Staged Total Hip Arthroplasty: A Novel Technique in Managing Native and Periprosthetic Acetabular Insufficiency

Abstract

Background: There is no consensus on how to best address acetabular insufficiency. Several described techniques have a high rate of loosening and most rely on fixation to intact innominate bones. They also require extensive exposure and expensive implants. We present a novel technique for acetabular insufficiency management including discontinuity and a series with mean 6.5-year follow-up.

Material and methods: After exposure, a femoral neck osteotomy is made, or the femoral component is removed. Bone graft is reverse reamed into the defect, and a porous coated acetabular shell is implanted with screws for supplemental fixation. In 3-6 months, after defect healing, the femoral component is implanted. All staged total hip arthroplasties for pelvic discontinuity from 2010 to 2015 by a single provider with minimum 5-year follow-up were identified. Implant survivorship, Merle d'Aubinge, and visual analog scale scores as well as complications were recorded.

Results: Nine patients were identified with mean 80.8-month follow-up (62-129). Merle D'Aubinge scores improved from 5.6 (4-8) to 15.3 (14-18), and Visual analog scale scores improved from 7.2 (6-9) to 0.8 (0-2). All implants were retained, and all patients were ambulatory at the terminal follow-up. There were 2 greater trochanter fractures, one calcar fracture managed with cerclage, and one patient developed heterotopic ossification.

Conclusion: Staged total hip arthroplasty can be used to address pelvic discontinuity with excellent short- to mid-term outcomes. This technique allows for a more limited exposure and the use of primary hip implants. Fixation is by ingrowth and does not rely on intact pelvic architecture.

Keywords: Acetabular fracture; Pelvic discontinuity; Protrusio; Revision hip arthroplasty; Staged hip arthroplasty.

Figure 1

A 68-y/o female presented 6 months after nondisplaced native acetabular fracture which failed conservative management and went on to pelvic discontinuity (a). Planned reduction and fixation before arthroplasty failed due to callous making reduction impossible. Acetabulum was prepared in situ with femoral head autograft (b), and the procedure was staged (c).

Figure 2

Patient underwent conversion from hemiarthroplasty to total hip arthroplasty at an outlying facility. Acetabular fracture with protrusion noted at 6-week follow-up with no reported history of fall or trauma (a). Referred to tertiary center and staged procedure with allograft performed electively (b-c).

Conflict of Interest Statement for Horberg

Conflict of Interest Statement for Kay

Conflict of Interest Statement for Allan

Conflict of Interest Statement for Bailey