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