THR in Osteoporotic

Acetabular Fractures

Hazem Abdel-Azeem, M.D

Professor of Orthopaedic Surgery
Cairo University
 In most Arab countries, life expectancy has increased in the past two decades.

• Distribution of the Arab population by

- In 1980-1985, the average broad age groups, 1980-2050

life expectancy was 58

years for men and 61.3
years for women.
- Currently, it is 71 for
females & 73for females
Matta et al…2010
In all, 235 patients were > 60 years of age and
the remaining 1074 were < 60 years. The
incidence of elderly patients with acetabular
fractures increased by 2.4-fold between the
first half of the study period and the second
half (10% (62) vs 24% (174), p < 0.001).
 Fractures are characterised by
• Displacement of the anterior column(64% )
• Separate quadrilateral-plate component
(50.8% )
• Roof impaction (40%) in the anterior
fractures, and
• Comminution (44%)
• Marginal impaction (38%) in posterior-wall
fractures.
 Epidemiology : Hip region injuries incidence in
elderlies
• In elderly, the incidence
of proximal femur, pelvic
60
and acetabular fracture
has been expressed by
the ratio 60:10:1
• Therefore, the fractures 10
of the Acetabulum may
be missed due to directed
attention towards other
hip fractures 1
Low energy trauma cases are commonly misdiagnosed
initially as fracture of fracture neck femur

• Some times fracture

neck femur and
femoral neck are
combined
 Study Series : 62 hips in 61 patients

• Cases 51 males 10 females

• Age avarage 68 years ( Yougest 55,Oldest 72)
• Bone quality
– Normal or osteopaenic 24 cases
– Osteoporotic 28 cases
– Severely osteoporotic 10 cases
 Mechanism of Injury

• Moderate or low energy

injuries in osteoporosis
( fall on to the greater
trochanter) n= 29 cases
• High energy trauma as
in normal bone n=32
• Study :
– Clinical examination , fitness for surgery
– Imaging Radiography and CT studies
– Classification with modification
– Densitometry when needed
– Duplex for the leg vessels ( A & V ) when needed
– Anticoagulation
– Operative or conservative
– End of follow up is either fracture healing or THR
 Cases Classification :

Recorded types are

– Isolated :
• Ant wall 3
• Ant col without comminution 6
• Ant col with comminution 10
• Post wall without comminution 7
• Post wall with comminution 5
• Post col without comminution 5
• Post col with comminution 2
• Transverse fr 0
– Combined :
• T fracture 0
• Transverse with pos wall 0
• Ant with post hemitransverse 12
• Post col with post wall without comminution 2
• Post col with post wall with comminution 2
• Associated both col without comminution 4
• Associated both col with comminution 4
 Radiological study

Recorded problems :
– Articular impaction 6
– Dislocation of the hip 13
– Comminuted Anterior or
posterior-wall fractures 17
– Injury to the femoral head 7
– Presence of OA 16
 Treatment Goals
• To obtain painless mobile stable life lasting
hip
• To get ambulant patient with less pain as
soon as possible
• To avoid 2nd go surgery
• To avoid DVT & thromboembolism and
other recumbancy complications
 For the sake of treatment line
choice and preoperative planning
The different types are
divided into groups
according to bone quality
and hip condition
Bone Quality : Hip join clinical condition :

• Cases of normal • Cases of associated

bone Quality hip osteoarthrosis

• Cases of poor bone • Cases with intra articular

quality (osteoporosis traumatic insult :
– depressed fracture or
& osteomalacia )
– Pipkin’s fracture
Bone Quality : Hip join clinical condition :

• Cases of normal • Cases of associated

bone Quality hip osteoarthrosis

• Cases of poor bone • Cases with intra articular

quality (osteoporosis traumatic insult :
– depressed fracture or
& osteomalacia )
– Pipkin’s fracture
 Conservative Treatment n=3

Indications
• All non displaced
fractures
• Minimally displaced (less
than 2 mm)
• Displaced low anterior
column, low transverse or
low T- fracture
• Unfit patients
 Conservative Treatment

• In all studies also in

ours; poor results
have been recorded
in at least 30% of
patients treated
conservatively...!!!
Operative treatment
Indications
• Displaced fractures
• Unstable fractures
• Associated traumatic
insult to the femoral head
• Associated proximal
femoral fracture
• Depressed fragment
• Associated osteoarthritis
 Surgical Treatment Options
In young adult In geriatric age
• Anatomic Reduction • Three Possibilities are there
And Internal Fixation 1st - To achieve anatomical
reduction and internal fixation
( n= 33 )

IF NOT
2nd - Acute THR ( n=16 )

IF NOT
3rd – Delayed THR ( n= 8 )
 Considering the first option :
Geriatric Pt does not differ from young
Reconstruction of the
acetabulum anatomically
by open reduction and
internal fixation

Obstacles are Comminution

and Osteoporotic bad quality
bone
Other difficulties are
- unrecognition of fracture
patterns
- severe comminution
- depressed fractures
- erosion of articular surfaces
- associated Pipkin's fracture
- or fractures of the proximal
femur
 Intraoperative Technical Consideration we
Adopted :
• Use only one approach
• Minimize the operative
time (less than 4 hrs)
• Use 4.5 plates and
4.5/6.5 screws
• Use plates and don’t
rely on lag screws alone
• Handle the vessels with
care ( It breaks)
 Results of 1 group ( n 33 )
st

• Anatomical reduction 21 • 2years follow up :

• Fair reduction ( gap or - Lost 7
step < 5 mm ) 9 - OA 11
• Poor reduction 3 - good 15
 Option 2 Acute THR ( n=16 )
• Is used when
reconstruction by
ORIF is impossible
( n= 11 )
• Also in associated :
– Pipkin's fracture
(n=2)
– Hip AO ( n= 3 )
 Option 2 THR
• Open reduction& int fixation
primarily
• Anatomical reduction is not
needed
• Internal fixation should be
by plate and screws
• Column screw is
inadequate
• Wrong to use the metal
back of the acetabular cup
as circular plate to fix the
fracture
Anterior plating then THR
Association with Pipkin's
Fracture acetabulum with hip OA
ACUTE BIL FR ACETABULUM CASE : Male 68 ys
 Results of Acute THR
• Plate fixation+ THR ( n=5 )
• Plate Fixation + Graft + THR ( n= 7 )
• Screw fixation + Graft + THR ( n=3)
• Reconstruction ring + Graft + THR ( n = 1 )
 Results of Acute THR
• Post operative : • 2 years Follow up :
– Dislocation 6 - Lost 3
– DVT 3 - Loosened cup 3
– Pulmonary showers 2
- Hip pain 2
– External iliac A
Thrombosis 1 - Doing well 8
 Option 3 Delayed THR ( n = 8 )

• Is considered a salvage
of unsatisfactory result
after conservative
treatment
• Segmental and cavitary
acetabular defects
usually result after
neglected acetabular
fractures and should be
grafted
 Option 3 Delayed THR

• However , leaving the

patient in bed or
traction followed by
late arthroplasty may
lead to significant
complications as well
as failure of
arthroplasty
 Delayed THR Results
• Grafting + THR ( n=2 )
• Plate + Graft + THR ( n= 5 )

• Reconstruction ring (n=1)

 Delayed THR Results
• Post operative • 2 Years Follow up :
complications : – Lost 1
- Dislocation 3 – Loosening of cup 3
- DVT 2 – Pain 2
– Doing well 2
- Pulmonary Embolism 1
 In conclusion
• Treatment of acetabular fracture in geriatric age group
posses challenges that are not always seen in the
younger age group
• This is due to comminution , osteoporosis and high
incidence of thrombo embolic problems
• Letournel classification is used in this study
• Letournel classical types were not always produced as
he described , some comminution was commonly there
due to osteoporosis
 Conclusion
• Displaced acetabular fractures + good bone stock
→ ORIF
• Acute THR depends on rigid fixation to build a
solid base for placement of the total hip
– Anatomic reduction is the not needed
– Never use the prosthetic shell as a “hemispherical
plate”
– Always use the traditional plates and screws and not
reconstruction rings
– Anticoagulation
 Conclusion
• Late arthroplasty is used for failed treatment
cases , the acetabulum must be reduced ,fixed
and grafted before cup application
Thank you