THA TO SALVAGE FAILED ACETABULAR FRACTURES

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Presentation transcript:

THA TO SALVAGE FAILED ACETABULAR FRACTURES Daniel J. Berry, MD Mayo Clinic Rochester, MN

THA AFTER ACETABULAR FX Technical Challenges Acetabular bone loss Residual pelvic deformity Nonunited fractures Retained hardware Heterotopic ossification Socket fixation

ACETABULAR COMPONENT CHOICE THA FOR ACETABULAR FX ACETABULAR COMPONENT CHOICE

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

SURVIVAL FREE REVISION FOR ASEPTIC ACET LOOSE/RADIOGRAPHIC LOOSENING Cemented vs Uncemented

THA AFTER ACETABULAR FX Acetabular Bone Loss Socket Fixation: Apply principles of revision THA (similar sclerotic, deficient bone) Consensus in North America: Uncemented hemispherical cup

THA AFTER ACETABULAR FX Long-Term Socket Fixation: Uncemented Cups Uncemented Cups: 5 Yr, Data, Rush: 1/30 (4%) revised for loosening JBJS(A), 2001

THA AFTER ACETABULAR FX Long-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

THA AFTER ACETABULAR FX MANAGEMENT OF BONE LOSS

THA AFTER ACETABULAR FX Acetabular Bone Loss Cavitary Bone Loss: Particulate Graft

THA AFTER ACETABULAR FX Acetabular Bone Loss Segmental Loss: The Posterior/Superior Wall Use autogenous femoral head graft if needed

THA AFTER ACETABULAR FX Acetabular Bone Loss Results: Reliable bone graft healing and incorporation

THA AFTER ACETABULAR FX PELVIC DEFORMITY

THA AFTER ACETABULAR FX Pelvic Deformity Landmarks distorted - care with cup position Bony prominence - beware of bone impingement causing instability

THA AFTER ACETABULAR FX NONUNITED FRACTURES

THA AFTER ACETABULAR FX Nonunited Fractures Typically nonunited transverse acetabular fx (pelvic discontinuity) Stabilize with post column plate

THA AFTER ACETABULAR FX Nonunited Fractures Results: High rate of fracture healing (100% in personal experience)

THA AFTER ACETABULAR FX Nonunited Fractures Plate Pelvic Discontinuity

THA AFTER ACETABULAR FX RETAINED HARDWARE

THA AFTER ACETABULAR FX Retained Hardware Leave in place if not problematic Selective removal when needed Beware of the sciatic nerve

THA AFTER ACETABULAR FX Retained Hardware Selective Hardware Removal

THA AFTER ACETABULAR FX Retained Hardware Selective Hardware Removal

THA AFTER ACETABULAR FX Retained Hardware Sciatic Nerve: Avoid if possible If working posteriorly: Identify (beneath g. max. tendon), handle carefully Do case with knee flexed

THA AFTER ACETABULAR FX HETEROTOPIC BONE

THA AFTER ACETABULAR FX Heterotopic Bone Heterotopic Ossification: Excise HO if symptomatic If HO formed after last procedure use prophylaxis (NSAID or radiation) after THA

THA AFTER ACETABULAR FX Heterotopic Bone HO: Excise, Postop Prophylaxis

THA AFTER ACETABULAR FX MINIMIZING COMPLICATIONS

THA FOR POSTTRAUMATIC HIP Minimizing Complications Reducing Complications: Careful preoperative assessment: - bone loss - fracture nonunion - r/o infection Know what you are up against

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)

THA AFTER ACETABULAR FX Reducing Complications Anticipate Special Needs (Intra/Postop): Pelvic reconstruction plates Autogenous bone grafting Metal cutting instruments HO prophylaxis

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