Functional outcomes and center of rotation restoration in total hip arthroplasty after acetabular fracture: A review of 367 hips

Background

Total hip arthroplasty (THA) after acetabular fracture is typically performed months or years later for posttraumatic arthritis after initial conservative treatment. But THA can be performed earlier after open reduction and internal fixation (ORIF) of the fracture. The aim of this study was to determine which strategy is best. The primary outcome measure was the radiological restoration of the hip's center of rotation (COR). The secondary outcome measures were the incidence of complications and the hip's functional scores.

Materials and methods

A multicenter cohort was analyzed by splitting patients into three groups: group A (THA within 3 weeks of fracture); group B (THA deferred after early ORIF); group C (THA more than 3 weeks after fracture, without ORIF). Group B was separated into two subgroups: B- (THA less than 1 year after ORIF) and B+ (THA more than 1 year after ORIF). The demographics, surgical techniques, COR superior and lateral migration coefficient and functional scores (HHS, HOOS-PS and FJS) were recorded. The functional scores were gathered using PROMs.

Results

In all, 367 patients were included: 108 in group A, 69 in group B-, 113 in group B+ and 77 in group C. The mean follow-up was 5.8 years [3.4 months-35 years]. The mean age of the patients was 69.2 years [SD 15; 26-101], 52 years [SD 16; 19-83], 49 years [SD 16; 16-85] and 58.1 years [SD 17; 13-94], respectively (p < 0.01). The mean ASA score was 2.13 [SD 0.70], 1.84 [SD 0.65], 1.67 [SD 0.63] and 1.79 [SD 0.60], respectively (p < 0.01). A complex Letournel fracture was present in 63 patients (61%), 46 patients (71%), 48 patients (49%) and 38 patients (62%), respectively (p < 0.01). A reinforcement cage was implanted in 38 patients (69%), 16 patients (62%), 5 patients (12%) and 19 patients (66%), respectively (p < 0.01). Cement was used in 45 patients (45%), 23 patients (35%), 19 patients (18%) and 21 patients (32%), respectively (p < 0.01). A graft was needed in 46 patients (46%), 35 patients (53%), 17 patients (16%) and 21 patients (48%), respectively (p < 0.01). Posterior ORIF was done in 40 patients (46%), 32 patients (55%), 64 patients (61%) and 9 patients (82%), respectively (p < 0.01). The COR lateral migration coefficient was significantly higher in group C with a mean of +0.17 (SD 0.85) [-0.27 to +6] compared to the other groups (p = 0.02). The COR superior migration coefficient was comparable between groups, with a mean of +0.77 (SD 2.26) [-0.99 to 27], p > 0.05. There were complications in 10 patients (9.2%), 6 patients (8.7%), 6 patients (5.3%) and 3 patients (3.9%), respectively, with no significant difference between groups. The PROMs were completed by 51% of patients. At the final review, the mean HHS was 79.2 (SD 21.8) and the mean HOOS-PS was 77.7 (SD 20.1) in the entire cohort, p > 0.05. The mean FJS by group was 55.9 (30.2), 47.7 (SD 36.4), 66.1 (SD 30.4) and 65.8 (SD 30.3), respectively (p = 0.02).

Discussion and conclusion

The B strategy (B+) yielded good outcomes in terms of function and COR restoration. When using this strategy, anterior ORIF preserves the native hip for a subsequent THA through a posterior approach. Strategy C also produces good functional outcomes but shifts the COR laterally. This study confirms the poor results of strategy A in previous publications. When the prognosis is poor, immediate mobilization after anterior ORIF followed by THA within 1 year appears to be a good strategy (group B-).

Level of evidence

IV, observational study.