THA in failed acetabular fractures Dr Ali Yeganeh Associat professor of Iran university of medical...
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THA in failed acetabular fracturesDr Ali Yeganeh
Associat professor of Iran university of medical sciences
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Acetabular FX treatment ORIF is mainstay ORIF in communited FX(head &acetabulom fx in young) ORIF in elderly
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THA after acetabulom non surgical treatment After initial nonsurgical treatment of an acetabular fracture,
an occult or frank acetabular nonunion and malunion are not uncommon and may extend to the residual pelvic ring
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Indications THA in failed acetabular FX DJD AVN chondrolysis Malunion Head resorption (infection?) Instability ??
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Preop planning Radiography (AP, oblique
views)
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Preop planning CT scan (3D, axial, sagital,
coronal)
medial wall defects
Ant. Or Post. Colomn defects
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Preop planning Infection R/O
x ray
bone scan
ESR/CRP
hip aspiration
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Preop planning Abductor function
EMG/NCV
PH exam
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Approuches Previous approuch Bone defects Condition of soft tissue Surgeon experience
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Approaches Fibrotic tissue in the field Make exposure difficult Soft tissue mobilization difficult More bleeding Ischemic necrosis of muscles because of forceful retraction
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Approaches Trochanteric osteotomy?
Sciatic n. exploration?
not routinely
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Hard ware removal If interferes with implantation
of components (cup, stem) More damage to soft tissues Infection? Corrosion wear???
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Equipments Cemented and cementless Reinforcement rings and cages Mesh
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Allograft (structural, chips)
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Post op. Abduction pillow Abduction brace Restricted weight bearing
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sciatic nerve palsywhether induced traumatically or iatrogenically, accompanies the initial acetabular injury, the palsy is likely to be exacerbated during a subsequent THA In the majority of cases, staying well away from the sciatic nerve is the best option. When the sciatic nerve is at especially high risk during surgery, intra-operative electromyography(EMG) monitoring may be considered
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Infection infection should always be ruled out before proceeding with
THR ESR /CRP/ clinic Aspiration Culture for aerobic & anaerobic If + 2 stage surgery…. all devices should be removed And debreded cartilag and replaced with AB cement
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bone deficiency Ant &post wall deficiency
When the anterior or posterior walls are absent, the use
of autograft bone fixed with a plate or screws. Bulk graft autograft bone from the femoral
head is mainly used in cases of protrusio or when columnar
defects are present. Posterior plating should be reserved for
cases of pelvic discontinuity and/or if the graft requires supplemental Fixation Necrosis or Nonunion
same that revision surgery
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pitfall In addition, the superior aspect of
the dome may also be sufficiently deformed as to
predispose the surgeon to place the acetabular component
in a more abducted position. In these circumstances an
intra-operative x-ray may help in determining appropriate
position
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instablity Because of impingment Larger head Dual mobility
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HTO Should be removed? shielded prophylactic radiation
therapy within 12 hours pre-operatively or 72 hours postoperatively.
16 A single dose of 800 cGy is the usual dose. In
extremely high-risk patients, the authors prefer the addition
of a non-steroidal anti-inflammatory drug (NSAID),
for additional protection
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THA results Total hip arthroplasty (THA) outcomes for posttraumatic
arthritis after acetabular fracture have yielded inferior results compared to primary nontraumatic THA
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FRACTURES ABOUT THE HIP
Acetabular fractures
THE ROLE OF TOTAL HIP REPLACEMENTFrom Mayo Clinic,
©2013 The British Editorial
Total hip replacement (THR) after acetabular fracture presents unique challenges. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further.
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thanks