Total Hip Replacement in Post Trauma

Possible Indications for Primary THR for Fracture

  • High demand patient
  • Pre-existing symptomatic arthritis
  • Paget’s disease
  • Rheumatoid arthritis

Problems with Femoral Neck Non-unions or Failed Fixation

  • Avascular Necrosis (AVN)
    • Hypervascular tissues and more blood loss
  • Non-Union:
    • Free trochanter, etc.
  • No calcar in IT fractures:
    • Deformity, shortening, and contracture
  • Scarring of nerves
  • Poor Bone Quality
  • Retained Hardware

AVN

  • Hypervascular tissues and more blood loss

Shortening

  • Soft tissue contracture:
    • Multiple releases required to expose, maintain stability, and provide range of motion

Trochanteric Non-unions

  • May need a calcar replacing stem ± claw plate

Existing Metalware

  • Remove if possible
  • Consider strut grafts to support weak bone
  • Plug holes to prevent cement extrusion
  • Uncemented prostheses if possible but not strictly necessary
  • Bypass screw holes by two bone diameters to avoid stress riser

Acetabular Fractures

  • Primary THR may be indicated if:
    • Co-existing neck fracture
    • Pre-existing arthritis
    • High demand with irreconstructable fracture

Problems with Old Acetabular Fractures

  • Bone Loss:
    • Especially posterior > cup retroversion
  • Medialise cup
  • Use structural graft to support uncovered posterior cup
  • Exposure difficult due to scarring
  • Deformity due to malunion
  • Protrusio
  • Displacement of NV structures
  • Retention of hardware if previous acetabular ORIF:
    • Remove if possible or ream and remove as becomes apparent
    • Leave what does not interfere with cup placement

Considerations in Proximal Femoral Deformity

  • Soft tissue problems
  • Difficulty accessing the canal due to sclerotic bone:
    • Use high speed burrs, drills or open retrograde via subtrochanteric osteotomy
  • Calcar replacement stems if necessary
  • DDH stems if very small or deformed canal
  • Osteotomy, realignment then bypass with long uncemented stem
  • Distal deformities can be ignored but may lead to early implant failure
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