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Acute Total Hip Arthroplasty in Acetabular Fractures in the Elderly Using the Octopus System
The Journal of Arthroplasty 28 (2013) 1005–1009
Contents lists available at SciVerse ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Acute Total Hip Arthroplasty in Acetabular Fractures in the Elderly Using the Octopus System Mid Term to Long Term Follow-Up Rajesh Malhotra MBBS, MS (Ortho) a, Davinder Pal Singh MBBS, MS (Ortho) a, Vaibhav Jain MBBS, MS (Ortho) b, Vijay Kumar MBBS, MS (Ortho), MRCS a, Ravijot Singh MBBS, MS (Ortho) a a b
Department of Orthopaedics, All India Institute Of Medical Sciences, New Delhi, India All India Institute of Medical Sciences, New Delhi, India
a r t i c l e
i n f o
Article history: Received 3 December 2011 Accepted 9 December 2012 Keywords: acetabular fractures total hip arthroplasty Octopus system elderly cementless
a b s t r a c t Patients older than 55 years presenting with acetabular fractures fulfilling the criteria for acute total hip arthroplasty (THA) were included. Cementless THA was done using the Octopus System and autologous bone grafting. 15 patients were available for latest follow up. The average follow-up was 81.5 months (62– 122 months). Mean Harris Hip Score was 91.1. 10 patients were walking without any support while 5 were using a cane. There were no cases of acetabular or femoral component loosening. This method of treatment is promising in the older population as there is deficiency of bone stock which may lead to fixation failures. It is, therefore, worthwhile to recommend primary THA using the Octopus system in the successful management of selected types of acetabular fractures in the elderly. © 2013 Elsevier Inc. All rights reserved.
Open reduction and fixation are the treatment of choice for displaced acetabular fracture(s) following injury/trauma, while total hip arthroplasty (THA) in selected cases has a definite role. The major indications for THA are secondary arthritis and avascular necrosis of femoral head. Moreover, post-traumatic hip arthritis is known to occur even after the restoration of acetabular stock with minimal deformity [1,2]. Acute THA with or without fixation has been recommended in the elderly [3,4]. Poor bone stock and frequently associated comminution may warrant the use of cage in cementless primary THA in the elderly. The Octopus cage system, Depuy, Johnson and Johnson, USA, a widely acclaimed device, was used to evaluate the clinical and radiological results in displaced acetabular fractures in the elderly.
column, open fracture, unfit for surgery, and not ambulatory before the fracture, were excluded. The initial evaluation was done with antero-posterior, iliac and obturator oblique radiographs and supplemented by a computed tomographic scan. Of the 18 patients only 15 were available for the follow-up. Their age group varied from 57 to 69 years with a mean age 64.5 years. The fractures were defined according to the Letournel classification, Table 2 [6]. Simple fall was the cause of fracture in 9, and motor vehicle collision in 6 patients. Thromboprophylaxis with low molecular weight heparin was started pre-operatively and was continued till full mobilization. Pre-anaesthetic check was an essential ingredient. It was considered mandatory to perform THA within 3 weeks of the injury.
Material and Methods
Operative Technique
In all 18 elderly patients of acetabular fractures, from May 2000 to July 2005 fulfilling the criteria (Table 1) for acute THA [3–5] over the age of 55 were taken up for the study. The Octopus system and autologous bone graft were used. Those who had associated both
The posterior approach was the mainstay for THA. The femoral head was dislocated in the first instance, after which the acetabular fracture was fixed with screws and/or 3.5-mm reconstruction plates. The femoral head was used as a structural graft in case of a major peripheral acetabular defect due to severe comminution. The reconstructed or grafted acetabulum was then reamed to produce a consistent hemispherical dome, and the trial acetabular ring was used to assess the ideal position of the three legs of the Octopus ring. The inferior leg was engaged in the obturator foramen using the hook positioner. The ring positioner was then used to orient the ring in 45°
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2012.12.003. Reprint requests: Davinder Pal Singh, MBBS, MS (Ortho), Department Of Orthopaedics, All India Institute Of Medical Sciences, Ansari Nagar, New Delhi, 110029, India. 0883-5403/2806-0025$36.00/0 – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2012.12.003
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R. Malhotra et al. / The Journal of Arthroplasty 28 (2013) 1005–1009
Oral Indomethacin 75 mg daily for two weeks was administered to prevent heterotopic ossification. Post-operative complications were recorded. The patients were regularly evaluated clinically and radiologically after surgery at an interval of 6 weeks, 3 months, 6 months, and 1 year. Subsequently, the patient was advised to report for checkup every year. In the course of follow-up, Harris Hip Score [7] was determined. It was complemented by the walking ability of each patients, the radiographic assessment of fracture-healing, osteolysis around the implant as well as changes in the angular position or migration of the acetabular component [8]. Migration of the cup more than 4 mm or change in abduction angle more than 5° was deemed as the indicator for loosening of the acetabular component. Femoral components were evaluated for any loosening in the zones aptly defined by Gruen et al [9].
Table 1 Indications for Acute THA in Acetabular Fractures [3–5]. Absolute
Relative
Indications • Impaction of the femoral head or acetabulum • Extensive abrasion of femoral head
• Delayed presentation • Medical comorbidities • Fracture of the femoral head • Morbid obesity • Completely displaced femoral neck fracture • Advanced age • Severely comminuted fracture • Significant destruction of the articular surface • Pre-existing arthritis of the hip • Elderly patients with osteoporosis
THA=Total Hip Arthroplasty.
of abduction and 15° of anteversion. The superior legs were contoured to match the patients’ anatomy and to fit any reconstructed acetabular anatomy. After contouring the legs of the trial ring, the definitive acetabular ring was matched with it fully. The definitive ring was placed over the prepared acetabulum, and fixed with cancellous screws through the fixation holes. The morselized bone grafts, taken from the head of femur were impacted to fill any contained defects. The acetabular shell was fixed to the ring with four connecting screws. A trial liner — standard or lateral offset, which lateralizes the center of rotation of head by 2.8 mm, was inserted and soft tissue tension and joint stability through a full range of motion were tested with trial components. Finally, the chosen liner, the one which snap fits and locks into the shell, was inserted. Uncemented femoral stems were used in all cases. The Octopus system is provided only with the liners with 28-mm internal diameter, therefore only femoral heads with 28-mm diameter were used in all cases. The patients were mobilized after 48 h of surgery with the help of walker. However, partial weight bearing was allowed after an interval of 3 weeks, and full weight bearing was started only after 6 weeks.
Results Of the 18, one patient was lost to follow-up, while 2 of them died of unrelated causes. The remaining 15 patients were evaluated for an average period of 81.5 months, the range being 62 to 122 months. There were 13 males and 2 females (Table 2). Average duration of surgery was 135 min with a range of 110 to 160 min and the average blood loss was 835 ml, the range being 450 to 1200 ml. Two post-operative patients had superficial infections, which healed following administration of antibiotics. There were no postoperative neurological complications. One patient had a history of pre-operative sciatic nerve injury, which during the latest follow-up had shown only partial recovery. Moreover, sciatic nerve was found to be apparently intact during surgery. There was one case of postoperative dislocation, which had occurred after 6 months of the surgery due to a simple fall on the ground, and was treated by closed reduction.
Table 2 Clinical Profile, Treatment Details and Follow Up of 15 Patients in the Study Group. Case No.
Sex, Age (Yrs)
Mechanism of injury
1
M, 58
Simple fall
Posterior column
Corail
74
97.0
Without cane
2
M, 62
MVC
Corail
89
92.6
Without cane
3
M, 69
Simple fall
Anterior+ posterior hemitransverse Transverse
Heterotrophic ossification (Brooker II) None
85
77.4
With cane
Dislocation ×1
4
F, 57
MVC
Transverse
109
96.4
Without cane
None
5
M, 59
MVC
99
95.2
Without cane
6 7
M, 66 M, 68
Simple fall Simple fall
122 81
96.8 72.0
Without cane With cane
8
M, 66
Simple fall
62
87.6
With cane
9 10
M, 67 M, 64
Simple fall MVC
AML Corail
67 78
86.3 95.9
With cane Without cane
Post-operative Superficial infection None Post-operative Superficial infection Heterotrophic ossification (Brooker II) None None
11
F, 69
Simple fall
Anterior+posterior hemitransverse Posterior column Posterior column + posterior wall Transverse + posterior wall Posterior wall Posterior column + posterior wall Posterior column
Versys beaded midcoat Versys fiber metal taper Corail
72
95.2
Without cane
None
12 13
M, 68 M, 67
MVC Simple fall
Posterior wall Posterior wall
63 69
88.9 91.6
Without cane Without cane
None None
14
M, 65
Simple fall
71
95.5
With cane
None
15
M, 63
MVC
Transverse + posterior wall Posterior column + posterior wall
Versys beaded midcoat AML Versys fiber metal taper Corail Corail
82
98.3
Without cane
None
Type of Fracture
Femoral Implant Used
Corail Versys beaded midcoat Corail
Duration of Harris Hip Score Follow-Up (Months) at Follow-Up
M=Male, F=Female, MVC=Motor Vehicle Collision, AML=Anatomic Medullary Locking. Corail, AML — DePuy Johnson and Johnson, USA; Versys — Zimmer, Warsaw.
Walking Ability of Patient at Follow-Up
Complications
R. Malhotra et al. / The Journal of Arthroplasty 28 (2013) 1005–1009
Clinical Evaluation All the patients were able to walk independently at their latest follow-up. 10 patients were walking without any support, while 5 were using a cane in the hand. At the last follow-up, Harris Hip Score was recorded for each patient. The score was excellent in 10, good in 3, while fair in the remaining 2 patients. The mean score was 91.1 with a range of 72 to 97. 12 patients had pain-free hip movements while 3 had slight pain on walking, and were walking with a slight limp. Radiological Evaluation Bone graft was found to be incorporated completely in all the patients. Though a difficulty was experienced in assessing for any radiolucent lines for the acetabulum due to the cage, there was neither any apparent osteolysis around the acetabular component, nor was there any medial migration or any change in the angulation of the component (Figs. 1 and 2). The seven zones around the femoral
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component, as described by Gruen et al. [9] were assessed for the presence of any osteolysis. There was no subsidence or loosening of the femoral component in the serial radiographs. Two cases with Brooker Grade II heterotopic ossification [10] were found, for which no intervention was required. Discussion Primary total hip arthroplasty in elderly patients having acetabular fractures is the mainstay of treatment in order to provide a stable hip with early pain free mobilization. Open reduction and internal fixation are the recognized treatment of displaced acetabular fractures in youngsters, however, they are not successful in the elderly [6,11–14]. Early reports of primary THA in acetabular fractures were discouraging because of technical difficulties [7,15,16]. In the current study, the Octopus System was used with the objective of achieving a stable construct rather than attempting anatomical reduction of the fracture. The fracture was also stabilized with the screws passing from the acetabular ring holes. Any fracture
Fig. 1. (A) Preoperative anteroposterior (AP) X-ray of a 66 year old male diabetic patient with two week old fracture. (B) Immediate postoperative AP X-ray after reconstruction with the Octopus system and the Corail femoral stem. (C) 10 year follow-up radiograph showing well integrated acetabular component.
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R. Malhotra et al. / The Journal of Arthroplasty 28 (2013) 1005–1009
Fig. 2. (A) Preoperative AP X-ray of 64 year male patient with 18 day old posterior column and posterior wall fracture. (B) 3D reconstructed CT image of the pelvis clearly showing the fracture pattern. (C) Immediate post operative AP X-ray with reconstructed with screws and octopus system. (D), (E) Latest follow-up showing well integrated acetabular component.
gaps were filled with the morselized graft taken from the femoral head. It ensured that the centre of rotation was correctly positioned, and aligned relative to Shenton's line. Moreover, the construct offered initial stability, whereas long-term stability was provided by integration of hydroxyapatite (HA) coating on the acetabular shell with the host bone. Initial stability of the system allowed the
patient to weight bear early, thus avoiding the complications related to the recumbency. In addition the construct provides a large contact area between the implant and the host bone without intervening cement, thereby decreasing the chances of implant migration. Furthermore, it acts as a hemispherical plate to hold the acetabular fracture in place, and
R. Malhotra et al. / The Journal of Arthroplasty 28 (2013) 1005–1009
augments bone by protecting the bone grafts during revascularization, incorporation and remodeling. The durability of fixation and good results of the study in the mid term to long term were possible, because of osteo-integration of the host bone with HA coating of the shell. Posterior wall and column fracture pattern were found to be relatively easier to fix in this system in contrast to others. Interestingly, the comminution in the fracture did not pose any problem for achieving the stable construct as the multiple screw hole options in the acetabular ring helped to have a purchase in the normal bone. The ease and efficiency of performing the procedure were reflected in shorter operative time and lesser blood loss [17,18]. Good results have been reported with early THA, and the principal complication was post-operative dislocation in 3.5% [19]. In the current series, there was only single case of dislocation that was caused by the fall on the ground 6 months after the surgery. Cochu et al [20] evaluated 16 patients with the mean age of 76.1 years, who underwent acute THA for acetabular fractures. They used reinforcement ring for fixation. There was no post-operative dislocation, and the fractures healed. It was concluded that acute THA in this setting provides pain free hip and immediate mobilization with a good functional outcome. Although there was a relatively younger mean age group of 64.5 years in the current series, the results were comparable. In a study of 57 patients, Mears and Velyvis [4] reported the late results of acute THA in acetabular fractures. It was concluded that primary THA seemed to be a promising therapeutic alternative for selected patients with an expected unsatisfactory outcome after fracture treatment. Good Harris Hip Scores were reported in 45 (79%) patients. The study included younger patients also and thus had a wider age group from 26 to 89 years. Excessive medialization of the cup was observed in six patients in the study. Harris Hip Scores were better in the present series, though there were only 15 patients. Excessive medialization of the cup was scrupulously avoided by using the Octopus acetabular ring fixed to the host bone with the help of three supports. The fixation of the ring is a crucial step for final acetabular component alignment, as once it is fixed it becomes difficult to change the version or abduction angle. Tidermark et al. [21] reported 10 patients, with mean age 73 years, who were treated acutely with a THA supported by a reinforcement ring (Burch–Schneider antiprotrusion cage, Zimmer) and autologous bone grafting of the acetabulum. At a mean follow-up of 38 months, range 11 to 84, good to excellent results were achieved in 60%, bone graft was completely incorporated in all cases, and there were no signs of loosening. Early dislocations occurred in 30% of the subjects. There have been a few studies using the Octopus system. The studies favored the use of the system in managing acetabular defects along with the use of bone grafts in the revision THA [22,23]. The system thus far has never been used for acute THA following acetabular fractures. This method is unique for it depends upon the stability of the Octopus ring to the host bone and not on the anatomical reduction of the fracture. Moreover, incorporation of the graft and integration of hydroxyapatite coating of the acetabular shell to the host bone provide the long term stability. The excellent
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clinical and radiological results achieved in the current series support the contention. Thus, all in all this modality of treatment seems promising in the older population since there is deficiency of bone stock, which may cause fixation failures. It is, therefore, worthwhile to recommend primary THA using the Octopus system in the successful management of selected types of acetabular fractures in the elderly.
References 1. Ragnarsson B, Mjoberg B. Arthrosis after surgically treated acetabular fractures. A retrospective study of 60 cases. Acta Orthop Scand 1992;63:511. 2. Giannoudis PV, Grotz MR, Papakostidis C, et al. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Jt Surg Br 2005;87:2. 3. Jimenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am 1997;28:435. 4. Mears DC, Velyvis JH. Acute total hip arthroplasty for selected displaced acetabular fractures: 2–12-year results. J Bone Jt Surg 2002;84(A):1. 5. Mears DC, Velyvis JH. Primary total hip arthroplasty after acetabular fracture. J Bone Joint Surg Am 2000;82:1328. 6. Letournel E, Judet R. Fractures of the acetabulum. 2nd ed.New York: SpringerVerlag; 1993. 7. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am 1969;51:737. 8. Russoti GM, Harris WH. Proximal placement of the acetabular component in total hip arthroplasty. A long-term follow up study. J Bone Joint Surg Am 1991; 73:587. 9. Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 1979:17. 10. Brooker AF, Bowerman JW, Robinson RA, et al. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629. 11. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78:1632. 12. Romness DW, Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. Long-term results. J Bone Joint Surg Br 1990;72:761. 13. Weber M, Berry DJ, Harmsen S. Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am 1998;80:1295. 14. Simko P, Braunsteiner T, Vajczikova´ S. Early primary total hip arthroplasty for acetabular fractures in elderly patients. Acta Chir Orthop Traumatol Cech 2006; 73:275. 15. Coventry MB. The treatment of fracture–dislocation of the hip by total hip arthroplasty. J Bone Joint Surg Am 1974;56:1128. 16. Kelly PJ, Lipscomb PR. Primary vitallium-mold arthroplasty for posterior dislocation of the hip with fracture of the femoral head. J Bone Joint Surg Am 1958;40:675. 17. Herscovici Jr D, Lindvall E, Bolhofner B, et al. 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(5): 291. 18. Boraiah S, Ragsdale M, Achor T, et al. Open reduction internal fixation and primary total hip arthroplasty of selected acetabular fractures. J Orthop Trauma 2009; 23(4):243. 19. Oransky M, Sanguinetti C. Surgical treatment of displaced acetabular fractures: results of 50 consecutive cases. J Orthop Trauma 1993;7:28. 20. Cochu G, Mabit C, Gougam T, et al. Total hip arthroplasty for treatment of acute acetabular fractures in elderly patients. Rev Chir Orthop Reparatrice Appar Mot 2007;93(8):818. 21. Tidermark J, Blomfeldt R, Ponzer S, et al. Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients. J Orthop Trauma 2003;17:193. 22. Marinoni EC, Fontana A, Castellano S, et al. The Octopus System for acetabular reconstruction. Chir Organi Mov 1994;79(4):357. 23. Vojtassák J, Jány R.Incorporation of bone allografts with use of Octopus revision system in total hip arthroplasty [article in Slovak]. Acta Chir Orthop Traumatol Cech. 2004;71(4):210–3. 267.
Contents lists available at SciVerse ScienceDirect
The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Acute Total Hip Arthroplasty in Acetabular Fractures in the Elderly Using the Octopus System Mid Term to Long Term Follow-Up Rajesh Malhotra MBBS, MS (Ortho) a, Davinder Pal Singh MBBS, MS (Ortho) a, Vaibhav Jain MBBS, MS (Ortho) b, Vijay Kumar MBBS, MS (Ortho), MRCS a, Ravijot Singh MBBS, MS (Ortho) a a b
Department of Orthopaedics, All India Institute Of Medical Sciences, New Delhi, India All India Institute of Medical Sciences, New Delhi, India
a r t i c l e
i n f o
Article history: Received 3 December 2011 Accepted 9 December 2012 Keywords: acetabular fractures total hip arthroplasty Octopus system elderly cementless
a b s t r a c t Patients older than 55 years presenting with acetabular fractures fulfilling the criteria for acute total hip arthroplasty (THA) were included. Cementless THA was done using the Octopus System and autologous bone grafting. 15 patients were available for latest follow up. The average follow-up was 81.5 months (62– 122 months). Mean Harris Hip Score was 91.1. 10 patients were walking without any support while 5 were using a cane. There were no cases of acetabular or femoral component loosening. This method of treatment is promising in the older population as there is deficiency of bone stock which may lead to fixation failures. It is, therefore, worthwhile to recommend primary THA using the Octopus system in the successful management of selected types of acetabular fractures in the elderly. © 2013 Elsevier Inc. All rights reserved.
Open reduction and fixation are the treatment of choice for displaced acetabular fracture(s) following injury/trauma, while total hip arthroplasty (THA) in selected cases has a definite role. The major indications for THA are secondary arthritis and avascular necrosis of femoral head. Moreover, post-traumatic hip arthritis is known to occur even after the restoration of acetabular stock with minimal deformity [1,2]. Acute THA with or without fixation has been recommended in the elderly [3,4]. Poor bone stock and frequently associated comminution may warrant the use of cage in cementless primary THA in the elderly. The Octopus cage system, Depuy, Johnson and Johnson, USA, a widely acclaimed device, was used to evaluate the clinical and radiological results in displaced acetabular fractures in the elderly.
column, open fracture, unfit for surgery, and not ambulatory before the fracture, were excluded. The initial evaluation was done with antero-posterior, iliac and obturator oblique radiographs and supplemented by a computed tomographic scan. Of the 18 patients only 15 were available for the follow-up. Their age group varied from 57 to 69 years with a mean age 64.5 years. The fractures were defined according to the Letournel classification, Table 2 [6]. Simple fall was the cause of fracture in 9, and motor vehicle collision in 6 patients. Thromboprophylaxis with low molecular weight heparin was started pre-operatively and was continued till full mobilization. Pre-anaesthetic check was an essential ingredient. It was considered mandatory to perform THA within 3 weeks of the injury.
Material and Methods
Operative Technique
In all 18 elderly patients of acetabular fractures, from May 2000 to July 2005 fulfilling the criteria (Table 1) for acute THA [3–5] over the age of 55 were taken up for the study. The Octopus system and autologous bone graft were used. Those who had associated both
The posterior approach was the mainstay for THA. The femoral head was dislocated in the first instance, after which the acetabular fracture was fixed with screws and/or 3.5-mm reconstruction plates. The femoral head was used as a structural graft in case of a major peripheral acetabular defect due to severe comminution. The reconstructed or grafted acetabulum was then reamed to produce a consistent hemispherical dome, and the trial acetabular ring was used to assess the ideal position of the three legs of the Octopus ring. The inferior leg was engaged in the obturator foramen using the hook positioner. The ring positioner was then used to orient the ring in 45°
The Conflict of Interest statement associated with this article can be found at http:// dx.doi.org/10.1016/j.arth.2012.12.003. Reprint requests: Davinder Pal Singh, MBBS, MS (Ortho), Department Of Orthopaedics, All India Institute Of Medical Sciences, Ansari Nagar, New Delhi, 110029, India. 0883-5403/2806-0025$36.00/0 – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.arth.2012.12.003
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R. Malhotra et al. / The Journal of Arthroplasty 28 (2013) 1005–1009
Oral Indomethacin 75 mg daily for two weeks was administered to prevent heterotopic ossification. Post-operative complications were recorded. The patients were regularly evaluated clinically and radiologically after surgery at an interval of 6 weeks, 3 months, 6 months, and 1 year. Subsequently, the patient was advised to report for checkup every year. In the course of follow-up, Harris Hip Score [7] was determined. It was complemented by the walking ability of each patients, the radiographic assessment of fracture-healing, osteolysis around the implant as well as changes in the angular position or migration of the acetabular component [8]. Migration of the cup more than 4 mm or change in abduction angle more than 5° was deemed as the indicator for loosening of the acetabular component. Femoral components were evaluated for any loosening in the zones aptly defined by Gruen et al [9].
Table 1 Indications for Acute THA in Acetabular Fractures [3–5]. Absolute
Relative
Indications • Impaction of the femoral head or acetabulum • Extensive abrasion of femoral head
• Delayed presentation • Medical comorbidities • Fracture of the femoral head • Morbid obesity • Completely displaced femoral neck fracture • Advanced age • Severely comminuted fracture • Significant destruction of the articular surface • Pre-existing arthritis of the hip • Elderly patients with osteoporosis
THA=Total Hip Arthroplasty.
of abduction and 15° of anteversion. The superior legs were contoured to match the patients’ anatomy and to fit any reconstructed acetabular anatomy. After contouring the legs of the trial ring, the definitive acetabular ring was matched with it fully. The definitive ring was placed over the prepared acetabulum, and fixed with cancellous screws through the fixation holes. The morselized bone grafts, taken from the head of femur were impacted to fill any contained defects. The acetabular shell was fixed to the ring with four connecting screws. A trial liner — standard or lateral offset, which lateralizes the center of rotation of head by 2.8 mm, was inserted and soft tissue tension and joint stability through a full range of motion were tested with trial components. Finally, the chosen liner, the one which snap fits and locks into the shell, was inserted. Uncemented femoral stems were used in all cases. The Octopus system is provided only with the liners with 28-mm internal diameter, therefore only femoral heads with 28-mm diameter were used in all cases. The patients were mobilized after 48 h of surgery with the help of walker. However, partial weight bearing was allowed after an interval of 3 weeks, and full weight bearing was started only after 6 weeks.
Results Of the 18, one patient was lost to follow-up, while 2 of them died of unrelated causes. The remaining 15 patients were evaluated for an average period of 81.5 months, the range being 62 to 122 months. There were 13 males and 2 females (Table 2). Average duration of surgery was 135 min with a range of 110 to 160 min and the average blood loss was 835 ml, the range being 450 to 1200 ml. Two post-operative patients had superficial infections, which healed following administration of antibiotics. There were no postoperative neurological complications. One patient had a history of pre-operative sciatic nerve injury, which during the latest follow-up had shown only partial recovery. Moreover, sciatic nerve was found to be apparently intact during surgery. There was one case of postoperative dislocation, which had occurred after 6 months of the surgery due to a simple fall on the ground, and was treated by closed reduction.
Table 2 Clinical Profile, Treatment Details and Follow Up of 15 Patients in the Study Group. Case No.
Sex, Age (Yrs)
Mechanism of injury
1
M, 58
Simple fall
Posterior column
Corail
74
97.0
Without cane
2
M, 62
MVC
Corail
89
92.6
Without cane
3
M, 69
Simple fall
Anterior+ posterior hemitransverse Transverse
Heterotrophic ossification (Brooker II) None
85
77.4
With cane
Dislocation ×1
4
F, 57
MVC
Transverse
109
96.4
Without cane
None
5
M, 59
MVC
99
95.2
Without cane
6 7
M, 66 M, 68
Simple fall Simple fall
122 81
96.8 72.0
Without cane With cane
8
M, 66
Simple fall
62
87.6
With cane
9 10
M, 67 M, 64
Simple fall MVC
AML Corail
67 78
86.3 95.9
With cane Without cane
Post-operative Superficial infection None Post-operative Superficial infection Heterotrophic ossification (Brooker II) None None
11
F, 69
Simple fall
Anterior+posterior hemitransverse Posterior column Posterior column + posterior wall Transverse + posterior wall Posterior wall Posterior column + posterior wall Posterior column
Versys beaded midcoat Versys fiber metal taper Corail
72
95.2
Without cane
None
12 13
M, 68 M, 67
MVC Simple fall
Posterior wall Posterior wall
63 69
88.9 91.6
Without cane Without cane
None None
14
M, 65
Simple fall
71
95.5
With cane
None
15
M, 63
MVC
Transverse + posterior wall Posterior column + posterior wall
Versys beaded midcoat AML Versys fiber metal taper Corail Corail
82
98.3
Without cane
None
Type of Fracture
Femoral Implant Used
Corail Versys beaded midcoat Corail
Duration of Harris Hip Score Follow-Up (Months) at Follow-Up
M=Male, F=Female, MVC=Motor Vehicle Collision, AML=Anatomic Medullary Locking. Corail, AML — DePuy Johnson and Johnson, USA; Versys — Zimmer, Warsaw.
Walking Ability of Patient at Follow-Up
Complications
R. Malhotra et al. / The Journal of Arthroplasty 28 (2013) 1005–1009
Clinical Evaluation All the patients were able to walk independently at their latest follow-up. 10 patients were walking without any support, while 5 were using a cane in the hand. At the last follow-up, Harris Hip Score was recorded for each patient. The score was excellent in 10, good in 3, while fair in the remaining 2 patients. The mean score was 91.1 with a range of 72 to 97. 12 patients had pain-free hip movements while 3 had slight pain on walking, and were walking with a slight limp. Radiological Evaluation Bone graft was found to be incorporated completely in all the patients. Though a difficulty was experienced in assessing for any radiolucent lines for the acetabulum due to the cage, there was neither any apparent osteolysis around the acetabular component, nor was there any medial migration or any change in the angulation of the component (Figs. 1 and 2). The seven zones around the femoral
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component, as described by Gruen et al. [9] were assessed for the presence of any osteolysis. There was no subsidence or loosening of the femoral component in the serial radiographs. Two cases with Brooker Grade II heterotopic ossification [10] were found, for which no intervention was required. Discussion Primary total hip arthroplasty in elderly patients having acetabular fractures is the mainstay of treatment in order to provide a stable hip with early pain free mobilization. Open reduction and internal fixation are the recognized treatment of displaced acetabular fractures in youngsters, however, they are not successful in the elderly [6,11–14]. Early reports of primary THA in acetabular fractures were discouraging because of technical difficulties [7,15,16]. In the current study, the Octopus System was used with the objective of achieving a stable construct rather than attempting anatomical reduction of the fracture. The fracture was also stabilized with the screws passing from the acetabular ring holes. Any fracture
Fig. 1. (A) Preoperative anteroposterior (AP) X-ray of a 66 year old male diabetic patient with two week old fracture. (B) Immediate postoperative AP X-ray after reconstruction with the Octopus system and the Corail femoral stem. (C) 10 year follow-up radiograph showing well integrated acetabular component.
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Fig. 2. (A) Preoperative AP X-ray of 64 year male patient with 18 day old posterior column and posterior wall fracture. (B) 3D reconstructed CT image of the pelvis clearly showing the fracture pattern. (C) Immediate post operative AP X-ray with reconstructed with screws and octopus system. (D), (E) Latest follow-up showing well integrated acetabular component.
gaps were filled with the morselized graft taken from the femoral head. It ensured that the centre of rotation was correctly positioned, and aligned relative to Shenton's line. Moreover, the construct offered initial stability, whereas long-term stability was provided by integration of hydroxyapatite (HA) coating on the acetabular shell with the host bone. Initial stability of the system allowed the
patient to weight bear early, thus avoiding the complications related to the recumbency. In addition the construct provides a large contact area between the implant and the host bone without intervening cement, thereby decreasing the chances of implant migration. Furthermore, it acts as a hemispherical plate to hold the acetabular fracture in place, and
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augments bone by protecting the bone grafts during revascularization, incorporation and remodeling. The durability of fixation and good results of the study in the mid term to long term were possible, because of osteo-integration of the host bone with HA coating of the shell. Posterior wall and column fracture pattern were found to be relatively easier to fix in this system in contrast to others. Interestingly, the comminution in the fracture did not pose any problem for achieving the stable construct as the multiple screw hole options in the acetabular ring helped to have a purchase in the normal bone. The ease and efficiency of performing the procedure were reflected in shorter operative time and lesser blood loss [17,18]. Good results have been reported with early THA, and the principal complication was post-operative dislocation in 3.5% [19]. In the current series, there was only single case of dislocation that was caused by the fall on the ground 6 months after the surgery. Cochu et al [20] evaluated 16 patients with the mean age of 76.1 years, who underwent acute THA for acetabular fractures. They used reinforcement ring for fixation. There was no post-operative dislocation, and the fractures healed. It was concluded that acute THA in this setting provides pain free hip and immediate mobilization with a good functional outcome. Although there was a relatively younger mean age group of 64.5 years in the current series, the results were comparable. In a study of 57 patients, Mears and Velyvis [4] reported the late results of acute THA in acetabular fractures. It was concluded that primary THA seemed to be a promising therapeutic alternative for selected patients with an expected unsatisfactory outcome after fracture treatment. Good Harris Hip Scores were reported in 45 (79%) patients. The study included younger patients also and thus had a wider age group from 26 to 89 years. Excessive medialization of the cup was observed in six patients in the study. Harris Hip Scores were better in the present series, though there were only 15 patients. Excessive medialization of the cup was scrupulously avoided by using the Octopus acetabular ring fixed to the host bone with the help of three supports. The fixation of the ring is a crucial step for final acetabular component alignment, as once it is fixed it becomes difficult to change the version or abduction angle. Tidermark et al. [21] reported 10 patients, with mean age 73 years, who were treated acutely with a THA supported by a reinforcement ring (Burch–Schneider antiprotrusion cage, Zimmer) and autologous bone grafting of the acetabulum. At a mean follow-up of 38 months, range 11 to 84, good to excellent results were achieved in 60%, bone graft was completely incorporated in all cases, and there were no signs of loosening. Early dislocations occurred in 30% of the subjects. There have been a few studies using the Octopus system. The studies favored the use of the system in managing acetabular defects along with the use of bone grafts in the revision THA [22,23]. The system thus far has never been used for acute THA following acetabular fractures. This method is unique for it depends upon the stability of the Octopus ring to the host bone and not on the anatomical reduction of the fracture. Moreover, incorporation of the graft and integration of hydroxyapatite coating of the acetabular shell to the host bone provide the long term stability. The excellent
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clinical and radiological results achieved in the current series support the contention. Thus, all in all this modality of treatment seems promising in the older population since there is deficiency of bone stock, which may cause fixation failures. It is, therefore, worthwhile to recommend primary THA using the Octopus system in the successful management of selected types of acetabular fractures in the elderly.
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