Acute Total Hip Arthroplasty

With concerns about potential failures of fixation or that a "wait and see" attitude in a displaced acetabular injury will produce significant morbidity to that patient, the options for treatment of acetabular fractures in the elderly become limited. The use of an acute arthroplasty for these patients may result in failure due to the development of pelvic nonunions, or insufficient bone stock resulting in loosening of the implants. In addition to these problems and concerns for failures from late arthroplasties, including the potential need for revisions or the use of multiple procedures performed through compromised tissues, investigations have resulted in the development of therapeutic alternatives for the management of these patients.

A suggested option is to combine procedures in an attempt to improve function and decrease morbidity. A combined approach, consisting of stabilization of the acetabular fracture along with immediate application of a total hip arthroplasty, has certain advantages (9,19,64,65,96). First, fixing the acetabular fracture stability to the pelvis allows a solid base to be built for the placement of a total hip. Second, fixing the fracture may help prevent the development of severe deformity of the pelvis and avoid the development of a nonunion. Last, it should be remembered that, since the goal is a rigid and stable fixation of the fracture, an anatomic reduction of the acetabulum is not necessary for success of this technique. Once the acetabular fracture has been stabilized, then the application of an acute arthroplasty of the hip can be performed (Fig. 10A-F). A combined approach, however, is not recommended for all elderly patients. Indeed, most elderly patients with acetabular fractures either present with nondisplaced injuries requiring nonoperative management, or with displaced fractures, who also possess excellent bone stock, for whom fixation using standard open reduction techniques produces satisfactory results (19,45). It is primarily recommended for acetabular fractures in the elderly who have also have arthritis of the hip joint, significant osteoporosis producing fractures that are not classifiable radiographically, those injuries resulting from low-energy mechanisms that produce marked displacement of the columns involving the weight-bearing dome, and in patients who present with associated fractures of the femoral head.

Butt Xrays

Figure 10 (A) Antero-posterior (AP) radiograph of a 73-year-old male who sustained an acetabular fracture after a motor vehicle accident. Notice the impaction of the roof and the medial displacement of the anterior and posterior columns. (B) Two-dimensional CT scans demonstrating displacement of the weight-bearing surface of the dome along with impaction of the femoral head. Notice that the acetabular fragment appears to be impinging on the femoral head. (C) CT reconstruction showing impaction of the joint along with flattening of the superior region of the femoral head. (Continued)

Figure 10 (A) Antero-posterior (AP) radiograph of a 73-year-old male who sustained an acetabular fracture after a motor vehicle accident. Notice the impaction of the roof and the medial displacement of the anterior and posterior columns. (B) Two-dimensional CT scans demonstrating displacement of the weight-bearing surface of the dome along with impaction of the femoral head. Notice that the acetabular fragment appears to be impinging on the femoral head. (C) CT reconstruction showing impaction of the joint along with flattening of the superior region of the femoral head. (Continued)

Acetabular Fractures

Figure 10 (Continued) (D) Anatomic specimen at the time of surgery demonstrating significant impaction of the femoral head. (E) AP radiograph of the pelvis after completion of a combined hip technique. Notice that anatomic fixation of the joint was not attempted but, rather, the goal of stable fixation of both columns was achieved, allowing for the placement of a total hip arthro-plasty. (F) An iliac oblique view of the pelvis after the use of a combined hip technique.

Figure 10 (Continued) (D) Anatomic specimen at the time of surgery demonstrating significant impaction of the femoral head. (E) AP radiograph of the pelvis after completion of a combined hip technique. Notice that anatomic fixation of the joint was not attempted but, rather, the goal of stable fixation of both columns was achieved, allowing for the placement of a total hip arthro-plasty. (F) An iliac oblique view of the pelvis after the use of a combined hip technique.

Results using a combined technique have reported a 100% union rate of the acetabular fractures, using either a posterior, anterior, or extended approach, between 6 and 12 weeks. At follow-up, using Harris hip scores (61), patients have averaged 80 points, there have been no reports of sciatic nerve injuries, failures of fixation, or deep wound infections, and the majority of patients have been able to ambulate either without support or require the use of a cane for long distances (19,65). Although lengths of surgery, blood loss, transfusion requirements, and lengths of stay were greater than for primary total hip surgeries, they appear to be consistent for those patients undergoing a total hip arthroplasty after an acetabular fracture (57,60). Orthopedic complications, consisting of the development of heterotopic bone, hip dislocations, osteolysis, and failure of the arthroplasty have all been reported, but not seen at noticeable levels when using either late arthroplasties, open reduction techniques, or nonoperative treatment of these patients.

It should be remembered however that there are few studies using a combined technique and, although it presents an attractive alternative for the management for these patients, there is concern that these patients may require substantial medical work-ups prior to surgery. There is also concern that the surgeries may be difficult to perform, resulting in higher rates of complications due to an unfamiliarity with the surgical approaches or the techniques needed for the management of acetabular fractures. Therefore, prior to using a combined technique, a careful preoperative planning should be undertaken. Surgeons should feel comfortable using open reduction techniques, instrumentation, and approaches as well as the implants and techniques used for the application of a hip arthroplasty. For those surgeons comfortable with both approaches, a combined technique may avoid high rates failure.

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