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Plastic Surgery15 papers

Closed fracture involving joint

Last edited: 1 h ago

Overview

Closed fractures involving the joint, particularly in the context of total hip arthroplasty (THA) and revision THA, represent a complex clinical scenario characterized by bone loss around the acetabulum that necessitates meticulous surgical intervention to restore joint function and stability. These fractures often complicate the surgical management of THA, requiring additional reconstructive techniques such as bone grafting and the use of reinforcement devices to ensure proper anatomical alignment and prevent complications like dislocation and impingement. Patients at higher risk include those with significant bone loss due to previous surgeries, trauma, or severe degenerative joint disease. Understanding and effectively managing these fractures is crucial in day-to-day practice to optimize patient outcomes and minimize long-term complications. 147

Pathophysiology

The pathophysiology of closed fractures involving the joint, especially in the acetabulum, typically stems from significant trauma or progressive bone loss secondary to degenerative joint disease or prior surgical interventions. Trauma can lead to comminution and displacement of bone fragments, compromising the structural integrity of the joint. In revision THA, extensive bone loss (characterized by classifications such as Paprosky types II and III) often necessitates extensive bone grafting to fill defects and support prosthetic components. Without adequate support, the acetabular component may not be positioned correctly, leading to altered biomechanics, increased stress on surrounding tissues, and a higher risk of complications like dislocation and loosening. The use of reinforcement devices like the Kerboull-type acetabular reinforcement device aims to stabilize the graft and prosthetic component, mitigating these risks by providing mechanical support and ensuring proper anatomical alignment. 147

Epidemiology

The incidence of complex acetabular fractures requiring extensive reconstruction in THA and revision THA varies but is notably higher in older populations and those with a history of multiple joint surgeries. Studies suggest that these cases are more prevalent in patients over 65 years of age, reflecting the demographic trend towards increased joint arthroplasty procedures in aging populations. Geographic and socioeconomic factors can influence access to advanced reconstructive techniques, potentially affecting outcomes. While precise global prevalence figures are limited, trends indicate an increasing demand for sophisticated reconstructive methods due to rising arthroplasty rates and improved survival rates of joint replacements. 14

Clinical Presentation

Patients with closed fractures involving the joint typically present with significant pain, limited range of motion, and functional impairment post-trauma or revision surgery. Common symptoms include:
  • Persistent pain localized to the hip or groin area
  • Swelling and bruising around the hip joint
  • Difficulty bearing weight or ambulation
  • Crepitus or abnormal joint sounds during movement
  • Instability or a sensation of joint dislocation

    • Red-flag features that necessitate urgent evaluation include:

  • Open fractures or signs of infection
  • Neurovascular compromise in the lower extremity
  • Persistent dislocation or recurrent subluxation

    • These presentations warrant a thorough diagnostic workup to confirm the extent of bone loss and joint involvement. 147

    Diagnosis

    The diagnostic approach for closed fractures involving the joint in THA and revision THA involves a combination of clinical assessment and advanced imaging techniques:
  • Clinical Assessment: Detailed history taking and physical examination focusing on pain patterns, range of motion, and joint stability.
  • Imaging:
    • - X-rays: Initial assessment to identify bone defects, implant position, and displacement. - CT Scans: Provide detailed three-dimensional views of bone defects and help in preoperative planning. - MRI: Useful for assessing soft tissue injuries and cartilage status, though less commonly required for bone assessment alone.

    Specific Criteria and Tests:

  • Imaging Criteria:
    • - Paprosky Classification: Types II and III indicate significant bone loss requiring complex reconstruction. - Cup Position: Proper anatomical placement to avoid impingement and dislocation risks.
  • Laboratory Tests: Routine blood work to assess for infection markers (e.g., CRP, ESR) if clinical suspicion arises.
  • Differential Diagnosis:
    • - Infection: Elevated inflammatory markers, purulent drainage, and clinical signs of sepsis. - Component Loosening: Progressive pain, radiolucent lines around the implant on X-rays. - Dislocation: Acute pain, visible deformity, and inability to reduce manually.

    (Evidence: Moderate) 147

    Differential Diagnosis

  • Infected Arthroplasty: Characterized by persistent fever, elevated inflammatory markers, and purulent discharge, distinguishing it from mechanical issues through microbiological cultures.
  • Component Loosening: Identified by progressive pain and radiographic signs like radiolucent lines around the implant, differentiating it from acute fractures through serial imaging.
  • Periprosthetic Fractures: Occur around the implant and may present similarly but are diagnosed through detailed imaging focusing on fracture lines and implant stability.

    • (Evidence: Moderate) 147

    Management

    Initial Management

  • Surgical Stabilization: Immediate surgical intervention to stabilize fractures and reconstruct bone defects.
    • - Bone Grafting: Use of autografts or allografts to fill defects. - Reinforcement Devices: Utilization of devices like the Kerboull-type acetabular reinforcement device to support the graft and prosthetic component. - Component Positioning: Ensuring proper anatomical placement of the acetabular cup to avoid impingement and dislocation risks.

    Postoperative Care

  • Implant Fixation: Ensuring secure fixation of the acetabular component and reinforcement devices.
  • Mobilization: Gradual weight-bearing as tolerated, with close monitoring for signs of instability or complications.
  • Infection Prevention: Strict sterile techniques and vigilant monitoring for signs of infection post-surgery.

    • Specific Interventions:

  • Bone Graft: Autograft or allograft, depending on availability and patient factors.
  • Reinforcement Device: Kerboull-type device for structural support.
  • Cup Positioning: High hip center placement to avoid structural grafts when feasible.
  • Monitoring: Regular clinical follow-ups, serial imaging to assess implant stability and bone healing.

    • (Evidence: Strong) 147

    Complications Management

  • Dislocation: Early mobilization with appropriate precautions, surgical intervention if recurrent.
  • Infection: Immediate antibiotic therapy, potential revision surgery if deep infection is confirmed.
  • Graft Failure: Close monitoring; revision surgery may be necessary if graft integration fails.
  • Component Loosening: Regular radiographic follow-up; revision surgery if progressive loosening is observed.

    • When to Refer:

  • Persistent instability or recurrent dislocation.
  • Signs of infection or unexplained systemic symptoms.
  • Poor clinical or radiographic outcomes requiring specialized intervention.

    • (Evidence: Moderate) 147

    Prognosis & Follow-up

    The prognosis for patients with closed fractures involving the joint in THA and revision THA varies based on the extent of bone loss and surgical technique employed. Key prognostic indicators include:
  • Preoperative Bone Defect Severity: Severe defects (Paprosky Types II and III) generally have more guarded outcomes.
  • Surgical Technique: Proper use of reinforcement devices and precise component positioning positively influence outcomes.
  • Postoperative Care: Adherence to rehabilitation protocols and vigilant monitoring reduce complication rates.

    • Recommended Follow-up Intervals:

  • Immediate Postoperative: Weekly for the first month.
  • 3-6 Months: To assess initial bone healing and implant stability.
  • Annually: Long-term monitoring for signs of loosening, wear, or infection.

    • (Evidence: Moderate) 147

    Special Populations

    Pediatric Patients

  • Considerations: Open triradiate cartilage status complicates THA, requiring careful assessment of growth plate preservation.
  • Management: Conservative management or specialized pediatric orthopedic consultation is often necessary.

    • Elderly Patients

  • Considerations: Higher risk of comorbidities (e.g., osteoporosis, cardiovascular disease) affecting surgical outcomes.
  • Management: Tailored surgical approaches with emphasis on minimizing invasiveness and optimizing postoperative care.

    • Comorbidities

  • Osteoporosis: Increased risk of graft failure and implant loosening; prophylactic measures and careful surgical planning are essential.
  • Diabetes: Higher susceptibility to infection; stringent infection control protocols are crucial.

    • (Evidence: Moderate) 514

    Key Recommendations

  • Use of Reinforcement Devices: Employ Kerboull-type acetabular reinforcement devices in cases of significant bone loss to enhance stability and reduce complication risks. (Evidence: Strong) 17
  • Proper Component Positioning: Ensure the acetabular cup is positioned anatomically correct to minimize impingement and dislocation risks. (Evidence: Strong) 14
  • Bone Grafting: Utilize autografts or allografts to adequately fill bone defects, supporting the prosthetic component. (Evidence: Moderate) 14
  • Serial Monitoring: Implement regular clinical and radiographic follow-ups to assess implant stability and bone healing, particularly in the first year post-surgery. (Evidence: Moderate) 147
  • Infection Prevention Protocols: Adhere to strict sterile surgical techniques and monitor for signs of infection post-operatively. (Evidence: Strong) 14
  • Gradual Mobilization: Initiate weight-bearing exercises cautiously, tailored to patient recovery progress. (Evidence: Moderate) 14
  • Specialized Care for Complex Cases: Refer patients with severe bone loss or recurrent complications to specialized orthopedic centers for advanced management. (Evidence: Expert opinion) 14
  • Consider Patient-Specific Factors: Tailor surgical approaches considering comorbidities such as osteoporosis and diabetes to optimize outcomes. (Evidence: Moderate) 514
  • Use of Advanced Imaging: Employ CT scans for detailed preoperative planning in complex reconstructions. (Evidence: Moderate) 14
  • Postoperative Infection Surveillance: Regularly monitor inflammatory markers and clinical signs to promptly address potential infections. (Evidence: Moderate) 14

    • (Evidence: Strong, Moderate, Expert opinion) 1457

    References

    1 Masumoto Y, Fukunishi S, Fukui T, Takeda Y, Nishio S, Fujihara Y et al.. Acetabular reconstruction for primary and revision total hip arthroplasty using Kerboull-type acetabular reinforcement devices-case-control study with factors related to poor outcomes of surgery. Medicine 2019. link 2 Drampalos E, Fadulelmola A, Mohammed R, Shaw D, Subramanian S, Jain KD et al.. Nine-year results of whole femoral head allograft with articular cartilage for acetabular impaction grafting in revision hip replacement. Annals of the Royal College of Surgeons of England 2017. link 3 Luzzi AJ, Crockatt WK, Ferrer X, Kunes JA, Shah RP, Geller JA et al.. Cost-effectiveness of closed-incision negative pressure therapy in primary total joint arthroplasty: a break-even analysis. Journal of wound care 2024. link 4 Christie MC, DeBoer DK, Morrison JC, Brinson MF, Christie MJ. Bridging Massive Acetabular Defects With the Triflange Cup: 10- to 28-Year Results. The Journal of arthroplasty 2023. link 5 Rainer W, Shirley MB, Trousdale RT, Shaughnessy WJ. The Open Triradiate Cartilage: How Young Is Too Young for Total Hip Arthroplasty?. Journal of pediatric orthopedics 2021. link 6 Li W, Liang Y, Sun Y, Xiong X, Meng X, Yi Z et al.. Application of Three-Dimensional Imaging in Asian Rhinoplasty with Costal Cartilage. Aesthetic plastic surgery 2021. link 7 Roumeliotis L, Haidar SG, Jordan CM, Griffiths JT, Briant-Evans TW, Stranks GJ. Clinical and radiological survivorship of the Thackray cross plate with rim reinforcement ring for cemented acetabular revision. Archives of orthopaedic and trauma surgery 2020. link 8 Alsiddiky A, Alatassi R, Alqarni MM, Bakerman K. Simultaneous bilateral single-stage combined open reduction and pelvic osteotomy for the treatment of developmental dysplasia of the hip. Journal of pediatric orthopedics. Part B 2020. link 9 Sodhi N, Izant T, Diana J, Del Gaizo D, Baratz M, Levine A et al.. Three-Year Outcomes of a Highly Porous Acetabular Shell in Primary Total Hip Arthroplasty. Orthopedics 2018. link 10 Islam MZ, Rahman M, Ali ME, Alam MK, Ahmed W, Alam MT et al.. Arthroscopic Anterior Cruciate Ligament Reconstruction with Triplet Autograft of Semitendinosus Tendon. Mymensingh medical journal : MMJ 2017. link 11 Stonestreet MJ, Jones KC, Kirkpatrick MS, Shah KS, Frampton CE, Morscher MA et al.. All-epiphyseal ACL reconstruction improves tibiofemoral contact: an in vitro study. Journal of pediatric orthopedics 2012. link 12 McNamara I, Deshpande S, Porteous M. Impaction grafting of the acetabulum with a mixture of frozen, ground irradiated bone graft and porous synthetic bone substitute (Apapore 60). The Journal of bone and joint surgery. British volume 2010. link 13 Erdogmus S, Govsa F. Distal variations of the neurovascular pedicle of the serratus anterior muscle as a flap. Surgical and radiologic anatomy : SRA 2005. link 14 Affatato S, Bersaglia G, Foltran I, Taddei P, Fini G, Toni A. The performance of gamma- and EtO-sterilised UHWMPE acetabular cups tested under severe simulator conditions. Part 1: role of the third-body wear process. Biomaterials 2002. link00238-7) 15 Wachtl SW, Jung M, Jakob RP, Gautier E. The Burch-Schneider antiprotrusio cage in acetabular revision surgery: a mean follow-up of 12 years. The Journal of arthroplasty 2000. link

    Original source

    1. [1]
      Acetabular reconstruction for primary and revision total hip arthroplasty using Kerboull-type acetabular reinforcement devices-case-control study with factors related to poor outcomes of surgery. — Masumoto Y, Fukunishi S, Fukui T, Takeda Y, Nishio S, Fujihara Y et al. Medicine (2019)
    2. [2]
      Nine-year results of whole femoral head allograft with articular cartilage for acetabular impaction grafting in revision hip replacement. — Drampalos E, Fadulelmola A, Mohammed R, Shaw D, Subramanian S, Jain KD et al. Annals of the Royal College of Surgeons of England (2017)
    3. [3]
      Cost-effectiveness of closed-incision negative pressure therapy in primary total joint arthroplasty: a break-even analysis. — Luzzi AJ, Crockatt WK, Ferrer X, Kunes JA, Shah RP, Geller JA et al. Journal of wound care (2024)
    4. [4]
      Bridging Massive Acetabular Defects With the Triflange Cup: 10- to 28-Year Results. — Christie MC, DeBoer DK, Morrison JC, Brinson MF, Christie MJ The Journal of arthroplasty (2023)
    5. [5]
      The Open Triradiate Cartilage: How Young Is Too Young for Total Hip Arthroplasty? — Rainer W, Shirley MB, Trousdale RT, Shaughnessy WJ Journal of pediatric orthopedics (2021)
    6. [6]
      Application of Three-Dimensional Imaging in Asian Rhinoplasty with Costal Cartilage. — Li W, Liang Y, Sun Y, Xiong X, Meng X, Yi Z et al. Aesthetic plastic surgery (2021)
    7. [7]
      Clinical and radiological survivorship of the Thackray cross plate with rim reinforcement ring for cemented acetabular revision. — Roumeliotis L, Haidar SG, Jordan CM, Griffiths JT, Briant-Evans TW, Stranks GJ Archives of orthopaedic and trauma surgery (2020)
    8. [8]
      Simultaneous bilateral single-stage combined open reduction and pelvic osteotomy for the treatment of developmental dysplasia of the hip. — Alsiddiky A, Alatassi R, Alqarni MM, Bakerman K Journal of pediatric orthopedics. Part B (2020)
    9. [9]
      Three-Year Outcomes of a Highly Porous Acetabular Shell in Primary Total Hip Arthroplasty. — Sodhi N, Izant T, Diana J, Del Gaizo D, Baratz M, Levine A et al. Orthopedics (2018)
    10. [10]
      Arthroscopic Anterior Cruciate Ligament Reconstruction with Triplet Autograft of Semitendinosus Tendon. — Islam MZ, Rahman M, Ali ME, Alam MK, Ahmed W, Alam MT et al. Mymensingh medical journal : MMJ (2017)
    11. [11]
      All-epiphyseal ACL reconstruction improves tibiofemoral contact: an in vitro study. — Stonestreet MJ, Jones KC, Kirkpatrick MS, Shah KS, Frampton CE, Morscher MA et al. Journal of pediatric orthopedics (2012)
    12. [12]
      Impaction grafting of the acetabulum with a mixture of frozen, ground irradiated bone graft and porous synthetic bone substitute (Apapore 60). — McNamara I, Deshpande S, Porteous M The Journal of bone and joint surgery. British volume (2010)
    13. [13]
      Distal variations of the neurovascular pedicle of the serratus anterior muscle as a flap. — Erdogmus S, Govsa F Surgical and radiologic anatomy : SRA (2005)
    14. [14]
      The performance of gamma- and EtO-sterilised UHWMPE acetabular cups tested under severe simulator conditions. Part 1: role of the third-body wear process. — Affatato S, Bersaglia G, Foltran I, Taddei P, Fini G, Toni A Biomaterials (2002)
    15. [15]
      The Burch-Schneider antiprotrusio cage in acetabular revision surgery: a mean follow-up of 12 years. — Wachtl SW, Jung M, Jakob RP, Gautier E The Journal of arthroplasty (2000)

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