Outcomes of acute versus delayed total hip arthroplasty following acetabular fracture

Functional outcomes and center of rotation restoration in total hip arthroplasty after acetabular fracture: A review of 367 hips

BACKGROUND

Total hip arthroplasty (THA) after acetabular fracture is typically performed months or years later for posttraumatic arthritis after initial conservative treatment. But THA can be performed earlier after open reduction and internal fixation (ORIF) of the fracture. The aim of this study was to determine which strategy is best. The primary outcome measure was the radiological restoration of the hip's center of rotation (COR). The secondary outcome measures were the incidence of complications and the hip's functional scores.

MATERIALS AND METHODS

A multicenter cohort was analyzed by splitting patients into three groups: group A (THA within 3weeks of fracture); group B (THA deferred after early ORIF); group C (THA more than 3weeks after fracture, without ORIF). Group B was separated into two subgroups: B- (THA less than 1year after ORIF) and B+ (THA more than 1year after ORIF). The demographics, surgical techniques, COR superior and lateral migration coefficient and functional scores (HHS, HOOS-PS and FJS) were recorded. The functional scores were gathered using PROMs.

RESULTS

In all, 367 patients were included: 108 in group A, 69 in group B-, 113 in group B+ and 77 in group C. The mean follow-up was 5.8years [3.4 months-35years]. The mean age of the patients was 69.2years [SD 15; 26-101], 52years [SD 16; 19-83], 49years [SD 16; 16-85] and 58.1years [SD 17; 13-94], respectively (p<0.01). The mean ASA score was 2.13 [SD 0.70], 1.84 [SD 0.65], 1.67 [SD 0.63] and 1.79 [SD 0.60], respectively (p<0.01). A complex Letournel fracture was present in 63 patients (61%), 46 patients (71%), 48 patients (49%) and 38 patients (62%), respectively (p<0.01). A reinforcement cage was implanted in 38 patients (69%), 16 patients (62%), 5 patients (12%) and 19 patients (66%), respectively (p<0.01). Cement was used in 45 patients (45%), 23 patients (35%), 19 patients (18%) and 21 patients (32%), respectively (p<0.01). A graft was needed in 46 patients (46%), 35 patients (53%), 17 patients (16%) and 21 patients (48%), respectively (p<0.01). Posterior ORIF was done in 40 patients (46%), 32 patients (55%), 64 patients (61%) and 9 patients (82%), respectively (p<0.01). The COR lateral migration coefficient was significantly higher in group C with a mean of +0.17 (SD 0.85) [-0.27 to +6] compared to the other groups (p=0.02). The COR superior migration coefficient was comparable between groups, with a mean of +0.77 (SD 2.26) [-0.99 to 27], p>0.05. There were complications in 10 patients (9.2%), 6 patients (8.7%), 6 patients (5.3%) and 3 patients (3.9%), respectively, with no significant difference between groups. The PROMs were completed by 51% of patients. At the final review, the mean HHS was 79.2 (SD 21.8) and the mean HOOS-PS was 77.7 (SD 20.1) in the entire cohort, p>0.05. The mean FJS by group was 55.9 (30.2), 47.7 (SD 36.4), 66.1 (SD 30.4) and 65.8 (SD 30.3), respectively (p=0.02).

DISCUSSION AND CONCLUSION

The B strategy (B+) yielded good outcomes in terms of function and COR restoration. When using this strategy, anterior ORIF preserves the native hip for a subsequent THA through a posterior approach. Strategy C also produces good functional outcomes but shifts the COR laterally. This study confirms the poor results of strategy A in previous publications. When the prognosis is poor, immediate mobilization after anterior ORIF followed by THA within 1year appears to be a good strategy (group B-).

LEVEL OF EVIDENCE

IV, observational study.

Acute Total Hip Arthroplasty Following Acetabular Fracture is Associated With a High Risk of Revision, Dislocation, and Periprosthetic Fracture

BACKGROUND

The aim of this study was to compare outcomes between acute, subacute, and delayed arthroplasty for acetabular fractures occurring within 1 week, from 1 week to 6 months, or more than 6 months before the index total hip arthroplasty (THA), versus THA without a history of acetabular fracture as a control.

METHODS

We analyzed the records of patients undergoing primary THA who were enrolled in a national database for at least 2 years before and after the index procedure. Patients who had an initial diagnostic code for acetabular fracture occurring less than 1 week, from 1 week to 6 months, or at least more than 6 months before the THA were classified as acute THA (aTHA), subacute THA (saTHA), or delayed THA (dTHA), respectively. The control group was patients undergoing THA who did not have a history of acetabular fracture. There were 430,349 control primary THAs, 462 aTHAs, 675 saTHAs, and 1,162 dTHAs.

RESULTS

After adjusting for age, sex, region, and comorbidities, patients who had an aTHA and saTHA experienced statistically significant increased odds of revision, dislocation, and periprosthetic fracture compared to primary THA without a history of acetabular fracture. Similarly, dTHA was associated with increased odds of revision, dislocation, and periprosthetic fractures compared to primary THA. In the multivariate analysis, aTHA had statistically significant higher rates of dislocation when compared to dTHA.

CONCLUSIONS

Patients who had a history of acetabular fractures undergoing aTHA, saTHA, or dTHA have significantly increased rates of revision, periprosthetic fracture, and dislocation compared to primary THA in those who did not have a history of acetabular fractures.

The outcome of conversion total hip arthroplasty following acetabular fractures: a systematic review and meta-analysis of comparative studies

BACKGROUND

Conversion total hip arthroplasty (THA) is considered the main treatment plan for patients with first-line treatment failure of acetabulum fracture. This meta-analysis aims to assess the effect of the type of initial treatment and timing of surgery on the outcomes of conversion THA.

METHODS

Using PRISMA guidelines, MEDLINE/PubMed, Scopus, Web of Science, and CENTRAL Cochrane were searched for articles published before October 14, 2022. Comparative studies investigating the outcome of THA following treatment failure of acetabular fracture were included. These articles were categorized into three groups, and the outcomes of treatment plans in each group were compared: (A) primary THA vs. conversion THA, (B) THA following conservative treatment vs. THA following ORIF, and (C) acute THA vs. delayed THA following prior treatment failure. Review Manager (RevMan, version 5.3) software was utilized to perform the statistical analysis.

RESULTS

Twenty-four comparative studies met the inclusion criteria (reported the data of 13,373 patients). Concerning group (A), the following complications were significantly higher in conversion THA: Infection (OR [95% CI] 3.19 [2.12, 4.79]; p value < 0.00001), dislocation (OR [95% CI] 4.58 [1.56, 13.45]; p value = 0.006), heterotopic ossification (OR [95% CI] 5.68 [3.46, 9.32]; p value < 0.00001), and Revision (OR [95% CI] 2.57 [1.65, 4.01]; p value < 0.00001). Postoperative HHS (SMD [95% CI] - 0.66 [- 1.24, - 0.08]; p value = 0.03) was significantly lower and operation time (SMD [95% CI] 0.88 [0.61, 1.15]; p value < 0.00001), blood loss (SMD [95% CI] 0.83 [0.56, 1.11]; p value < 0.00001), and bone graft need (OR [95% CI] 27.84 [11.80, 65.65]; p value < 0.00001) were significantly higher in conversion THA. Regarding group (B), bone graft need (OR [95% CI] 0.48 [0.27, 0.86]; p value = 0.01) was considerably higher in patients with prior acetabular fracture conservative treatment, while other outcomes were comparable. Respecting group (C), there were no significant differences in analyzed outcomes. However, systematically reviewing existing literature suggested a higher incidence rate of DVT following acute THA.

CONCLUSION

There were significantly higher postoperative complications and lower functional outcomes in conversion THA compared to primary THA. While complications and functional outcomes were comparable between ORIF and the conservative groups, the bone graft need was significantly higher in the conservative group. There were no significant differences between aTHA and dTHA. These results can assist surgeons in designing treatment plans based on each patient's clinical situation. Prospero registration code: CRD42022385508.

LEVEL OF EVIDENCE

III/IV.

Risk of Revision and Complications after Total Hip Arthroplasty for Acute Treatment of Acetabular Fracture

BACKGROUND

Total hip arthroplasty (THA) for the treatment of acute acetabular fractures may be indicated where there is high risk for failure of open reduction and internal fixation. This study aimed to determine risks of revision and rates of major complications of THA for acute acetabular fractures.

METHODS

A retrospective review was performed (all-claims data files of a large national database) by querying International Classification of Disease, tenth revision procedure codes for THA within 14 days of acetabular fracture. We identified all-cause revision and surgical complications including dislocations, mechanical failures (loosenings or broken prostheses), infections, as well as medical complications. Demographic data collected included age, sex, obesity and Charlson Comorbidity Index (CCI). Multivariate analyses evaluated the association of revision and major surgical complications after adjusting for demographic characteristics and comorbidities. We identified 956 THAs for the treatment of acute acetabular fracture from 2015 to 2020. Of all acute acetabular fractures treated with THA, 241 were concomitant with ORIF, and 715 were THA alone.

RESULTS

All-cause revision risk was 18.2%, overall major surgical complication rate 26.9%, and medical complication rate was 13.2%. Women were associated with increased risk of revision (adjusted Odds Ratio (aOR) 1.8; Confidence Interval (CI) 1.3-2.6, P=0.001), dislocation (aOR 2.0; CI 1.5-3.1, P<0.001), mechanical complication (aOR 2.1; CI 1.4-3.2, P<0.001), and infection (aOR 1.6; CI 1.0-2.5, P=0.044).

CONCLUSION

We noted risk of all-cause revision of 18.2%, overall major surgical complication rate of 26.9%, and overall major medical complication rate of 13.2% for THA as the treatment of acute acetabular fracture. We caution against broad expansion of THA for treatment of acute acetabular fractures. Furthermore, increased risks of revision and complications in women warrant additional investigation into patient and fracture characteristics that may contribute to this finding.

Total Hip Arthroplasty in the Setting of Post-Traumatic Arthritis Following Acetabular Fracture: A Systematic Review

Background

Acetabular fractures are frequently associated with post-traumatic arthritis (PTA), for which total hip arthroplasty (THA) has emerged as the established procedure. The purpose of this systematic review is to report the patient outcomes, complications, and implant survival of delayed THA for patients with PTA following acetabular fracture.

Methods

A systematic review was performed in December 2021 as per Preferred Reporting Items for Systematic Review and Meta-Analysis Guidelines to identify all studies reporting outcomes of delayed THA performed for PTA with a history of acetabular fracture. From an initial screen of 893 studies, 29 studies which met defined inclusion criteria including minimum 12 months of follow-up and minimum 10 THA were included in the final review.

Results

A total of 1220 THA were reported across 29 studies, with 1174 THA completing a minimum of 1-year follow-up at a mean of 86 months. All 29 studies reported upon complications, with a control included in 6 for comparison. Higher complication rates were observed both in patients who had prior open reduction internal fixation and conservative treatment, most notably infection which was observed following 3.6% THA. The total joint revision rate was 9.7%. An improvement was noted in all 25 studies which recorded patient-reported outcomes, with a mean rise in the Harris hip score from 45 to 86 across 18 studies.

Conclusions

THA may reduce reported pain levels and improve functional outcomes in selected patients experiencing PTA following acetabular fractures. There is an increased risk of complications, necessitating careful consideration when planning the operation and open discussion with prospective patients and caregivers.

Total hip arthroplasty for posttraumatic osteoarthritis secondary to acetabular fracture: An evidence based on 1,284 patients from 1970 to 2018

BACKGROUND

Posttraumatic osteoarthritis (PTOA) can be a crippling sequela of acetabular fracture (AF), and total hip arthroplasty (THA) is often necessary to alleviate the clinical progression of symptoms. The purpose of this study was to summarize the existing clinical evidence concerning the surgical management of AF with THA through meta-analyses.

METHODS

Databases were searched for articles published between 1995 and January 2022 that contained the keywords "acetabular," "fracture," "arthroplasty," and "osteoarthritis." Our study was registered in PROSPERO under number CRD42022314997.

RESULTS

We screened 3,125 studies and included data from 31 studies with 1,284 patients. The median patient age at the time of THA was 52 years and ranged from 19 to 94 years. The pooled overall survival rate was 88% [86%-90%, 95% confidence interval (CI)] and could reach 83% at ≥15-year follow-up. For the Harris Hip Score, we pooled 22 studies with an overall mean difference of 43.25 (40.40-46.10, 95% CI; P < 0.001), indicating a large clinical effect. The pooled complications (incidence rates) across studies were: heterotopic ossification (22.53%), implant dislocation (4.66%), implant infection (3.44%), and iatrogenic nerve injury (1.07%).

CONCLUSION

THA in patients with PTOA following AF leads to significant improvement in symptoms and function at ≥15-year follow-up. Survival rates of implants free from re-operation or revision after THA decreased with follow-up time and could still reach 83% at ≥15-year follow-up. THA might be an effective therapeutic method for patients with PTOA due to AF.

Gunshot Wound to the Hip Resulting in a Femoral Head and Acetabulum Fracture Treated With Open Reduction and Internal Fixation and Bipolar Hemiarthroplasty

Combined fractures of the femoral head and acetabulum due to ballistic injuries are rare injuries, especially in the elderly. We present a case of a 70-year-old female who sustained a gunshot wound to the left hip, resulting in a comminuted femoral head fracture and posterior wall acetabular fracture. She was treated with open reduction and internal fixation of the acetabulum, as well as bipolar hemiarthroplasty for treatment of her femoral head fracture. At her 18-month follow-up visit, the patient was doing well and had no complaints.