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Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
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Original article
Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis Julio J. Jauregui a, Tristan B. Weir a, Jin F. Chen b, Aaron J. Johnson a, Neil R. Sardesai a, Aditya V. Maheshwari b, Theodore T. Manson a, *, 1 a b
R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, USA Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 September 2019 Received in revised form 5 January 2020 Accepted 6 January 2020 Available online xxx
Objective: Multiple treatment options for acetabular fractures in geriatric patients exist. However, no large-scale studies have reported the outcomes of acute total hip arthroplasty (THA) in this patient population. We systematically evaluated all available evidence to characterize clinical outcomes, complications, and revisions of acute THA for acetabular fractures in geriatric patients. Methods: Meta-analysis of 21 studies of 430 acetabular fractures with mean follow-up of 44 months (range, 1797 months). Two independent researchers searched and evaluated the databases of Ovid, Embase, and United States National Library of Medicine using a Boolean search string up to December 2019. Population demographics and complications, including presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE), were recorded and analyzed. Results: Weighted mean Harris Hip Score was 83.3 points, and 20% of the patients had reported complications. The most common complication was HO, with a rate of 19.5%. Brooker grade III and IV HO rates were lower at 6.8%. Hip dislocation occurred at a rate of 6.1%, 4.1% of patients developed VTE, deep infection occurred in 3.8%, and neurological complications occurred in 1.9%. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the time to each revision was described in only a few studies. The revision rate was 4.3%. Conclusions: Acute THA is a viable option for treatment of acetabular fracture and can result in acceptable clinical outcomes and survivorship rates in older patients but with an associated complication rate of approximately 20%. Considering the limited treatment options, THA might be a viable alternative for appropriately selected patients. © 2020 Delhi Orthopedic Association. All rights reserved.
Keywords: Acetabular fractures Geriatric patients Total hip arthroplasty
1. Introduction When managing acetabular fractures, open reduction and internal fixation (ORIF) is the treatment of choice for the younger population. However, ORIF is technically challenging in the elderly population in which it has a high risk of failure of fixation and incidence of posttraumatic osteoarthritis.1e4 Moreover, the results
Abbreviations: THA, total hip arthroplasty; HO, heterotopic ossification; VTE, venous thromboembolic event; ORIF, open reduction and internal fixation; PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analyses; MINORS, Methodological Index for Non-Randomized Studies. * Corresponding author. Towson Orthopaedics Associates, 8322 Bellona Avenue, Towson, MD, 21204, USA. E-mail address: [email protected] (T.T. Manson). 1 Present address ¼ Towson Orthopaedics Associates, Towson, Maryland, USA.
of delayed total hip arthroplasty (THA) after initial ORIF often lead to suboptimal outcomes.5e7 Compared with historical results for ORIF alone or with delayed THA, ORIF with acute THA in elderly patients has shown better functional scores and lower complication rates.4,8e11 Although multiple studies have described treating acetabular fracture using primary THA, conclusions are difficult to draw because of the small numbers of patients and the variable methods of follow-up. In addition, no study has systematically evaluated the effectiveness and the complications of acute THA after acetabular fracture. Hence, we systematically evaluated all available evidence. The purposes of our study were to determine the overall demographic characteristics, characterize the complications associated with acute THA for acetabular fracture, and assess the revision rate for acute THA for acetabular fracture.
https://doi.org/10.1016/j.jcot.2020.01.003 0976-5662/© 2020 Delhi Orthopedic Association. All rights reserved.
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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2. Methods We performed a comprehensive literature search and evaluated all related published studies through December 2019. Using the Preferred Reporting Items for Systematic Review and MetaAnalyses (PRISMA) guideline,12 we searched the databases of Ovid, Embase, and the United States National Library of Medicine using the search string ‘fract’ AND ‘acetab’ AND ‘arthropl’ OR ‘replace’, which returned 1930 studies. After excluding publications written in languages other than English, 1521 articles remained. After reviewing the abstracts of the 1521 studies, we identified 126 studies that examined the use of THA for the treatment of acetabular fracture. Cross-referencing the 126 studies yielded an additional 21 studies. Our inclusion criteria encompassed studies that evaluated the treatment of acetabular fractures with acute THA with a mean patient age of 60 years or older. Studies that examined THA as a delayed treatment of acetabular fracture, studies with a mean patient age younger than 60 years, case reports, systematic reviews, expert opinions, and follow-up reports of previously published studies were excluded. Each manuscript was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria, which was modified to an all-or-nothing scale with which studies that adequately reported an index of the MINORS criteria received 1 point.13 Studies that did not report or inadequately reported a given criterion received 0 points. Studies with fewer than 6 points were excluded.14 Twenty-one studies were included in our meta-analysis.4,8,10,15e32 Two reviewers independently executed this method to prevent the exclusion of any relevant studies. Table 1 describes the indications for performing acute THA for each of the studies included in the analysis. We reviewed each study included in the analysis for population demographics and clinical outcomes, including the mean age of the population, types of acetabular fractures based on the classification by Letournel and Judet,33 types of implants used in addition to THA, and type of prosthetic used (cemented or cementless). The complications that were specifically assessed included the presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE). For the purpose of our analysis, deep venous thrombosis and pulmonary embolism were grouped and defined as VTE. HO was recorded by Brooker grade, but if no grade was provided, it was assumed the HO was clinically significant (Brooker grade III or IV).34 Only Brooker grades III and IV were included in the overall complication rate calculation. All obtained results were recorded on an electronic spreadsheet (Microsoft Excel; Microsoft Office, Redmond, WA). Certain variables were not provided in some studies, such as participant demographics, Harris Hip Score, type of fracture, and surgical details. Therefore, each specific analysis was performed individually and studies were excluded from an analysis if information from that data point was not provided. Using statistical software (MedCalc version 15.2; MedCalc Software, Ostend, Belgium), we performed descriptive statistics for demographic characteristics. Complication
rates and revision rates were analyzed using a random effects model of proportions when heterogeneous and a fixed effect model when not heterogeneous. 3. Results Twenty-one studies evaluating 430 acetabular fractures managed with acute THA were included in our final analysis (Fig. 1). Thirty-nine percent of the participants were women, and 61% were men. The mean patient age was 72 years (range of the means, 6081 years). The mean follow-up time was 44 months (range of the means, 1797 months) (Table 2). In terms of fixation before THA, all patients in the included studies underwent some type of fixation with screws, cables, wires, plates, rings, or cages (Appendix). Twenty of the 21 studies reported the type and subtype of the acetabular fracture (n ¼ 416). In accordance with classification by Letournel and Judet,33 elementary fractures accounted for 43% (n ¼ 179) of the cases and 57% (n ¼ 237) were associated fractures. Posterior wall fracture was the most common type of elementary fracture (19%, n ¼ 77), and anterior column or wall and posterior hemi-transverse were the most common types of associated fractures (16%, n ¼ 66). The rates of subtypes of acetabular fractures are presented in Table 3. In terms of clinical outcomes, the weighted mean Harris Hip Score at latest follow-up was 83.3 points (range of
Fig. 1. Flowchart of study selection. Table 1 Indications for acute total hip arthroplasty. Indication
References
Displaced acetabular fracture with intraarticular comminution and/or protrusion Acetabular impaction involving weight bearing zone Femoral head cartilage loss, impaction, or fracture Preexisting, severe hip osteoarthritis or avascular necrosis Concomitant displaced femoral neck fracture Radiographic evidence of osteopenia/osteoporosis Anterior column fracture with posterior column involvement (intact or partially intact) or associated both column
4 8 10 16e18 2023 25e30 32
, , , , , , , , , , , , , , 4 8 10 17 19 20 21 24 27 , , , , , , , , 4 10 16 17 19e21 28 , , , , , 4 10 15 20 21 28 , , , , , 4 8 10 17 19e21 24 25 29 , , , , , , , 18 25 31 , ,
4 8 10 15 17 20 21 24 28e32
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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Table 2 Study details and demographics. Study
THA (n)
10
Female (n)
e e 3 5 e 8 e 10 e 2 6 7 8 18 11 4 6 18 5 4 10
57 11 10 10 18 18 9 22 20 15 19 15 24 33 11 9 18 37 13 27 34
Mears and Velyvis, 2002 Mouhsine et al., 200223 Tidermark et al., 200326 et al., 200415 Beaule Mouhsine et al., 200422 Boraiah et al., 20098 Carroll et al., 20104 Herscovici et al., 201019 maly et al., 201317 Che Malhotra et al., 201321 Chakravarty et al., 201416 Enocson and Blomfeldt, 201418 Rickman et al., 201424 Lin et al., 201520 Solomon et al., 201525 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829 Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932
Male (n)
Age (y)
e e 7 5 e 10 e 12 e 13 13 8 16 15 4 5 12 19 8 23 24
Follow-up (mo)
Avg
Range
Avg
Range
69 79 73 61 76 72 67 75 60 65 77 76 77 66 81 80 66 79 77 69 71
26e89 65e93 57e87 50e85 65e93 55e86 56e89 60e95 28e89 57e69 57e90 63e84 63e90 47e92 76e87 63e90 35e81 66e90 64e89 57e84 56e92
97 24 38 34 36 47 63 29 31 82 22 48 24 67 e e 22 22 24 48 17
24e144 e 11e84 24e53 12e46 12e120 24e188 13e67 12e79 62e122 2e80 e 8e38 12e170 12e24 e 12e36 6e89 e 12e84 0e72
THA, total hip arthroplasty; Avg, average.
the means, 7093 points).8,10,19,26,28,29,31 Various techniques were used in these 21 studies in conjunction with THA for acute management of acetabular fracture. Most of the included studies used plates and screws for internal fixation. Four studies used ring devices,18,19,27,32 one used a specific cage system (Octopus; DePuy Synthes, Johnson & Johnson, Raynham, MA),21 and four others implemented a cup-cage device (Appendix).25,26,29,30 The estimated weighted mean blood loss was 925 mL (range of the means, 5331163 mL),15e21,24,26,27,30e32 and the surgical procedures had a weighted mean length of 176 min
(range of the means, 110244 min) (Table 4).4,15e22,24,26e28,30e32 Using our random effects model, we determined that 20% of the patients had a reported complication (95% confidence interval [CI], 13.8%e27.6%) (Table 5 and Fig. 2). The most common complication was HO, with a rate of 19.5% (95% CI, 11.9%e28.5%) for any Brooker grade. The rate of clinically significant HO (Brooker grade III or IV) was lower at 6.8% (95% CI, 3.2%e11.7%). Hip dislocation occurred at a rate of 6.1% (95% CI, 4.0%e8.5%), 4.1% developed VTE (95% CI, 2.1%e6.8%), deep infection occurred in 3.8% (95% CI, 2.2%e5.9%), and neurological complications occurred in 1.9% (95% CI, 0.8%e
Table 3 Types of acetabular fractures. Study
Mears and Velyvis, 200210 Mouhsine et al., 200223 Tidermark et al., 200326 et al., 200415 Beaule Mouhsine et al., 200422 Boraiah et al., 20098 Carroll et al., 20104 Herscovici et al., 201019 maly et al., 201317 Che Malhotra et al., 201321 Chakravarty et al., 201416 Enocson and Blomfeldt, 201418 Rickman et al., 201424 Lin et al., 201520 Solomon et al., 201525 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829a Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932 Rate (%)
Elementary
Associated
n
PW
PC
AW
AC
Tr
n
PCPW
T-s
AWCPHT
ABC
TPW
34 0 5 8 2 16 e 0 10 8 4 11 13 15 1 5 12 15 1 15 4 43
11 0 0 0 0 15 e 0 6 3 0 0 1 13 0 0 9 7 1 9 2 19
3 0 0 0 0 0 e 0 2 3 0 0 0 0 0 0 0 0 0 2 0 2
0 0 0 4 0 0 e 0 0 0 0 0 0 2 0 2 0 0 0 0 0 2
10 0 0 4 0 0 e 0 1 0 1 10 4 0 1 1 0 8 0 0 1 10
10 0 5 0 2 1 e 0 1 2 3 1 8 0 0 2 3 0 0 4 1 10
23 11 5 2 16 2 e 22 10 7 15 4 11 18 10 4 6 17 12 12 30 57
6 3 0 0 2 0 e 0 1 3 0 0 3 4 0 0 1 0 1 0 2 6
3 8 0 0 9 0 e 0 4 0 1 0 0 0 0 0 2 3 0 2 19 12
6 0 5 2 1 1 e 7 0 2 5 4 2 5 7 0 1 6 5 5 2 16
4 0 0 0 0 1 e 6 3 0 5 0 6 2 3 4 1 4 5 5 5 13
4 0 0 0 4 0 e 9 2 2 4 0 0 7 0 0 1 4 1 0 2 10
PW, posterior wall; PC, posterior column; AW, anterior wall; AC, anterior column; Tr, Transverse; PCPW, posterior column and posterior wall; T-s, T-shaped; AWCPHT, anterior wall or column with posterior hemi-transverse; ABC, associated both column; TPW, transverse and posterior wall. a Five patients had fractures classified as “other,” and were not included in the analysis.
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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Table 4 Estimated blood loss and operative time. Study
Table 5 Complications of acute total hip arthroplasty for acetabular fracture.
THA (n) EBL (mL) Mean Range 10
Mears and Velyvis, 2002 Mouhsine et al., 200223 Tidermark et al., 200326 et al., 200415 Beaule Mouhsine et al., 200422 Boraiah et al., 20098 Carroll et al., 20104 Herscovici et al., 201019 maly et al., 201317 Che Malhotra et al., 201321 Chakravarty et al., 201416 Enocson and Blomfeldt, 201418 Rickman et al., 201424 Lin et al., 201520 Solomon et al., 201525 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829 Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932
57 11 10 10 18 18 9 22 20 15 19 15 24 33 11 9 18 37 13 27 34
e e 1100 1060 e e e 1163 992 835 700 665 1100 852 e 533 e e 800 827 1100
e e 700e1600 100e3200 e e e 300e4500 300e2000 450e1200 220e1800 250e1600 500e2500 200e5000 e 0e2000 e e 400e1700 152e3019 400e2700
Op Time (min)
Complication Type
n
Rate (%) 95% Confidence Interval References
Mean Range
HO (any grade) HO (grade III or IV) Dislocation VTE Infection Neurological deficit Revision Overalla
386 386 410 410 410 410 383 421
19.5 6.8 6.1 4.1 3.8 1.9 4.3 20.2
e e 159 180 165 e 244 232 171 135 231 149 193 200 e 189 122 e 188 110 169
e e 125e185 135e210 120e180 e 89e403 50e510 105e315 110e160 125e465 115e285 130e280 148e296 e 136e266 65e180 e 175e321 65e170 97e310
THA, total hip arthroplasty; EBL, estimated blood loss; Op Time, operative time.
3.4%) of patients who underwent acute THA for the management of acetabular fracture. The revision rate for the cohort was 4.3% (95% CI, 2.4%e6.8%).
4. Discussion ORIF is well accepted as the treatment of choice for acetabular fracture in the younger population; however, no guidelines have been definitively established for the management of acetabular fracture in the elderly. Maintaining anatomic fracture reduction and avoiding posttraumatic osteoarthritis in this group of patients are challenging.2,35 Acute THA combined with ORIF can be an option for properly selected patients and can allow for earlier rehabilitation and weight bearing, lower need for reoperation, and better functional scores compared with ORIF alone or delayed THA.15 Acute THA is a viable option and can be used by the treating surgeon in appropriately selected patients, including older patients with osteopenia and/or osteoporosis, comminuted acetabular fractures not amenable to ORIF, acetabular protrusion, marginal impaction, femoral head injuries, and femoral neck fractures (Table 1). To our knowledge, this study is the first meta-analysis of complications after acute THA for the treatment of acetabular fracture. THA has been used in acute management of elementary and associated acetabular fractures. Various acetabular fracture subtypes are included in this study, with posterior wall, anterior column or wall, and posterior hemi-transverse being the most common fracture subtypes. These subtypes were also most common in a 16-year prospective epidemical study based in the United Kingdom.36 The overall complication rate of 20% in our selected patient population was higher compared with all patients undergoing elective THA.37 The complication rate associated with acute THA, however, is lower than that reported (38.8%) for older patients undergoing ORIF for acetabular fractures.38 HO frequently occurs after acetabular fracture as a result of the substantial inflammation, extensive muscle dissection, blood loss,
11.9e28.5 3.2e11.7 4.0e8.5 2.1e6.8 2.2e5.9 0.8e3.4 2.4e6.8 13.8e27.6
8 10 15e23 2632
, , , , , , 8 10 15e22 2432 , , , 8 10 15e22 2432 , , , 8 10 15e22 2432 , , , 8 10 15e22 2432 , , , 8 10 15e22 2430 32 , , , , 8 10 15e32 , , 8 10 15e23 2632
HO, heterotopic ossification; VTE, venous thromboembolic event, including deep vein thrombosis and pulmonary embolism. a Overall complication rate includes HO (grade III and IV), dislocation, VTA, infection, and neurologic deficit.
length of procedure, and possible coexisting head trauma.17 In the series presented herein, the most common complication was HO (19.5%). The rate is lower than what others have described for the acute operative management for acetabular fractures. In a 2005 meta-analysis, the incidence of HO was 25.6% for 613 cases of displaced acetabular fracture that received operative treatment within the first 4 weeks after trauma.39 The rate of clinically significant HO (Brooker grade III or IV) was much lower in the present study, reported to be 6.8%. This indicates that most HO cases are not clinically relevant in patients undergoing acute THA for acetabular fractures. The prevalence of dislocation after primary THA has been reported to be 2%e4% by various studies of various follow-up lengths.40e42 With the use of larger diameter femoral heads in recent years, dislocation rate in primary THA has plateaued at approximately 2% depending on the approach.43 However, the dislocation rate in the cohort evaluated in this study was higher at 6.1%, likely due to the traumatic insult to the surrounding tissues that would otherwise provide stability of the THA. The revision rate for this series was 4.3% with a mean follow-up time of 44 months. With variation in follow-up length, it is difficult to predict the long-term success of this procedure considering that most THA revisions occur after the first decade. In addition, the infection rates after primary THA for a diagnosis of osteoarthritis have been reported to be <1%,14 which is lower than our reported infection rate of 3.8% for acute THA after acetabular fracture. The difference in the rate of infection can be attributed to several factors, such as longer operative time required for stabilizing the fractures and lack of optimization of the patients before nonelective surgery. Reports have shown a high incidence of failure (50%) with cemented acetabular components in delayed THA after acetabular fractures,44 but failure rates seem to be much lower (3%e19%) for cementless acetabular components.45,46 The revision rate described herein is at the low end of the delayed cementless THA, but acute THA has the added benefit of avoiding a second surgical insult and the challenges associated with revision surgery after ORIF (subclinical infection, residual nonunion and pelvic deformity, bone loss, osteonecrosis, and retained instrumentation).47 This study had several limitations. The 21 studies included for analysis were retrospective case series with heterogeneous designs, interventions, and follow-up periods. The internal fixation methods varied in individual studies as necessitated by the fracture types.5 Although this added heterogeneity to the cohort, the primary goal of internal fixation is to obtain sufficient reduction and fixation of the fracture to stabilize the cup when performing arthroplasty.11
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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Fig. 2. Forest plot of overall complications associated with acute THA for acetabular fractures.
The studies were unified, however, by the use of acute THA for definitive treatment. Our analysis also focused on the overall and specific complications after THA, which were variably reported. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the exact time to each revision was described in only a few studies. Furthermore, the studies varied by fracture type, surgical technique, and approach. We were unable to perform subgroup analyses for complication and revision rates based on these factors because of the lack of granular data inherent in meta-analyses. Future studies should examine the effects of these clinical and surgical factors on the complication and revision rates. The rates of complications and revisions could be affected by the variable follow-up, which should be addressed by future studies. Although this study was restricted to include articles written in the English language, the findings are representative of the current literature considering that most studies on acute THA for acetabular fractures are in English. In addition, our inclusion criteria allowed studies with patients younger than 60 years as long as the mean age was 60 years or older. Those studies were included to reduce heterogeneity and provide more meaningful results. Although these limitations are present, this is the largest study describing acute THA for the treatment of acetabular fractures in an elderly population. In older patients with poor bone quality, the optimal management of acetabular fractures remains poorly defined. Acute THA for acetabular fractures can result in higher revision and complication rates compared with primary THA but has complication and revision rates similar to those associated with ORIF and delayed THA for acetabular fractures. However, because of the limited alternatives in this selected group of patients, THA might be the best alternative. Surgeons should be aware of this possibility, and patients and their families should be educated regarding all the possible risks of this procedure. Further prospective studies are needed to diminish the limitations and define the best management for acute acetabular fractures.
Funding No external funding was received for this work.
Author contributions Julio Jauregui: conceptualization and design of the study; data collection; data curation and statistical analysis; formal analysis; writing, original draft; writing, review and editing. Tristan Weir: data collection; data curation and statistical analysis; formal analysis; writing, original draft; writing, review and editing. Jin Chen: data collection; writing, original draft. Aaron Johnson: conceptualization and design of the study; resources; writing, original draft. Neil Sardesai: data collection; writing, original draft. Aditya Maheshwari: formal analysis; resources; writing, original draft. Theodore Manson: conceptualization and design of the study; formal analysis; project administration; resources; supervision; writing, original draft; writing, review and editing.
Declaration of competing interest TM and his institution receive money from various law firms for providing expert testimony; TM’s institution received a grant from the Orthopaedic Research and Education Foundation; TM receives money from AO North America and the Maine Review Course as payment for lectures. No other relationships, conditions, or circumstances present potential conflicts of interest.
Acknowledgments The authors thank Senior Editor and Writer Dori Kelly, MA, for professional manuscript editing.
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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Appendix A. Surgical Techniques by Study
Study
Internal Fixation
Total Hip Arthroplasty Technique Femoral
Acetabular
Approach
Mouhsine et al., 200223 Mears and Velyvis, 200210 Tidermark et al., 200326 Mouhsine et al., 200422 et al., 200415 Beaule Boraiah et al., 20098
Cables Screws and braided cables Cage Cables Plates and screws Plates and screws
NC NC C NC NC NC
NR AL (67%), EL (5%), O (28%) P (40%), AL (60%) P (56%), O (44%) A (100%) P (100%)
Herscovici et al., 201019 Carroll et al., 20104 maly et al., 201317 Che Malhotra et al., 201321 Rickman et al., 201424 Enocson and Blomfeldt, 201418 Chakravarty et al., 201416 Solomon et al., 201525 Lin et al., 201520 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829 Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932
Plates and screws, Ganz ring NR Plates and screws Cage Plates and screws Burch-Schneider ring Percutaneous screws Cage Plates and screws Burch-Schneider ring, plates, screws Plates and screws Plates and screws, cage Cage Plates and screws Plates and screws, ring
C C (70%), NC (30%) C C NR C (older), NC (younger) C (91%), NC (9%) NR NC NC C C NC (89%), C (11%) NR NC (79%), C (21%) NC (89%), C (11%) NC (100%) NC (100%) C (100%) C (100%) NC (38%), C (62%)
C (50%), NC(50%) NR NC NC NC (cup), C (liner) C NC NC (cup), C (liner) NC (97%), C (3%) C (100%) NC (100%) NC (100%) C (100%) C (100%) C (100%)
A (14%), P (86%) NR EP (100%) P (100%) NR AL (87%), PL (13%) P (100%) EP (100%) NR P (100%) P (100%) A (NR%), P (NR%) P (85%), AL (15%) P (78%), A&P (22%) P (100%)
C, Cemented; NC, Not cemented; NR, not reported; A, Anterior; P, Posterior; AL, Anterolateral; EL, Extended lateral; PL, Posterolateral; EP, Extended posterior; O, Other.
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18. Enocson A, Blomfeldt R. Acetabular fractures in the elderly treated with a primary Burch-Schneider reinforcement ring, autologous bone graft, and a total hip arthroplasty: a prospective study with a 4-year follow-up. J Orthop Trauma. 2014;28:330e337. 19. Herscovici Jr D, Lindvall E, Bolhofner B, Scaduto JM. The combined hip procedure: open reduction internal fixation combined with total hip arthroplasty for the management of acetabular fractures in the elderly. J Orthop Trauma. 2010;24:291e296. 20. Lin C, Caron J, Schmidt AH, Torchia M, Templeman D. Functional outcomes after total hip arthroplasty for the acute management of acetabular fractures: 1- to 14-year follow-up. J Orthop Trauma. 2015;29:151e159. 21. Malhotra R, Singh DP, Jain V, Kumar V, Singh R. Acute total hip arthroplasty in acetabular fractures in the elderly using the Octopus System: mid term to long term follow-up. J Arthroplast. 2013;28:1005e1009. 22. Mouhsine E, Garofalo R, Borens O, Blanc CH, Wettstein M, Leyvraz PF. Cable fixation and early total hip arthroplasty in the treatment of acetabular fractures in elderly patients. J Arthroplast. 2004;19:344e348. 23. Mouhsine E, Garofalo R, Borens O, et al. Acute total hip arthroplasty for acetabular fractures in the elderly: 11 patients followed for 2 years. Acta Orthop Scand. 2002;73:615e618. 24. Rickman M, Young J, Trompeter A, Pearce R, Hamilton M. Managing acetabular fractures in the elderly with fixation and primary arthroplasty: aiming for early weightbearing. Clin Orthop Relat Res. 2014;472:3375e3382. 25. Solomon LB, Studer P, Abrahams JM, et al. Does cup-cage reconstruction with oversized cups provide initial stability in THA for osteoporotic acetabular fractures? Clin Orthop Relat Res. 2015;473:3811e3819. 26. Tidermark J, Blomfeldt R, Ponzer S, Soderqvist A, Tornkvist H. Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients. J Orthop Trauma. 2003;17: 193e197. 27. Boelch SP, Jordan MC, Meffert RH, Jansen H. Comparison of open reduction and internal fixation and primary total hip replacement for osteoporotic acetabular fractures: a retrospective clinical study. Int Orthop. 2017;41:1831e1837. 28. Salama W, Mousa S, Khalefa A, et al. Simultaneous open reduction and internal fixation and total hip arthroplasty for the treatment of osteoporotic acetabular fractures. Int Orthop. 2017;41:181e189. 29. Weaver MJ, Smith RM, Lhowe DW, Vrahas MS. Does total hip arthroplasty reduce the risk of secondary surgery following the treatment of displaced acetabular fractures in the elderly compared to open reduction internal fixation? A pilot study. J Orthop Trauma. 2018;32(Suppl 1):S40eS45. 30. Borg T, Hernefalk B, Hailer NP. Acute total hip arthroplasty combined with internal fixation for displaced acetabular fractures in the elderly: a short-term comparison with internal fixation alone after a minimum of two years. Bone Joint Lett J. 2019;101-B:478e483. 31. Giunta JC, Tronc C, Kerschbaumer G, et al. Outcomes of acetabular fractures in the elderly: a five year retrospective study of twenty seven patients with
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J.J. Jauregui et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx primary total hip replacement. Int Orthop. 2019;43:2383e2389. 32. Lont T, Nieminen J, Reito A, et al. Total hip arthroplasty, combined with a reinforcement ring and posterior column plating for acetabular fractures in elderly patients: good outcome in 34 patients. Acta Orthop. 2019;90:275e280. Judet R, Elson R. Fractures of the Acetabulum. second ed. Berlin ; 33. Letournel E, New York: Springer-Verlag; 1993. 34. 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 Am. 1973;55:1629e1632. 35. Butterwick D, Papp S, Gofton W, Liew A, Beaule PE. Acetabular fractures in the elderly: evaluation and management. J Bone Joint Surg Am. 2015;97:758e768. 36. Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br. 2005;87:969e973. 37. Le Manach Y, Collins G, Bhandari M, et al. Outcomes after hip fracture surgery compared with elective total hip replacement. J Am Med Assoc. 2015;314: 1159e1166. 38. Daurka JS, Pastides PS, Lewis A, Rickman M, Bircher MD. Acetabular fractures in patients aged > 55 years: a systematic review of the literature. Bone Joint Lett J. 2014;96-B:157e163. 39. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br.
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2005;87:2e9. 40. Berry DJ, von Knoch M, Schleck CD, Harmsen WS. Effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. J Bone Joint Surg Am. 2005;87:2456e2463. 41. Malkani AL, Ong KL, Lau E, Kurtz SM, Justice BJ, Manley MT. Early- and lateterm dislocation risk after primary hip arthroplasty in the Medicare population. J Arthroplast. 2010;25:21e25. 42. Burroughs BR, Hallstrom B, Golladay GJ, Hoeffel D, Harris WH. Range of motion and stability in total hip arthroplasty with 28-, 32-, 38-, and 44-mm femoral head sizes. J Arthroplast. 2005;20:11e19. 43. Goel A, Lau EC, Ong KL, Berry DJ, Malkani AL. Dislocation rates following primary total hip arthroplasty have plateaued in the Medicare population. J Arthroplast. 2015;30:743e746. 44. Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. Long-term results. J Bone Joint Surg Br. 1990;72:761e764. 45. Ranawat A, Zelken J, Helfet D, Buly R. Total hip arthroplasty for posttraumatic arthritis after acetabular fracture. J Arthroplast. 2009;24:759e767. 46. Bellabarba C, Berger RA, Bentley CD, et al. Cementless acetabular reconstruction after acetabular fracture. J Bone Joint Surg Am. 2001;83-A:868e876. 47. Sierra RJ, Mabry TM, Sems SA, Berry DJ. Acetabular fractures: the role of total hip replacement. Bone Joint Lett J. 2013;95-B:11e16.
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Original article
Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis Julio J. Jauregui a, Tristan B. Weir a, Jin F. Chen b, Aaron J. Johnson a, Neil R. Sardesai a, Aditya V. Maheshwari b, Theodore T. Manson a, *, 1 a b
R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland Medical Center, Baltimore, MD, USA Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
a r t i c l e i n f o
a b s t r a c t
Article history: Received 3 September 2019 Received in revised form 5 January 2020 Accepted 6 January 2020 Available online xxx
Objective: Multiple treatment options for acetabular fractures in geriatric patients exist. However, no large-scale studies have reported the outcomes of acute total hip arthroplasty (THA) in this patient population. We systematically evaluated all available evidence to characterize clinical outcomes, complications, and revisions of acute THA for acetabular fractures in geriatric patients. Methods: Meta-analysis of 21 studies of 430 acetabular fractures with mean follow-up of 44 months (range, 1797 months). Two independent researchers searched and evaluated the databases of Ovid, Embase, and United States National Library of Medicine using a Boolean search string up to December 2019. Population demographics and complications, including presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE), were recorded and analyzed. Results: Weighted mean Harris Hip Score was 83.3 points, and 20% of the patients had reported complications. The most common complication was HO, with a rate of 19.5%. Brooker grade III and IV HO rates were lower at 6.8%. Hip dislocation occurred at a rate of 6.1%, 4.1% of patients developed VTE, deep infection occurred in 3.8%, and neurological complications occurred in 1.9%. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the time to each revision was described in only a few studies. The revision rate was 4.3%. Conclusions: Acute THA is a viable option for treatment of acetabular fracture and can result in acceptable clinical outcomes and survivorship rates in older patients but with an associated complication rate of approximately 20%. Considering the limited treatment options, THA might be a viable alternative for appropriately selected patients. © 2020 Delhi Orthopedic Association. All rights reserved.
Keywords: Acetabular fractures Geriatric patients Total hip arthroplasty
1. Introduction When managing acetabular fractures, open reduction and internal fixation (ORIF) is the treatment of choice for the younger population. However, ORIF is technically challenging in the elderly population in which it has a high risk of failure of fixation and incidence of posttraumatic osteoarthritis.1e4 Moreover, the results
Abbreviations: THA, total hip arthroplasty; HO, heterotopic ossification; VTE, venous thromboembolic event; ORIF, open reduction and internal fixation; PRISMA, Preferred Reporting Items for Systematic Review and Meta-Analyses; MINORS, Methodological Index for Non-Randomized Studies. * Corresponding author. Towson Orthopaedics Associates, 8322 Bellona Avenue, Towson, MD, 21204, USA. E-mail address: [email protected] (T.T. Manson). 1 Present address ¼ Towson Orthopaedics Associates, Towson, Maryland, USA.
of delayed total hip arthroplasty (THA) after initial ORIF often lead to suboptimal outcomes.5e7 Compared with historical results for ORIF alone or with delayed THA, ORIF with acute THA in elderly patients has shown better functional scores and lower complication rates.4,8e11 Although multiple studies have described treating acetabular fracture using primary THA, conclusions are difficult to draw because of the small numbers of patients and the variable methods of follow-up. In addition, no study has systematically evaluated the effectiveness and the complications of acute THA after acetabular fracture. Hence, we systematically evaluated all available evidence. The purposes of our study were to determine the overall demographic characteristics, characterize the complications associated with acute THA for acetabular fracture, and assess the revision rate for acute THA for acetabular fracture.
https://doi.org/10.1016/j.jcot.2020.01.003 0976-5662/© 2020 Delhi Orthopedic Association. All rights reserved.
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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2. Methods We performed a comprehensive literature search and evaluated all related published studies through December 2019. Using the Preferred Reporting Items for Systematic Review and MetaAnalyses (PRISMA) guideline,12 we searched the databases of Ovid, Embase, and the United States National Library of Medicine using the search string ‘fract’ AND ‘acetab’ AND ‘arthropl’ OR ‘replace’, which returned 1930 studies. After excluding publications written in languages other than English, 1521 articles remained. After reviewing the abstracts of the 1521 studies, we identified 126 studies that examined the use of THA for the treatment of acetabular fracture. Cross-referencing the 126 studies yielded an additional 21 studies. Our inclusion criteria encompassed studies that evaluated the treatment of acetabular fractures with acute THA with a mean patient age of 60 years or older. Studies that examined THA as a delayed treatment of acetabular fracture, studies with a mean patient age younger than 60 years, case reports, systematic reviews, expert opinions, and follow-up reports of previously published studies were excluded. Each manuscript was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria, which was modified to an all-or-nothing scale with which studies that adequately reported an index of the MINORS criteria received 1 point.13 Studies that did not report or inadequately reported a given criterion received 0 points. Studies with fewer than 6 points were excluded.14 Twenty-one studies were included in our meta-analysis.4,8,10,15e32 Two reviewers independently executed this method to prevent the exclusion of any relevant studies. Table 1 describes the indications for performing acute THA for each of the studies included in the analysis. We reviewed each study included in the analysis for population demographics and clinical outcomes, including the mean age of the population, types of acetabular fractures based on the classification by Letournel and Judet,33 types of implants used in addition to THA, and type of prosthetic used (cemented or cementless). The complications that were specifically assessed included the presence of heterotopic ossification (HO), dislocation, infection, revision rate, neurological deficits, and venous thromboembolic event (VTE). For the purpose of our analysis, deep venous thrombosis and pulmonary embolism were grouped and defined as VTE. HO was recorded by Brooker grade, but if no grade was provided, it was assumed the HO was clinically significant (Brooker grade III or IV).34 Only Brooker grades III and IV were included in the overall complication rate calculation. All obtained results were recorded on an electronic spreadsheet (Microsoft Excel; Microsoft Office, Redmond, WA). Certain variables were not provided in some studies, such as participant demographics, Harris Hip Score, type of fracture, and surgical details. Therefore, each specific analysis was performed individually and studies were excluded from an analysis if information from that data point was not provided. Using statistical software (MedCalc version 15.2; MedCalc Software, Ostend, Belgium), we performed descriptive statistics for demographic characteristics. Complication
rates and revision rates were analyzed using a random effects model of proportions when heterogeneous and a fixed effect model when not heterogeneous. 3. Results Twenty-one studies evaluating 430 acetabular fractures managed with acute THA were included in our final analysis (Fig. 1). Thirty-nine percent of the participants were women, and 61% were men. The mean patient age was 72 years (range of the means, 6081 years). The mean follow-up time was 44 months (range of the means, 1797 months) (Table 2). In terms of fixation before THA, all patients in the included studies underwent some type of fixation with screws, cables, wires, plates, rings, or cages (Appendix). Twenty of the 21 studies reported the type and subtype of the acetabular fracture (n ¼ 416). In accordance with classification by Letournel and Judet,33 elementary fractures accounted for 43% (n ¼ 179) of the cases and 57% (n ¼ 237) were associated fractures. Posterior wall fracture was the most common type of elementary fracture (19%, n ¼ 77), and anterior column or wall and posterior hemi-transverse were the most common types of associated fractures (16%, n ¼ 66). The rates of subtypes of acetabular fractures are presented in Table 3. In terms of clinical outcomes, the weighted mean Harris Hip Score at latest follow-up was 83.3 points (range of
Fig. 1. Flowchart of study selection. Table 1 Indications for acute total hip arthroplasty. Indication
References
Displaced acetabular fracture with intraarticular comminution and/or protrusion Acetabular impaction involving weight bearing zone Femoral head cartilage loss, impaction, or fracture Preexisting, severe hip osteoarthritis or avascular necrosis Concomitant displaced femoral neck fracture Radiographic evidence of osteopenia/osteoporosis Anterior column fracture with posterior column involvement (intact or partially intact) or associated both column
4 8 10 16e18 2023 25e30 32
, , , , , , , , , , , , , , 4 8 10 17 19 20 21 24 27 , , , , , , , , 4 10 16 17 19e21 28 , , , , , 4 10 15 20 21 28 , , , , , 4 8 10 17 19e21 24 25 29 , , , , , , , 18 25 31 , ,
4 8 10 15 17 20 21 24 28e32
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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Table 2 Study details and demographics. Study
THA (n)
10
Female (n)
e e 3 5 e 8 e 10 e 2 6 7 8 18 11 4 6 18 5 4 10
57 11 10 10 18 18 9 22 20 15 19 15 24 33 11 9 18 37 13 27 34
Mears and Velyvis, 2002 Mouhsine et al., 200223 Tidermark et al., 200326 et al., 200415 Beaule Mouhsine et al., 200422 Boraiah et al., 20098 Carroll et al., 20104 Herscovici et al., 201019 maly et al., 201317 Che Malhotra et al., 201321 Chakravarty et al., 201416 Enocson and Blomfeldt, 201418 Rickman et al., 201424 Lin et al., 201520 Solomon et al., 201525 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829 Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932
Male (n)
Age (y)
e e 7 5 e 10 e 12 e 13 13 8 16 15 4 5 12 19 8 23 24
Follow-up (mo)
Avg
Range
Avg
Range
69 79 73 61 76 72 67 75 60 65 77 76 77 66 81 80 66 79 77 69 71
26e89 65e93 57e87 50e85 65e93 55e86 56e89 60e95 28e89 57e69 57e90 63e84 63e90 47e92 76e87 63e90 35e81 66e90 64e89 57e84 56e92
97 24 38 34 36 47 63 29 31 82 22 48 24 67 e e 22 22 24 48 17
24e144 e 11e84 24e53 12e46 12e120 24e188 13e67 12e79 62e122 2e80 e 8e38 12e170 12e24 e 12e36 6e89 e 12e84 0e72
THA, total hip arthroplasty; Avg, average.
the means, 7093 points).8,10,19,26,28,29,31 Various techniques were used in these 21 studies in conjunction with THA for acute management of acetabular fracture. Most of the included studies used plates and screws for internal fixation. Four studies used ring devices,18,19,27,32 one used a specific cage system (Octopus; DePuy Synthes, Johnson & Johnson, Raynham, MA),21 and four others implemented a cup-cage device (Appendix).25,26,29,30 The estimated weighted mean blood loss was 925 mL (range of the means, 5331163 mL),15e21,24,26,27,30e32 and the surgical procedures had a weighted mean length of 176 min
(range of the means, 110244 min) (Table 4).4,15e22,24,26e28,30e32 Using our random effects model, we determined that 20% of the patients had a reported complication (95% confidence interval [CI], 13.8%e27.6%) (Table 5 and Fig. 2). The most common complication was HO, with a rate of 19.5% (95% CI, 11.9%e28.5%) for any Brooker grade. The rate of clinically significant HO (Brooker grade III or IV) was lower at 6.8% (95% CI, 3.2%e11.7%). Hip dislocation occurred at a rate of 6.1% (95% CI, 4.0%e8.5%), 4.1% developed VTE (95% CI, 2.1%e6.8%), deep infection occurred in 3.8% (95% CI, 2.2%e5.9%), and neurological complications occurred in 1.9% (95% CI, 0.8%e
Table 3 Types of acetabular fractures. Study
Mears and Velyvis, 200210 Mouhsine et al., 200223 Tidermark et al., 200326 et al., 200415 Beaule Mouhsine et al., 200422 Boraiah et al., 20098 Carroll et al., 20104 Herscovici et al., 201019 maly et al., 201317 Che Malhotra et al., 201321 Chakravarty et al., 201416 Enocson and Blomfeldt, 201418 Rickman et al., 201424 Lin et al., 201520 Solomon et al., 201525 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829a Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932 Rate (%)
Elementary
Associated
n
PW
PC
AW
AC
Tr
n
PCPW
T-s
AWCPHT
ABC
TPW
34 0 5 8 2 16 e 0 10 8 4 11 13 15 1 5 12 15 1 15 4 43
11 0 0 0 0 15 e 0 6 3 0 0 1 13 0 0 9 7 1 9 2 19
3 0 0 0 0 0 e 0 2 3 0 0 0 0 0 0 0 0 0 2 0 2
0 0 0 4 0 0 e 0 0 0 0 0 0 2 0 2 0 0 0 0 0 2
10 0 0 4 0 0 e 0 1 0 1 10 4 0 1 1 0 8 0 0 1 10
10 0 5 0 2 1 e 0 1 2 3 1 8 0 0 2 3 0 0 4 1 10
23 11 5 2 16 2 e 22 10 7 15 4 11 18 10 4 6 17 12 12 30 57
6 3 0 0 2 0 e 0 1 3 0 0 3 4 0 0 1 0 1 0 2 6
3 8 0 0 9 0 e 0 4 0 1 0 0 0 0 0 2 3 0 2 19 12
6 0 5 2 1 1 e 7 0 2 5 4 2 5 7 0 1 6 5 5 2 16
4 0 0 0 0 1 e 6 3 0 5 0 6 2 3 4 1 4 5 5 5 13
4 0 0 0 4 0 e 9 2 2 4 0 0 7 0 0 1 4 1 0 2 10
PW, posterior wall; PC, posterior column; AW, anterior wall; AC, anterior column; Tr, Transverse; PCPW, posterior column and posterior wall; T-s, T-shaped; AWCPHT, anterior wall or column with posterior hemi-transverse; ABC, associated both column; TPW, transverse and posterior wall. a Five patients had fractures classified as “other,” and were not included in the analysis.
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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Table 4 Estimated blood loss and operative time. Study
Table 5 Complications of acute total hip arthroplasty for acetabular fracture.
THA (n) EBL (mL) Mean Range 10
Mears and Velyvis, 2002 Mouhsine et al., 200223 Tidermark et al., 200326 et al., 200415 Beaule Mouhsine et al., 200422 Boraiah et al., 20098 Carroll et al., 20104 Herscovici et al., 201019 maly et al., 201317 Che Malhotra et al., 201321 Chakravarty et al., 201416 Enocson and Blomfeldt, 201418 Rickman et al., 201424 Lin et al., 201520 Solomon et al., 201525 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829 Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932
57 11 10 10 18 18 9 22 20 15 19 15 24 33 11 9 18 37 13 27 34
e e 1100 1060 e e e 1163 992 835 700 665 1100 852 e 533 e e 800 827 1100
e e 700e1600 100e3200 e e e 300e4500 300e2000 450e1200 220e1800 250e1600 500e2500 200e5000 e 0e2000 e e 400e1700 152e3019 400e2700
Op Time (min)
Complication Type
n
Rate (%) 95% Confidence Interval References
Mean Range
HO (any grade) HO (grade III or IV) Dislocation VTE Infection Neurological deficit Revision Overalla
386 386 410 410 410 410 383 421
19.5 6.8 6.1 4.1 3.8 1.9 4.3 20.2
e e 159 180 165 e 244 232 171 135 231 149 193 200 e 189 122 e 188 110 169
e e 125e185 135e210 120e180 e 89e403 50e510 105e315 110e160 125e465 115e285 130e280 148e296 e 136e266 65e180 e 175e321 65e170 97e310
THA, total hip arthroplasty; EBL, estimated blood loss; Op Time, operative time.
3.4%) of patients who underwent acute THA for the management of acetabular fracture. The revision rate for the cohort was 4.3% (95% CI, 2.4%e6.8%).
4. Discussion ORIF is well accepted as the treatment of choice for acetabular fracture in the younger population; however, no guidelines have been definitively established for the management of acetabular fracture in the elderly. Maintaining anatomic fracture reduction and avoiding posttraumatic osteoarthritis in this group of patients are challenging.2,35 Acute THA combined with ORIF can be an option for properly selected patients and can allow for earlier rehabilitation and weight bearing, lower need for reoperation, and better functional scores compared with ORIF alone or delayed THA.15 Acute THA is a viable option and can be used by the treating surgeon in appropriately selected patients, including older patients with osteopenia and/or osteoporosis, comminuted acetabular fractures not amenable to ORIF, acetabular protrusion, marginal impaction, femoral head injuries, and femoral neck fractures (Table 1). To our knowledge, this study is the first meta-analysis of complications after acute THA for the treatment of acetabular fracture. THA has been used in acute management of elementary and associated acetabular fractures. Various acetabular fracture subtypes are included in this study, with posterior wall, anterior column or wall, and posterior hemi-transverse being the most common fracture subtypes. These subtypes were also most common in a 16-year prospective epidemical study based in the United Kingdom.36 The overall complication rate of 20% in our selected patient population was higher compared with all patients undergoing elective THA.37 The complication rate associated with acute THA, however, is lower than that reported (38.8%) for older patients undergoing ORIF for acetabular fractures.38 HO frequently occurs after acetabular fracture as a result of the substantial inflammation, extensive muscle dissection, blood loss,
11.9e28.5 3.2e11.7 4.0e8.5 2.1e6.8 2.2e5.9 0.8e3.4 2.4e6.8 13.8e27.6
8 10 15e23 2632
, , , , , , 8 10 15e22 2432 , , , 8 10 15e22 2432 , , , 8 10 15e22 2432 , , , 8 10 15e22 2432 , , , 8 10 15e22 2430 32 , , , , 8 10 15e32 , , 8 10 15e23 2632
HO, heterotopic ossification; VTE, venous thromboembolic event, including deep vein thrombosis and pulmonary embolism. a Overall complication rate includes HO (grade III and IV), dislocation, VTA, infection, and neurologic deficit.
length of procedure, and possible coexisting head trauma.17 In the series presented herein, the most common complication was HO (19.5%). The rate is lower than what others have described for the acute operative management for acetabular fractures. In a 2005 meta-analysis, the incidence of HO was 25.6% for 613 cases of displaced acetabular fracture that received operative treatment within the first 4 weeks after trauma.39 The rate of clinically significant HO (Brooker grade III or IV) was much lower in the present study, reported to be 6.8%. This indicates that most HO cases are not clinically relevant in patients undergoing acute THA for acetabular fractures. The prevalence of dislocation after primary THA has been reported to be 2%e4% by various studies of various follow-up lengths.40e42 With the use of larger diameter femoral heads in recent years, dislocation rate in primary THA has plateaued at approximately 2% depending on the approach.43 However, the dislocation rate in the cohort evaluated in this study was higher at 6.1%, likely due to the traumatic insult to the surrounding tissues that would otherwise provide stability of the THA. The revision rate for this series was 4.3% with a mean follow-up time of 44 months. With variation in follow-up length, it is difficult to predict the long-term success of this procedure considering that most THA revisions occur after the first decade. In addition, the infection rates after primary THA for a diagnosis of osteoarthritis have been reported to be <1%,14 which is lower than our reported infection rate of 3.8% for acute THA after acetabular fracture. The difference in the rate of infection can be attributed to several factors, such as longer operative time required for stabilizing the fractures and lack of optimization of the patients before nonelective surgery. Reports have shown a high incidence of failure (50%) with cemented acetabular components in delayed THA after acetabular fractures,44 but failure rates seem to be much lower (3%e19%) for cementless acetabular components.45,46 The revision rate described herein is at the low end of the delayed cementless THA, but acute THA has the added benefit of avoiding a second surgical insult and the challenges associated with revision surgery after ORIF (subclinical infection, residual nonunion and pelvic deformity, bone loss, osteonecrosis, and retained instrumentation).47 This study had several limitations. The 21 studies included for analysis were retrospective case series with heterogeneous designs, interventions, and follow-up periods. The internal fixation methods varied in individual studies as necessitated by the fracture types.5 Although this added heterogeneity to the cohort, the primary goal of internal fixation is to obtain sufficient reduction and fixation of the fracture to stabilize the cup when performing arthroplasty.11
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
J.J. Jauregui et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
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Fig. 2. Forest plot of overall complications associated with acute THA for acetabular fractures.
The studies were unified, however, by the use of acute THA for definitive treatment. Our analysis also focused on the overall and specific complications after THA, which were variably reported. Although the revision rate was described in most studies, we were unable to perform a survival analysis because the exact time to each revision was described in only a few studies. Furthermore, the studies varied by fracture type, surgical technique, and approach. We were unable to perform subgroup analyses for complication and revision rates based on these factors because of the lack of granular data inherent in meta-analyses. Future studies should examine the effects of these clinical and surgical factors on the complication and revision rates. The rates of complications and revisions could be affected by the variable follow-up, which should be addressed by future studies. Although this study was restricted to include articles written in the English language, the findings are representative of the current literature considering that most studies on acute THA for acetabular fractures are in English. In addition, our inclusion criteria allowed studies with patients younger than 60 years as long as the mean age was 60 years or older. Those studies were included to reduce heterogeneity and provide more meaningful results. Although these limitations are present, this is the largest study describing acute THA for the treatment of acetabular fractures in an elderly population. In older patients with poor bone quality, the optimal management of acetabular fractures remains poorly defined. Acute THA for acetabular fractures can result in higher revision and complication rates compared with primary THA but has complication and revision rates similar to those associated with ORIF and delayed THA for acetabular fractures. However, because of the limited alternatives in this selected group of patients, THA might be the best alternative. Surgeons should be aware of this possibility, and patients and their families should be educated regarding all the possible risks of this procedure. Further prospective studies are needed to diminish the limitations and define the best management for acute acetabular fractures.
Funding No external funding was received for this work.
Author contributions Julio Jauregui: conceptualization and design of the study; data collection; data curation and statistical analysis; formal analysis; writing, original draft; writing, review and editing. Tristan Weir: data collection; data curation and statistical analysis; formal analysis; writing, original draft; writing, review and editing. Jin Chen: data collection; writing, original draft. Aaron Johnson: conceptualization and design of the study; resources; writing, original draft. Neil Sardesai: data collection; writing, original draft. Aditya Maheshwari: formal analysis; resources; writing, original draft. Theodore Manson: conceptualization and design of the study; formal analysis; project administration; resources; supervision; writing, original draft; writing, review and editing.
Declaration of competing interest TM and his institution receive money from various law firms for providing expert testimony; TM’s institution received a grant from the Orthopaedic Research and Education Foundation; TM receives money from AO North America and the Maine Review Course as payment for lectures. No other relationships, conditions, or circumstances present potential conflicts of interest.
Acknowledgments The authors thank Senior Editor and Writer Dori Kelly, MA, for professional manuscript editing.
Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003
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J.J. Jauregui et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
Appendix A. Surgical Techniques by Study
Study
Internal Fixation
Total Hip Arthroplasty Technique Femoral
Acetabular
Approach
Mouhsine et al., 200223 Mears and Velyvis, 200210 Tidermark et al., 200326 Mouhsine et al., 200422 et al., 200415 Beaule Boraiah et al., 20098
Cables Screws and braided cables Cage Cables Plates and screws Plates and screws
NC NC C NC NC NC
NR AL (67%), EL (5%), O (28%) P (40%), AL (60%) P (56%), O (44%) A (100%) P (100%)
Herscovici et al., 201019 Carroll et al., 20104 maly et al., 201317 Che Malhotra et al., 201321 Rickman et al., 201424 Enocson and Blomfeldt, 201418 Chakravarty et al., 201416 Solomon et al., 201525 Lin et al., 201520 Boelch et al., 201727 Salama et al., 201728 Weaver et al., 201829 Borg et al., 201930 Giunta et al., 201931 Lont et al., 201932
Plates and screws, Ganz ring NR Plates and screws Cage Plates and screws Burch-Schneider ring Percutaneous screws Cage Plates and screws Burch-Schneider ring, plates, screws Plates and screws Plates and screws, cage Cage Plates and screws Plates and screws, ring
C C (70%), NC (30%) C C NR C (older), NC (younger) C (91%), NC (9%) NR NC NC C C NC (89%), C (11%) NR NC (79%), C (21%) NC (89%), C (11%) NC (100%) NC (100%) C (100%) C (100%) NC (38%), C (62%)
C (50%), NC(50%) NR NC NC NC (cup), C (liner) C NC NC (cup), C (liner) NC (97%), C (3%) C (100%) NC (100%) NC (100%) C (100%) C (100%) C (100%)
A (14%), P (86%) NR EP (100%) P (100%) NR AL (87%), PL (13%) P (100%) EP (100%) NR P (100%) P (100%) A (NR%), P (NR%) P (85%), AL (15%) P (78%), A&P (22%) P (100%)
C, Cemented; NC, Not cemented; NR, not reported; A, Anterior; P, Posterior; AL, Anterolateral; EL, Extended lateral; PL, Posterolateral; EP, Extended posterior; O, Other.
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Please cite this article as: Jauregui JJ et al., Acute total hip arthroplasty for older patients with acetabular fractures: A meta-analysis, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.01.003