Delayed Total Hip Arthroplasty

In those patients who have significant osteoporosis, comminution, arthritis, associated femoral head fractures, or significant medical comorbidities that preclude the use of any early orthopedic surgical intervention, some surgeons may elect to initially treat the patient with the use of bedrest or traction followed by late arthroplasty. Unfortunately prolonged immobilization, with or without traction, may result in significant complications including the development of deep vein thrombosis, decubitus ulcers, pulmonary problems, and joint stiffness. Orthopedic complications resulting from the nonoperative treatment of these patients may include the development of significant osteoporosis, loss of bone stock, severe pelvic deformities, the development of post-traumatic arthritis of the hip, and the potential development of avascular necrosis of the femoral head and acetabulum (60,63,71,84).

Knowing that these orthopedic and medical complications can occur may persuade surgeons to perform an open reduction of the fracture in an attempt to minimize late complications. Unfortunately, as just described, the fixation may fail or be inadequate, resulting in collapse of the joint, producing a malunion or nonunion of the acetabulum, contributing to disuse osteoporosis, producing heterotopic bone, and resulting in the development soft tissue contractures about the hip joint (60,72). Therefore, if late arthroplasty is to be considered as the treatment for these patients, it should be reserved as salvage for those who have developed symptomatic posttraumatic arthritis of the hip and have failed an attempt at conservative care (Fig. 9A-C). Regardless of conflicting reports as to whether cemented or cementless arthroplasties are better for these patients, some things are certain. Operative times, blood loss, transfusion requirements will be increased, and the difficulty in performing a total hip arthroplasty is expected to be greater for these patients than those treated with arthroplasties for non-traumatic arthritis of the hip (57,58,60).

In performing a late arthroplasty, it is important that a thorough preoperative assessment and planning of the procedure are performed. Preoperative assessments should include obtaining medical clearance for any underlying medical comorbidities, potential vascular work-ups if concern exists regarding the vascular status of the extremity, along with the predonation of autologous blood. Radiographic studies should include standard anteroposterior and lateral views of the hip in addition to anteroposter-ior, obturator, and iliac oblique views of the pelvis. Two- and three-dimensional computed tomographic (CT) scans of the acetabulum may be helpful in assessing bone loss, heterotopic bone, and the pathology of the acetabulum. In the presence of previous fixation, however, some scatter of the scans may result in difficulty in adequately evaluating the acetabulum. Component selection is at the discretion of the surgeon, but implants and instrumentations used to reduce and fix an acetabular fracture should also be available. If bone graft is to be used, and the patient's femoral head is considered inadequate due to the size of the defect, an allograft should be made available.

Although some studies have demonstrated good results in patients treated with arthroplasty after an acetabular fracture, it is not surprising that most long-term studies, following operative or nonoperative treatment of acetabular fractures, have demonstrated higher rates of failure than arthroplasties that were performed in patients with nontraumatic arthritis of the hip (55,58,60,61,64,85). Romness and Lewallen (55)

Figure 9 (A) Antero-posterior (AP) radiograph in a 77-year-old female who fell at home. The concern was that because of the patient's age and fracture pattern she would not do well with surgery. The initial treating surgeon subsequently managed the patient with nonoperative care. (B) At 2 years, the patient had developed severe degeneration of the hip and was referred for treatment options. AP radiograph demonstrating salvage through the use of a total hip arthroplasty using a protrusion cup. (C) Lateral view of the total hip arthroplasty.

Figure 9 (A) Antero-posterior (AP) radiograph in a 77-year-old female who fell at home. The concern was that because of the patient's age and fracture pattern she would not do well with surgery. The initial treating surgeon subsequently managed the patient with nonoperative care. (B) At 2 years, the patient had developed severe degeneration of the hip and was referred for treatment options. AP radiograph demonstrating salvage through the use of a total hip arthroplasty using a protrusion cup. (C) Lateral view of the total hip arthroplasty.

described a projected 10-year failure rate (revision plus symptomatic loosening without revision) of 39.1%, increasing to 49% if they included all symptomatic or asymptomatic cases of loosening. They also noted that radiographic loosening of the acetabular component (52.9%) was more common than the femoral component (29.4%). Mears (86) also documented high rates of failure, approaching 51% within two years of the initial arthroplasty, with almost 40% of the entire population eventually requiring a revision arthroplasty. Finally the studies by Weber et al. (60) and Harris (61) have also described the difficulties in managing these patients reporting failures approaching 40%. This is significant when one realizes that the frequency for aseptic loosening after 10 years has fallen from 8% of all primary hips in 1979 to 3% by 1985 (87).

Excluding a poorly performed surgery, some factors have been identified as contributing to high failure rates. One is the development of deep infections (87), which may be decreased with the use of preoperative intravenous antibiotics. A second factor is performing arthoplasties in younger, higher demand patients. Failure rates have been reported near 80% when performed in patients younger than 60 years compared to 45% for those individuals over 60 years of age (55). A third factor is performing the procedure on male patients who already have posttraumatic arthritis of the hip. Studies have reported that at two years, men were already at risk for needing a revision, which is theorized to be due to greater activity levels in these individuals (55,87). A fourth cause has been noted to be patients who have large acetabular defects necessitating the use of bone grafts. These may ultimately reabsorb and contribute to radiolucency that develops, specifically around the acetabular component (88). One final factor may be the development of avascular necrosis about the acetabulum (86). Biopsy specimens at the time of arthroplasty have demonstrated avascular necrosis about the central portion of the acetabulum (89), which may be the reason some physicians have discouraged initial open reduction for these patients (92). Looking at these five factors, however, only the first three may be preventable or electively excluded for surgical treatment. So in addition to being difficult surgeries to perform, with potentially high rates of failure, and greater risks for causing neurovascular injuries, producing infections, heterotopic bone, and developing soft tissue contractures, why offer late arthroplasty to any of these patients? Because the other option is to allow patients to continue to live with poorly functioning hips or undergo an arthrodesis. Neither of these alternatives is particularly attractive to patients who are otherwise healthy and may have projected life spans ranging between 15 and 50 years.

Fortunately, not all studies describe such terrible results. Some studies, using actual and projected 10-year survival rates (90), with component survival and no revision or radiographic loosening, have reported rates of success occurring between 78 and 100% (56,57,59,60,91). The question is why these studies have reported lower rates of failure than other studies. Some measures have been identified that help reduce the risk of later revisions. These include improved fixation, advanced surgical techniques, and better implants (87). Studies have shown that using preventative measures have decreased the risk of deep infections. These have included using prophylactic systemic antibiotic therapy, gentamycin containing cement, laminar airflow, and the use of exhaust gowns (87). Studies have also shown that by using third generation cementing techniques, consisting of retrograde filling, cleaning by pulse lavage, distal plugging, and pressurization by means of a proximal seal, the risk of osteolysis can be decreased

(93,94). Incorporating these steps has been shown to reduce the risk for a revision by approximately 25% (87). Interestingly, one other factor has been shown to improve the rates of success, the use of cementless techniques (56,57,59,60,91). The common denominator for high 10-year survival in these studies appears to be cementless application of the implants. This may be due to the implants having a collared along with a matte surface, but is more likely due to improved design and instrumentation of the implants along with careful bone bed preparation.

Therefore, it appears that with modern designs, especially for instrumentation and techniques, improved rates of survival can occur using late arthroplasy in patients who develop post-traumatic arthritis of the hip after a fracture of the acetabulum. However, one should realize that there are significant risks and difficulties in performing an arthroplasty in these patients, and that the overall rates of success are still lower than those procedures performed in patients for primary arthritis of the hip (55,58,95).

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