Abstract
ORIF is the treatment of choice for the majority of acetabular fractures with the ultimate goal of native hip preservation. As long as anatomic reduction and joint congruency is achieved, the results of ORIF have led to good to excellent outcomes. Total hip arthroplasty (THA) after acetabular fracture is indicated: 1.) acutely in the setting of a fracture where ORIF has been shown to portray a poor prognosis (severe femoral head and/or posterior wall impaction, dome comminution (gull sign) or 2.) in the presence of the sequelae of acetabular fractures such as posttraumatic arthritis or osteonecrosis. Independent of the setting, THA after acetabular fracture presents unique challenges to the orthopaedic surgeon and in many instances requires a team approach that includes both joint reconstruction and trauma specialists. The main goal of the operation is to restore continuity of the fractured columns prior to implantation of an uncemented acetabular component. Technical challenges include infection, residual pelvic deformity, acetabular bone loss and/ or ununited fractures, osteonecrosis of bone fragments, retained hardware, heterotopic ossification, sciatic nerve compromise, and the difficulties in obtaining long-term socket fixation. Careful pre-operative assessment with review of x-rays and CT scans to assess bone loss, fracture nonunion, and infection is necessary. The surgeon must anticipate more blood loss, longer operative times, and difficulties with exposure and must anticipate the need of special tools intra-operatively such as pelvic reconstruction plates, use of autogenous bone graft, metal cutting instruments and post-operative heterotopic ossification prophylaxis either in the form of NSAIDS or radiation. In case of a necrosis, nonunion, or bone loss principles of revision total hip arthroplasty are commonly used and today the use of highly porous metals is particularly useful. Cemented acetabular components should be avoided. Care should be taken with cup position as distorted anatomy may influence cup position and bony impingement may lead to dislocation. The results of THA in general has provided excellent pain relief and functional improvement but the biggest historical problem has been socket fixation and bearing surface wear, hopefully now improved with the advent of highly porous metals and alternative bearing surfaces.
