement, ambulatory status, and physiological appropriateness. Patients received either ORIF alone or ORIF + THA (accomplished at same surgery through same incision). Outcome measurements included Western Ontario and McMaster Universities Osteoarthritis Index hip score, Short Form 36, Harris Hip Score, and Patient Satisfaction Questionnaire Short Form scores. Additionally, patients were monitored for any unplanned reoperation within 2 years.

RESULTS

Forty-seven of 165 eligible patients with an average age of 70.7 years were included. The mean Harris Hip Score difference favored ORIF + THA (mean difference, 12.3, [95% confidence interval (CI), -0.3 to 24.9, p = 0.07]). No clinically important differences were detected in any other validated outcome score or patient satisfaction score 1 year after surgery. ORIF + THA decreased the absolute risk of reoperation by 28% (95% CI, 13% to 44%, p < 0.01). No postoperative hip dislocation occurred in either group.

CONCLUSIONS

In patients older than 60 years with an operative displaced acetabular fracture with specific fracture features (dome impaction, femoral head fracture, or posterior wall component), treatment with ORIF + THA resulted in fewer reoperations than treatment with ORIF alone. No differences in patient satisfaction and other validated outcome measures were detected.

Treatment of Geriatric Acetabular Fractures-A Concise Review of the Literature

Optimal management of acetabular fractures (AF) in the elderly has not been defined clearly. The incidence of such fractures is rising in the aging population. Advancements in implant technology have improved the longevity of combined or staggered total hip arthroplasty procedures for this patient population, thus allowing earlier weight bearing and continued functional independence. Perioperative/postoperative complication rates remain significantly high in all treatment arms. Overall, the best outcomes with the lowest complication rates are achieved when AF are treated by a surgeon or a team of surgeons who specialize in both orthopedic traumatology and adult reconstruction.

Open Reduction and Internal Fixation Plus Total Hip Arthroplasty for the Acute Treatment of Older Patients with Acetabular Fracture: Surgical Techniques

Open reduction and internal fixation of displaced acetabular fractures has been the gold standard for treatment of these complex injuries. The subset of older patients with dome impaction, femoral head impaction, or a posterior wall component are considered for treatment with concomitant open reduction and internal fixation and total hip arthroplasty. Little has been written on the surgical techniques to perform concomitant open reduction and internal fixation plus total hip arthroplasty safely. This article describes the important intrinsic factors for acetabular component stability, choice of surgical approach for management of these injuries, and surgical technique for anterior and posterior approaches.

Functional outcome of acute primary total hip replacement after complex acetabular fractures

PURPOSE

To assess the functional outcome of acute primary total hip replacement in the management of complex acetabular fractures.

MATERIALS AND METHODS

This prospective observational study was conducted in orthopedic department of Liaquat National Hospital and Medical College, Karachi. The study was approved by the Ethics review committee of hospital (0190-2016). Patients who encountered between January 2010 to January 2016 were entered. Fifty-four patients with acetabular fractures with certain indications (marginal impaction or significant comminution (> 3 fragments) of the articular surface of the acetabulum, full-thickness articular injury to the femoral head, an associated femur neck fracture, or preexisting symptomatic osteoarthritis) were treated with primary total hip replacement. Patients were followed in outpatient clinic at regular intervals after discharge to assess the radiological union of fractures and complications. Functional outcome was evaluated after 2 years by applying Harris Hip Score. All statistical analysis was done by using SPSS version 20.

RESULTS

All patients achieved radiological union of fractures at an average duration of 21 weeks. During the follow-up, seven complications were observed. Two patients developed superficial surgical site infection which was treated conservatively. One patient had dislocation which was reduced closely, while two patients had acetabular cup loosening which was revised. We also observed two cases of Brooker I heterotopic ossification and one case of Brooker II. At 2-year follow-up, 78% of patients had an excellent and good functional outcome according to Harris Hip score.

CONCLUSION

Primary total hip replacement is a valid and reasonable one stage surgical treatment of complex acetabular fractures and in aged individuals. However, the complications are not uncommon.

Acetabular Fracture after Hip Hemiarthroplasty: One Stage Procedure to a Total Hip Arthroplasty after Stabilization of the Fracture by Means of Cerclage Wires

Introduction:

Hip fractures in the elderly pose an increasing problem in society. In the elderly, a bipolar hemiarthroplasty (HA) remains the treatment of choice in case of hip fractures related to osteoporosis. However, due to an ongoing osteoporosis in this age group, a periprosthetic femoral fracture and a fracture of the unresurfaced acetabulum are increasingly noticed.

In the literature, no information can be found regarding the treatment options for this kind of periprosthetic acetabular fracture.

Case Report:

We present a case report of a patient suffering an acetabular fracture 6 years after a HA. A one stage surgical procedure was the treatment of choice, consisting of a stabilization the acetabulum fracture by means of cerclage wires and a conversion of the HA to a total hip arthroplasty (THA). 4 months after surgery, she regained her pre-operative functional status, and a radiographic evaluation of the right hemipelvis showed good signs ofthe fracture healing without migration ofthe acetabular component.

Conclusion:

This case shows a “one stage” surgery solution for an acetabular fracture after HA. Stabilization of the acetabulum fracture by means of cerclage wires and a conversion ofthe HA to a THAis a viable solution for this rare and challenging problem.

Does Total Hip Arthroplasty Reduce the Risk of Secondary Surgery Following the Treatment of Displaced Acetabular Fractures in the Elderly Compared to Open Reduction Internal Fixation? A Pilot Study

OBJECTIVES

The goal of open reduction and internal fixation (ORIF) is to anatomically reduce the facture and maintain a congruent hip joint. However, ORIF in the elderly is technically challenging. Therefore, there are advocates for acute total hip arthroplasty (THA) in this patient population. The primary purpose of this study was to evaluate the rate of revision surgery in elderly patients with acetabular fractures treated with ORIF or THA. The secondary purpose was to compare patient's self-reported functional outcomes.

DESIGN

Retrospective review.

SETTING

Two American College of Surgeons Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Thirty-three patients were treated with ORIF and 37 were treated with THA. The mean follow-up was 22 months (range 6-89 months). Patients were interviewed, and radiographs were examined.

INTERVENTION

Treatment of displaced acetabular fractures with either ORIF or THA.

MAIN OUTCOME MEASUREMENTS

Need for reoperation. Harris Hip Score and SF-36 questionnaire.

RESULTS

Those treated with ORIF had a higher rate of reoperation (10/33, 30%) compared with those treated with THA (5/37, 14%); however, this was not statistically significant (P = 0.12). Patients reported better bodily pain scores as measured by SF-36 (48 vs. 39, P = 0.04), and a trend toward improved function as measured by patient reported Harris Hip Scores (82 vs. 63, P = 0.06) in those treated with THA compared with ORIF.

CONCLUSIONS

Acute reconstruction of acetabular fractures with THA in the geriatric population seems to compare favorably with ORIF, with a similar rate of complications, but with improved pain scores. In addition, there was a high rate of conversion to THA within 2 years of injury when patients were treated with ORIF. Acute THA as primary treatment in this patient population merits further, more controlled, comparative study.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Variation in Treatment of Displaced Geriatric Acetabular Fractures Among 15 Level-I Trauma Centers

OBJECTIVES

To document the initial treatment of displaced acetabular fractures among older adults across multiple trauma centers and to investigate the factors that influence the decision to operate and the choice of operative procedure [open reduction internal fixation (ORIF) vs. total hip arthroplasty (THA)].

DESIGN

Retrospective observational study.

SETTING

Fifteen US level-I trauma centers participating in the Major Extremity Trauma Research Consortium.

PATIENTS/PARTICIPANTS

Overall, 269 patients aged 60 years or older admitted for the treatment of a displaced acetabular fracture.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Treatment.

RESULTS

Sixty percent of fractures (n = 162) were treated operatively. Younger age (<80 years), injury from high-energy mechanism, fractures with femoral head impaction, and fractures without hip congruency were significantly associated with receiving operative treatment (P < 0.05). Significant site variation in operative versus nonoperative treatment occurred even after accounting for these factors (P = 0.0044). Among operatively treated patients, 88% (n = 142) received ORIF and 12% (n = 20) received THA as the initial treatment. Women were more likely to be treated with initial THA compared with men; of the known risk factors for poor outcomes with ORIF (ie, dome or roof impaction, femoral head impaction, or posterior wall involvement), only dome impaction was significantly associated with receiving initial THA (P < 0.05).

CONCLUSIONS

Currently, no treatment guidelines exist for acetabular fractures in older adults, which likely explains the significant site variation in operative versus nonoperative treatment. This study identifies patient and injury factors that drive treatment decisions, which will be important in planning and designing future trials needed to determine the best treatment for these fractures.

A Guide to Improving the Care of Patients with Fragility Fractures, Edition 2

Over the past 4 decades, much has been learned about the pathophysiology and treatment of osteoporosis, the prevention of fragility fractures, and the perioperative management of patients who have these debilitating injuries. However, the volume of published literature on this topic is staggering and far too voluminous for any clinician to review and synthesize by him or herself. This manuscript thoroughly summarizes the latest research on fragility fractures and provides the reader with valuable strategies to optimize the prevention and management of these devastating injuries. The information contained in this article will prove invaluable to any health care provider or health system administrator who is involved in the prevention and management of fragility hip fractures. As providers begin to gain a better understanding of the principles espoused in this article, it is our hope that they will be able to use this information to optimize the care they provide for elderly patients who are at risk of or who have osteoporotic fractures.

Functional outcomes after total hip arthroplasty for the acute management of acetabular fractures: 1- to 14-year follow-up

OBJECTIVE

This study reports the complications and functional outcomes in patients treated acutely with combined open reduction internal fixation (ORIF) and immediate total hip arthroplasty (THA) for displaced comminuted acetabular fractures.

DESIGN

Single surgeon retrospective case series.

SETTING

Level 1 trauma center.

PATIENTS

Thirty-three consecutive patients (18 women; mean age, 66 years) from 1996 to 2011 with an average follow-up of 5.6 years (range, 1-14.3 years) were included in this study.

INTERVENTION

ORIF and immediate THA.

MAIN OUTCOME MEASUREMENTS

Oxford Hip Score and reoperation.

METHODS

All patients had at least 1 year of telephone or clinical follow-up. Postoperative complications, reoperations, and available radiographs were reviewed.

RESULTS

Six patients died of causes unrelated to their injuries or surgery; before death, these patients had well-functioning hips. There was a 15% complication rate. At last follow-up, 94% of hips remained in situ and were functioning well. The average Oxford Hip Score at final follow-up was 17 (range, 12-32), with 93% of patients reporting good to excellent function. There was no statistical association between fracture type, age, or fixation type and outcome.

CONCLUSIONS

Acute ORIF and immediate THA for selected acetabular fractures is a safe viable treatment option with good to excellent functional outcomes and may reduce the need for 2 separate operations in many patients. Functional outcomes are equivalent to those after primary THA for osteoarthritis. This study does not address at which age acute THA is a cost-effective treatment option.

LEVEL OF EVIDENCE

Therapeutic level IV. See Instructions for authors for a complete description of levels of evidence.

Open reduction and internal fixation of osteoporotic acetabular fractures through the ilio-inguinal approach: use of buttress plates to control medial displacement of the quadrilateral surface

The number of acetabular fractures in the geriatric population requiring open reduction and internal fixation is increasing. Fractures with medial or anterior displacement are the most frequent types, and via the ilio-inguinal approach buttress plates have proved helpful to maintain the quadrilateral surface or medial acetabular wall. Seven to ten hole 3.5 mm reconstruction plates may be used as buttress plates, placed underneath the usual pelvic brim plate. This retrospective study presents our results with this technique in 13 patients at a minimum follow-up of 12 months (average, 31 months). 85% of the patients had a good result. The early onset of post-traumatic osteoarthritis necessitated total hip arthroplasty in two patients (15%) at 12 and 18 months follow-up, respectively. This treatment option should be considered in the surgeon's armamentarium when fixing these challenging cases.

Total hip arthroplasty after acetabular fracture: incidence of complications, reoperation rates and functional outcomes: evidence today

The outcome of THA following acetabular fracture was analyzed on 654 patients with a systematic review approach. An uncemented acetabular and femoral component was used in 80.1% and 59.8% of the cases respectively. The median Harris hip score was 88 points. In the early THA group, Kaplan-Meier survivorship analysis with any loosening, osteolysis or revision as the end point revealed that the 10-year cup survival was 81% whereas in the late THA group was 76% (P=0.287). The 10-year survival was 95% for the early stems and 85% for the late ones (P=0.001). Due to their complexity these fractures should be managed in highly specializing units where the expertise of arthroplasty and trauma reconstruction is available.

Percutaneous column fixation and total hip arthroplasty for the treatment of acute acetabular fracture in the elderly

We used our database of primary total hip arthroplasties to identify those patients who had acetabular fractures fixed with percutaneous screws under the same anesthesia as for the arthroplasty procedure. There were 19 patients with the average follow-up of 22 months. Fourteen patients sustained the fracture secondary to a low-energy trauma, while the remaining patients were involved in a high-energy trauma accident. The mean survival time was calculated to be 2.5 ± 0.6 years for the low-energy group and 4 ± 1.4 years for the high-energy group. We believe that this unique treatment of acetabular fractures has a role in carefully selected patients and provides the necessary reduction and immediate stability of the fracture needed to ensure adequate fit for the acetabular cup in the subsequent THA.

The osteoporotic acetabular fracture

Fractures of the acetabulum are some of the most challenging fractures that face orthopedic surgeons. In geriatric patients, these challenges are enhanced by the complexity of fracture patterns, the poor biomechanical characteristics of osteoporotic bone, and the comorbidities present in this population. Nonsurgical management is preferable when the fracture is stable enough to allow mobilization, and healing in a functional position can be expected. When significant displacement and/or hip instability are present, operative management is preferred in most patients, which may include open reduction and internal fixation with or without total hip arthroplasty.

Predictors of clinical outcomes after surgical treatment of displaced acetabular fractures in the elderly

Outcomes following the open reduction and internal fixation (ORIF) of displaced acetabular fractures in the elderly have been inconsistent. Several factors associated with significant poor clinical outcomes have been reported; however, the factor that contributes independently to the outcomes remains unknown. This study aims to identify independent prognostic factors for the outcomes of surgically treated displaced acetabular fractures in the elderly. A total of 86 elderly patients with displaced acetabular fractures were treated by ORIF between May 1990 and June 2010. Matta's criteria and modified Merle d'Aubigne-Postel score were used as reduction grades and clinical outcome measures, respectively. Reduction grades and six radiographic features were identified as prognostic factors. The six radiographic features include quadrilateral plate fracture, Gull sign, posterior dislocation of hip, femoral head injury (FHI), comminuted posterior wall fracture (CPWF), and posterior wall marginal impaction. The average clinical score of the patients associated with the six radiographic features was 14.4 ± 3.1, whereas the average clinical score for those without was 17.2 ± 1.6 points. The average clinical score of the patients with anatomical, imperfect, and poor reduction were 16.8 ± 2.4, 14.5 ± 2.3, and 11.3 ± 1.4 points, respectively. Multivariate analysis identified three independent predictors of clinical outcomes: reduction grades (t = -10.45, p = 0.000), CPWF (t = -2.74, p = 0.008), and FHI (t = -3.51, p = 0.000). Both CPWF and FHI are important risk factors for clinical outcome. The postoperative quality of reduction independently predicted patient prognosis, and anatomical reduction is predictive of a good prognosis.

Quadrilateral plate fractures of the acetabulum: an update

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures, which are not specifically defined by any current classification system. Their incidence is increasing due to the rising number of elderly osteoporotic fractures. They have always been notoriously difficult fractures to treat. We present a systematic review of conservative and operative management and their respective outcomes over the last century.

Fractures of the acetabulum in elderly patients: an update

The incidence of acetabular fractures in elderly patients is increasing. Poor bone quality and concomitant diseases are the main features of these patients. Fracture patterns are marked by a high degree of variability in terms of patient and fracture characteristics. Preoperative planning with plain radiographs and computed tomography, including 3-dimensional reconstructions, is recommended. Treatment remains challenging because of precarious general health, severe osteopenia, comminution, and associated femoral head damage. Treatment options available include closed management, open reduction with internal fixation, percutaneous fixation in situ, and acute or staged total hip arthroplasty (THA) whether alone or combined with osteosynthesis. In the case of significant destruction of the articular cartilage, primary THA may provide the best solution. Whichever surgical method is chosen, the objective is rapid mobilisation of the patient on a walker or crutches. Late local complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, malunion, wound infection, dislocation, intrusive hardware, nerve palsy, and heterotopic bone formation. In this article an overview of the current trends in the management of acetabulum fractures in the elderly is presented.

Cup-cage construct for acute fractures of the acetabulum, re-defining indications

Acetabular fractures in the elderly are challenging injuries. The use of a trabecular metal acetabular cage was investigated as the treatment option in a series of elderly patients with acetabular fractures. At a 2-year follow up, 6 elderly patients were found to have mimimum pain, increased function, and increased scores using the Merle d'Aubigné and Postel system modified by Charnley. Radiographically, the areas of morsellised autograft that surrounded the cups were seen to have incorporated uniformly well, and the acetabular fractures were healed within six months after surgery. No mechanical failure, screw breakage, loosening, or migration was noticed. This novel indication of the cup-cage construction that uses revision techniques, for selected patients and fractures, to achieve an acute stable reconstruction, should be considered as an alternative reconstruction option in elderly patients presenting with acetabular fractures.

[Fractures of the acetabulum. Diagnostic and therapeutic strategies]

Fractures of the acetabulum are a challenge in terms of orientation and the surgical skills of the orthopedic trauma surgeon. Due to the surrounding soft tissues and because of the indirect reduction control, operative treatment of acetabular fractures can be very demanding. This review includes the anatomical and clinical features, the radiological diagnostic approach, the classification systems, and, in particular, the surgical approaches and treatment principles. The work houses for surgical approaches are the ilioinguinal and the posterior (Kocher-Langenbeck) approach. In view of the high complication rate, the extended approaches are of less relevance. The therapeutic relevance of recent developments including navigation is discussed.

Cerclage wire-plate composite for fixation of quadrilateral plate fractures of the acetabulum: a checkrein and pulley technique

Acetabular fractures with complete or incomplete quadrilateral plate separation frequently present with central displacement of the femoral head. Failure of stable fixation of medial wall fractures leaves residual subluxation despite reduction of other fracture components. Several fixation techniques may be either technically demanding or insufficient for stable fixation in conditions of comminution, osteoporosis, or neglected injuries. The proposed wire-plate composite uses a reconstruction spring plate over the pelvic brim for medial wall buttressing. One hole on its true pelvic limb provides a pulley to deviate a cerclage wire or cable passed through the greater sciatic notch into the true pelvis. This enhances buttressing against medial protrusion. Application through anterior approaches is simple and fixation is reliable in difficult fractures without the risk of joint penetration because all quadrilateral plate buttressing implants remain extraosseous.

The combined hip procedure: open reduction internal fixation combined with total hip arthroplasty for the management of acetabular fractures in the elderly

OBJECTIVE

The objective of this study was to evaluate acetabular fractures in elderly patients treated with open reduction internal fixation combined with acute total hip arthroplasty during the same anesthetic.

DESIGN

The authors conducted a retrospective analysis of a treatment.

SETTING

Level I and Level II trauma centers.

PATIENTS

Between September 1995 through January 2005, 22 elderly patients were treated using the combined hip procedure. There were nine transverse/posterior wall patterns, seven anterior column/posterior hemitransverse patterns, and six presented as a both column injury. Six patients had hip dislocations and 14 patients demonstrated some impaction. Patients underwent medical evaluations and clearance before surgical intervention.

INTERVENTION

Standard open reduction internal fixation techniques followed by immediate total hip arthroplasty during the same anesthesia. Ilioinguinal patients were repositioned and redraped for total hip placement.

MAIN OUTCOME MEASUREMENTS

Complications, physical examinations, and Harris hip scores assessed outcomes. Radiographs evaluated union and stability of the femoral and acetabular components, osteolysis, or the development of any heterotopic bone.

RESULTS

Follow up averaged 29.4 months. Surgeries averaged 232 minutes with 1163 mL average blood loss. Hospital stays approximated 8 days with full weightbearing occurring at 3 months. Hip motion averaged 102 degrees of flexion, 32 degrees of abduction, and 16 degrees of adduction. Harris hip scores averaged 74. Four patients developed heterotopic ossification, and five underwent revisions as result of osteolysis or multiple hip dislocations.

CONCLUSIONS

The combined hip procedure is an option for acetabular fractures in elderly patients. Complications, surgical times, and hospitalizations are consistent with open reductions or belated total hip arthroplasties. Aggressive medical workups may be needed, but a single posterior surgical procedure will avoid the "wait-and-see" approach often used for these patients.

Treatment options of pelvic and acetabular fractures in patients with osteoporotic bone

The incidence of pelvic ring and acetabular fractures in the elderly is climbing relentlessly. This increase is attributed to a greater longevity and a decrease in the incidence of alcohol-related trauma in younger adults. Often, the elderly trauma patient has compromised physiological reserve and healing capacity due to concomitant morbidities, resulting in a less favourable clinical outcome. The presence of osteopenic or osteoporotic bone and other treatments for existing comorbidities hamper some treatment alternatives, especially those designed for younger patients. Diverse clinical presentations include minor trauma, major polytrauma and insufficiency fractures. An assessment of the general health and functional status of the patient is of utmost importance to determine the optimal treatment. The different treatment options of pelvic and acetabular fractures in the presence of osteoporosis vary mainly according to the clinical presentation and include: conservative methods, percutaneous or minimally invasive procedures, open reduction and fixation, and primary total hip arthroplasty. Whichever treatment is chosen, even for elderly people, the aim is a rapid mobilisation of the patient in order to reduce complications to some extent inherent to this age group.

Acetabular fractures in the elderly: treatment recommendations

Acetabular fractures in the elderly population are marked by a high degree of variability in terms of patient and fracture characteristics. Successful outcomes depend on application of highly individualized management principles by experienced teams. Reviewed are indications and outcomes associated with various management options, including closed treatment, open reduction internal fixation, and acute or staged total hip arthroplasty. Proper initial management choices are critical, as early failures and subsequent salvage surgery can be accompanied by significant morbidity. Clinical results after ORIF closely follow the quality of articular reduction and the ability to maintain a congruent reduction of the hip joint. Fracture characteristics predictive of anatomic articular reduction should be treated with ORIF. Fracture characteristics predictive of early post-traumatic arthritis should be treated with simultaneous ORIF and THA. Presented is one referral institution's treatment algorithm and management approach.

[The chronic central fracture dislocation of the hip]

The acetabulum fracture with chronic dislocation of the femoral head is relatively uncommon. Due to complex morphology and bone defect of the acetabular dome, stable internal fixation is difficult. Primary total hip arthroplasty represents an alternative treatment. We report the case of a 66-year-old patient with a 3-month history of acetabular fracture with central dislocation of the femoral head. The patient was treated with cemented total hip arthroplasty and cancellous bone grafting of the central dome defect for stable cup fixation.

Arthroplastie de hanche pour séquelle de fracture de l’acétabulum

PURPOSE OF THE STUDY

The aim of this retrospective analysis was to examine complications and technical difficulties observed during implantation of total hip arthroplasty (THA) after treatment of an acetabular fracture.

MATERIAL AND METHODS

Forty patients (thirty men and ten women), mean age 50 years, were included in the study. The acetabular fracture had been treated surgically in 23 and orthpedically in 17. Mean time from initial trauma to implantation of the THA was eleven years. Hydroxyapatite-coated cups were inserted without cement in 32 patients. Cemented cups in eight (with two Kerboull cross, one Muller ring, and five simple polyethylene). Five femoral stems were cemented. Preoperative planning was designed to restore the center of the initial hip rotation to avoid excessive cup medialisation. Acetabular defects found intra-operatively were significantly greater in the group of patients treated orthopedically than in those treated surgically (p = 0.02). Autografts were thus used more frequently in the former (65%).

RESULTS

One patient presented an intraoperative complication. The postoperative complications included phlebitis (n = 1), infection (n = 1), fibular nerve paralysis (n = 2), dislocation (n = 4), and heterotopic ossification (n = 7). The rate of postoperative complications was significantly higher in the group of patients treated surgically (52.2% versus 17.6%, p < 0.02). At last follow-up, mean 52 months, the mean Postel-Merle-d'Aubigne function score was 16.7. The rate of acetabular revision was 15% with four cemented cups being replaced at more than ten years due to aseptic loosening. Two press-fit cups were replaced early for infection in one patient and disassembly in another.

DISCUSSION

Despite the high rate of complications, the mid-term results were good, encouraging us to continue this procedure as the first intention treatment using either a press fit cup with or without an autograft, or a cemented cup with a metal ring (Kerboull or Burch-Schneider).

Die Behandlung von Acetabulumfrakturen bei geriatrischen Patienten mittels modifizierter Kabelcerclage und prim�rer H�fttotalprothese

This prospective study addresses early results of the treatment of acute acetabular fractures in elderly patients by total hip arthroplasty and cerclage wiring. Fifteen patients with an average age of 81 years were treated at our institution between February 1998 and December 2000. There were two transverse fractures, eight T-shaped fractures, two transverse fractures with associated posterior wall fracture, two posterior column fractures with associated posterior wall fracture, and one fracture of both columns. Treatment consisted of cerclage wiring of the fracture and primary non-cemented total hip replacement. All of the patients were followed for a mean of 36 months. Although there was one patient with three hip dislocations during the first 10 months after the operation, we found an excellent or good result for the entire group. During this relatively short follow-up period, we have not found a radiological loss of fracture reduction of more than 1 mm or a cup migration of more than 3.2 mm. All of the fractures healed and no loosening of the implant was evident. Primary total hip arthroplasty combined with internal fixation is a valid treatment option for acetabular fractures in the elderly. Preliminary results are convincing, but a bigger patient population and a longer follow-up time are necessary before we are able to draw final conclusions.

The Levine anterior approach for total hip replacement as the treatment for an acute acetabular fracture

The treatment of acetabular fractures in part relies on the selection of a specific surgical approach that allows for accurate reduction of fracture fragments. Moreover, these acetabular approaches were not developed for the insertion of a total hip replacement. Therefore, if a total hip arthroplasty is to be the treatment of an acute acetabular fracture, a single incision that permits reduction of the acetabular fracture fragments and ease of insertion of the arthroplasty components would be desirable. The Levine anterior approach provides both accesses to the anterior wall/column for reduction and fixation and to the femoral shaft for insertion of a total hip replacement. This paper describes that surgical technique and our initial clinical experience with this approach for acute acetabular fractures. A consecutive group of 10 patients with acetabular fractures, all involving the anterior wall/column with articular impaction (>50% of the acetabular roof) including 2 cases with an associated posterior hemitrans-verse component, were reviewed. After fracture reduction and fixation, a hybrid total hip replacement was implanted in all cases with an average acetabular component size of 56 mm (range 52-64). At a mean follow-up of 36 months (range 24-53), all fractures united, and all acetabular components remained fixed with no evidence of migration or loosening. There were 2 complications, a Brooker grade II heterotopic ossification and 1 postoperative anterior dislocation treated successfully with closed reduction and spica cast immobilization. The average Merle d'Aubigné hip score at latest follow-up was 16 (range 13-18). The Levine anterior approach is a reliable, safe, and efficient technique that permits early mobilization of patients with anterior wall/column acetabular fractures requiring a total hip replacement.

Cable fixation and early total hip arthroplasty in the treatment of acetabular fractures in elderly patients

Eighteen patients with acetabular fractures, with a mean age of 76 years, were treated with cable fixation and acute total hip arthroplasty. Nine were T-shaped fractures, 4 associated transverse and posterior wall, 2 transverse, 2 posterior column and posterior wall, and 1 anterior and posterior hemitransverse fractures. One patient experienced 3 episodes of hip dislocation within 10 months after surgery. All the others had a good outcome at a mean follow-up time of 36 months. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This option provides good primary fixation, stabilizes complex acetabular fractures in elderly patients, and permits early postoperative mobilization.

The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures

OBJECTIVES

To identify factors affecting the outcomes of surgery for acetabular fracture in patients over the age of 60 years.

DESIGN

Retrospective review of records and radiographs; current examination, radiographs and outcome surveys when possible.

SETTING

Academic, Level 1 trauma center.

PATIENTS/PARTICIPANTS

Forty-eight patients over age 60 with displaced acetabulum fractures.

INTERVENTION

Surgical reduction and fixation.

MAIN OUTCOME MEASUREMENTS

Clinical ratings and radiographic evaluations, Short Musculoskeletal Functional Assessment survey (SMFA), SF-36, and hip-specific questions. Radiographs were evaluated using the criteria of Matta.

RESULTS

Ten patients died since surgery. Four were lost to follow-up. Seven had >12 months of follow-up information in the chart. Twenty-seven had current evaluations for the study. Average follow-up was 37 months, range 1-114 months. The average age at surgery was 71.6 years (range 61-88). No perioperative deaths occurred. Initial reductions achieved: 61% anatomic, 34% imperfect, and 5% poor. A specific radiographic finding (superomedial dome impaction) predictive of failure was identified. This was designated the "Gull Sign." These patients had inadequate reduction, early fixation failure, or medial/superior joint narrowing and subluxation. Functional outcomes in patients with current examination were similar to age-matched controls. Radiographic outcomes: 30% excellent, 30% good, 9% fair, 23% poor, and 7% arthroplasty. Anatomic reduction was closely related to good or excellent radiographic result.

CONCLUSIONS

While some patients over sixty years of age can have satisfactory functional outcomes after acetabular fracture fixation, a significant number will have failure of the procedure. Osteopenic patients with superomedial dome impaction (the Gull Sign) did not benefit from attempted open reduction and internal fixation in this series.

Displaced acetabular fractures managed operatively: indicators of outcome

This study examined retrospectively the clinical and radiographic features of acute displaced acetabular fractures which heavily influence the quality of an open reduction and clinical outcome. Of 424 acute fractures (119 simple and 305 associated injuries) in 411 patients, the mean time from the injury to surgery was 8.2 days (range, 0-21 days). The mean age of the patients was 46.5 years (range, 13-89 years), and followup was an average of 9.3 years (range, 3-21 years). For the 424 hips, the reduction was anatomic in 282 (67%), imperfect in 90 (21%), poor in 39 (9%), and secondarily congruent in 13 both-column fractures (3%). The quality of the reductions markedly deteriorated with advancing age. Clinically, the Harris hip score was excellent in 179 (42%), good in 126 (30%), fair in 54 (13%), and poor in 65 (15%). Excellent or good clinical outcomes were recorded in 249 of 282 patients (89%) with an anatomic reduction. Of the 119 patients with fair and poor results, 92 patients (77%) had complicating factors recognizable at clinical presentation, including extensive impaction, articular abrasion, a femoral head or neck fracture, or endogenous obesity. Although stable anatomic reduction of most displaced acetabular fractures affords the optimal prognosis, especially in younger patients, the initial clinical and radiologic evaluations delineate a sizable minority with poorly prognostic features that favor a poor clinical outcome after internal fixation, by minimizing the likelihood for an anatomic reduction or compromising the outcome despite an anatomic reduction. With the rapidly aging population accentuating this trend, a reappraisal for the role of the current therapeutic alternatives of nonoperative treatment, a limited open reduction, or an acute total hip replacement merits review.

Acute total hip arthroplasty for selected displaced acetabular fractures: two to twelve-year results

BACKGROUND

We assessed the role of acute total hip arthroplasty in a selected group of patients with a displaced acetabular fracture and complicating features that greatly diminished the likelihood of a favorable outcome after open reduction and internal fixation.

METHODS

Between 1985 and 1997, fifty-seven patients underwent an acute total hip arthroplasty for a displaced acetabular fracture. Patients were followed for a mean of 8.1 years (range, two to twelve years). The mean time from the injury to the arthroplasty was six days (range, one to twenty days). The mean age of the patients at the time of the arthroplasty was sixty-nine years (range, twenty-six to eighty-nine years). Indications for the acute arthroplasty included intra-articular comminution as well as 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.

RESULTS

At the time of the latest follow-up, the mean Harris hip score was 89 points (range, 69 to 100 points); forty-five patients (79%) had an excellent or good outcome. There were six cases of heterotopic bone formation, including one of symptomatic grade-IV ossification. During the initial six postoperative weeks, the acetabular cups subsided an average of 3 mm medially and 2 mm vertically. All of the cups then stabilized, and none were loose at the latest follow-up evaluation. Six patients had excessive medialization of the cup, but none had late loosening or osteolysis. Nine cups (16%) had notable polyethylene wear, but none were revised. No cup or stem had late clinical or radiographic evidence of loosening. There were three late procedures: one for revision of a malaligned cup because of recurrent dislocations, one for removal of hardware from the greater trochanter, and one for excision of heterotopic bone.

CONCLUSIONS

In selected patients with a displaced acetabular fracture that has a low likelihood of a favorable outcome after fracture treatment, an acute total hip arthroplasty may provide an alternative means with which to achieve a painless, mobile hip. These complex procedures are best undertaken by a surgical team with substantial experience with both acetabular trauma and hip arthroplasty.

Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone

The incidence of acetabular fractures in the elderly has recently shown a marked increase due to the combination of greater longevity for the population as a whole and a relative decrease in the incidence of alcohol-related trauma in younger adults. The compromised physiologic reserve and the diminished healing capacity of the typical elderly patient have an adverse effect on the potential for a favorable clinical outcome. The presence of osteopenic bone or degenerative arthritis and the effects of previous radiation therapy to the hip and pelvis hamper diagnostic imaging and the utility of some treatment alternatives that were designed primarily for younger patients. The diverse clinical presentations include major polytrauma, minor trauma, and insufficiency fractures. An assessment of the prior health and functional status of the patient is crucial in determining the optimal therapeutic protocol. Treatment options vary according to the clinical presentation and include conservative methods, percutaneous fixation in situ, open reduction, and acute total hip arthroplasty. The feasibility of acute total hip arthroplasty rests on the use of newly developed techniques for minimally invasive stabilization of the acetabular fracture with cables and the application of morselized or structural autograft harvested from the femoral head. Whichever surgical method is chosen, the objective is rapid mobilization of the patient on a walker or crutches. Late complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, wound infection, and heterotopic bone formation.