MS Park M.D., WC Chung, M.D, HM Cho M.D, and KB Kim M.D.

Department of Orthopedic Surgery, Medical School, Chonbuk National University Hospital, Jeonju, Korea

The survival of Cementless Acetabular Cup for The survival of Cementless Acetabular Cup for Post-Traumatic Osteoarthritis Caused by Post-Traumatic Osteoarthritis Caused by

Acetabular Fracture Compared with Primary Acetabular Fracture Compared with Primary Osteoarthritis and Avascular Necrosis of the HipOsteoarthritis and Avascular Necrosis of the Hip

Introduction

Total hip arthroplasty (THA) is a common form of surgical treatment when significant joint changes and pain presents such as primary degenerative osteoarthritis, avascular necrosis of femoral head and posttraumatic arthritis

In past, the implant survival rate and clinical outcomes was different according to etiologic disease entities in cemented THA

The clinical outcomes of cemented THA in patients with AVN were inferior to those of patients with primary osteoarthritis

Saito S et al,Clin Orthop Relat Res1989;244:198 Murzic WJ et al, Clin Orthop Relat Res1994;299:212

Introduction

Recent advances in cementless THA have led to improved radiographic and functional parameters

The clinical and radiographic findings after noncemented arthroplasty in patients with osteonecrosis of the femoral head and in patients with degenerative arthritis of the hip were similar in the two groups

Xenakis TA et al, Clin Orthop Relat Res 1997;341:62

Introduction

The clinical outcomes of THA in patients with posttraumatic arthritis after acetabular fracture usually were inferior to those of patients undergoing the procedure for nontraumatic conditions because the higher acetabular cup failure rate

Romness DW et al, J Bone Joint Surg Br 1990;72-B:761 Stauffer RN et al, J Bone Joint Surg Am 1982;64-A:983

Recent several clinical studies have demonstrated similar clinical and radiologic outcomes between traumatic OA and primary OA

Bellabarba C, JBJS Am 2001 Pritchett JW, Orthop Rev. 1991

Introduction

Purpose

To compare the clinical and radiologic results undergoing total hip arthroplasty for posttraumatic arthritis after acetabular fracture with those of the same procedure in patients with avascular necrosis of femoral head and degenerative osteoarthritis

Materials and methodsMaterials and methods

Materials From March 1993 to May 2000, 512 patients

Primary total hip arthroplasty by single surgeon (MS Park. M.D) Duofit; SAMO, Bologna, Italy, Mallory-Head; Biomet, Warsaw, USA

Exclusion criteria ( excluded 403 patients)Over 70 yearsBilateral hip replacementRheumatoid arthritisCrowe type IV

Patients demography　 Group A* Group B† Group C¥

Gender (M/F) 34(6:24) 42(24:6) 33(15:6)

Average age (yrs) 62.7 58.7 56.4

Average follow up(yrs) 10.2 9.8 10.4

Bearing type MOP MOP MOP

Femoral head size 28mm 28mm 28mm

Implant Duo(SAMO, Bologna, Italy) 25 28 20

Mallory-Head(Biomet, Warsaw, USA 9 14 13

* Group A : Primary osteoarthritis† Group B : Avascular necrosis of the femoral head¥ Group C : Post-Traumatic osteoarthritis

Materials

Sex 22 males /11 females

Side 19 right / 14 left

Management 28 ORIF / 5 non-op

Age (trauma) 53 yrs ( 33-68 )

Age (THA) 56 yrs ( 36-69 )

Time (trauma to THA) 36 months ( 1-127 mo)

Associated injury 13

Group C – 33 patients

Demographic data

Materials

Osteolysis Extent of the osteolysis : ≥2mm Zone of the osteolysis

DeLee and Charnley

Methods

Acetabular migration ≥2mm

By Massin P et al

Vertical migration

Horizontal migration

Methods

Polyethylene liner wear

By Livermore et al

Methods

Clinical assessment - Harris hip score

Static analysis

Chi –square test ANOVA test Survivorship analysis by Kaplan-Meier method

The end Point○ Revision for any reason

Radiologic sign of loosening of acetabular componentInfection dislocation

Methods

ResultsResults

Acetabular osteolysis - ≥2mm

*: Cases † : Cases (percentage)

　 Group A Group B Group C P-value

Zone I 1* 2 3

Zone II 2 5 2

Zone III 6 8 6

9 (29.4%) † 15(35.7%) 11(33.3%) 0.067

Radiologic results

Acetabular migration

Radiologic results

*: Mean scores ± SD P = 0.12

　 Cases (%) Migration (mm)

Group A 1(3) 1.0±1.74*

Group B 5(12) 1.7±0.56

Group C 3(10) 1.9±0.78

Liner Wear

　 Linear Wear(mm) Rate of Linear Wear (mm/yr.)

Group A 0.58 (0-1.7) ± 0.7* 0.06 (0-0.16) ± 0.06

Group B 1.35 (0-4.3) ± 1.0 0.13 (0-0.41) ± 01

Group C 1.51 (0-6.1) ± 1.4 0.14 (0-0.59) ± 0.11

*: Mean scores ± SD P = 0.058

Radiologic results

Harris hip score

* Group A :Post-Traumatic osteoarthritis† Group B : Primary osteoarthritis¥ Group C : Avascular necrosis of the femoral head

Clinical results

P = 0.43 Analysis by ANOVA test

Clinical results

Operation

　 OP times(min) Bleeding amount (ml)

Group A 88±2.34* 363± 5.41

Group B 82±3.45 350± 4.41

Group C 105±4.15 698± 7.15

*: Mean scores ± SD OP times P = 0.037 Bleeding amounts P = 0.042

Complications

Clinical results

Complications 　 Cases

Peroneal nerve palsy 2

Dislocation 2

Deep vein thrombosis 4

Superficial infection 1

Deep infection 1

Revision

Clinical results

　 Group A Group B Group C

Whole cup exchange 1 3* 0

Cemented isolated liner exchange

0 2 1

Cup and stem revision 0 0 1†

1 5 2

*: 1 case : Recurrent dislocation – acetabular cup malposition (10 〫 anteversion)† : 1 case : Deep infection – 2nd stage reimplantation)

Survivorship analysisClinical results

CasesCases

58 / M Fx & D/L posterior wall, acetabulumn, Lt. (T-E III)

GROUP C

ORIF

GROUP C

Last FU – 112 months

GROUP C

46/M – POD 34 monthsAvascular necrosis of femral head

REVISION

Last FU – 129 months

REVISION

DiscussionDiscussion

Total hip arthroplasty in the setting of an acetabular fracture remains a difficult reconstructive dilemma

This results were arised from the adhesion of previous scar tissue formation, poor operation field, and more excessive dissection during previous internal fixators

Discussion

The longer operation times and more amount of bleeding was needed during reconstructive surgery

Bellabarba C, JBJS Am 2001

In our study, Traumatic arthritis group was statistically the longer operation times and the more amount of bleeding than the other groups

Discussion

In general , the ages and activity level were affected the clinical and radiological results after the THA according to acetabular higher failure rate

Jimenez ML et al, Orthop Clin North Am 1979 Mears DC et al, Instr Course Lect 2001

Berry DJ et al, Orthopedics 1999

In our study, to effort the minimize the influence of age and activity , the age of the three groups were not different statstically .

Discussion

The postoperative Harris hip score of the three groups was improved markedly and was not different statstically

Radiologic results of post-traumatic group were not significantly different compare with non-traumatic other groups.

Discussion

Component survival rate was also comparable between the groups treated for post-traumatic and non-traumatic other groups

In addition, Of the 8 cases undergone revision, 6 cases were loosened by aseptic osteolysis and all these cases were below the 50yrs old

Discussion

The two other revised cases were affected the patients comorbidity(DM), and implant malpositioning (10° anteversion)

We consider that implant survival was affected the combination factors not etiologic disease entities

Discussion

Cementless THA for posttraumatic arthritis after acetabular fracture shows the almost same clinical and radiological results of compared with the same age group of patients of avascular osteonecrosis of the femoral head and degenerative osteoarthritis.

Conclusion

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