THA in failed acetabular fractures Dr Ali Yeganeh Associat professor of Iran university of medical sciences

Acetabular FX treatment  ORIF is mainstay  ORIF in communited FX(head &acetabulom fx in young)  ORIF in elderly

THA after acetabulom non surgical treatment  After initial nonsurgical treatment of an acetabular fracture, an occult or frank acetabular nonunion and malunion are not uncommon and may extend to the residual pelvic ring

Indications THA in failed acetabular FX  DJD  AVN  chondrolysis  Malunion  Head resorption (infection?)  Instability ??

Preop planning  Radiography (AP, oblique views)

Preop planning  CT scan (3D, axial, sagital, coronal) medial wall defects Ant. Or Post. Colomn defects

Preop planning  Infection R/O x ray bone scan ESR/CRP hip aspiration

Preop planning  Abductor function EMG/NCV PH exam

Approuches  Previous approuch  Bone defects  Condition of soft tissue  Surgeon experience

Approaches  Fibrotic tissue in the field  Make exposure difficult  Soft tissue mobilization difficult  More bleeding  Ischemic necrosis of muscles because of forceful retraction

Approaches  Trochanteric osteotomy?  Sciatic n. exploration? not routinely

Hard ware removal  If interferes with implantation of components (cup, stem)  More damage to soft tissues  Infection?  Corrosion wear???

Equipments  Cemented and cementless  Reinforcement rings and cages  Mesh

Allograft (structural, chips)

Post op.  Abduction pillow  Abduction brace  Restricted weight bearing

sciatic nerve palsy whether induced traumatically or iatrogenically, accompanies the initial acetabular injury, the palsy is likely to be exacerbated during a subsequent THA In the majority of cases, staying well away from the sciatic nerve is the best option. When the sciatic nerve is at especially high risk during surgery, intra-operative electromyography(EMG) monitoring may be considered

Infection  infection should always be ruled out before proceeding with THR  ESR /CRP/ clinic  Aspiration  Culture for aerobic & anaerobic  If + 2 stage surgery…. all devices should be removed  And debreded cartilag and replaced with AB cement

bone deficiency  Ant &post wall deficiency When the anterior or posterior walls are absent, the use of autograft bone fixed with a plate or screws.  Bulk graft autograft bone from the femoral head is mainly used in cases of protrusio or when columnar defects are present. Posterior plating should be reserved for cases of pelvic discontinuity and/or if the graft requires supplemental Fixation  Necrosis or Nonunion same that revision surgery

pitfall  In addition, the superior aspect of the dome may also be sufficiently deformed as to predispose the surgeon to place the acetabular component in a more abducted position. In these circumstances an intra-operative x-ray may help in determining appropriate position

instablity  Because of impingment  Larger head  Dual mobility

HTO  Should be removed?  shielded prophylactic radiation therapy within 12 hours pre-operatively or 72 hours postoperatively. 16 A single dose of 800 cGy is the usual dose. In extremely high-risk patients, the authors prefer the addition of a non-steroidal anti-inflammatory drug (NSAID), for additional protection

THA results  Total hip arthroplasty (THA) outcomes for posttraumatic arthritis after acetabular fracture have yielded inferior results compared to primary nontraumatic THA

 FRACTURES ABOUT THE HIP Acetabular fractures THE ROLE OF TOTAL HIP REPLACEMENT From Mayo Clinic, ©2013 The British Editorial Total hip replacement (THR) after acetabular fracture presents unique challenges. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further.

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