Transcript THA in failed acetabular fractures

THA in failed acetabular
fractures
Dr Ali Yeganeh
Associat professor of Iran university of medical sciences
Acetabular FX treatment
 ORIF is mainstay
 ORIF in communited FX(head &acetabulom fx in young)
 ORIF in elderly
THA after acetabulom non surgical
treatment
 After initial nonsurgical treatment of an acetabular fracture,
an occult or frank acetabular nonunion and malunion are not
uncommon and may extend to the residual pelvic ring
Indications THA in failed
acetabular FX
 DJD
 AVN
 chondrolysis
 Malunion
 Head resorption (infection?)
 Instability ??
Preop planning
 Radiography (AP, oblique
views)
Preop planning
 CT scan (3D, axial, sagital,
coronal)
medial wall defects
Ant. Or Post. Colomn
defects
Preop planning
 Infection R/O
x ray
bone scan
ESR/CRP
hip aspiration
Preop planning
 Abductor function
EMG/NCV
PH exam
Approuches
 Previous approuch
 Bone defects
 Condition of soft tissue
 Surgeon experience
Approaches
 Fibrotic tissue in the field
 Make exposure difficult
 Soft tissue mobilization difficult
 More bleeding
 Ischemic necrosis of muscles because of forceful retraction
Approaches
 Trochanteric osteotomy?
 Sciatic n. exploration?
not routinely
Hard ware removal
 If interferes with implantation
of components (cup, stem)
 More damage to soft tissues
 Infection?
 Corrosion wear???
Equipments
 Cemented and cementless
 Reinforcement rings and cages
 Mesh
Allograft (structural, chips)
Post op.
 Abduction pillow
 Abduction brace
 Restricted weight bearing
sciatic nerve palsy
whether induced traumatically or iatrogenically, accompanies
the initial acetabular injury, the palsy is likely to be exacerbated
during a subsequent THA In the majority of cases, staying well
away from the sciatic nerve is the best option. When the sciatic
nerve is at especially high risk during surgery, intra-operative
electromyography(EMG) monitoring may be considered
Infection
 infection should always be ruled out before proceeding with
THR
 ESR /CRP/ clinic
 Aspiration
 Culture for aerobic & anaerobic
 If + 2 stage surgery…. all devices should be removed
 And debreded cartilag and replaced with AB cement
bone deficiency
 Ant &post wall deficiency
When the anterior or posterior walls are absent, the use
of autograft bone fixed with a plate or screws.
 Bulk graft autograft bone from the femoral
head is mainly used in cases of protrusio or when columnar
defects are present. Posterior plating should be reserved for
cases of pelvic discontinuity and/or if the graft requires
supplemental Fixation
 Necrosis or Nonunion
same that revision surgery
pitfall
 In addition, the superior aspect of
the dome may also be sufficiently deformed as to
predispose the surgeon to place the acetabular component
in a more abducted position. In these circumstances an
intra-operative x-ray may help in determining appropriate
position
instablity
 Because of impingment
 Larger head
 Dual mobility
HTO
 Should be removed?
 shielded prophylactic radiation
therapy within 12 hours pre-operatively or 72 hours
postoperatively.
16 A single dose of 800 cGy is the usual dose. In
extremely high-risk patients, the authors prefer the addition
of a non-steroidal anti-inflammatory drug (NSAID),
for additional protection
THA results
 Total hip arthroplasty (THA) outcomes for posttraumatic
arthritis after acetabular fracture have yielded inferior results
compared to primary nontraumatic THA
FRACTURES ABOUT THE HIP
Acetabular fractures
THE ROLE OF TOTAL HIP REPLACEMENT

From Mayo Clinic,
©2013 The British Editorial
Total hip replacement (THR) after acetabular fracture presents unique
challenges. Technical challenges however include infection, residual
pelvic deformity, acetabular bone loss with ununited fractures,
osteonecrosis of bone fragments, retained metalwork, heterotopic
ossification, dealing with the sciatic nerve, and the difficulties of
obtaining long-term acetabular component fixation. Indications for
an acute THR include young patients with both femoral head and
acetabular involvement with severe comminution that cannot be
reconstructed, and the elderly, with severe bony comminution. The
outcomes of THR for established post-traumatic arthritis include
excellent pain relief and functional improvements. The use of modern
implants and alternative bearing surfaces should improve outcomes
further.
thanks