Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO. The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome. Cite this article: Bone Joint J 2013;95-B:95–100

Total hip arthroplasty (THA) is often performed in symptomatic patients with developmental dysplasia of the hip (DDH) who do not qualify for periacetabular osteotomy (PAO). The impact of osteoarthritis (OA) severity on postoperative outcomes in DDH patients who undergo THA is not well described. We hypothesized that DDH patients who undergo THA with mild OA have slower initial recovery postoperatively, but similar one-year patient reported outcome measures (PROMs) when compared to DDH patients with severe OA.

We performed a retrospective review at a single academic institution over a six-year period of patients with DDH who underwent primary THA and compared them to patients without DDH who underwent THA. Within the DDH cohort, we compared PROMs stratified by DDH severity and OA severity. Diagnosis of DDH was verified using radiographic lateral center edge angle (LCEA). Minimum one-year follow-up was required. PROMs were collected through one-year postoperatively. Logistic and linear regression models were used adjusting for age, sex, body mass index, and Charlson Comorbidity Index.

263 patients with DDH were compared to 1,225 THA patients without DDH. No significant differences were found in postoperative PROMs or revision rates (p=0.49). When stratified by DDH severity, patients with LCEA<10° had worse preoperative pain (p=0.01), mental health (p<0.01) and physical function (p=0.03) scores but no significant difference in postoperative PROMs. Within the DDH group, when stratified by OA severity, patients with Grade 3 Tonnis score had worse preoperative pain (p=0.04) but no significant difference in postoperative PROMs. Recovery curves in DDH patients based upon severity of DDH and OA were not significantly different at 2-weeks, 6-weeks and 1-year.

DDH patients who have mild OA have similar recovery curves compared to those with severe OA. THA is reasonable in symptomatic DDH patients who have mild arthritis and do not qualify for PAO.

Background

Hard-on-hard bearings showed advantages of reduction of wear rates, osteolysis and aseptic loosening in total hip arthroplasty (THA). A new combination of ceramic-on-metal (COM) was developed to compensate the disadvantages of MOM and COC. COM showed good short-term results in vitro and in vivo studies. There was no report of stripe wear and metal ion level elevation. Our study was designed to evaluate the wear pattern of this bearing in early loosening THA.

We managed three elderly patients who had central fracture dislocations with early total hip arthroplasty (THA), using anteprotrusio supports. Bone grafting was used to re-establish acetabular bone stock. Intraoperatively and postoperatively, these patients had no more complications than did patients undergoing THA for hip fractures. However, the surgical times were longer than for routine THA and blood replacement was slightly higher. Patients were mobilised early and aggressively. All became independent walkers and regained good range of movement. Radiologically the acetabular/pelvic fractures united and good bone-implant interfaces were established. There was no excessive heterotrophic bone formation. We regard THA in the management of acetabular fractures in the elderly as a reasonable approach, enabling patients to mobilise early and keeping morbidity to an acceptable level

Severe central facture dislocations of the hip in the elderly can be catastrophic. Conservative treatment yields poor results with stiff painful hips. Reasonable hip function may be achieved with multiple surgical procedures and extended periods of immobilisation, but morbidity and mortality remain high. We managed three elderly patients who had central fracture dislocations with early total hip arthroplasty (THA), using anteprotrusio supports. Bone grafting was used to re-establish acetabular bone stock. Intraoperatively and postoperatively, these patients had no more complications than did patients undergoing THA for hip fractures. However, the surgical times were longer than for routine THA and blood replacement was slightly higher. Patients were mobilised early and aggressively. All became independent walkers and regained good range of movement. Radiologically the acetabular/pelvic fractures united and good bone-implant interfaces were established. There was no excessive heterotrophic bone formation. We regard THA in the management of acetabular fractures in the elderly as a reasonable approach, enabling patients to mobilise early and keeping morbidity to an acceptable level

Introduction and Aims: Severe central fracture dislocations of the hip in the elderly can be catastrophic events. Conservative treatment yields poor results with stiff painful hips. We assessed the results of three patients treated with a total hip replacement for a central fracture dislocation of the hip, using ante-protrusio supports and bone grafts. Method: Three elderly patients with central fracture dislocations were treated with early total hip replacement utilising ante-protrusio supports. Bone grafting was used to re-establish acetabular bone stock. Intra and post-operatively these patients had no more complications than a comparable group undergoing hip replacement for femoral neck fractures. The surgical times were longer than for routine hip replacment, and blood replacement requirements was slightly higher. Patients were mobilised early and aggressively. Results: All became independent walkers. All regained a good range of movement. Radiologically the acetabular/pelvic fractures united and good bone-implant interfaces were obtained. There was no excessive heterotrophic bone formation. The economic assessment indicated that it was more cost-effective to treat these patients with a hip replacement than with alternative methods. Conclusion: We regard total hip replacements in the management of acetabular fractures in the elderly as a reasonable approach, enabling our patients to mobilise early and keeping morbidity to an acceptable level. The procedure is also more cost-effective than internal fixation and delayed arthroplasty

The aim of this research was to elaborate indications for application of some methods of surgical treatment of DDH in teenagers. There are some significant problems with surgical treatment of DDH in teenagers. The most serious one is that the results of routine reconstructive methods usually satisfy neither the patients nor the orthopaedists. In addition, in most of the cases it is too early for total hip arthroplasty. From 1985 to 1996, we operated twenty teenagers with late stages of DDH. Group A was eight patients (12 to 14 years old) with marginal hip luxation (acetabulum angle was more than 40°). Group B was seven patients (10 to12 years old) with iliac hip dislocation (acetabulum angle was more than 50°) and Group C was five patients (11 to 14 years old) with iliac hip dislocation (plane acetabulum). In Group A we performed our first two-stage method of surgical treatment. For the first stage we performed corrective transtrochanteric femur osteotomy (AO plate fixation) and partial acetabuloplasty, and corrected not more than half of the acetabulum angle deficiency. The second stage was performed four to six months later. We removed the femur AO plate and again performed a partial acetabuloplasty. A spherical acetabulum with normal angle and stable hip joint were the results of this method. In Group B we performed our second two-stage method of surgical treatment. For the first stage we performed a corrective and shortening (2 to 3 cm) transtrochanteric femur osteotomy (AO plate fixation), open reduction of the hip and partial acetabuloplasty and corrected not more than half of acetabulum angle deficiency. The second stage was performed 4 to 6 months later and we removed the femur AO plate and performed a Salter osteotomy. A spherical acetabulum with normal angle and a stable hip joint were also the results of the application of this method. In Group C we performed the well-known Ilizarov technique of femur reconstruction (modification of Schanz osteotomy with correction of femur shortening). Normalisation of gait and reduction of the Trendelenburg sign were the results of the application of this method. The results of these methods were studied 3 to 10 years after the end of postoperative rehabilitation. Good results were obtained in 16 cases, satisfactory in four (one in Group A, two in Group B and one in Group C)

Using a prospective database of 1309 displaced acetabular fractures gathered between 1980 and 2007, we calculated the annual mean age and annual incidence of elderly patients > 60 years of age presenting with these injuries. We compared the clinical details and patterns of fracture between patients > 60 years of age (study group) with those < 60 years (control group). We performed a detailed evaluation of the radiographs of the older group to determine the incidence of radiological characteristics which have been previously described as being associated with a poor patient outcome.

In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001). Fractures characterised by displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% (150) vs 43% (462), respectively, p < 0.001). Common radiological features of the fractures in the study group included a separate quadrilateral-plate component (50.8% (58)) and roof impaction (40% (46)) in the anterior fractures, and comminution (44% (30)) and marginal impaction (38% (26)) in posterior-wall fractures.

The proportion of elderly patients presenting with acetabular fractures increased during the 27-year period. The older patients had a different distribution of fracture pattern than the younger patients, and often had radiological features which have been shown in other studies to be predictive of a poor outcome.