Fracture and Patient Characteristics Associated With Early Conversion Total Hip Arthroplasty After Acetabular Fracture Fixation

Posttraumatic Arthritis After Acetabular Fractures

This article highlights patient, radiographic, and surgical risk factors for the development of posttraumatic arthritis after acetabular fractures. Surgical treatment options including acute and staged total hip arthroplasty as well as outcomes after arthroplasty for fracture management are addressed.

Anatomical Posterior Acetabular Plate Versus Conventional Reconstruction Plates for Acetabular Posterior Wall Fractures: A Comparative Study

Background: Functional recovery following the surgical fixation of acetabular posterior wall fractures remains a challenge. This study compares outcomes of posterior wall fracture reconstruction using an anatomical posterior acetabular plate (APAP) versus conventional reconstruction plates. Methods: Forty patients with acetabular fractures involving the posterior wall or column underwent surgery, with 20 treated using APAPs (APAP group) and 20 with conventional pelvic reconstruction plates (control group). Baseline patient characteristics, intraoperative blood loss and time, reduction quality, postoperative function, and postoperative complications were compared using appropriate non-parametric statistical tests. A general linear model for repeated measures analysis of variance was employed to analyze trends in functional recovery. Results: No significant differences were observed in baseline characteristics. APAP significantly reduced surgical time by 40 min (186.5 ± 51.0 versus 225.0 ± 47.7, p =0.004) and blood loss (695 ± 393 versus 930 ± 609, p = 0.049) compared to conventional plates. At 3 and 6 months following surgery, the APAP group exhibited higher functional scores (modified Merle d'Aubigné scores 10 ± 1.8 versus 7.8 ± 1.4, p < 0.001; 13.4 ± 2.8 versus 10.1 ± 2.1, p = 0.001), converging with the control group by 12 months (modified Merle d'Aubigné scores 14.2 ± 2.6 versus 12.7 ± 2.6, p = 0.072; OHS 31.6 ± 12.3 versus 30.3 ± 10.1, p = 0.398). Radiologically, the APAP group demonstrated superior outcomes (p = 0.047). Complication and conversion rates to hip arthroplasty did not significantly differ between groups (10% versus 15%, p = 0.633). Conclusions: The use of an APAP in reconstructing the posterior acetabulum significantly reduces surgical time, decreases intraoperative blood loss, and leads to earlier functional recovery compared to conventional reconstruction plates. The APAP provides stable fixation of the posterior wall and ensures the durable maintenance of reduction, ultimately yielding favorable surgical outcomes.

Traumaplasty: When and How to Perform Acute Arthroplasty for Fractures Around the Hip in the Elderly Patient

Acute fractures around the hip are prevalent injuries associated with potentially devastating outcomes. The growing utilization of arthroplasty for femoral neck fractures in the elderly is likely a result of improvements in reoperation rates and postoperative function. Compared to hemiarthroplasty, total hip arthroplasty is associated with a slight functional benefit that is unlikely noticeable for many patients, as well as minimal differences in complications and patient reported outcome measures. However, the evidence supporting cement use in femoral stem fixation is robust. Multiple high power randomized controlled trial-based studies indicate cement fixation brings more predictable outcomes and fewer reoperations. In the setting of acute acetabular fracture, total hip arthroplasty is a favorable approach for elderly patients and fracture patterns associated with increased risk of revision after open reduction and internal fixation. Variations in patient characteristics and fracture patterns demand careful consideration whenever selecting the optimal treatment. In fracture patient populations, comanagement is an important consideration when seeking to reduce complications and promote cost-effective quality care.

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.

Similar Medium-Term Revision Rates Following Acute Total Hip Arthroplasty Versus Open Reduction and Internal Fixation for Acetabular Fractures in the Elderly

BACKGROUND

The management of elderly acetabular fractures is complex, with high rates of conversion total hip arthroplasty (THA) after open reduction and internal fixation (ORIF), but potentially higher rates of complications after acute THA.

METHODS

The California Office of Statewide Health Planning and Development database was queried between 2010 and 2017 for all patients aged 60 years or older who sustained a closed, isolated acetabular fracture and underwent ORIF, THA, or a combination. Chi-square tests and Student t tests were used to identify demographic differences between groups. Multivariate regression was used to evaluate predictors of 30-day readmission and 90-day complications. Kaplan-Meier (KM) survival analysis and Cox proportional hazards model were used to estimate the revision surgery-free survival (revision-free survival [RFS]), with revision surgery defined as conversion THA, revision ORIF, or revision THA.

RESULTS

A total of 2,184 surgically managed acetabular fractures in elderly patients were identified, with 1,637 (75.0%) undergoing ORIF and 547 (25.0%) undergoing THA with or without ORIF. Median follow-up was 295 days (interquartile range, 13 to 1720 days). 99.4% of revisions following ORIF were for conversion arthroplasty. Unadjusted KM analysis showed no difference in RFS between ORIF and THA (log-rank test P = 0.27). RFS for ORIF patients was 95.1%, 85.8%, 78.3%, and 71.4% at 6, 12, 24 and 60 months, respectively. RFS for THA patients was 91.6%, 88.9%, 87.2%, and 78.8% at 6, 12, 24 and 60 months, respectively. Roughly 50% of revisions occurred within the first year postoperatively (49% for ORIF, 52% for THA). In propensity score-matched analysis, there was no difference between RFS on KM analysis ( P = 0.22).

CONCLUSIONS

No difference was observed in medium-term RFS between acute THA and ORIF for elderly acetabular fractures in California. Revision surgeries for either conversion or revision THA were relatively common in both groups, with roughly half of all revisions occurring within the first year postoperatively.

LEVEL OF EVIDENCE

III.

Frequency and Characteristics of Posterior Labral Injuries in Operative Acetabular Fractures Treated Through a Posterior Approach: A Prospective Observational Study

OBJECTIVES

The association between labral injuries and acetabular fractures is unknown. This study aimed to identify the frequency and characteristics of labral injuries in operatively treated acetabular fractures that cannot be identified on preoperative imaging.

METHODS

.

DESIGN

Prospective observational cohort.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Adult patients with an acetabular fracture operatively treated through a posterior approach.

OUTCOME MEASURES AND COMPARISONS

The frequency and characteristics of labral injuries.

RESULTS

Fifty-three of 71 acetabular fractures (75%; 95% confidence interval, 63%-83%) demonstrated a labral injury visible via the posterior approach. Posterior labral injuries occurred in 89% of operative acetabular fracture patterns involving the posterior wall and most commonly represent a detachment of the posteroinferior labrum (n = 39, 75%). Fractures with a labral injury were more likely to have gluteus minimus damage (93% vs. 61%, P = 0.02), femoral head lesions (38% vs. 17%, P = 0.03), joint capsule detachment (60% vs. 33%, P = 0.05), and fracture patterns involving the posterior wall (89% vs. 50%, P = 0.05).

CONCLUSIONS

This study describes the high rate (89%) of posterior labral injuries in posterior wall fractures, the most common injury pattern being a detachment of the posteroinferior labrum. Labral injuries in acetabular fractures may have important clinical implications and this study is the first to identify the frequency and characteristics of these injuries. Further studies should assess the relationship between labral injuries, treatment strategies, and the progression to post-traumatic osteoarthritis.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Saint-Joseph Acetabular score: a reproducible and accurate prediction of the outcome of open reduction and internal fixation of acetabular fractures

PURPOSE

Acetabular fractures are associated to an increased risk of subsequent hip osteoarthritis. The only available score for post-operative reduction assessment in acetabular fractures (Matta's score) is x-ray based. CT-scan was shown superior to X-rays in post-operative reduction assessment. We aim to describe a CT-scan-based post-operative reduction score in acetabular fractures and evaluate its accuracy and reproducibility.

METHODS

This is a retrospective study that includes 138 patients who underwent surgery for an acetabular fracture in our tertiary referral centre with a mean follow-up of 104.39±42.2 months. The post-operative CT-scan was reviewed and residual displacement (maximum gap and step) measured by three independent observers. The association between the occurrence of THA and the CT-scan measurements was evaluated. This led to a new prognostic score. The interobserver reliability and accuracy of this score were calculated.

RESULTS

Interobserver reproducibility for the residual maximal gap was 0.82 (95% CI [0.70-0.89]) and 0.61 (95% CI [0.52-0.70]) for the residual maximal step displacement measurements. We created a score from a logistic regression model, attributing 1 point for every 1 mm of residual maximal step displacement and 1 point for every 2 mm of residual maximal gap displacement. The interobserver reproducibility of this score was 0.78 (95% CI [0.71-0.84]), and its AUC was 0.79 (95% CI [0.69-0.88]).

CONCLUSION

This is the first CT-scan-based score for the assessment of residual displacement of a surgically treated acetabular fracture. It shows good interobserver reproducibility and accuracy in predicting the risk for secondary THA. It should be regularly used per-operatively (if per-operative 3D imaging is available) and post-operatively to predict the prognosis.

Outcomes of acute versus delayed total hip arthroplasty following acetabular fracture

PURPOSE

Post-traumatic arthritis is known complication following acetabular fracture. The aim was to compare mid- to long-term outcomes of acute THA (aTHA) for acetabular fracture and delayed THA (dTHA) following failure of ORIF or conservative management.

METHODS

We retrospectively analysed 60 THA (21 aTHA; 39 dTHA) performed for acetabular fracture between 2004 and 2014 in 60 patients with a mean age of 59 years (20-94). Functional and Radiographic outcomes were assessed at a mean follow-up of 5 years (2-13) utilizing Oxford, Harris Hip (HHS), and Postel Merle d'Aubigné (PMA) scores and Brooker classification.

RESULTS

The mean HHS (73), Oxford (32) and PMA (12) scores were significantly lower in the aTHA group. Acute THA was significantly associated with lower postoperative Oxford (β = -4.2), HHS (β = -7.8), and PMA (β = -2.2) scores at mean 5 years (2-13). Eleven patients returned to the operating room. There were no significant differences between THA performed in acute or delayed fashion. The two primary reasons for revision were periprosthetic joint infection (n = 5) and aseptic loosening (n = 4). Survivorship free from reoperation at 10 years was 91% and 82% for aTHA and dTHA, respectively (p = 0.24). Increased PMA scores were associated with decreased overall survival of the THA free from reoperation (HR = 0.60). The degree of heterotopic ossification was significantly higher in the aTHA group (p < 0.001).

CONCLUSION

Acute THA in the setting of acetabular fracture is a technically challenging procedure. However, in the present series, aTHA provided satisfactory immediate stability and good survivorship at 10 years in a medically vulnerable patient population.

LEVEL OF EVIDENCE

Level 3; Therapeutic study.

Influence of associated femoral head fractures on surgical outcomes following osteosynthesis in posterior wall acetabular fractures

Background

To date, no study has compared the surgical outcomes between posterior wall acetabular fractures with and without associated femoral head fractures. Therefore, we evaluated whether an associated femoral head fracture increases the incidence of fracture sequelae, including post-traumatic osteoarthritis (PTOA) and osteonecrosis of the femoral head (ONFH), following osteosynthesis for posterior wall acetabular fractures.

Methods

This retrospective clinical study enrolled 183 patients who underwent osteosynthesis for posterior wall acetabular fractures between 2009 and 2019 at a level-1 trauma center. The incidence of PTOA, ONFH, and conversion to total hip arthroplasty (THA) was reviewed.

Results

The incidence of PTOA, ONFH, and conversion to THA following osteosynthesis were 20.2%, 15.9%, and 17.5%, respectively. The average time for conversion to THA was 18.76 ± 20.15 months (range, 1–82). The results for the comparison of patients with associated femoral head fractures and isolated posterior wall acetabular fractures were insignificant (PTOA: 27.3% vs. 15.7%, p = 0.13; ONFH: 18.2% vs. 14.3%, p = 0.58; conversion to THA: 20.4% vs. 15.7%, p = 0.52). Upon evaluating other variables, only marginal impaction negatively affected ONFH incidence (odds ratio: 2.90).

Conclusions

Our methods failed to demonstrate a significant difference in the rate of PTOA, ONFH, or conversion to THA in posterior wall acetabular fractures with and without an associated femoral head fracture. Beyond femoral head fractures, the marginal impaction of the acetabulum could have led to early sequelae.

Level of evidence

Level III