Surgical techniques: Total hip arthroplasty for neglected acetabular fractures

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In this part of the series, Ramesh K Sen from the Institute of Orthopedic Surgery at the Max Hospital, Mohali, India, leads us through the use of delayed total hip arthroplasty (THA) in neglected or previously treated acetabular fractures. In this part, a new type of classification for bone defects in neglected acetabular fractures is also presented, with options for bone grafting and augmentation discussed. The surgical techniques for optimal THA in each defect type are explained, supplemented by a series of interesting patient cases.

Ramesh K Sen

Institute of Orthopedic Surgery, Max Hospital, Mohali, India

Challenges in arthroplasty in neglected acetabular fractures

There are different situations in which THA is performed as a treatment for acetabular fractures in a delayed setting as discussed in Part 1 of this series of articles. However, in some situations, the acetabular fracture is neglected, which is commonly thought of as a fracture which has been left untreated for more than 3 weeks after trauma [1, 2]. This situation can cause changes in the fracture site which make not only treatment of the acetabular fracture more challenging but also impact the patient’s quality of life [2].

Symptoms of neglected acetabular trauma

The symptoms of neglected acetabular trauma are varied; patients may have a painful hip, a limp, or decreased activity level. On physical examination, the patient may exhibit adaptive changes; they may have an antalgic or stiff hip gait, a shortened leg, local tenderness, contractures, or sciatic nerve palsy causing hypoesthesia of the foot or motor weakness. In the acetabular area, voids or defects, anatomical alterations, or malunited positions of the wall and columns are likely [3]. The patient may also have pain and joint instability; these latter symptoms could be due to malunited or nonunited acetabular fragments, in such situations THA is clearly indicated [4].

Altered reference points in neglected acetabular fractures

In THA, standard reference points in the native acetabulum are used to aid in positioning the acetabular cup. These reference points are not subject to anatomical variation in most conditions necessitating THA. When an uncemented acetabular cup is used in a primary THA, the acetabular area can be prepared by reaming [5], whereas for a cemented cup, sufficient support already exists. This situation is similar when an acetabular fracture has been previously operated on and well reduced [6]. Nevertheless, even in well-reduced acetabular fractures, THA may still be indicated if the patient develops posttraumatic arthritis, avascular femoral head or acetabular wall necrosis, infection, acetabulum floor nonunion, or implant migration into the joints [4]. Surrounding fibrosis and presence of metal can create problems in exposure, and defects caused by subsequent osteolysis can also be an issue. In these cases, the acetabular cup is placed as in a primary THA [7].

The situation in neglected acetabular fractures is different because the standard reference points used for acetabular cup positioning may have changed. Similarly, this may be the case in nonoperatively managed fractures, if reduction and stability of the fracture was not achieved [8]. In neglected acetabular fractures, the acetabular floor can be fractured, displaced or absent, and there may be small- to large-sized bone defects due to the displaced acetabular columns or wall [9], necessitating the use of bone grafts or augments. In such cases, there is a chance of leg-length discrepancy.

Changed anatomy in neglected acetabular fractures

Neglected acetabular fractures can be characterized by the changed anatomy of the hip joint. The acetabular columns may be displaced, the posterior wall can be absent, and the bone fragments may be malunited or crushed creating a large void [10]. Depending on the anatomical injury pattern, the femoral head can migrate posterosuperiorly or medially. When considering a THA, stability of the acetabular cup is dependent on whether the fracture has united or is in nonunion. Many acetabular nonunions can be stable enough for cup placement due to the presence of fibrous tissue. However, the area of osseous contact required for cup integration may be reduced due to the lack of underlying acetabular bone, necessitating grafts or augments [11].

New thinking around bone defect classification

In revision THA, the Paprosky and the American Academy of Orthopaedic Surgeons (AAOS) classification systems for osseous defects have been widely used [12]. However, the Paprosky classification is not meant for posttraumatic situations [13].

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  • Challenges in arthroplasty in neglected acetabular fx
  • Changed anatomy in neglected acetabular fx
  • Classification of neglected acetabular defects
  • Radiological workup
  • Surgical approach
  • Bone graft and implants
  • Acetabular reconstruction
  • Small bone defects
  • Metal mesh
  • Fixation of acetabular cups
  • Surgical techniques for total hip arthroplasty
  • Type 1 - Acetabular defect
  • Type 2 - Acetabular defect (posterior or posterosuperior support loss)
  • Type 3A – Stable displaced posterior column defect
  • Type 3B – Unstable displaced posterior column defect with nonunion
  • Type 4A – Transverse discontinuity with either osseous or fibrous stability
  • Type 4B – Transverse discontinuity with instability due to nonunion
  • Type 5 - Anterior column defect
  • Management
  • Conclusion

Part 1 | Types of acetabular fractures and their indications

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Part 2 | Acute 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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