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Planning for THR: Considerations for Acetabular Fracture

- See:
      - Acetabular Fractures:
      - Total Hip Arthroplasty:

- Discussion:
    - in the report by Bellabarba C, et al, the authors compared the results of arthroplasty in patients who had had prior operative
         treatment of their acetabular fracture with those in patients who had had prior closed treatment of their acetabular fracture;
          - 30 THR were performed with use of a cementless hemispheric, fiber-metal-mesh-coated acetabular component for the treatment
                  of posttraumatic osteoarthritis after acetabular fracture;
          - median interval between the fracture and the arthroplasty was 37 months (range, eight to 444 months);
          - average age at the time of the arthroplasty was fifty-one years, and the average duration of follow-up was 63 months;
          - 15 patients had had prior open reduction and internal fixation of their acetabular fracture (open-reduction group), and 15
                  patients had had closed treatment of the acetabular fracture (closed-treatment group);
          - operative time (p < 0.001), blood loss (p < 0.001), and perioperative transfusion requirements (p < 0.001) were
                  greater in the patients with posttraumatic arthritis than they were in the patients with nontraumatic arthritis;
          - hardware was removed only as needed to allow an unimpeded press-fit of the acetabular component;
          - bone-grafting was performed as required to provide two-column support for the acetabular component and to maintain the
                   integrity of the dome and the medial wall;
          - in the nine patients requiring bone-grafting of acetabular defects, morselized cancellous graft was taken from the femoral head
                   and from the acetabular reamings and was impacted into the contained cavitary defect both manually and by reverse
                   reaming (no structural grafts were required);
          - prophylaxis against HO consisted of a single dose of radiation (500 to 1000 cGy) in 7 patients (four who had had ORIF and
                  three who had had closed treatment) and indomethacin (50 mg orally, 3 times a day for 3 weeks) in 1 patient w/
                  a prior ORIF;
          - of the patients with posttraumatic arthritis, those who had had ORIF of their acetabular fracture had a significantly longer index
                  procedure (p = 0.01), greater blood loss (p = 0.008), and a higher transfusion requirement (p = 0.049) than those in whom
                  the fracture had been treated by closed methods;
          - 2 of the 15 patients with a previous ORIF required bone-grafting of acetabular defects compared with seven of the fifteen
                  patients treated by closed means (p = 0.04).
          - Kaplan-Meier ten-year survival rate, with revision or radiographic loosening as the end point, was 97%;
          - results were similar to those of the patients who underwent primary total hip arthroplasty for nontraumatic arthritis;
          - the only failure occurred in a patient with an unsupported acetabular discontinuity;
          - authors recommend plate fixation is required in conjunction with acetabular reconstruction in such patients;
    - in the report by Mears DC and Velyvis JH (2002), the authors assessed the role of acute THR 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.
          - 57 patients underwent an acute total hip arthroplasty for a displaced acetabular fracture;
          - mean follow up was 8.1 years;
          - mean time from the injury to the arthroplasty was six days (range, one to twenty days);
          - mean age of the patients at the time of the arthroplasty was sixty-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;
          - at the time of the latest follow-up, the mean Harris hip score was 89 points (range, 69 to 100 points);
          - 45 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.
          - 6 patients had excessive medialization of the cup, but none had late loosening or osteolysis.
          - no cup or stem had late clinical or radiographic evidence of loosening; 

    - technical considerations:
          - bone grafting for acetabular defects
          - gap cup
          - infra-tectal or juxatecal transverse fractures and comminuted anterior column fractures: stabilized with
               two 2.0 mm braided cables  
               - Stabilization of an acetabular fracture with cables for acute total hip arthroplasty.

Cementless Acetabular Reconstruction After Acetabular Fracture.     

Acute Total Hip Arthroplasty for Selected Displaced Acetabular Fractures. Two to Twelve-Year Results. 

Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients.

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

The Levine Anterior Approach for Total Hip Replacement as the Treatment for an Acute Acetabular Fracture.

Persistent Bladder Entrapment Following Acetabular Fracture with Subsequent Vesical Injury During Total Hip Arthroplasty. 

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

THA After Acetabular Fracture Fixation: Is Frozen Section Necessary?

Young patients with acetabular fractures show comparable results when treated with ORIF, acute THA

Acetabular fractures in the elderly treated with a primary Burch-Schneider reinforcement ring, autologous bone graft and a total hip arthroplasty. A prospective study with a 4-year follow-up.

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