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THA TO SALVAGE FAILED ACETABULAR FRACTURES

THA TO SALVAGE FAILED ACETABULAR FRACTURES. Daniel J. Berry, MD Mayo Clinic Rochester, MN. THA AFTER ACETABULAR FX Technical Challenges. Acetabular bone loss Residual pelvic deformity Nonunited fractures Retained hardware Heterotopic ossification Socket fixation. THA FOR ACETABULAR FX.

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THA TO SALVAGE FAILED ACETABULAR FRACTURES

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  1. THA TO SALVAGE FAILED ACETABULAR FRACTURES Daniel J. Berry, MD Mayo Clinic Rochester, MN

  2. THA AFTER ACETABULAR FXTechnical Challenges • Acetabular bone loss • Residual pelvic deformity • Nonunited fractures • Retained hardware • Heterotopic ossification • Socket fixation

  3. THA FOR ACETABULAR FX ACETABULAR COMPONENT CHOICE

  4. THA AFTER ACETABULAR FX Previous ORIF Results: Long Term: • Higher failure rate than THA for OA • Pts young/male/unilateral disease • Uncemented cups better so far than cemented (similar scenario to revision THA) Weber et al. JBJS 80A(9):1295-1305, 1998

  5. SURVIVAL FREE REVISION FOR ASEPTIC ACET LOOSE/RADIOGRAPHIC LOOSENINGCemented vs Uncemented

  6. THA AFTER ACETABULAR FXAcetabular Bone Loss Socket Fixation: • Apply principles of revision THA (similar sclerotic, deficient bone) • Consensus in North America: Uncemented hemispherical cup

  7. THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups Uncemented Cups: 5 Yr, Data, Rush: • 1/30 (4%) revised for loosening JBJS(A), 2001

  8. THA AFTER ACETABULAR FXLong-Term Socket Fixation: Uncemented Cups Uncemented Cups: Mayo Clinic Data: • 34 hips • Minimum F/U 10 yrs (10-16) • Aseptic Loosening 2/34 (6%) Halasy, Berry, CORR 2002

  9. THA AFTER ACETABULAR FX MANAGEMENT OF BONE LOSS

  10. THA AFTER ACETABULAR FXAcetabular Bone Loss Cavitary Bone Loss: Particulate Graft

  11. THA AFTER ACETABULAR FXAcetabular Bone Loss Segmental Loss: The Posterior/Superior Wall • Use autogenous femoral head graft if needed

  12. THA AFTER ACETABULAR FXAcetabular Bone Loss Results: • Reliable bone graft healing and incorporation

  13. THA AFTER ACETABULAR FX PELVIC DEFORMITY

  14. THA AFTER ACETABULAR FXPelvic Deformity • Landmarks distorted • - care with cup position • Bony prominence • - beware of bone impingement causing instability

  15. THA AFTER ACETABULAR FX NONUNITED FRACTURES

  16. THA AFTER ACETABULAR FXNonunited Fractures • Typically nonunited transverse acetabular fx (pelvic discontinuity) • Stabilize with post column plate

  17. THA AFTER ACETABULAR FXNonunited Fractures Results: • High rate of fracture healing (100% in personal experience)

  18. THA AFTER ACETABULAR FXNonunited Fractures Plate Pelvic Discontinuity

  19. THA AFTER ACETABULAR FX RETAINED HARDWARE

  20. THA AFTER ACETABULAR FXRetained Hardware • Leave in place if not problematic • Selective removal when needed • Beware of the sciatic nerve

  21. THA AFTER ACETABULAR FXRetained Hardware Selective Hardware Removal

  22. THA AFTER ACETABULAR FXRetained Hardware Selective Hardware Removal

  23. THA AFTER ACETABULAR FXRetained Hardware Sciatic Nerve: • Avoid if possible • If working posteriorly: Identify (beneath g. max. tendon), handle carefully • Do case with knee flexed

  24. THA AFTER ACETABULAR FX HETEROTOPIC BONE

  25. THA AFTER ACETABULAR FXHeterotopic Bone Heterotopic Ossification: • Excise HO if symptomatic • If HO formed after last procedure use prophylaxis (NSAID or radiation) after THA

  26. THA AFTER ACETABULAR FXHeterotopic Bone HO: Excise, Postop Prophylaxis

  27. THA AFTER ACETABULAR FX MINIMIZING COMPLICATIONS

  28. THA FOR POSTTRAUMATIC HIPMinimizing Complications Reducing Complications: • Careful preoperative assessment: • - bone loss • - fracture nonunion • - r/o infection • Know what you are up against

  29. THA FOR POSTTRAUMATIC HIP Minimizing Complications Reducing Complications: • Anticipate more blood loss (cell saver) • Longer operative time • Exposure difficulties (choose based on preference/HO/hardware)

  30. THA AFTER ACETABULAR FXReducing Complications Anticipate Special Needs (Intra/Postop): • Pelvic reconstruction plates • Autogenous bone grafting • Metal cutting instruments • HO prophylaxis

  31. THA AFTER ACETABULAR FX Conclusions • Good planning, careful execution • Modern technology • Usually excellent results despite technical challenges • The patients like these operations--they have a previous failure and you fix it

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