Case Report Hip Knee J.
Vol.
No.
1, 2024, pp.
p-ISSN: 2723-7818 e-ISSN: 2723-7826 http://dx.
org/10.
46355/hipknee.
THE COMBINED HIP PROCEDURE: OPEN REDUCTION INTERNAL FIXATION
COMBINED WITH TOTAL HIP ARTHROPLASTY FOR THE MANAGEMENT OF
SEVERE ACETABULAR FRACTURES IN THE ELDERLY: A CASE REPORT
Rolandi Indra Pramukti1.
Mohammad Zaim Chilmi2.
Jifaldi A.
Sedar3 Fellow of Indonesia Hip and Knee Society.
Orthopaedic and Traumatology Surgery Department, dr.
Soetomo General Hospital.
Surabaya.
Indonesia Senior Consultant Orthopaedic and Traumatology Surgery Department, dr.
Soetomo General Hospital.
Surabaya.
Indonesia Consultant Orthopaedic and Traumatology Surgery Department, dr.
Soetomo General Hospital.
Surabaya.
Indonesia
ABSTRACT
There are many varieties of acetabular fractures affecting the elderly are due to various patient characteristics and fracture characteristics.
Applying highly individualized .
ailor mad.
management principles is essential in order to achieve successful outcomes.
Previous literatures have described indications and outcomes of different option of management, including closed treatment, open reduction internal fixation, and direct or staged total hip arthroplasty.
Appropriate opted initial management is critical, as early failures and subsequent salvage surgery can be resulted in morbidity.
Clinical results after ORIF closely largely depend on the quality of articular reduction and the ability of maintaining a congruent reduction of the hip joint.
Fracture characteristics and ability to achieve anatomic-articular reduction, should be treated with ORIF.
However, fracture characteristics predictive, prior to early post-traumatic arthritis should be treated with simultaneous ORIF and THA (Combine Hip Procedure.
CHP).
The case presented is one referral institutions treatment algorithm and management approach in dr.
Soetomo general hospital.
Keywords: Acetabulum Fracture.
Elderly.
Combine Hip Procedure.
ORIF.
Total Hip Arthroplasty This is an open access article under the CCAeBY-SA license.
Article History:
Corresponding Author:
Submission Revision Accepted : April 15th, 2022 : December 19th, 2023 : January 29th, 2024 Rolandi Indra Pramukti Fellow of Indonesia Hip and Knee Society.
Orthopaedic and Traumatology Surgery Department, dr.
Soetomo General Hospital.
Surabaya.
Indonesia rolandman@gmail.
THE COMBINED HIP PROCEDURE: OPEN REDUCTION INTERNAL FIXATION COMBINED WITH TOTAL HIP
ARTHROPLASTY FOR THE MANAGEMENT OF SEVERE ACETABULAR FRACTURES IN THE ELDERLY: A CASE
REPORT
INTRODUCTION
High-energy trauma may cause the acetabulum to suffer from fractures.
These cases most commonly occurred in younger patients of less than 40 years and, open reduction and internal fixation required in displaced cases .
Restoring the joint and achieving anatomical reduction have been shown to halt post traumatic arthritis development, yet, there might be a possibility of degeneration and femoral head avascular necrosis .
Regardless of these and other potential complications, restoring the displaced acetabular fractures anatomically has still been regarded as the treatment of choice for most displaced fracture.
In elderly patients, acetabulum fractures may be resulted from a high-energy injury.
Nevertheless, in the presence of osteoporosis or osteopenia, fractures may also follow a moderate- or even low-energy injuries such as a fall to the ground from a standing position.
These falls may cause similar patterns of displacement and comminution along with impaction of the acetabulum and the femoral head.
Previous literatures have described treatment of choice ranging from nonoperative care, acute total hip arthroplasty, a delayed total hip replacement and the use of ORIF technique .
Whilst, poor outcomes may develop due to poor quality of the bone or unstable pelvic column injuries.
In order to better outcomes, a complex .
ailor mad.
approach may be essential in treating these injured elderly patients.
As simultaneous internal fixation and early total hip arthroplasty were done, we may achieve Copyright A 2024 the author.
| http://thehipkneejournal.
stabilization of fracture, reduction of pain reduction, and early mobilization.
This approach may reduce complications related to soft tissue, via wider surgical opening and avoid reoperation through same tissue.
PRESENTATION OF CASE
A 69-year-old male suffered from an injury in his left hip joint after falling from a high place and was rushed to a hospital.
At the hospital, he was diagnosed with a T- shaped acetabular fracture.
Figure 1.
Initial anteroposterior radiograph (A) Alar and obturator (B) CT scan showing iliac wing, anterior and posterior wall acetabular fracture (C,D,E,F) The patient was given skeletal traction on his left femur and given treatment for other comorbidity, which has Hypertension and Diabetes mellitus, and prepared for optimal surgical procedure.
THE COMBINED HIP PROCEDURE: OPEN REDUCTION INTERNAL FIXATION COMBINED WITH TOTAL HIP
ARTHROPLASTY FOR THE MANAGEMENT OF SEVERE ACETABULAR FRACTURES IN THE ELDERLY: A CASE
REPORT
Figure 2.
The Judet and Letournel acetabular fracture classification system We identified corona mortis vessel and made a ligation into it, then reduced the fracture site and put two recon-plates in the anterior and posterior acetabular column.
After placement of the fixation device, one is 10 holes recon-plate and put 3 screws on proximal and 2 screw in distal on anterior column and the other 10-hole recon- plate, 2 screw both proximal and distal hole, we checked under c-arm.
The operative management consisted of fracture stabilization using standard ORIF techniques followed immediately by THA during the same anaesthesia.
In this case, both column fracture fixation is using modified Stoppa approach, combined with lateral window of the ilioinguinal approach .
o called Olerud approac.
exposing all fractures lines extending superiorly to the iliac crest.
Figure 3.
Modified Stoppa Approach (A) Identify corona mortis vessel (B) Ligation of corona mortis (C) Reduce and plate placement (D) Lateral window are used to insert the screw (E).
Copyright A 2024 the author.
| http://thehipkneejournal.
Figure 4.
AP position c-Arm (A) Obturator view position c-Arm (B).
The osteosynthesis can reduce fracture site, compared with initial x-ray.
Then, the patient was positioned in lateral decubitus, and a postero-lateral approach was used THE COMBINED HIP PROCEDURE: OPEN REDUCTION INTERNAL FIXATION COMBINED WITH TOTAL HIP
ARTHROPLASTY FOR THE MANAGEMENT OF SEVERE ACETABULAR FRACTURES IN THE ELDERLY: A CASE
REPORT
for posterior wall osteosynthesis followed by the THA.
Figure 5.
Postero-lateral approach (A) Bended plate following acetabulum (B,C) 7-hole recon-plate placement to posterior wall acetabulum using 2 screw on proximal and distal hole, showing Schanz pin on superior aspect.
After osteosynthesis of the posterior wall, we proceed to THA, first we dislocated the head femur and decapitated, later on we use the head of femur as morselized bone graft, to fill the defect of acetabular joint After the reverse reamer, we could achieve round shaped acetabulum and bone defect had all filled with bone graft.
We proceed to put cementless acetabular cup and fixate with 2 screws superiorly.
Then we proceed to placing the femoral Copyright A 2024 the author.
| http://thehipkneejournal.
After inspecting final reduction and position of implant, the wound is then irrigated using saline solution.
Two drains were inserted, one in the space of Retzius .
edial windo.
and another in the iliac fossa .
ateral windo.
of the ilioinguinal approach.
Afterwards, closure of the inguinal canal, external abdominal fascia, and inguinal ligament are done using nonabsorbable Then the wound is closed in layers using absorbable sutures.
Figure 6.
Dislocating head of femur, and morselized it.
Figure 7.
Ellipse shaped and acetabular
wall bone defect
THE COMBINED HIP PROCEDURE: OPEN REDUCTION INTERNAL FIXATION COMBINED WITH TOTAL HIP
ARTHROPLASTY FOR THE MANAGEMENT OF SEVERE ACETABULAR FRACTURES IN THE ELDERLY: A CASE
REPORT
Figure 8.
Fill the bone defect (A,B) impaction morselized bone graft using reverse reamer / impactor (C).
Post Operative In order to verify adequate fracture reduction and implant positioning.
Figure 9.
Round shaped acetabulum (A) Placement cement- less acetabular cup (B) Placing femoral stem (C) Copyright A 2024 the author.
| http://thehipkneejournal.
Figure 10.
Post-operative x-ray, showing good reduction of both column and posterior wall osteosynthesis, also good THA result.
DISCUSSION
ORIF techniques used in managing displaced acetabular fractures have been shown to provide good to excellent outcomes .
Previous literatures have even detailed the usage of an ORIF technique in certain fracture management in elderly resulting in good outcome .
However, not every acute acetabular fracture affecting the elderly can be appropriately deal with ORIF.
Several studies have reported in the presence of pre- existing arthritis, associated fracture patterns, impacted margins, intra-articular suboptimal reduction of fracture, with or without the presence of osteoporosis, and patients older than 55 years of age have demonstrated that ORIF will result in poor clinical outcomes in comparison to other.
Acute THA may be the attractive solution for managing such patients.
Nevertheless, fracture with coexisting presence of osteoporosis may cause obtainment of adequate fixation using hip replacements alone seems impossible.
Only few articles have previously discussed combined techniques as management of acetabular fractures in the elderly.
Weber et and Bellabarba et al8 discussed the advantage of acetabulum osseous subsequent development of osteoarthritis.
THE COMBINED HIP PROCEDURE: OPEN REDUCTION INTERNAL FIXATION COMBINED WITH TOTAL HIP
ARTHROPLASTY FOR THE MANAGEMENT OF SEVERE ACETABULAR FRACTURES IN THE ELDERLY: A CASE
REPORT
and the usage of plate fixation for recognized fracture line.
used to gain access to anterior acetabulum In 2019.
Borg et al.
reported the only cohort study comparing CHP with ORIF alone for treatment of displaced comminuted acetabular fractures in the elderly .
From total the combined hip procedure.
CHP, comprises of an acetabular fracture stabilization through operation followed by acute placement of a total hip arthroplasty.
The justification of this procedure is that one operation could be completed for those elderly patients with acetabular fractures that have a disadvantageous prognosis and have possibility of requiring arthroplasty conversion later.
The objective of reduction and stabilization of the acetabular fracture is not to merely achieve an anatomic reduction, but rather to provide a stable construct for cup Indications for the combined hip procedure include conditions such as the presence of a femoral neck fracture or significant femoral head damage, including abrasions, impaction, or fracture to the femoral head.
severe, unreconstructible comminuted acetabulum and impaction involving 30% of its surface.
preexisting hip arthrosis.
multiple associated fractures.
and those who have a low likelihood for a satisfactory outcome following ORIF, and in whom ORIF has been shown to compromise the success of a subsequent arthroplasty.
REFERENCES