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Total hip replacement for acetabular fractures
Injury, Int. J. Care Injured (2008) 39, 914—921
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Total hip replacement for acetabular fractures Results in 121 patients operated between 1983 and 2003 A. Sermon *, P. Broos, P. Vanderschot Department of Traumatology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium Accepted 3 December 2007
KEYWORDS Acetabular fracture; Total hip replacement; Complications
Summary Total hip replacement has an important role in the treatment of acetabular fractures. Immediate total hip arthroplasty is only indicated for some rare cases but late reconstruction is performed more frequently and may follow failed nonoperative or operative treatment of the original acetabular fracture. Introduction: The purpose of this study is to determine the results of the use of total hip replacement for the treatment of acetabular fractures and to compare the results of the early and late reconstruction group. Materials and methods: 121 acetabular fractures treated with total hip arthroplasty between 1983 and 2003 at the University Hospitals Gasthuisberg in Leuven, Belgium were retrospectively studied. The patients were divided into two groups. In the ‘‘early reconstruction group’’ total hip arthroplasty was performed as primary treatment of the acetabular fracture. In the ‘‘late reconstruction group’’: total hip arthroplasty was performed following failed operative or non-operative treatment of the acetabular fracture. The indications for total hip arthroplasty and the surgical technique in both the early and late reconstruction group were compared. Secondly, complications were reviewed in both groups and a functional scoring system was applied for each patient. Results: Primarily there was a significant difference in the age of the patient population of each group with a predominance for older patients in the early reconstruction group. Secondly, less revisions were performed in the early reconstruction group: 8% compared to 22% in the late reconstruction group. Discussion: The results obtained in our patient groups were compared to the results found in literature by a Medline search. In general, our results were comparable to the results found in literature but a remarkable difference was found between different authors.
* Corresponding author. Tel.: +32 16 344666; fax: +32 16 344677. E-mail address: [email protected] (A. Sermon). 0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.12.004
Total hip replacement for acetabular fractures
915
Conclusion: Total hip replacement for acetabular fractures is rarely indicated in the acute phase. After failed treatment of an acetabular fracture, total hip replacement has to be considered as a salvage procedure. In both cases, one may not forget total hip arthroplasty is a severe intervention associated with a high number of complications. # 2007 Elsevier Ltd. All rights reserved.
Introduction Acetabular fractures have to be considered as a major injury to the hip joint and place the long-term performance of the hip joint in jeopardy. In the management of acetabular fractures, total hip arthroplasty plays an important role. This includes immediate total hip replacement for certain rare cases and late reconstruction following failed nonoperative or operative treatment, leading to symptomatic arthritis, malunion or non-union. Recent studies confirm the association of a good reduction and a better long-time result.13,14,16,17 However, series ranging in size from 60 to 465 patients show the appearance of posttraumatic arthritis in 12—67% of the cases, even when the acetabular bone stock could be restored with minimal deformity.5,13,14,19,21,24. Posttraumatic avascular necrosis of the femoral head following an acetabular fracture has been reported to range from 2 to 40%12,26,30. If major symptomatic degenerative changes or avascular necrosis develop, total hip arthroplasty remains the best available surgical option for the restoration of function and relief from pain. The purpose of this study is to review the indications for and the results of the use of total hip arthroplasty for the treatment of acetabular fractures. A comparison is made between the early and late reconstruction group.
Materials and methods Between 1983 and 2003, total hip arthroplasty was performed for 121 acetabular fractures in 121 patients in the department of Traumatology of the University Hospitals Gasthuisberg in Leuven, Belgium. The results were reviewed retrospectively using the patients’ hospital and operation charts.
65 men and 56 women were included in the study. The mean age of the patients at the time of the accident was 65.5 years; the mean age of the patients at the time of total hip replacement was 67 years, with a range between 18 and 95 years. The aetiology of the acetabular fractures could be classified as follows: high energy trauma in 62 patients (51.2%), low energy trauma in 55 patients (45.4%) and pathological fracture in four patients (3.3%). The fractures were classified using the Letournel classification. 49 fractures were included in the elementary fracture group and 72 fractures were included in the associated fracture group (for details of fracture classification: see Table 1). Total hip arthroplasty was performed for acute fractures in 64 cases (Images 1, 2) and after failed treatment of an acetabular fracture in 57 cases (Images 3, 4, 5). The indications for early total hip arthroplasty could be classified into three groups: high age or extensive osteoporosis (54 patients), combined acetabular and femoral neck fracture (six cases) and pathological fracture (four cases). The indications for total hip replacement after failed treatment of acetabular fractures could be classified into two groups: avascular necrosis of the femoral head and symptomatic posttraumatic or postoperative arthritis. In this ‘‘late’’ total hip replacement group, previous surgery was performed in 51 patients, in six patients, previous therapy of the acetabular fracture had been conservative. In the majority of the cases, the surgical approach used was anterolateral (108 cases). A posterior approach was used in eight cases and in five cases another approach was used. 51 of the 121 patients included in our study underwent previous surgery for their acetabular fracture. An anterolateral approach was used in 18 of these patients, a posterior approach in 17 patients, an ilio-
Table 1 Fracture classification (Letournel and Judet) Elementary Fractures
49 (40%)
Associated Fractures
72 (60%)
Posterior wall Transverse Anterior column Posterior column Anterior wall
26 10 6 5 2
Transverse and posterior wall Both columns T shaped Anterior wall and posterior hemitransverse Posterior column and posterior wall
28 25 9 6 4
916
A. Sermon et al.
Figs. 1 and 2
Total hip arthroplasty (2) as primary treatment of an acetabular fracture (1).
inguinal approach in nine cases and a combined approach was used in seven cases. In 73 of the 121 patients, bone grafts were used. For structural defects of the posterior rim, femoral head grafts were used. In case of segmental defects, morselised cancellous bone grafts were used. An autograft was used in 58 patients, an allograft was used in nine patients and in six patients, both auto- and allografts were used. The technical details of the surgical procedures performed were as follows: Concerning the acetabular component, an uncemented technique was used in most of the cases (116). In 59 cases, a screwed Schu ¨ster cup was used; a Duraloc cup was used 33 times; a Moscher ring was used in 16 cases; a Moscher cup in 4 cases and a Bu ¨rch-Schneider reinforcement cup in 4 cases. In five patients, a cemented cup was used. Concerning the femoral component, a cemented technique was used in 73 cases and an uncemented technique in 44 cases; in four cases, a Wagner uncemented stem was used.
Results A retrospective review was performed by using the patients’ hospital and operation charts. 13 of the 121 patients were lost to follow-up. For the remaining 108 patients, follow-up time varied between 12 and 180 months with an average of 30.7 months. Six patients died during follow-up due to unrelated causes. Postoperative complications and functional results using the Harris Hip Score were determined
for each patient. A statistically significant difference in age between the primary and secondary total hip replacement group was found: mean age in the early arthroplasty group was 78 while the mean age in the secondary total hip arthroplasty group was 53 (P < 0.05). There were 30 general complications: four dislocations, six nerve lesions (four femoral nerve palsies and two sciatic nerve palsies), one femoral artery lesion and 19 infections of which eight evolved towards persisting low grade infections. To evaluate late follow-up, the Harris Hip Score was used. The Harris Hip Score was excellent in 33 patients, good in 38 patients, fair in 28 patients and bad in nine patients. The walking ability was normal in 49 patients, 18 patients had a slight limp, 27 patients walked with a cane or crutches, six patients were in a wheelchair and for eight patients the postoperative walking ability was not relevant because they were bedridden pre-operatively. Postoperative pain could be classified as follows: 69 patients had no pain, 21 patients had mild pain, 14 patients had moderate pain and four patients had severe pain postoperatively. Finally, the functional results in the early and late arthroplasty groups were compared. There was a significant difference ( p < 0.05) in the mean age with a predominance of older patients in the primary total hip replacement group: in this group the mean age at operation was 78, while in the secondary total hip replacement group, the mean age was 53 at time of operation. No difference in type of fracture and
Total hip replacement for acetabular fractures
917
Figs. 3—5 Total hip arthroplasty (5) as secondary treatment after failed treatment (avascular necrosis of femoral head) (4) of an acetabular fracture treated with plate and screw osteosynthesis (3).
timing for total hip replacement could be found: there were 37 (59%) complex fractures in the primary total hip replacement group versus 35 (62%) complex fractures in the secondary total hip replacement group (for details of the relationship between fracture classification and timing of total hip replacement: see Table 2). Concerning heterotopic ossification and revision operations, a difference could be seen between the groups although none of these results were statistically significant. In the primary arthroplasty group,
there was heterotopic ossification in 18 patients (28%) versus 23 patients (41%) in the secondary arthroplasty group. In the primary total hip replacement group, only four patients (8%) needed a revision operation versus 12 patients in the secondary total hip replacement group (with a total of 18 revision operations in this group: one revision in eight patients, two revisions in two patients and three revisions in two patients). The Harris Hip Score was slightly better in the secondary total hip replacement group: 76% of
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A. Sermon et al.
Table 2 Fracture classification (Letournel and Judet) and timing of total hip replacement Fracture classification
Primary total hip replacement
Secondary total hip replacement
Elementary Posterior wall Transverse Anterior column Posterior column Anterior wall
27 Cases (41%) 14 6 3 3 1
22 Cases (38%) 12 4 3 2 1
Complex Transverse and posterior wall Both columns T shaped Anterior wall and posterior hemitransverse Posterior column and posterior wall
37 Cases (59%) 14 13 5 3 2
35 Cases (62%) 14 12 4 3 2
Table 3 Harris Hip Score after primary and secondary total hip replacement
excellent and good results in this group versus 58% of excellent and good results in the primary total hip replacement group, but these results were not significantly different (For details of the Harris Hip Score: see Table 3). When we look at the Harris Hip Score in the patients with secondary total hip replacement, there is a statistically significant ( p < 0.01) improvement of the score after total hip replacement (For details: see Table 4).
Discussion An acetabular fracture is a major injury of the hip joint. The causes can be very different and especially in the aged, even a low energy trauma can cause an acetabular fracture. In the literature, very Table 4 Harris Hip Score before and after secondary total hip replacement (N = 57) Harris Hip Score Excellent Good Fair Bad P < 0.01
Before THR
After THR
2}33% 17 24}67% 14
15}76% 28 12}24% 1 1 pt died
different causes of acetabular fractures were found. In the series of Mears18 of 75 patients treated with total hip arthroplasty for displaced acetabular fractures, the mechanism of injury was characterised as minor trauma in 27 patients (47%) and as major trauma in 30 patients (53%), using the definition of Lonner and Koval15. In the series of Romness23 of 55 patients with primary total hip arthroplasty after fracture of the acetabulum, the fractures included motor vehicle accidents (39 patients), falls (7 patients), pathological fractures (3), farm accidents (3), a tornado accident, a shotgun injury and a seizure. The results of our study are comparable to these results: the cause of the acetabular fracture was a low energy trauma in 62 patients (51.2%), a high energy trauma in 55 patients (45.4%) and a pathological fracture in four patients (3.3%). Fractures of the acetabulum generally are classified using the system of Judet and Letournel10,14 and the system of Tile28. It is clear that especially more complex fractures (fractures of the posterior part of the acetabulum and transverse fractures) are indications for arthroplasty. In Mears’ series18, 34% of the fractures were simple fractures and 65% of the fractures were more complex injuries. Romness and Lewallen23 used the Tile classification28 and 40% of the fractures were of the posterior column and/or posterior wall and 13% were transverse fractures. Our results are comparable to the results found in literature: 49 fractures (40%) were
Total hip replacement for acetabular fractures simple fractures while 72 fractures (60%) were complex fractures. However, no correlation could be found between fracture classification and timing of total hip replacement: in both the primary and secondary total hip replacement group, approximately 60% of the patients had a complex fracture. In our study, the indications for total hip arthroplasty after failed operative or non-operative treatment of acetabular fractures was symptomatic posttraumatic or postoperative arthritis or avascular necrosis of the femoral head. This corresponds to the indications found in literature: Boardmann, Rogan, Romness and Stauffer all mention avascular necrosis with collapse of the femoral head or symptomatic posttraumatic arthritis as most important indications for secondary total hip replacement after failed operative or non-operative treatment of acetabular fractures3,22,23,25. The results of secondary total hip replacement after failed treatment of acetabular fractures as found in the literature, are various. Pritchett and Bortel20 evaluated 19 patients who underwent secondary total hip arthroplasty using a cementless acetabular component after failed treatment of an acetabular fracture. The main Harris Hip Score after surgery was 84. This result is comparable to our 76% of excellent and good results. In contrast to our study, no infections, dislocations or significant heterotopic ossification occurred. Boardman and Charnley3 reported a series of 66 patients operated on during a 15-year period using a cemented Charnley low friction total hip prosthesis following failed treatment of an acetabular fracture. They noted excellent short term results with a mean follow-up time of 3.5 years. Carnesale et al.5 on the other hand reviewed the records of 39 patients with acetabular fractures who underwent secondary total hip arthroplasty. They reported improvement in most patients despite a high complication rate including dislocation, acetabular segment fracture, severe heterotopic bone formation4 and deep sepsis resulting in total failure of the arthroplasty. The best long-term study was done by Romness and Lewallen23. The purpose of their study was not only to determine the long-term outcome of total hip arthroplasty performed in patients with a history of prior fracture of the acetabulum but also to compare these results to the results of routine hip arthroplasty. Using the Kaplan—Meier method, they concluded that the projected 10-year revision rate would be 18.2%. The curve for revision plus radiographic loosening shows a 5-year failure rate of 21% and a 10-year failure rate of 49%, so their conclusion was that a history of prior acetabular fracture has a significant adverse impact on the long-term outcome of any subsequent total hip arthroplasty. Bellabara et al.1 studied the results of
919 a cementless acetabular reconstruction after acetabular fractures. The purpose of this study was to compare the intermediate-term results of total hip arthroplasty in patients with posttraumatic arthritis to the results of a cementless acetabular component in patients with non-traumatic arthritis. They also compared the results of arthroplasty in patients who had prior operative treatment of their acetabular fracture to those patients who had prior closed reduction of their acetabular fracture. Their conclusion was that total hip arthroplasty is a more severe intervention in patients with posttraumatic arthritis, especially if an internal fixation of the acetabulum was previously performed: the mean operating time was longer, there was a higher transfusion need, more patients needed bone grafting and there was a higher incidence of intra-operative hip instability. Nevertheless, prosthetic survival rate was similar to prosthetic survival rate of patients who underwent total hip arthroplasty for non-traumatic arthritis. Previous open reduction and internal fixation of an acetabular fracture, however, predisposed the hip to more preoperative instability leading to more revision operations and there were more than twice as many patients with heterotopic ossifications following total hip arthroplasty. In our study an important improvement in the Harris Hip Score was seen before and after secondary total hip replacement: there were 33% of excellent and good results preoperatively versus 76% of excellent and good results postoperatively. Nevertheless, the revision rate was higher in the secondary arthroplasty group: 18 versus four in the primary arthroplasty group. Initial management of an acetabular fracture with primary total hip prosthesis is rarely indicated because of the difficulty to achieve stability of the acetabular component. As to Jimenez et al.8, indications are: pathological fractures, pre-existing symptomatic hip arthritis and associated femoral head injuries including head-splitting fractures and ipsilateral femoral neck fractures. As to Mears9,18, indications for primary total hip arthroplasty are: intra-articular comminution, full thickness abrasive loss of the articular cartilage, impaction of the femoral head and impaction of the acetabulum. Tidermark, Volkmann and Hollen6,27,29, also mentioned osteopenia as an indication for primary total hip arthroplasty. All these findings correspond to our indications for primary total hip arthroplasty acetabular fractures: high age with extensive osteoporosis, combined acetabular and femoral neck fractures and pathological fractures. Concerning the results of primary total hip replacement for acetabular fractures, only very limited numbers of patients could be found in the literature. Kelly and Lipscomb11 reported seven satisfactory
920 results. Westerborn30 reported encouraging results in six cases of central acetabular fracture dislocations. Mears18 published late results of acute total hip arthroplasty in 49 patients. 79% had an excellent or good Harris Hip Score. This result is comparable to our results: 58% of the patients had an excellent or good Harris Hip Score. Concerning the type of femoral and acetabular components, we see an evolution towards an uncemented technique, for the femoral component as well as for the acetabular component. This corresponds to the findings in the literature. Huo7 reports a series of 21 patients undergoing cementless total hip replacement for acetabular fracture. After a mean follow-up period of 65 months, there was only 1 patient with symptomatic radiographic loosening. Berry and Halasy2 also observed very good results after the use of uncemented acetabular components: there was only loosening in 2 of his 26 described cases. Romness and Lewallen23 on the other hand reported for cemented components a radiographic loosening of the acetabular component in 52.9% of the cases with a revision rate of 13.7%. In our series, we also see a trend towards the use of uncemented acetabular and femoral components. Corresponding to Tidermark et al.27, we also use a Burch-Schneider antiprotrusion cage and bone grafting in case of displaced acetabular fractures in elderly patients with very osteoporotic bone.
Conclusions Only few reports could be found concerning the topic of primary and secondary total hip replacement in the acetabular fractures. The results found in literature are also very variable, so no meta-analysis could be performed. The results of our study correspond to the findings in the literature: there are only few indications for primary total hip arthroplasty in acetabular fractures. After failed treatment of acetabular fractures, total hip arthroplasty may be used as a salvage procedure. One should not forget this is a severe intervention which may lead to major complications. Nevertheless, early or late total hip replacement for acetabular fractures has an acceptable final result and functional outcome and has an equal revision rate compared to total hip replacement for femoral neck fractures.
Conflict of interest statement All authors hereby disclose any financial and personal relationships with other people or organisations that could inappropriately influence this work.
A. Sermon et al.
References 1. Bellabarba C, Berger RA, Bentley ChD, Quigley LR, et al. Cementless acetabular reconstruction after acetabular fracture. J Bone Joint Surg 2001;83-A:868—76. 2. Berry DJ, Halasy M. Uncemented acetabular components for arthritis after acetabular fractures. Clin Orthop Rel Res 2002;405:164—7. 3. Boardman KP, Charnley J. Low-friction arthroplasty after fracture-dislocations of the hip. J Bone Joint Surg 1978;60B:495. 4. Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg 1973;55-A:1629— 32. 5. Carnesale PG, Stewart MJ, Barnes SN. Acetabular disruption and central fracture-dislocation of the hip: a long-term study. J Bone Joint Surg 1975;57-A:1054. 6. Ho ¨llen IP, Mentzel M, Bischoff M, Kinzl L. Acetabular fractures in elderly persons. Primary endoprosthetic treatment. Orthopa ¨de 1997;26:348—53. 7. Huo MH, Solberg BD, Zatorski LE, Keggi KJ. Total hip replacements done without cement after acetabular fractures in 4to 8-year follow-up study. J Arthroplasty 1999;14:827—31. 8. Jimenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am 1997;28:435—46. 9. Jolly MJ, Mears DC. The role of total hip arthroplasty in acetabular fracture management. Oper Tech Orthop 1993;1:80. 10. Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. J Bone Joint Surg 1964;46-A:1615—46. 11. Kelly PJ, Lipscomb PR. Primary Vitallium-mold arthroplasty for posterior dislocation of the hip with fracture of the femoral head. J Bone Joint Surg 1958;40-A:675. 12. Larson CB. Fracture dislocation of the hip. Clin Orthop 1973;92:147. 13. Letournel E. Acetabulum fractures: classification and management. Clin Orthop 1980;151:81—106. 14. Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop 1993;292:62—76. 15. Lonner JH, Koval KJ. Polytrauma in the elderly. Clin Orthop 1995;318:136—43. 16. Matta JM, Merritt PO. Displaced acetabular fractures. Clin Orthop 1988;230:83—97. 17. Mayo KA. Open reduction and internal fixation of fractures of the acetabulum. Results in 163 fractures. Clin Orthop 1994;305:31—7. 18. Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures: 2—12-year results. J Bone Joint Surg 2002;84-A:1—9. 19. Pennal GF, Davidson J, Garside H, Plewes J. Results of treatment of acetabular fractures. Clin Orthop 1980;151:115—23. 20. Pritchett JW, Bortel DT. Total hip replacement after central fracture dislocation of the acetabulum. Orthop Rev 1991;20:607—10. 21. Ragnarsson B, Mjoberg B. Arthrosis after surgically treated acetabular fractures. A retrospective study of 60 cases. Acta Orthop Scand 1992;63:511—4. 22. Rogan IM, Weber FA, Solomon L. Total hip replacement following fracture dislocation of the acetabulum. J Bone Joint Surg 1979;61-B:252. 23. Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. J Bone Joint Surg 1990;72-B:761—4. 24. Rowe CR, Lowell JD. Prognosis of fractures of the acetabulum. J Bone Joint Surg 1961;43-A:30—59.
Total hip replacement for acetabular fractures 25. Stauffer RN. Ten-year follow-up study of total hip replacement with particular reference to ro ¨ntgenographic loosening of the components. J Bone Joint Surg 1982;64-A: 983—90. 26. Stewart MJ, Milfort LW. Fracture-dislocation of the hip: an end result study. J Bone Joint Surg 1954;36-A:315. 27. Tidermark J, Blomfeldt R, Ponzer S, et al. Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular
921 fractures in elderly patients. J Orthop Trauma 2003; 17:193—7. 28. Tile M. Fractures of the pelvis and acetabulum. Baltimore, etc: Williams & Wilkins, 1984. 29. Volkmann R, Maurer F, Eingartner C, Weller S. Primary total endoprosthetic hip joint replacement in acetabulum fractures. Unfallchirurgie 1995;21:292—7. 30. Westerborn A. Central dislocation of the femoral head treated with mold arthroplasty. J Bone Joint Surg 1954;36-A:307.
www.elsevier.com/locate/injury
Total hip replacement for acetabular fractures Results in 121 patients operated between 1983 and 2003 A. Sermon *, P. Broos, P. Vanderschot Department of Traumatology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium Accepted 3 December 2007
KEYWORDS Acetabular fracture; Total hip replacement; Complications
Summary Total hip replacement has an important role in the treatment of acetabular fractures. Immediate total hip arthroplasty is only indicated for some rare cases but late reconstruction is performed more frequently and may follow failed nonoperative or operative treatment of the original acetabular fracture. Introduction: The purpose of this study is to determine the results of the use of total hip replacement for the treatment of acetabular fractures and to compare the results of the early and late reconstruction group. Materials and methods: 121 acetabular fractures treated with total hip arthroplasty between 1983 and 2003 at the University Hospitals Gasthuisberg in Leuven, Belgium were retrospectively studied. The patients were divided into two groups. In the ‘‘early reconstruction group’’ total hip arthroplasty was performed as primary treatment of the acetabular fracture. In the ‘‘late reconstruction group’’: total hip arthroplasty was performed following failed operative or non-operative treatment of the acetabular fracture. The indications for total hip arthroplasty and the surgical technique in both the early and late reconstruction group were compared. Secondly, complications were reviewed in both groups and a functional scoring system was applied for each patient. Results: Primarily there was a significant difference in the age of the patient population of each group with a predominance for older patients in the early reconstruction group. Secondly, less revisions were performed in the early reconstruction group: 8% compared to 22% in the late reconstruction group. Discussion: The results obtained in our patient groups were compared to the results found in literature by a Medline search. In general, our results were comparable to the results found in literature but a remarkable difference was found between different authors.
* Corresponding author. Tel.: +32 16 344666; fax: +32 16 344677. E-mail address: [email protected] (A. Sermon). 0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.12.004
Total hip replacement for acetabular fractures
915
Conclusion: Total hip replacement for acetabular fractures is rarely indicated in the acute phase. After failed treatment of an acetabular fracture, total hip replacement has to be considered as a salvage procedure. In both cases, one may not forget total hip arthroplasty is a severe intervention associated with a high number of complications. # 2007 Elsevier Ltd. All rights reserved.
Introduction Acetabular fractures have to be considered as a major injury to the hip joint and place the long-term performance of the hip joint in jeopardy. In the management of acetabular fractures, total hip arthroplasty plays an important role. This includes immediate total hip replacement for certain rare cases and late reconstruction following failed nonoperative or operative treatment, leading to symptomatic arthritis, malunion or non-union. Recent studies confirm the association of a good reduction and a better long-time result.13,14,16,17 However, series ranging in size from 60 to 465 patients show the appearance of posttraumatic arthritis in 12—67% of the cases, even when the acetabular bone stock could be restored with minimal deformity.5,13,14,19,21,24. Posttraumatic avascular necrosis of the femoral head following an acetabular fracture has been reported to range from 2 to 40%12,26,30. If major symptomatic degenerative changes or avascular necrosis develop, total hip arthroplasty remains the best available surgical option for the restoration of function and relief from pain. The purpose of this study is to review the indications for and the results of the use of total hip arthroplasty for the treatment of acetabular fractures. A comparison is made between the early and late reconstruction group.
Materials and methods Between 1983 and 2003, total hip arthroplasty was performed for 121 acetabular fractures in 121 patients in the department of Traumatology of the University Hospitals Gasthuisberg in Leuven, Belgium. The results were reviewed retrospectively using the patients’ hospital and operation charts.
65 men and 56 women were included in the study. The mean age of the patients at the time of the accident was 65.5 years; the mean age of the patients at the time of total hip replacement was 67 years, with a range between 18 and 95 years. The aetiology of the acetabular fractures could be classified as follows: high energy trauma in 62 patients (51.2%), low energy trauma in 55 patients (45.4%) and pathological fracture in four patients (3.3%). The fractures were classified using the Letournel classification. 49 fractures were included in the elementary fracture group and 72 fractures were included in the associated fracture group (for details of fracture classification: see Table 1). Total hip arthroplasty was performed for acute fractures in 64 cases (Images 1, 2) and after failed treatment of an acetabular fracture in 57 cases (Images 3, 4, 5). The indications for early total hip arthroplasty could be classified into three groups: high age or extensive osteoporosis (54 patients), combined acetabular and femoral neck fracture (six cases) and pathological fracture (four cases). The indications for total hip replacement after failed treatment of acetabular fractures could be classified into two groups: avascular necrosis of the femoral head and symptomatic posttraumatic or postoperative arthritis. In this ‘‘late’’ total hip replacement group, previous surgery was performed in 51 patients, in six patients, previous therapy of the acetabular fracture had been conservative. In the majority of the cases, the surgical approach used was anterolateral (108 cases). A posterior approach was used in eight cases and in five cases another approach was used. 51 of the 121 patients included in our study underwent previous surgery for their acetabular fracture. An anterolateral approach was used in 18 of these patients, a posterior approach in 17 patients, an ilio-
Table 1 Fracture classification (Letournel and Judet) Elementary Fractures
49 (40%)
Associated Fractures
72 (60%)
Posterior wall Transverse Anterior column Posterior column Anterior wall
26 10 6 5 2
Transverse and posterior wall Both columns T shaped Anterior wall and posterior hemitransverse Posterior column and posterior wall
28 25 9 6 4
916
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Figs. 1 and 2
Total hip arthroplasty (2) as primary treatment of an acetabular fracture (1).
inguinal approach in nine cases and a combined approach was used in seven cases. In 73 of the 121 patients, bone grafts were used. For structural defects of the posterior rim, femoral head grafts were used. In case of segmental defects, morselised cancellous bone grafts were used. An autograft was used in 58 patients, an allograft was used in nine patients and in six patients, both auto- and allografts were used. The technical details of the surgical procedures performed were as follows: Concerning the acetabular component, an uncemented technique was used in most of the cases (116). In 59 cases, a screwed Schu ¨ster cup was used; a Duraloc cup was used 33 times; a Moscher ring was used in 16 cases; a Moscher cup in 4 cases and a Bu ¨rch-Schneider reinforcement cup in 4 cases. In five patients, a cemented cup was used. Concerning the femoral component, a cemented technique was used in 73 cases and an uncemented technique in 44 cases; in four cases, a Wagner uncemented stem was used.
Results A retrospective review was performed by using the patients’ hospital and operation charts. 13 of the 121 patients were lost to follow-up. For the remaining 108 patients, follow-up time varied between 12 and 180 months with an average of 30.7 months. Six patients died during follow-up due to unrelated causes. Postoperative complications and functional results using the Harris Hip Score were determined
for each patient. A statistically significant difference in age between the primary and secondary total hip replacement group was found: mean age in the early arthroplasty group was 78 while the mean age in the secondary total hip arthroplasty group was 53 (P < 0.05). There were 30 general complications: four dislocations, six nerve lesions (four femoral nerve palsies and two sciatic nerve palsies), one femoral artery lesion and 19 infections of which eight evolved towards persisting low grade infections. To evaluate late follow-up, the Harris Hip Score was used. The Harris Hip Score was excellent in 33 patients, good in 38 patients, fair in 28 patients and bad in nine patients. The walking ability was normal in 49 patients, 18 patients had a slight limp, 27 patients walked with a cane or crutches, six patients were in a wheelchair and for eight patients the postoperative walking ability was not relevant because they were bedridden pre-operatively. Postoperative pain could be classified as follows: 69 patients had no pain, 21 patients had mild pain, 14 patients had moderate pain and four patients had severe pain postoperatively. Finally, the functional results in the early and late arthroplasty groups were compared. There was a significant difference ( p < 0.05) in the mean age with a predominance of older patients in the primary total hip replacement group: in this group the mean age at operation was 78, while in the secondary total hip replacement group, the mean age was 53 at time of operation. No difference in type of fracture and
Total hip replacement for acetabular fractures
917
Figs. 3—5 Total hip arthroplasty (5) as secondary treatment after failed treatment (avascular necrosis of femoral head) (4) of an acetabular fracture treated with plate and screw osteosynthesis (3).
timing for total hip replacement could be found: there were 37 (59%) complex fractures in the primary total hip replacement group versus 35 (62%) complex fractures in the secondary total hip replacement group (for details of the relationship between fracture classification and timing of total hip replacement: see Table 2). Concerning heterotopic ossification and revision operations, a difference could be seen between the groups although none of these results were statistically significant. In the primary arthroplasty group,
there was heterotopic ossification in 18 patients (28%) versus 23 patients (41%) in the secondary arthroplasty group. In the primary total hip replacement group, only four patients (8%) needed a revision operation versus 12 patients in the secondary total hip replacement group (with a total of 18 revision operations in this group: one revision in eight patients, two revisions in two patients and three revisions in two patients). The Harris Hip Score was slightly better in the secondary total hip replacement group: 76% of
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Table 2 Fracture classification (Letournel and Judet) and timing of total hip replacement Fracture classification
Primary total hip replacement
Secondary total hip replacement
Elementary Posterior wall Transverse Anterior column Posterior column Anterior wall
27 Cases (41%) 14 6 3 3 1
22 Cases (38%) 12 4 3 2 1
Complex Transverse and posterior wall Both columns T shaped Anterior wall and posterior hemitransverse Posterior column and posterior wall
37 Cases (59%) 14 13 5 3 2
35 Cases (62%) 14 12 4 3 2
Table 3 Harris Hip Score after primary and secondary total hip replacement
excellent and good results in this group versus 58% of excellent and good results in the primary total hip replacement group, but these results were not significantly different (For details of the Harris Hip Score: see Table 3). When we look at the Harris Hip Score in the patients with secondary total hip replacement, there is a statistically significant ( p < 0.01) improvement of the score after total hip replacement (For details: see Table 4).
Discussion An acetabular fracture is a major injury of the hip joint. The causes can be very different and especially in the aged, even a low energy trauma can cause an acetabular fracture. In the literature, very Table 4 Harris Hip Score before and after secondary total hip replacement (N = 57) Harris Hip Score Excellent Good Fair Bad P < 0.01
Before THR
After THR
2}33% 17 24}67% 14
15}76% 28 12}24% 1 1 pt died
different causes of acetabular fractures were found. In the series of Mears18 of 75 patients treated with total hip arthroplasty for displaced acetabular fractures, the mechanism of injury was characterised as minor trauma in 27 patients (47%) and as major trauma in 30 patients (53%), using the definition of Lonner and Koval15. In the series of Romness23 of 55 patients with primary total hip arthroplasty after fracture of the acetabulum, the fractures included motor vehicle accidents (39 patients), falls (7 patients), pathological fractures (3), farm accidents (3), a tornado accident, a shotgun injury and a seizure. The results of our study are comparable to these results: the cause of the acetabular fracture was a low energy trauma in 62 patients (51.2%), a high energy trauma in 55 patients (45.4%) and a pathological fracture in four patients (3.3%). Fractures of the acetabulum generally are classified using the system of Judet and Letournel10,14 and the system of Tile28. It is clear that especially more complex fractures (fractures of the posterior part of the acetabulum and transverse fractures) are indications for arthroplasty. In Mears’ series18, 34% of the fractures were simple fractures and 65% of the fractures were more complex injuries. Romness and Lewallen23 used the Tile classification28 and 40% of the fractures were of the posterior column and/or posterior wall and 13% were transverse fractures. Our results are comparable to the results found in literature: 49 fractures (40%) were
Total hip replacement for acetabular fractures simple fractures while 72 fractures (60%) were complex fractures. However, no correlation could be found between fracture classification and timing of total hip replacement: in both the primary and secondary total hip replacement group, approximately 60% of the patients had a complex fracture. In our study, the indications for total hip arthroplasty after failed operative or non-operative treatment of acetabular fractures was symptomatic posttraumatic or postoperative arthritis or avascular necrosis of the femoral head. This corresponds to the indications found in literature: Boardmann, Rogan, Romness and Stauffer all mention avascular necrosis with collapse of the femoral head or symptomatic posttraumatic arthritis as most important indications for secondary total hip replacement after failed operative or non-operative treatment of acetabular fractures3,22,23,25. The results of secondary total hip replacement after failed treatment of acetabular fractures as found in the literature, are various. Pritchett and Bortel20 evaluated 19 patients who underwent secondary total hip arthroplasty using a cementless acetabular component after failed treatment of an acetabular fracture. The main Harris Hip Score after surgery was 84. This result is comparable to our 76% of excellent and good results. In contrast to our study, no infections, dislocations or significant heterotopic ossification occurred. Boardman and Charnley3 reported a series of 66 patients operated on during a 15-year period using a cemented Charnley low friction total hip prosthesis following failed treatment of an acetabular fracture. They noted excellent short term results with a mean follow-up time of 3.5 years. Carnesale et al.5 on the other hand reviewed the records of 39 patients with acetabular fractures who underwent secondary total hip arthroplasty. They reported improvement in most patients despite a high complication rate including dislocation, acetabular segment fracture, severe heterotopic bone formation4 and deep sepsis resulting in total failure of the arthroplasty. The best long-term study was done by Romness and Lewallen23. The purpose of their study was not only to determine the long-term outcome of total hip arthroplasty performed in patients with a history of prior fracture of the acetabulum but also to compare these results to the results of routine hip arthroplasty. Using the Kaplan—Meier method, they concluded that the projected 10-year revision rate would be 18.2%. The curve for revision plus radiographic loosening shows a 5-year failure rate of 21% and a 10-year failure rate of 49%, so their conclusion was that a history of prior acetabular fracture has a significant adverse impact on the long-term outcome of any subsequent total hip arthroplasty. Bellabara et al.1 studied the results of
919 a cementless acetabular reconstruction after acetabular fractures. The purpose of this study was to compare the intermediate-term results of total hip arthroplasty in patients with posttraumatic arthritis to the results of a cementless acetabular component in patients with non-traumatic arthritis. They also compared the results of arthroplasty in patients who had prior operative treatment of their acetabular fracture to those patients who had prior closed reduction of their acetabular fracture. Their conclusion was that total hip arthroplasty is a more severe intervention in patients with posttraumatic arthritis, especially if an internal fixation of the acetabulum was previously performed: the mean operating time was longer, there was a higher transfusion need, more patients needed bone grafting and there was a higher incidence of intra-operative hip instability. Nevertheless, prosthetic survival rate was similar to prosthetic survival rate of patients who underwent total hip arthroplasty for non-traumatic arthritis. Previous open reduction and internal fixation of an acetabular fracture, however, predisposed the hip to more preoperative instability leading to more revision operations and there were more than twice as many patients with heterotopic ossifications following total hip arthroplasty. In our study an important improvement in the Harris Hip Score was seen before and after secondary total hip replacement: there were 33% of excellent and good results preoperatively versus 76% of excellent and good results postoperatively. Nevertheless, the revision rate was higher in the secondary arthroplasty group: 18 versus four in the primary arthroplasty group. Initial management of an acetabular fracture with primary total hip prosthesis is rarely indicated because of the difficulty to achieve stability of the acetabular component. As to Jimenez et al.8, indications are: pathological fractures, pre-existing symptomatic hip arthritis and associated femoral head injuries including head-splitting fractures and ipsilateral femoral neck fractures. As to Mears9,18, indications for primary total hip arthroplasty are: intra-articular comminution, full thickness abrasive loss of the articular cartilage, impaction of the femoral head and impaction of the acetabulum. Tidermark, Volkmann and Hollen6,27,29, also mentioned osteopenia as an indication for primary total hip arthroplasty. All these findings correspond to our indications for primary total hip arthroplasty acetabular fractures: high age with extensive osteoporosis, combined acetabular and femoral neck fractures and pathological fractures. Concerning the results of primary total hip replacement for acetabular fractures, only very limited numbers of patients could be found in the literature. Kelly and Lipscomb11 reported seven satisfactory
920 results. Westerborn30 reported encouraging results in six cases of central acetabular fracture dislocations. Mears18 published late results of acute total hip arthroplasty in 49 patients. 79% had an excellent or good Harris Hip Score. This result is comparable to our results: 58% of the patients had an excellent or good Harris Hip Score. Concerning the type of femoral and acetabular components, we see an evolution towards an uncemented technique, for the femoral component as well as for the acetabular component. This corresponds to the findings in the literature. Huo7 reports a series of 21 patients undergoing cementless total hip replacement for acetabular fracture. After a mean follow-up period of 65 months, there was only 1 patient with symptomatic radiographic loosening. Berry and Halasy2 also observed very good results after the use of uncemented acetabular components: there was only loosening in 2 of his 26 described cases. Romness and Lewallen23 on the other hand reported for cemented components a radiographic loosening of the acetabular component in 52.9% of the cases with a revision rate of 13.7%. In our series, we also see a trend towards the use of uncemented acetabular and femoral components. Corresponding to Tidermark et al.27, we also use a Burch-Schneider antiprotrusion cage and bone grafting in case of displaced acetabular fractures in elderly patients with very osteoporotic bone.
Conclusions Only few reports could be found concerning the topic of primary and secondary total hip replacement in the acetabular fractures. The results found in literature are also very variable, so no meta-analysis could be performed. The results of our study correspond to the findings in the literature: there are only few indications for primary total hip arthroplasty in acetabular fractures. After failed treatment of acetabular fractures, total hip arthroplasty may be used as a salvage procedure. One should not forget this is a severe intervention which may lead to major complications. Nevertheless, early or late total hip replacement for acetabular fractures has an acceptable final result and functional outcome and has an equal revision rate compared to total hip replacement for femoral neck fractures.
Conflict of interest statement All authors hereby disclose any financial and personal relationships with other people or organisations that could inappropriately influence this work.
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