Management strategies for pelvic discontinuity

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Pelvic discontinuity (PD), also called pelvic disassociation or acetabular disassociation, is an uncommon condition most frequently encountered during revision total hip arthroplasty (rTHA). The management of pelvic discontinuity involves acetabular reconstruction to restore the center of rotation and acetabular integrity. Depending on the degree of bone loss, this can be demanding and challenging even for experienced revision arthroplasty surgeons. In this article, Theofilos Karachalios, Chairman of the Orthopaedic Department, University General Hospital of Larissa at the University of Thessaly, Larissa, Greece, will share with us some of the most important aspects in treating PDs.

Theofilos Karachalios

University General Hospital of Larissa at the University of Thessaly, Larissa, Greece

Pelvic discontinuity

Pelvic discontinuity is the loss of structural continuity between the superior and the inferior part of the pelvis. It progresses through the anterior and posterior columns of the acetabulum so that the superior aspect of the pelvis is completely dissociated from the inferior structures [1–4]. It can be acute or chronic, with chronic PD being much more common [1, 4]. Acute PD is usually caused by trauma such as a fresh periprosthetic fracture arising during the impaction of an uncemented acetabular component or during the removal of an acetabular component in rTHA. An acute PD is more likely to have minimum gapping between the superior and inferior pelvis, thus bone apposition may be less problematic [1, 5]. Chronic PD involves progressively increasing bone loss around loose acetabular components and may involve a large amount of fibrous tissue between the superior and inferior hemipelves, with the bone itself being sclerotic and nonvascularized. Due to the difference in biology and mechanics, the healing potentials are different between the two types of PD [1–4]. Although PD is relatively uncommon, its incidence has been projected to increase due to the increasing number of primary and rTHAs [6].

Classification

Acetabular deficiencies are commonly classified according to either the American Academy of Orthopaedic Surgeons (AAOS) classification scheme or the Paprosky system (See Part 1 of this series for more details). According to the AAOS classification, PDs are type IV deficiencies [7]. Berry et al [2] further divided the type IV deficiencies into type IVa (PD with cavitary bone loss), type IVb (PD with segmental bone loss), and type IVc (PD in previously irradiated pelvis with or without bone defects). In the commonly used Paprosky Classification, PD is often associated with type IIIB defects but can also be seen in type IIC and IIIA bone defects [8].

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  • Pelvic discontinuity
  • Classification
  • Diagnosis
  • Did you know?
  • Preoperative assessment
  • Intraoperative assessment
  • Postoperative assessment
  • Acute pelvic discontinuity
  • Chronic pelvic discontinuity
  • Cages and rings with graft
  • Internal fixation with acetabular reconstruction
  • Acetabular distraction with cementless acetabular cup
  • Tantalum cementless acetabular cups with augments
  • Cup and cage construct
  • Triflange and custom-made acetabular implants
  • Asking the expert
  • Conclusion

Part 1 | Acetabular bone defects: classification and diagnosis

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Part 2 | Managing bone defects using large acetabular cups and highly porous augments

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AO Recon resources

Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Theofilos Karachalios

University General Hospital of Larissa at the University of Thessaly, Larissa, Greece

Thomas Kostakos

Henry Dunant Medical Center, Athens, Greece

George A Macheras

Henry Dunant Medical Center, Athens, Greece

The authors thank Maio Chen, medical writer at AO Innovation Translation Center, Switzerland, for contributing to the writing and editing of the articles.

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