Primary stability of multi-hole acetabular cup combined with posterior column plating for the fixation of complex acetabular fractures in elderly patients: a biomechanical analysis.

BACKGROUND: Acute total hip arthroplasty has gained increasing popularity in the treatment of complex acetabular fractures in elderly patients, but the biomechanical evidence is lacking. Therefore, we measured the primary stability to evaluate whether acute total hip arthroplasty using a multi-hole acetabular cup and posterior column plating through a single K-L approach can safely be used for treating complexed acetabular fractures in the elderly. METHODS: In 18 composite osteoporotic hemipelves, T-type acetabular fractures were treated in three ways: CSP (Cup with acetabular screws augmentation combined with posterior plate) group, CP (Cup without acetabular screw combined with posterior plate) group and CSPA (Cup with acetabular screws combined with posterior plate and anterior plate) group. Each specimen was dynamically loaded (300 to 1700 N, 1 Hz). Primary stability of the acetabular cup and fracture gap was evaluated by 3-dimensional (3D) micromotions. RESULTS: No significant differences in the 3D-micromotions were observed among the CSP, CP and CSPA groups except the test point on the anterior column of the acetabulum in the CP scenario (CSP 49.33 ± 21.08 µm vs. CP 224.83 ± 52.29 µm, p < 0.001; CSPA 45.50 ± 12.16 µm vs. CP 224.83 ± 52.29 µm, p < 0.001). No significant differences in the fracture gap displacement on the posterior column of acetabulum were observed among the CSP, CP and CSPA groups. CONCLUSION: Our results show, that acute total hip arthroplasty using a multi-hole cup with acetabular screws and posterior column plating through single a K-L approach offers good primary stability to allow good osseous integration for treating complex acetabular fractures in the elderly. Furthermore, it also provides good fracture gap displacement on the posterior column.

Indications, complications, and clinical outcomes of fixation and acute total hip arthroplasty for the treatment of acetabular fractures: A systematic review.

PURPOSE: Acetabular fracture fixation can be challenging, especially in the elderly. Open reduction and internal fixation (ORIF) alone may not allow for early weight bearing and is associated with a high rate of secondary osteoarthritis; therefore, a combined hip procedure (CHP) or ORIF with acute total hip arthroplasty, may be beneficial in this population. The objective of this study was to perform a systematic review of all reported cases of CHP. METHODS: PubMed, Embase, Scopus, and Cochrane databases were searched for studies analyzing acetabular fractures in the elderly managed with a combined hip procedure (CHP). The research was performed following the PRISMA guidelines. The included studies' methodological quality was evaluated using the MINORS score. The present study was registered on PROSPERO. RESULTS: Eleven clinical studies were included in the final analysis. The mean age was 74.4 (63.2-78) years. Low-energy trauma was the most common mechanism of injury (64%). The most prevalent fracture pattern was the anterior column and posterior hemitransverse (ACPHT) (30.6%). The Kocher-Langenbeck approach was preferred for ORIF of posterior fractures and hip arthroplasty. The ilioinguinal approach and modified Stoppa were generally used for anterior fractures. The overall complication rate was 12.2%, and hip dislocation was the most frequent cause of reoperation (4.4%). The average Harris Hip Score reported postoperatively was 81.6 points, which was considered "good." CONCLUSIONS: CHP is a safe treatment for elderly acetabular fractures with an acceptable complication and reoperation rate that results in good clinical outcomes. LEVEL OF EVIDENCE: Level of evidence IV.

Comparison of primary total hip arthroplasty with limited open reduction and internal fixation vs open reduction and internal fixation for geriatric acetabular fractures: a systematic review and meta-analysis.

Purpose: Comminuted fractures with poor bone quality in the elderly are associated with poor outcomes. An alternative to open reduction and internal fixation (ORIF) alone, primary or acute total hip arthroplasty (aTHA), allows early mobilization with full weight bearing. In this study, we aim to analyze whether treatment of aTHA with/withtout ORIF (limited ORIF) vs ORIF alone yields better intra-operative results, functional outcomes, and less complications. Methods: PubMed, Cochrane, Embase, and Scopus databases were searched in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Random-effects model and 95% confidence intervals were used. The outcomes of interest were surgery time, blood loss, length of hospital stay, Harris hip score (HHS), 36-Item Short Form Survey (SF-36), complication rate, surgical site infection rate, heterotopic ossification rate, reoperation rate, and mortality rate. Results: Ten observational studies with a total of 642 patients (415 ORIF alone and 227 aTHA with/without ORIF) were included in the systematic review. Compared to ORIF alone, aTHA with limited ORIF provided higher HHS (P = 0.029), better physical function (P = 0.008), better physical component summary (P = 0.001), better mental component summary (P = 0.043) in postoperative 1-year SF-36, lesser complication rate (P = 0.001), and lesser reoperation rate (P = 0.000), but however greater bodily pain (P = 0.001) in acetabular fractured elderlies. Conclusions: Acute THA with limited ORIF is favorable alternative to ORIF technique alone. It provided better HHS, physical, and mental component summary in SF-36 and yielded lower complication and reoperation rate compare to ORIF alone.

Biomechanical comparison of acetabular fracture fixation with stand-alone THA or in combination with plating.

PURPOSE: A common surgical treatment in anterior column acetabular fractures with preexisting osteoarthritis is THA, which is commonly combined with plate osteosynthesis. Implantation of a solitary revision cup cranially fixed to the os ilium is less common. The purpose of this study was to compare the stabilization of anterior column acetabular fractures fixed with a cranial socket revision cup with flange and iliac peg or with a suprapectineal plate osteosynthesis combined with an additional revision cup. METHODS: In 20 human hemipelves, an anterior column fracture was stabilized by either a cranial socket revision cup with integrated flange (CF = Cup with Flange) or by a suprapectineal plate combined with a revision cup (CP = Cup and Plate). Each specimen was loaded under a stepwise increasing dynamic load protocol. Initial construct stiffness, interfragmentary movements along the fracture line, as well as femoral head movement in relation to the acetabulum were analyzed. RESULTS: Both groups showed comparable initial construct stiffness (CP: 3180 ± 1162 N/mm and CF: 3754 ± 668 N/mm; p = 0.158). At an applied load of 1400 N, interfragmentary movements at the acetabular (p = 0.139) and the supraacetabular region (p = 0.051) revealed comparable displacement for both groups and remained below 1 mm. Femoral head movement in relation to the acetabulum also remained below 1 mm for both test groups (p = 0.260). CONCLUSION: From a biomechanical point of view, both surgical approaches showed comparable fracture reduction in terms of initial construct stiffness and interfragmentary movement. The potential benefit of the less-invasive cranial socket revision cup has to be further investigated in clinical studies.

Current indications for acute total hip arthroplasty in older patients with acetabular fracture: Evidence in 601 patients from 2002 to 2021.

Purpose: Older patient population with acetabular fractures is increasing rapidly, requiring enhanced recovery. Acute total hip arthroplasty (THA) is a good option for these patients, and it is becoming increasing popular. However, acute THA has different indications in different studies. Therefore, a systematic review is needed to assess and comprehend the indications for acute THA in older patients. Methods: A systematic literature review was conducted to identify a retrospective series or prospective studies in older patients (>60 years) with acetabular fractures. The search timeline was from database construction till December 2021; PubMed, Embase, and Cochrane Library databases were searched. Two trained professional reviewers independently read the full text of documents that met the inclusion criteria and extracted information on the specific methods used and indication information based on the research design. Results: In total, there were 601 patients with acetabular fractures aged >60 years from 33 studies were obtained. Twenty-eight studies reported that THA was a feasible treatment option for acetabular fractures in geriatric patients with good outcome. The primary indications were dome impaction, irreducible articular comminution, femoral head injury, and pre-existing osteoarthritis or avascular necrosis. The most common patterns were anterior column and posterior hemitransverse, posterior wall, both columns, and T-type. Conclusion: Acute THA is an effective treatment strategy for older patients with acetabular fractures and should be considered when the abovementioned indications are observed on preoperative images. (PROSPERO: CRD42022329555).

"Acute Primary Total Hip Arthroplasty for Combined Posterior Acetabulum Fracture with Ipsilateral Associated Posteriorly Dislocated Femoral Head with Femoral Neck Fracture. Using of Femoral Head as an Autograft Would be an Advantage".

INTRODUCTION: Traumatic posterior hip dislocation with comminuted fracture of the ipsilateral acetabulum and femoral neck is a rare fracture pattern. These injuries are associated with high energy trauma and pose challenges during management. Controversy exists between hip preservation and replacement surgeries in middle-age patients. Open reduction and internal fixation (ORIF) have a high risk of non-union, avascular necrosis, and post-traumatic osteoarthritis of hip requiring total hip arthroplasty hip replacement (THA) as a secondary procedure later. CASE REPORT: A 56-year-old male presented with posterior hip dislocation and comminuted fracture of ipsilateral wall and column of the acetabulum, and femoral neck following a high energy trauma. He was managed by acetabular reconstruction using femoral head structural autograft combined with acute primary uncemented THA. At 2-year follow-up, the patient had good functional outcome with a satisfactory range of motion without any difficulty in weight-bearing and doing his daily activities. CONCLUSION: Although uncommon, acetabular reconstruction using femoral head structural autograft and acute primary uncemented THA is a viable alternative treatment option compared to ORIF in middle-age patients with fracture of ipsilateral neck and acetabulum. This facilitates post-operative rehabilitation and avoids further operations for possible developing AVN or secondary arthritis.

Acute total hip arthroplasty in acetabular fractures using modern porous metal cup.

PURPOSE: The aim of this study was to report the clinical and radiological outcome of using the modern porous metal cup in patients undergoing acute total hip arthroplasty (THA) for selected subset of acetabular fractures. PATIENT AND METHODS: Eighteen patients with acetabular fracture underwent acute THA with modern porous metal cup from a single manufacturer. Fifteen males and three females with a mean age of 46.4 years (range 21-57 years) were ambispectively followed up for a minimum period of 48 months. All patients were evaluated clinically with Harris Hip Scores (HHS) and radiographically with serial X-rays. RESULTS: No patient was lost to follow-up. The HHS was excellent in nine patients, good in six patients, fair in two patients, and poor in one patient. All the fractures were united and the cups were well integrated. There was no lucent line seen in any acetabular zones on the X-rays. One patient had infection, which resolved with debridement. There was one dislocation following fall, which was reduced by closed means and remained stable. One of the two patients with heterotopic ossification had restricted movement of hip but not restricting the activities of daily living. No failures of acetabular component were seen in the study. CONCLUSION: The current study showed that the modern porous metal cup provides sufficient primary stability and appear suitable for primary THA in acute acetabular fractures at mid-term follow-up: (i) In selected fractures, acute THA can be extended to young adult patients as well. (ii) Modern porous metal cup may provide sufficient stability with or without additional fixation required.

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.

Acute total hip arthroplasty versus open reduction internal fixation for posterior wall acetabular fractures in middle-aged patients.

INTRODUCTION: Open reduction internal fixation (ORIF) is the standard of care for displaced acetabular fractures, but the inability to achieve anatomic reduction, involvement of the posterior wall, articular impaction, and femoral head cartilaginous injury are known to lead to poorer outcomes. Acute total hip arthroplasty (THA) is a reasonable treatment option for older patients with an acetabular fracture and risk factors for a poor outcome, but it is only described in case series. The purpose of this study is to compare outcomes of ORIF and acute THA in middle-aged patients with an acetabular fracture from a single center. METHODS: Retrospective case-controlled study of patients aged 45 to 65 years old with acetabular fractures involving the posterior wall treated with acute THA or ORIF at a level 1 trauma center between 1996 and 2011. Patients were matched by fracture pattern and age at a 2 (ORIF):1 (acute THA) ratio. Functional outcome, complications, and reoperation rates of acute THA and ORIF were compared. RESULTS: Sixteen acute THA patients (average age 56.4 years) and 32 ORIF patients (average age 54.3 years) were evaluated at an average follow-up of 6.2 years (range 1-15.2). The average Oxford Hip Score in the acute THA group was 44 compared to 40 in the ORIF group (P = .075). Complication rates were similar between both the groups. Twelve hips (37%) in the ORIF group had undergone THA or been referred for THA, and 2 revisions (13%) had occurred in the acute THA group. A Kaplan-Meier survival analysis showed that those undergoing acute THA had significantly better survival of their index procedure (P = .031). CONCLUSIONS: Both ORIF and acute THA for high-energy acetabular fractures involving the posterior wall in middle-aged patients can provide excellent results, with acute THA patients achieving improved survival of the index procedure and improved functional scores.

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

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.

Surgical treatment of acetabular fractures in the elderly: a systematic review of the results.

We performed a systematic review of the literature involving a number of databases to identify studies that included outcomes of surgical treatment of acetabular fractures in patients aged > 55 years. An initial search identified 1564 studies. After exclusion by two independent reviewers, 15 studies met the inclusion criteria. All studies were case series and the mean Coleman Methodology score for methodological quality assessment was 43.7 (standard deviation 12.3). There were 354 patients with acetabular fractures. Pooled analysis revealed a mean age of 71.6 years (55 to 96) and a mean follow-up of 43 months (20 to 188). Complex fractures were reported in 70.1% of patients.Seven studies presented the results of open reduction and internal fixation (ORIF); in eight other studies a total hip arthroplasty (THA), alone or combined with different internal fixation techniques, was the chosen treatment. In the ORIF sub-group, conversion to THA was performed at a mean of 25.5 months with anatomical reduction in 11.6% and imperfect and poor reduction in 22.3%. In the THA sub-group, an acetabular ring or cage with a cemented acetabular component was used in four studies (52 patients) and a cementless acetabular component was implanted in five studies (78 patients). Six patients (4.9%) underwent revision at a mean of 39 months after the index procedure.The analysis of intra-operative and post-operative parameters showed a statistical difference between the two sub-groups with regards to the mean operating time (236 mins ORIF vs 178 mins THA), the mean blood loss (707 mL ORIF vs 974 mL THA) and the mean mortality rate at one year (22.6% ORIF vs 8.8% THA).Based on the current data available, acute THA (alone or in combination with internal fixation) may have a role in the treatment of older patients with complex acetabular fractures. Despite the wide heterogenecity of fracture types and patient co-morbidities, THA procedures were associated with lower rates of mortality and further surgery when compared with the ORIF procedures. Cite this article: EFORT Open Rev 2017;2:97-103. DOI: 10.1302/2058-5241.2.160036.