Surgical techniques—acute total hip arthroplasty in nonreconstructible geriatric acetabular fractures

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Acute total hip arthroplasty (THA) after acetabular fracture has become a more common procedure, particularly in the elderly, prompted by the need to overcome poor outcomes seen after open reduction and internal fixation in elderly patients [1, 2]. In this article, Ashok S Gavaskar from Rela Institute and Medical Centre, Chennai, India, discusses reasons for choosing THA in the acute setting, takes a look at risk factors and complications, and presents the surgical approaches and techniques for performing THA in this setting.

Ashok S Gavaskar

Orthopedic Trauma and Arthroplasty Services, Rela Institute and Medical Centre, Chennai, India

Why should you consider primary total hip arthroplasty?

Conventional surgical treatment for acetabular fractures in the form of open reduction and internal fixation (ORIF) can be associated with inferior clinical outcomes in the elderly population [1]. Age has been shown to be an independent risk factor for failure after ORIF of acetabular fractures [3]. Fracture patterns that do not allow anatomical reduction and fractures with major chondral damage, such as the ones with superior dome impaction and severe marginal impactions, are considered a high risk for failure after ORIF. Indeed, the reported failure rates after ORIF in the elderly population are as high as 64% with the need for conversion to hip arthroplasty occurring within 3 years [2].

With such poor short-term clinical outcomes after ORIF in this population, it is quite understandable that the indications for and practice of THA alone or with ORIF (combined hip procedure) as a primary treatment for acetabular fractures have seen a rapid increase over the last decade. A successful primary THA in the acute setting has the advantages of early mobilization and a reduced need for further surgical procedures. However, THA in the setting of an acute acetabular fracture is a complex procedure with higher levels of morbidity and complications than THA for arthritis or fractures of the femoral neck. The reported results on outcomes and complications have been variable in the recent literature [4, 5].

When to perform a primary total hip arthroplasty? Best indications considering risks and complications.

With anatomical reduction being possible only in about 50% of geriatric acetabular fractures [6], it is very important to consider THA with supplemental ORIF in a wide variety of injury patterns. Apart from poor acetabular injury characteristics, such as chondral impaction, comminution, and associated fractures in the femoral neck or head (Figure 1), important patient characteristics like osteoporosis, age, gender, and associated medical comorbidities should also be considered when choosing THA with ORIF or ORIF alone. Given that some of the more recent literature has reported a higher incidence of medical and surgical complications with acute THA and supplemental ORIF [7, 8], it is important to carefully weigh risks against benefits of this technically complex procedure. If THA can be performed through the same surgical approach used for ORIF, or by extending it, then it is less likely to be riskier than ORIF alone. ORIF of both columns through separate surgical approaches combined with THA in a single setting can be associated with increased morbidity but, if needed, can be staged to minimize risks.

Figure 1. This case is of an osteoporotic multifragmentary posterior wall fracture in a 74-year-old woman with associated fractures in the femoral neck and the trochanteric region (a) and (b). She underwent a combined open reduction and internal fixation (ORIF) and total hip arthroplasty using a dual mobility articulation and a distal loading stem (c), along with reconstruction of the abductor attachment allowing immediate out-of-bed mobilization (d). Follow-up x-ray at 4 years shows healed fractures and stable hip components (e). (Images courtesy of Ashok S Gavaskar, Chennai, India.)

Which surgical approach?

The choice of surgical approach for THA depends on the fracture pattern and the intended method of internal fixation. The posterior approach is the most used approach reported in the literature and is preferred for many reasons: 

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Access full article here
  • Why a primary total hip arthroplasty
  • When to perform a primary total hip arthroplasty
  • Which surgical approach
  • Technical considerations
  • Clinical outcomes after acute THA
  • Conclusion

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Part 1 | Types of acetabular fractures and their indications

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Part 3 | Delayed total hip arthroplasty


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Contributing experts

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

Ashok S Gavaskar

Orthopedic Trauma and Arthroplasty Services, Rela Institute and Medical Centre, Chennai, India

Rodrigo Pesantez

Universidad de los Andes Medical School and Colegio Mayor de Nuestra Señora del Rosario, Bogotá, Colombia

Ramesh K Sen

Institute of Orthopedic Surgery,
Max Hospital, Mohali, India

This article was edited by Lyndsey Kostadinov, AO Innovation Translation Center, Clinical Science, Switzerland.

References

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