tha to salvage failed acetabular fractures daniel j. berry, md mayo clinic rochester, mn
TRANSCRIPT
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THA TO SALVAGE FAILED ACETABULAR FRACTURES
Daniel J. Berry, MD
Mayo Clinic
Rochester, MN
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THA AFTER ACETABULAR FXTechnical Challenges
• Acetabular bone loss• Residual pelvic deformity• Nonunited fractures• Retained hardware• Heterotopic ossification• Socket fixation
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THA FOR ACETABULAR FX
ACETABULAR COMPONENT CHOICE
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THA AFTER ACETABULAR FX Previous ORIF
Results: Long Term:• Higher failure rate than THA for OA• Pts young/male/unilateral disease• Uncemented cups better so far than
cemented (similar scenario to revision THA)
Weber et al. JBJS 80A(9):1295-1305, 1998
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SURVIVAL FREE REVISION FOR ASEPTIC ACET LOOSE/RADIOGRAPHIC LOOSENING
Cemented vs Uncemented
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THA AFTER ACETABULAR FXAcetabular Bone Loss
Socket Fixation:• Apply principles of revision
THA (similar sclerotic, deficient bone)
• Consensus in North America: Uncemented hemispherical cup
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THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups
Uncemented Cups: 5 Yr, Data, Rush:• 1/30 (4%) revised for loosening
JBJS(A), 2001
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THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups
Uncemented Cups: Mayo Clinic Data:• 34 hips• Minimum F/U 10 yrs (10-16)• Aseptic Loosening 2/34 (6%)
Halasy, Berry, CORR 2002
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THA AFTER ACETABULAR FX
MANAGEMENT OF BONE LOSS
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THA AFTER ACETABULAR FXAcetabular Bone Loss
Cavitary Bone Loss: Particulate Graft
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THA AFTER ACETABULAR FXAcetabular Bone Loss
Segmental Loss: The Posterior/Superior Wall• Use autogenous femoral head graft if
needed
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THA AFTER ACETABULAR FXAcetabular Bone Loss
Results: • Reliable bone graft healing and
incorporation
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THA AFTER ACETABULAR FX
PELVIC DEFORMITY
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THA AFTER ACETABULAR FXPelvic Deformity
• Landmarks distorted
- care with cup position• Bony prominence
- beware of bone impingement causing instability
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THA AFTER ACETABULAR FX
NONUNITED FRACTURES
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THA AFTER ACETABULAR FXNonunited Fractures
• Typically nonunited transverse acetabular fx (pelvic discontinuity)
• Stabilize with post column plate
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THA AFTER ACETABULAR FXNonunited Fractures
Results:• High rate of fracture healing
(100% in personal experience)
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THA AFTER ACETABULAR FXNonunited Fractures
Plate Pelvic Discontinuity
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THA AFTER ACETABULAR FX
RETAINED HARDWARE
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THA AFTER ACETABULAR FXRetained Hardware
• Leave in place if not problematic• Selective removal when needed• Beware of the sciatic nerve
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THA AFTER ACETABULAR FXRetained Hardware
Selective Hardware Removal
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THA AFTER ACETABULAR FXRetained Hardware
Selective Hardware Removal
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THA AFTER ACETABULAR FXRetained Hardware
Sciatic Nerve:• Avoid if possible• If working posteriorly:
Identify (beneath g. max. tendon), handle carefully
• Do case with knee flexed
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THA AFTER ACETABULAR FX
HETEROTOPIC BONE
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THA AFTER ACETABULAR FXHeterotopic Bone
Heterotopic Ossification:• Excise HO if symptomatic• If HO formed after last
procedure use prophylaxis (NSAID or radiation) after THA
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THA AFTER ACETABULAR FXHeterotopic Bone
HO: Excise, Postop Prophylaxis
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THA AFTER ACETABULAR FX
MINIMIZING COMPLICATIONS
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THA FOR POSTTRAUMATIC HIPMinimizing Complications
Reducing Complications:• Careful preoperative
assessment:
- bone loss
- fracture nonunion
- r/o infection• Know what you are up
against
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THA FOR POSTTRAUMATIC HIP Minimizing Complications
Reducing Complications:• Anticipate more blood loss (cell
saver)• Longer operative time• Exposure difficulties (choose
based on preference/HO/hardware)
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THA AFTER ACETABULAR FXReducing Complications
Anticipate Special Needs (Intra/Postop):• Pelvic reconstruction plates• Autogenous bone grafting• Metal cutting instruments• HO prophylaxis
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THA AFTER ACETABULAR FX Conclusions
• Good planning, careful execution
• Modern technology
• Usually excellent results despite technical challenges
• The patients like these operations--they have a previous failure and you fix it