Cup-cage construct for acute fractures of the acetabulum, re-defining indications

Fix and replace: Simultaneous fracture fixation and hip replacement for acetabular fractures in older patients

INTRODUCTION

Displaced acetabular fractures in the elderly present significant treatment challenges. The 'fix and replace' concept involves open reduction and internal fixation of the acetabulum, providing bony stability to accept the press-fit of an acetabular cup, with a cemented femoral stem. This allows early mobilisation and the advantages this confers. This study of 57 patients treated with fix and replace describes our technique, outcomes, and survival analysis.

METHODS

A retrospective review of 57 'fix and replace' procedures in patients aged over 60 was performed. Data was collected on mechanism, fracture type, demographics, time to surgery, comorbidity index, complications, EQ-5D and Oxford hip scores (OHS). Radiographs were reviewed for fracture healing, implant loosening, cup migration, and heterotopic ossification.

RESULTS

57 patients aged 60 to 95 had fix and replace surgery. The median ASA score was 3. The mean Charlson Index was 4.8. 45 patients had a low-energy fall, 6 had a road traffic accident, 3 fell off a bicycle, and 1 mechanism was unclear. The fracture patterns were anterior column posterior hemitransverse (67%), associated both columns (9%), posterior column (9%), posterior column and posterior wall (9%), and transverse (2%). The mean time to surgery was 8.4 days (0-14). 26 out of 57 (46%) received a blood transfusion. Mean length of stay was 17.6 days (7-86). The mean follow-up was 35.5 months. 4 dislocations were treated with closed reduction, whilst 1 required excision arthroplasty. 2 infections resolved with debridement, antibiotics, and implant retention (DAIR), whilst 1 required a two-stage revision. 1 acetabular component had migrated requiring revision. The median pre-injury OHS was 44 (26-48) compared to 37.3 (28-48) at 1 year. There were no deaths at 30-days, whilst at 1 year 7 patients had died. Kaplan Meier survival analysis showed mean survival was 1984.5 days. Implant survival was 90% at 1 year.

CONCLUSION

While fix and replace is conceptually attractive, this medically complex patient group requires considerable support peri‑ and post-operatively. Further studies are required to provide clinicians with more information to decide on how best to provide a holistic management strategy for such injuries in this frail patient cohort.

Outcomes of acute fix and replace in complex hip posterior fracture dislocations with acetabular fractures : a minimum of 3 years follow-up

Simultaneous open reduction and internal fixation of acetabular fractures combined with total hip replacement (THR) have some potential advantages over the more traditional approach in specific patient subgroups. The aim of this study was to evaluate the outcomes of patients who had the "fix and replace" construct for complex posterior hip fracture dislocation treated at our tertiary referral pelvic unit. This was a retrospective review of prospectively collected data for patients who underwent this procedure between 2011-2018 with a minimum of 3 year follow up. Data collected were: patient demographics, date of injury, injury pattern, fixation methods, type of implants used and post-operative complications. There were 14 patients with a mean age of 63.2 years (range 43-94 years) who underwent this procedure between 2011-2018. The mean follow up was 58 months. All cases involved a posterior wall fracture and six cases had an associated posterior column involvement. Femoral head autograft was used in 13 patients (93%). Six patients (43%) had their posterior acetabular wall reconstructed with a femoral head autograft. Seven patients had a fully cemented (THR) and the seven others had a hybrid implant. There were no surgical related complications. From our study we can conclude that the acute "fix and replace" construct for complex posterior hip fracture dislocation yields good clinical outcomes in the short and medium term with low complication rate. It is best performed by a surgeon who specialises in both acetabular and hip arthroplasty surgery.

The management of osteoporotic acetabular fractures: Current methods and future developments

Acetabular fractures in the elderly are challenging. Management is complicated by patients' poor physiological status and osteoporotic bone. Analysis of the management of these patients must be separated from the treatment of younger patients. Conservative management continues to have a role in patients who sustain fractures that are non-displaced and are considered stable with weight bearing mobilisation, and in those patients considered too medically frail to undergo surgical intervention. The mainstay of current surgical intervention is open reduction and internal fixation (ORIF) and variations of ORIF and total hip arthroplasty (THA), or fix and replace. Fix and replace is being increasingly favoured in those patients who display poor prognostic factors for long term joint survival after ORIF. Percutaneous fixation has the theoretical benefits of minimally invasive surgery and the potential to make any subsequent THA less complicated. However, it requires specialised fluoroscopic skills and is not suitable for all fracture patterns. There are a number of developments being reported. The use of a reinforcement ring and THA in has been reported in a number of centres, as has the use of trabecular metal acetabular implants. A coned hemi pelvic prosthesis and THA has been described in our centre, with promising early results. The potential for 3D printing to improve preoperative planning and reduce intra-operative time is also being explored. The aim of this review is to provide a summary of the literature supporting current and future treatment methods, tips on reduction techniques and an overview of the treatment algorithm of these patients in our unit.

Cup-Cage Construct Using Porous Cup with Burch-Schneider Cage in the Management of Complex Acetabular Fractures

Purpose

Cup-cage construct technique was developed to address the massive acetabular defects during revision hip arthroplasty. Indications have extended to complex acetabular fractures with pelvic discontinuity necessitating acute total hip arthroplasty. However, its use is constrained in low socioeconomic countries due to non-availability of the original cages from Trabecular Metal Acetabular Revision System and high cost. We used a novel technique using the less expensive Burch-Schneider (BS) cage and Trabecular Metal Revision Shell (TMRS) to address the problem.

Materials and Methods

We reviewed a consecutive series of 8 cases of acetabular fractures reconstructed using a ‘cup-cage construct’ technique using a BS cage along with a TMRS. The mean age of the patients was 61.4 years. Patients were followed up for a mean period of 50.5 months (24 to 72 months). The patients were assessed clinically with Harris Hip Score and radiologically with serial X-rays.

Results

All the patients were available at the latest follow up. The mean Harris Hip Score was 87.2. There was no radiological evidence of failure. One patient had dislocation two months following the surgery, which was treated by closed reduction and hip abduction brace. One patient developed an infection at 3 weeks necessitating debridement. The same patient had sciatic nerve palsy that recovered after 4 months.

Conclusion

This novel technique of the cup-cage construct seems to provide a stable construct at short to midterm follow-up. However, a long-term follow up would be required.

Fix and replace; an emerging paradigm for treating acetabular fractures

Although technically challenging even for the experienced surgeon, simultaneous open reduction and internal fixation (ORIF) of acetabular fracture and total hip replacement (THR) have some potential advantages over the more traditional treatment options in specific patient subgroups; theoretically allowing immediate weight bearing and faster rehabilitation, reducing the cost of inpatient stay, and reducing the risks of early and late local complications associated with standard treatment for this type of injury. We review the evolution of the indications and techniques, outline the surgical challenges, and discuss implant options and outcomes for this treatment paradigm.

Should Total Hip Arthroplasty be Performed Acutely in the Treatment of Acetabular Fractures in Elderly or Used as a Salvage Procedure Only?

BACKGROUND

Total hip arthroplasty (THA) is now an increasingly common procedure for people sustaining acetabular fractures. The incidence of acetabular fractures among the elderly population is increasing, and contemporary treatment aims to avoid the risks of prolonged incumbency associated with poor bone stock for fixation or inability to comply with limited weightbearing in this patient group. The concept of acute hip arthroplasty as a treatment for acetabular fracture is, therefore, becoming more topical and relevant. Our systematic review investigates whether THAs for acetabular fractures should be performed acutely, with a short delay, or as a late procedure for posttraumatic osteoarthritis (PTOA) if it develops.

MATERIALS AND METHODS

Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were followed when undertaking this systematic review. Detailed searches were performed on three different databases, using keywords, such as "acetabular fracture," "acetabular trauma," "total hip arthroplasty," "hip arthroplasty," and "hip prosthesis." Studies from 1975 to September 2016 were included in the study. All studies included in the review were independently critically appraised by two of the authors.

RESULTS

Forty three studies were included in this review. Only two of them actually compared acute and delayed THAs for acetabular fractures with the rest focusing on one or the other. Results were comparable between acute and late THAs in terms of aseptic loosening, operative time, blood loss, Harris Hip Score, and ability to mobilize postoperatively without aid. Complication rates, however, were much higher in the acute group.

CONCLUSION

Evidence based on this topic is scarce and therefore we have to be cautious about drawing a definitive conclusion. The findings of this systematic review do suggest, however, that acute THAs should be considered in elderly patients, where fixation is not possible, or when their health and ability to rehabilitate are poor. It should also be considered in patients where PTOA is very likely, or where there is already some preexisting degenerative osteoarthritis.

Does cup-cage reconstruction with oversized cups provide initial stability in THA for osteoporotic acetabular fractures?

BACKGROUND

The incidence of acetabular fractures in osteoporotic patients is increasing. Immediate total hip arthroplasty (THA) has potential advantages, but achieving acetabular component stability is challenging and, at early followup, reported revision rates for loosening are high.

QUESTIONS/PURPOSES

This study measured acetabular component stability and the initial surface contact achieved between the acetabular component and unfractured region of the pelvis after THA using an oversized acetabular component and cup-cage reconstruction.

METHODS

Between November 2011 and November 2013, we treated 40 acute acetabular fractures in patients older than 70 years of age. Of these, 12 (30%) underwent immediate THA using an oversized acetabular component with screws inserted only into the ilium and a cup-cage construct. Postoperatively all patients were mobilized without weightbearing restrictions. Indications for immediate THA after acetabular fractures were displaced articular comminution deemed unreducible. Eleven of the 12 were prospectively studied to evaluate the initial stability of the reconstructions using radiostereometric analysis. One of the patients died of a pulmonary embolism after surgery, and the remaining 10 (median age, 81 years; range, 72-86 years) were studied. Of these, five were analyzed at 1 year and five were analyzed at 2 years. Acetabular component migration was defined as acceptable if less than the limits for primary THA that predict later loosening (1.76 mm of proximal migration and 2.53° of sagittal rotation). The contact surface between the acetabular component and ilium in direct continuity with the sacroiliac joint, and the ischium and pubis in direct continuity with the symphysis pubis, was measured on postoperative CT scans.

RESULTS

At 1 year the median proximal migration was 0.83 mm (range, 0.09-5.13 mm) and sagittal rotation was 1.3° (range, 0.1°-7.4°). Three of the 10 components had migration above the suggested limits for primary THA at 1 year postoperatively. The contact surface achieved at surgery between the acetabular component and pelvis ranged from 11 to 17 cm(2) (15%-27% of each component).

CONCLUSIONS

The majority of acetabular components in this cohort were stable despite the small contact surface achieved between the component and pelvic bone. Three of 10 migrated in excess of the limits that predict later loosening in primary THA but it remains to be seen whether these limits apply to this selected group of frail osteoporotic patients. We continue to use this technique routinely to treat patients with the same indications, but since the analysis of these data we have added screw fixation of the acetabular component to the ischial tuberosity and the superior pubic ramus.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

A growing problem: acetabular fractures in the elderly and the combined hip procedure

Acetabular fractures in the elderly are most frequently the result of low-energy trauma and present unique management challenges to orthopedic surgeons. Evaluation and treatment should be performed in a multidisciplinary fashion with early involvement of internal medicine subspecialists and geriatricians. Distinct fracture patterns and pre-existing osteoarthritis and osteoporosis necessitate careful preoperative planning. The role of total hip arthroplasty should also be considered when surgical treatment is indicated. The outcomes of acetabular fractures in the elderly have improved, but complications remain higher and results less satisfactory than in younger individuals. The lack of randomized controlled trials has limited the ability to establish an evidence-based treatment algorithm.

Acute total hip replacement for acetabular fractures: a systematic review of the literature

INTRODUCTION

Immediate total hip replacement (THR) in patients with acetabular fractures is controversial because of concerns about high complication rates. The current article is a systematic review of the literature on the use of acute THR for the treatment of acetabular fractures.

MATERIALS AND METHODS

This systematic review included studies published in English between 1992 and 2012 of subjects with acetabular fracture undergoing immediate THR. Outcomes of interest included indications; clinical assessment, including walking ability; comparison with control group; associated procedures, and rate of complications, such as loosening or revision surgery.

RESULTS

This review identified six studies, of which only one included a control group. Acute THR was associated with satisfying outcomes with regard to clinical assessment and walking ability. The comparative study assessed the difference between acute THR and delayed THR in acetabular fractures: improved outcomes were observed in the delayed THR group, although the differences between the two groups were not statistically significant.

DISCUSSION

According to data reported in the literature, acute primary THR can be successful in patients with poor bone quality, combined acetabular and femoral neck fractures, or pathological fractures and concurrent osteoarthritis of the hip. Relative indications include old age, delayed presentation, substantial medical comorbidities, and pathologic obesity. Clinical outcomes with acute THR were similar to those with delayed THR. Although the results reported in the six studies reviewed here were satisfying overall, there is limited evidence in this area in the existing literature and future prospective investigations are required.

CONCLUSION

Data reported in the literature indicate that immediate THR can be successful in appropriately selected elderly patients or patients with extensive osteoporosis, combined acetabular and femoral neck fractures or pathological fractures. There is currently a limited evidence base for THR in patients with acetabular fractures; therefore, physicians' practice and expertise are the most useful tools in clinical practice.