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Outcomes of delayed total hip arthroplasty in patients with a previous ipsilateral acetabular fracture Expert Rev. Med. Devices 12(3), 297–306 (2015)
Eddie S Wu, Julio J Jauregui, Samik Banerjee, Jeffrey J Cherian and Michael A Mont* Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA *Author for correspondence: Tel.: +1 410 601 8500 Fax: +1 410 601 8501 [email protected]
Post-traumatic arthritis of the hip can develop in 12–57% of patients after an acetabular fracture. Once it develops, salvage treatment options include arthroplasty or arthrodesis. Delayed total hip arthroplasty (THA) has been shown to be a viable treatment option to decrease pain, improve stability and increase functional outcomes. Using cemented designs, earlier long-term studies reported satisfactory functional outcomes of delayed THA used to treat previously failed acetabular fractures. However, high aseptic loosening rates were also observed. Recent advances in cementless acetabular designs have shown comparable functional outcomes and loosening rates compared to those undergoing THA for non-traumatic arthritis. However, even with improvements in functional and radiographic outcomes, unique complications are commonly encountered in patients with previous acetabular fractures, including heterotopic bone around the hip, increased operative times and blood loss, aseptic loosening, sciatic nerve injury and dislocation. The outcomes and complications of delayed THA in patients with previous acetabular fracture will be reviewed. KEYWORDS: acetabular . arthroplasty . fracture . hip . post-traumatic
Acetabular fractures can result from both highand low-energy mechanisms of injury in both young and elderly patient populations. Anatomic reduction with rigid internal fixation of the acetabulum has been shown to minimize the risk of developing post-traumatic arthritis [1,2]. Unfortunately, these fractures commonly lead to arthritic hip disease regardless of whether non-operative or operative intervention was initially chosen [3,4]. Several factors play a role in the development of secondary arthritis, including quality of articular reduction/fixation, presence of femoral head osteochondral defects and/or acetabulum and osteonecrotic fracture fragments [5,6]. Studies have reported between 12 and 57% of patients with acetabular fractures subsequently developing post-traumatic arthritis [7,8]. Historically, most were treated non-operatively, which often resulted in suboptimal outcomes [9–11]. Therefore, many surgeons currently treat these injuries surgically depending on the magnitude of displacement and fracture
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pattern with various strategies, including percutaneous fixation [12–14], open reduction internal fixation [15,16] or hip arthroplasty [17,18]. Even when operative treatment goals are achieved, arthritis can develop in up to 30% of patients [1,2,7,19,20]. Once post-traumatic joint disease develops, total hip arthroplasty (THA) or arthrodesis may be the only options available. Delayed THA can be an effective strategy for post-traumatic joint disease. However, studies have described inferior THA outcomes performed in the setting of a previous acetabular fracture when compared to THA for primary hip osteoarthritis [3,5,21,22]. However, with surgical technique and implant design advancements, improved outcomes with modern cementless acetabular components have been reported [23]. Some have reported acetabular component revision rates comparable to THA performed for primary osteoarthritis [24–27]. Impaction grafting used cemented all-polyethylene cups has also shown promising results in restoring acetabular bony defects [28–30].
2015 Informa UK Ltd
ISSN 1743-4440
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Wu, Jauregui, Banerjee, Cherian & Mont
A delayed THA can provide excellent outcomes. However, this procedure brings a unique set of potential complications. There is an increased risk for infection, sciatic nerve palsy, loosening and/or dislocation [6,28,30,31]. For example, if nonoperative treatment was initially chosen, native anatomy may be altered from acetabular malunion/nonunion. If operative fixation was initially performed, it may be complicated by pelvic deformity, previous hardware, scar tissue and heterotopic bone [28,32]. In addition, one must always consider risk of occult infection when contemplating arthroplasty after prior surgery [31]. Our purpose was to review the literature describing THA as a treatment option for post-traumatic hip joint disease after acetabular fractures. We focused on clinical outcomes as they pertain to the acetabulum and potential complications. Methods
The electronic databases PubMed, EMBASE and Ovid were used to query potentially relevant reports addressing secondary post-acetabular fracture hip arthritis treated with hip arthroplasty. Initial search string was: ‘fract* AND acetab* AND arthropl* or replace*’ which returning 88 articles. After review, 11 reports used THA to manage post-traumatic hip disease. Reference lists of these reports returned 19 additional studies, yielding 30 relevant articles. Of those, four did not describe results and three were case reports, leading to 22 reports included in this review (TABLE 1). Outcomes
Multiple studies have documented inferior outcomes with cemented acetabular components for post-traumatic arthritis compared to cementless components [3,21,33]. Factors that might contribute include early cementing techniques, poor cement interdigitation into sclerotic bone, younger age and the distorted acetabular anatomy [5]. Cementless acetabular components have become popular for acetabular fixation in this setting. Furthermore, we have analyzed the difference in Harris hip scores (HHS) and implant survivorship between cementless and cemented fixation. Harris hip scores
Historically, inferior outcomes were reported for THA performed for post-traumatic arthritis when compared to degenerative disease [21,22]. Lizaur-Utrilla et al. [29] compared the outcomes of THA for both patient subsets (n = 24 vs 48 patients). Mean age was 56 years (range, 28–77). After a mean follow-up of approximately 8 years (range, 5–15 years), there were significantly lower HHS in the post-traumatic cohort (77 vs 88 points; p = 0.03). Conversely, Ranawat et al. [32] reported favorable outcomes in 32 patients with post-traumatic THAs. At 4.7 years follow-up (range, 2–9.7), patients who had undergone prior open reduction internal fixation had a higher mean HHS than those managed non-operatively; however, this difference was not significant (84 vs 74 points, respectively; p = 0.33). 298
Additionally, bone grafting with cementation has shown encouraging results in recent studies [28,30,34]. In a prospective 30 hip studies, Bellabarba et al. [30] reported good results in 27 of 30 (90%) patients treated with cementless acetabular components. Similarly, Schreurs et al. [34] retrospectively studied 20 patients who had some degree of acetabular bone stock deficiency by the American Academy of Orthopaedic Surgeons classification [35]. Acetabular defects were treated with autograft and/or allograft bone chips with a cemented all-polyethylene cup. At a follow-up of 9.5 years (range, 3–18), the mean HHS was 93 points (range, 62–100 points) in the 16 surviving patients, 14 who were pain free. Zhang et al. [28] assessed the ability to restore hip center using an acetabular reinforcement ring and a cemented cup in patients treated with prior open reduction internal fixation (n = 49 hips). At 64 months followup, (range, 32–123), mean HHS increased significantly from preoperative levels (49.5–90; p < 0.001). Implant survivorship
As with patient-reported outcomes, implant survivorship has been lower in THA for post-traumatic arthritis [21,22]. In a study of 55 cemented THAs performed, Romness et al. [21] had 52.9% acetabular loosenings and 13.7% revisions rate at a follow-up of 7.3 years (range, 7 days to 16.6). Comparison to a control cohort of 231 ‘routine’ THAs revealed a four- to fivefold increase in the rate of component loosening in the fracture group [36]. Young age may be a contributing factor, particularly with cemented components. Weber et al. [3] evaluated outcomes in 66 THAs performed at a mean follow-up of 112 months (range, 24–240). A cemented technique was utilized in 66% (44 out of 66 THAs) and a cementless technique in 33% (22 out of 66 THAs). Mean age was 52 years (range 19–88). Overall acetabular implant survivorship was 87% (95% CI: 76–99%). An age of less than 50 years was a significant risk factor for revision (p = 0.02). They attributed this high failure rate to Charnley class A involvement (unilateral joint disease), a predominantly male cohort and the young age. More recently, cementless acetabular components have had good survivorship. Bellabarba et al. [30] (n = 30 patients) using radiographic loosening or revision as an endpoint had a 10-year Kaplan–Meier survivorship of 97%. Similarly, Ranawat et al. [32], using revision of any kind as an endpoint, found Kaplan–Meier survivorship at 5 years to be 79%, but increased to 97% when only aseptic acetabular loosening was an endpoint. They concluded that excellent clinical outcomes could be obtained with cementless acetabular fixation. Berry and Halasy [33] further supported the use of uncemented acetabular components. In 34 hips in 33 patients who had a mean age of 49.8 years (range, 19–78), there were nine acetabular revisions at mean follow-up of approximately 12 years (range, 10–16). Of the 26 acetabular components with a minimum 10 years follow-up, only two were loose. The authors found high rates of acetabular osteolysis, which they attributed to the younger population. Of note is that the bearing surfaces used in this study included a metal femoral head on conventional Expert Rev. Med. Devices 12(3), (2015)
Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
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Table 1. Studies. Study (year)
THA
Age (range), years
Follow-up (range), months
Cemented versus cementless
Type of THA
Liner
Level of evidence
Boardman and Charnley (1978)
68
55
–
Not stated
Not stated
Not stated
IV
[39]
(24–77)
–
Romness and Lewallen (1990)
55
53 Cementless
Not stated
Not stated
IV
[21]
Pritchett and Bortel (1991)
19
Cementless
Not stated
Not stated
IV
[40]
Weber et al. (1998)
66
44 Cemented
54 standard; 2 rings
Not stated
IV
[3]
Huo et al. (1999)
21
Cementless
Standard hip prosthesis
Not stated
IV
[6]
Bellabarba et al. (2001)
30
Cementless
Standard hip prosthesis
21 lipped; 9 offset
III
[30]
Berry and Halasy, 2002
34
Cementless
33 standard; 1 dual mobility
Not stated
IV
[33]
Schreurs et al. (2005)
20
Cemented
Not stated
Not stated
IV
[34]
Glas et al. (2005)
40
32 Cementless
37 standard; 2 rings; 1 cage
Not stated
IV
[41]
Pavelka et al. (2006)
49
38 Cemented
Standard hip prosthesis
Not stated
IV
[42]
Sermon et al. (2008)
57
Cementless
Not stated
Not stated
III
[43]
Ranawat et al. (2009)
32
Cementless
Standard hip prosthesis
19 offset; 13 lipped
IV
[32]
Carroll et al. (2010)
26
Not stated
Not stated
Not stated
IV
[45]
Zhang et al. (2011)
55
47 Cementless
50 standard; 5 rings
Not stated
IV
[28]
Lizaur-Utrilla et al. (2012)
24
Cementless
Standard hip prosthesis
Not stated
III
[29]
Dunet et al. (2013)
25
Not stated
Not stated
Not stated
IV
[47]
Kamath et al. (2013)
12
Cementless
Standard hip prosthesis
Not stated
IV
[49]
Chemaly et al. (2013)
20
Cementless
Standard hip prosthesis
Not stated
IV
[50]
Floris et al. (2013)
39
29 Cemented
Standard hip prosthesis
Not stated
IV
[51]
56
88
(19–91)
(1–199)
49
34
–
(24 to –)
52
112
(19–80)
(24–240)
52
65
(23–78)
(48–104)
51
63
(26–86)
(24–140)
50
143
(19–78)
(120–192)
53
112
(35–75)
(36–216)
50
52
–
–
42
42
–
(18–92)
53
78
(18–95)
(18–95)
–
56
–
(24–116)
67
63
(56–89)
(24–188)
47
64
(22–65)
(32–123)
56
101
(28–77)
(60–180)
41
82
(16–75)
(3–132)
57
39
(29–88)
(24–49)
60
29
(28–89)
(9–61)
45
–
(25–73)
(– to 48)
Ref.
THA: Total hip arthroplasty.
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Complications
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Table 2. (Initial management). Study (year)
THA
Non-operative% (n)
ORIF% (n)
Boardman and Charnley (1978)
68
–
19 (13)
[39]
Romness and Lewallen (1990)
55
76 (42)
24 (13)
[21]
Pritchett and Bortel (1991)
19
–
–
[40]
Weber et al. (1998)
66
0 (0)
100 (66)
[3]
Huo et al. (1999)
21
67 (14)
33 (7)
[6]
Bellabarba et al. (2001)
30
50 (15)
50 (15)
[30]
Berry and Halasy (2002)
34
56 (19)
44 (15)
[33]
Schreurs et al. (2005)
20
40 (8)
60 (12)
[34]
Glas et al. (2005)
40
43 (17)
58 (23)
[41]
Pavelka et al. (2006)
49
–
–
[42]
Sermon et al. (2008)
57
11 (6)
89 (51)
[43]
Ranawat et al. (2009)
32
25 (8)
75 (24)
[32]
Chu et al. (2010)
18
–
–
[44]
Carroll et al. (2010)
26
–
–
[45]
Zhang et al. (2011)
55
42 (23)
58 (32)
[28]
Shang et al. (2012)
13
23 (3)
77 (10)
[46]
Lizaur-Utrilla et al. (2012)
24
63 (15)
38 (9)
[29]
Dunet et al. (2013)
25
36 (9)
64 (16)
[47]
O’Toole et al. (2013)
13
0 (0)
100 (13)
[48]
Kamath et al. (2013)
12
–
–
[49]
Chemaly et al. (2013)
20
10 (2)
90 (18)
[50]
Floris et al. (2013)
39
–
–
[51]
41 (236)
59 (337)
ORIF: Open reduction and internal fixation; THA: Total hip arthroplasty.
polyethylene that was g-irradiated in air. Modern polyethylene might have led to less acetabular osteolysis. The use of bone grafting with cementation has also shown good implant survivorship. Schreurs et al. [34] (n = 20 patients) had only two patients revised at a follow-up of 9.5 years (range, 3–18). One was revised for septic loosening and the other for aseptic loosening at 14.5 years and 15.3 years, respectively. Using acetabular revision as an endpoint, Kaplan–Meier survival rate was 100% at 10 years and 80% at 15 years (95% CI: range, 62–98%). They stressed the excellent long-term clinical outcomes obtained, particularly in young patients. In summary, there are mixed results on the outcomes of THA after an acetabular fracture. Reasons may be multifactorial with differing fracture pattern, patient cohorts and surgical techniques used. In general, cemented components have led to higher rates of loosening when compared to cementless components (TABLES 2 & 3). 300
Ref.
These patients often have higher complication rates when compared to primary osteoarthritis. These complications include heterotopic bone around the hip, aseptic loosening, sciatic nerve injury and dislocation (TABLE 4). Heterotopic bone
Heterotopic bone can form from soft tissue trauma at the time of injury, as well as from previous surgical procedures. Also, concomitant closed head injuries are common and can lead to a higher risk of developing heterotopic bone. Heterotopic bone can lead to an increased operative time and blood loss. Ranawat et al. [32] reported 53% (n = 17 out of 32 patients) of patients having heterotopic ossification (HO). However, not all heterotopic bone around the hip requires removal at the time of THA. Zhang et al. [28] found a 31% (n = 16 of 51 hips) incidence of HO. All patients received HO prophylaxis in the form of indomethacin 25 mg twice a day for 4 weeks, and no patients in this cohort developed Brooker class IV HO. Those at high risk of developing HO, such as males with closed head injuries and previous surgical procedures, should be considered for prophylaxis perioperatively in the form of radiation and/or indomethacin or a similar agent and counseled on the increased risks at the time of THA if ectopic bone has already developed and matured.
Increased operative times & blood loss
Increased operative times and blood loss are commonly encountered. Bellabarba et al. [30] (n = 30 patients) reported significant differences in both the mean operative time (p < 0.001) and blood loss (p < 0.001) in their prospective study comparing a post-traumatic arthritis cohort to a nontraumatic cohort. The post-traumatic group had a mean operative time of 179 min (range, 90–300 min) compared to 122 min (range, 46–300 min). The mean intraoperative blood loss in the post-traumatic group was 898 ml (range, 250–2900) compared to 413 ml (range, 125–1800) in the non-traumatic group. Average perioperative transfusion requirements were also found to be significant (2.2 vs 1.3 units, p < 0.001). Similarly, in a prospective, matched cohort study, LizaurUtrilla et al. [29] found significant differences in the mean operative times of 24 patients who underwent THA for posttraumatic osteoarthritis compared to the 48 individuals in a non-traumatic cohort (81 vs 73 min; p = 0.002). However, the Expert Rev. Med. Devices 12(3), (2015)
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Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
incidence of blood transfusion was 16.7% (4 out of 24 hips) and 14.6% (7 out of 48 hips), respectively (p = 0.43). Therefore, they concluded that those with post-traumatic arthritis may have an increase in operative time, but no increased risk of requiring blood transfusions. Ranawat et al. [32] reported an average blood loss of 718 ml (range, 100 ml to 2 l) in 37 patients. No differences in blood loss were noted between those who were initially treated non-operatively versus those treated operatively. Using a cementless design on both the acetabular and femoral side, Huo et al. [6] found a mean estimated blood loss of 960 ml (range, 500–2200 ml) and a mean operative time of 97 min (range, 60–190 min). The degree of scarring from previous procedures, residual pelvic deformity and presence of heterotopic bone and retained hardware necessitating removal are all contributing factors to the potentially increased surgical time and average blood loss. Intuitively, the complexity of the procedure is likely correlated with the operative time and average blood loss (TABLE 5). Despite these results, there were no studies that reported how blood loss was measured, and this is a weakness that should be addressed in future studies.
Table 3. (Outcomes).
Aseptic loosening
Previous studies have reported on aseptic loosening rates using only cemented components, and some studies have even included both cemented and uncemented acetabular components in their results. Therefore, direct comparison across studies is difficult since cemented acetabular components have largely been abandoned. Romness et al. [21] reported a greater than 50% acetabular loosening rate at a mean follow-up of 7.3 years (range, 7 days–16.6 years) using a cemented cup in patients with a previous acetabular fracture and equated this to a four- to fivefold increase in loosening when compared to patients who underwent THA for non-traumatic reasons. Weber et al. [3] reported a Kaplan–Meier survival rate of 87% (95% CI: 76–99%) for the acetabular component informahealthcare.com
Review
Study (year)
THA
Preoperative HHS (range) points
Postoperative HHS (range) points
Survivorship Kaplan–Meier % (confidence interval)
Ref.
Boardman and Charnley (1978)
68
– –
– –
– –
[39]
Romness and Lewallen (1990)
55
– –
– –
89 –
[21]
Pritchett and Bortel (1991)
19
42 –
84 –
– –
[40]
Weber et al. (1998)
66
49 –
93 –
87 (76–99)
[3]
Huo et al. (1999)
21
30 –
90 –
91 –
[6]
Bellabarba et al. (2001)
30
41 –
88 (47–100)
97 (95–100)
[30]
Berry and Halasy (2002)
34
– –
– –
93 –
[33]
Schreurs et al. (2005)
20
44 (32–61)
93 (62–100)
100 –
[34]
Glas et al. (2005)
40
– –
– –
90 –
[41]
Pavelka et al. (2006)
49
– –
– –
– –
[42]
Sermon et al. (2008)
57
– –
– –
– –
[43]
Ranawat et al. (2009)
32
28 (0–56)
82 (20–100)
97 –
[32]
Chu et al. (2010)
18
50 (26–70)
86 (80–92)
– –
[44]
Carroll et al. (2010)
26
– –
– –
– –
[45]
Zhang et al. (2011)
55
49 –
90 (56–100)
98 –
[28]
Shang et al. (2012)
13
37 –
83 –
– –
[46]
Lizaur-Utrilla et al. (2012)
24
35 –
77 (45–94)
90 (87–93)
[29]
Dunet et al. (2013)
25
– –
– –
– –
[47]
O’Toole et al. (2013)
13
– –
– –
– –
[48]
Kamath et al. (2013)
12
– –
– –
– –
[49]
Chemaly et al. (2013)
20
– –
– –
– –
[50]
Floris et al. (2013)
39
42 –
81 (52–96)
– –
[51]
HHS: Harris hip scores; THA: Total hip arthroplasty.
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Table 4. (Complications). Study (year)
n THA
HO% (n)
HO PPx
Dis% (n)
Inf% (n)
Neu% (n)
Rev% (n)
SL% (n)
TE% (n)
TE PPx
Death% (n)
Ref.
Boardman and Charnley (1978)
68
22 (15)
–
–
1 (1)
–
–
–
9 (6)
–
4 (3)
[39]
Romness and Lewallen (1990)
55
–
–
–
2 (1)
–
13 (7)
13 (7)
–
–
7 (4)
[21]
Pritchett and Bortel (1991)
19
0 (0)
Y
0 (0)
0 (0)
5 (1)
0 (0)
0 (0)
0 (0)
–
–
[40]
Weber et al. (1998)
66
39 (26)
–
5 (3)
0 (0)
2 (1)
5 (10)
14 (9)
2 (1)
–
–
[3]
Huo et al. (1999)
21
29 (6)
–
5 (1)
0 (0)
5 (1)
10 (2)
5 (1)
0 (0)
Y
0 (0)
[6]
Bellabarba et al. (2001)
30
34 (13)
Y
–
0 (0)
–
3 (1)
3 (1)
0 (0)
Y
0 (0)
[30]
Berry and Halasy (2002)
34
–
–
9 (3)
3 (1)
–
26 (9)
6 (2)
0 (0)
–
0 (0)
[33]
Schreurs et al. (2005)
20
–
Y
–
5 (1)
–
10 (2)
–
–
Y
–
[34]
Glas et al. (2005)
40
18 (7)
–
10 (4)
3 (1)
5 (2)
18 (7)
–
–
–
–
[41]
Pavelka et al. (2006)
49
0 (0)
–
–
–
–
–
–
–
–
–
[42]
Sermon et al. (2008)
57
40 (23)
–
–
0 (0)
–
21 (12)
–
0 (0)
–
0 (0)
[43]
Ranawat et al. (2009)
32
44 (14)
Y
9 (3)
19 (6)
–
19 (6)
6 (2)
0 (0)
–
3 (1)
[32]
Zhang et al. (2011)
55
29 (16)
Y
2 (1)
0 (0)
5 (3)
2 (1)
2 (1)
–
–
0 (0)
[28]
Lizaur-Utrilla et al. (2012)
24
0 (0)
N
4 (1)
–
4 (1)
16 (4)
–
0 (0)
Y
0 (0)
[29]
O’Toole et al. (2013)
13
–
–
–
–
–
0 (0)
–
–
–
–
[48]
Kamath et al. (2013)
12
–
–
–
–
–
–
8 (1)
–
–
–
[49]
Chemaly et al. (2013)
20
15 (3)
–
0 (0)
0 (0)
–
–
–
5 (1)
–
10 (2)
[50]
Floris et al. (2013)
39
–
Y
–
5 (2)
5 (1)
5 (2)
–
3 (1)
Y
–
[51]
–: Not reported; Dis: Dislocation; HO: Heterotopic ossification; Inf: Infection; N: No; Neu: Neurologic lesion; PPx: Prophylaxis; Rev: Revision; SL: Symptomatic loosening; TE: Thrombo-embolic; Y: Yes.
(44 cemented, 22 uncemented) at a mean follow-up of 9.6 years (range, 2–26 years). Interestingly, none of the cementless acetabular components demonstrated signs of radiographic loosening or were revised at the latest follow-up. Using all uncemented acetabular cups, Bellabarba et al. [30] reported a Kaplan–Meier survival rate of 97% at 10 years using radiographic loosening or revision for any reason as an endpoint. Only 1 out of 30 acetabular reconstructions required revision due to aseptic loosening at a mean follow-up of 63 months (range, 24–140). In summary, the use of cementless cups has resulted in better survivorship than their cemented counterparts. However, comparison of outcomes is difficult given the use of different implant designs. Sciatic nerve injury
Sciatic nerve palsies can occur iatrogenically from THA, regardless of the operative approach used. Huo et al. [6] reported one 302
sciatic nerve palsy in a study involving 21 acetabular fractures treated with a delayed cementless THA using a modified anterior approach. However, the authors did not specify whether this nerve palsy was present pre- or postoperatively. Zhang et al. [28] reported three iatrogenic postoperative sciatic nerve injuries in a series of 55 hips utilizing a posterolateral approach. In their follow-up, one patient had complete resolution of the nerve palsy, one had partial resolution and one never recovered. The sciatic nerve may be injured at the time of the initial injury. As a result, the sciatic nerve can be susceptible to further injury at the time of THA. Matta [1] reported nerve palsies in 32 patients at the time of initial injury in a study of 262 displaced acetabular fractures. Similarly, Weber et al. [3] noted a 19.6% (13 out of 66 hips) incidence at the time of fracture. Sciatic nerve palsies can also result from previous operative fixation of the acetabular fracture. Ranawat et al. [32] reported 8 out of 32 (25%) patients having sciatic nerve palsies prior to Expert Rev. Med. Devices 12(3), (2015)
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Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
Review
THA, of which two were caused iatro- Table 5. Blood loss. genically from previous procedures. AberStudy (year) THA Blood loss ml Operative time min Ref. rant retractors placing undue tension on Mean Range Mean Range the nerve along with prominent hardware outside of the acetabulum during screw Weber et al. (1998) 66 – – 170 90–315 [3] placement are potential contributing Huo et al. (1999) 21 960 500–2200 97 60–190 [6] factors. Bellabarba et al. 30 898 250–2900 179 90–300 [30] Multiple previous surgeries can cause distortion of anatomic planes and exces- (2001) sive scarring around the sciatic nerve. In Ranawat et al. (2009) 32 718 100–200 – – [32] fact, many surgeons consider delayed Chemaly et al. (2013) 20 416 200–1500 76 39–140 [50] THA in the setting of previous acetabular THA: Total hip arthroplasty. fracture revision hip surgery due to the scarring, potential pelvic deformity and bone loss, and overall higher risk of complications. Prior to fracture. Patients who present with an acetabular fracture are delayed THA, a thorough history and physical exam must be treated operatively or non-operatively based on a number of performed and documented in all patients. In addition, patients factors, including fracture pattern as described by Letournel must be appropriately counseled preoperatively on the potential and Judet [37], patient age and activity level, associated medical comorbidities, presence of osteochondral loose bodies and femrisk of neurological complications. oral head involvement. Fractures that are amenable to nonoperative treatment based on the aforementioned factors are Dislocation Ranawat et al. [32] reported three dislocations in a study involving allowed to consolidate over a period of 6–8 weeks. During this 32 hips (9%). Only one required component revision in the time, patients are allowed to progressively advance their weightform of a polyethylene liner exchange. However, the authors uti- bearing as dictated by clinical examination and fracture healing. lized a 10-degree lipped liner in 59% (19 out of 32) of their hips Routine plain radiographs are obtained at each office visit to enhance stability, which may have underestimated the actual including an AP pelvis, inlet, outlet, iliac oblique and obturator dislocation rate based on the fact design liners been used. These oblique view to monitor for fracture union. In patients who require operative fixation of a displaced acelipped liner constructs have become more widely used because of tabular fracture, we routinely consult our orthopedic traumatoltheir potential for improved stability over other THA designs. ogist where a collaborative operative treatment strategy is Similarly, Bellabarba et al. [30] used a 20-degree liner in 9 out of developed with the goal of restoring the articular anatomy. The 30 patients to achieve stability and reported no dislocations at a chosen surgical approach is largely based on the fracture patmean follow-up of 63 months (range, 24–140) using posterotern. We routinely risk stratify our patients for the developlateral, antero-lateral and transtrochanteric approaches. Huo ment of HO and order prophylaxis in the form of radiation et al. [6] reported one postoperative dislocation using a modified therapy and/or indomethacin in high-risk patients. The operaanterior approach in 21 hips. The dislocation was treated closed tive fixation of the acetabular fracture is performed with the with no need for subsequent component revision. Using a goal of avoiding subsequent THA. postero-lateral approach, Schreurs et al. [34] reported no dislocaIf post-traumatic arthritis develops, patients are counseled on tions in 20 patients treated with a cemented all-polyethylene cup and impaction bone grafting at a mean follow-up of 9.5 years the available salvage procedures including hip arthrodesis or THA. It is the preference of the senior author to perform a (range, 3–18 years). Pelvic deformity may lead to suboptimal component posi- THA in the setting of post-traumatic degenerative joint disease tioning, leading to higher rates of dislocation. However, surgi- (DJD), as the functional results of arthrodesis are largely infecal techniques to address these bony defects, such as structural rior to those of THA, even in the younger population. allografts and lipped liners, are subject to variability based on A thorough history and physical exam is performed in all surgeon training and preference. As mentioned above, the use patients to document any sensory or motor deficits and the of lipped liners is commonly used to achieve intraoperative sta- risks of the procedure, as mentioned earlier, are explained to bility, thus underestimating the true dislocation rate in this the patient. Preoperative planning begins with obtaining blood work to patient cohort. The presence of heterotopic bone, as well as residual pelvic deformity, can also lead to femoral component include a complete blood count, C-reactive protein and erythimpingement, resulting in dislocation if not properly identified rocyte sedimentation rate to screen for infection, as previous surgeries with retained hardware place the patient at an and addressed intraoperatively. increased risk of occult infection and subsequent periprosthetic joint infection. If these values are abnormal, we proceed with Author’s preferred treatment Emphasis is always placed on the prevention of post-traumatic hip aspiration. If the results of the hip aspiration are concernjoint disease in patients who present with an acetabular ing for infection, the treatment algorithm for the treatment of informahealthcare.com
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periprosthetic joint infection, as delineated by Della Valle et al. [38] and Parvizi et al. [31], is followed. In addition to plain radiographs, advanced imaging in the form of a CT scan of the pelvis and hip with 3D reconstructions are obtained in patients with significant pelvic deformity and/or bone loss for preoperative planning. All options to address pelvic deformity and/or bone loss are made available at the time of surgery including bone graft substitutes, structural allografts and metal augments. It is common for our institution to use primary constructs whenever possible in the post-traumatic arthritis setting. However, revision prostheses routinely made available at our institution include revision metal-backed cups, acetabular cages and lipped, offset and constrained liners. At the time of surgery, the surgical approach is largely based on surgeon training and preference, although previous incisions are preferably used. If the surgical exposure will be compromised, we will not hesitate to create a new incision. Although the risk of vascular compromise to skin surrounding the incision is not very high, efforts can made to incorporate previous incisions into new incisions to decrease potential vascular insult to the skin flaps as well as improve cosmesis. Postoperatively, patients are admitted to the hospital and placed on both mechanical and pharmacologic deep venous thromboembolic prophylaxis for at least 6 weeks. Physical therapy and occupational therapy commences as soon as the patient is able to participate, preferably on the day of surgery. The patient’s weight-bearing status is based on the degree and stability of the pelvic reconstruction and is made on a case-bycase basis. Patients are seen in follow-up in the office at 2 weeks for a wound check and suture/staple removal and then at 6 weeks, 12 weeks, 6 months, 1 year and annually thereafter.
increased risk for postoperative complication after THA, including HO, dislocation and periprosthetic joint infection. Though the complexity of the procedure from previous surgery and/or distorted native anatomy may be increased compared to THA performed for primary DJD, favorable clinical outcomes (TABLE 4) and implant survivorship rates can be obtained. Educating operating room personnel on the potential for increased operative time and blood loss is of paramount importance to minimize intraoperative complications as is having all implant options available at the time of surgery to reconstruct the pelvis and create a stable THA. The incidence of acetabular fracture has remained relatively constant over the past several decades. Patients across all age groups can be affected by this disabling condition stemming from high-energy injuries in the younger patient population to low-energy mechanical falls in the elderly. Therefore, it is unlikely that the rate of performing THA for failed acetabular fracture will decrease in the next 5 years. The literature contains mixed results on the clinical and radiographic outcomes after delayed THA performed for post-traumatic DJD after an acetabular fracture and as mentioned earlier, the reason for this likely multifactorial. With modern advances in bearing surfaces and prosthesis design, promising long-term results using cementless acetabular components are beginning to surface in the literature. Also, as our understanding of periprosthetic joint infection continues to evolve and advance, the prevention and treatment of this devastating complication can be minimized. In the future, prospective, randomized studies using standardized surgical techniques and comparing the outcomes of various implant designs will be needed. However, the heterogeneity in patient-, surgeon- and implant-related factors will continue to be obstacles in future study designs.
Expert commentary & five-year view
Acetabular fractures commonly develop into post-traumatic degenerative joint disease of the hip with a reported incidence of 12–57% [7,8]. Whether initial treatment of these injuries involves non-operative or operative strategies, the goal of treatment should be anatomic reduction of the articular surface with early mobilization to prevent concomitant morbidity from prolonged recumbancy. Non-operative treatment strategies can lead to loss of reduction before fracture consolidation and result in stiffness, malunion or nonunion, while operative measures can result in persistent pelvic deformity, excessive scar formation, heterotopic bone and retained hardware. Regardless of the initial treatment strategy, any or all of these factors can add to the complexity of future THA as a salvage operation. In addition, occult infection in the setting of previous surgery should always be ruled out. Once post-trauamtic DJD has developed, THA can be used as a salvage procedure. Patient should be counseled on the
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Financial & competing interests disclosure
M Mont receives royalties from Stryker and Wright Medical Technology, Inc. He is a paid consultant for DJ Orthopaedics, Janssen, Joint Active Systems, Medical Compression Systems, Medtronic, Sage Products, Inc., Stryker, TissueGene and Wright Medical Technology, Inc. He receives research support from DJ Orthopaedics, Joint Active Systems, National Institute of Health (NIAMS & NICHD), Sage Products, Inc., Strker, TissueGene and Wright Medical Technology, Inc. Medical/Orthopaedic publications editorial/governing board are American Journal of Orthopedics, the Journal of Athroplasty, the Journal of Bone and Joint Surgery – American, the Journal of Knee Surgery, Orthopedics and Surgical Techniques International. He is also an appointed board member of AAOS. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Expert Rev. Med. Devices 12(3), (2015)
Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
Review
Key issues .
Recent cementless designs show favorable functional outcomes and loosening rates.
.
Complications of total hip arthroplasty (THA) for post-traumatic arthritis are the formation of heterotopic bone, increased operative
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times and blood loss, aseptic loosening, sciatic nerve injury and dislocation. .
Heterotopic ossification prophylaxis with indomethacin or radiation may be considered in high-risk patients.
.
Cemented acetabular components have higher rates of loosening and failure compared to cementless.
.
Patients undergoing THA for post-traumatic arthritis have longer operation times, but no difference in blood loss.
.
Those who undergo delayed THA for post-traumatic arthritis have a higher risk of sciatic nerve injury.
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Expert Rev. Med. Devices 12(3), (2015)
Review
Outcomes of delayed total hip arthroplasty in patients with a previous ipsilateral acetabular fracture Expert Rev. Med. Devices 12(3), 297–306 (2015)
Eddie S Wu, Julio J Jauregui, Samik Banerjee, Jeffrey J Cherian and Michael A Mont* Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA *Author for correspondence: Tel.: +1 410 601 8500 Fax: +1 410 601 8501 [email protected]
Post-traumatic arthritis of the hip can develop in 12–57% of patients after an acetabular fracture. Once it develops, salvage treatment options include arthroplasty or arthrodesis. Delayed total hip arthroplasty (THA) has been shown to be a viable treatment option to decrease pain, improve stability and increase functional outcomes. Using cemented designs, earlier long-term studies reported satisfactory functional outcomes of delayed THA used to treat previously failed acetabular fractures. However, high aseptic loosening rates were also observed. Recent advances in cementless acetabular designs have shown comparable functional outcomes and loosening rates compared to those undergoing THA for non-traumatic arthritis. However, even with improvements in functional and radiographic outcomes, unique complications are commonly encountered in patients with previous acetabular fractures, including heterotopic bone around the hip, increased operative times and blood loss, aseptic loosening, sciatic nerve injury and dislocation. The outcomes and complications of delayed THA in patients with previous acetabular fracture will be reviewed. KEYWORDS: acetabular . arthroplasty . fracture . hip . post-traumatic
Acetabular fractures can result from both highand low-energy mechanisms of injury in both young and elderly patient populations. Anatomic reduction with rigid internal fixation of the acetabulum has been shown to minimize the risk of developing post-traumatic arthritis [1,2]. Unfortunately, these fractures commonly lead to arthritic hip disease regardless of whether non-operative or operative intervention was initially chosen [3,4]. Several factors play a role in the development of secondary arthritis, including quality of articular reduction/fixation, presence of femoral head osteochondral defects and/or acetabulum and osteonecrotic fracture fragments [5,6]. Studies have reported between 12 and 57% of patients with acetabular fractures subsequently developing post-traumatic arthritis [7,8]. Historically, most were treated non-operatively, which often resulted in suboptimal outcomes [9–11]. Therefore, many surgeons currently treat these injuries surgically depending on the magnitude of displacement and fracture
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10.1586/17434440.2015.1026327
pattern with various strategies, including percutaneous fixation [12–14], open reduction internal fixation [15,16] or hip arthroplasty [17,18]. Even when operative treatment goals are achieved, arthritis can develop in up to 30% of patients [1,2,7,19,20]. Once post-traumatic joint disease develops, total hip arthroplasty (THA) or arthrodesis may be the only options available. Delayed THA can be an effective strategy for post-traumatic joint disease. However, studies have described inferior THA outcomes performed in the setting of a previous acetabular fracture when compared to THA for primary hip osteoarthritis [3,5,21,22]. However, with surgical technique and implant design advancements, improved outcomes with modern cementless acetabular components have been reported [23]. Some have reported acetabular component revision rates comparable to THA performed for primary osteoarthritis [24–27]. Impaction grafting used cemented all-polyethylene cups has also shown promising results in restoring acetabular bony defects [28–30].
2015 Informa UK Ltd
ISSN 1743-4440
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A delayed THA can provide excellent outcomes. However, this procedure brings a unique set of potential complications. There is an increased risk for infection, sciatic nerve palsy, loosening and/or dislocation [6,28,30,31]. For example, if nonoperative treatment was initially chosen, native anatomy may be altered from acetabular malunion/nonunion. If operative fixation was initially performed, it may be complicated by pelvic deformity, previous hardware, scar tissue and heterotopic bone [28,32]. In addition, one must always consider risk of occult infection when contemplating arthroplasty after prior surgery [31]. Our purpose was to review the literature describing THA as a treatment option for post-traumatic hip joint disease after acetabular fractures. We focused on clinical outcomes as they pertain to the acetabulum and potential complications. Methods
The electronic databases PubMed, EMBASE and Ovid were used to query potentially relevant reports addressing secondary post-acetabular fracture hip arthritis treated with hip arthroplasty. Initial search string was: ‘fract* AND acetab* AND arthropl* or replace*’ which returning 88 articles. After review, 11 reports used THA to manage post-traumatic hip disease. Reference lists of these reports returned 19 additional studies, yielding 30 relevant articles. Of those, four did not describe results and three were case reports, leading to 22 reports included in this review (TABLE 1). Outcomes
Multiple studies have documented inferior outcomes with cemented acetabular components for post-traumatic arthritis compared to cementless components [3,21,33]. Factors that might contribute include early cementing techniques, poor cement interdigitation into sclerotic bone, younger age and the distorted acetabular anatomy [5]. Cementless acetabular components have become popular for acetabular fixation in this setting. Furthermore, we have analyzed the difference in Harris hip scores (HHS) and implant survivorship between cementless and cemented fixation. Harris hip scores
Historically, inferior outcomes were reported for THA performed for post-traumatic arthritis when compared to degenerative disease [21,22]. Lizaur-Utrilla et al. [29] compared the outcomes of THA for both patient subsets (n = 24 vs 48 patients). Mean age was 56 years (range, 28–77). After a mean follow-up of approximately 8 years (range, 5–15 years), there were significantly lower HHS in the post-traumatic cohort (77 vs 88 points; p = 0.03). Conversely, Ranawat et al. [32] reported favorable outcomes in 32 patients with post-traumatic THAs. At 4.7 years follow-up (range, 2–9.7), patients who had undergone prior open reduction internal fixation had a higher mean HHS than those managed non-operatively; however, this difference was not significant (84 vs 74 points, respectively; p = 0.33). 298
Additionally, bone grafting with cementation has shown encouraging results in recent studies [28,30,34]. In a prospective 30 hip studies, Bellabarba et al. [30] reported good results in 27 of 30 (90%) patients treated with cementless acetabular components. Similarly, Schreurs et al. [34] retrospectively studied 20 patients who had some degree of acetabular bone stock deficiency by the American Academy of Orthopaedic Surgeons classification [35]. Acetabular defects were treated with autograft and/or allograft bone chips with a cemented all-polyethylene cup. At a follow-up of 9.5 years (range, 3–18), the mean HHS was 93 points (range, 62–100 points) in the 16 surviving patients, 14 who were pain free. Zhang et al. [28] assessed the ability to restore hip center using an acetabular reinforcement ring and a cemented cup in patients treated with prior open reduction internal fixation (n = 49 hips). At 64 months followup, (range, 32–123), mean HHS increased significantly from preoperative levels (49.5–90; p < 0.001). Implant survivorship
As with patient-reported outcomes, implant survivorship has been lower in THA for post-traumatic arthritis [21,22]. In a study of 55 cemented THAs performed, Romness et al. [21] had 52.9% acetabular loosenings and 13.7% revisions rate at a follow-up of 7.3 years (range, 7 days to 16.6). Comparison to a control cohort of 231 ‘routine’ THAs revealed a four- to fivefold increase in the rate of component loosening in the fracture group [36]. Young age may be a contributing factor, particularly with cemented components. Weber et al. [3] evaluated outcomes in 66 THAs performed at a mean follow-up of 112 months (range, 24–240). A cemented technique was utilized in 66% (44 out of 66 THAs) and a cementless technique in 33% (22 out of 66 THAs). Mean age was 52 years (range 19–88). Overall acetabular implant survivorship was 87% (95% CI: 76–99%). An age of less than 50 years was a significant risk factor for revision (p = 0.02). They attributed this high failure rate to Charnley class A involvement (unilateral joint disease), a predominantly male cohort and the young age. More recently, cementless acetabular components have had good survivorship. Bellabarba et al. [30] (n = 30 patients) using radiographic loosening or revision as an endpoint had a 10-year Kaplan–Meier survivorship of 97%. Similarly, Ranawat et al. [32], using revision of any kind as an endpoint, found Kaplan–Meier survivorship at 5 years to be 79%, but increased to 97% when only aseptic acetabular loosening was an endpoint. They concluded that excellent clinical outcomes could be obtained with cementless acetabular fixation. Berry and Halasy [33] further supported the use of uncemented acetabular components. In 34 hips in 33 patients who had a mean age of 49.8 years (range, 19–78), there were nine acetabular revisions at mean follow-up of approximately 12 years (range, 10–16). Of the 26 acetabular components with a minimum 10 years follow-up, only two were loose. The authors found high rates of acetabular osteolysis, which they attributed to the younger population. Of note is that the bearing surfaces used in this study included a metal femoral head on conventional Expert Rev. Med. Devices 12(3), (2015)
Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
Review
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Table 1. Studies. Study (year)
THA
Age (range), years
Follow-up (range), months
Cemented versus cementless
Type of THA
Liner
Level of evidence
Boardman and Charnley (1978)
68
55
–
Not stated
Not stated
Not stated
IV
[39]
(24–77)
–
Romness and Lewallen (1990)
55
53 Cementless
Not stated
Not stated
IV
[21]
Pritchett and Bortel (1991)
19
Cementless
Not stated
Not stated
IV
[40]
Weber et al. (1998)
66
44 Cemented
54 standard; 2 rings
Not stated
IV
[3]
Huo et al. (1999)
21
Cementless
Standard hip prosthesis
Not stated
IV
[6]
Bellabarba et al. (2001)
30
Cementless
Standard hip prosthesis
21 lipped; 9 offset
III
[30]
Berry and Halasy, 2002
34
Cementless
33 standard; 1 dual mobility
Not stated
IV
[33]
Schreurs et al. (2005)
20
Cemented
Not stated
Not stated
IV
[34]
Glas et al. (2005)
40
32 Cementless
37 standard; 2 rings; 1 cage
Not stated
IV
[41]
Pavelka et al. (2006)
49
38 Cemented
Standard hip prosthesis
Not stated
IV
[42]
Sermon et al. (2008)
57
Cementless
Not stated
Not stated
III
[43]
Ranawat et al. (2009)
32
Cementless
Standard hip prosthesis
19 offset; 13 lipped
IV
[32]
Carroll et al. (2010)
26
Not stated
Not stated
Not stated
IV
[45]
Zhang et al. (2011)
55
47 Cementless
50 standard; 5 rings
Not stated
IV
[28]
Lizaur-Utrilla et al. (2012)
24
Cementless
Standard hip prosthesis
Not stated
III
[29]
Dunet et al. (2013)
25
Not stated
Not stated
Not stated
IV
[47]
Kamath et al. (2013)
12
Cementless
Standard hip prosthesis
Not stated
IV
[49]
Chemaly et al. (2013)
20
Cementless
Standard hip prosthesis
Not stated
IV
[50]
Floris et al. (2013)
39
29 Cemented
Standard hip prosthesis
Not stated
IV
[51]
56
88
(19–91)
(1–199)
49
34
–
(24 to –)
52
112
(19–80)
(24–240)
52
65
(23–78)
(48–104)
51
63
(26–86)
(24–140)
50
143
(19–78)
(120–192)
53
112
(35–75)
(36–216)
50
52
–
–
42
42
–
(18–92)
53
78
(18–95)
(18–95)
–
56
–
(24–116)
67
63
(56–89)
(24–188)
47
64
(22–65)
(32–123)
56
101
(28–77)
(60–180)
41
82
(16–75)
(3–132)
57
39
(29–88)
(24–49)
60
29
(28–89)
(9–61)
45
–
(25–73)
(– to 48)
Ref.
THA: Total hip arthroplasty.
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Complications
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Table 2. (Initial management). Study (year)
THA
Non-operative% (n)
ORIF% (n)
Boardman and Charnley (1978)
68
–
19 (13)
[39]
Romness and Lewallen (1990)
55
76 (42)
24 (13)
[21]
Pritchett and Bortel (1991)
19
–
–
[40]
Weber et al. (1998)
66
0 (0)
100 (66)
[3]
Huo et al. (1999)
21
67 (14)
33 (7)
[6]
Bellabarba et al. (2001)
30
50 (15)
50 (15)
[30]
Berry and Halasy (2002)
34
56 (19)
44 (15)
[33]
Schreurs et al. (2005)
20
40 (8)
60 (12)
[34]
Glas et al. (2005)
40
43 (17)
58 (23)
[41]
Pavelka et al. (2006)
49
–
–
[42]
Sermon et al. (2008)
57
11 (6)
89 (51)
[43]
Ranawat et al. (2009)
32
25 (8)
75 (24)
[32]
Chu et al. (2010)
18
–
–
[44]
Carroll et al. (2010)
26
–
–
[45]
Zhang et al. (2011)
55
42 (23)
58 (32)
[28]
Shang et al. (2012)
13
23 (3)
77 (10)
[46]
Lizaur-Utrilla et al. (2012)
24
63 (15)
38 (9)
[29]
Dunet et al. (2013)
25
36 (9)
64 (16)
[47]
O’Toole et al. (2013)
13
0 (0)
100 (13)
[48]
Kamath et al. (2013)
12
–
–
[49]
Chemaly et al. (2013)
20
10 (2)
90 (18)
[50]
Floris et al. (2013)
39
–
–
[51]
41 (236)
59 (337)
ORIF: Open reduction and internal fixation; THA: Total hip arthroplasty.
polyethylene that was g-irradiated in air. Modern polyethylene might have led to less acetabular osteolysis. The use of bone grafting with cementation has also shown good implant survivorship. Schreurs et al. [34] (n = 20 patients) had only two patients revised at a follow-up of 9.5 years (range, 3–18). One was revised for septic loosening and the other for aseptic loosening at 14.5 years and 15.3 years, respectively. Using acetabular revision as an endpoint, Kaplan–Meier survival rate was 100% at 10 years and 80% at 15 years (95% CI: range, 62–98%). They stressed the excellent long-term clinical outcomes obtained, particularly in young patients. In summary, there are mixed results on the outcomes of THA after an acetabular fracture. Reasons may be multifactorial with differing fracture pattern, patient cohorts and surgical techniques used. In general, cemented components have led to higher rates of loosening when compared to cementless components (TABLES 2 & 3). 300
Ref.
These patients often have higher complication rates when compared to primary osteoarthritis. These complications include heterotopic bone around the hip, aseptic loosening, sciatic nerve injury and dislocation (TABLE 4). Heterotopic bone
Heterotopic bone can form from soft tissue trauma at the time of injury, as well as from previous surgical procedures. Also, concomitant closed head injuries are common and can lead to a higher risk of developing heterotopic bone. Heterotopic bone can lead to an increased operative time and blood loss. Ranawat et al. [32] reported 53% (n = 17 out of 32 patients) of patients having heterotopic ossification (HO). However, not all heterotopic bone around the hip requires removal at the time of THA. Zhang et al. [28] found a 31% (n = 16 of 51 hips) incidence of HO. All patients received HO prophylaxis in the form of indomethacin 25 mg twice a day for 4 weeks, and no patients in this cohort developed Brooker class IV HO. Those at high risk of developing HO, such as males with closed head injuries and previous surgical procedures, should be considered for prophylaxis perioperatively in the form of radiation and/or indomethacin or a similar agent and counseled on the increased risks at the time of THA if ectopic bone has already developed and matured.
Increased operative times & blood loss
Increased operative times and blood loss are commonly encountered. Bellabarba et al. [30] (n = 30 patients) reported significant differences in both the mean operative time (p < 0.001) and blood loss (p < 0.001) in their prospective study comparing a post-traumatic arthritis cohort to a nontraumatic cohort. The post-traumatic group had a mean operative time of 179 min (range, 90–300 min) compared to 122 min (range, 46–300 min). The mean intraoperative blood loss in the post-traumatic group was 898 ml (range, 250–2900) compared to 413 ml (range, 125–1800) in the non-traumatic group. Average perioperative transfusion requirements were also found to be significant (2.2 vs 1.3 units, p < 0.001). Similarly, in a prospective, matched cohort study, LizaurUtrilla et al. [29] found significant differences in the mean operative times of 24 patients who underwent THA for posttraumatic osteoarthritis compared to the 48 individuals in a non-traumatic cohort (81 vs 73 min; p = 0.002). However, the Expert Rev. Med. Devices 12(3), (2015)
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Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
incidence of blood transfusion was 16.7% (4 out of 24 hips) and 14.6% (7 out of 48 hips), respectively (p = 0.43). Therefore, they concluded that those with post-traumatic arthritis may have an increase in operative time, but no increased risk of requiring blood transfusions. Ranawat et al. [32] reported an average blood loss of 718 ml (range, 100 ml to 2 l) in 37 patients. No differences in blood loss were noted between those who were initially treated non-operatively versus those treated operatively. Using a cementless design on both the acetabular and femoral side, Huo et al. [6] found a mean estimated blood loss of 960 ml (range, 500–2200 ml) and a mean operative time of 97 min (range, 60–190 min). The degree of scarring from previous procedures, residual pelvic deformity and presence of heterotopic bone and retained hardware necessitating removal are all contributing factors to the potentially increased surgical time and average blood loss. Intuitively, the complexity of the procedure is likely correlated with the operative time and average blood loss (TABLE 5). Despite these results, there were no studies that reported how blood loss was measured, and this is a weakness that should be addressed in future studies.
Table 3. (Outcomes).
Aseptic loosening
Previous studies have reported on aseptic loosening rates using only cemented components, and some studies have even included both cemented and uncemented acetabular components in their results. Therefore, direct comparison across studies is difficult since cemented acetabular components have largely been abandoned. Romness et al. [21] reported a greater than 50% acetabular loosening rate at a mean follow-up of 7.3 years (range, 7 days–16.6 years) using a cemented cup in patients with a previous acetabular fracture and equated this to a four- to fivefold increase in loosening when compared to patients who underwent THA for non-traumatic reasons. Weber et al. [3] reported a Kaplan–Meier survival rate of 87% (95% CI: 76–99%) for the acetabular component informahealthcare.com
Review
Study (year)
THA
Preoperative HHS (range) points
Postoperative HHS (range) points
Survivorship Kaplan–Meier % (confidence interval)
Ref.
Boardman and Charnley (1978)
68
– –
– –
– –
[39]
Romness and Lewallen (1990)
55
– –
– –
89 –
[21]
Pritchett and Bortel (1991)
19
42 –
84 –
– –
[40]
Weber et al. (1998)
66
49 –
93 –
87 (76–99)
[3]
Huo et al. (1999)
21
30 –
90 –
91 –
[6]
Bellabarba et al. (2001)
30
41 –
88 (47–100)
97 (95–100)
[30]
Berry and Halasy (2002)
34
– –
– –
93 –
[33]
Schreurs et al. (2005)
20
44 (32–61)
93 (62–100)
100 –
[34]
Glas et al. (2005)
40
– –
– –
90 –
[41]
Pavelka et al. (2006)
49
– –
– –
– –
[42]
Sermon et al. (2008)
57
– –
– –
– –
[43]
Ranawat et al. (2009)
32
28 (0–56)
82 (20–100)
97 –
[32]
Chu et al. (2010)
18
50 (26–70)
86 (80–92)
– –
[44]
Carroll et al. (2010)
26
– –
– –
– –
[45]
Zhang et al. (2011)
55
49 –
90 (56–100)
98 –
[28]
Shang et al. (2012)
13
37 –
83 –
– –
[46]
Lizaur-Utrilla et al. (2012)
24
35 –
77 (45–94)
90 (87–93)
[29]
Dunet et al. (2013)
25
– –
– –
– –
[47]
O’Toole et al. (2013)
13
– –
– –
– –
[48]
Kamath et al. (2013)
12
– –
– –
– –
[49]
Chemaly et al. (2013)
20
– –
– –
– –
[50]
Floris et al. (2013)
39
42 –
81 (52–96)
– –
[51]
HHS: Harris hip scores; THA: Total hip arthroplasty.
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Table 4. (Complications). Study (year)
n THA
HO% (n)
HO PPx
Dis% (n)
Inf% (n)
Neu% (n)
Rev% (n)
SL% (n)
TE% (n)
TE PPx
Death% (n)
Ref.
Boardman and Charnley (1978)
68
22 (15)
–
–
1 (1)
–
–
–
9 (6)
–
4 (3)
[39]
Romness and Lewallen (1990)
55
–
–
–
2 (1)
–
13 (7)
13 (7)
–
–
7 (4)
[21]
Pritchett and Bortel (1991)
19
0 (0)
Y
0 (0)
0 (0)
5 (1)
0 (0)
0 (0)
0 (0)
–
–
[40]
Weber et al. (1998)
66
39 (26)
–
5 (3)
0 (0)
2 (1)
5 (10)
14 (9)
2 (1)
–
–
[3]
Huo et al. (1999)
21
29 (6)
–
5 (1)
0 (0)
5 (1)
10 (2)
5 (1)
0 (0)
Y
0 (0)
[6]
Bellabarba et al. (2001)
30
34 (13)
Y
–
0 (0)
–
3 (1)
3 (1)
0 (0)
Y
0 (0)
[30]
Berry and Halasy (2002)
34
–
–
9 (3)
3 (1)
–
26 (9)
6 (2)
0 (0)
–
0 (0)
[33]
Schreurs et al. (2005)
20
–
Y
–
5 (1)
–
10 (2)
–
–
Y
–
[34]
Glas et al. (2005)
40
18 (7)
–
10 (4)
3 (1)
5 (2)
18 (7)
–
–
–
–
[41]
Pavelka et al. (2006)
49
0 (0)
–
–
–
–
–
–
–
–
–
[42]
Sermon et al. (2008)
57
40 (23)
–
–
0 (0)
–
21 (12)
–
0 (0)
–
0 (0)
[43]
Ranawat et al. (2009)
32
44 (14)
Y
9 (3)
19 (6)
–
19 (6)
6 (2)
0 (0)
–
3 (1)
[32]
Zhang et al. (2011)
55
29 (16)
Y
2 (1)
0 (0)
5 (3)
2 (1)
2 (1)
–
–
0 (0)
[28]
Lizaur-Utrilla et al. (2012)
24
0 (0)
N
4 (1)
–
4 (1)
16 (4)
–
0 (0)
Y
0 (0)
[29]
O’Toole et al. (2013)
13
–
–
–
–
–
0 (0)
–
–
–
–
[48]
Kamath et al. (2013)
12
–
–
–
–
–
–
8 (1)
–
–
–
[49]
Chemaly et al. (2013)
20
15 (3)
–
0 (0)
0 (0)
–
–
–
5 (1)
–
10 (2)
[50]
Floris et al. (2013)
39
–
Y
–
5 (2)
5 (1)
5 (2)
–
3 (1)
Y
–
[51]
–: Not reported; Dis: Dislocation; HO: Heterotopic ossification; Inf: Infection; N: No; Neu: Neurologic lesion; PPx: Prophylaxis; Rev: Revision; SL: Symptomatic loosening; TE: Thrombo-embolic; Y: Yes.
(44 cemented, 22 uncemented) at a mean follow-up of 9.6 years (range, 2–26 years). Interestingly, none of the cementless acetabular components demonstrated signs of radiographic loosening or were revised at the latest follow-up. Using all uncemented acetabular cups, Bellabarba et al. [30] reported a Kaplan–Meier survival rate of 97% at 10 years using radiographic loosening or revision for any reason as an endpoint. Only 1 out of 30 acetabular reconstructions required revision due to aseptic loosening at a mean follow-up of 63 months (range, 24–140). In summary, the use of cementless cups has resulted in better survivorship than their cemented counterparts. However, comparison of outcomes is difficult given the use of different implant designs. Sciatic nerve injury
Sciatic nerve palsies can occur iatrogenically from THA, regardless of the operative approach used. Huo et al. [6] reported one 302
sciatic nerve palsy in a study involving 21 acetabular fractures treated with a delayed cementless THA using a modified anterior approach. However, the authors did not specify whether this nerve palsy was present pre- or postoperatively. Zhang et al. [28] reported three iatrogenic postoperative sciatic nerve injuries in a series of 55 hips utilizing a posterolateral approach. In their follow-up, one patient had complete resolution of the nerve palsy, one had partial resolution and one never recovered. The sciatic nerve may be injured at the time of the initial injury. As a result, the sciatic nerve can be susceptible to further injury at the time of THA. Matta [1] reported nerve palsies in 32 patients at the time of initial injury in a study of 262 displaced acetabular fractures. Similarly, Weber et al. [3] noted a 19.6% (13 out of 66 hips) incidence at the time of fracture. Sciatic nerve palsies can also result from previous operative fixation of the acetabular fracture. Ranawat et al. [32] reported 8 out of 32 (25%) patients having sciatic nerve palsies prior to Expert Rev. Med. Devices 12(3), (2015)
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Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
Review
THA, of which two were caused iatro- Table 5. Blood loss. genically from previous procedures. AberStudy (year) THA Blood loss ml Operative time min Ref. rant retractors placing undue tension on Mean Range Mean Range the nerve along with prominent hardware outside of the acetabulum during screw Weber et al. (1998) 66 – – 170 90–315 [3] placement are potential contributing Huo et al. (1999) 21 960 500–2200 97 60–190 [6] factors. Bellabarba et al. 30 898 250–2900 179 90–300 [30] Multiple previous surgeries can cause distortion of anatomic planes and exces- (2001) sive scarring around the sciatic nerve. In Ranawat et al. (2009) 32 718 100–200 – – [32] fact, many surgeons consider delayed Chemaly et al. (2013) 20 416 200–1500 76 39–140 [50] THA in the setting of previous acetabular THA: Total hip arthroplasty. fracture revision hip surgery due to the scarring, potential pelvic deformity and bone loss, and overall higher risk of complications. Prior to fracture. Patients who present with an acetabular fracture are delayed THA, a thorough history and physical exam must be treated operatively or non-operatively based on a number of performed and documented in all patients. In addition, patients factors, including fracture pattern as described by Letournel must be appropriately counseled preoperatively on the potential and Judet [37], patient age and activity level, associated medical comorbidities, presence of osteochondral loose bodies and femrisk of neurological complications. oral head involvement. Fractures that are amenable to nonoperative treatment based on the aforementioned factors are Dislocation Ranawat et al. [32] reported three dislocations in a study involving allowed to consolidate over a period of 6–8 weeks. During this 32 hips (9%). Only one required component revision in the time, patients are allowed to progressively advance their weightform of a polyethylene liner exchange. However, the authors uti- bearing as dictated by clinical examination and fracture healing. lized a 10-degree lipped liner in 59% (19 out of 32) of their hips Routine plain radiographs are obtained at each office visit to enhance stability, which may have underestimated the actual including an AP pelvis, inlet, outlet, iliac oblique and obturator dislocation rate based on the fact design liners been used. These oblique view to monitor for fracture union. In patients who require operative fixation of a displaced acelipped liner constructs have become more widely used because of tabular fracture, we routinely consult our orthopedic traumatoltheir potential for improved stability over other THA designs. ogist where a collaborative operative treatment strategy is Similarly, Bellabarba et al. [30] used a 20-degree liner in 9 out of developed with the goal of restoring the articular anatomy. The 30 patients to achieve stability and reported no dislocations at a chosen surgical approach is largely based on the fracture patmean follow-up of 63 months (range, 24–140) using posterotern. We routinely risk stratify our patients for the developlateral, antero-lateral and transtrochanteric approaches. Huo ment of HO and order prophylaxis in the form of radiation et al. [6] reported one postoperative dislocation using a modified therapy and/or indomethacin in high-risk patients. The operaanterior approach in 21 hips. The dislocation was treated closed tive fixation of the acetabular fracture is performed with the with no need for subsequent component revision. Using a goal of avoiding subsequent THA. postero-lateral approach, Schreurs et al. [34] reported no dislocaIf post-traumatic arthritis develops, patients are counseled on tions in 20 patients treated with a cemented all-polyethylene cup and impaction bone grafting at a mean follow-up of 9.5 years the available salvage procedures including hip arthrodesis or THA. It is the preference of the senior author to perform a (range, 3–18 years). Pelvic deformity may lead to suboptimal component posi- THA in the setting of post-traumatic degenerative joint disease tioning, leading to higher rates of dislocation. However, surgi- (DJD), as the functional results of arthrodesis are largely infecal techniques to address these bony defects, such as structural rior to those of THA, even in the younger population. allografts and lipped liners, are subject to variability based on A thorough history and physical exam is performed in all surgeon training and preference. As mentioned above, the use patients to document any sensory or motor deficits and the of lipped liners is commonly used to achieve intraoperative sta- risks of the procedure, as mentioned earlier, are explained to bility, thus underestimating the true dislocation rate in this the patient. Preoperative planning begins with obtaining blood work to patient cohort. The presence of heterotopic bone, as well as residual pelvic deformity, can also lead to femoral component include a complete blood count, C-reactive protein and erythimpingement, resulting in dislocation if not properly identified rocyte sedimentation rate to screen for infection, as previous surgeries with retained hardware place the patient at an and addressed intraoperatively. increased risk of occult infection and subsequent periprosthetic joint infection. If these values are abnormal, we proceed with Author’s preferred treatment Emphasis is always placed on the prevention of post-traumatic hip aspiration. If the results of the hip aspiration are concernjoint disease in patients who present with an acetabular ing for infection, the treatment algorithm for the treatment of informahealthcare.com
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Wu, Jauregui, Banerjee, Cherian & Mont
periprosthetic joint infection, as delineated by Della Valle et al. [38] and Parvizi et al. [31], is followed. In addition to plain radiographs, advanced imaging in the form of a CT scan of the pelvis and hip with 3D reconstructions are obtained in patients with significant pelvic deformity and/or bone loss for preoperative planning. All options to address pelvic deformity and/or bone loss are made available at the time of surgery including bone graft substitutes, structural allografts and metal augments. It is common for our institution to use primary constructs whenever possible in the post-traumatic arthritis setting. However, revision prostheses routinely made available at our institution include revision metal-backed cups, acetabular cages and lipped, offset and constrained liners. At the time of surgery, the surgical approach is largely based on surgeon training and preference, although previous incisions are preferably used. If the surgical exposure will be compromised, we will not hesitate to create a new incision. Although the risk of vascular compromise to skin surrounding the incision is not very high, efforts can made to incorporate previous incisions into new incisions to decrease potential vascular insult to the skin flaps as well as improve cosmesis. Postoperatively, patients are admitted to the hospital and placed on both mechanical and pharmacologic deep venous thromboembolic prophylaxis for at least 6 weeks. Physical therapy and occupational therapy commences as soon as the patient is able to participate, preferably on the day of surgery. The patient’s weight-bearing status is based on the degree and stability of the pelvic reconstruction and is made on a case-bycase basis. Patients are seen in follow-up in the office at 2 weeks for a wound check and suture/staple removal and then at 6 weeks, 12 weeks, 6 months, 1 year and annually thereafter.
increased risk for postoperative complication after THA, including HO, dislocation and periprosthetic joint infection. Though the complexity of the procedure from previous surgery and/or distorted native anatomy may be increased compared to THA performed for primary DJD, favorable clinical outcomes (TABLE 4) and implant survivorship rates can be obtained. Educating operating room personnel on the potential for increased operative time and blood loss is of paramount importance to minimize intraoperative complications as is having all implant options available at the time of surgery to reconstruct the pelvis and create a stable THA. The incidence of acetabular fracture has remained relatively constant over the past several decades. Patients across all age groups can be affected by this disabling condition stemming from high-energy injuries in the younger patient population to low-energy mechanical falls in the elderly. Therefore, it is unlikely that the rate of performing THA for failed acetabular fracture will decrease in the next 5 years. The literature contains mixed results on the clinical and radiographic outcomes after delayed THA performed for post-traumatic DJD after an acetabular fracture and as mentioned earlier, the reason for this likely multifactorial. With modern advances in bearing surfaces and prosthesis design, promising long-term results using cementless acetabular components are beginning to surface in the literature. Also, as our understanding of periprosthetic joint infection continues to evolve and advance, the prevention and treatment of this devastating complication can be minimized. In the future, prospective, randomized studies using standardized surgical techniques and comparing the outcomes of various implant designs will be needed. However, the heterogeneity in patient-, surgeon- and implant-related factors will continue to be obstacles in future study designs.
Expert commentary & five-year view
Acetabular fractures commonly develop into post-traumatic degenerative joint disease of the hip with a reported incidence of 12–57% [7,8]. Whether initial treatment of these injuries involves non-operative or operative strategies, the goal of treatment should be anatomic reduction of the articular surface with early mobilization to prevent concomitant morbidity from prolonged recumbancy. Non-operative treatment strategies can lead to loss of reduction before fracture consolidation and result in stiffness, malunion or nonunion, while operative measures can result in persistent pelvic deformity, excessive scar formation, heterotopic bone and retained hardware. Regardless of the initial treatment strategy, any or all of these factors can add to the complexity of future THA as a salvage operation. In addition, occult infection in the setting of previous surgery should always be ruled out. Once post-trauamtic DJD has developed, THA can be used as a salvage procedure. Patient should be counseled on the
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Financial & competing interests disclosure
M Mont receives royalties from Stryker and Wright Medical Technology, Inc. He is a paid consultant for DJ Orthopaedics, Janssen, Joint Active Systems, Medical Compression Systems, Medtronic, Sage Products, Inc., Stryker, TissueGene and Wright Medical Technology, Inc. He receives research support from DJ Orthopaedics, Joint Active Systems, National Institute of Health (NIAMS & NICHD), Sage Products, Inc., Strker, TissueGene and Wright Medical Technology, Inc. Medical/Orthopaedic publications editorial/governing board are American Journal of Orthopedics, the Journal of Athroplasty, the Journal of Bone and Joint Surgery – American, the Journal of Knee Surgery, Orthopedics and Surgical Techniques International. He is also an appointed board member of AAOS. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. No writing assistance was utilized in the production of this manuscript.
Expert Rev. Med. Devices 12(3), (2015)
Outcomes of delayed THA in patients with a previous ipsilateral acetabular fracture
Review
Key issues .
Recent cementless designs show favorable functional outcomes and loosening rates.
.
Complications of total hip arthroplasty (THA) for post-traumatic arthritis are the formation of heterotopic bone, increased operative
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times and blood loss, aseptic loosening, sciatic nerve injury and dislocation. .
Heterotopic ossification prophylaxis with indomethacin or radiation may be considered in high-risk patients.
.
Cemented acetabular components have higher rates of loosening and failure compared to cementless.
.
Patients undergoing THA for post-traumatic arthritis have longer operation times, but no difference in blood loss.
.
Those who undergo delayed THA for post-traumatic arthritis have a higher risk of sciatic nerve injury.
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Expert Rev. Med. Devices 12(3), (2015)
