Complex Total Hip Arthroplasty in a Young Patient with Previous Acetabulum Fracture and Exposed Intra-Articular Hardware: A Case Report and Review of the Literature
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Citation: Complex Total Hip Arthroplasty in a Young Patient with Previous Acetabulum Fracture and Exposed Intra-Articular Hardware: A Case Report and Review of the Literature. American Research Journal of Orthopedics and Traumatology. 2017; 2(1): 1-6.
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Acetabular fractures can complicate hip arthroplasty and result in higher rates of intraoperative complications and worse long-term outcomes1 . Previous studies have shown increased rates of acetabular-sided complications and worse long-term outcomes in the setting of prior acetabular fractures. We present a total hip arthroplasty complicated by severe post-traumatic arthritis and a vascular necrosis. The patient was found to have a Paprosky Type IIA acetabular defect with exposed intra-articular hardware due to aprevious both-column acetabulum fracture treated with open reduction and internal fixation. Cancellous autograft was used for acetabular reconstruction and a cementless acetabular cup was inserted, as survival has been shown to be superior to cemented cups in patients with acetabular deficiency. Subsequent follow-up showed well fixated components with a good functional outcome in this patient.
Total hip arthroplasty (THA) has drastically improved the quality of life in patients dealing with debilitating conditions of the hip, and has even been called the operation of the century2 . With the advance of surgical techniques, we are performing total hip arthroplasty in more complicated patients including patients with complex acetabular pathology. However, studies have shown increased complication and revision rates in patients with a history of acetabulum fractures when compared with patients undergoing THA for primary osteoarthritis or avascular necrosis (AVN)1 . Overall intermediate survivorship has been shown to be lower in these patients due to aseptic loosening, infection, dislocation, and heterotopic ossification. It has been reported that THA survivorship is independent of fracture management: open reduction and internal fixation (ORIF) versus non-operative treatment1 . Despite the challenges, Roth et. al. reported positive outcomes in 87% of patients ten years post-operatively who underwent THA with a history of previous acetabular fracture3 .
We now report a complex primary THA in a young patient with a previous both-column acetabular fracture status-post ORIF oneyear prior who went on to develop severe post-traumatic arthritis and AVN with subsequent limb-length discrepancy and acetabular bone loss with exposed intra-articular hardware. A posterolateral approach was utilized. Acetabular bone grafting was performed using healthy femoral neck cancellous autograft. A similar case report noted a positive outcome three years post-operatively in a patient who underwent acetabular ORIF followed by autograft acetabular reconstruction and cementless THA4 .
This patient is a 46 year old female referred to our clinic for right hip pain. She was riding a bicycle one year prior when she was struck by a vehicle. She went to an outside facility with multiple injuries including a right both column acetabulum fracture and left sacroiliac (SI) joint disruption. She also had a right tibia fracture, multiple fractured ribs, and various abdominal injuries. The both-column acetabular fracture was treated with open reduction and internal fixation (ORIF) through a Stoppa approach with a separate lateral window at the outside facility. Percutaneous screws were placed across the left SI joint. Her post operative course was complicated by a bladder injury requiring reopening of the Stoppa incision, bladder repair, and a suprapubic catheter. She has gone on to heal all her wounds but complained of persistent and severe, aching right groin pain for one-year duration. She has been unable to bear weight on her right lower extremity over the last year. She is a one-half pack-per-day smoker on chronic narcotics. In addition, she has low back pain with radicular symptoms likely secondary to scoliotic deformity and pelvic obliquity due to shortening of the right lower extremity of approximately five centimeters. Clinically, the patient showed evidence of lower extremity wasting due to disuse. Right hip aspiration was negative for infection two months prior. X-rays (Figure 1) and CT scans reveal severe post-traumatic arthritis and AVN of the right hip with resultant superomedial migration of the acetabulum and limb-length discrepancy. Hardware was observed anterior, posterior, and superior to the acetabulum with possibility of at least threeintra-articular screws.
Total hip arthroplasty was planned with anticipation of acetabular bone graft augmentation and possible diamond tipped burr for reaming of intra-articular hardware. The risks, benefits, and alternatives of the procedure were explained and the patient elected to proceed. The patient was brought to the operating room and positioned in the right lateral decubitus position and a standard posterior approach to the hip was utilized. Once dissection was carried down to the hip joint and femoral neck cut made, the femoral head was extracted and observed to be completely atrophic (Figure 2).
The neck was found to be relatively healthy and therefore the cancellous bone was harvested for acetabular defect reconstruction. Following excision of the acetabular scar tissue and serial reaming, the acetabular rim was intact, but there was superomedial bone loss resulting in visualization of the anterior column plate and associated screws (Figure 3).