L’arthroplastie totale de hanche dans le traitement des fractures récentes de l’acétabulum du sujet âgé

RésuméLe but de cette étude était d’analyser les résultats après arthroplastie totale de hanche de première intention pour fracture récente déplacée de l’acétabulum.Seize patients âgés en moyenne de 76,1 ans (64 à 89 ans) ont présenté une fracture déplacée de l’acétabulum. Une arthroplastie totale de hanche a été réalisée de première intention avec stabilisation par renfort acétabulaire et greffe osseuse autologue. Tous les patients ont été évalués avec un recul clinique de plus de 3 ans, avec scores fonctionnels (Postel-Merle d’Aubigné, et Harris) et échelle d’activité de Devane. Un bilan radiographique a analysé la consolidation et les ossifications selon Brooker.Les scores fonctionnels étaient en moyenne de 13,8 (10 à 17) selon Postel-Merle d’Aubigné, et de 73,6 (47 à 93) selon Harris. Sur l’échelle de Devane, douze patients (75 %) ont conservé leur niveau antérieur ; seuls quatre patients ont diminué leur activité d’un grade. Aucune luxation n’est survenue en postopératoire. Toutes les fractures ont consolidé, sans qu’aucun descellement n’ait été observé. Six patients (37 %) ont développé des ossifications hétérotopiques péri-articulaires, dont un cas a nécessité une résection chirurgicale.Dans notre série, cette stratégie thérapeutique permet d’obtenir la consolidation fracturaire en une intervention chirurgicale unique, tout en autorisant une verticalisation et une reprise de l’autonomie rapide des patients. La littérature internationale confirme les bons résultats de cette attitude, tout en proposant des modalités techniques différentes sur la stabilisation acétabulaire.

Purpose of the studyThe standard treatment of displaced acetabular fractures is open reduction and internal fixation (ORIF). In elderly patients, ORIF may not be the best option because of osteoporotic bone and the necessary period of bed rest. Primary total hip arthroplasty (THA) for displaced acetabular fractures was initiated by Westerborn in 1954. Since then, several authors described their experience and since 1986 many studies have reported good results with this type of treatment. This study assessed outcome obtained in patients treated by primary THA for acetabular fracture in the orthopedic department of the Dupuytren Teaching Hospital in Limoges.Material and methodsBetween 1981 and 2001, 16 patients, mean age 76.1 years (range 64-89) were treated with primary THA for recent displaced acetabular fractures. Bone loss was quantified using the SOFCOT classification for acetabular revision THA: stage III was noted in four patients (25%) and stage IV in twelve (75%). No attempts were made to achieve anatomic reduction of fracture fragments, but a reinforcement ring was used, coupled with autologous bone graft for the acetabulum. All patients were assessed clinically using the Postel-Merle d’Aubigné et Harris scores and the Devane activity scale. Radiographs were used to assess union and signs of loosening according to De Lee and Charnley and the Gruen classifications. Ossifications were quantified with the Brooker classification.ResultsMean follow-up was three years. The mean Harris hip score was 73.6 (range 47-93), and the mean Postel-Merle d’Aubigné score 13.8 (range 10-17). Twelve patients (75%) returned to their initial activity level on the Devane scale; only four decreased their daily activity by one level. All patients but one were satisfied. There was one case of partial neurological sensorial deficit. There were no postoperative dislocations. All fractures healed. There were six cases (37%) of heterotopic bone formation including grade IV ossification in one patient with a stiff hip which required surgical resection. There were five cases of radiolucent halo in one zone of the cup, and one case in two zones; all these lucencies were non-progressive and there was not sign of loosening at last follow-up.DiscussionOrthopedic treatment for displaced acetabular fractures in elderly patients may not be suitable because of the risk of complications due to the prolonged period of decubitus. ORIF requires one surgery, but may nevertheless lead to a second operation because of osteoarthritis. Primary THA has many advantages: full weight bearing is achieved rapidly, decubitus complications are avoided, functional outcome was good with union for all of the fractures in our series. Nevertheless, despite differences between surgical procedures reported in the literature, ectopic ossifications are common and the overall rate of dislocation reaches 7% considering all reported series.ConclusionsIn selected patients with a displaced acetabular fracture, we believe that an acute THA may provide several advantages including only one procedure and quick weight bearing with a lower rate of decubitus complications. In this small series, functional outcome was good for most of the patients who recovered their initial activity level.