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Pelvic Discontinuity in Revision Total Hip Arthroplasty*
DANIEL J. BERRY, M.D.†; DAVID G. LEWALLEN, M.D.†; ARLEN D. HANSSEN, M.D.†; MIGUEL E. CABANELA, M.D.†, ROCHESTER, MINNESOTA
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Investigation performed at the Mayo Clinic and Mayo Foundation, Rochester
J Bone Joint Surg Am, 1999 Dec 01;81(12):1692-1702
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Abstract

Background: Pelvic discontinuity is a distinct form of bone loss, occurring in association with total hip arthroplasty, in which the superior aspect of the pelvis is separated from the inferior aspect because of bone loss or a fracture through the acetabulum. The purpose of this study was to describe the population of patients who are at risk for this condition, to identify the characteristic radiographic features associated with it, and to report the results of revision total hip arthroplasty for the treatment of pelvic discontinuity.Methods: The cases of all twenty-seven patients (thirty-one hips) who were identified as having a pelvic discontinuity at the time of a reoperation for a failed hip arthroplasty at one institution were reviewed retrospectively, and demographic information was collected. The preoperative radiographs and the operative notes were reviewed, and the postoperative results and complications were recorded.Results: Pelvic discontinuity was identified in association with thirty-one (0.9 percent) of 3505 acetabular revisions. The mean age of the patients was sixty-one years (range, thirty-eight to eighty years). Twenty-eight hips were in women, and three were in men. Women (p < 0.001) and patients who had rheumatoid arthritis (p = 0.003) had a significantly increased risk of pelvic discontinuity. The radiographic findings included a visible fracture line through the anterior and posterior columns, medial translation of the inferior aspect of the hemipelvis relative to the superior aspect (seen as a break in Kohler's line), and rotation of the inferior aspect of the hemipelvis relative to the superior aspect (seen as asymmetry of the obturator rings) on a true anteroposterior radiograph.Two patients died within two years after the revision, and two had a resection arthroplasty for the treatment of the pelvic discontinuity; thus, twenty-seven hips were reconstructed and were eligible for follow-up at least two years after the operation. A number of different methods were used for reconstruction, but the results were best in patients who did not have severe segmental acetabular bone loss (type IVa [a satisfactory result in three of three hips]) and poorer in those who had severe segmental or combined segmental and cavitary bone loss (type IVb [a satisfactory result in ten of nineteen hips]) and in those who previously had been treated with irradiation to the pelvis (type IVc [a satisfactory result in three of five hips]). Nine of the twenty-seven hips needed another operation: four, because of aseptic loosening of the acetabular component; four, because of recurrent dislocation; and one, because of deep infection. Excluding three hips that were revised early because of infection or dislocation, a mechanically stable construct (that is, a stable socket and a possibly or definitely healed discontinuity) was obtained in seventeen of twenty-four hips.Conclusions: Pelvic discontinuity is uncommon, and treatment is associated with a high rate of complications. For hips with type-IVa bone loss and selected hips with type-IVb defects, in which a socket inserted without cement can be satisfactorily supported by native bone, we prefer to use a posterior column plate to stabilize the pelvis and a porous-coated socket inserted without cement. For most hips with type-IVb and type-IVc bone loss, we prefer to use particulate bone graft or a single structural bone graft protected with an antiprotrusio cage.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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