The Classification and Treatment of Pelvic Discontinuity

BA Rogers, PM Whittingham-Jones, SH Bridle, O Safir,

D Backstein, PA Mitchell, MD Bircher, AE Gross

The Treatment of Pelvic Discontinuity DuringAcetabular Revision

Sporer, O’Rourke & Paprosky,

Journal of Arthroplasty 20(4):2005: 79 – 84

Level V Evidence

“The long-term clinical results of this treatment remain unknown”

HealingPotential

Yes

No

Compression

Distraction

BA Rogers, D Backstein, O Safir, AE GrossHip Revision ArthroplastyAO Manual of Fracture Management: Periprosthetic FracturesCarsten Perka (Ed), 2011

Clinical evidence for acute vs chronic

• 2 centre study– St Georges Hospital, UK ACUTE– Mount Sinai Hospital, Toronto CHRONIC

• 2 case series, 2 surgical techniques– ACUTE Compression– CHRONIC Distraction

• Single outcome: acetabular revision

Duration of Discontinuity Causes

Acute <12 weeksIatrogenic

Traumatic

Chronic >12 weeks

Aseptic Osteolysis

Septic Osteolysis

Fracture Non-union

Pathological Bone

Acute Chronic

N= 9 62

Age (mean, yrs) 67.4 67.5

Female 100% 75.9%

Follow - up 34 months 35 months

Acute Pelvic Discontinuity

• N=9• compression• 8 posterior column plate and uncemented cup• At last follow up– No revisions, 100% survivorship– No dislocation/infection

• x1 radiographic ischial non-union

Complication Ilio-ischial cage(n=20)

Dislocation 1

Infection 1

Loose/failed 1

Revision (instability) 1 (5%)

Revision (Cage failure) 5 (25%)

Total Revisions 6 (30%)

Time to Revision 18 months

Complication Cup-Cage (n=42)

Dislocation 6

Infection 1

Loose/failed 1

Revision (instability) 2 (4.7%)

Revision (Cage failure) 2 (4.7%)

Total Revisions 4 (9.5%)

Time to Revision 6.5 months

Kaplan – Meier survivorship graph for chronic pelvic discontinuity patients treated with cup-cage reconstruction

Any revision = end point.

86.3%

Kaplan – Meier survivorship graph for chronic pelvic discontinuity patients managed with a cup-cage reconstruction.

Revision for a failed pelvic discontinuity reconstruction = end point.

93.8%

Trabecular Metal

High co-efficient of friction

Similar Young’s modulus to bone

Tantalum (Zimmer)Titanium (Stryker)

Very porous

Chronic reconstructions<30% bleeding host bone contact

N= Mean Follow-up Acute or Chronic JournalYear of

PublicationLevel ofEvidence

Christie et al 39 4.4 years Chronic CORR 2001 IV

Berry et al 27 3 years Chronic JBJS (Am) 1999 IV

Koster et al 4 3.6 years Chronic J.Arthroplasty 2006 IV

Paprosky et al 16 2.6 years Chronic CORR 2006 IV

Bostrom et al 6 30 months Chronic CORR 2006 IV

Springer et al 7 18 months Acute JBJS (Am) 2005 IV

Kerboull et al 12 10 years Chronic CORR 2000 IV

Peters et al 15 29 months Chronic J.Arthroplasty 2004 IV

Lietman et al 11 5 months Chronic Orthopedics 2001 IV

Kosashvili et al 26 44.6 months Chronic JBJS (Br) 2009 IV

Eggli et al 7 96 months Chronic CORR 2002 IV

van Haaren et al 6 7 years Chronic JBJS (Br) 2007 IV

Stiehl et al 10 83 months Chronic J.Arthroplasty 2000 IV

Goodman et al 10 3.3 years Chronic J.Arthroplasty 2004 IV

This Study 71 3 yearsAcute (9) & Chronic (62)

- 2011 IV

ConclusionWhat this study confirms ….

• Important diagnosis

• Difficult diagnosis to make

• Different surgical techniques

• Academic Teaching Units

Pre-op imaging • Judet obliques• CT

Intra-operative

Efficiency

Technique development

Audit & Research

- Surgical- Nursing- Logistics

ConclusionWhat this study adds ….

Acute

Chronic