Review Question - QID 775

The patient described in this question has sustained an insufficiency fracture of the right acetabulum that has been neglected. Total hip arthroplasty (THA), with use of flanged and/or custom acetabular components as needed, is necessary to reconstruct the acetabulum and address the significant femoral head damage.

Total hip arthroplasty as the primary treatment for acetabular fracture remains controversial. Osteopenia, pre-fracture hip arthritis and significant chondral impaction injuries make osteosynthesis difficult and more prone to failure. In the elderly patient with these injury characteristics or delayed presentation, THA may be a preferred first procedure as it can definitively address these issues.

Weber et al reviewed delayed THA in acetabular fractures that had previously undergone open reduction internal fixation, and reported a 78% 10-year survival rate, with worse outcomes in patients < 50 years old, males, weight >80kg, and patients with large residual segmental acetabular defects.

Jiminez et al review the the use of THA after acetabular fractures, either in a delayed or acute fashion. They note that THA as an acute treatment of acetabular fractures is rarely indicated: "Circumstances in which this may be a consideration include certain pathologic fractures, patients with pre-existing symptomatic hip arthritis who are already candidates for hip arthroplasty prior to injury, and rare instances of associated femoral side injuries, including head-splitting fractures that preclude a satisfactory operative result or significantly displaced ipsilateral femoral neck fractures."

Mears reviews acute THA in osteopenic acetabular fractures, with presentation of treatment algorithms and techniques, including conservative treatment, minimally invasive fixation, conventional fixation, acute and delayed THA.

Figure A shows a delayed-presentation right acetabular fracture with significant femoral head impaction injury and acetabular protrusio. Illustration A shows an algorithm for treatment of acetabular fractures in osteopenic patients.

Incorrect answers:
Answer 1: Traction would be acceptable if the patient had an unacceptable medical risk for surgery
Answer 2: Conservative treatment inappropriate unless patient not a surgical candidate for medical reasons
Answer 3: Several injury factors make this choice more prone to failure (1) delayed presentation, (2) osteopenia, (3) femoral head injury, (4) medial roof impaction
Answer 5: Close reduction may improve the protrusio if the fracture is still mobile but cannot address the significant chondral injury.