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THA TO SALVAGE FAILED ACETABULAR FRACTURES
Daniel J. Berry, MD
Mayo Clinic
Rochester, MN
THA AFTER ACETABULAR FXTechnical Challenges
• Acetabular bone loss• Residual pelvic deformity• Nonunited fractures• Retained hardware• Heterotopic ossification• Socket fixation
THA FOR ACETABULAR FX
ACETABULAR COMPONENT CHOICE
THA AFTER ACETABULAR FX Previous ORIF
Results: Long Term:• Higher failure rate than THA for OA• Pts young/male/unilateral disease• Uncemented cups better so far than
cemented (similar scenario to revision THA)
Weber et al. JBJS 80A(9):1295-1305, 1998
SURVIVAL FREE REVISION FOR ASEPTIC ACET LOOSE/RADIOGRAPHIC LOOSENING
Cemented vs Uncemented
THA AFTER ACETABULAR FXAcetabular Bone Loss
Socket Fixation:• Apply principles of revision
THA (similar sclerotic, deficient bone)
• Consensus in North America: Uncemented hemispherical cup
THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups
Uncemented Cups: 5 Yr, Data, Rush:• 1/30 (4%) revised for loosening
JBJS(A), 2001
THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups
Uncemented Cups: Mayo Clinic Data:• 34 hips• Minimum F/U 10 yrs (10-16)• Aseptic Loosening 2/34 (6%)
Halasy, Berry, CORR 2002
THA AFTER ACETABULAR FX
MANAGEMENT OF BONE LOSS
THA AFTER ACETABULAR FXAcetabular Bone Loss
Cavitary Bone Loss: Particulate Graft
THA AFTER ACETABULAR FXAcetabular Bone Loss
Segmental Loss: The Posterior/Superior Wall• Use autogenous femoral head graft if
needed
THA AFTER ACETABULAR FXAcetabular Bone Loss
Results: • Reliable bone graft healing and
incorporation
THA AFTER ACETABULAR FX
PELVIC DEFORMITY
THA AFTER ACETABULAR FXPelvic Deformity
• Landmarks distorted
- care with cup position• Bony prominence
- beware of bone impingement causing instability
THA AFTER ACETABULAR FX
NONUNITED FRACTURES
THA AFTER ACETABULAR FXNonunited Fractures
• Typically nonunited transverse acetabular fx (pelvic discontinuity)
• Stabilize with post column plate
THA AFTER ACETABULAR FXNonunited Fractures
Results:• High rate of fracture healing
(100% in personal experience)
THA AFTER ACETABULAR FXNonunited Fractures
Plate Pelvic Discontinuity
THA AFTER ACETABULAR FX
RETAINED HARDWARE
THA AFTER ACETABULAR FXRetained Hardware
• Leave in place if not problematic• Selective removal when needed• Beware of the sciatic nerve
THA AFTER ACETABULAR FXRetained Hardware
Selective Hardware Removal
THA AFTER ACETABULAR FXRetained Hardware
Selective Hardware Removal
THA AFTER ACETABULAR FXRetained Hardware
Sciatic Nerve:• Avoid if possible• If working posteriorly:
Identify (beneath g. max. tendon), handle carefully
• Do case with knee flexed
THA AFTER ACETABULAR FX
HETEROTOPIC BONE
THA AFTER ACETABULAR FXHeterotopic Bone
Heterotopic Ossification:• Excise HO if symptomatic• If HO formed after last
procedure use prophylaxis (NSAID or radiation) after THA
THA AFTER ACETABULAR FXHeterotopic Bone
HO: Excise, Postop Prophylaxis
THA AFTER ACETABULAR FX
MINIMIZING COMPLICATIONS
THA FOR POSTTRAUMATIC HIPMinimizing Complications
Reducing Complications:• Careful preoperative
assessment:
- bone loss
- fracture nonunion
- r/o infection• Know what you are up
against
THA FOR POSTTRAUMATIC HIP Minimizing Complications
Reducing Complications:• Anticipate more blood loss (cell
saver)• Longer operative time• Exposure difficulties (choose
based on preference/HO/hardware)
THA AFTER ACETABULAR FXReducing Complications
Anticipate Special Needs (Intra/Postop):• Pelvic reconstruction plates• Autogenous bone grafting• Metal cutting instruments• HO prophylaxis
THA AFTER ACETABULAR FX Conclusions
• Good planning, careful execution
• Modern technology
• Usually excellent results despite technical challenges
• The patients like these operations--they have a previous failure and you fix it