Secondary Total Hip Arthroplasty Research Articles

Total hip replacement after prior of the core decompression of the femoral head: efficacy and complications

Relevance. A history of core decompression using porous tantalum rods has a negative impact on the course of total hip arthroplasty surgery, the postoperative period and the frequency and nature of postoperative complications. Opinions are contradictory with regard to the effect of other techniques of necrosis decompression on total hip arthroplasty.Purpose of the study: evaluation of the effect of core decompression of the femoral head on the intraand postoperative parameters of total hip arthroplasty surgery.Object and methods. The study included 44 patients with osteonecrosis of the femoral head who underwent total hip arthroplasty. The first group consisted of 30 patients with osteonecrosis of the femoral head (ARCO grade II-IV) who had no previous hip surgery – primary total hip arthroplasty. The second group included 14 patients with osteonecrosis who had undergone the core decompression on the same joint (secondary total hip arthroplasty) 6–24 months earlier in stage II of the disease. The duration of surgery, blood loss volume, complications in the postoperative period, pain syndrome dynamics and hip joint function were assessed.Results. Comparative analysis showed the absence of significant technical intraoperative complications in total hip arthroplasty: duration of operations in group I – 85 ± 25 minutes, in group II – 80 ± 20 minutes, that is, almost identical; volume of intraoperative blood loss: 300 ± 100 ml in both groups. Survival rate of the hip replacement was 100 % in both groups. Superficial inflammation of the operating wound was diagnosed in 3.3 % of group I patients and in 7.1 % of group II patients (%). Dislocation of the hip replacement was observed in one patient in Group I (primary total hip arthroplasty). Twelve months after THA, osteolysis around the hip replacement element was detected by X-ray in 6.7 % of group I patients.Conclusion. Total hip arthroplasty in patients with a history of the core decompression of the femoral head is not accompanied by intraoperative technical difficulties and is a relatively safe surgical intervention. Prior core decompression is not an additional risk factor for intraand postoperative complications of total hip arthroplasty.

Uncemented hip revision cup as an alternative for T-type acetabular fractures: A cadaveric study

BackgroundThe current rise in elderly patients with compromised bone quality complicates the surgical treatment of acetabular T-type fractures (AO type 62B2 fractures). There is on ongoing discussion about the treatment options, mostly consisting of an open reduction and internal fixation (ORIF) with or without primary or secondary total hip arthroplasty (THA). Yet, these patients are oftentimes unable to fulfil weight-bearing restrictions and mostly present with an unavailability of a stable anchor site. Consequently, this study investigates the feasibility of a cementless hip revision cup for acetabular T-type fractures and compares its biomechanical properties to ORIF. HypothesisThe cementless hip revision cup provides sufficient biomechanical stability under the simulation of full weight-bearing. Patients and methodsThe study compared two groups of human cadaveric hip bones with T-type fractures, of whom 6 subjects were treated with ORIF (6 male; mean age: 62±17years; mean body weight: 75±15) versus 6 subjects treated with a cementless hip revision cup (2 male; 69±12 years; 73±15kg). The group-assignment was controlled for comparable BMD results (mean BMD: ORIF 110±37 mg Ca-Ha/mL versus hip revision cup 134±32 mg Ca-Ha/mL). To compare for biomechanical stability cyclic loading was applied measuring the force and dislocation of the fracture gap at standardized bone loci using an all-electric testing machine and a 3D-ultrasound measuring system. ResultsComparing superior pubic ramus versus iliac wing (cementless hip revision cup versus ORIF [mean±standard deviation]: 5.8±2.0 versus 7.0±3.2; p=0.032) as well as sacral ala versus iliac wing (4.6±2.2 versus 6.4±3.7; p=0.002), the cementless revision cup achieved a significantly higher stability than the plate osteosynthesis. ConclusionRevision cup and ORIF withstood biomechanical loading forces exceeding full weight-bearing in this biomechanical study. The results of our study suggest that the cementless hip revision cup might be promising alternative to the current standard care of ORIF with or without primary THA. Level of evidenceIII; case control experimental study.

The fate of acetabular fracture fixation at 10 years: rates of conversion to arthroplasty.

Post-traumatic arthritis, implant failure, non-union or avascular necrosis may result in a total hip arthroplasty (THA) after acetabular fracture fixation (AFF). The aim of this study was to report the occurrence of THA after AFF and analyse factors that predict its occurrence. All patients with AFF between 2010 and 2014, in a major trauma centre, were included. Patients treated conservatively or with acute THA were excluded. Data regarding classification of fracture, details of surgery and follow-up using EQ-5D and Oxford Hip Score (OHS) were recorded prospectively. Postoperative radiographs and CT scans were analysed for accuracy of reduction. The number of patients who underwent secondary THA and indications were recorded. 122 patients with a mean age of 42 years were included. At a mean follow-up of 10 years, the mean OHS was 39 (range 22-48) and EQ-5D was 22 (range 10-25). THA was performed in 10 patients (8%), 50% of which were performed between 2-5 years after AFF. Age >40 years, posterior dislocation and presence of posterior wall fracture, were the only factors associated with progression to THA. The survivorship of fixation at 5 years was 95% (95% CI, 91-98%) and at 10 years was 91% (95% CI, 86-96%). Conversion to THA after AFF was 8%, with even anatomically reduced posterior wall fractures having a poor prognosis. A period of follow-up of at least 5 years is suggested in patients with risk factors.

Differences of hip involvement in systemic and non-systemic juvenile idiopathic arthritis

Systemic corticosteroids are continued to be administered in juvenile idiopathic arthritis (JIA) patients, especially in systemic JIA (sJIA), despite the ability of biologic therapy. One of the complications of long-term CS treatment is delayed hip arthritis development with risk of secondary hip osteoarthritis formation and total hip arthroplasty (THA).We compared different types of hip joint lesions in JIA, especially, secondary hip osteoarthritis development and THA rates in systemic and non-systemic JIA, and evaluate systemic corticosteroids contribution to those complications.The study included 753 JIA patients. They were divided into 2 groups: patients with sJIA and non-systemic JIA (nsJIA). Clinical and demographic characteristics, CS treatment regimens were compared.Results. Hip arthritis was found equally often in both groups, but both secondary hip osteoarthritis (19% vs 5,3%) and THA (8.6% vs 1.6%) prevailed in the sJIA. Patients with sJIA had delayed hip involvement (57.9% vs 30.6%; p=0.019), earlier secondary hip osteoarthritis development (4.5 vs 5.1 years after the JIA onset) with younger age of secondary hip osteoarthritis achievement (13.7 vs 15.2 years; р=0.045), they also had higher inflammatory activity, greater systemic corticosteroids administration (94.8% vs 56.1%; р=0.0000001) and higher cumulative systemic corticosteroids dose (3085 mg vs 2000 mg; p=0,005). More than half patients (56.1%) with nsJIA had systemic corticosteroids treatment and impaired calcium-phosphorus metabolism.Conclusion. Systemic corticosteroid treatment and delayed hip involvement are independent predictors of secondary hip osteoarthritis in all JIA categories. Calcium and phosphate metabolism disturbances are additional predictor for secondary hip osteoarthritis in non-systemic JIA categories

Risk of Total Hip Arthroplasty After Acetabular Fracture Fixation: The Importance of Age

BackgroundGeriatric patients are the most rapidly growing cohort of patients sustaining acetabular fractures (AFs). The purpose of this study was to examine the risk of a secondary total hip arthroplasty (THA) in older patients (>60 year old) with a prior AF open reduction internal fixation (ORIF) compared with younger patients (<60 year old) with an AF ORIF on a large population level. MethodsUsing administrative health care data from 1996 to 2010 inclusive of all 202 hospitals in Ontario, Canada, all adult patients with an AF ORIF and a minimum of two year follow-up were identified and included. The risk of THA was examined using a Cox proportional hazards model adjusting for patient risk factors. Secondary outcomes included surgical complications and all-cause mortality. ResultsA total of 1725 patients had an AF ORIF; 1452 (84.2%, mean age of 38.3 ± 12.1 years) aged <60 years (“younger”) and 273 (15.8%, mean age of 69.9 ± 7.8 years) > 60 years (“older”). The mean (SD) follow-up time for all patients was 6.9 (4.2) years. In older patients, 19.4% (53 of 273) went on to receive a secondary THA with a median time to event of 3.9 years, compared with 12.9% (187 of 1452) in the younger patient cohort with a median time of 6.9 years (HR 1.7, 95% CI: 1.2-2.3). As expected, older patients had a higher 90-day mortality rate compared with younger patients (7.7% vs. 0.7%, respectively; HR 9.2, 95% CI: 4.3-19.9; P < .001). ConclusionOlder patients with an AF ORIF are at a significantly higher risk for a secondary THA than younger patients with an AF ORIF.

Osteonecrosis of the hip: is there a difference in the survivorship of total hip arthroplasty with or without previous vascular iliac bone grafting?

BackgroundOsteonecrosis of the femoral head (ONFH) is a debilitating condition. Vascularized iliac bone graft (VIBG) is a joint-preserving surgery to improve blood supply to the avascular portion of the femoral head which may delay secondary osteoarthritis and total hip arthroplasty (THA). However, whether VIBG will affect the subsequent THA survivorship and outcomes are still uncertain.MethodsImplant survivorship and clinical outcomes were compared between 27 patients who had undergone prior VIBG and 242 patients who had only undergone THA for ONFH. Baseline characteristics and the postoperative Harris Hip Score (HHS) were also recorded and compared between the two groups. Implant survivorship was determined using Kaplan-Meier survival analysis.ResultsThe overall implant survival for all patients who had a primary diagnosis of ONFH and eventually underwent THA was 92.9%. There was no significant difference in the implant survivorship between the group who directly received THA (survivorship of 93%) and the group which failed VIBG and was subsequently converted to THA (survivorship of 91.9%) (p = 0.71). In addition, higher THA revision rates were associated with smokers and drinkers.ConclusionsVIBG may be a reasonable option as a “buy-time” procedure for ONFH. Even if conversion to THA is eventually required, patients may be reassured that the overall survivorship and clinical outcomes may not be compromised. Patients are recommended to give up smoking and binge drinking prior to THA to increase implant survival rate.

Medial buttressing of the quadrilateral surface in acetabular and periprosthetic acetabular fractures.

BackgroundIn geriatric acetabular fractures, the quadrilateral plate is often involved in the fracture pattern and medially displaced. Open reduction and internal fixation (ORIF) includes reduction of the quadrilateral plate and securing its position. In this study, the concept of medial buttressing in acute and periprosthetic acetabular fractures is evaluated.Materials and methodsPatients, who sustained an acetabular fracture between 2012 and 2018, in whom ORIF with a specific implant for medial buttressing was performed, were included in the study. Patients were divided in two groups; acute acetabular fractures (group 1) and periprosthetic acetabular fractures (group 2). Demographics, type of fracture, surgical approach, type of implant for medial buttressing, comorbidities, general and surgical in-hospital complications and length of hospital stay were recorded retrospectively. The following data were collected from the surviving patients by telephone interview: EQ-5D-5L, SF-8 physical and SF-8 mental before trauma and at follow-up, UCLA activity scale, Parker Mobility Score and Numeric Rating Scale.ResultsForty-six patients were included in this study, 30 males (65.2%) and 16 females (34.8%). Forty patients were included group 1 and six patients in group 2. The median age of patients of group 1 was 78 years. Among them, 82.5% presented with comorbidities. Their median length of in-hospital stay was 20.5 days. 57.5% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all but one patient. ORIF together with primary total hip arthroplasty (THA) was carried out as a single stage procedure in 3 patients. Secondary THA was performed in 5 additional patients (5/37 = 13.5%) within the observation period. Among surviving patients, 79.2% were evaluated after 3 years of follow-up. Quality of life, activity level and mobility dropped importantly and were lower than the values of a German reference population. SF-8 mental did not change. The median age of patients of group 2 was 79.5 years, all of them presented with one or several comorbidities. The median length of in-hospital stay was 18.5 days. 50% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all patients. 5 of 6 patients (83.3%) could be evaluated after a median of 136 weeks. In none of these patients, secondary surgery was necessary. Quality of life, activity level and mobility importantly dropped as well in this group. SF-8 mental remained unchanged.ConclusionIn geriatric acetabular fractures with involvement and medial displacement of the quadrilateral plate, medial buttressing as part of ORIF proved to be reliable. Only 13.5% of patients of group 1 needed a secondary THA within 3 years of follow-up, which is lower than in comparable studies. Despite successful surgery, quality of life, activity level and mobility dropped importantly in all patients. The loss of independence did however not influence SF-8 mental values.

Porous tantalum rod implantation is associated with low survival rates in patients with type C2 osteonecrosis of the femoral head but has no effect on the clinical outcome of conversion total hip arthroplasty: a retrospective study with an average 8-year follow-up

BackgroundOur study aimed to investigate the clinical outcomes and survival rates following porous tantalum rod surgery (PTRS) and conversion total hip arthroplasty (THA) subsequent to failed PTRS.MethodsA total of 38 subjects (40 hips) with osteonecrosis of the femoral head (ONFH) were included in this retrospective study between January 2008 and December 2011. All subjects were evaluated before surgery by using the Association Research Circulation Osseous (ARCO) classification system, the Japan Investigation Committee (JIC) classification and the Harris hip score (HHS). The endpoint of this study was set as final follow-up (including the survival time of PTRS and conversion THA). The rates of radiological progression were also evaluated. Patients who received conversion THA were further followed and compared to a control group of 58 patients with ONFH who underwent primary THA.ResultsThe mean follow-up time was 120.7 ± 9.2 (range, 104–143) months, and the overall survival rate was 75% at 96 months (ARCO stage II: 81.5%; stage III: 38.5%; JIC type C1: 83.3%; C2: 30%). The HHS before surgery was 59 (55–61), in contrast to 94 (91–96) at 96 months follow-up (P < 0.01). HHS in stage III show a significant poorer result compared to stage II at 24 months. HHS in Type C2 group show no significant difference compared to HHS before surgery at 24 and 60 months follow up (P = 0.91, P = 0.30). Twelve hips requiring secondary THA were followed for 66.9 ± 31.7 months, and control hips that underwent primary THA was followed for 75.4 ± 14.9 months. The HHS in the conversion group was 89 (86–93) and that in the primary THA group was 92 (79–95, P = 0.09) at the 5-year follow-up.ConclusionIn the mid-term follow-up, porous tantalum implants showed an encouraging survival rate in symptomatic patients in early stages (ARCO stage II) or with limited necrotic lesions (JIC type C1). In addition, our results did not demonstrated any difference between primary THA and conversion THA.

Open reduction and internal fixation of acetabular fractures in patients of old age

Material and methodsThere is an ongoing debate on which treatment for acetabular fractures in elderly patients is the most appropriate. This study was set up to identify the role of open reduction and internal fixation of acetabular fractures in persons of old age.We retrospectively reviewed the medical charts and radiological data of all patients older than 65 years, who suffered an isolated acetabular fracture and were admitted in our Department between 2010 and 2014 (5-year period). Complications, outcome and mortality were recorded. Of all surviving patients, quality of life (QoL), mobility and independence were graded with European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), European Quality of Life 5 Dimensions Visual Analogue Scale (EQ-5D-VAS), Numeric Rating Scale (NRS), Elderly Mobility Scale (EMS) and Tinetti Mobility Test (TMT).ResultsSeventy patients could be identified. There were 52 men (74%) and 18 women (26%) with a median age of 79.0 years (range: 65–104 years). Forty-six patients (66%) had been treated with open reduction and internal fixation (ORIF), 24 (34%) conservatively. There were negative predictive factors—subchondral impaction, damage to the femoral head and multiple fragments—in 54% of the operative group. With ORIF, an anatomical reduction could be achieved in 27 patients (59%), an acceptable in 18 (39%) and a poor in one (2%). At follow-up, 18 patients (26%) had died and 23 (33%) were not able to participate. The follow-up rate of the surviving operatively treated patients was 77%. Eleven of 46 operated patients (24%) needed a conversion to a total hip arthroplasty (THA). All patients undergoing conversion had imperfect reduction after surgery. No patient in the non-operative group underwent conversion to THA during follow-up. The median follow-up time of operatively treated patients without conversion (n = 17) was 30 months (range, 16–73 months), of patients with THA (n = 9) 30 months after conversion (range, 17–55 months). Quality of reduction correlated to QoL, mobility and independence in all recorded parameters. Patients with secondary THA had similar good outcomes as patients after ORIF without later conversion. Men had better outcome than women.ConclusionORIF of acetabular fractures in patients of old age results in excellent outcomes at short-term follow-up when anatomical reduction can be achieved. In case of negative predictive factors, ORIF cannot be regarded as a definitive solution, rather as the construction of a stable socket for secondary THA. The decision of therapy should be made dependent on pre-operative radiographic parameters.

Patient-Reported Outcomes of Femoral Head Fractures with a Minimum 10-Year Follow-Up.

To evaluate the clinical-reported and patient-reported outcomes of patients with femoral head fractures treated at a single level I trauma center with a minimum 10-year follow-up. Retrospective review. Academic Level-1 Trauma Center. One hundred one consecutive femoral head fractures were identified for this study. The final study group consisted of 28 patients with a minimum of 10 years of clinical follow-up. All patients were treated with one or in combination with the following treatments: nonoperative management, open reduction and internal fixation, fragment excision, or total hip arthroplasty (THA). The Oxford Hip Score (OHS) at final follow-up along with clinical and radiological complications: infection, avascular necrosis, post-traumatic osteoarthritis, heterotopic ossification, and conversion to THA. Twenty-eight patients with greater than 10 years of follow-up were included in this evaluation. The average follow-up was 14 years, and the average age was 39.2 years. Surgical management occurred in 86% of patients, and the mean time to definitive treatment was 3.7 days. Overall, 21 patients (75%) experienced a complication. Seven patients (30%) were later converted to a THA at an average of 6.4 years from initial injury. Three of the 7 late THA conversions (43%) required later revision. OHSs were obtained in all 28 patients at the final follow-up. The average OHS was 36.6. The mean OHS of the native hips was 37 at an average follow-up of 13.6 years. The mean OHS of primary THA was 41, and the mean OHS of secondary THA at final follow-up was 31.4, but this was not statistically significant (P = 0.134). Patients should be counseled that the long-term results of open reduction and internal fixation may be satisfactory but unfortunately are not predictable. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Long-term outcome after revision of hip arthroplasty with the BioBall® adapter system in multimorbid patients

IntroductionLong-term study evidence about the BioBall® adapter system is limited, especially in highly morbid elderly patients. Thus, we analysed the long-term outcome of revision hip arthroplasty using this system in highly morbid elderly patients. Materials and methodsWe included 19 patients undergoing revision hip arthroplasty after primary or secondary total hip arthroplasty dislocations between July 2002 and August 2004 and followed up their long-term outcome until 2015. ResultsThe patients achieved a median of 17 points in the Merle d'Aubigné hip score in 2004 and a median of 18 points in 2011, and the 4 surviving patients in 2015 achieved 18 points. For the four 12-year survivors, the Merle d'Aubigné score was virtually stable over the complete observation period. The Harris Hip Score showed comparable results. The patients had a median Barthel index of 90 in 2004 and 100 in 2011, and the 4 survivors in 2015 had Barthel indices of 65, 95, 100, and 100, respectively, in 2015. ConclusionsIn multimorbid patients, using the BioBall® adapter system for total hip arthroplasty, revision due to dislocation results in good long-term outcome without impairment of quality of life. Translational potentialOur study provides long-term evidence in a vulnerable patient population. It shows how the therapeutic concept of revision hip replacement with an adapter device translates into long-term outcome and quality of life in these patients. Thus, it adds important information for evaluation of therapeutic options in this field.

Difficulty of Total Hip Arthroplasty Following Open Reduction and Internal Fixation of Acetabular Fractures.

The incidence of posttraumatic arthrosis after acetabular fractures is significant, and patients frequently require secondary total hip arthroplasty. Conversion arthroplasty is more technically difficult, and there is higher risk than with routine primary total hip arthroplasty. The goal of this study was to identify the challenges and risks of secondary total hip arthroplasty compared to primary total hip arthroplasty. We retrospectively identified 30 patients who underwent secondary total hip arthroplasty after open reduction and internal fixation of an acetabulum fracture and compared them with 20 patients who had undergone primary total hip arthroplasty for degenerative joint disease. Demographic data were similar between groups. Hardware removal was deemed necessary in 21 patients (70%). Allograft was needed for bone defects in 33% of secondary total hip arthroplasty cases, while no primary cases required grafting. Operative time (217.4 vs. 113.7 min, P < 0.01) and estimated blood loss (875.8 vs. 365 mL, P < 0.01) were significantly greater in the secondary arthroplasty group. Early postoperative complications were also higher in the secondary arthroplasty group. Total hip arthroplasty after acetabular fracture open reduction and internal fixation is a more complex procedure due to exposure difficulty, possible implant removal, management of bony deficits, and the potential use of cages and revision components. Experienced surgeons managing these complicated cases must take great care not only in ensuring appropriate technique but also in appropriate patient education regarding increased risk of major and minor complications. Level III.

Total hip arthroplasty after failed fixation of a proximal femur fracture: Analysis of 59 cases of intra- and extra-capsular fractures

The indications for total hip arthroplasty (THA) after failed internal fixation of a proximal femur fracture vary. Published studies on this topic are broad-ranging and do not distinguish between intracapsular and extracapsular fractures. This led us to conduct a retrospective analysis comparing the clinical outcomes, radiological outcomes, technical problems and complications between these two types of fractures. The functional outcomes of THA after an extracapsular fracture will be worse than the ones after an intracapsular fracture. This was a retrospective, single-center study of 59 THA cases performed after internal fixation of a proximal femur fracture. These procedures were performed between 2002 and 2013 in 58 patients (22 men, 36 women). There were 40 intracapsular fractures and 19 extracapsular fractures. The initial fracture fixation involved a screw-plate (n=50), intramedullary nail (n=6) or screws (n=3). The mean patient age at the time of THA was 67 years [22-94]. The THA was performed an average of 2.8 years [0.2-28] after the fracture. The posterolateral approach was used in 55 cases (93%). Ten patients (17%) had the fixation hardware removed before the THA procedure, on average at 30 months [1-240] after the fracture. During the THA procedure, a cemented stem was used in 31 cases (53%) and a cementless stem in 28 cases (47%). A cementless press-fit cup was used in 56 cases (95%), of which 35 were dual mobility cups (60%), and a cemented cup was used in the other 3 cases (5%). All patients were reviewed by a physician not involved in the surgical procedures who performed a clinical and radiological examination. No patients were lost to follow-up; two patients died. Ten patients suffered an intraoperative femur fracture (17%) and four suffered a dislocation (2 early, 2 late) (6.8%). Nine hips had to be reoperated (15%), of which five required an implant change (8.5%). There were significantly more intraoperative fractures and postoperative complications in the THA cases after extracapsular fracture. With a mean follow-up of 38 months [12-149], the mean PMA and Harris scores were 14.6 [3-18] and 74 [10-100], respectively; these scores were significantly lower in the THA cases after extracapsular fracture (p<0.05). With an endpoint of revision with implant change, the overall 40-month survival was 94% (95% CI: 0.25-0.55); it was 97% (95% CI: 0.62-0.85) for the intracapsular fracture cases and 84% (95% CI: 0.39-0.75) for the extracapsular fracture cases (p<0.05). Secondary THA after failed fixation of proximal femur fractures has more complications than primary THA. Subgroup analysis identified more technical problems in the THA cases after extracapsular fracture and a higher number of complications, particularly dislocation and periprosthetic fractures. IV-Retrospective study.

Reduced survival for uncemented compared to cemented total hip arthroplasty after operatively treated acetabular fractures

BackgroundPost traumatic arthritis and avascular necrosis of the femoral head are common complications after operatively treated acetabular fractures. This may cause severe disabilities for the patient, necessitating a total hip arthroplasty. Even though an arthroplasty may provide good symptomatic relief, the long-term results are more uncertain and no consensus exists according to preferred prosthetic designs. With this cohort study, we aimed to investigate the medium to long term arthroplasty survival and clinical results of total hip arthroplasty after operatively treated acetabular fractures. MethodsWe included 52 patients treated with a secondary total hip arthroplasty at a median of 2.4 (0.1–14.1) years after an operatively treated acetabular fracture. The median age was 54 (11–82) years. Cemented arthroplasty was used for 33 patients, 10 patients had an uncemented arthroplasty and 9 patients received a hybrid arthroplasty. Average follow up was 8.0 (SD 5.0) years. ResultsTen-year revision free arthroplasty survival was 79%. Uncemented arthroplasties had a significantly worse 10-year survival of 57%. Arthroplasties performed at a centre without a pelvic fracture service also had a significantly worse 10-years survival of 51%. Cox regression showed similar results with an 8-fold increase in risk of revision for both uncemented arthroplasties and operations performed at a non-pelvic trauma centre. ConclusionTotal hip arthroplasty secondary to an operatively treated acetabular fracture provides good symptomatic relief. These patients are, however, complex cases and are probably best treated at specialist centres with both pelvic trauma surgeons and arthroplasty surgeons proficient in complex revisions present.

Acetabular Reconstruction with Reinforcement Ring and Morsellised Graft: Technique and Medium-term Result: 以髖臼加強環及切碎骨來重建髖臼 - 技術及中期結果

BackgroundAcetabular bone defects are commonly seen in both primary and secondary total hip arthroplasty, creating difficulties in restoring anatomical hip centres, which results in high mechanical failure rate. MethodsTotal hip arthroplasty with acetabular reinforcement rings were performed in 18 hips in 18 patients from 1996 to 2011 in United Christian Hospital. Both clinical and radiographical assessment were performed during follow-up. ResultsEight patients died of unrelated diseases with average follow-up of 30.5 months. At the latest follow-up, none of them showed radiographic signs of loosening or migration of implants and none of them required revision surgery. The remaining 10 patients with mean age of 77.9 years (range, 65–88) at the time of operation were followed-up for an average of 67.4 months (range, 11–121). The average Harris hip score was 78.3 (range, 58.5–87). The average vertical and horizontal difference of hip centres was 1.5 mm superiorly (p = 0.431) and 0.4 mm medially (p = 0.619) respectively when postoperative hip centres were compared to their contralateral hips. The average inclination of the polyethylene cup was 47.8 degrees (range, 42–58). There was no evidence of radiographic loosening during our follow-up and none of them required revision surgery. ConclusionAcetabular reconstruction with the use of acetabular reinforcement rings and morsellised bone grafts showed satisfactory clinical and radiographic results at a medium-term follow-up.

Outcome 5years after surgical treatment of acetabular fractures: a prospective clinical and radiographic follow-up of 101 patients.

The aim of this study was to evaluate functional outcome after surgically treated acetabular fracture using radiography and patient-reported outcome measures, and to determine predictors of hip joint failure 5years post-surgery. All patients with acetabular fractures treated with open reduction and internal fixation (ORIF) at our unit are prospectively entered into a local register. 101 acetabular fractures in 112 patients treated from 2004 to 2007 were eligible for analysis 5years after surgery. Radiographs and questionnaires regarding physical function (Short Form[SF]-36) and pelvic discomfort index (PDI, 100%=worst outcome) were obtained. The primary outcome measure was "joint failure" defined as either secondary total hip arthroplasty (THA) or a Girdlestone situation. Univariable analysis was used to compare patients with joint failure to those without, and binary logistic regression analysis was performed to identify risk factors of joint failure. 77% of 101 followed patients had a preserved hip joint 5years after surgery, and failure of the hip joint most often occurred within the first 2years after injury. Patients with preserved hip joints had higher scores in the SF-36 physical function domain (median 75 vs. 48; p=0.004) and better PDI (28 vs. 43%, p=0.03). Femoral head impaction was associated with an increased risk of joint failure [relative risk (RR)=15.2, 95% CI 3-95; p=0.002], as was an age of ≥60years at the time of injury (RR=4.2, CI 1.3-15; p=0.02). Patients with failed hip joints after surgery for acetabular fracture have inferior global and disease-specific functional outcomes, even after secondary arthroplasty surgery. We suggest that patients with predictors of joint failure could benefit from other treatment strategies than ORIF, and primary insertion of THA may be an alternative treatment strategy for this subgroup.

Operative Treatment of Acetabular Fractures in an Older Population Through a Limited Ilioinguinal Approach

To compare treatment of acetabular fractures in elderly patients through a limited approach versus a standard ilioinguinal approach and assess changes in outcome and morbidity. Retrospective cohort comparison analysis. Tertiary referral center. Between January 1992 and January 2006, 143 patients 55 years of age or older were treated for acetabular fractures. Of these, 41 were treated through either a traditional or limited ilioinguinal approach. Patients with unilateral surgeries and a minimum follow-up of 2 years were included. Open reduction and internal fixation of acetabular fractures through a limited (lateral two windows) approach versus traditional three window ilioinguinal approach. Radiographic assessment of healing, reduction quality, progression to arthritis and total hip arthroplasty, operative time, length of stay, complications, SF-36, Musculoskeletal Functional Assessment, and the Short Musculoskeletal Functional Assessment. The two groups were equivalent in terms of preinjury comorbidities, mechanism of injury, type and severity of fracture pattern, time to surgery, length of hospitalization, and incidence of postoperative complications. The overall rate of secondary total hip arthroplasty was 26.8% and was equivalent between the two groups. Functional outcome scores were comparable. The use of the lateral two windows was associated with a significant reduction in both blood loss and operative time. The limited ilioinguinal approach to certain fracture patterns commonly seen in the elderly was associated with a decreased blood loss and surgical time. Moreover, there was no negative impact on outcomes in our cohort. The benefits of decreased blood loss and shorter operative time have a potential positive impact on management of these injuries. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Mortality After Femoral Neck Fractures: A Two-Year Follow-up

To identify the survival and standardized mortality ratio with respect to gender, age, and treatment method of patients treated for femoral neck fractures. A retrospective review of medical records of 736 patients treated for femoral neck fractures at Vilnius University Emergency Hospital during 2004-2006 was carried out. The overall 1- and 2-year survival rates were 77.4% and 67.1%, respectively. Lower survival rates were observed in the internal fixation group than in the primary and secondary total hip arthroplasty groups (63.2% vs. 72.0% and 75.1%). Cox proportional hazards model analysis showed patient age to be a significant risk factor for survival (hazard ratio, 1.05; 95% CI, 1.04-1.07; P<0.001). The overall standardized mortality ratio was 2.50. The standardized mortality ratios for men and women were 3.07 and 2.27, respectively, but the difference between these groups was not significant. Standardized mortality and survival rates decreased with increasing patients' age. Significantly lower survival rates were documented in the internal fixation group as compared with primary and secondary total hip arthroplasty groups. There was a trend toward a higher standardized mortality ratio in men than women, but the difference was not significant.

Traumatic damage to the cartilage influences outcome of anatomically reduced acetabular fractures: A medium-term retrospective analysis

We reviewed 77 patients with an acetabular fracture, treated operatively through a non-extensile approach after an average time of 45 months. The ilioinguinal approach was chosen in 41, the Kocher–Langenbeck approach in 36 patients. Following the Letournel classification, the most frequent lesions were posterior wall (26%), two-column (22.1%) and anterior column (14.3%) fractures. Subchondral impaction, intra-articular fracture fragments and fracture comminution, called modifiers, could be identified in the preoperative CT-data of 38 patients (49.4%). Patients were operated after an average of 4 days. Average hospital stay was 19 days. Sciatic nerve and peroneal nerve palsy were registered in 5.6%. Deep venous thrombosis was seen in 10.4%, peri-articular ossifications in 7.8%. During the 45-months follow-up, 10.4% patients needed secondary total hip arthroplasty. Using the Merle d’Aubigné score, 15 patients had an excellent, 39 a good, 15 a moderate, and 8 a bad result. In accordance with the Harris Hip Score, 29 patients achieved an excellent, 26 a good, 9 a moderate and 13 a bad result. Twenty of twenty-three (Merle d’Aubigné score) and twenty of twenty-two (Harris Hop Score) patients with moderate or bad results had one or more modifiers. Patients with operatively treated acetabular fractures, who had CT-findings such as subchondral impaction, fracture comminution or intra-articular fracture fragments in their preoperative examination, score significantly lower at middle term in the Harris Hip and Merle d’Aubigné scoring systems.

Treatment of Acetabular Fractures in an Older Population

To identify factors predicting poor radiographic and functional outcome and delayed total hip arthroplasty in operatively managed acetabular fractures in patients 55 years of age and older. Retrospective chart and radiographic review of a prospectively maintained database. Tertiary care hospital. Ninety-three with a mean age of 67 years met all inclusion criteria and had follow up averaging 5 years. Open reduction and internal fixation and less commonly acute total hip arthroplasty for displaced acetabular fractures in an older cohort. Three validated patient self-assessment measures were used: the Musculoskeletal Functional Assessment, the Short Musculoskeletal Functional Assessment, and the SF-36. The overall rate of hip replacement in our study was 30.95%. Poor fracture reduction (P < 0.02), development of avascular necrosis (P < 0.001), and previous contralateral hip arthroplasty (P = 0.02) were statistically associated with the need for secondary surgeries. Functional outcome scores in the current study compared favorably with functional outcome scores reported for acetabular fractures in younger populations and with age-matched "non-injured" norms published in recent literature. There was an acceptably low rate of major complications in 93 operatively managed fractures in this population. Nearly 70% of patients achieved functional outcomes similar to age- and injury-matched control subjects without the need for secondary surgeries. Thirty percent of patients required secondary total hip arthroplasty for posttraumatic arthritis. These patients achieved outcomes similar to patients in the other outcome groups and to injury- and age-matched norms.