Beruflich Dokumente
Kultur Dokumente
Instructional
Course
Lectures
THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS*
FRANKLIN H. SIM, Editor, Vol. 50
COMMITTEE
JAMES H. BEATY, Chairman
FRANKLIN H. SIM
S. TERRY CANALE
DONALD C. FERLIC
DAVID L. HELFET
EX OFFICIO
FRANKLIN H. SIM, Editor, Vol. 50
DEMPSEY S. SPRINGFIELD, Deputy Editor of
The Journal of Bone and Joint Surgery
for Instructional Course Lectures
JAMES D. HECKMAN, Editor-in-Chief,
The Journal of Bone and Joint Surgery
*Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other
lectures presented at the Academys Annual Meeting, will be available in March 2001 in Instructional Course
Lectures, Volume 50. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726
(8 A.M.-5 P.M., Central time).
1328
be impeded by dense scar tissue, heterotopic bone, avascularity of the hip muscles or the acetabulum, obstructive hardware, or occult infection6. On the basis of a
review of the few prior studies in the literature7-10, we
found that the overall prognosis for a patient managed
with a total hip arthroplasty after an acetabular fracture
is less favorable than that for one managed with an arthroplasty performed because of primary degenerative
arthritis. In the present study, we address the principal
concerns regarding management with total hip arthroplasty after initial treatment of an acetabular fracture
with closed or open reduction.
In view of the principal shortcoming of acute management with total hip arthroplasty following an acetabular fracture namely, the vulnerability to premature
failure and the subsequent need for one or more surgical revisions the potential therapeutic alternatives
merit serious consideration. For example, young male laborers or other young, exceptionally active individuals
are highly susceptible to premature failure of an arthroplasty11. In such patients, one therapeutic alternative is
arthrodesis of the hip, which is mainly indicated if there
is relative preservation of the osseous architecture of the
hip joint. The other criteria for an arthrodesis namely,
a normal contralateral hip, normal knees, and an asymptomatic lower back also must be met12. Currently,
most individuals in North America are reluctant to consider arthrodesis. When a patient has avascular necrosis
of the femoral head, loss of acetabular bone stock,
marked osteoporosis, or a persistent acetabular nonunion that impairs the mechanical stability of a hip fusion and hampers the healing of the bone, the likelihood
of achieving a solid fusion is considerably compromised.
In such complex cases, the main practical alternative is a
resection arthroplasty, with or without the use of a cement spacer13.
Certain other symptomatic acetabular fractures may
be associated with secondary problems that can be addressed by reconstruction of the hip, thus preserving the
hip as a functional joint. Examples of the problems include heterotopic bone leading to hip stiffness; sympTHE JOURNAL OF BONE AND JOINT SURGERY
1329
TABLE I
CLASSIFICATION OF ACETABULAR DEFICIENCIES IN
TOTAL HIP ARTHROPLASTY ACCORDING TO THE SYSTEM
21
OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS
Type
Deficiency
I
IA
IB
II
IIA
IIB
III
Segmental deficiencies
Peripheral
Central (medial wall absent)
Cavitary deficiencies
Peripheral
Central (medial wall intact)
Combined deficiencies
IV
V
Pelvic discontinuity
Arthrodesis
1330
TABLE II
CLASSIFICATION OF ACETABULAR DEFICIENCIES
IN TOTAL HIP ARTHROPLASTY ACCORDING
22
TO THE SYSTEM OF GROSS ET AL.
Type
I
Deficiency
Contained cavitary defect (protrusio)
II
IIA
IIB
FIG. 1-A
Figs. 1-A, 1-B, and 1-C: The structural importance of acetabular defects is related to their size, location, and characterization as a cavitary or segmental lesion.
Fig. 1-A: Oblique three-dimensional computed tomographic scan,
made one year after a fracture-dislocation of the posterior wall, showing a large segmental defect of the posterior wall secondary to failed
fixation.
FIG. 1-B
Anteroposterior radiograph of a hip, made two years after a transtectal transverse fracture that was treated nonoperatively, showing a
central segmental defect of moderate size with a principal axis of
more than ten millimeters but less than twenty-five millimeters.
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1331
FIG. 1-C
Anteroposterior radiograph of a pelvis, made two years after a transtectal T-type fracture that was treated nonoperatively, showing progression to a large central segmental defect with a principal axis of approximately fifty millimeters.
1332
FIG. 2-A
Figs. 2-A and 2-B: A forty-eight-year-old man sustained a T-type
acetabular fracture, which was managed with limited internal fixation. Subsequent symptomatic posttraumatic arthritis was complicated by an excessively large superocentral acetabular defect and
necrotic bone in the roof. Three years after the injury, as part of a total hip arthroplasty, the necrotic bone was removed and a structural
autograft from the femoral head was used to obliterate the acetabular
defect.
Fig. 2-A: Anteroposterior radiograph of the right hip, made three
years after the injury, showing the large acetabular defect.
FIG. 2-B
Anteroposterior radiograph made after the total hip arthroplasty,
showing the large defect obliterated by a jumbo cup.
1333
TABLE III
FOR SURGICAL STRATEGIES TO ADDRESS PELVIC AND
ACETABULAR DEFORMITIES AS PART OF A TOTAL HIP ARTHROPLASTY
GUIDELINES
Type of Defect
Intrinsic acetabular defects
Small superior acetabular defect
Large superior acetabular defect
Medial acetabular defect
Posterior acetabular defect
Associated deformities of pelvic ring
Iliac defect, nonunion, malalignment
External rotational deformity of ipsilateral
or contralateral sacroiliac joint
Unstable, windswept pelvis
Vertical defect
Ipsilateral
Contralateral
Treatment
Morselized impaction grafting if contained defect, supplementary
mesh if uncontained defect, cementless cup
Structural or morselized grafting, cementless cup, jumbo cup,
bilobed cup, protrusio cage
Central mesh, morselized impaction grafting, cage
Structural or morselized grafting, posterior plate, mesh, standard
cup, cage
Open reduction and internal fixation of ilium, standard cup
Open reduction and internal fixation of sacroiliac joint, standard
cup
Open reduction and internal fixation of both sacroiliac joints,
standard cup
Reduction of hemipelvis, long-stemmed component
Reduction of hemipelvis, standard cup
1334
FIG. 3-A
FIG. 3-B
Figs. 3-A through 3-D: Illustrations showing the surgical approaches commonly used in total hip arthroplasty for late reconstruction of acetabula with various defects and accompanying deformities.
Fig. 3-A: The modified Hardinge (anterolateral) incision is useful for hips with posttraumatic arthritis, cavitary lesions, or most limited segmental defects, including ones that involve the posterior wall. Our preferred modification of the approach includes an orientation of 30 degrees
from the long axis of the limb so that more direct visualization of the acetabulum is achieved with a shorter incision.
Fig. 3-B: The Kocher-Langenbeck incision is useful for fractures involving the posterior wall and column.
FIG. 3-C
FIG. 3-D
Fig. 3-C: The modified triradiate incision, with preservation of the greater trochanter, is an extensile approach that is useful for complete visualization of both the anterior and posterior columns and the hip joint. The incision is appropriate for exposure of a large central defect, a displaced ipsilateral sacroiliac joint, or a hip with grade-IV heterotopic bone that completely surrounds the hip joint.
Fig. 3-D: The limited extended iliofemoral incision is an extensile approach that is useful for visualization of the entire hemipelvis and allows
for a corrective pelvic osteotomy. The approach is modified by extending the incision to the posterior inferior iliac spine and by preserving the
insertions of the gluteal muscles and piriformis tendons on the greater trochanter.
DEVICES
TO
MANAGE
TABLE IV
LARGE DEFECT AND INDICATIONS
Device
Mesh
Bilobed cup
FOR
THEIR USE
Indication
Superior or middle central defect or superior posterior wall defect
(remaining acetabulum must be intact)
Superior wall and dome defect
Mller ring
Ganz ring with hook in
obturator foramen
Burch-Schneider cage
1335
timal diameter. Any persistent small defect at the junction between the graft and the residual acetabulum is
filled with morselized cancellous bone. Then, a metal
backing for a cementless cup in an appropriate size is
impacted into the acetabular recess and is anchored
with two or three cancellous screws.
Large Uncontained Defects
Large uncontained defects present a principal structural problem in the posterior, superior, or central aspect
of the acetabulum. Some reconstructive recommendations are described for each type of defect.
When a patient has a large defect in the posterior
part of the acetabulum that involves the wall and the adjacent column, perhaps the most formidable mechanical
challenge is the transfer of the patient from the bed to
a chair. Thus, a highly stable configuration of the reconstruction is essential. Historically, the most popular
form of reconstruction has been the application of a
posterior plate with the use of a structural autograft
(Figs. 5, 8-A, 8-B, and 8-C). Alternative potential solutions include the use of a cage or a mesh, which is anchored around the rim of the defect with screws. Then,
impaction grafting of the defect is performed with autologous bone in order to create a suitable bed for the cup.
Another option is the fabrication of a custom implant that is designed on the basis of a three-dimensional
computed tomographic scan or a corresponding model
of the hip (Figs. 9-A and 9-B). While this method permits
the use of an unlimited variety of shapes to address truly
unique structural problems, it possesses several shortcomings. Not only is this technique costly, but only a single implant design can be available during the procedure.
If an unanticipated defect within an avascular bed is
identified during the operation, so that additional bone
has to be excised, then the custom implant no longer fits
precisely into the defect. In this situation, structural autograft or, suboptimally, allograft is needed to restore the
structural stability of the reconstruction.
A viable solution for a defect in the superior aspect
of the acetabulum that includes a corresponding segment of wall is a bilobed or oblong cup38. One newer
modular model permits the application of a lobe of
three different sizes for obliteration of the correspond-
1336
FIG. 4-A
Figs. 4-A, 4-B, and 4-C: A forty-one-year-old pilot sustained a displaced iliac-wing, or so-called crescent, fracture of the left hip and a T-type
acetabular fracture of the right hip in a free fall in his helicopter from 200 feet (sixty-one meters). Two years after nonoperative treatment, he
was referred to us with bilateral pelvic pain and a persistent and highly displaced nonunion of both the left iliac fracture and the right acetabular fracture. A partial realignment and stabilization of the left hemipelvis was performed with a right total hip arthroplasty and open reduction
and internal fixation of the right acetabulum. In order to improve the patients sitting balance, the right ischial tuberosity was osteotomized and
partly resected so that his weight rested on the inferior end of the posterior column.
Fig. 4-A: A three-dimensional computed tomography scan, made at the time of presentation, showing a persistent vertical and rotational deformity of the left hemipelvis and a displaced nonunion of the right T-type acetabular fracture with distal displacement of the inferior half of
the acetabulum.
FIG. 4-B
Postoperative anteroposterior radiograph showing a partial correction of the left pelvic deformity and a right cementless total hip replacement with immobilization of the acetabulum.
ing defects (Fig. 10). The principal shortcoming of a bilobed cup is the need to orient it so that the lobe is
directed superiorly. If a defect is posterosuperior, the
1337
When a partial union of a displaced acetabular fracture creates a gap of as much as twenty-five millimeters,
the fracture gap is usually managed with dbridement
and obliteration with autograft. If a mobile nonunion is
FIG. 5
A T-type fracture of the posterior wall that initially was managed nonoperatively progressed to a nonunion with deformity and degenerative
change. Two years later, the posterior column was stabilized, through a Kocher-Langenbeck approach, with a reconstruction plate while the defective wall was replaced with a precisely fitting structural autograft and lag screws. This intraoperative photograph was made after a metalbacked cup was secured to the pelvis while the autograft was secured with multiple screws.
VOL. 82-A, NO. 9, SEPTEMBER 2000
1338
FIG. 6-A
Figs. 6-A and 6-B: A twenty-eight-year-old man sustained a transverse fracture of the posterior wall of the left acetabulum. Open reduction
and internal fixation was performed with use of a triradiate incision. Within two weeks, the posterior wall fragment had displaced; subsequently, the hip progressed to posttraumatic arthritis with grade-IV heterotopic bone formation. Two years later, a total hip arthroplasty was
performed and augmented with a Mller ring to stabilize the wall defect.
Fig. 6-A: Anteroposterior radiograph, made two years after the open reduction and internal fixation, showing grade-IV heterotopic bone
formation and a fusion of the hip.
FIG. 6-B
Currently, the optimal design of a cemented or cementless femoral stem remains highly controversial41. As
Anteroposterior radiograph, made five years after the total hip arthroplasty, showing stable fixation of the ring along with a cemented
polyethylene cup and a cementless stem.
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1339
FIG. 7-A
Figs. 7-A, 7-B, and 7-C: Drawings showing multiple designs of cages
with diverse extension plates that are available for use with a cemented cup.
Fig. 7-A: Mller ring with a smaller posterosuperior flange.
FIG. 7-B
Ganz ring with a superior flange and an inferior hook for anchorage in the obturator foramen.
FIG. 7-C
Burch-Schneider cage with large superior and inferior flanges for
anchoring screws.
1340
FIG. 8-B
Transaxial computed tomographic scan, made four weeks after the
injury, showing erosive damage to more than 30 percent of the femoral head. This finding was not visualized on plain radiographs made at
that time.
THE JOURNAL OF BONE AND JOINT SURGERY
FIG. 8-C
Iliac oblique radiograph, made after the total hip arthroplasty,
showing the structural autograft secured with two cancellous screws.
VOL. 82-A, NO. 9, SEPTEMBER 2000
1341
1342
FIG. 9-A
Figs. 9-A and 9-B: A thirty-five-year-old man sustained a fracture
of the posterior wall and posterior column of the right acetabulum
and was managed initially with limited internal fixation. The fixation
rapidly failed, which provoked secondary degenerative change. Two
years later, the patient was referred to us with marked erosive damage to the femoral head, an absent posterior wall, and a partial defect
of the posterior column. A total hip arthroplasty with a custom cup
that had a large posterior flange with drill-holes to permit effective
screw fixation to the pelvis was performed.
Fig. 9-A: Transaxial three-dimensional computed tomographic reconstruction with a template of the custom cup.
FIG. 9-B
Anteroposterior radiograph of the right hip, made six years after
the total hip arthroplasty, showing continued stable fixation of the
cup in a superior position.
THE JOURNAL OF BONE AND JOINT SURGERY
1343
FIG. 10
Photograph showing the modular bilobed cup (Mars; Biomet, Warsaw, Indiana), which allows application of a lobe of three different
sizes to obliterate corresponding acetabular defects. The polyethylene
liner is secured mechanically to the bilobed cup, in contrast to the
case with a conventional cage.
1344
FIG. 11-A
Figs. 11-A, 11-B, and 11-C: A fifty-six-year-old man who had failure
of fixation of a transverse acetabular fracture of the right hip was
managed with a total hip arthroplasty with use of central mesh, morselized bone graft, and lag screws.
Fig. 11-A: Anteroposterior radiograph, made before the total hip
arthroplasty, showing failure of internal fixation solely with lag screws
and marked abrasive destruction of the femoral head.
1345
FIG. 11-B
Schematic drawings of the central mesh and morselized impacted bone chips.
able before embarking on the procedure. If the potential for acetabular reconstruction remains unclear to the
surgeon, a review of the clinical and radiographic features with an orthopaedist who is highly experienced
with this problem may be beneficial.
Salvage of Complex Late Cases
A limited spectrum of acetabular fractures, after failure of the initial open reduction and internal fixation,
have a heterogeneous mixture of complicating factors. A
patient may have a serious deep wound infection, possi-
FIG. 11-C
Obturator oblique radiograph, made after the hybrid total hip arthroplasty, showing a central mesh and a metal-backed cup secured with
three screws.
VOL. 82-A, NO. 9, SEPTEMBER 2000
1346
FIG. 12-A
Figs. 12-A, 12-B, and 12-C: Cables can be used for reconstruction of
the inner pelvic table in a so-called geriatric acetabular fracture pattern in which the quadrilateral plate is displaced medially. As displayed in Fig. 1-C, a sixty-two-year-old woman with osteopenic bone
sustained a T-type acetabular fracture with marked displacement of
the posterior column, including most of the quadrilateral surface. Following nonoperative treatment, she was seen two years later with
marked protrusion of the femoral head through the site of the nonunion. Cables were used to reduce and immobilize the displaced posterior column and to buttress the quadrilateral surface. After the
application of a structural femoral head autograft, a hybrid total hip
arthroplasty was performed.
Fig. 12-A: Photograph of an intact anatomical pelvic model, showing the position of the cables on the inner pelvic table.
FIG. 12-B
Photograph of an intact anatomical pelvic model, showing the position of a cable on the outer pelvic table.
THE JOURNAL OF BONE AND JOINT SURGERY
FIG. 12-C
Anteroposterior radiograph made after total hip arthroplasty with
two cables that buttress the crucial quadrilateral surface.
1347
FIG. 13
Increased radiodensity of the acetabular roof on the left side is a subtle but important finding of acetabular avascular necrosis. This twentyeight-year-old woman sustained a transverse fracture that was managed acutely with open reduction and was managed one year later with
removal of the metal. Three years after the injury, a total hip arthroplasty was performed to manage posttraumatic arthritis. Within another
two-year period, the patient complained of recurrent hip pain, and an aspiration arthrogram confirmed an aseptically loose cup. This anteroposterior radiograph shows superior migration of the failed cup into the necrotic acetabular roof.
VOL. 82-A, NO. 9, SEPTEMBER 2000
1348
(a single dose of 700 centigray). Alternatively, indomethacin can be used in younger female patients in
whom radiation exposure should be avoided. When
indomethacin and anticoagulation with low-molecularweight heparin or warfarin are used concomitantly, appropriate medical supervision is needed to minimize
the risk of a coagulopathy.
Clinical Outcome of Total Hip
Arthroplasty After Acetabular Fracture
According to a few prior studies on the late outcome of a belated total hip replacement after closed or
open treatment of an acetabular fracture7,8,43,80, the clinical outcome is generally less favorable than that after
total hip arthroplasty performed to manage degenerative arthritis. Undoubtedly, the outcome of belated total
hip arthroplasty after acetabular fracture is best when
the fracture pattern is one of minor displacement with
union, especially following nonoperative treatment. In
earlier published reports, such as one by Boardman and
Charnley76, even when open reduction of the acute acetabular fracture had been performed, the indication for
the late total hip arthroplasty typically was a posterior
FIG. 14-B
Anteroposterior radiograph made soon after the total hip arthroplasty and six years after the initial injury.
THE JOURNAL OF BONE AND JOINT SURGERY
1349
FIG. 14-C
Iliac oblique radiograph, made two years after the total hip arthroplasty, showing a completely loose cup and a transverse dissociation secondary to marked osteolysis of the anterior and posterior columns.
VOL. 82-A, NO. 9, SEPTEMBER 2000
1350
FIG. 15
Three-dimensional computed tomographic scan of the hip of a seventy-three-year-old woman who had complete, traumatic loss of the posterior acetabular column. This acetabular defect presents one of the most challenging reconstruction problems, as it can be very difficult to
achieve a stable acetabular component that will resist the forces that are imposed by sitting and sitting transfers as well as standing and walking.
1351
When heterotopic bone is evident, an extensile approach may be needed to allow adequate exposure for
its complete removal. After a bone defect and/or a nonunion with displacement has been characterized, one or
more strategies for obliteration of the defect are considered; these include the use of impaction grafting, a structural graft, a cup inserted with multiple screws, mesh, or
a suitable ring or other fixation device.
Evaluation of results has shown that, overall, the late
outcome of total hip arthroplasty after acetabular fracture is inferior to that of arthroplasty performed because
of degenerative arthritis. Although open reduction and
internal fixation of an acute acetabular fracture was previously hypothesized as an effective way to improve the
anticipated late outcome of total hip arthroplasty by the
elimination of a large fracture gap or the prevention of a
potential nonunion, current observations do not support
that hypothesis. An initial open reduction may compromise the outcome of a subsequent total hip arthroplasty
by compromising the blood supply of the acetabulum
and by initiating the formation of scar tissue, heterotopic
bone, or an occult or frank infection.
For a highly selected group of especially severe acetabular fractures, particularly those in elderly patients,
total hip arthroplasty appears to be a promising therapeutic alternative.
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