Total hip arthroplasty in acetabular fractures

Abstract

Total Hip Arthroplasty (THA) is a well-accepted treatment for established hip arthritis following acetabular fractures. If a conservatively managed or operated case progresses to non-union/mal-union failing to restore the joint integrity, it may eventually develop secondary arthritis warranting a total hip arthroplasty. Also, in recent years, acute total hip arthroplasty is gaining importance in conditions where the fracture presents with pre-existing hip arthritis, is not amenable to salvage by open reduction and internal fixation, or, a poor prognosis is anticipated following fixation. There are several surgical challenges in performing total hip arthroplasty for acetabular fractures whether acute or delayed. As a separate entity elderly patients pose a distinct challenge due to osteoporosis and need stable fixation for early weight bearing alleviating the risk of any thromboembolic event, pulmonary complications and decubitus ulcer. The aim of surgery is to restore the columns for acetabular component implantation rather than anatomic fixation. Meticulous preoperative planning with radiographs and Computed Tomography (CT) scans, adequate exposure to delineate the fracture pattern, and, availability of an array of all instruments and possible implants as backup are the key points for success. Previous implants if any should be removed only if they are in the way of cup implantation or infected. Press fit uncemented modern porous metal acetabular component with multiple screw options is the preferred implant for majority of cases. However, complex fractures may require major reconstruction with revision THA implants especially when a pelvic discontinuity is present.

Keywords: Acetabular fracture; Pelvic discontinuity; Post traumatic osteoarthritis; Total hip arthroplasty.

Fig. 1

Figure showing the important bony landmarks (black arrows) for acetabular component placement during total hip arthroplasty for acetabular fractures. The vertical arrow shows subchondral bone beneath the AIIS and the oblique arrow is showing the ischium supporting posteroinferior acetabulum.

Fig. 2

Radiograph of Pelvis with both hips in Anteroposterior view showing post traumatic arthritis in left hip following fixation for acetabular fractures (A) Post-operative radiograph following Total Hip Arthroplasty (B). Note the hardware in situ which was retained as they were not coming on the way of THA. Also note the kick-stand screws in the superior pubic ramus as well as the ischium (white arrows).

Fig. 3

Radiograph of Pelvis with both hips in Anteroposterior view showing old acetabular fracture with segmental bone defect in left hip (A) Post-operative radiograph following Total Hip Arthroplasty with use of trabecular metal buttress to address the bone defect as the femoral head autograft was not available (B). Note the hardware in situ which was retained as they were not coming on the way of THA. Also note the kick-stand screws (white arrows).

Fig. 4

Acetabular corridors for screw fixation. S= Sciatic buttress corridor, G = Gluteal corridor, A = Anterior corridor, I= Ischial corridor, R = Superior pubic ramus corridor.

Fig. 5

Flow chart showing algorithm for Total Hip Arthroplasty in management of acetabular fractures.