Sciatic nerve injuries associated with acetabular fractures may be a result of the initial trauma or injury at the time of surgical reconstruction. Patients may present with a broad range of symptoms ranging from radiculopathy to foot drop. There are several posttraumatic, perioperative, and postoperative causes for sciatic nerve palsy including fracture–dislocation of the hip joint, excessive tension or inappropriate placement of retractors, instrument- or implant-related complications, heterotopic ossification, hematoma, and scarring. Natural history studies suggest that nerve recovery depends on several factors. Prevention requires attention to intraoperative limb positioning, retractor placement, and instrumentation. Somatosensory evoked potentials and spontaneous electromyography may help minimize iatrogenic nerve injury. Heterotopic ossification prophylaxis can help reduce delayed sciatic nerve entrapment. Reports on sciatic nerve decompression are not uniformly consistent but appear to have better outcomes for sensory than motor neuropathy.
sciatic nerve palsy; acetabular fracture; hip dislocation; heterotopic ossification
Femoral head fractures may present in various patterns with or without associated fractures around the hip. As a result, the treating orthopaedic surgeon must understand not only the fracture pattern, but also patient-related fractures and the relevant operative exposures and reconstructive options to achieve the best functional outcome while minimizing complications. Treatment options range from non-operative treatment to fracture fragment excision or fracture fixation using various surgical exposures and implants. This article reviews the current literature on the treatment options for femoral head fractures and presents modern operative techniques that have improved exposure of the fracture while minimizing associated risks such as avascular necrosis, heterotopic ossification, and neurovascular compromise. A sound understanding of the anatomy and these newer techniques can enable the surgeon to provide improved expectations and clinical outcomes.
Femoral head fracture; Hip; Surgical dislocation; Hip dislocation; Trauma
There are a few studies reporting the long term outcome of conservatively treated acetabular fractures. The present study aims to evaluate the quality of reduction, and radiological and functional outcome in displaced acetabular fractures treated conservatively.
Materials and Methods:
Sixty-nine patients (55 men and 14 women) with 71 displaced acetabular fractures (mean age 38.6 years) managed conservatively were retrospectively evaluated. There were 11 posterior wall, 5 posterior column, 6 anterior column, 13 transverse, 2 posterior column with posterior wall, 9 transverse with posterior wall, 6 T-shaped, 1 anterior column with posterior hemi-transverse, and 18 both-column fractures. The follow-up radiographs were graded according to the criteria developed by Matta J. Functional outcome was assessed using Harris hip score and Merle d’Aubigne and Postel score at final followup. Average follow-up was 4.34 years (range 2–11 years).
Patients with congruent reduction (n=45) had good or excellent functional outcome. Radiologic outcome in incongruent reduction (n=26) was good or excellent in 6 and fair or poor in 20 hips. The functional outcome in patients with incongruent reduction was good or excellent in 16 and satisfactory or poor in 10 hips. Good to excellent radiologic and functional outcome was achieved in all patients with posterior wall fractures including four having more than 50% of broken wall. Good to excellent functional outcome was observed in 88.8% of both-column fractures with secondary congruence despite medial subluxation.
Nonoperative treatment of acetabular fractures can give good radiological and functional outcome in congruent reduction. Posterior wall fractures with a congruous joint without subluxation on computed tomography axial section, posterior column, anterior column, infratectal transverse or T-shaped, and both-column fractures may be managed conservatively. Small osteochondral fragments in the cotyloid fossa or non–weight-bearing part of the hip with a congruous joint do not seem to adversely affect the functional outcome. Displaced transverse fractures with “V” sign may require operative treatment.
Acetabulum fracture; anterior column fractures; posterior column fractures; conservative treatment
The general outcome of posterior wall acetabular fractures is still the source of discussion. Posterior wall fractures are recognized throughout the literature as being difficult to treat. The aim of the present study was to analyze in our own patients the relevance of the classical prognostic criteria for the outcome of isolated posterior wall fractures and those with associated lesions.
Materials and methods
A prospective cohort of 33 consecutive patients treated operatively between 1996 and 2006 in a single level 1 trauma center for a posterior wall fracture of the acetabulum was analyzed retrospectively. Included were posterior wall acetabular fractures or associated posterior wall fractures, such as the combinations of posterior column with posterior wall, transverse with posterior wall, or T-shaped fracture with posterior wall fracture. Outcome measurement of the postoperative survival of the hip joints until the primary outcome reoperation (total hip replacement or fusion) and secondary outcome diagnosis of symptomatic osteoarthritis were performed.
Twenty-six of the 33 patients with posterior wall fractures also had a dislocated joint. Twelve had isolated and 21 associated fractures. Six patients were reoperated with a THA (four patients within 2 years and one after 10 years), and one arthrodesis was done to treat a hematogenous septic arthritis in a degenerative hip joint. Secondary arthritis was observed in 10 patients.
No difference was found between the outcome in cases of isolated posterior wall acetabular fracture and the outcome in those with associated lesions. The classical prognostic criteria were not found to be relevant to the outcome for our group.
Acetabulum; Posterior wall acetabular fractures; Associated lesion; Outcome; Prognosis
Background and Purpose
Acetabular fractures are often combined with associated injuries to the hip joint. Some of these associated injuries seem to be responsible for poor long-term results and these injuries seem to affect the outcome independent of the quality of the acetabular reduction. The aim of our study was to analyze the outcome of both column acetabular fractures and the influence of osseous cofactors such as initial fracture displacement, hip dislocation, femoral head lesions and injuries of the acetabular joint surface.
A retrospective cohort study in patients with both column acetabular fractures treated over a 30 year period was performed. Patients with a follow-up of more than two years were invited for a clinical and radiological examination. Displacement was analyzed on initial and postoperative radiographs. Contusion and impaction of the femoral head was grouped. Injuries of the acetabular joint surface consisting of impaction, contusion and comminution were recorded. The Merle d’Aubigné Score was documented and radiographs were analysed for arthritis (Helfet classification), femoral head avascular necrosis (Ficat/Arlet classification) and heterotopic ossifications (Brooker classification).
115 patients were included in the follow up examination. Anatomic reduction (malreduction ≤ 1mm) was associated with a significantly better clinical outcome than nonanatomical reduction (p = 0.001). Initial displacement of more than 10mm (p = 0.031) and initial intraarticular fragments (p = 0.041) were associated with worse outcome. Other associated injuries, such as the presence of a femoral head dislocation, femoral head injuries and injuries to the acetabular joint surface showed no significant difference in outcome individually, but in fractures with more than two associated local injuries the risk for joint degeneration was significant higher (p < 0.001) than in cases with less than two of them.
In the subgroup of anatomically reconstructed fractures no significant influence of the analyzed cofactors could be observed.
Anatomical reduction appears to be an important parameter for a good clinical outcome in patients with both column acetabular fractures. Additional fracture characteristics such as the initial displacement and intraarticular fragments seem to influence the results. Patients should also be advised that both column acetabular fractures with more than two additional associated factors have a significantly higher risk of joint degeneration.
Both column acetabular fractures; Outcome prediction; Long term results
Isolated acetabular revision can be associated with variable patient outcomes; there is a risk of hip instability. We evaluated 42 isolated acetabular revision operations and investigated the impact of patient age, diagnosis, bone stock, bone loss, bone augmentation, and obesity on pain and the Harris hip score. Preoperative radiographs were graded according to Paprosky et al. Postoperative radiographs were graded according to Moore et al. and for implant position, prosthetic fixation, and osteolysis. Complications, patient outcome, reoperations, and acetabular rerevisions were recorded. All patients had complete clinical and radiographic followup with a minimum followup of 2 years (mean, 6.4 years; range, 2–13 years). The mean pain score and the mean Harris hip score improved postoperatively. There was one infection 6 months after operation. There were no dislocations. There were three acetabular rerevisions (7%) for aseptic loosening. Patient age, preoperative diagnosis, bone loss, and pelvic bone augmentation had no influence on pain or Harris hip scores. Before operation, obese patients tended to have less pain than nonobese patients but at followup obese patients had less improvement in pain scores than nonobese patients.
Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Acetabular fractures in the elderly are increasingly common; however, an antecedent of trauma may not be known, and the diagnosis easily missed. Early identification and prompt management are needed in order to minimise morbidity rates, but little has been published on occult acetabular fracture.
In this paper we present three cases of occult acetabular fracture in patients older than 75 years. All three are females and had previously been operated on the ipsilateral hip with an implant (two proximal femur fractures treated with a proximal intramedullary femoral nail, and one case of total joint replacement); these acetabular fractures could be related to the existence of a stress shielding mechanism.
We believe that whenever an elderly patient feels groin pain, and anteroposterior pelvis X-rays are normal, oblique Judet projections (obturator and iliac) should be obtained. In any case, displacement will make any fracture evident within a few weeks.
Acetabular fracture; elderly; fracture; hip arthroplasty; occult; missed diagnosis; total hip replacement
Between 1982 and 1995, 84 patients with
displaced acetabular fractures underwent open reduction and
internal fixation in our institution. The mean follow-up was 5.5
years with a minimum of 2 years. There were 33 simple and 51
complex fractures according to the classification of Judet and
Letournels. Reduction after operation was anatomical in 49% of
the patients, satisfactory in 24%, and unsatisfactory in 27%.
Using Merle d’Aubigné’s scale, the clinical results were
excellent in 39% of the patients, good in 29%, fair in 8%, and
poor in 24%. Factors of statistical significance associated with
a poor clinical outcome were T-shaped fractures, unsatisfactory
reduction (>3 mm residual displacement), age >40 years and
development of avascular necrosis. Acetabular surgery is
demanding, and a high rate of complications can be expected.
Trauma centres should designate a group of surgeons who will
consistently treat these fractures in order to obtain more
experience and better results.
To evaluate the effects of clinical factors on outcome after acetabular revision with a cementless beaded cup.
Retrospective case series.
Tertiary care referral centre.
Forty-one patients who underwent acetabular revision with a cementless cup were followed up for a mean of 3.4 years.
Acetabular revision with a beaded cementless cup in all patients. A morcellized allograft was used in 10 patients.
A modified Harris hip score (range of motion measurement omitted), the SF-36 health survey, and the Western Ontario McMaster (WOMAC) osteoarthritis index. Multivariate analysis was used to evaluate the effects of age, gender, morcellized allografting, time to revision from the previous operation, acetabular screw fixation and concurrent femoral revision on outcome.
Gender accounted for a significant portion of the variation seen in the SF-36 physical component scores (r = 0.36, p = 0.02), with women tending to have worse results. Increasing age was associated with lower WOMAC index function scores (r = 0.36, p = 0.03), whereas concurrent femoral revision tended to have a positive effect on WOMAC index function (r = 0.39, p = 0.01). None of the potential clinical predictors had any significant effect on the SF-36 mental component scores, or WOMAC index pain and stiffness scores.
In cementless acetabular revision arthroplasty, physical function, as measured by generic and limb-specific scales, may be affected by gender, age and the presence of a concurrent femoral revision. Time to revision from the previous operation, morcellized allografting and screw fixation of the acetabulum did not affect outcomes. This information may provide some prognostic value for patients’ expectations.
Hemiarthroplasty (HA) is generally considered to be the treatment of choice in the most elderly patients with a displaced fracture of the femoral neck. However, there is inadequate evidence to support the choice between unipolar HA or bipolar HA. The primary aim of this study was to analyse the outcome regarding hip function and health-related quality of life (HRQoL) in patients randomised to either a unipolar or bipolar HA. The secondary aim was to analyse the degree of acetabular erosion and its influence upon outcome.
One hundred twenty patients with a mean age of 86 years and an acute displaced fracture of the femoral neck were randomly allocated to treatment by either unipolar or bipolar HA. Outcome measurements included hip function (Harris Hip Score, HHS), HRQoL (EQ-5D) and acetabular erosion. The patients were summoned at four and 12 months for follow-up.
There were no significant differences between the groups regarding complications. The HHS scores were equal at both follow-ups, but there was a trend towards better HRQoL in the bipolar HA group at four months, EQ-5D index score 0.62 vs 0.54 (p = 0.06). Twenty percent of the patients in the unipolar HA group displayed acetabular erosion at the 12-month follow-up compared to 5% in the bipolar HA group (p = 0.03), and there were trends towards worse hip function and HRQoL among patients with acetabular erosion compared to those without: HHS scores 70.4 and 79.3, respectively (p = 0.09), and EQ-5D index scores 0.48 and 0.63, respectively (p = 0.13).
Unipolar HA and bipolar HA appeared to produce equivalent clinical outcomes after one year, but the significantly higher incidence of acetabular erosion in the unipolar HA group may imply that bipolar HA should be the preferred treatment.
Although the incidence of
post-operative nerve palsy after total hip replacement is rare,
it is an important complication for the patient. In a
retrospective study the results of 2713 hip arthroplasties were
reviewed. Sixty-one cases (2.24%) of post-operative neuropathy
were identified, 13 of the sciatic nerve, 33 of the peroneal
nerve and 15 of the femoral nerve. The risk is significantly
higher in revisions (3.06%), especially when exchanging the
acetabular component (8.5%) rather than in primary
arthroplasties (2.13%). After an average period of 107 months
(11 – 240) from operation, 41 patients with nerve lesions were
questioned about their subjective functional capacity: 17% had
recovered completely, 39% had noticed an improvement, and in 44%
there was no change; 56.1% complained of weakness and had a
complete paralysis. In all cases there was dysfunction of
sensibility. Another 17.1% had a sensibility defect without
weakness. There was pain in 51.2%, paraesthesia in 34.1% and
areas of complete anaesthesia in 19.5%. Altogether 61% of the 41
patients had either gait problems or were dependent on orthotic
devices. In summary, only about a third of the patients studied
achieved a satisfactory degree of functional
Operative management of displaced acetabular fractures yields better results than nonoperative management. Over the past decade, surgical approaches to the acetabulum and the surgical tactic for repair of common fracture patterns have been advanced. Excellent outcomes after repair of these injuries can be achieved. In some cases, as in the elderly, or in those cases in which there is significant destruction of the articular cartilage, primary total hip arthroplasty may provide the best solution. Removal of the femoral head allows for excellent exposure of the acetabulum, making it possible to stabilize most fractures without the need for extensile or intrapelvic approaches. The surgical technique that has been successfully used calls for gaining primary stability of the acetabular columns by open reduction and internal fixation and then using the acetabular component to replace the articular surface. The columns need not be anatomically reduced. Multiholed acetabular shells can be used as internal fixation devices by placing screws into the columns enhancing the stability of the repair. In older individuals with severe osteoporosis, a typical fracture pattern results in intrapelvic dislocation of the femoral head with a blowout fracture of the anterior column and medial wall. Reinforcement rings with cemented acetabular fixation can be used in these cases. The femoral head can be used as bulk bone graft to replace and reinforce the reconstruction. Techniques common to revision of failed acetabular components are helpful in this setting. The results of reconstruction of severe acetabular fractures with total hip replacement have been reported to be similar to those achieved for reconstruction of osteoarthritis.
Controversy exists regarding the outcome of THA after prior pelvic osteotomy.
We conducted a retrospective chart and radiographic review to obtain outcome measures for perioperative complications, acetabular and femoral component revisions, Harris hip score, and survivorship and compared these outcomes for patients presenting with developmental dysplasia of the hip treated surgically using THA with and without prior pelvic osteotomy.
Patients and Methods
We performed 103 primary THAs in 87 patients with osteoarthritis secondary to developmental dysplasia of the hip with a minimum 3-year followup. Previous pelvic osteotomy was performed in 52 hips (Salter, 40; Chiari, nine; Salter and Chiari, three), and 51 hips had no previous surgery (control group).
The pelvic osteotomy group did not have higher rates of femoral or acetabular intraoperative fracture or dislocation compared with the control group. The overall revision rate was 28.8% in the pelvic osteotomy group compared with 19.6% in the control group. The revision rate for aseptic loosening was 23.1% in the pelvic osteotomy group compared with 17.6% in the control group. Harris hip scores (range, 20–87) were not compromised, and overall survivorship rates 8 years postoperatively were not different at any time between the pelvic osteotomy (83.3%) and control (88.4%) groups.
Prior pelvic osteotomy did not lead to a higher perioperative complication rate, higher revision rate, compromised Harris hip score, or shortened survivorship in eventual THA in developmental dysplasia of the hip.
Level of Evidence
Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Ninety-nine hips treated by the Chiari pelvic osteotomy were included in this study designed as a retrospective review. The group consisted of 36 male and 50 female patients, with mean age of 15.6 years. Each was diagnosed with developmental dysplasia of the hip (DDH) or avascular necrosis of the femoral head—Legg-Calve-Perthes disease (LCP)—and postreduction avascular necrosis (PAN). Five hip parameters (the acetabular angle of Sharp, the center-edge (CE) angle of Wiberg, the percentage of femoral head uncoverage, the acetabular depth ratio, and the Shenton-Menard arch continuity) were evaluated. Functional outcome was assessed according to Harris hip score (HHS) and McKay criteria for clinical evaluation. The postoperative results showed improvement in all the radiographic parameters. The angle of Sharp showed a decrease of 8.62º (p < 0.01). The CE angle of Wiberg showed an increase of 28.76º (p < 0.01), and the uncoverage of the femoral head showed a decrease of 51.51% (p < 0.01). The improvement of HHS was 11.93 (p < 0.05). The patients’ satisfaction was indicated by grade 4.1 ± 0.94 and the doctor’s satisfaction by grade 3.7 ± 1.16. The Chiari pelvic osteotomy, in spite of the development of biologically better procedures, has retained its position in the treatment of adolescent hip disorders.
We describe the clinical and radiological long-term outcomes of 77 primary total hip replacements in 69 patients using the fully hydroxyapatite-coated JRI (Furlong) total hip replacement. The total cases followed up were 77 hips, performed at a mean duration of 11 years and 2 months. Twelve hips could not be followed up for various reasons, which are discussed in the results section. The mean Harris hip score was 89. Seventeen acetabular cups were revised for aseptic loosening. Only one femoral stem was revised, for fracture. By Engh’s criteria there were a further two unstable cups with no symptoms, and all femoral stems were stable. Kaplan–Meier survivorship analysis revealed a survival of 98.8% for the femoral stem, 78.7% for the acetabular cup, and a combined survival of 77.8% for both components. Our findings suggest that the JRI (Furlong) hip gives a durable femoral stem implant fixation, whereas the prosthesis–bone interface achieved with the acetabular component is questionable.
Hip dislocation after arthroplasty for femoral neck fractures remains a serious complication. The aim of our study was to investigate the dislocation rate in acute femoral neck fracture patients operated with a posterior approach with cemented conventional or dual articulation acetabular components.
We compared the dislocation rate in 56 consecutive patients operated with conventional (single mobility) cemented acetabular components to that in 42 consecutive patients operated with dual articulation acetabular components. All the patients were operated via posterior approach and were followed up to one year postoperatively.
There were 8 dislocations in the 56 patients having conventional components as compared to no dislocations in those 42 having dual articulation components (p = 0.01). The groups were similar with respect to age and gender distribution.
We conclude that the use of a cemented dual articulation acetabular component significantly reduces the dislocation rates in femoral neck fracture patients operated via posterior approach.
We conducted a prospective study of the clinical and radiographic variables related to the survival of 114 cementless resurfacing double-cup hip replacements (RHR) with a mean follow-up of 9 (range: 1–16) years. Three patients died, and 22 were unavailable for the final review in 2003. Sixty-one RHRs had to be revised to a total hip replacement. Failure analysis of these revised RHRs showed femoral head and neck resorption under the prosthesis in 33, acetabular protrusion in seven, both femoral and acetabular resorption in 14 and a femoral-neck fracture in three. One hip had dislocated, and there were three hips with unexplained pain. The Kaplan–Meier 5-year mean survival was 92%, the 10-year survival was 47% (95% CI 37–57%) and the 15-year survival was 30% (95% CI 20–40%). Pre-operative joint destruction (grade 1), a high degree of radiological osteoporosis, a body mass index >25 and prosthesis mismatch were significantly related to failure of the RHR. We believe that in young, non-obese patients with pre-operative radiological central destruction but without severe proximal femoral osteoporosis, a resurfacing arthroplasty may have some value. Our failures were mainly due to femoral resorption under the prosthetic femoral component.
The ilio-inguinal approach has come to be used routinely in the management of acetabular fractures involving the anterior wall. Thrombotic complications following surgery via this route are a serious, but rare, complication.
We report the case of a 66-year-old male patient who slipped on an icy pavement and fell on his left hip. He sustained a comminuted acetabular fracture (a transtectal T-fracture with an incomplete posterior stem through the ischial tuberosity), and was operated on five days later, via an ilio-inguinal approach. In the recovery room, his left lower limb was found to be cool and pale. Immediate re-exploration showed a left external iliac artery thrombosis, and thrombectomy was performed. In the surgical management of acetabular fractures, thrombosis of a major pelvic artery is a rare but potentially devastating complication. We discuss the possible aetiology (initial vessel trauma versus iatrogenic, intraoperative arterial injury) and pathomechanism, and wish to draw attention to this complication and to recommend ways in which it can be prevented.
We recommend circulation monitoring in patients with acetabular fractures, especially where nerve blocks and/or deep sedation/analgesia have been used. High-risk patients should be identified and subjected to intensive preoperative screening, including ultrasonography and if necessary angiography.
We followed prospectively 27 patients with severe acetabular bone-stock deficiencies due to developmental dysplasia of the hip. Mean preoperative patient age was 56 (34–78) years, mean Harris hip score was 31 (16–66) points and pre-operative mean acetabular angle of Sharp was 47° (34°–61°). Operative acetabular reconstruction was performed in 28 hips using reinforcement ring with a hook placed in the true acetabulum and autologous bone grafting. A 2-year clinical and radiological follow-up was available in 27 hips. Mean Harris hip score improved to 91 (70–100) points. There were no clinical or radiological signs of aseptic loosening in 25 hips, and the bone graft was radiologically incorporated in all hips. In 24 hips, a radiostereometric analysis showed low rates of non-progressive translation and rotation in 21 reinforcement rings. Three rings showed progressive translation and/or rotation at the 2-year follow-up and were rated probably loose.
The aim of this study was to determine whether a complex surgical procedure such as peri-acetabular osteotomy could be safely learnt by using a programme involving mentoring by a distant expert. To determine this, we examined the incidence of intra-operative complications, the acetabulum correction achieved, the late incidence of re-operation and progressive degenerative arthritis.
Between 1992 and 2004, peri-acetabular osteotomy was performed in 26 hips in 23 patients. The median follow-up was ten (5–17) years. The median age of the patients at operation was 28 (14–41) years. Clinical outcomes were reported and radiographic results were determined by an independent expert.
There were no intra-articular osteotomies, sciatic nerve injuries, hingeing deformities or vascular injuries. There was one ischial nonunion. The lateral centre-edge angle improved from a median 4° pre-operatively to 25°. One revision osteotomy, one osteectomy and three total hip replacements were required, two for progression of osteoarthritis.
The programme of mentoring was successful in that there was a low incidence of the major intra-operative complications that are often reported during the learning curve period and the acetabular corrections achieved were similar to the originators.
Medicine & Public Health; Orthopedics
It has been suggested that variances in the anatomy of the acetabulum determine the type of hip fracture in elderly patients. Based on this concept, an overly anteverted acetabulum would lead to impingement of the femoral neck against the posterior rim of the acetabulum, causing a femoral neck fracture, whereas with a retroverted acetabulum, external rotation of the hip would be limited by the capsular tissues attached to the trochanteric region, causing a trochanteric fracture. To test the hypothesis that acetabular version predicts hip fracture type in elderly patients, we measured acetabular version using computed tomography scans for 135 patients with hip fracture. Logistic regression analysis was used to check for an association between version angle and fracture type. No significant relationship between acetabular version and fracture type was found. Therefore, we conclude that acetabular version angle does not predict hip fracture type in the elderly, and our data do not support the impingement concept as the mechanism of hip fractures.
hip fracture; elderly; femoral neck fracture; trochanteric fracture
Pelvic discontinuity is an increasingly common complication of THA. Treatments of this complex situation are varied, including cup-cage constructs, acetabular allografts with plating, pelvic distraction technique, and custom triflange acetabular components. It is unclear whether any of these offer substantial advantages.
We therefore determined (1) revision and overall survival rates, (2) discontinuity healing rate, and (3) Harris hip score (HHS) after treatment of pelvic discontinuity with a custom triflange acetabular component and (4) the cost of this reconstructive operation compared to other constructs.
We retrospectively reviewed 57 patients with pelvic discontinuity treated with revision THA using a custom triflange acetabular component. We reviewed operative reports, radiographs, and clinical data for clinical and radiographic results. We also performed a cost comparison with utilization of other techniques. Minimum followup was 24 months (average, 65 months; range, 24–215 months).
Fifty-six of 57 (98%) were free of revision for aseptic loosening at latest followup. Fifty-four (95%) were free of revision of the triflange component for any reason. Thirty-seven (65%) were free of revision for any reason. Twenty-eight (49%) were free of revision for any reason and free of any component migration and had a healed discontinuity. Forty-six (81%) had a stable triflange component with a healed pelvic discontinuity. Average HHS was 74.8. The costs of the custom triflange implants and a Trabecular Metal® cup-cage construct were equivalent: $12,500 and $11,250, respectively.
In this group of patients with osteolytic pelvic discontinuity, triflange implants provided predictable mid-term fixation at a cost equivalent to other treatment methods.
Level of Evidence
Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Between 1997 and 2001 we treated 54 elderly patients with unstable intertrochanteric fractures by primary hemiarthroplasty using a cemented bipolar prosthesis. Mean patient age was 75.6 (64–91) years and mean follow-up was 22.3 (5–48) months. Seven patients died before the fourth post-operative month. Thirty-three patients were able to walk with a walker in the first post-operative week. There were no dislocations or aseptic loosening. One deep infection was encountered after 1 year. Acetabular erosion was seen in one patient and non-union of the greater trochanter was seen in four. Five patients experienced leg-length discrepancy. We obtained 17 excellent and 14 good results after 12 months according to the Harris hip-scoring system. We observed that the inner motion of the bipolar head decreased over time.
A 4-U hybrid total hip arthroplasty (THA) system was specifically designed for patients with developmental dysplasia of the hip (DDH). Straight stem with an appropriate offset and various size variations are advantages. We followed 128 hips in 124 patients, 13 men and 111 women, for a mean of 6.5 years (range, 5.0–7.5 years). Two acetabular and femoral components in two patients had been revised for infection, one acetabular component had been revised for recurrent dislocation, and one femoral component had been revised for periprosthetic femoral fracture. None of the acetabular or femoral components were revised for loosening or were found to be loose at follow-up. The Harris hip score increased from a preoperative average of 42 points to 88 points at the most recent follow-up. Primary THA using the 4-U system had a good mid-term result in patients with DDH. This system could be applied for all patients including those with the narrowest and deformed femurs.
Between January 1991 and December 1994, 132 uncemented total hip arthroplasties (THA) were performed on 125 patients over 65 years of age; of which 102 arthroplasties, performed in 90 patients, were followed for at least 4 years. One revision was necessary following fracture of an acetabular component secondary to trauma. The post-operative Harris hip score (HHS) ranged from 87 to 99. Radiologically there were no signs of subsidence of more than 3 mm, nor of osteolysis. Five patients experienced thigh pain. Based on the clinical and radiological results, uncemented total hip arthroplasties can give satisfactory function in elderly patients.