JBJS | Acute Total Hip Arthroplasty for Selected Displaced Acetabular Fractures : Two to Twelve-Year Results

The Journal of Bone & Joint Surgery, Volume 84, Issue 1

Scientific Article | January 01, 2002

Acute Total Hip Arthroplasty for Selected Displaced Acetabular Fractures : Two to Twelve-Year Results

Dana C. Mears, MD, PhD; John H. Velyvis, MD

Investigation performed at the Division of Orthopaedic Surgery, Albany Medical Center, Albany, New York

Dana C. Mears, MD, PhD
Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224-2780. E-mail address: mearshouse@prodigy.net

John H. Velyvis, MD
Division of Orthopaedic Surgery, Albany Medical Center, 47 New Scotland Avenue, Albany, NY 12208-3479. E-mail address: jhv1@hotmail.com

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 2002; 84:1-9

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Abstract

Background: We assessed the role of acute total hip arthroplasty in a selected group of patients with a displaced acetabular fracture and complicating features that greatly diminished the likelihood of a favorable outcome after open reduction and internal fixation.

Methods: Between 1985 and 1997, fifty-seven patients underwent an acute total hip arthroplasty for a displaced acetabular fracture. Patients were followed for a mean of 8.1 years (range, two to twelve years). The mean time from the injury to the arthroplasty was six days (range, one to twenty days). The mean age of the patients at the time of the arthroplasty was sixty-nine years (range, twenty-six to eighty-nine years). Indications for the acute arthroplasty included intra-articular comminution as well as full-thickness abrasive loss of the articular cartilage, impaction of the femoral head, and impaction of the acetabulum that involved >40% of the joint surface and included the weight-bearing region.

Results: At the time of the latest follow-up, the mean Harris hip score was 89 points (range, 69 to 100 points); forty-five patients (79%) had an excellent or good outcome. There were six cases of heterotopic bone formation, including one of symptomatic grade-IV ossification. During the initial six postoperative weeks, the acetabular cups subsided an average of 3 mm medially and 2 mm vertically. All of the cups then stabilized, and none were loose at the latest follow-up evaluation. Six patients had excessive medialization of the cup, but none had late loosening or osteolysis. Nine cups (16%) had notable polyethylene wear, but none were revised. No cup or stem had late clinical or radiographic evidence of loosening. There were three late procedures: one for revision of a malaligned cup because of recurrent dislocations, one for removal of hardware from the greater trochanter, and one for excision of heterotopic bone.

Conclusions: In selected patients with a displaced acetabular fracture that has a low likelihood of a favorable outcome after fracture treatment, an acute total hip arthroplasty may provide an alternative means with which to achieve a painless, mobile hip. These complex procedures are best undertaken by a surgical team with substantial experience with both acetabular trauma and hip arthroplasty.

Figures in this Article

Introduction

Introduction | Materials and Methods | ResultsClinical Results | Discussion | References

While the preferred treatment of most displaced acetabular fractures is open reduction and internal fixation, the prognosis is poor for certain injury patterns, notably in patients with osteopenic bone. There have been anecdotal reports of treatment of these exceptional cases with an acute total hip arthroplasty^1-4. The purpose of the present study was to evaluate the clinical and radiographic results at a minimum of two years after acute total hip arthroplasties for the treatment of selected acute displaced acetabular fractures. Features of these fractures included intra-articular comminution as well as full-thickness abrasive loss of articular cartilage, femoral head impaction, and acetabular impaction that involved >40% of the joint surface and included the weight-bearing region.

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Fig. 1-A:: Figs. 1-A, 1-B, and 1-C An alcoholic man sustained a left peritrochanteric hip fracture that healed uneventfully after internal fixation. Two years later, at the age of sixty years, the patient sustained, in another fall, a left both-column fracture with marked comminution of the anterior column and impaction of the femoral head. An acute total hip arthroplasty with cable fixation of the acetabulum was performed. Fig. 1-A Preoperative anteroposterior radiograph showing the left both-column fracture with the impacted femoral head.

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Fig. 1-B:: Figs. 1-A, 1-B, and 1-C An alcoholic man sustained a left peritrochanteric hip fracture that healed uneventfully after internal fixation. Two years later, at the age of sixty years, the patient sustained, in another fall, a left both-column fracture with marked comminution of the anterior column and impaction of the femoral head. An acute total hip arthroplasty with cable fixation of the acetabulum was performed. Fig. 1-B Preoperative posterior view of a three-dimensional computed tomographic scan showing the impacted femoral head and the comminuted anterior and posterior columns of the left hip.

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Fig. 1-C:: Postoperative obturator oblique radiograph showing residual protrusion of the cup. The dome screw was inserted medial to the ilium, a technical shortcoming.

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Fig. 2-A:: Figs. 2-A, 2-B, and 2-C A twenty-six-year-old woman sustained a left both-column fracture with marked impaction of the femoral head and a dislocation of the ipsilateral sacroiliac joint in a motor-vehicle accident. An acute total hip arthroplasty was performed after plate fixation of the ilium and insertion of two sacroiliac joint screws. Two years later, the greater trochanteric fixation was removed because of local discomfort. The patient had a Harris hip score of 100 points at the twelve-year follow-up evaluation. Fig. 2-A Preoperative anteroposterior radiograph showing the left both-column fracture with femoral head impaction.

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Fig. 2-B:: Fig. 2-B Immediate postoperative anteroposterior radiograph showing internal fixation of the both-column fracture and the total hip replacement with morselized femoral head autograft at the medial wall of the cup.

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Fig. 2-C:: Fig. 2-C Iliac oblique radiograph, made eight years after the procedure, showing continuous osseous contact around the entire cup. There is an area of localized femoral osteolysis at the proximal aspect of the stem. This was the only patient in the series with notable femoral osteolysis.

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TABLE I: Acetabular Fracture Types and Associated Complicating Features*

*Comprehensive Classification of Fractures^8,9. †Involving >40% of the surface area and the weight-bearing area.

Fract. Type⁶	Fract. Class*	No. of Fract.	Intra-Artic.Comminut. (10 Fragments)	Impaction†		Fem. Head Abrasive Wear†	Fem. Fract.		Degen. Joint Dis.	Osteo- porosis	Osteo- malacia
Acetab.	Fem. Head	Neck	Head
Simple		25
Post. wall	A1	11	?7	?8	?2		1	1		10
Post. column	A2	?3	?1	?2	?1					?2
Ant. wall	A3.1	?0
Ant. column	A3.2, A3.3	?1	?1				1			?1
Transverse	B1	10		?3	?7				1
Associated		32
Post. column-post. wall	A2.3	?6	?4	?3	?3					?2
Transverse-post. wall	B1.3d3	?4	?2	?2	?1	1
T-type	B2	?3		?2	?1
Ant. column-post. hemitransverse	B3	?6	?3	?2	?1	2	2			?5	1
Both column	C1, C2	?4	?4	?3	?1		1			?4
Comminut. ant. column	A3.3a3	?9	?9	?2	?1	3		2	1	?9
Total		57	31	27	18	6	5	3	2	33	1

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TABLE I: Acetabular Fracture Types and Associated Complicating Features*

*Comprehensive Classification of Fractures^8,9. †Involving >40% of the surface area and the weight-bearing area.

Fract. Type⁶	Fract. Class*	No. of Fract.	Intra-Artic.Comminut. (10 Fragments)	Impaction†		Fem. Head Abrasive Wear†	Fem. Fract.		Degen. Joint Dis.	Osteo- porosis	Osteo- malacia
Acetab.	Fem. Head	Neck	Head
Simple		25
Post. wall	A1	11	?7	?8	?2		1	1		10
Post. column	A2	?3	?1	?2	?1					?2
Ant. wall	A3.1	?0
Ant. column	A3.2, A3.3	?1	?1				1			?1
Transverse	B1	10		?3	?7				1
Associated		32
Post. column-post. wall	A2.3	?6	?4	?3	?3					?2
Transverse-post. wall	B1.3d3	?4	?2	?2	?1	1
T-type	B2	?3		?2	?1
Ant. column-post. hemitransverse	B3	?6	?3	?2	?1	2	2			?5	1
Both column	C1, C2	?4	?4	?3	?1		1			?4
Comminut. ant. column	A3.3a3	?9	?9	?2	?1	3		2	1	?9
Total		57	31	27	18	6	5	3	2	33	1

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TABLE II: Results of Late Clinical Assessments of Fifty-seven Patients

	No. (%)
Pain
None	40 (70)
Slight, intermittent	?9 (16)
Occasional, with walking	?6 (11)
Moderate, altered activity	?2 (4)
Severe, disabling	?0
Walking
Normal	22 (39)
Slight limp, no walking aid	17 (30)
Walking aid, unlimited distance	13 (23)
Walking aid, limited distance	?5 (9)
Activity
Strenuous labor	?2 (4)
Moderate labor	?5 (9)
Light labor	11 (19)
Semi-sedentary	21 (37)
Sedentary	18 (32)
Patient satisfaction
Extremely satisfied	46 (81)
Satisfied	11 (19)
Unsatisfied	?0
Harris hip score
Excellent	33 (58)
Good	12 (21)
Fair	?9 (16)
Poor	?3 (5)

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TABLE II: Results of Late Clinical Assessments of Fifty-seven Patients

	No. (%)
Pain
None	40 (70)
Slight, intermittent	?9 (16)
Occasional, with walking	?6 (11)
Moderate, altered activity	?2 (4)
Severe, disabling	?0
Walking
Normal	22 (39)
Slight limp, no walking aid	17 (30)
Walking aid, unlimited distance	13 (23)
Walking aid, limited distance	?5 (9)
Activity
Strenuous labor	?2 (4)
Moderate labor	?5 (9)
Light labor	11 (19)
Semi-sedentary	21 (37)
Sedentary	18 (32)
Patient satisfaction
Extremely satisfied	46 (81)
Satisfied	11 (19)
Unsatisfied	?0
Harris hip score
Excellent	33 (58)
Good	12 (21)
Fair	?9 (16)
Poor	?3 (5)

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TABLE III: Acetabular Fracture Types and Patient Outcomes by Patient Age in Decades*

*The numbers in the table indicate the number of fractures except for those in the last row, which indicate the number of points.

Fract. Type	Total	20-29 yr	30-39 yr	40-49 yr	50-59 yr	60-69 yr	70-79 yr	80-89 yr
Simple	25
Post. wall	11	??1		1	1	?2	?5	1
Post. column	?3				1	?2
Ant. wall	?0
Ant. column	?1			1
Transverse	10			1	3	?6
Associated	32
Post. column-post. wall	?6			2	2	?1	?1
Transverse-post. wall	?4		?1	1	2
T-type	?3			1		?2
Ant. column-post. hemitransverse	?6					?2	?3	1
Both column	?4					?1	?1	2
Comminut. ant. column	?9					?1	?4	4
Total	57	??1	?1	7	9	17	14	8
Mean Harris hip score (range)	89 (69-100)	100	93	95 (87-99)	93 (84-98)	91 (83-96)	87 (79-96)	75 (69-84)

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TABLE III: Acetabular Fracture Types and Patient Outcomes by Patient Age in Decades*

*The numbers in the table indicate the number of fractures except for those in the last row, which indicate the number of points.

Fract. Type	Total	20-29 yr	30-39 yr	40-49 yr	50-59 yr	60-69 yr	70-79 yr	80-89 yr
Simple	25
Post. wall	11	??1		1	1	?2	?5	1
Post. column	?3				1	?2
Ant. wall	?0
Ant. column	?1			1
Transverse	10			1	3	?6
Associated	32
Post. column-post. wall	?6			2	2	?1	?1
Transverse-post. wall	?4		?1	1	2
T-type	?3			1		?2
Ant. column-post. hemitransverse	?6					?2	?3	1
Both column	?4					?1	?1	2
Comminut. ant. column	?9					?1	?4	4
Total	57	??1	?1	7	9	17	14	8
Mean Harris hip score (range)	89 (69-100)	100	93	95 (87-99)	93 (84-98)	91 (83-96)	87 (79-96)	75 (69-84)

Materials and Methods

Introduction | Materials and Methods | ResultsClinical Results | Discussion | References

From July 1985 through December 1997, the senior author (D.C.M.) managed sixty-three unilateral displaced acetabular fractures with an acute total hip arthroplasty at the University of Pittsburgh Medical Center (Presbyterian and Shadyside) and Albany Medical Center. This group was a subset of a consecutive series of 789 displaced acetabular fractures treated by the senior author, of which thirty-nine were treated nonoperatively and the remaining 687 were treated with open reduction and internal fixation. Each fracture in the study group was displaced 5 mm. The procedures were undertaken one to twenty days (average, six days) after the injury.

Complete initial data were available for all sixty-three patients, but late follow-up data were unavailable for six. Two of these six patients died of unrelated causes, and the other four were lost to follow-up less than two years after the procedure; none of the six had sustained a postoperative complication as of their latest follow-up evaluation. The remaining fifty-seven patients, who formed the basis of this report, were followed for an average of 8.1 years (range, two to twelve years).

The patient population included thirty men and twenty-seven women. The mean age of the patients at the time of the index arthroplasty was sixty-nine years (range, twenty-six to eighty-nine years). With use of the definitions of Lonner and Koval⁵, the mechanism of injury was characterized as minor trauma in twenty-seven patients (47%) and as major trauma in thirty (53%). Of the thirty patients with major trauma, fourteen (47%) sustained at least one additional injury; these associated injuries included four closed head injuries, two abdominal injuries, three chest injuries, two genitourinary injuries, five other injuries involving an extremity, and two spine injuries.

The initial evaluation included a plain anteroposterior radiograph and two plain 45Â° oblique pelvic radiographs⁶ as well as a computed tomographic scan⁷. The fracture displacement was measured directly on the plain radiographs and averaged 18 mm (range, 5 to 45 mm). The fractures were classified with the method of Judet et al.⁶ as well as with the alpha-numeric coding system of the Comprehensive Classification of Fractures^8,9. Of the fifty-seven fractures, twenty-five (44%) were Judet-type simple fractures and thirty-two (56%) were associated injuries (Table I).

The principal indications for the acute total hip arthroplasty included a comminuted intra-articular fracture with ten or more fragments as well as full-thickness abrasive loss of the articular cartilage of the femoral head, impaction of the femoral head, and impaction of the acetabulum involving >40% of the articular surface, including the weight-bearing area. Additional indications were pre-existing severe degenerative arthritis with a complete loss of articular cartilage and loss of hip joint congruity, a displaced and comminuted fracture of the femoral head, and a completely displaced fracture of the femoral neck. An additional criterion was the degree of osteopenia, as determined by a review of the patient’s history and radiographic findings. All twenty-seven patients who had sustained minor trauma had extensive impaction or comminution of the acetabulum or substantial damage to the femoral head. Thirty-three of the patients, including twenty-one of the twenty-seven patients with minor trauma, had a Singh index¹⁰ that was consistent with marked osteoporosis of the hip.

Operative Technique

On the basis of the specific fracture configuration, a posterolateral approach was used for sixteen patients (28%) with a posterior injury pattern; an anterolateral exposure was used for thirty-eight patients (67%); and an extended lateral approach was used for the three remaining patients (5%), two of whom had a triradiate excision¹¹ and one of whom had an extended iliofemoral incision¹². The triradiate incisions were used, early in the series, for two both-column fractures in which percutaneous fixation of a high anterior column fragment with cannulated screws was undertaken. The extended iliofemoral approach was used for an anterior column fracture that was complicated by an extensive fracture-dislocation of the posterior aspect of the ilium and sacroiliac joint and a completely displaced subcapital fracture of the femoral neck.

Reduction

Displaced column fractures and supratectal transverse patterns were reduced with tenaculum forceps and stabilized with multiple screws that extended through the acetabular component. Infratectal or juxtatectal transverse fractures and comminuted anterior column fractures with displacement of the quadrilateral surface were stabilized with two 2.0-mm braided cables with use of a technique that has been described elsewhere¹³. For the most complex cases (both-column fractures), the superior anterior column fragment that included the anterior superior and anterior inferior spines along with the acetabular roof was reduced with tenaculum forceps and stabilized with a percutaneous lag screw in the anterior inferior spine. The crucial correction of the protruding medial wall was achieved with the cabling technique described previously¹³.

Acetabular Component

For a posterior wall fracture involving >40% of the acetabular surface area, a structural autograft was prepared from the resected femoral head with use of cup arthroplasty reamers (DePuy, Warsaw, Indiana). The autograft was contoured with a curved groove to provide a stable mortise fit into the intact portion of the posterior wall and was anchored with multiple 3.5-mm screws. Morselized femoral head autograft was impacted into residual gaps between the structural graft and the intact portion of the acetabulum. The acetabulum was prepared with acetabular reamers with medialization to the floor of the foveal notch. The acetabular subchondral bone was preserved. A cup was selected that was 2 mm larger than the outside diameter of the final acetabular reamer for an interference fit. The cup was anchored with two, three, or four screws. A Harris-Galante-I or II acetabular cup (Zimmer, Warsaw, Indiana) was used in each patient. Each structural autograft was secured with at least one of the cup-anchoring screws.

Femoral Component

Younger individuals with nonosteopenic bone were treated with an Anatomic or Multilock uncemented stem (Zimmer, Warsaw, Indiana). Initially, elderly patients with osteopenia were treated with a Harris Precoat cemented stem (two patients) or a Harris Design-2 cemented stem (nine patients) (Zimmer), but in the last eight years of the study a collarless, polished, double-tapered (CPT) cemented stem (Zimmer) was employed (twenty-nine patients). When a cemented stem was used, the femoral canal was prepared with the method of Bourne et al.¹⁴.

Postoperative Treatment and Evaluation

Following the procedure, each patient used a touchdown gait with crutches or a walker. Six weeks later, weight-bearing was increased as tolerated, with the patient using a cane beginning at ten weeks. Routine anticoagulation with warfarin or low-molecular-weight heparin was used for three weeks. No prophylaxis against heterotopic bone formation was given.

Postoperatively, all patients were evaluated at six weeks, three months, six months, one year, and yearly thereafter. A standard evaluation form that included a clinical and radiographic assessment was employed¹⁵. The clinical assessment included a Harris hip score¹⁵, a pain assessment, and questions regarding the need for medications, the current level of activity, the need for supplementary walking aids, and patient satisfaction. The Harris hip score was categorized as excellent (90 to 100 points), good (80 to 89 points), fair (70 to 79 points), or poor (£69 points). The clinical results also were categorized according to the ages of the patients, by decade, at the time of the procedure. Six patients had moved, but they were examined clinically and with appropriate radiographs by local orthopaedic surgeons, with the remainder of our evaluation completed by telephone or by letter, and they were included in the study.

The radiographic assessment included documentation of fracture-healing as well as measurement of medial and vertical subsidence and changes in the angular position of the acetabular cup with the quantitative technique of Russotti and Harris¹⁶. Acetabular loosening was defined as migration of >4 mm in any direction or a change in the acetabular abduction angle of more than 4Â°. The presence of heterotopic bone was assessed according to the three-view method described by Moed and Smith¹⁷, which is a modification of the technique originally described by Brooker et al.¹⁸. Early postoperative gaps and late osteolysis of the acetabulum were measured according to the three zones described by DeLee and Charnley¹⁹. Polyethylene wear was documented by assessing the eccentricity of the femoral head on the postoperative radiographs.

The bone around the femoral stems was assessed for resorption and osteolysis in the seven zones described by Gruen et al.²⁰. Loosening of the stems was assessed with the criteria of Harris and McGann²¹, with a radiolucent line of 2 mm in width surrounding 50% to 99% of the stem indicating possible loosening and a similar radiolucent line around 100% of the stem indicating definite loosening. The stems were also evaluated for subsidence; associated calcar rounding; alignment; and, when applicable, cement technique as described by Dowdy et al.²².

ResultsClinical Results

Introduction | Materials and Methods | ResultsClinical Results | Discussion | References

(Table II)

At the time of the latest follow-up, forty-nine patients (86%) had no pain or slight, intermittent pain. Eighteen patients (32%) returned to some degree of work. Forty-five patients (79%) had an excellent or good Harris hip score. The younger patients had the highest scores, and there was a progressive decrease in the scores with advancing age (Table III). Thirty-nine patients (68%) walked normally or with a slight limp and without a support, thirteen (23%) could walk for long distances with a cane, and five (9%) were limited with regard to their walking ability even with support. Four of the five patients who had limited walking ability even with support were more than seventy years of age, and the fifth had sustained a traumatically induced complete lumbosacral plexopathy with a footdrop. Of the eighteen patients who used a cane, nine were more than seventy years of age and had used a cane prior to the surgery. All fifty-seven patients were either extremely satisfied or satisfied with the clinical result.

Radiographic Results

Radiographically, six (11%) of the acetabular fractures were healed at six weeks after surgery and the remaining fifty-one (89%) were healed at twelve weeks; there were no delayed unions or nonunions. There were six cases (11%) of heterotopic bone formation. Two cases (4%) were grade I; three (5%), grade II; and one (2%), grade IV. The grade-IV heterotopic bone was symptomatic and was successfully treated with excision.

Cups

At six weeks postoperatively, the average medial displacement of the cup was 3 mm (range, 1 to 4 mm) and the average vertical displacement was 2 mm (range, 1 to 4 mm). No further displacement was detected on the subsequent radiographs, and no relationship between the magnitude of the displacement and the pattern of the acetabular fracture was identified. There was no radiographic evidence of late loosening of any cup.

Medialization of the cup secondary to residual protrusion or suboptimal reduction of the fracture was present in six hips (11%). Two of these hips had a comminuted anterior column fracture; three, an anterior column-posterior hemitransverse fracture; and one, a both-column fracture. The magnitude of the medialization of the six cups, best measured on the obturator oblique radiograph, ranged from 0.4 to 1.8 cm, with an average of 0.9 cm (Figs. 1-A, 1-B, and 1-C). There was no association between the magnitude of early postoperative displacement and late loosening or osteolysis.

Although no loose or broken screws were detected, one patient with renal osteodystrophy had a radiolucent halo around two of the three acetabular component anchorage screws on the radiographs made at twenty-four weeks. The patient had no symptoms consistent with loosening of the cup. One year after the acetabular fracture, the patient received a cadaveric renal transplant. Subsequent radiographic evaluations at two and five years after the index arthroplasty revealed that the halos had disappeared.

Gaps (lucencies) between the acetabular bed and the acetabular component were documented on the immediate postoperative radiographs of thirty-six (63%) of the fifty-seven hips. All of these gaps were localized to one of the acetabular zones. In thirty-one cases, the gaps resolved within two years (Figs. 2-A, 2-B, and 2-C). Of the twenty-one hips with no gaps after surgery, fifteen had no gaps at the time of the last follow-up evaluation. New but localized lucencies developed in the remaining hips. None of the hips had a continuous lucency in all three zones (indicative of loosening) either immediately after the surgery or at the latest follow-up evaluation.

Localized cavitary acetabular osteolysis was seen on the latest radiographs of twelve hips (21%). There were ten cases of peripheral resorption in zone I, seven in zone II, and four in zone III. No linear osteolytic lesion extended across zones I and II or across zones II and III, and none was associated with late loosening. Polyethylene wear with eccentricity of the femoral head of >2 mm occurred in nine hips (16%). Wear was first detected at three years, although most cases were first identified after five years.

Cementless Stems

Four of the seventeen cementless femoral stems subsided between 1 and 3 mm within the first year after implantation. There was no progression of the subsidence with subsequent follow-up evaluations. Nine of the femora had calcar rounding. Two hips had osteopenia proximally, in zone I and/or zone VII. Two stems were in varus alignment, and the remainder were in neutral. There were seven cases of focal resorption adjacent to the most proximal extent of the ingrowth pads on the stem. At the time of the last evaluation, none of the cementless stems were loose radiographically or clinically (Figs. 2-A, 2-B, and 2-C).

Cemented Stems

On analysis of the radiographs of the forty cemented stems, the cementation columns were characterized as type A in twelve hips, type B in twenty-three, and type C in five; there were no type-D columns. None of the two Harris Precoat or nine Harris Design-2 stems migrated, and all were neutrally aligned. The twenty-nine CPT stems subsided an average of 1.5 mm during the initial six weeks, with no further subsidence subsequently. Two of these stems were in valgus alignment, and the remainder were in neutral. On the basis of the criteria of Harris and McGann²¹, none of the cemented stems were possibly or definitely loose at the latest radiographic evaluation.

Complications

During the initial six weeks after the surgical procedures, there were no deaths, deep wound infections, dislocations, sciatic nerve palsies, or pulmonary emboli. Three cases of symptomatic deep venous thrombosis were managed with short-term heparin and longer-term warfarin therapy. Two patients (4%) had dislocation after the initial six-week postoperative period, and one of them required a revision of the cup at two years because of recurrent dislocations. No more dislocations occurred in that patient. Up to the time of the last follow-up assessment, there were no symptomatic or radiographically loose components and no revision procedures had been done for loosening. One year after the arthroplasty, one patient had localized pain at the site of a trochanteric wire and mesh; the pain was relieved following removal of this hardware. One other patient underwent surgical excision of grade-IV heterotopic bone. There were no late deep wound infections, and no other late surgical procedures were performed.

Discussion

Introduction | Materials and Methods | ResultsClinical Results | Discussion | References

Open reduction and internal fixation is thought to offer the highest likelihood of a favorable functional outcome after most displaced acetabular fractures^12,23-26. Nevertheless, selected displaced acetabular fractures with extensive impaction or erosion of the acetabular or femoral articular surface or with marked comminution and osteopenia have an intrinsically poor prognosis, even when a concentric anatomical reduction of the fracture is achieved. Letournel and Judet¹² documented good to excellent results for only seven of nine anterior wall fractures, seventy-four of 101 transverse-posterior wall fractures, and eight of seventeen posterior wall-posterior column fractures, in marked contrast to eighteen of nineteen transverse fractures, seven of nine anterior column fractures, and ten of eleven posterior column fractures. They attributed the unfavorable outcomes of the anterior wall and posterior wall-posterior column fractures to the higher percentage of elderly osteoporotic patients who sustained these injuries.

In an analysis of outcome by patient age, Letournel and Judet¹² observed the best results in their teenage and young adult patients and the poorest results in patients over the age of fifty, with the results progressively deteriorating with increasing age. A similarly unfavorable effect of aging on clinical outcome was reported by Matta²³.

Structurally compromising osteoporosis is best identified by the presence of a complicated acetabular fracture provoked by minor trauma, such as a simple fall from a standing height; this was observed in twenty-seven patients in our series. Nineteen patients had a history of another fracture provoked by minor trauma, and five of them had had a prior hip fracture. A total of thirty-three patients had a Singh index¹⁰ that was consistent with marked osteoporosis of the hip.

Previous reports on late total hip arthroplasty after initial open or closed treatment of an acetabular fracture have documented results that were considerably less favorable than those after primary total hip arthroplasty for degenerative arthritis^1,27-30. In a study of the results of fifty-five arthroplasties in fifty-three patients, Romness and Lewallen³⁰ found that cemented cups that had been inserted late after an acetabular fracture had a fivefold greater rate of late loosening than cemented implants used to manage degenerative arthritis, as reported by Stauffer³¹. In contrast, the late failure rates for the corresponding stems were similar in the two series. Weber et al.³², in a study of late arthroplasties performed with either a cemented or an uncemented acetabular component after an acetabular fracture, documented more favorable results. Of twenty-two cementless cups, none had been revised or had radiographic evidence of loosening after ten years of follow-up.

A late total hip arthroplasty after an open reduction of an acetabular fracture may be complicated by the presence of heterotopic bone, proliferative scar tissue, obstructive hardware, or occult infection^28,30,32,33. An arthroplasty performed late after nonoperative treatment may be hampered by the presence of a bone defect, nonunion, or malunion. If a particular acute acetabular fracture can be identified as having a poor prognosis irrespective of the initial method of treatment, then the role for a therapeutic alternative such as an acute total hip arthroplasty merits consideration.

Prior reports on the unsuccessful use of primary arthroplasty to treat an acute acetabular fracture have emphasized technical difficulties with reduction and fixation of the acetabular fracture and with effective anchorage of the acetabular component^15,34-36. Our primary objective when performing the reduction was to achieve a stable construct rather than a truly anatomical restoration, a strategy that helped to limit the need for an extensile exposure. The routine availability of the femoral head and neck provided a source of structural or morselized bone graft to fill acetabular defects and to augment the stability of the cup²⁸. Our use of an interference fit with a cup that was oversized by 2 mm compared with the largest reamer appeared to augment the stability of the bone graft and the acetabular fracture fragments. Radiographically, the areas of morselized or structural autograft that surrounded the cups were seen to have incorporated uniformly well. Only minimal cavitary acetabular osteolysis or peripheral resorption was observed on the late follow-up radiographs.

We found it difficult to document the degree of damage to the femoral head or acetabulum with preoperative radiographs and computed tomographic scans. Not infrequently, in a geriatric patient with a posterior wall fracture after minor trauma, the femoral head appeared intact radiographically but nearly 50% of it was found to be impacted at surgery.

A technical concern was excessive medialization of the cup, which was observed in six patients in our series and averaged of 0.9 mm. Such medialization, which was best visualized on the obturator oblique radiograph (Fig. 1-C), indicated an inadequate reduction of central protrusion. Although these patients did not have a worse outcome, an anatomical alignment of the cup is preferred to ensure that a superiorly directed, long retaining screw courses between the inner and outer iliac tables to provide effective anchorage and to ensure that the screw is situated in a "safe" zone well away from the external iliac vessels³⁷.

The functional outcomes for the elderly patients deteriorated with age. The mean Harris hip score was 87 points for the patients in their eighth decade of life and 75 points for the patients in their ninth decade. These scores appeared to be related to a general functional impairment in the elderly. Bourne et al.¹⁴ reported a similar deterioration of hip scores for elderly patients who had undergone a total hip arthroplasty for degenerative arthritis. Nevertheless, acute total hip arthroplasty for the management of selected acetabular fractures appeared to be a successful procedure in elderly patients.

References

Introduction | Materials and Methods | ResultsClinical Results | Discussion | References

Berry DJ. Total hip arthroplasty following acetabular fracture. Orthopedics,1999;22: 837-9. 22837 1999 [PubMed]

Joly JM,Mears DC. The role of total hip arthroplasty in acetabular fracture management. Op Tech Orthop,1993;3: 80-102.. 380 1993

Kannus P, Palvanen M, Niemi S, Parkkari J,Jarvinen M. Epidemiology of osteoporotic pelvic fractures in elderly people in Finland: sharp increase in 1970-1997 and alarming projections for the new millenium. Osteoporos Int,2000;11: 443-8. 11443 2000 [PubMed]

Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg,1999;7: 128-41. 7128 1999 [PubMed]

Lonner JH,Koval KJ. Polytrauma in the elderly. Clin Orthop,1995;318: 136-43. 318136 1995 [PubMed]

Judet R, Judet J,Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am,1964;46: 1615-46, 1675. 461615 1964 [PubMed]

Mears DC, Ward AJ,Wright MS. The radiological assessment of pelvic and acetabular fractures using three-dimensional computed tomography. Int J Orthop Trauma,1992;2: 196-209. 2196 1992

. Fracture and dislocation compendium. Orthopaedic Trauma Association Committee for Coding and Classification. J Orthop Trauma,1996;10 Suppl 1: 1-154. 10 Suppl 11 1996

Muller ME, Allgower M, Schneider R, Willenegger H. Manual of internal fixation: techniques recommended by the AO-ASIF Group. 3rd ed. Berlin: Springer; 1991.

Singh M, Nagrath AR,Maini PS. Changes in trabecular pattern of the upper end of the femur as an index of osteoporosis. J Bone Joint Surg Am,1970;52: 457-67.. 52457 1970 [PubMed]

Mears DC, MacLeod MD. Acetabular fractures: triradiate and modified triradiate approaches. In: Wiss DA, editor. Master techniques in orthopaedic surgery. Fractures. New York: Lippincott-Raven; 1998. p 697-724.

Letournel E, Judet R. Fractures of the acetabulum. 2nd ed. New York: Springer; 1993.

Mears DC,Shirahama M. Stabilization of an acetabular fracture with cables for acute total hip arthroplasty. J Arthroplasty,1998;13: 104-7. 13104 1998 [PubMed]

Bourne RB, Rorabeck CH, Skutek M, Mikkelsen S, Winemaker M,Robertson D. The Harris Design-2 total hip replacement fixed with so-called second-generation cementing techniques. A ten to fifteen-year follow-up. J Bone Joint Surg Am,1998;80: 1775-80. 801775 1998 [PubMed]

Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am,1969;51: 737-55. 51737 1969 [PubMed]

Russotti GM,Harris WH. Proximal placement of the acetabular component in total hip arthroplasty. A long-term follow-up study. J Bone Joint Surg Am,1991;73: 587-92. 73587 1991 [PubMed]

Moed BR,Smith ST. Three-view radiographic assessment of hetero- topic ossification after acetabular fracture surgery. J Orthop Trauma,1996;10: 93-8. 1093 1996 [PubMed]

Brooker AF, Bowerman JW, Robinson RA,Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am,1973;55: 1629-32. 551629 1973 [PubMed]

DeLee JG,Charnley J. Radiological demarcation of cemented sockets in total hip replacement. Clin Orthop,1976;121: 20-32. 12120 1976 [PubMed]

Gruen TA, McNeice GM,Amstutz HC. "Modes of failure" of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop,1979;141: 17-27. 14117 1979 [PubMed]

Harris WH,McGann WA. Loosening of the femoral component after use of the medullary-plug cementing technique. Follow-up note with a minimum five-year follow-up. J Bone Joint Surg Am,1986;68: 1064-6.. 681064 1986 [PubMed]

Dowdy PA, Rorabeck CH,Bourne RB. Uncemented total hip arthroplasty in patients 50 years of age or younger. J Arthroplasty,1997;12: 853-62. 12853 1997 [PubMed]

Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am,1996;78: 1632-45. 781632 1996 [PubMed]

Mears DC, Rubash HE. Pelvic and acetabular fractures. Thorofare, NJ: Slack; 1986. p 429-86.

Rommens PM, Broos PL,Vanderschot P. [Preparation and technique for surgical treatment of 225 acetabulum fractures. 2 year results of 175 cases]. Unfallchirurg,1997;100: 338-48. German100338 1997 [PubMed]

Templeman DC, Olson S, Moed BR, Duwelius R,Matta JM. Surgical treatment of acetabular fractures. Instr Course Lect,1999;48: 481-96. 48481 1999 [PubMed]

Boardman KP,Charnley J. Low-friction arthroplasty after fracture-dislocations of the hip. J Bone Joint Surg Br,1978;60: 495-7. 60495 1978 [PubMed]

Malkin C,Tauber C. Total hip arthroplasty and acetabular bone grafting for unreduced fracture-dislocation of the hip. Clin Orthop,1985;201: 57-9. 20157 1985 [PubMed]

Rogan IM, Weber FA,Solomon L. Total hip replacement following fracture dislocation of the acetabulum. From the Proceedings of the South African Orthopaedic Association. J Bone Joint Surg Br,1979;61: 252. 61252 1979

Romness DW,Lewallen DG. Total hip arthroplasty after fracture of the acetabulum. Long-term results. J Bone Joint Surg Br,1990;72: 761-4. 72761 1990 [PubMed]

Stauffer RN. Ten-year follow-up study of total hip replacement. With particular reference to roentgenographic loosening of the components. J Bone Joint Surg Am,1982;64: 983-90. 64983 1982 [PubMed]

Weber M, Berry DJ,Harmsen S. Total hip arthroplasty after operative treatment of an acetabular fracture. J Bone Joint Surg Am,1998;80: 1295-305. 801295 1998 [PubMed]

Jimenez ML, Tile M,Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am,1997;28: 435-46. 28435 1997 [PubMed]

Coventry MB. The treatment of fracture-dislocation of the hip by total hip arthroplasty. J Bone Joint Surg Am,1974;56: 1128-34. 561128 1974 [PubMed]

Kelly PJ,Lipscomb PR. Primary vitallium-mold arthroplasty for posterior dislocation of the hip with fracture of the femoral head. J Bone Joint Surg Am,1958;40: 675-80. 40675 1958 [PubMed]

Westerborn A. Central dislocation of the femoral head treated with mold arthroplasty. J Bone Joint Surg Am,1954;36: 307-14. 36307 1954 [PubMed]

Wasielewski RC, Cooperstein LA, Kruger MP,Rubash HE. Acetabular anatomy and the transacetabular fixation of screws in total hip arthroplasty. J Bone Joint Surg Am,1990;72: 501-8. 72501 1990 [PubMed]

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Fig. 1-C:: Postoperative obturator oblique radiograph showing residual protrusion of the cup. The dome screw was inserted medial to the ilium, a technical shortcoming.

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TABLE I: Acetabular Fracture Types and Associated Complicating Features*

*Comprehensive Classification of Fractures^8,9. †Involving >40% of the surface area and the weight-bearing area.

Fract. Type⁶	Fract. Class*	No. of Fract.	Intra-Artic.Comminut. (10 Fragments)	Impaction†		Fem. Head Abrasive Wear†	Fem. Fract.		Degen. Joint Dis.	Osteo- porosis	Osteo- malacia
Acetab.	Fem. Head	Neck	Head
Simple		25
Post. wall	A1	11	?7	?8	?2		1	1		10
Post. column	A2	?3	?1	?2	?1					?2
Ant. wall	A3.1	?0
Ant. column	A3.2, A3.3	?1	?1				1			?1
Transverse	B1	10		?3	?7				1
Associated		32
Post. column-post. wall	A2.3	?6	?4	?3	?3					?2
Transverse-post. wall	B1.3d3	?4	?2	?2	?1	1
T-type	B2	?3		?2	?1
Ant. column-post. hemitransverse	B3	?6	?3	?2	?1	2	2			?5	1
Both column	C1, C2	?4	?4	?3	?1		1			?4
Comminut. ant. column	A3.3a3	?9	?9	?2	?1	3		2	1	?9
Total		57	31	27	18	6	5	3	2	33	1

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TABLE I: Acetabular Fracture Types and Associated Complicating Features*

*Comprehensive Classification of Fractures^8,9. †Involving >40% of the surface area and the weight-bearing area.

Fract. Type⁶	Fract. Class*	No. of Fract.	Intra-Artic.Comminut. (10 Fragments)	Impaction†		Fem. Head Abrasive Wear†	Fem. Fract.		Degen. Joint Dis.	Osteo- porosis	Osteo- malacia
Acetab.	Fem. Head	Neck	Head
Simple		25
Post. wall	A1	11	?7	?8	?2		1	1		10
Post. column	A2	?3	?1	?2	?1					?2
Ant. wall	A3.1	?0
Ant. column	A3.2, A3.3	?1	?1				1			?1
Transverse	B1	10		?3	?7				1
Associated		32
Post. column-post. wall	A2.3	?6	?4	?3	?3					?2
Transverse-post. wall	B1.3d3	?4	?2	?2	?1	1
T-type	B2	?3		?2	?1
Ant. column-post. hemitransverse	B3	?6	?3	?2	?1	2	2			?5	1
Both column	C1, C2	?4	?4	?3	?1		1			?4
Comminut. ant. column	A3.3a3	?9	?9	?2	?1	3		2	1	?9
Total		57	31	27	18	6	5	3	2	33	1

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TABLE II: Results of Late Clinical Assessments of Fifty-seven Patients

	No. (%)
Pain
None	40 (70)
Slight, intermittent	?9 (16)
Occasional, with walking	?6 (11)
Moderate, altered activity	?2 (4)
Severe, disabling	?0
Walking
Normal	22 (39)
Slight limp, no walking aid	17 (30)
Walking aid, unlimited distance	13 (23)
Walking aid, limited distance	?5 (9)
Activity
Strenuous labor	?2 (4)
Moderate labor	?5 (9)
Light labor	11 (19)
Semi-sedentary	21 (37)
Sedentary	18 (32)
Patient satisfaction
Extremely satisfied	46 (81)
Satisfied	11 (19)
Unsatisfied	?0
Harris hip score
Excellent	33 (58)
Good	12 (21)
Fair	?9 (16)
Poor	?3 (5)

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TABLE II: Results of Late Clinical Assessments of Fifty-seven Patients

	No. (%)
Pain
None	40 (70)
Slight, intermittent	?9 (16)
Occasional, with walking	?6 (11)
Moderate, altered activity	?2 (4)
Severe, disabling	?0
Walking
Normal	22 (39)
Slight limp, no walking aid	17 (30)
Walking aid, unlimited distance	13 (23)
Walking aid, limited distance	?5 (9)
Activity
Strenuous labor	?2 (4)
Moderate labor	?5 (9)
Light labor	11 (19)
Semi-sedentary	21 (37)
Sedentary	18 (32)
Patient satisfaction
Extremely satisfied	46 (81)
Satisfied	11 (19)
Unsatisfied	?0
Harris hip score
Excellent	33 (58)
Good	12 (21)
Fair	?9 (16)
Poor	?3 (5)

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TABLE III: Acetabular Fracture Types and Patient Outcomes by Patient Age in Decades*

*The numbers in the table indicate the number of fractures except for those in the last row, which indicate the number of points.

Fract. Type	Total	20-29 yr	30-39 yr	40-49 yr	50-59 yr	60-69 yr	70-79 yr	80-89 yr
Simple	25
Post. wall	11	??1		1	1	?2	?5	1
Post. column	?3				1	?2
Ant. wall	?0
Ant. column	?1			1
Transverse	10			1	3	?6
Associated	32
Post. column-post. wall	?6			2	2	?1	?1
Transverse-post. wall	?4		?1	1	2
T-type	?3			1		?2
Ant. column-post. hemitransverse	?6					?2	?3	1
Both column	?4					?1	?1	2
Comminut. ant. column	?9					?1	?4	4
Total	57	??1	?1	7	9	17	14	8
Mean Harris hip score (range)	89 (69-100)	100	93	95 (87-99)	93 (84-98)	91 (83-96)	87 (79-96)	75 (69-84)

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TABLE III: Acetabular Fracture Types and Patient Outcomes by Patient Age in Decades*

*The numbers in the table indicate the number of fractures except for those in the last row, which indicate the number of points.

Fract. Type	Total	20-29 yr	30-39 yr	40-49 yr	50-59 yr	60-69 yr	70-79 yr	80-89 yr
Simple	25
Post. wall	11	??1		1	1	?2	?5	1
Post. column	?3				1	?2
Ant. wall	?0
Ant. column	?1			1
Transverse	10			1	3	?6
Associated	32
Post. column-post. wall	?6			2	2	?1	?1
Transverse-post. wall	?4		?1	1	2
T-type	?3			1		?2
Ant. column-post. hemitransverse	?6					?2	?3	1
Both column	?4					?1	?1	2
Comminut. ant. column	?9					?1	?4	4
Total	57	??1	?1	7	9	17	14	8
Mean Harris hip score (range)	89 (69-100)	100	93	95 (87-99)	93 (84-98)	91 (83-96)	87 (79-96)	75 (69-84)