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The Journal of Bone and Joint Surgery 80:1295-1305 (1998)
© 1998 The Journal of Bone and Joint Surgery, Inc.

Total Hip Arthroplasty after Operative Treatment of an Acetabular Fracture*

MARTIN WEBER, M.D.{dagger}, DANIEL J. BERRY, M.D.{ddagger} and W. SCOTT HARMSEN, M.S.{ddagger}, ROCHESTER, MINNESOTA

Investigation performed at the Department of Orthopedics, Mayo Clinic, Rochester


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Sixty-six primary total hip arthroplasties were performed to treat post-traumatic osteoarthrosis that had developed following an acetabular fracture and subsequent open reduction and internal fixation. The mean age of the patients at the time of the total hip arthroplasty was fifty-two years (range, nineteen to eighty years). The arthroplasty was performed with cement in forty-four hips and without cement in twenty hips; in the remaining two hips, the acetabular component was inserted without cement and the femoral component was inserted with cement (a so-called hybrid procedure). Scarring from a previous procedure, retained hardware, heterotopic bone, and residual osseous deformity and deficiency made the procedure more complex than routine total hip arthroplasty in most patients. However, only one of the sixty-six procedures was associated with an operative complication. Three patients were lost to follow-up. The remaining sixty-three patients were followed for a mean of 9.6 years (range, two to twenty years). The mean duration of follow-up was 14.9 years for the acetabular components inserted with cement, 11.6 years for the femoral components inserted with cement, 4.6 years for the femoral components inserted without cement, and 3.9 years for the acetabular components inserted without cement. The mean Harris hip score improved from 49 points preoperatively to 93 points at the latest follow-up evaluation for the forty-six patients who did not have a revision procedure after the index arthroplasty. Seventeen patients had a revision; sixteen revisions were performed because of aseptic loosening of one or both components (nine acetabular and eleven femoral components). Mechanical failure (radiographic loosening or revision due to aseptic loosening) occurred in twenty-five hips. As determined with use of the Kaplan-Meier method, the ten-year survival rate, with revision due to aseptic loosening as the end point, was 78 per cent (95 per cent confidence interval, 66 to 92 per cent) for the prosthesis as a whole (that is, no revision of either component), 87 per cent (95 per cent confidence interval, 76 to 99 per cent) for the acetabular component, and 84 per cent (95 per cent confidence interval, 72 to 97 per cent) for the femoral component. An age of less than fifty years (p = 0.02), a weight of eighty kilograms or more (p = 0.047), and large residual combined segmental and cavitary deficiencies in the acetabular bone (p < 0.0001) were significant risk factors for revision because of aseptic loosening. At the ten-year follow-up, none of the twenty-two acetabular components that had been inserted without cement had been revised or demonstrated radiographic loosening. The ten-year rate of failure due to aseptic loosening was higher than that in many reported series of total hip arthroplasties performed for other indications; this was probably partly because of the young mean age of the patients, the high number of patients who had Charnley class-A involvement, and the predominantly male cohort.


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Degenerative joint disease after an acetabular fracture may develop as a result of residual articular incongruity, damage to the articular cartilage at the time of the injury, or avascular necrosis of the femoral head. When post-traumatic osteoarthrosis develops, total hip arthroplasty is frequently performed as a salvage procedure. Open reduction and internal fixation of a displaced acetabular fracture can reduce the risk of post-traumatic osteoarthrosis. It may also optimize acetabular bone stock and minimize pelvic deformity, which is theoretically advantageous if a total hip arthroplasty becomes necessary. Unfortunately, the results of several relatively short-term studies have shown total hip arthroplasty after operative treatment of acetabular fractures to be associated with high rates of failure, more technical problems, and complications related to the previous injury and operations16,18. The aim of the present study was to evaluate the clinical results of total hip arthroplasty performed in a large number of patients to treat post-traumatic osteoarthrosis that had developed after open reduction and internal fixation of a displaced acetabular fracture. Special attention was paid to the risk of complications, the frequency of technical difficulties, and the factors affecting long-term survival of the prosthesis.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Between 1970 and 1993, sixty-six hips in sixty-six patients were treated at our institution with total hip arthroplasty after previous open reduction and internal fixation of an acetabular fracture. There were fifty-two men and fourteen women. Twenty-seven right hips and thirty-nine left hips were involved. The mean age at the time of the acetabular fracture was forty-three years (range, fourteen to seventy-nine years), and the mean age at the time of the total hip arthroplasty was fifty-two years (range, nineteen to eighty years). The mean weight at the time of the total hip arthroplasty was eighty kilograms (range, forty-five to 132 kilograms).

Fifty-seven of the acetabular fractures were sustained in a motor-vehicle accident, seven were the result of a fall, and two were due to another cause. Thirty-seven patients were known to have had a dislocation of the hip at the time of the fracture. Thirteen patients had an injury of the sciatic nerve that was related to the fracture.

The pattern of the acetabular fracture was classified, according to the system of Judet et al.15, on the basis of the intraoperative findings and a review of the radiographs (Table I). The operative approach for the open reduction and internal fixation of the acetabular fracture as well as the method of fixation were ascertained by a review of the operative records (Table I). Associated procedures were performed in seven patients; five patients had open reduction and internal fixation of a fracture of the femoral diaphysis or of the femoral neck, one had resection of the femoral head, and one had repair of a traumatic laceration of the sciatic nerve.


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  		TABLE I DATA REGARDING THE PREVIOUS ACETABULAR FRACTURE AND OPEN REDUCTION AND INTERNAL FIXATION

 
The total hip arthroplasty was performed through an anterolateral approach in nineteen patients, a transtrochanteric approach in thirty-six, and a posterolateral approach in eleven.

Forty-four acetabular components were inserted with cement, and twenty-two were inserted without it. Forty-six femoral components were inserted with cement, and twenty were inserted without it. Both components were inserted with cement in forty-four hips, both were inserted without cement in twenty, and the acetabular component was inserted without cement and the femoral component was inserted with cement (a so-called hybrid arthroplasty) in two. Of the acetabular components inserted with cement, thirty-three were all-polyethylene sockets (twenty-eight Charnley types and five other types), nine were metal-backed sockets, and two were sockets with an acetabular reinforcement ring. Of the acetabular components that were inserted without cement, eleven were Harris-Galante I or II porous-coated sockets (Zimmer, Warsaw, Indiana), seven were spherical or PSL cups (Osteonics, Allendale, New Jersey), three were dual-geometry cups (Osteonics), and one was a porous-coated anatomic socket (Howmedica, Rutherford, New Jersey). Of the femoral components inserted with cement, twenty-seven were Charnley-type components, five were computer-assisted-design (CAD) components (Howmedica), three were Harris Design-2 components (Howmedica), three were Centralign components (Zimmer), three were Trapezoidal-28 components (Zimmer), two were Omnifit components (Osteonics), one was an Aufranc-Turner component (Howmedica), one was a DF-80 component (Zimmer), and one was a Precision component (Howmedica). Of the femoral components inserted without cement, five were Omnifit components (Osteonics), three were Omniflex components (Osteonics), three were Omnifit-HA components (Osteonics), three were Harris-Galante components (Zimmer), two were Mayo components (Zimmer), two were BIAS components (Zimmer), one was a porous-coated anatomic component (Howmedica), and one was an anatomic component (Zimmer).

Acetabular bone graft was used in fifteen hips. There were eleven particulate, one bulk, and three combined bulk and particulate grafts. Thirteen grafts were autogenous, and two were allogenic. Data on ununited acetabular bone fragments and necrotic acetabular bone at the time of the operation were obtained by a review of the operative reports.

Postoperatively, only three patients received prophylactic radiation therapy for the prevention of heterotopic bone. All three patients received 1000 centigray in five fractions beginning on or before the third postoperative day.

Data regarding the outcome of all procedures were collected prospectively at one, two, and five years postoperatively and every five years thereafter. All living patients who had not had a revision and had not been seen for follow-up in the two years before the study were contacted at the time of the study. Attempts were made to examine all patients and to interview all in person. When this was not possible, the patient completed a detailed standardized questionnaire by letter or telephone. Modified Harris hip scores12 were derived from data obtained from the interview and examination or from the questionnaire. The Charnley class was A (unilateral hip disease without other major accompanying joint disease) for all sixty-six patients at the time of the total hip arthroplasty.

All preoperative and serial postoperative radiographs were evaluated by two of us (M. W. and D. J. B.). As proposed by Hodgkinson et al.14, probable or definite radiographic loosening of the cemented acetabular components was defined as a continuous radiolucent line of any width, migration of the component, or a change in the position of the component. Probable or definite loosening of the cemented femoral components was defined, according to a slight modification of the definition proposed by Stauffer32, as a complete radiolucent line at the cement-bone interface, a change in the position of the component, or a fracture of the cement. Debonded Charnley prostheses with a radiolucent line of less than two millimeters in width in zone 1 of the cement-prosthesis interface, as defined by DeLee and Charnley8, were not considered loose1. Sockets that had not been inserted with cement were considered loose if there was progressive shedding of beads, migration of the socket, or a change in the position of the socket. The stability of the femoral components inserted without cement was assessed with the criteria of Engh et al.10. Osteolysis around the acetabular and femoral components, if present, was recorded by zone and the size of the lesion8,11.

Heterotopic bone was evaluated on the preoperative and postoperative radiographs with the system of Brooker et al.3. Deficiencies in the acetabular bone before the total hip arthroplasty were classified with the system of D'Antonio et al.7.

Survival rates and 95 per cent confidence intervals were each estimated with the Kaplan-Meier method for three different end points: reoperation, revision for aseptic loosening, and mechanical failure (revision for aseptic loosening or radiographic loosening)17. Differences in the survival of subgroups were tested with the log-rank test. The calculations of the rates of survival until aseptic loosening for the separate components were performed as follows. If only one component was revised, the other component was considered stable and was kept in the study until the latest follow-up evaluation or until it was known to have failed. If both components were revised even though one was stable intraoperatively, the component that was stable intraoperatively was considered as being stable until the date of the revision. For calculation of the survival until revision for any reason, the time to the first revision of either component was used.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 

Findings and Problems at the Total Hip Arthroplasty
At the time of the total hip arthroplasty, the surgeon noted difficulties with exposure due to extensive scarring in twenty-seven patients (41 per cent). In twenty-six patients (39 per cent), the implants from the previous acetabular fixation were believed to interfere with the procedure. Removal of all internal fixation devices was necessary in twenty-four patients (36 per cent), and selective removal was necessary in sixteen (24 per cent). Twelve patients (18 per cent) had heterotopic bone excised during the total hip arthroplasty. Scarring, the need to remove hardware, or the need to excise heterotopic bone led the surgeon to increase the operative exposure in five patients, but a different type of exposure was not necessary for any patient. It should be noted, however, that a transtrochanteric approach had originally been selected for most of the patients in the series. The mean operative time was 170 minutes (range, ninety to 315 minutes). The reasons noted for prolonged operative times included difficult exposure due to scar tissue, the need to excise heterotopic bone, the need to remove hardware, and complex acetabular reconstruction as a result of deficiencies in the acetabular bone. A mean of 3.5 units (range, zero to fourteen units) of blood was transfused in the perioperative period. Eleven patients (17 per cent) needed at least six units of blood.

Clinical Results
Three patients had died by the time of the review performed for this study; none died less than two years after the arthroplasty. Three patients were lost to follow-up within two years after the arthroplasty. Therefore, sixty-three of the sixty-six patients were followed for at least two years. The mean duration of the clinical follow-up for the sixty living patients for whom follow-up data were available was 10.3 years (range, 2.4 to 18.1 years), and the mean duration for all sixty-three patients was 9.6 years (range, two to twenty years). The mean duration of follow-up for the acetabular components inserted with cement was 14.9 years, and the mean duration for the acetabular components inserted without cement was 3.9 years. The mean duration of follow-up for the femoral components inserted with cement was 11.6 years, and the mean duration for the femoral components inserted without cement was 4.6 years.

The mean Harris hip score improved from 49 points preoperatively to 93 points at the latest follow-up evaluation for the forty-six patients who did not have a revision (p < 0.0001). Preoperatively, sixty-one (92 per cent) of the sixty-six patients had moderate or severe pain. At the latest follow-up evaluation, four (9 per cent) of the forty-six patients who had not had a revision had moderate or severe pain.

Radiographic Results
Radiographs were available at a minimum of two years (mean, 8.7 years) postoperatively for forty-five of the forty-six patients who did not have a revision. Before the total hip arthroplasty, nineteen hips had grade-I heterotopic bone, five had grade-II, five had grade-III, ten had grade-IV, and twenty-seven did not have heterotopic bone. On the latest radiographs, fifteen (33 per cent) of the forty-five hips had grade-I heterotopic bone, two (4 per cent) had grade-II, eight (18 per cent) had grade-III, one (2 per cent) had grade-IV, and nineteen (42 per cent) did not have heterotopic bone.

Six unrevised cemented acetabular components and four unrevised femoral components (three that had been inserted without cement and one that had been inserted with cement) had radiographic evidence of probable or definite loosening. Three patients who had not had a revision had radiographic evidence of acetabular or femoral osteolysis. One of these patients had osteolysis in zones 4 through 7, as defined by Gruen et al.11, around a loose patch-porous-coated femoral component that had been inserted without cement, and the other two patients had a lesion that was less than one centimeter long adjacent to an acetabular component that had been inserted without cement.

Revisions
Seventeen revisions were performed in seventeen patients three months to 18.1 years (median, 9.0 years) after the total hip arthroplasty. Ten acetabular components were revised: nine were revised because of aseptic loosening at a mean of nine years (range, three months to 18.1 years) postoperatively, and one stable acetabular component was revised because of recurrent dislocation at 2.3 years. Eleven femoral components were revised because of aseptic loosening (one also was associated with a periprosthetic fracture of the femur). Both components were revised simultaneously in four of the seventeen patients. The only reoperation that did not involve revision of a component was removal of a trochanteric cerclage wire from one patient twelve years postoperatively. In total, sixteen hips (nine acetabular and eleven femoral components) were revised for aseptic loosening.

Nine patients who did not have a revision had probable or definite radiographic loosening of at least one of the components (six acetabular and four femoral components). Thus, twenty-five patients had mechanical failure (radiographic loosening or revision due to aseptic loosening) of one or both components. In total, fifteen acetabular components and fifteen femoral components were loose.

The components that had been inserted without cement were also analyzed separately. None of the twenty-two acetabular components that had been inserted without cement were revised (Figs. 1-A and 1-B) or had signs of radiographic loosening; thus, no socket that had been inserted without cement loosened. Two of the femoral components that had been inserted without cement were revised because of aseptic loosening, at 5.7 and 5.9 years postoperatively, and three of the femoral components that had been inserted without cement had radiographic evidence of loosening. Thus, five of the twenty femoral components that had been inserted without cement had mechanical failure.



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  		FIG1-A: Figs. 1-A and 1-B: A forty-five-year-old man who had post-traumatic osteoarthrosis in the right hip. Fig. 1-A: Radiograph made four years after open reduction and internal fixation of an acetabular fracture involving both columns.

 


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  		FIG1-B: Fig. 1-B: Radiograph made two years after a successful total hip arthroplasty in which the acetabular component was inserted without cement and the femoral component was inserted with cement (a so-called hybrid arthroplasty).

 

Survival of the Components
The ten-year survival rate with revision for any reason as the end point was 76 per cent (95 per cent confidence interval, 65 to 91 per cent), and the fifteen-year survival rate was 67 per cent (95 per cent confidence interval, 54 to 84 per cent). Survival with aseptic loosening as the end point was determined at ten and fifteen years for the prostheses as a whole (either component) and for the acetabular and femoral components separately (Figs. 2-A, 2-B, and 2-C). The ten-year survival rate with revision due to aseptic loosening as the end point was 78 per cent (95 per cent confidence interval, 66 to 92 per cent) for the prostheses (either component), 87 per cent (95 per cent confidence interval, 76 to 99 per cent) for the acetabular component, and 84 per cent (95 per cent confidence interval, 72 to 97 per cent) for the femoral component (Table II). Survival with mechanical failure as the end point was also determined, at ten and fifteen years, for the prostheses as a whole, for each component separately (Table II), and for the acetabular components inserted with cement and those inserted without cement (Fig. 3). Although all of the failed acetabular components had been inserted with cement and there was a trend toward better survival rates for the sockets inserted without cement, the duration of follow-up of the sockets inserted without cement was not long enough to demonstrate a significant difference in survival rates between the sockets inserted with cement and those inserted without it (p = 0.33).



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  		FIG2-A: Figs. 2-A, 2-B, and 2-C: Survivorship curves as determined with the Kaplan-Meier method17. The error bars indicate the 95 per cent confidence intervals. Fig. 2-A: Survival with revision of either component due to aseptic loosening as the end point.

 


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  		FIG2-B: Fig. 2-B Survival of the acetabular components with revision due to aseptic loosening as the end point.

 


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  		FIG2-C: Fig. 2-C Survival of the femoral components with revision due to aseptic loosening as the end point.

 

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  		TABLE II SURVIVAL RATES FOR THE COMPONENTS*

 


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  		FIG3: Fig. 3 Survivorship curves, as determined with the Kaplan-Meier method17, for the acetabular components inserted with cement and those inserted without cement. Revision due to mechanical failure (aseptic or radiographic loosening) was the end point. The error bars indicate the 95 per cent confidence intervals.

 
Survival with revision due to aseptic loosening as the end point (for the acetabular and femoral components together and separately) was analyzed further with respect to several variables: the type of acetabular fracture (posterior wall compared with all other types), type of deficiency of the acetabular bone noted at the total hip arthroplasty, presence of non-union of acetabular fragments, type of fixation (with or without cement), age at the time of the arthroplasty (less than fifty years compared with fifty years or more), gender, and body weight (less than eighty kilograms compared with eighty kilograms or more).

A necrotic segment of acetabular bone was noted in five patients, and thirteen patients had non-union of an acetabular fragment. No patient had non-union of an anterior or posterior column or pelvic discontinuity. Forty-six hips had no or only slight deficiency of the acetabular bone, seven had type-I (segmental) deficiency, eight had type-II (cavitary), and five had type-III (combined segmental and cavitary). An age of less than fifty years (p = 0.002) and a weight of eighty kilograms or more (p = 0.04) were significantly associated with a poorer rate of survival of the acetabular and femoral components (Table III). The rate of survival of the femoral component was poorer in men than in women (Table III). Type-III bone loss7 was significantly associated with a poorer rate of survival of the acetabular component (p < 0.0001) (Table III): the ten-year survival rate of the acetabular components associated with type-III deficiency was only 27 per cent (Figs. 4-A, 4-B, and 4-C) compared with 93 per cent for the rest of the cohort (Figs. 5-A and 5-B). None of the remaining variables were found to have a significant effect on the survival of either the acetabular or the femoral component. In some cases, the number of events that occurred in the two groups was small; hence, the power to detect differences was limited.


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  		TABLE III TEN-YEAR SURVIVAL RATES ACCORDING TO VARIOUS FACTORS*

 


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  		FIG4-A: Figs. 4-A, 4-B, and 4-C: A twenty-three-year-old man who had post-traumatic osteoarthrosis in the right hip. Fig. 4-A: Radiograph made two years after open reduction and internal fixation of a fracture-dislocation of the posterior column and posterior wall of the acetabulum. There is combined segmental and cavitary (type-III) loss of acetabular bone.

 


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  		FIG4-B: Fig. 4-B Radiograph made four months after a total hip arthroplasty performed with cement and use of a bulk acetabular bone graft. The trochanteric fixation wires have broken.

 


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  		FIG4-C: Fig. 4-C Radiograph, made six years postoperatively, demonstrating complete dislodgment of the acetabular component from the pelvis and associated dislocation of the femoral head, loosening of the femoral component, and a trochanteric non-union.

 


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  		FIG5-A: Figs. 5-A and 5-B: A thirty-seven-year-old man who had post-traumatic osteoarthrosis in the left hip. Fig. 5-A: Radiograph made twenty-one years after open reduction and internal fixation of a fracture-dislocation of the posterior wall of the acetabulum. There is little loss or deformity of the acetabular bone.

 


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  		FIG5-B: Fig. 5-B: Radiograph made twenty years after a successful total hip arthroplasty.

 

Complications
A partial peroneal nerve palsy developed in one patient postoperatively. There were no infections. Three hips dislocated at two, six, and eighteen years postoperatively. Two dislocations were due to forced hyperflexion of the hip, and the third was due to a fall from a tree. One of these hips was ultimately revised at 2.3 years postoperatively because of recurrent dislocation, as mentioned previously, and one hip remained stable. Recurrent painless subluxation developed in the remaining hip, but the patient declined operative treatment.

Six patients had a total of six medical complications, including a urinary tract infection, intestinal ileus, upper gastrointestinal bleeding, cholecystitis, atrial fibrillation, and a non-fatal pulmonary embolism. There were no clinically evident deep venous thromboses. The non-fatal pulmonary embolism occurred on the fourth postoperative day.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
The purpose of this study was to evaluate the results of total hip arthroplasty performed in a large series of patients after previous operative treatment of an acetabular fracture. We focused on the degree to which sequelae of the previous injury and its treatment affected the difficulty of, and the rate of complications associated with, a subsequent total hip arthroplasty. In addition, we attempted to identify the factors affecting the long-term survival rate of total hip prostheses inserted under these circumstances.

The results in several large series of operatively treated acetabular fractures have demonstrated a close association between the accuracy of the reduction and the clinical outcome4,20,22,23,25,28,31,35. Unfortunately, even when the procedure is performed by an expert, degenerative osteoarthrosis or symptomatic osteonecrosis of the femoral head sometimes develops following treatment of an acetabular fracture with open reduction and internal fixation19,20. When this occurs, a total hip arthroplasty is often used as a salvage procedure. The outcomes of total hip arthroplasties performed after an acetabular fracture have varied greatly in different series2,6,12,16,18,21,27,34,36, possibly in part because of the different forms of treatment that were used before the arthroplasties. Residual pelvic and acetabular deformity after non-operative treatment of an acetabular fracture has been shown to increase the rate of loosening of the acetabular component associated with total hip arthroplasty30. However, total hip arthroplasty after previous open reduction and internal fixation has been reported to be associated with a high rate of complications, including infection and the formation of heterotopic bone16,18.

A clinician who treats an acetabular fracture should know the degree to which failure of an open reduction and internal fixation procedure will influence the outcome of a subsequent total hip arthroplasty. Similarly, a physician who treats an osteoarthrotic hip with a total hip arthroplasty after previous open reduction and internal fixation of an acetabular fracture should know the likelihood of a satisfactory outcome and of complications. This information is difficult to obtain from the available literature. Previous studies either have included both operatively and non-operatively managed patients or have included only a limited number of patients who were followed for a relatively short time.

The present study demonstrates that total hip arthroplasty performed after previous operative treatment of an acetabular fracture, although more difficult technically than routine primary total hip replacement, can be reasonably safe and efficacious. The rate of survival of the prostheses was lower than that in most reported series of total hip arthroplasties in the general population. This is probably partly because the patients were predominantly young, active, and male. Although the rate of survival of the acetabular components inserted without cement appeared to be better than that of the components inserted with cement, a significant difference could not be demonstrated with the numbers available.

It takes many years to obtain a large cohort of patients who need total hip arthroplasty after open reduction and internal fixation of an acetabular fracture, even at a center that performs more than 1000 hip arthroplasties a year. One strength of the present study is the large number of patients that was analyzed. The primary weakness is that the study covers twenty-three years, during which the designs and techniques of total hip arthroplasty have evolved. While the heterogeneity of the prosthetic designs in this study is acknowledged, we believe that it is important to include prostheses that are intended for insertion with cement as well as those intended for insertion without it (with separate subanalysis of both) in order to provide information on the outcomes associated with the breadth of prosthetic fixation options that are currently available. Survivorship analysis was used to allow comparison of the outcomes associated with multiple variables despite the different durations of follow-up.

The results of this study are consistent with those of previous reports that showed that hip arthroplasty is an effective means of salvaging a hip in which post-traumatic osteoarthrosis has developed following an acetabular fracture6,12,21,36. Boardman and Charnley2 reported mostly good results following sixty-eight total hip arthroplasties that had been performed in hips that had a fracture-dislocation (thirteen had been treated previously with open reduction and internal fixation). Pritchett and Bortel27, in 1991, and Waddell34, in 1994, also reported good or excellent short and mid-term results in nineteen and thirty-four hips, respectively, that had been treated with total hip arthroplasty after an acetabular fracture; most of the fractures had been treated non-operatively.

Previously reported results of total hip arthroplasty in patients managed exclusively with open reduction and internal fixation for an acetabular fracture have been mostly disappointing. Joly et al.16 reported twelve failures in thirty patients due to loosening, massive heterotopic ossification, or infection at an average of twenty-three months postoperatively. The findings of the present study are similar to those reported by Karpos et al.18 for twenty-five patients (seventeen of whom had been managed previously with open reduction and internal fixation and eight of whom had not). Karpos et al. found that the arthroplasty was more difficult to perform in the group that had been treated with open reduction and internal fixation, but they reported excellent results for both groups.

We found that previous operative treatment of an acetabular fracture increased the technical complexity of the total hip arthroplasty (moderately in most hips) compared with a routine primary total hip arthroplasty. Extensive scar tissue, excision of heterotopic bone, and retained hardware all contributed to the greater difficulty. The combination of these factors, in addition to the technical difficulties of acetabular reconstruction imposed by loss and deformity of pelvic bone, all contributed to the longer operative times and greater blood loss in some patients.

The rate of complications in the present series was lower than that reported by some authors. Boardman and Charnley2 reported ten complications, including three deaths, in a study of sixty-six patients. Rogan et al.29 reported nine complications after thirty-nine operations, and Waddell34 reported eight after thirty-four operations. The complications in those series included dislocation, infection, and the formation of heterotopic bone. There were no infections or early postoperative dislocations in the present series; however, three hips had late dislocation.

To our knowledge, the present study provides the longest-term information on the survival of total hip prostheses that were implanted after previous operative treatment of acetabular fractures. The survival rate in the present series is inferior to the rates reported in most long-term series of total hip arthroplasties performed for other indications. However, it is important to recognize that the patients in this series were predominantly young, male, and heavy and had unilateral hip disease; all of these factors are known to be associated with a higher risk of mechanical failure of prostheses5,9.

In 1990, Romness and Lewallen30 reported on fifty-five hips that had been treated with total hip arthroplasty after an acetabular fracture (thirteen had had previous open reduction and internal fixation). At a mean of 7.3 years after the arthroplasty, they found rates of symptomatic loosening and revision of the acetabular component that were four to five times higher than those in a comparative group of hips that had had primary total hip arthroplasty for other indications at the same institution. These findings are consistent with those reported by Herberts and Malchow13, who reviewed data from the Swedish Joint Registry and found that, of any demographic subgroup, male patients who had post-traumatic osteoarthrosis had the poorest rate of survival of total hip prostheses. Five of the twenty femoral components that had been inserted without cement in the present study had loosened. The implants that failed were early designs that were meant to be inserted without cement; thus, the high rate of failure of these femoral implants was probably related in part to the design rather than to femoral abnormalities associated with the acetabular fracture.

In the present study, the degree of deficiency of the acetabular bone after the open reduction and internal fixation was strongly associated with the risk of mechanical failure of the acetabular component. Patients who had extensive combined segmental and cavitary (type-III) loss of acetabular bone had a markedly higher rate of failure of the acetabular component than those who had less bone loss. This suggests that restoration of the acetabular osseous anatomy at the time of open reduction and internal fixation can be beneficial, even if the hip subsequently becomes osteoarthrotic and a total hip arthroplasty is needed. Because all of the acetabular components that loosened (clinically and radiographically) in this series had been inserted with cement, it is not known whether the amount of residual deformity of the acetabular bone will have such a marked impact on the survival rate of sockets inserted without cement.

No acetabular component that had been inserted without cement in this series was revised because of aseptic loosening or was radiographically loose. Because these components were not followed for as long as the components that had been inserted with cement, the trend toward better survival of components inserted without cement was not found to be significant with the numbers available. Nevertheless, insertion of the acetabular component without cement appears to offer advantages compared with insertion with cement after operative treatment of an acetabular fracture, much as insertion of the socket without cement appears to be advantageous in an acetabular revision procedure, a similar setting in which deficiencies in the acetabular bone are common and remaining bone is often sclerotic24,26,33.

In summary, the present study demonstrates that total hip arthroplasty after previous operative treatment of an acetabular fracture is often more difficult than a routine total hip arthroplasty because of extensive scarring, heterotopic bone, retained internal fixation devices, and residual deformity of the acetabular bone. Despite these difficulties, the clinical outcome was good in most patients and the rate of complications was moderate. Large deficiencies in the acetabular bone were associated with a poorer rate of long-term survival of the acetabular components inserted with cement. This cohort of mostly young, active male patients had a higher long-term rate of loosening of the components compared with published series of mostly older patients who had other underlying diagnoses.


   Footnotes
 
*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

{dagger}Department of Orthopaedic Surgery, University of Bern, Inselspital, CH-3010 Bern, Switzerland.

{ddagger}Departments of Orthopedics (D. J. B.) and Medical Statistics (W. S. H.), Mayo Clinic, 200 First Street S.W., Rochester, Minnesota 55905.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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