Abstract
Background
The problem of failed acetabulum fracture fixation is increasing due to increased incidence of high-velocity injury and a large number of patients are being operated on in the past few years. Limited evidence is available regarding results of Total hip arthroplasty (THA) in patients with failed acetabulum fracture fixation surgery. We assessed the clinical, radiological and postoperative complications. Besides this, we also evaluated functional outcome and quality of life following THA in failed open reduction and internal fixation of acetabular fractures.
Method
The current retrospective study was performed at the tertiary center from 2015 to 2020. Eighteen patients of failed acetabulum fracture fixation surgery (14 males and 4 females) were included with a mean follow-up period of 2.4 years. Postero-lateral approach was done in all cases. Clinico-radiological outcome, functional outcomes were recorded according to Harris Hip score (HHS) and quality of life was assessed by using the 12-Item Short Form Health Survey (SF-12) score. Postoperative complications were also assessed.
Results
The age of patients ranged from 20 years to 68 years with a mean age of 44.7 years. 16 of the patients (88.9%) had a united acetabular fracture while 2 of them (11.1%) presented with un-united acetabular fracture. The THA implant was found to be stable in all 18 cases. The Harris Hip score of the study ranged from 82 to 95 with a mean of 89.72 ± 4.24 while the SF-12 score ranged from 40.0 to 49.4 with a mean of 44.29 ± 2.95. Out of 18 cases, 11 (61.1%) returned with excellent outcomes while the rest 7 (38.9%) returned with good outcomes as per Harris Hips score criteria. The correlation and regression analysis shows between HHS and SF-12 was positive and statistically significant (r = 0.592, p = 0.010).
Conclusion
THA in patients with failed acetabulum fracture fixation surgery provides a reliable option with satisfactory outcomes along with a better quality of life.
Keywords: Acetabulum fracture, Total hip arthroplasty, Failed fixation, Hip arthritis, Non union
1. Introduction
Acetabulum fracture is a complex intra-articular injury that occurs more frequently in younger patients involved in high energy blunt trauma and in elder patients due to low energy falls and increased prevalence of osteoporosis and osteopenia.1,2 Open reduction and internal fixation (ORIF) is considered as a gold standard modality to treat young patients with acetabulum fracture in contrast to older one.3 Nowadays ORIF of acetabulum fracture is more common due to the better understanding of complex anatomy and special training of orthopedic surgeons which also increases the burden of complications because a higher number of acetabulum fractures are being operated on. Previous studies are suggestive of the complications following surgical fixation of acetabular fracture by ORIF includes arthritis (20%–50%), myositis ossificans (25.6%), AVN (10%–15%), sciatic nerve palsy (0%–2.8%) and infection (4.4%).3, 4, 5, 6, 7Other clinical studies demonstrated the occurrence of post-traumatic osteoarthritis after treatment of acetabulum fracture with ORIF.8,9 A meta-analysis performed by Giannoudis et al.,10 showed that 13%–14% of patients with acetabular fracture developed post-traumatic osteoarthritis after being treated initially with ORIF. Although, if the anatomical reduction was unsatisfactory then the incidence of osteoarthritis was significantly found to be increased up to 44%. Patients with a previous history of surgically operated acetabulum fracture developing osteoarthritis indicate failed acetabular fracture fixation whose management is operatively challenging due to previous surgical scarring tissue, bony cavities, hardware problems and risk of infections. Postoperative arthritis is a consequence of Open reduction and internal fixation of Acetabulum fracture which has been treated with total hip arthroplasty (THA) to prevent the ongoing development of symptoms.12 Earlier studies showed that 9%–22% of patients with Acetabulum fracture underwent THA previously managed with ORIF.3,11 However, only a few studies are available in the literature which show results of THA in failed acetabulum fracture surgeries previously managed by ORIF.12,13 Therefore, the purpose of this study is to investigate the clinical, radiological and functional outcomes of THA in patients with acetabulum fracture previously managed by ORIF. We also focus on the quality of life and complications associated with THA in patients with acetabulum fracture initially treated with ORIF.
2. Materials and methods
The current retrospective study (Level of Evidence-4) was performed at the tertiary center from 2015 to 2020. The patients were observed in the out patients department. After following the history and examination of patients, they were subjected to X-ray of pelvis of both hips - AP, lateral and Judet's view in all patients. CT-scan specifically axial cuts which show the position of implants, bone defects and union of wall and column was done in all patients. Templating of the acetabulum was done to assess the precise bone defects and the required acetabulum cup size preoperatively. A total of 18 patients were available for this study with inclusion criteria of all acetabulum fractures previously treated with ORIF with arthritis with or without the union of acetabulum fracture in adults with a minimum of one year of follow-up. Exclusion criteria were patients having failed ORIF of acetabulum fracture with infection and less than one year follow up. After the routine investigation of blood including ESR, CRP to exclude the infections, and also examined for sciatic nerve injury pre-operatively. Total hip Arthroplasty was performed by a surgical team with the postero-lateral surgical approach in a lateral position. Intra-operative parameters such as surgical time, blood loss, gluteal artery and sciatic nerve injury were evaluated. Postoperative clinical outcomes including pain and swelling, limitation of work, hip range of movement were assessed. Radiological outcomes like acetabular inclination was measured on X-rays with AP view of pelvis by drawing a line through the medial and lateral margins of cups and angle was defined with the trans-ischial tuberosity line. The acetabular anteversion is determined by the angle between the coronal plane and the acetabular axis on a lateral view. Migration of acetabulum cups was evaluated and further examined the THA implant stability by clinical and radiographic signs. Functional outcome was measured according to Harris hip score postoperatively. Quality of life was evaluated based on SF-12 score. Documented complications like infection, myositis ossificans were assessed according to Brooker classification,14 and also assessed the THR implant loosening.
3. Surgical technique
After all aseptic preparation, the patient was placed in a lateral position. A Standard postero-lateral approach was used incorporating previous surgical scars. Haemostasis was achieved. Femoral neck osteotomy was done, the posterior column of acetabulum and hip joint was exposed by putting bone levers in sciatic notches, while maintaining hip extension and knee in flexion to avoid sciatic nerve injury. Assessment is done for the previous implant, bony cavity and fracture site which come in the surgical field. Any recon plate and screws coming in between surgical fields were removed. If two recon plates were applied, the posterior column plate was not required to be removed because as it did not interfere with the surgical field as well as its removal required more surgical dissection around the sciatic notch. Exposure of the acetabular cavity was done after the cautious placement of Hohmann retractors. Acetabulum preparation has started. Any fracture site or bony cavity encountered was curetted and filled with bone grafts. The screws which are protruding into the acetabular cavity were either back hammered or removed using a hollow mill. A soft tissue landmark (transverse acetabular ligament) and reamer position were employed to confirm the acetabular version and inclination. Sometimes, it may require shifting the hip center to a higher level as in cases of large posterior wall defects. The trial of the acetabulum cup was done according to the last size reamer. Implant in all cases used was a hemispherical porous coated acetabular cup with multiple screws, to avoid sinking or migration of the cup. Standard femoral preparation was done. After placement of both acetabular cup and femoral stem, the hip joint is relocated and intra-operative range of motion is checked for satisfactory stability. The posterior capsule and short external rotators were repaired by way of trans-osseous suture bone tunnels. Thereafter, closure was done in layers with drain. While continuing in-bed exercises, partial weight-bearing was allowed after 6 weeks followed by full weight-bearing according to clinical and radiological status. Patients were followed up to 3 weeks, 6 weeks, 12 weeks, 24 weeks and yearly for the clinico-radiological outcomes. Scoring was performed in patients with at least one year follow up.
4. Statistical analysis
The results were analyzed using descriptive statistics and comparisons were done among various groups. Categorical data were summarized as proportions and percentages (%) while discrete (quantitative) as mean (SD). All the associations were tested by using Fisher's exact test. Unpaired t-test was used to compare quantitative variables between the two groups. Linear regression analysis and Pearson's correlation was used to establish a linear relationship between HHS and SF-12 scores. Statistical analyses were performed using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). A value of p < 0.05 was considered statistically significant.
5. Results
Out of the total 18 cases included in this study, 14 were males (77.8%) and 4 were females (22.2%). The age of patients ranged from 20 years to 68 years with a mean age of 44.7 years (Table-1). 15 patients had sustained trauma as a result of road traffic accidents and 3 patients had a history of fall from height. The time duration between acetabulum surgery and THA ranged from 3 months to 60 months with an average duration of 30 months. Sixteen of the patients (88.9%) had a united acetabular fracture while 2 of them (11.1%) presented with a non-united acetabular fracture (Table-1). All 18 cases were associated with arthritis hip with one case having preoperative sciatic nerve palsy. Postero-lateral approach was used in all the cases. The average operative time was 120 min (90 min–160 min) with an average postoperative blood loss was around 530 ml (350–800 ml). Implant from the previous acetabular surgery was not removed in 3 cases while the rest 15 cases were managed by removal of acetabular implant followed by THA. Uncemented type of THA implant was used in 14 (77.8%) cases while 4 (22.2%) cases were managed using a hybrid (an uncemented hemispherical porous-coated acetabular cup with cemented femoral stem) THA implant (Table-1). All cases had an uneventful surgery with no intraoperative complications. All patients were followed up for a minimum duration of one year with a mean follow-up of 2.4 years (Table-1). The THA implant was found to be stable in all 18 cases. Though, one patient had suffered from an acetabular cup migration which was not found to be significant due to the satisfactory clinical and functional outcome and acetabulum cup was incorporated in acceptable position. One patient developed a superficial infection which was treated by debridement and antibiotic therapy, myositis ossificans was found in one case. Abduction angle of acetabulum was found in a range of 30–55° with mean of 42° and acetabulum version was found 10–30° with a mean of 16°. Out of 18 patients’ higher hip center was found in 4 cases while the remaining 14 hips had a normal hip center. All femoral stem versions (ranged from 11.78° to 13.56° with the mean radiological measurement was 12.53° ± 0.81°) and position were found satisfactory. The Harris Hip score of the study cases was calculated and ranged from 82 to 95 with a mean of 89.72 ± 4.24 while the SF-12 score ranged from 40.0 to 49.4 with a mean of 44.29 ± 2.95. Out of 18 cases, 11 (61.1%) returned with an excellent outcome while the rest 7 (38.9%) returned with a good outcome as per Harris Hips score criteria. The correlation and regression analysis shows between HHS and SF-12 was positive and statistically significant (r = 0.592, p = 0.010) (Table-2). The difference in HHS and SF-12 score was found to be statistically significant according to age (p = 0.026, p = 0.005) with high HHS and SF-12 score in lower age group (<40 yrs) as compared to the upper age group. However, no significant difference was found in HHS and SF-12 scores between males & females (p = 0.357; p = 0.688) (Table-3). The duration between acetabulum fixation surgery and THA did not seem to affect the final outcome of surgery (p > 0.05). There was no significant association found between the type of implant used and the final outcome (p = 0.598).
Table – 1.
Demographic representation of patient's characteristics.
| No. | Variables | |
|---|---|---|
| 1 | Age | Range: 20–68 years Mean age: 44.72 ± 11.99 years |
| 2 | Gender | Male 14 (77.8%) & Female 4 (22.2%) |
| 3 | Type of acetabular fracture (Judet and Letournel Classification) | Simple: 6 (33.33%) & complex: 12 (66.66%) |
| 4 | Diagnosis at the time of presentation | Previously treated acetabular fracture with arthritis:18 - With Union: 16 (88.9%) -Without Union: 2 (11.1%) -With femoral head collapse: 5 (27.7%) -With plate/screw loosening: 4 (22.2%) -With sciatic nerve injury: 1 (5.5%) |
| 5 | Side | Unilateral: 18 (100%) |
| 6 | Previous surgery | Open reduction and internal fixation by Recon Plate: 18 (100%) |
| 7 | The symptoms at the time of diagnosis | Groin Pain and limping |
| 8 | Duration of symptoms | Range: 3–12 months Mean: 6.2 ± 1.8 months |
| 9 | THR cemented/uncemented | Uncemented: 14 (77.8%) & Hybrid: 4 (22.2%) |
| 10 | Follow-up | Range: 12–60 months Mean: 28 ± 15.4 months |
| 11 | Outcome | Excellent: 11 (61.1%) & Good: 7 (38.9%) |
| 12 | Complications | Superficial Infection: 1 (5.55%), Myositis Ossificans: 1 (5.55%), Acetabular cup migration: 1 (5.55%) |
| 13 | Management of Complications | Debridement + I·V Antibiotics for Superficial Infection |
Table - 2.
Correlation & regression analysis between HHS and SF-12.
| Variable | Un-standardized Coefficients |
t-value | p- value | Pearson's correlation | |
|---|---|---|---|---|---|
| B | SE | ||||
| (Constant) | 7.370 | 12.576 | .586 | .566 | 0.592 |
| HHS | .412 | .140 | 2.939 | .010 | |
Table - 3.
Intergroup comparison of HHS and SF-12 by age and sex.
| Variable | HHS |
t-value | p-value | SF-12 |
t-value | p- value | |||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | ||||||
| Age | <40 yr | 92.43 | 1.51 | 2.46 | 0.026 | 46.57 | 2.02 | 3.28 | 0.005 |
| >= 40 yr | 88.00 | 4.56 | 42.85 | 2.52 | |||||
| Sex | Male | 89.21 | 4.04 | −0.95 | 0.357 | 44.45 | 2.76 | 0.41 | 0.688 |
| Female | 91.50 | 5.07 | 43.75 | 3.96 | |||||
6. Discussion
THA is recommended to restore the normal functioning of the hip and reported as a successful rescue approach for failed acetabular fractures. Studies have reported conflicting results after mid and long-term follow-up of total hip replacement after acetabular fracture managed by ORIF.15, 16 Although, few studies also reported satisfactory results with mid-term follow-up study.17, 18 A retrospective study reported that the mean age of patients was 48 ± 9 years.19 Recently a study performed by Kumar et al.,13 reported that the age of patients ranged from 20 to 65 years with a mean age of 46.08 years. In this current study, the age of patients ranged from 20 years to 68 years with a mean age of 44.7 years. In the current study, the majority of THA cases were found to be associated with younger age as they are involved in a more active life and to attain a functional status for a fertile life. Studies showed that males are predominantly associated with THA cases.20, 21 In the current study, mostly males (77.8%) were found to undergo total hip replacement with respect to females (22.2%). Studies suggested that most of the patients that underwent THA previously managed with ORIF belong to road traffic accidents.14, 22, 23 In this current study, 15 of the 18 patients had sustained trauma as a result of road traffic accidents. One of the studies reported the united acetabulum fracture in all patients previously managed with ORIF.23 The overall incidence of non-union in ORIF groups was 2%–5%.17, 18 In this current study, 16 of the patients (88.9%) had a united acetabular fracture while 2 of them (11.1%) presented with a non-united acetabular fracture. Studies reported the mean time was 37 months between acetabulum fracture fixation surgery and THR.13, 18 In this current study, the time duration between acetabulum surgery and THA ranged from 3 months to 60 months with an average duration of 30 months. Few patients developed femoral head destruction earlier either due to initial injury or chondrolysis. The duration between acetabulum fixation surgery and THR did not seem to affect the final outcome of surgery. Several studies performed the THA after the removal of implants due to increased loosening, impaction and suspicion of infection.24, 25 In addition to this, one of the studies performs the THR without removal of implants.25 In this current study, an implant from the previous acetabular surgery was not removed in 3 cases while the remaining 15 cases were managed by removal of the acetabular implant followed by THA. Several studies utilized this approach for the THA.26, 27 Gavaskar et al.19 showed that the average surgical time of THA was 86 ± 24 min. In this current study, the average operative time was 120 min (90 min–160 min). One of the studies showed that acetabulum fracture previously managed by ORIF leads to greater blood loss.27 Recently a study conducted by Gavaskar et al.,19 showed that the mean blood loss during THA surgery was 448 ± 105 ml. In this current study, the mean blood loss was 530 ml (350–800 ml). Intraoperative acetabular fracture is a rare complication of primary total hip replacement.28 The overall incidence of nerve injury after THR surgery is approximately between 0.05 and 1.9%29 and sciatic nerve injury accounts for 7.9% of this.29 In the current study, we did not observe the sciatic and gluteal injury following THR in failed acetabular fracture previously managed by ORIF. In this current study, all cases had an uneventful surgery with no intraoperative complications. Uncemented implants manifest a greater range of designs, employing tapered, wedged, modular, anatomic and cylindrical shapes. Implant loosening was one of the complications found to be associated with cemented implants,4 hence uncemented is more preferable over cemented ones. Uncemented THR is recommended for younger and active patients. Recently a study showed that an uncemented implant is better for the delayed THR patients previously managed by ORIF.30 In this current study, an uncemented type of total hip replacement implant was used in 14 (77.8%) cases, Acetabular migration and development of radiolucent lines were the complications associated with cemented as well as with uncemented after two decades.31 One of the studies reported the progressive development of radiolucent lines (2%) with hybrid implant while they did not observe acetabular migration in any of the cases with hybrid implant.31 In the current study, only 4 (22.2%) cases were managed by using a hybrid THR implant. Also, no significant association was found between the type of implant used and the final outcome. All patients were followed up for a minimum duration of one year with a mean follow-up of 2.4 years. The THA implant was found to be stable in all 18 cases. The alignment of the implant during THA is very crucial for the stability of the joint. Previous studies reported the stable THA implant during follow-up of 50 months on radiograph.32, 33 Stable bony in-growth was reported after THA associated with failed acetabular fracture previously managed with ORIF.13 One of the studies reported that the abduction angle ranged from 16 to 54° with a mean abduction angle 33.8° ± 8.5° in a failed acetabular fracture previously managed with ORIF.20 A few studies reported the anteverted cup in all patients in failed acetabular fracture following ORIF20, 32 and also showed that 74% of cups manifest superior placement while 26% of cups have inferior placement after comparison with contra-lateral hip.33 In the current study, the THA implant was found to be stable in all the cases. The mean Abduction angle and version of acetabulum were 42° and 16° respectively. Out of 18 patients’ higher hip center was found in 4 cases while the remaining 14 hips were normally placed. Studies reported postoperative complications like pain and swelling, limitation of work, hip range of movement.30, 34 All patients received physiotherapy input in association with exercise to maintain range of motion, strength and proprioception. Satisfactory hip range of motion was achieved in all patients (Fig. 1, Fig. 2, Figure-3). Limitation of work was found in one patient with sciatic nerve palsy. Previous studies used Harris Hip score for the validation of functional outcome following THA.35, 36, 37 Several studies reported that the Harris Hip score ranged from 56 to 100 with mean Harris Hip score was 84.35,13. One of the recent studies also reported the excellent to good outcome in acetabulum fracture treated with acute THA.38 In the current study, the Harris Hip score of the study cases was calculated and ranged from 82 to 95 with a mean of 89.72 ± 4.24. Out of 18 cases, 11 (61.1%) returned with excellent outcomes while the rest 7 (38.9%) returned with good outcomes (Fig. 1, Fig. 2, Figure-3). SF-12 score is made up of mental and physical component scales and is basically composed of twelve items for self-administered personal interview. Previous studies validated this for functional outcomes associated with THA.7,39 Recently a study conducted by Kumar et al.,13 reported that the average SF-12 score was 49.1 with a standard deviation (SD) of 11.36. In the current study, quality of life was assessed according to the SF-12 score which ranged from 40.0 to 49.4 with a mean of 44.29 ± 2.95. The correlation between HHS and SF-12 was positive and statistically significant. Incidence of infection was 9.4% for THA40 while the infection is at between 0.3 and 1.5% after the prophylaxis use of antibiotics.6,40 In the current study, three patients presented with complications during the follow-up: one patient developed a superficial infection (5.55%) which was treated by debridement and antibiotic therapy. Several studies reported that the rates of myositis ossificans following THR varies between 0.6 and 90%.41, 42, 43, 44 In the current study, only one patient develops myositis ossificans (5.55%). A few studies reported acetabular migration as a complication associated with uncemented (5%), as well as hybrid implant (2%) postoperatively.30,45 In the current study, only one patient (5.55%) suffered from an acetabular cup migration which was not significant. The weakness of our study is that we analyze the smaller number of patients with the limitation of retrospective study.
Fig. 1.
(a & b): Pre operative X-ray and 3D CT exhibiting acetabular fracture.
Figure 1(c): ORIF of acetabular fracture with implant in situ with arthritic hip joint.
Figure 1(d): Follow up X-ray at 12 months of THA.
Figure 1(e): Follow up X-ray at 36 months of THA.
Figure 1(f): Functional outcome.
Fig. 2.
(a, b & c): Pre op X-ray and 3D CT exhibiting fracture acetabulum.
Figure 2(d): ORIF of fracture acetabulum with implant in situ.
Figure 2(e): Follow up X-ray at 24 months with THA.
Figure 2(f & g): Follow up X-rays at 60 months with THA.
Figure 2(h): Functional outcome.
Figure-3.
(a & b): Pre-op X-ray displays acetabulum fracture with implant in situ and un-united fracture.
Figure-3(c & d): Follow up X-rays at 6 months with THA.
Figure-3(e & f): Follow up X-rays at 18 months with THA.
Figure-3(g): Functional outcome.
7. Conclusion
THA in patients with previously treated failed acetabulum fracture fixation surgery with or without union is a technically demanding procedure that requires vigilant preoperative planning and meticulous surgical steps provides a salvage option with a satisfactory outcome and allows returning with improved quality of life. Further, more studies are required based on large multicentric study with randomized control trials and long-term follow-ups to validate the functional outcomes in these cases.
Declaration of competing interest
The authors declare that they possess no commercial or financial relationships that could be interpreted as a potential conflict of interest.
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