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.

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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]. As noted, the defects created by trauma are different from those observed in revision THA. For example, in revision scenarios the acetabular columns tend to lose bone, yet bone quality does not diminish in neglected acetabular fractures, even if the whole column could be fractured and displaced. Additionally, while an isolated posterior acetabular wall defect is uncommon in revision scenarios, it is one of the most common defects in neglected acetabular cases. Furthermore, there may be ischial bone lysis in revision cases, but this remains one of the strongest inferior supports for acetabular cup stability in neglected acetabular cases. As Sen points out, these factors mean that surgeons need to look differently at defects in neglected acetabular fracture.

Traditionally, the well-known Letournel and Judet [14] classification of acetabular fractures has been used. This classification relies on the fact that most acetabular fractures occur in a specific pattern and follow an expected direction and extent of displacement. However, in neglected acetabular fractures, further changes to the acetabulum can occur such as malunion or nonunion of the columns or wall, displacement, ongoing wear, or instability, and as such the patient may develop pain on ambulation. Additionally, underlying osteoporosis in elderly patients may lead to exaggerated defects. 
These factors led Sen to develop the recently published new classification system for neglected acetabular fractures, which looks specifically at the bone defect and aims to provide guidance for performing THA in these complex cases [15]. Sen’s classification was statistically validated by ten surgeons experienced in revision hip and pelvis and acetabular trauma surgery [15]

 

New classification of acetabular defects in neglected or previously managed acetabular fractures

The classification system from Sen et al [15] is based on Letournel and Judet's classification [14] but considers the acetabular defects occurring from primary traumatic displacement of the acetabular wall and columns. It incorporates how the complications of malunion or nonunion could impact the stability of the acetabular cup for that particular fracture situation. 
The classification categorizes the neglected acetabular fractures into five types [15]. This is shown in Table 1 which presents the new classification types for the acetabular bone defects based on radiographic parameters identified on AP view of the pelvis [15]. Figure 1 shows the landmarks for the acetabular bone defect classification seen on the AP view of the pelvis and provides an explanation of each defect type [15].

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Table 1. The new classification of acetabular bone defects based on radiographic landmarks seen on AP x-ray of the pelvis with bilateral hips. Reproduced with permission from Sen RK et al [15]. Copyright 2022, Indian Orthopaedics Association.
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Table 2. The images show the landmarks for evaluation of the acetabular bone defects per type according to the new classification by Sen et al [15]. Images reproduced with permission from Sen RK [15]. Copyright 2022, Indian Orthopaedics Association. 

Radiological workup

The basic radiological workup includes AP views of the pelvis with affected hip, plus iliac oblique and obturator oblique views of the affected side. Additional pelvic images of the inlet and outlet can be obtained. A computed tomography (CT) scan provides information for defining structural displacement in the bone defects, including nonunion or presence of incarcerated fragments in the joint.

 

Surgical approach

For THA in neglected acetabular fractures, an extensile surgical approach provides adequate exposure. In case series and case reports, the most common approach adopted has been the posterolateral exposure, because most case reports have dealt with posterior or posterosuperior bone loss [4]. In this approach, major landmarks include the greater and lesser trochanter, tendinous gluteus maximus muscle, and the edge of the gluteus medius and minimus muscles. The sciatic nerve can also be identified. Through this access, scarred tissue can be removed from the residual acetabular cavity, and the transverse ligament at the inferior side of the acetabulum can be defined. The posterior inferior exposure—like the Kocher-Langenbeck incision—can be used if a fractured posterior wall or column requires reconstruction [17]. Proximal access is required for reconstruction of the posterior support using bone autograft/allograft, augments, or cages. In patients where pelvic fracture also accompanies the acetabular deformity, a corrective osteotomy may be required.

For primarily medial defects, as in Type 1 or Type 5, any of the conventional approaches can be used. Reconstruction procedures within the acetabulum, ie, medial bone graft impaction with or without metallic mesh, are required.

 

Bone graft and implants required

In most neglected acetabular fracture cases, the femoral head is available and can be used for osseus grafting. Small and contained defects can be easily managed by impaction grafting using morselized bone from the femoral head [18]. In large medial or anterior defects, small circular slices of the femoral head can be impacted to support the acetabular cup. The most common Type 2 defect, caused by loss of posterior wall, or Type 3 defect due to loss of posterior column can be reconstructed with the femoral head as a structural graft. This structural graft can be implanted as a filler, fixed with screws alone, and reamed accordingly. However, many surgeons prefer various designs of metallic augments (trabecular metal, titanium, or tritanium) as the structural support for the acetabular cup [19].

In neglected fractures, the posterior column and wall fragments need to be stabilized. If an autograft or allograft is used as a mechanical buttress, plate fixation is required to attach it to the ilium superiorly and ischium inferiorly (Figure 2). The reconstruction plates are also used to stabilize nonunited columns in Type 3 or the ilium and ischial segments in Type 4 defects. For medial defects, metal mesh may be needed to support larger gaps where impaction grafting can subsequently be performed [20].

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Figure 1. A femoral head autograft. (a) Positioning of the femoral head graft with K-wires. (b) Femoral head graft shaped to fill the defect. (c) Femoral head graft fixed with screws. (d) Graft fixed with uncemented arthroplasty. (Images courtesy of Ramesh K Sen, Mohali, India.) 

Acetabular reconstruction

For acetabular reconstruction, various shaped cages have been used, depending on the type of defect. A type of acetabular reinforcement cage has been used primarily to support osseous defects present in the posterior and medial aspects of hip joints [19]. The cemented cup is placed in the cage after anchoring with screws (Figure 3). However, there have been multiple reports of cage failure within 5–7 years [21]. In gross pelvic discontinuity with significant bone loss, as sometimes seen in Type 4B defects, there is a concept of using the cup-cage construct [22]. A mega-sized highly porous trabecular metal or titanium cup is placed in the defect and a cage is placed over it to house the cemented cup.

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Figure 2. Use of a cage in neglected acetabular fractures. (a) X-ray of the neglected acetabular fracture showing loss of superior weight-bearing dome. (b) CT scan of neglected acetabular fracture showing loss of superior weight-bearing dome. (c) Use of an octopus case with hip arthroplasty. (d) Postoperative x-ray. (e) Four-year follow-up x-ray. (Images courtesy of Ramesh K Sen, Mohali, India.)  

Type 2 - Acetabular defect (posterior or posterosuperior support loss)

Sometimes the femoral head can be displaced posteriorly and proximally; in this case, the reduction requires the adequate release of the surrounding contractures, which is easier once the femoral head is excised. In such cases, the following tissues need to be released or cleared: fibrous tissue within the residual acetabular area, the contracted inferior and anterior capsule, including release of the rectus femoris muscle and fibrous adhesions from the superior and anterior aspect of the hip, and the anterior capsular attachment of the capsule from the femoral neck. Any residual osseous fragments that are either malunited or loose posterior wall bone fragment need to be cleared to allow good soft-tissue relaxation. Scar tissue needs to be removed for better vascularity in the area. Care must be taken to not damage the sciatic nerve which lies in proximity and may be found in fibrous tissue. One way to define and release the sciatic nerve is by carefully exploring it from the acetabular osseus margin of the fibrous tissue. A stepwise dissection into the area is needed with clearance of the underlying healthy bone. Old fracture fragments of the displaced posterior wall will also need to be cleared and removed.

The femoral head can then be retracted to the required level and the posterior defect in the acetabulum cleared of its fibrous cover. Reaming into the residual acetabulum is performed, taking care of the proper anteroposterior and inferior positioning of the reamer to avoid asymmetrical reaming. The reamer size is increased until the capture in between the superior ilium, anterior pubis, and inferior ischium side starts to appear. At this point, the need for additional posterior buttress support for cup stability is evaluated. If cup capture is sufficient on its own within the ilium, ischium, and pubis without any additional support, the femoral head graft can be put in a classical ‘Figure 7’ shape into the gap and fixed with lag screws or fully threaded screws (3.5 mm or 4.0 mm). After the final reaming, the acetabular cup can be correctly placed.

In situations where the cup capture is found to be insufficient with residual osseous support, a structural graft or augment may be required for optimum stability of the uncemented cup. The femoral head graft can be shaped to fill the void and can be supported by using a reconstruction plate supporting the graft. This reconstruction plate is fixed onto the intact ilium superiorly and the ischium inferiorly. If a femoral head graft is not available or is inadequate in size, then porous wedge augments are required to create the posterior acetabular wall to achieve the acetabular cup stability. These augments need to be fixed in the defect if osseous support is available, but if it is lacking, a flying buttress augment can be used. For optimum stability and incorporation of the augment, the underlying area is freshened and prepared, and stepwise reaming of the defect area is performed for osseus defects. The augment is then trialed to establish the correct size. Both implants, ie, a highly porous cup and the augment, need to be fixed with screws in the final position and cement can be placed between the two components to unite the cup and augment. In these cases, multihole cups allow for screw fixation in multiple directions, whereas highly porous cups provide better chances of integration of the cup with the host bone.

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Figure 4. A case of total hip arthroplasty in a Type 2 neglected acetabular fracture. (a) X-ray 4 months after injury. (b) computed tomography scan of the pelvis showing the readapted acetabulum. (c) 2-year follow-up x-ray of the affected hip. (d) The patient showing a stable hip with good abductors. (Images courtesy of Ramesh K Sen, Mohali, India.) 

Nowadays, highly porous metal augments which allow for osseointegration providing good structural support are available [19]. The augments are usually of various shapes, ie, shim, buttress, or button augments, and these can be used in various combinations depending on the defects.

 

Small bone defects

Impaction grafting is a favored technique for small bone defects [19]. Bone chips of 7–10 mm diameter are obtained from the femoral head or iliac crest. If needed, a combined autograft and allograft can be used. After pulsatile lavage, the acetabulum is tightly packed with bone chips, which are impacted using special impactors depending on the acetabular size, for example, a hemispherically shaped impact area with serial increase in diameter to match the acetabular size. Reverse reaming should be avoided because the impactions are not obtained in the deeper layers, and they do not incorporate well with the impacted bone tissue. During impaction grafting, the smaller cavities are filled first, then the entire socket is filled layer by layer. To obtain a sufficient cement layer, the last impactor is usually oversized by 2–4 mm relative to the planned cup diameter.

 

Metal mesh

A metal mesh is used in the cavity to support the graft in situations where the defect size does not allow the bone grafts to stay in position. These metal meshes have also been used to reconstruct peripheral wall deficiencies [19]. The flexible meshes are trimmed and adapted to the defect using special scissors and clamps. At the periphery, the meshes can be fixed with screws to secure rigidity. If necessary, a sclerotic acetabular wall can be revitalized with multiple small, but superficial, drill holes (2–3 mm diameter) to enhance surface contact and facilitate revascularization of the graft.

 

Fixation of acetabular cups

Both cemented and uncemented acetabular cups can be used in neglected acetabular fracture reconstruction. Sen notes that it may be easier to obtain good stability of an uncemented cup, particularly in younger patients with better osseous quality in the columns and walls. The first option is usually to try an uncemented acetabular cup to see if the stability of the trial cup can be achieved at three points of fixation, ie, ilium, ischium and pubic side, and if there is enough host bone to allow for incorporation of the acetabular shell. If the bone quality of the ilium and ischium is good—in contrast to a revision THA scenario—even two points of stability, ie, the ilium and ischium, can suffice for the acetabular cup placement. For good stability, multihole cups are preferred as these provide the option to fix the cup with screws both proximally and distally. Highly porous metal cups are recommended in patients with neglected fractures due to inadequate intact host bone. A cemented cup is a good option if optimum capture of the uncemented acetabular cup is not expected, or if there is inadequate osseous surface available for osseointegration of the acetabular cup [23].

Difficulties in reconstruction in these cases may occur, so various types of cages have been used to support the arthroplasty [24]. Furthermore, dual mobility hip systems are advocated because there is an increased chance of dislocation as seen in THA after acetabular fracture [25]; depending upon the risk factors, this option can be considered in selected cases. In uncemented THA, the use of highly porous cups is also preferred, because the contact area of the host bone is relatively poor in these cases [26]. Multihole cups are also an option, because these permit the use of screws in different directions to increase the stability of the acetabular cup where stability is poor in many of these cases.

 

Surgical techniques for total hip arthroplasty

 

Type 1 - Acetabular defect

Bone loss is likely to be symmetrical and circumferential defects in the acetabular area occur where the bone loss is symmetrical. Any large-sized cup can be used, though a jumbo cup is rarely needed, as much of the surrounding bone should still have good-quality support. Simple cup placement is possible and can be performed with or without screws with a good capture. In case a cemented cup is preferred, a standard technique can be used because the osseus defect is not large.

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Figure 3. A case of total hip arthroplasty in a Type 1 neglected acetabular fracture. (a) X-ray showing a 12-year-old neglected dislocation. ( b) Computed tomography scan of the pelvis showing the readapted acetabulum. (c) 2-year follow-up x-ray of the affected hip. (d) The patient showing a stable hip with good abductors. (Images courtesy of Ramesh K Sen, Mohali, India.) 

Type 3A – Stable displaced posterior column defect

The posterior column displacement is usually posterior and medial taking a part of the acetabulum and the femoral head along with it. The column could also be rotated. In the displaced position, the column can be stabilized either by osseous union or with significant fibrous union. At such a stage, it is usually difficult to reduce the column back to its anatomical position, as an osteotomy at the ischial neck may be needed. In most displacement cases, the posterior column bone is strong enough to allow for further bone build-up to provide posterior support to the acetabular cup. Bone can be built up by a femoral head autograft or allograft. If a bone graft is not available, it is better to use column buttress augments, which tend to be side specific. Straight column support is appropriate if the loss is primarily posterior and superior. The acetabulum is prepared by reaming whilst taking care of the proposed version and inclination. There is usually enough residual bone to provide superior and inferior capture to the cup. Whenever the cup capture is less due to bone loss on the superior side, a column buttress is a better option. Note, posterior build-up can be adequate with a bone graft, which can be stabilized with graft with plate fixation; however, the column buttress augments provide much better stability. The primary concern, however, should be the positioning of the acetabular cup in the correct offset.

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Figure 5. A case of total hip arthroplasty in a Type 3A neglected acetabular fracture. (a) X-ray showing a 17-month-old injury with nonunion of the posterior column. (b) Reconstruction of the nonunion using a plate followed by arthroplasty. (c) 6-year follow-up x-ray of the affected hip. (d) The patient showing a stable hip with good abductors. (Images courtesy of Ramesh K Sen, Mohali, India.) 

Type 3B – Unstable displaced posterior column defect with nonunion

 

Nonunion of the posterior column needs stability to host the acetabular cup. Thus, the first step in this defect type is to create posterior column stability. This is done by posterior column fixation across the nonunion with the use of a reconstruction plate. The nonunion might permit some level of reduction in some cases. Once the column is stabilized, subsequent reaming may be able to provide an appropriate stable position for the cup placement. The need for further build-up of posterior support can be assessed after trying to attain the required cup capture between the ilium, ischium, and pubic area. If build-up is required, a femoral head graft or buttress augments can be used. The augments will be necessary if the superior ilium support is lacking, as that area is primarily loaded; otherwise, early failure may occur.

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Figure 6. A case of total hip arthroplasty in a Type 3B neglected acetabular fracture. (a) and (b) X-rays showing a 13-month-old injury with nonunion of the posterior column. (c) Follow-up x-ray of the affected hip showing plate fixation of the posterior column and arthroplasty. (d) The patient showing a stable hip with good abductors. (Images courtesy of Ramesh K Sen, Mohali, India.)

Type 4A - Transverse discontinuity with either osseous or fibrous stability

In the transverse, T-type, anterior column with posterior hemitransverse fracture, and neglected ABC fractures, instability between the upper and lower parts of the acetabulum can develop. Depending upon the fracture pattern, there can be various levels of instabilities or malunions. In most cases, if neglected, malunion can develop between many of the fractures in the displaced position, and the femoral head becomes adjusted in a pseudoacetabulum. In such cases, many patients ambulate with a limp and have restricted abilities. Because of these disabilities, THA is indicated in most patients, especially the elderly. During THA, the first step of dislocating the femoral head could be difficult due to the protrusion effect. Femoral neck osteotomy is performed in situ and with gradual release around the superior and anterior parts of the acetabulum, after which the femoral head can be pulled out. Subsequently, femoral head extraction is performed. Depending upon each case, there can be either large void in the acetabular floor or continuity which creates a stable environment for grafts to be pushed in. Additionally, after careful curettage of the pseudoacetabular floor, there will be enough space for graft insertion and impaction.

To create optimum space for the cup placement at the proper point, stepwise reaming is done whilst considering the proposed version and inclination of the cup. Reaming in the proper direction is continued until at least 1 cm of host bone is available around the peripheral circumference for cup capture. A minimum of two points of stability must be achieved, ie, superiorly and inferiorly, though any further stability provided by the anterior or posterior column fixation can be evaluated. Subsequently, the femoral head graft can be prepared and impacted into the acetabular floor. If the floor has a void, this can be fixed with a mesh and a graft added and impacted. Impaction is performed with a stepwise increase in impactor size. Once impaction size nears the final reamer of the acetabular peripheral reaming, trials to evaluate cup capture and stability can be done. Once the cup size is determined, a cup implant, preferably a multihole cup, can be placed and impacted until the stable position is achieved. The periphery can be fixed around the cup with screws, adding stability to the acetabulum.

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Figure 7. A case of total hip arthroplasty in a Type 4A neglected acetabular fracture. (a) and (b) X-rays showing an 11-month-old malunion of an anterior column with posterior hemitransverse fracture. (c) Intraoperative image of the acetabular reconstruction and hip arthroplasty. (d) One-year follow-up x-ray of the affected hip. (e) The patient with a stable hip at follow-up. (Images courtesy of Ramesh K Sen, Mohali, India.) 

Type 4B – Transverse discontinuity with instability due to nonunion

 

This is a classic situation of pelvic discontinuity where two parts of the acetabulum do not maintain any stability. In contrast to similar instability in revision hip cases, in neglected acetabular trauma, there is usually hardly any stability. This leads to a situation where for every stepwise increase in diameter of the reamers and trial cup, the gap will keep on increasing. Even jumbo cups may not prove stable enough. The solution in such cases lies in creating stability across the proximal and distal half of the acetabulum by osteosynthesis after refining the nonunion sites. It is not that difficult to stabilize the posterior column, where a plate can be applied across the nonunion extending from the ilium to the ischium, but ideal stability also requires anterior column fixation. This is usually achieved by putting a screw across the anterior column passing from the superior part of the acetabulum towards the iliopectineal eminence. Afterwards, a multihole cup can be placed with good stability. Rarely a thin plate can be placed inside the acetabulum anteriorly to fix the superior and inferior fragments. This fixation automatically settles with cemented acetabular cups.

In cases where a lot of osseous structure is absent, a conventional cage was commonly used to further support the discontinuity and share load by using a cemented cup. Nowadays the cup-cage construct is used, where the highly porous outer cup settles between two halves of the acetabular construct in the best possible fit. A cage is applied over this cup with stability in the ilium and ischium, and finally a cemented cup is placed within this cage.

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Figure 8. A case of total hip arthroplasty in a Type 4B neglected acetabular fracture. (a) x-ray showing a 3-month nonunion of an ABC fracture. (b) Intraoperative image of the acetabular reconstruction using a plate and graft impaction. (c) Early postoperative x-ray of the affected hip with a cemented dual mobility acetabular cup. (d) X-ray of the patient at seven months follow up. (Images courtesy of Ramesh K Sen, Mohali, India.) 

Type 5 - Anterior column defect

In acetabular fractures where the anterior column is significantly medially displaced, the femoral head is also invariably pulled in medially. The patient might be ambulating with this displacement with a pseudoacetabulum. In these cases, an initial femoral neck osteotomy is required, as the residual part of the acetabulum is usually large enough to provide stability. Care must be taken to properly place the starting reamer to avoid undue reaming. With a malunited anterior column defect, impaction grafting is one of the best options to fill the gap to allow for cup placement. The acetabular reinforcement ring has also been used to fill such a defect and to provide stability to the cemented cup. Serial reaming can provide acetabular cup capture in between the superior, posterior, and inferior ischium. Even in nonunited anterior column fractures, a similar management plan can work because loading primarily occurs posterosuperiorly, where there are no fractures.

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Figure 9. A case of total hip arthroplasty in a Type 5 neglected acetabular fracture. (a) X-ray showing a 5-month nonunion of an anterior column fracture. (b) Intraoperative image of the acetabular reconstruction using a metallic mesh and graft. (c) Follow-up x-ray of the affected hip with cemented arthroplasty. (d) Early postoperative x-ray of the affected hip with a cemented dual mobility acetabular cup. (d) The patient at the 1-year follow-up. Images reproduced in part with permission from Sen RK et al [15]. Copyright 2022, Indian Orthopaedics Association.

Management

Most patients experience significant relief from pain and improved function after THA. However, some patients may face complications such as dislocation, prosthesis wear, or the need for further surgeries [23]. Depending on the surgical procedure and the patient's condition, weight-bearing activities may be gradually introduced. Physiotherapy should focus on restoring the range of motion, strengthening surrounding muscles, and improving function.

 

Conclusion

Total hip arthroplasty can be an effective treatment for patients with neglected acetabular fractures [9, 27]. However, careful assessment and planning are required to manage the complexities associated with such cases. The decision-making process should involve a risk-benefit analysis and discussion with the patient, and a multidisciplinary approach for optimal outcomes.

Read more
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Part 1 | Fracture types and indications

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Part 2 | Acute total hip arthroplasty

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AO Recon resources

Contributing experts

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

Ashok S Gavaskar

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

Rodrigo Pesantez

Rodrigo Pesantez

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

Ramesh K Sen

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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