THA TO SALVAGE FAILED ACETABULAR FRACTURES

Daniel J. Berry, MD

Mayo Clinic

Rochester, MN

THA AFTER ACETABULAR FXTechnical Challenges

• Acetabular bone loss• Residual pelvic deformity• Nonunited fractures• Retained hardware• Heterotopic ossification• Socket fixation

THA FOR ACETABULAR FX

ACETABULAR COMPONENT CHOICE

THA AFTER ACETABULAR FX Previous ORIF

Results: Long Term:• Higher failure rate than THA for OA• Pts young/male/unilateral disease• Uncemented cups better so far than

cemented (similar scenario to revision THA)

Weber et al. JBJS 80A(9):1295-1305, 1998

SURVIVAL FREE REVISION FOR ASEPTIC ACET LOOSE/RADIOGRAPHIC LOOSENING

Cemented vs Uncemented

THA AFTER ACETABULAR FXAcetabular Bone Loss

Socket Fixation:• Apply principles of revision

THA (similar sclerotic, deficient bone)

• Consensus in North America: Uncemented hemispherical cup

THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups

Uncemented Cups: 5 Yr, Data, Rush:• 1/30 (4%) revised for loosening

JBJS(A), 2001

THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups

Uncemented Cups: Mayo Clinic Data:• 34 hips• Minimum F/U 10 yrs (10-16)• Aseptic Loosening 2/34 (6%)

Halasy, Berry, CORR 2002

THA AFTER ACETABULAR FX

MANAGEMENT OF BONE LOSS

THA AFTER ACETABULAR FXAcetabular Bone Loss

Cavitary Bone Loss: Particulate Graft

THA AFTER ACETABULAR FXAcetabular Bone Loss

Segmental Loss: The Posterior/Superior Wall• Use autogenous femoral head graft if

needed

THA AFTER ACETABULAR FXAcetabular Bone Loss

Results: • Reliable bone graft healing and

incorporation

THA AFTER ACETABULAR FX

PELVIC DEFORMITY

THA AFTER ACETABULAR FXPelvic Deformity

• Landmarks distorted

- care with cup position• Bony prominence

- beware of bone impingement causing instability

THA AFTER ACETABULAR FX

NONUNITED FRACTURES

THA AFTER ACETABULAR FXNonunited Fractures

• Typically nonunited transverse acetabular fx (pelvic discontinuity)

• Stabilize with post column plate

THA AFTER ACETABULAR FXNonunited Fractures

Results:• High rate of fracture healing

(100% in personal experience)

THA AFTER ACETABULAR FXNonunited Fractures

Plate Pelvic Discontinuity

THA AFTER ACETABULAR FX

RETAINED HARDWARE

THA AFTER ACETABULAR FXRetained Hardware

• Leave in place if not problematic• Selective removal when needed• Beware of the sciatic nerve

THA AFTER ACETABULAR FXRetained Hardware

Selective Hardware Removal

THA AFTER ACETABULAR FXRetained Hardware

Selective Hardware Removal

THA AFTER ACETABULAR FXRetained Hardware

Sciatic Nerve:• Avoid if possible• If working posteriorly:

Identify (beneath g. max. tendon), handle carefully

• Do case with knee flexed

THA AFTER ACETABULAR FX

HETEROTOPIC BONE

THA AFTER ACETABULAR FXHeterotopic Bone

Heterotopic Ossification:• Excise HO if symptomatic• If HO formed after last

procedure use prophylaxis (NSAID or radiation) after THA

THA AFTER ACETABULAR FXHeterotopic Bone

HO: Excise, Postop Prophylaxis

THA AFTER ACETABULAR FX

MINIMIZING COMPLICATIONS

THA FOR POSTTRAUMATIC HIPMinimizing Complications

Reducing Complications:• Careful preoperative

assessment:

- bone loss

- fracture nonunion

- r/o infection• Know what you are up

against

THA FOR POSTTRAUMATIC HIP Minimizing Complications

Reducing Complications:• Anticipate more blood loss (cell

saver)• Longer operative time• Exposure difficulties (choose

based on preference/HO/hardware)

THA AFTER ACETABULAR FXReducing Complications

Anticipate Special Needs (Intra/Postop):• Pelvic reconstruction plates• Autogenous bone grafting• Metal cutting instruments• HO prophylaxis

THA AFTER ACETABULAR FX Conclusions

• Good planning, careful execution

• Modern technology

• Usually excellent results despite technical challenges

• The patients like these operations--they have a previous failure and you fix it