So what does the literature say about the outlook for THR after acetabular fracture?
Romness & Lewallen, J Bone Joint Surg [Br] 1990; 72-B:761-4. These authors made a retrospective study of 55 primary total hip arthroplasties in 53 patients with a history of previous acetabular fracture. The mean follow-up was 7.5 years and the average age at fracture was 48.7 years. The incidence of radiographic femoral loosening (29.4%), symptomatic loosening (15.7%), and femoral revision (7.8%) were similar to those previously reported at 10 years for routine arthroplasties by Stauffer (1982). On the acetabular side, the incidence of radiographic loosening (52.9%), symptomatic loosening (27.5%), and revision (13.7%) were four to five times higher. They concluded that a history of prior acetabular fracture has a significant adverse impact on the long-term outcome of any subsequent total hip arthroplasty.
Weber, Berry, Harmsen, J Bone Joint Surg [Am] 1998; 80-A: 1295-1305. 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.
Bellabarba et al, ‘Cementless Acetabular Reconstruction After Acetabular Fracture’, J Bone Joint Surg Am. 2001 Jun;83(6):868-76. doi: 10.2106/00004623-200106000-00008. Thirty patients treated for posttraumatic arthritis had an average preoperative Harris hip score of 41 points, which increased to 88 points at the time of follow-up; there was no significant difference between the open-reduction and closed-treatment groups (p = 0.39). Twenty-seven patients (90%) had a good or excellent result. There were no dislocations or deep infections. The Kaplan-Meier ten-year survival rate, with revision or radiographic loosening as the end point, was 97%. These results were similar to those of the patients who underwent primary total hip arthroplasty for nontraumatic arthritis.The intermediate-term clinical results of total hip arthroplasty with cementless acetabular reconstruction for posttraumatic osteoarthritis after acetabular fracture were similar to those after the same procedure for nontraumatic arthritis, regardless of whether the acetabular fracture had been internally fixed initially. However, total hip arthroplasty after acetabular fracture was a longer procedure with greater blood loss, especially in patients with previous open reduction and internal fixation.
The results quoted by Bellabarba and colleagues are exceptionally good, but quite different to those of other authors. It is natural to wonder what contributes to this difference. 15/30 acetabular fractures had been treated by closed reduction rather than open reduction initially. Thus we are looking at the results of two distinct groups combined into one, but we are not given the indications for selecting open -v- closed. It may be difficult to reproduce these results without more information about selection, surgical process etc.
Von Roth, Abdel, Harmsen, & Berry, J Bone Joint Surg Am. 2015;97:288-91 d http://dx.doi.org/10.2106/JBJS.N.00871. Total Hip Arthroplasty after Operatively Treated Acetabular Fracture. This is the 20 year follow up of the series described above. ‘We previously presented the ten-year results of THA performed for posttraumatic arthritis after an acetabular fracture; we now present the twenty-year outcomes. The original publication included sixty-six patients who underwent THA between 1970 and 1993 for posttraumatic arthritis after open reduction and internal fixation (ORIF) of an acetabular fracture. Clinical outcomes, implant survivorship, radiographic results, and complications were evaluated. A total of thirty-six patients had died. The mean Harris hip score was 80 at the latest follow-up. Nineteen acetabular and/or femoral components had been revised: eleven for aseptic loosening, seven for osteolysis, and one for instability. Twenty-year survivorship of the acetabular component was 71% free from revision for aseptic loosening and 57% free from revision for any reason. THA after ORIF of an acetabular fracture was associated with fair implant survivorship at twenty years after surgery. It is possible that newer implants with improved fixation surfaces and bearing materials may enhance long-term results, as the most common reasons for failure at twenty years were aseptic loosening and osteolysis’.
Morison et al, ‘Total Hip Arthroplasty After Acetabular Fracture Is Associated With Lower Survivorship and More Complications’. Clin Orthop Relat Res (2016) 474:392–398. DOI 10.1007/s11999-015-4509-1. This was a retrospective case control study, (Level of Evidence Level III, therapeutic study). The controls were based on an algorithm that matched patients based on preoperative diagnosis, date of operation, age, gender, and type of prosthesis. The 10-year survivorship after THA was lower in patients with a previous acetabular fracture than in the matched cohort (70%, 95% confidence interval [CI], 64%–78%, versus 90%, 95% CI, 86–95%; p \ 0.001). There was no difference in the 10-year survival rate for those patients whose acetabular fracture was initially treated conservatively and those treated by open reduction and
internal fixation. Patients with previous acetabular fracture had a higher likelihood of developing infection (7% [five of 74] versus 0% [zero of 74]; odds ratio [OR], 11.79; p = 0.028), dislocation (11% [eight of 74] versus 3% [two of 74]; OR, 4.36; p = 0.048), or heterotopic ossification (43% [32 of 74] versus 16% [12 of 74]; OR, 3.93; p\0.001).
The authors concluded that patients with a prior acetabular fracture had markedly inferior 10-year survivorship and more frequent serious complications when compared with patients undergoing THA for primary
osteoarthritis or AVN. Given these findings, management of these complex cases should be in highly specialized units where the expertise of arthroplasty and trauma reconstruction is available.
Clarke-Jenssen et al, ‘Reduced Survival for Uncemented Compared to Cemented Total Hip Arthroplasty after Operatively Treated Acetabular Fractures’. ‘Injury’, 2017 Nov;48(11):2534-2539. doi:10.1016/j.injury.2017.08.071. Epub 2017 Sep 4.
The authors studied 52 patients rom a prospective registry. Overall ten-year revision free arthroplasty survival was 79%. Cemented THA (33 patients) had an estimated 10-year survival of 80% (95% CI 56%-91%), and hybrid prosthesis (9 patients) had 100% 10-year survival. Uncemented arthroplasties had a significantly worse 10-year survival of 57%. Arthroplasties performed at a centre without a pelvic fracture service also had a significantly worse 10-years survival of 51%. Cox regression showed similar results with an 8-fold increase in risk of revision for both uncemented arthroplasties and operations performed at a non-pelvic trauma centre. There were 3 infections.
I think that broad generalisations about fixation method should not be made solely on the basis of this paper; some other papers come to the opposite conclusion regarding cemented -v- uncemented. There were 10 uncemented; 9 hybrids; & 33 cemented hips. Selection of treatment was not detailed, but was associated with increasing age, in the order uncemented/ hybrid/ cemented. Follow up was relatively short, with a median of 7.3 years. However, the overall survivorship does support other papers that suggest that THR after acetabular fracture has a worse prognosis than THR for osteoarthritis.
Freitman, Biert, & Edwards: ‘Patient-reported outcome measures after
surgery for an acetabular fracture’. Bone Joint J 2018;100-B:640–5. These authors studied patient reported outcome measures after acetabular fracture.A total of 220 patients were included, of which 55 (25%) developed post-traumatic OA and 33 (15%) underwent THA. A total of 164 patients completed both questionnaires. At a mean follow-up of six years (2 to 10), the mean SF-36 score for patients with a preserved hip joint was higher on role limitations due to physical health problems than for those with OA or
those who underwent THA. In the dimension of bodily pain, patients with OA had a significantly better score than those who underwent THA. Patients with a preserved hip joint had a significantly better score on the function scale of the mHHS and a better total score than those with OA or who underwent THA.
Rezaie et al, ‘Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern’. The Journal of Arthroplasty xxx (2020) 1-5.https://doi.org/10.1016/j.arth.2020.04.085. 72 patients undergoing THR after acetabular fracture were case-matched with 215 patients undergoing THR for arthritis on a 1:3 ratio. Mean follow up was quite short in both groups; about 3 years.Patients with a previous acetabular fracture, compared with the primary THA patients, had longer operative times, greater operative blood loss, and an increased need for allogeneic blood transfusion (26.4% vs 4.7%). Most notably, the peri-prosthetic joint infection rate was significantly higher in the acetabular fracture group at 6.9% compared with 0.5% in the control group. Complications, such as aseptic revision, venous thromboembolism, and mortality, were similar between both groups.
Busch et al. ‘Total hip arthroplasty following acetabular fracture: a clinical
and radiographic outcome analysis of 67 patients’. Archives of Orthopaedic and Trauma Surgery (2020) 140:331–341
https://doi.org/10.1007/s00402-019-03272-x.
67 patients who received THA for the treatment of posttraumatic osteoarthritis after acetabular fracture between January 2007 and December 2012 were analyzed consecutively. The group consisted of 13 female (19%) and 54 male (81%) patients with a mean age of 59 (25–87) years at the time of THA. The time between acetabular injury and arthroplasty was 107 (1–504) months on average. The all-cause 8-year survival rate was 0.87% (0.76–0.93) and there were 8 revisions, half
of them were due to aseptic loosening of the cup. The Harris Hip Score achieved was 75.7 ± 21.3 (26.9–100) points. Prior to THA, heterotopic ossifications were detected in 28% and after THA implantation in 42%.
Conclusion The decrease of the interval between injury and arthroplasty was associated with increasing patient age (p = 0.001) and surgical treatment of the acetabular fracture (p = 0.04). Complex fracture patterns were accompanied by acetabular bone defects more often than simple patterns (p = 0.03). Overall, arthroplasty due to posttraumatic osteoarthritis after acetabular fracture resulted in decreased overall survival rates and poorer clinical outcome as compared to primary arthroplasty.