PROTR

USIO

ACETABULI

ARTHROKATADYSIS

Dr.Ghazwan A. Hasan 5th year Arab Board Trainee

DEFINITION • Is a hip joint deformity in which the medial wall of the

acetabulum invades into the pelvic cavity, with associated medial displacement of the femoral head.

• It is caused by primary idiopathic and secondary neoplastic, infectious, metabolic, inflammatory, traumatic, and genetic disorders.

• 1st case was published by Adolph William Otto, a German pathologist, in 1824

((the right acetabulum protrudes into the pelvis like half an orange))• In 1854, Gurlt blamed acetabular fractures as the

cause of the deformity, referring to it as ‘a coxalgia with acetabular fracture.

ETIOLOGY 1ry 2ndary Infectious (Gonococcus, Echinococcus, Staphylococcus,

Streptococcus, Mycobacterium tuberculosis). Neoplastic (Hemangioma, Metastatic carcinoma, Neurofibromatosis

Radiation-induced osteonecrosis. Inflammatory (Rheumatoid arthritis, Ankylosing spondylitis,

Juvenile rheumatoid arthritis, Psoriatic arthritis, Acute idiopathic chondrolysis, Reiteris syndrome, Osteolysis, following hip replacement).

Metabolic (Pagetis disease, Osteogenesis imperfecta, Acrodysostosis, Osteomalacia Hyperparathyroidism )

Traumatic (Sequelae of acetabular fracture Surgical error during hip replacement)

Genetic (Trichorhinophalangeal syndrome Stickler syndrome, Trisomy 18, Ehler-Danlos syndrome, Marfan syndrome, Sickle cell disease).

DIAGNOSIS Clinical: Radiological:

CLASSIFICATION• Sotelo-Garza and Charnley used the ilioischial line on an

AP radiograph of the pelvis as a reference point from which to measure the location of the acetabulum.

TREATMENT• Identification and treatment of any underlying disease

process.• Surgical Option is based on the patientis age and skeletal

maturity and the extent of degenerative changes visualized on plain radiographs.

• Skeletally Immature patients: Surgical Closure of Triradiate cartilage +/- VITO.

TREATMENT• Adolescent or Young Adult Patients: VITO by Pauwels

TREATMENT• Older Adult Patients: VITO, THA • Total hip arthroplasty is the recommended treatment

for the older adult with protrusio acetabuli and degenerative changes.

• Ranawat et al reported on 35 hips with protrusio acetabuli secondary to rheumatoid arthritis that had been treated with cemented THA and had been followed up for an average of 4.3 years. They reported loosening in 16 of 17 hips recon- structed with the cup center more than 10 mm from the anatomic center. Of the 13 hips reconstructed with the cup center within 5 mm of the anatomic center, none was loose.

•

TREATMENT• Bayley et al and Gates et al confirmed the importance of

restoring the hip to an anatomic center. They noted that 50% of reconstructed hips with a cup center more than 10 mm from the anatomic hip center had failed.

• Ranawat and Zahn have recommended the following guidelines: In cases in which the protrusion is less than 5 mm, bone graft is not required. When the protrusion is greater than 5 mm and there is an intact medial wall, bone graft without augmentation devices is appropriate.

• If there is gross deficiency of the medial wall, bone graft with consideration of additional fixation devices (hemispherical non-cemented cup with screw supplementation or antiprotrusio ring) is indicated.

TREATMENT• Ring Hip Prosthesis.

CEMENTLESS CUP TECHNIQUE

• McBride MT, Muldoon MP, Santore RF, Trousdale RT, Wenger DR. Protrusio acetabuli: diagnosis and treatment. J Am Acad Orthop Surg. 2001; 9(2):79-88.

• Kroeber M, Ries MD, Suzuki Y, Renowitzky G, Ashford F, Lotz J. Impact biomechanics and pelvic deformation during insertion of press-fit acetabular cups. J Arthroplasty. 2002; 17(3):349-354.

CASE PRESENTATION• 52 years old female • History of RTA presented with pelvic fracture 4

months ago.• Treated conservatively• Presented with pain, Limitation of movement of

Right Hip.

POST OPERATIVE