Types of acetabular fractures and their indications

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In the first part of this series, Rodrigo Pesantez from the Universidad de los Andes Medical School and Colegio Mayor de Nuestra Señora del Rosario, Bogotá, Colombia, explains the acetabular fracture patterns commonly seen in elderly patients, walks us through the definitions of and indications for acute and delayed total hip arthroplasty (THA) as a treatment for acetabular fractures, presents known (negative) prognostic factors, and looks at outcomes for both acute and delayed THA.

Rodrigo Pesantez

Universidad de los Andes Medical School and Colegio Mayor de Nuestra Señora del Rosario, Bogotá, Colombia

Acetabular fracture patterns in the elderly

Acetabular fractures in elderly patients are increasing, with the incidence in patients over 60 years of age being 24% of all acetabular fractures [1]. The failure rate of open reduction and internal fixation (ORIF) as a treatment for these fractures in this population is high, leading to delayed THA in around 17‑30.4% of patients [2]. Acetabular fractures according to Letournel [3] are classically divided into elementary and associated patterns, with elementary patterns including posterior wall, posterior column, anterior wall, anterior column, and transverse fracture patterns; the associated patterns include T-shaped, posterior wall and posterior column, transverse and posterior wall, anterior and hemitransverse, and fractures of both columns [3]. It has been shown that the fracture pattern occurring in the elderly is different to that occurring in the younger population [1]. Ferguson et al [1]—in their epidemiological and radiological study of acetabular fractures in patients over 60 years of age—revealed that fractures characterized by displacement of the anterior column are more common in the elderly (64%) than in younger patients (43%). Here, the common fracture patterns in the elementary group were anterior column (19.2%) and posterior wall (13.2%), and in the associated group were both column (26.4%), anterior column posterior hemitransverse (14.9%), T-shaped (10.2%) and transverse posterior wall (8.1%) (Figure 1) [1].

Figure 1. Most common acetabular fracture patterns observed in patients over 60 years of age, as reported by Ferguson et al [1].

Definition of acute versus delayed total hip arthroplasty

Total hip arthroplasty as a treatment for acetabular fractures can be used in different settings. According to Pesantez, surgeons are faced with performing a THA in an acute or in a delayed setting. When an acute THA is performed, it is either used as an immediate intervention or it can be staged by up to 3 weeks [4]. “On the contrary,” as Pesantez notes, “a delayed THA can be performed in different instances. The perhaps most extreme scenario is when a patient presents with an untreated acetabular fracture. This can also be referred to as a neglected fracture, which is discussed in more detail in Part 3  of this series of articles. Otherwise, a delayed THA can be performed after failure of acetabular fracture management be it nonoperative or ORIF”. Pesantez adds, “in some cases, the original ORIF was perhaps poorly executed resulting in a bad outcome for the patient, whereas in other cases the ORIF was well executed, but due to the severity of the injury the patient has a bad outcome with the development of osteoarthritis.” The following two cases describe classical situations in which an acute THA is performed as the immediate treatment for an acetabular fracture (Case 1), and in which a delayed THA is performed because of failure of the nonoperative treatment (Case 2).

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  • Acetabular fracture patterns in the elderly
  • Acute vs delayed total hip arthroplasty definition
  • THA indications
  • (Negative) prognostic factors
  • Treatment options & outcomes
  • Conclusions

Part 2 | Acute total hip arthroplasty

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Part 3 | Delayed total hip arthroplasty


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Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):

Ashok S Gavaskar

Orthopedic Trauma and Arthroplasty Services, Rela Institute and Medical Centre, Chennai, India

Rodrigo Pesantez

Universidad de los Andes Medical School and Colegio Mayor de Nuestra Señora del Rosario, Bogotá, Colombia

Ramesh K Sen

Institute of Orthopedic Surgery,
Max Hospital, Mohali, India

This article was edited by Lyndsey Kostadinov, AO Innovation Translation Center, Clinical Science, Switzerland.

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