1. Introduction
Periprosthetic fractures typically occur from low-energy trauma and are often seen in frail older patients. Prompt diagnosis of pelvic ring and acetabular injuries is useful and can guide timely management. Definitive management of these rare pelvic injuries continues to be a topic of much debate among the trauma community, especially if the injury is a periprosthetic fracture and is associated with discontinuity of the pelvis. Owing to the ever-increasing number of osteoporotic pelvic fractures, periprosthetic pelvic fractures with pelvic discontinuity (PD) will rise in the near future. Recent studies continue to inform our understanding of static and dynamic pelvic ring stability. Furthermore, the literature that investigates outcomes after nonoperative and operative management will help guide trauma surgeons to select the treatment that will allow affected patients to be as mobile as they were before the injury.
The following article represents a summary of the management of periprosthetic osteoporotic pelvic ring injuries by a group of international experts, covering 5 topics relevant to the diagnosis and treatment of these rare pelvic ring injuries. These topics include epidemiology and discussion of present pelvic ring injury classifications, with the central question focused on pelvic ring stability. Finally, this summary article will cover how to select the appropriate approaches and fixation strategies for definitive management of various pelvic ring injury patterns.
2. Epidemiology
Although the risk of periprosthetic femoral fracture around a total hip arthroplasty (THA) is well described,[1,2] the incidence of periprosthetic acetabular fractures seems to be much smaller.[3] The first description of acetabular fractures around THA was published in 1972.[4] However, there remains a lack of population-based studies on periprosthetic acetabular fractures (PAFs). Only a few published series of PAFs can be found in the literature, all small cohorts.[5–8] The series by Haidukewych et al[8] demonstrated that intraoperative acetabular fractures have a prevalence of 0.4% in cementless socket fixation. Peterson et al found that postoperative acetabular fractures occurred in 0.07% of patients with a THA[5] performed over a 20-year period. However, another report based on routine postoperative computed tomography findings documented occult fractures of the acetabulum in 41 of 486 primary hips (8%), primarily involving the superolateral wall, suggesting that the rate of intraoperative acetabular fractures is much higher than previously assumed.[9] It is difficult to detect a fracture by intraoperative visualization or on plain radiographs because the acetabulum has a 3D structure, the bone is cancellous, and the bone surface is covered by soft tissue.[10–12] The use of computed tomography or Judet radiological views is not routine in the immediate postoperative period after THA, so if minimally displaced, these fractures can be easily missed and be deemed as early loosening during follow-up, or they can progress and displace, resulting in an obvious early postoperative acetabular fracture after minor trauma with the patient reporting the groin pain weeks after the surgery. Considering the aging of the population, an increase in high-energy trauma, a decrease in the mortality index, the increasing number of uncemented THAs inserted in a press-fit manner, and the greater number of revision THA procedures performed each year, an increase in the frequency of periprosthetic fractures around the acetabulum is to be expected in the coming years.
3. Classifications of Periprosthetic Pelvic Fractures
Periprosthetic pelvic fractures may be viewed as a combination of “two orthopaedic worlds”—trauma surgery of the pelvis (acetabulum and pelvic ring) and elective orthopaedic surgery of the hip joint. Given this dichotomy, periprosthetic pelvic fractures can be described as acetabular fractures that occur in patients with ipsilateral hip protheses with or without PD or as pelvic ring fractures (high or low energy) that occur in patients with ipsilateral hip protheses. The former situation is well known and well described in the literature[13–15]; the latter one is only presented in few case reports.[16]
In PAFs, it is important to distinguish between intraoperative and postoperative/traumatic fractures. For classical acetabular fractures, the standard classification of Letournel or the AO-OTA classification can be used.[17,19] In 1996, Peterson and Lewallen reported the first classification dedicated to those PAFs.[5] The authors distinguished PAF into 2 types according to acetabular component stability: stable (Type I) or unstable (Type II). In 1998, Callaghan et al described 4 fracture patterns (anterior wall, transverse, inferior lip, and posterior wall) based on an in vitro investigation.[19]
When PD exists, several classifications have been proposed. In its classification of acetabular bone loss in patients undergoing revision hip surgery, the American Academy of Orthopaedic Surgeons defined a PD as a Type IV deficiency.[20] Berry et al[21] further distinguished the degree of bone loss associated with PD as Type IVa if the discontinuity is associated with cavitary or mild segmental bone loss; Type IVb if the discontinuity is associated with a large segmental or combined defect; and Type IVc if the pelvis had been previously irradiated, regardless of the presence of cavitary or segmental bone loss. The classification proposed by Paprosky and Della Valle in 2003 is based on the severity of bone loss and the ability to obtain cementless fixation for a given bone loss pattern.[22] This classification is the most widely used and includes fracture timing, implant stability, and bone osteolysis.
Of periprosthetic pelvic ring fractures, no existing classifications assess the way the pelvic ring fracture can compromise the stability and function of the acetabular component. For high-energy trauma, the Tile, AO-OTA, or Young and Burgess classifications can be used to describe and treat the pelvic ring injury, but they do not assess periprosthetic fractures or assist in preoperative analysis and subsequent management.[19,23,24] In the same way, for low-energy trauma, the classification of fragility fractures of the pelvis proposed recently by Rommens et al[25] does not assess periprosthetic fractures nor assist in preoperative analysis and subsequent management. In 2014, Duncan and Haddad[26] proposed the use of the unified classification system (UCS) not only for PAFs but also for the pelvis as a whole including periprosthetic pelvic ring fractures. It corresponds to an expansion of the Vancouver classification system adapted to the pelvis and includes 3 other types of fractures that may occur in combination or in isolation (Table 1). This classification was assessed through an international collaboration and is associated with high interobserver and intraobserver agreements.[27] For completeness and ability to describe most of the cases, type C in the UCS should include sacral fractures. Indeed, according to the fragility fractures of the pelvis (FFP) classification of Rommens et al,[25] every FFP pattern should be clear of the implant. To be relevant, a classification should describe all different patterns, be easy to use and understandable (interobserver and intraobserver reliability), and assist in preoperative analysis and subsequent management.
TABLE 1 -
The Unified Classification System of Periprosthetic Fractures
[30]
| UCS Classification for Periprosthetic Pelvic Fractures |
| Type A: Apophyseal or extra-articular/periarticular |
| Avulsion of anterior inferior and superior iliac spine or ischial tuberosity |
| Type B: Bed of the implant or around the implant |
| B1: Fracture of the acetabular lip, wall, or floor, which does not affect the stability of the component, which is still well fixed |
| B2: Fracture of the acetabulum or pelvic discontinuity, with a loose acetabular component but adequate bone stock to support an uncomplicated acetabular component revision; with or without bone graft; with or without plated fixation of the fracture |
| B3: Fracture of the acetabulum, with a loose acetabular component, and severe bone loss such that complex reconstruction or a salvage procedure is required |
| Type C: Clear of the implant |
| Ilium, superior, and/or inferior rami |
| Type D: Dividing the pelvis between implants |
| Fracture of the pelvis complicating bilateral replacements |
| Type E: Each of 2 bones supporting one joint replacement |
| Acetabulum and femur |
| Type F: Facing a joint replacement |
| Fracture of the acetabulum after hemiarthroplasty |
When a trauma surgeon has a patient with a periprosthetic pelvic osteoporotic fracture and PD, surgeons should describe and manage the fracture using the existing trauma classifications and, in parallel, describe and manage the periprosthetic fracture using the existing classifications for PAF (acute or chronic, stable or unstable prosthesis, with or without bone loss) to get a complete overview of these rare and challenging combinations. The combined use of the Rommens FFP and the UCS classifications offers a complete overview of fracture patterns and options for treatment.
4. Treatment Strategies for Periprosthetic Acetabular Fractures
Surgical treatment of PAF is a significant challenge. The fracture must be addressed with stable bone fixation of the revision cup. In addition, these are often older patients with poor bone quality and multiple co-morbidities, so surgical treatment is preferable and should use techniques that allow full weight-bearing post-operatively. According to the classification of the PAF and the affected columns, different treatment strategies can be distinguished.
4.1. Cup Replacement Without Osteosynthesis
4.1.1. Standard Revision Cup: Treatment Considerations
In rare cases, isolated fracture of the posterior or anterior wall occurs. If the containment of the acetabulum is preserved or an improved containment can be achieved by medialization of the new cup, the simple replacement with a cemented or cementless cup is feasible without additional osteosynthesis. In this case, the existing surgical approach can be used. The risk of postoperative hip dislocation can be reduced by using dual mobility cups.
Case 1: A 68-year-old woman presented after a fall following a recent THA performed using a posterior approach. Images showed an isolated fracture of the posterior wall that was classified as a type 2 PAF according to the classification of Peterson and Lewallen.[5] Revision surgery was performed using the existing posterior approach with implantation of a cemented dual mobility cup and improvement of containment by medialization of the new cup (Fig. 1).
;)
Figure 1.: A, Schematic illustration of an isolated fracture of the posterior wall according to the classification of Letournel and Judet (1993) [reprinted with permission; © Thieme
[28]], (B) X-ray image of PAF type 2 according to the classification of Peterson and Lewallen,
[5] (C) preoperative CT scan of the pelvis with visualization of the posterior wall fracture, and (D) intraoperative control of the correct position of a double mobility cup in the AP plane with the image intensifier [B, C, and D: Reprinted with permission © Springer Medizin Verlag GmbH, all rights reserved
[29]].
4.1.2. Cranial Socket Revision Cup With Flange and Iliac Peg: Treatment Considerations
If there is a sufficient acetabular socket with an anterior column fracture with or without a hemitransverse or T-fracture component, the use of a cranial socket revision cup with a flange and iliac peg can be considered. The concept of the revision cup with flange and pelvic peg involves cranial fixation of the cup into the iliac bone, and containment or press-fit of the cup is not necessary. In a biomechanical study by Wenzl et al,[30] it was shown that the treatment of an anterior column fracture using a cranial socket revision cup with a flange and iliac peg provides the same biomechanical stability as anterior plate osteosynthesis and a revision cup. The advantage of the former surgical method is the single approach and minor surgical trauma.
Case 2: A 64-year-old obese woman (BMI 50.8) underwent implantation of a primary cementless THA using a previous posterior approach. During postoperative mobilization, a fall occurred with a PAF (Letournel[17]: T-fracture; Petersen and Lewallen[5]: Type 2). Owing to a suspected infection resulting from a postoperative wound healing disorder and elevated inflammatory markers, a two-stage procedure with temporary resection arthroplasty was performed. Intraoperative specimens confirmed a Staphylococcus epidermidis infection, and antibiotic therapy was administered for 6 weeks. Preoperative 3D planning showed that the defect could be addressed with a revision cup with flange and iliac peg. During the revision surgery, the fracture had partially healed; therefore, implantation of the revision cup with flange and iliac peg alone was sufficient (Fig. 2).
Figure 2.: A, Schematic illustration of a T-fracture according to the classification of Letournel and Judet
[32] [reprinted with permission; © Thieme], (B) X-ray image of PAF type 2 according to the classification of Peterson and Lewallen,
[5] (C) preoperative 3D analysis of the T-fracture based on a CT data set (iProcess AQ implant), (D) preoperative 3D planning of the positioning and fit of the cranial socket revision cup with a flange and iliac peg, (E) intraoperative control of the correct position of the iliac peg in the AP plane and lateral plane (F) with the image intensifier, and (G) postoperative pelvic x-ray [B, C, D, E, F, G: Reprinted with permission © Springer Medizin Verlag GmbH, all rights reserved
[33]].
4.2. Cup Replacement and ORIF of Ventral Column
4.2.1. Treatment Considerations
If the anterior column is involved, open reduction using a pararectus approach and stabilization with a suprapectineal plate may be preferable in most cases. The advantage of the suprapectineal plate is that the quadrilateral surface is simultaneously stabilized and medialization of the revision cup is prevented. Before reduction of the fracture, however, removal of the loose cup is necessary because this often represents an obstacle for reduction. With the patient already in the supine position, an anterolateral or anterior approach to the hip joint can be used to remove the loose cup. The fracture is then reduced using the pararectus approach and stabilized with a suprapectineal plate. Containment of the acetabulum is hereby restored and, after the application of an allogenic cancellous bone grafting into the fracture or the remaining defects of the acetabulum, a revision cup can be positioned using the press-fit technique. It is important not to select a cup diameter that is too small to prevent the cup from slipping medially and to promote bone healing with a distraction component on the compression of the fracture.
Case: An 85-year-old woman (BMI 26), who underwent a primary THA 8 years earlier, sustained a PAF after a ground-level fall (Letournel[17]: anterior column fracture; Peterson and Lewallen[5]: Type 2).
A single-stage two-approach procedure was performed with removal of the loose cup using an anterior approach, reduction of the fracture using a pararectus approach, stabilization of the fracture with a suprapectineal plate, and implantation of a cementless revision dual mobility cup with a screw fixation option using the anterior approach (Fig. 3).
Figure 3.: A, Schematic illustration of an anterior column fracture according to the classification of Letournel and Judet
[32] [reprinted with permission; © Thieme], (B) X-ray image of PAF type 2 according to the classification of Peterson and Lewallen,
[5] (C) intraoperative control of the correct position of the suprapectineal plate and the cementless revision double mobility cup with the image intensifier, (D) postoperative computed tomography of the pelvis for verification of the reduction result and implant position, and (E) postoperative pelvic x-ray.
4.3. ORIF Posterior Column and Cup Replacement
4.3.1. Treatment Considerations
In cases when the posterior column is involved, revision surgery using a posterior approach (Kocher-Langenbeck approach) is an appropriate option. After the loose cup has been removed, reduction of the posterior column and osteosynthesis using a small-fragment plate can be performed. The plate osteosynthesis restores the containment of the acetabulum so that a cementless revision cup can be implanted, which is additionally secured with cranial screws. The advantage is a single approach, and the disadvantage is an increased risk of secondary hip dislocation due to the large posterior approach with detachment of the external rotators. For this reason, the use of dual mobility cups is recommended.
Case 4: A 76-year-old woman (BMI 28) presented with implantation of a primary THA 6 years earlier. She had a fall while shopping and subsequently sustained a PAF. In conventional X-ray imaging, no fracture classification could be made. The CT scan showed Type 2 according to Peterson and Lewallen[5] and posterior column fracture according to Letournel and Judet. A one-stage revision using a single posterior approach (Kocher-Langenbeck) with removal of the loose cup, reduction of the posterior column fracture, and osteosynthesis with a small fragment plate and implantation of a cementless double mobility revision cup was performed (Fig. 4).
Figure 4.: A, Schematic illustration of a posterior column fracture according to the classification of Letournel and Judet
[32] [reprinted with permission; © Thieme
[28]], (B) X-ray image of PAF with an unclear fracture classification according to the classification of Peterson and Lewallen
[5] or Letournel and Judet
[32], (C) preoperative computed tomography of the pelvis for the analysis and classification of fracture, and (D) postoperative pelvic x-ray [b, c, and d: Reprinted with permission © Springer Medizin Verlag GmbH, all rights reserved
29].
4.4. Additional Treatment Strategies for Periprosthetic Acetabular Fractures
When considering treatment options for periprosthetic fractures of the acetabulum, surgeons need to bear in mind several patient-specific and injury-specific factors. Those factors add to the already high complexity of acetabular fracture treatment. While initially Emile Letournel and Robert Judet, the pioneers of acetabular surgery, did not operate on patients older than 60 years with osteoporosis, decreased bone mineral density is regularly found in patients with periprosthetic fractures of the acetabulum.[35,36] In elderly patients with periprosthetic fractures of the acetabulum, not only the morphology of the fracture but also other patient-related factors such as the grade of mobility before the accident, the ability to be compliant with weight-bearing restrictions, and the patient's comorbidities need to be considered. The latter considerations are of particular importance when it comes to deciding for either nonoperative or operative treatment or choosing between different surgical procedures. Owing to the high invasiveness of the surgical procedures, not every elderly patient with comorbidities will qualify for a staged approach of osteosynthesis, followed by the replacement of a loosened prosthetic cup.
Despite these considerations, the general treatment principles and decision making in acetabular fractures are also valid for periprosthetic fractures. Periarticular fractures of the superior pubic ramus and minimally displaced acetabular fractures can be treated nonoperatively, as long as there is no loosening of the prosthetic cup or significant bone lysis around the cup. The surgeon must bear in mind that nonoperative treatment will usually require partial weight-bearing for 6 to 8 weeks. If a patient is not able to adhere to these restrictions, minimally invasive stabilization might be the better option to avoid secondary displacement.
If operative treatment is necessary, there are different concepts which may be considered: (1) plate osteosynthesis of a displaced anterior column fracture with a stable prosthetic cup, (2) sole osteosynthesis if there is a hemiprosthesis, (3) combined osteosynthesis and revision arthroplasty (staged or simultaneous, see the case study), and (4) sole revision arthroplasty without osteosynthesis.[33]
In surgical treatment of PAFs, the most important aim is to provide the prosthetic cup with sufficient stability. As any dislocation of an acetabular column or wall leads to a “pseudobone defect,” reduction and osteosynthesis can be used to downgrade a defect and thereby facilitate positioning and anchoring of the prosthetic cup.[34] Residual bone defects are regularly grafted with allogenous bone and/or addressed by augmentation systems as is known from revision hip arthroplasty.[35] Comprehensive algorithms to approach PAFs have been suggested by Masri et al[36] in 2004 and in even more detail by Simon et al[33] in 2015.
Case study: A 77-year-old female patient presented with severe pain in the left hip after a low-energy fall when closing her garage door. The left hip joint had been replaced by a total hip endoprosthesis 18 years earlier. Three years before presentation, the stem was exchanged because of aseptic loosening. Radiography showed a PAF with loosening and posterior dislocation of the prosthetic cup. The fracture was classified as anterior column with posterior hemitransverse fracture. The dislocation of the cup had led to an additional fracture of the posterior wall, which was still attached to the cup (Fig. 5Figure 5.: Periprosthetic acetabular fracture with loosening and posterior dislocation of the prosthetic cup, classified as anterior column with posterior hemitransverse fracture.
).
For treatment, a staged approach with plate osteosynthesis, followed by acetabular revision arthroplasty through a posterior approach, was chosen. In a first step, the anterior column of the acetabulum was stabilized by an anterior intrapelvic approach (Stoppa) plus the lateral window of the ilioinguinal approach to downgrade the acetabular pseudobone defect (Fig. 6).
Figure 6.: First-stage repair of the fracture shown in
Fig. 5 with a long plate placed using the anterior intrapelvic approach and lateral window of the ilioinguinal approach.
Four days later, a Kocher-Langenbeck approach was used to remove the displaced cup. After bone grafting, a cemented cup-in-cage construct with additional screw fixation was implanted, providing satisfactory stability (Fig. 7).Figure 7.: Second-stage repair of the fracture shown in
Fig. 5 using a Kocher-Langenbeck approach with revision of the acetabular component using a cup-in-cage construct.
The patient was mobilized with weight-bearing as tolerated. Owing to 2 prosthetic dislocation events, revision surgery was felt necessary. A dual mobility inlay was chosen to increase the stability of the construct, aiming for a reduced risk of dislocation. At 3 months postoperatively, the routine radiograph showed a good integration of the well-functioning and stable revision hip endoprosthesis (Fig. 8).
Figure 8.: 3-month follow-up after two-stage reconstruction of the case demonstrated in
Fig. 5.
4.5. Pelvic Periprosthetic Fractures: Complications
It is reported that specific fracture patterns are linked to higher complication rates. More specifically, Dammerer et al[37] in their classification identified fractures involving the medial wall (H1-type fractures) as prone to lead to early failure and premature loosening. In the same study, the highest acetabular implant migration was reported in fractures involving the superolateral wall (H3-type fracture).[37] By contrast, Brown et al[38] found that patients with posterior wall and/or posterior column fractures eventually led to revision surgery after failed nonoperative treatment. Commonly encountered complications are described below further.
4.5.1. Implant Migration
Periacetabular periprosthetic fractures can lead to later migration of the cup, which will require revision surgery, even when initially deemed to be stable and treated nonoperatively. This migration could alter the orientation of the cup. Dammerer et al reported a median cup inclination ranging between 24 degrees and 57 degrees and cup anteversion between 19 degrees and 35 degrees, 2 years after occult periprosthetic acetabular fractures. Significant implant migration (>2 mm) was reported in 45% of these cases.[37]
4.5.2. Implant Loosening and Failure
Intraoperative PAFs, associated with cementless implant insertion, should be identified and treated accordingly with either fixation or protective weight-bearing if the acetabular component is considered stable after manual testing intraoperatively. Failure to identify these injuries can lead to loosening of the acetabular component.[19,39] Nonoperative treatment is recommended for periprosthetic fractures of the acetabulum around cemented implants that are stable radiologically and clinically. The reported rate of revision surgery is as high as 38% in the first postoperative year and can reach 80% subsequently.[44] This high incidence of failure raises the question about the reliability of radiological/clinical evaluation of these fractures, even when the fractures are nondisplaced, and the cups seem stable with no migration in comparison with preinjury radiographs. In these situations, a close follow-up is of paramount importance with a low threshold for early operative intervention that almost always involves revision surgery.[19]
4.5.3. Pelvic Discontinuity
The periacetabular fractures can lead to PD at the moment of revision surgery (prevalence of 0.9%). These should be treated accordingly with anti-protrusio cages. In these cases, the uncemented implants seem to have better outcomes than the cemented ones.[19,40,41]
4.5.4. Delayed Union/Nonunion
Although nonoperative management of PAFs with a stable prosthesis can lead to good outcomes, some rare cases of delayed union or even nonunion have been reported. These cases can be treated with revision surgery, bone grafting, and subsequent fixation of the nonunion.[5] Springer et al reported 2 cases of nonunion after plate fixation of transverse pelvic periprosthetic fractures, leading to plate breakage. One of these fractures united despite the broken plate, and another necessitated a revision surgery.[42]
4.5.5. Persistent Pain
PAFs associated with intraoperative fracture due to cementless cup insertion are more likely to lead to persistent postoperative groin pain, even in cases in which the implant is deemed to be stable and with a healed fracture.[5,39]
4.5.6. Infection
Revision surgery because of PAF is linked with a high risk of infection, which can manifest up to 2 years after the revision surgery.[37] Brown et al[38] reported one case of periprosthetic infection treated eventually with resection arthroplasty 3 weeks after the index procedure.[43]
4.5.7. Vascular Injury
The acetabular component and possible stabilization screws can migrate medially inside the pelvis after severe trauma leading to a periprosthetic pelvic fracture. The intrapelvic vascular structures can be compromised either by the bone fragments or by the implants, leading to life-threatening hemorrhage.[5]
4.5.8. Ileus
Brown et al[38] reported one case of postoperative ileus after a THA associated with periacetabular fracture. This case was treated with the use of a nasogastric tube for decompression.
4.5.9. General Complications Related to Pelvic Fractures and Surgery
Complications related to pelvic fractures and hip surgery/revision THA should not be ignored.[44] These include thromboembolic events, such as deep vein thrombosis, pulmonary embolism, and stroke, as well as the risks of prophylactic antithrombotic therapy, such as heparin-induced thrombocytopenia/thrombosis and bleeding.[44,45] Fat embolism and other problems from the respiratory system, including pneumonia and atelectasis, may also occur. Local complications include surgical wound problems, hematoma formation, delayed wound healing, persistent oozing, and infection. Finally, damage to the local neurovascular structures has also been reported, mainly affecting the superior gluteal vein and the sciatic and peroneal nerves. These injuries can occur either from the fracture fragments or may be iatrogenic, after surgical maneuver or misplacement of retractors.[45]
5. Conclusion
Periprosthetic acetabular fractures are rare but potentially disastrous injuries that may affect the fixation of the adjacent acetabular implants. It is of paramount importance to properly diagnose and treat these injuries. Intraoperative fractures are likely more common than reported, and when identified should be treated so that fixation of the acetabular cup is not compromised. Postoperative fractures require detailed evaluation for to select proper treatment. Specific fracture patterns in which non-operative treatment is more likely to fail include medial wall fractures, which could result in central migration, and posterior column fractures, which affect support of the acetabular implant. Failure to identify and/or treat these fractures adequately can lead to late implant aseptic loosening or implant instability and migration, both necessitating revision surgery. When surgery is needed, a thorough understanding of the fracture pattern and its effect on the acetabular component must be understood.
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