Aims. After failed acetabular fractures, total hip arthroplasty (THA) is a challenging procedure and considered the gold standard treatment. The complexity of the procedure depends on the fracture pattern and the initial fracture management. This study’s primary aim was to evaluate patient-reported outcome measures (PROMs) for patients who underwent delayed uncemented acetabular THA after acetabular fractures. The secondary aims were to assess the radiological outcome and the incidence of the associated complications in those patients. Methods. A total of 40 patients underwent cementless acetabular THA following failed treatment of acetabular fractures. The postoperative clinical and radiological outcomes were evaluated for all the cohort. Results. The median (interquartile range (IQR)) Oxford Hip Score (OHS) improved significantly from 9.5 (7 to 11.5), (95% confidence interval (CI) (8 to 10.6)) to 40 (39 to 44), (95% CI (40 to 43)) postoperatively at the latest follow-up (p < 0.001). It was worth noting that the initial acetabular fracture type (simple vs complex), previous acetabular treatment (ORIF vs conservative), fracture union, and restoration of anatomical centre of rotation (COR) did not affect the final OHS. The reconstructed centre of rotation (COR) was restored in 29 (72.5%) patients. The mean abduction angle in whom acetabular fractures were managed conservatively was statistically significantly higher than the surgically treated patients 42.6° (SD 7.4) vs 38° (SD 5.6)) (p = 0.032). We did not have any case of acetabular or femoral loosening at the time of the last follow-up. We had two patients with successful two-stage revision for infection with overall eight-year survival rate was 95.2% (95% CI 86.6% to 100%) with revision for any reason at a median (IQR) duration of follow-up 50 months (16 to 87) months following THA. Conclusion. Delayed cementless acetabular THA in patients with previous failed acetabular fracture treatments produces good clinical outcomes (PROMS) with excellent survivorship, despite the technically demanding nature of the procedure. The initial fracture treatment does not influence the outcome of delayed THA. In selected cases of acetabular fractures (either nondisplaced or with secondary congruency), the initial nonoperative treatment neither resulted in large acetabular defects nor required additional acetabular reconstruction at the time of THA. Cite this article: Bone Jt Open 2021;2(12):1067–1074

Aims. The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures. Methods. A multicentre cross-sectional study was performed in 170 patients who were treated nonoperatively for an acetabular fracture in three level 1 trauma centres. Using the post-injury diagnostic CT scan, the maximum gap and step-off values in the weightbearing dome were digitally measured by two trauma surgeons. Native hip survival was reported using Kaplan-Meier curves. Predictors for conversion to THA were determined using Cox regression analysis. Results. Of 170 patients, 22 (13%) subsequently received a THA. Native hip survival in patients with a step-off ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 94% vs 70% vs 74%). Native hip survival in patients with a gap ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 100% vs 84% vs 78%). Step-off displacement > 2 mm (> 2 to 4 mm hazard ratio (HR) 4.9, > 4 mm HR 5.6) and age > 60 years (HR 2.9) were independent predictors for conversion to THA at follow-up. Conclusion. Patients with minimally displaced acetabular fractures who opt for nonoperative fracture treatment may be informed that fracture displacement (e.g. gap and step-off) up to 2 mm, as measured on CT images, results in limited risk on conversion to THA. Step-off ≥ 2 mm and age > 60 years are predictors for conversion to THA and can be helpful in the shared decision-making process. Cite this article: Bone Joint J 2023;105-B(9):1020–1029

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded. . A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans. . There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001). . These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach. . This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns. Cite this article: Bone Joint J 2015;97-B:1271-8

Aims. Post-traumatic periprosthetic acetabular fractures are rare but serious. Few studies carried out on small cohorts have reported them in the literature. The aim of this work is to describe the specific characteristics of post-traumatic periprosthetic acetabular fractures, and the outcome of their surgical treatment in terms of function and complications. Methods. Patients with this type of fracture were identified retrospectively over a period of six years (January 2016 to December 2021). The following data were collected: demographic characteristics, date of insertion of the prosthesis, details of the intervention, date of the trauma, characteristics of the fracture, and type of treatment. Functional results were assessed with the Harris Hip Score (HHS). Data concerning complications of treatment were collected. Results. Our series included 20 patients, with a mean age of 77 years (46 to 90). All the patients had at least one comorbid condition. Radiographs showed that 75% of the fractures were pure transverse fractures, and a transverse component was present in 90% of patients. All our patients underwent surgical treatment: open reduction and internal fixation, revision of the acetabular component, or both. Mean follow-up was 24 months, and HHS at last follow-up was 75.5 (42 to 95). The principal complications observed were dislocations of the prosthesis (30%) and infections (20%). A need for revision surgery was noted in 30% of patients. No dislocation occurred in patients undergoing osteosynthesis with acetabular reconstruction. We did not note either mechanical loosening of the acetabular component nor thromboembolic complications. In all, 30% of patients presented acute anemia requiring transfusion, and one death was reported. Conclusion. Post-traumatic periprosthetic acetabular fractures frequently have a transverse component that can destabilize the acetabular implant. The frequency of complications, principally dislocations, led to a high rate of revision surgery. Improvements in preoperative planning should make it possible to codify management to reduce this high rate of complications. The best results were obtained when the surgical strategy combined osteosynthesis with acetabular reconstruction. Cite this article: Bone Jt Open 2024;5(1):28–36

Aims. To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality. Methods. We retrieved information from the Swedish Fracture Register (SFR) on all patients with acetabular fractures, of the native hip joint in the adult skeleton, sustained between 2014 and 2020. Study variables included patient age, sex, injury date, injury mechanism, fracture classification, treatment, and mortality. Results. In total, 2,132 patients with acetabular fractures from the SFR were included in the study. The majority of the patients were male (62%) and aged over 70 years old (62%). For patients aged > 70 years, the 30-day mortality was 8% and one-year mortality 24%. For patients aged ≤ 70 years, the 30-day mortality was 0.2% and one-year mortality 2%. Low-energy injuries (63%) and anterior wall fractures (20%) were most common. Treatment was most often non-surgical (75%). Conclusion. The majority of patients who sustain an acetabular fracture are elderly (> 70 years), of male sex, and the fracture most commonly occurs after a simple, low-energy fall. Non-surgical treatment is chosen in the majority of acetabular fracture patients. The one-year mortality for elderly patients with acetabular fracture is similar to the mortality after hip fracture, and a similar multidisciplinary approach to care for these patients should be considered. Cite this article: Bone Jt Open 2023;4(9):652–658

Aims. Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years. Methods. Eligible patients at a level I trauma centre were recruited into a longitudinal registry of surgical acetabular fractures between June 2004 and August 2019. Patient-reported outcome measures (PROMs), including the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS), were recorded at baseline pre-injury recall and six months, one year, two years, and five years postoperatively. Comparative analyses were performed for elementary and associated fracture patterns. The proportion of patients achieving minimal clinically important difference (MCID) was determined. The rate of, and time to, conversion to total hip arthroplasty (THA) was also established. Results. We recruited 251 patients (253 fractures), with a 4:1 male to female ratio and mean age of 46.1 years (SD 16.4). Associated fracture patterns accounted for 56.5% of fractures (n = 143). Trajectory analysis showed all timepoints had significant disability versus baseline, including final follow-up (p < 0.001). Elementary fractures had higher SF-36 PCS at six months (p = 0.023) and one year (p = 0.007) compared to associated fractures, but not at two years (p = 0.135) or five years (p = 0.631). The MCID in SF-36 PCS was observed in 37.3% of patients (69/185) between six months and one year, 26.9% of patients (39/145) between one and two years, and 23.3% of patients (20/86) between two and five years, highlighting the long recovery potential of these injuries. A significant proportion of patients failed to attain the MCID after five years (38.1%; 40/105). Conversion to THA occurred in 13.1% of patients (11/110 elementary and 22/143 associated fractures). Approximately two-thirds of THAs (21/33 patients; 63.6%) were performed within two years of index surgery. Conclusion. Acetabular fractures significantly impact physical function. Recovery trajectory is often elongated beyond one year, with two-thirds of our patients displaying persistent clinically relevant long-term disability. Cite this article: Bone Joint J 2024;106-B(1):69–76

Aims. Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. Methods. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d’Aubigné score and Matta’s radiological grading at one year and at latest follow-up. Results. Immediate postoperative radiological Matta’s reduction accuracy showed anatomical reduction (0 to 1 mm) in 23 cases (67.6%), satisfactory (2 to 3 mm) in nine (26.4%), and unsatisfactory (> 3 mm) in two (6%). Merle d’Aubigné score at the end of one year was calculated to be excellent in 18 cases (52.9%), good in 11 (32.3%), fair in three (8.8%), and poor in two (5.9%). Matta’s radiological grading at the end of one year was calculated to be excellent in 16 cases (47%), good in nine (26.4%), six in fair (17.6%), and three in poor (8.8%). Merle d’Aubigné score at latest follow-up deteriorated by one point in some cases, but the grading remained the same; Matta’s radiological grading at latest follow-up also remained unchanged. Conclusion. Stabilization of posterior column through AIP by medial surface plate along the sciatic notch gives good stability to posterior column, and at the same time can avoid morbidity of the additional lateral window. Cite this article: Bone Jt Open 2024;5(2):147–153

Surgical management of acetabular fractures in older patients remains controversial. The purpose of this study is to compare outcomes of primary THA with outcomes after THA for acute acetabular fractures (aTHA) as well as outcomes following delayed THA (dTHA) following prior acetabular fracture. We analyzed data from a large, national administrative claims database containing diagnostic, procedural, and demographic records from over 157 million patients. We identified all patients undergoing primary total hip arthroplasty THA continuously enrolled in the database at least 2 years prior and after the index procedure. Patients with an initial diagnostic code for acetabular fracture occurring the same day as the THA were classified as acute acetabular fractures. Patients with an initial acetabular fracture diagnostic code occurring at least 6 months before THA were classified as chronic acetabular fractures. The comparator group was patients undergoing THA with no history of acetabular fracture. There were 426,734 patients undergoing primary THA, 235 patients undergoing aTHA and 1,255 patients undergoing dTHA. Patients with an aTHA had higher complication rates, including revisions (9.8% vs 5.6%,), dislocations (8.9% vs 6.4%), and periprosthetic fracture (5.1% vs 2.3%) compared to dTHA. After adjusting for age, sex, region, and comorbidities, receiving an aTHA increased the odds of revision (OR = 3.65 [95% CI: 2.30–5.49]), dislocation (OR = 4.09 [95% CI: 2.53–6.27]), and periprosthetic fracture (OR = 4.29 [95% CI: 2.26–7.36]) compared to primary THA. Receiving a dTHA significantly increased the odds of revision (adjusted OR = 1.80 [95% CI: 1.40–2.27]), dislocation (adjusted OR = 2.50 [95% CI: 1.97–3.13]), and periprosthetic fracture (adjusted OR = 1.99 [95% CI: 1.34–2.83]) compared to primary THA. Patients undergoing aTHA in the treatment of an acetabular fracture have significantly increased rates of revision, periprosthetic fracture, and dislocation compared to dTHA and primary THA

Aims. Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA). Methods. We conducted a retrospective, registry-based study of 80 patients aged 60 years and older with acetabular fractures treated surgically at The Alfred and Royal Melbourne Hospital. We reviewed charts and radiological investigations and performed patient interviews/examinations and functional outcome scoring. Data were provided by the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR). Survival analysis was used to describe conversion to THA in the group of patients who initially underwent open reduction and internal fixation (ORIF). Multivariate regression analyses were performed to identify factors associated with conversion to THA. Results. Seven patients (8.8%) had died at a median follow-up of 18 months (interquartile range (IQR) 12 to 25), of whom four were in the acute THA group. Eight patients (10%) underwent acute THA. Of the patients who underwent ORIF, 17/72 (23.6%) required conversion to THA at a median of 10.5 months (IQR 4.0 to 32.0) . After controlling for other factors, transport-related cases had an 88% lower rate of conversion to THA (hazard ratio (HR) 0.12, 95% confidence interval (CI) 0.02 to 0.91). Mean standardized Physical Component Summary Score (PCS-12) of the 12-Item Short Form Health Survey (SF-12) was comparable with the general population (age-/sex-matched) by 12 to 24 months. Over half of patients working prior to injury (14/26) returned to work by six months and two-thirds of patients (19/27) by 12 months. Conclusion. Patients over 60 years of age managed operatively for displaced acetabular fractures had a relatively high mortality rate and a high conversion rate to THA in the ORIF group but, overall, patients who survived had mean PCS-12 scores that improved over two years and were comparable with controls. Cite this article: Bone Joint J 2020;102-B(12):1735–1742

Aims. To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment. Methods. Patients were recruited from seven UK NHS centres and randomized to a three-arm pilot trial if aged older than 60 years and had a displaced acetabular fracture. Feasibility outcomes included patients’ willingness to participate, clinicians’ capability to recruit, and dropout rates. The primary clinical outcome measure was the EuroQol five-dimension questionnaire (EQ-5D) at six months. Secondary outcomes were Oxford Hip Score, Disability Rating Index, blood loss, and radiological and mobility assessments. Results. Between December 2017 and December 2019, 60 patients were recruited (median age 77.4 years, range 63.3 to 88.5) (39/21 M/F ratio). At final nine-month follow-up, 4/60 (7%) had withdrawn, 4/60 (7%) had died, and one had been lost to follow-up; a 98% response rate (50/51) was achieved for the EQ-5D questionnaire. Four deaths were recorded during the three-year trial period: three in the non-surgical treatment group and one in the fix-and-replace group. Conclusion. This study has shown a full-scale RCT to be feasible, but will need international recruitment. The Acetabular Fractures in older patients Intervention Trial (AceFIT) has informed the design of a multinational RCT sample size of 1,474 or 1,974 patients for a minimal clinically important difference of 0.06 on EQ-5D, with a power of 0.8 or 0.9, and loss to follow-up of 20%. This observed patient cohort comprises a medically complex group requiring multidisciplinary care; surgeon, anaesthetist, and ortho-geriatrician input is needed to optimize recovery and rehabilitation. Cite this article: Bone Joint J 2024;106-B(4):401–411

3D printing techniques have attracted a lot of curiosity in various surgical specialties and the applications of the 3D technology have been explored in many ways including fracture models for education, customized jigs, custom implants, prosthetics etc. Often the 3D printing technology remains underutilized in potential areas due to costs and technological expertise being the perceived barriers. We have applied 3D printing technology for acetabular fracture surgeries with in-house, surgeon made models of mirrored contralateral unaffected acetabulum based on the patients’ trauma CT Scans in 9 patients. The CT Scans are processed to the print with all free-ware modeling software and relatively inexpensive printer by the surgeon and the resulting model is used as a ‘reduced fracture template’ for pre-contouring the standard pelvic reconstruction plates. This allows use of the standard surgical implants, saves time on intra-operative plate contouring, and also aids in reduction to an extent. We share through this presentation the workflow of the freeware softwares to use in order to use this surgical planning and implant preparation that may remove the perceived barriers of cost and technology from surgeons that wish to explore using 3D printing technology for acetabular fracture management and may extend applications to other regions

We prospectively analysed the epidemiology of acetabular fractures over a period of 16 years in order to identify changes in their incidence or other demographic features. Our study cohort comprised a consecutive series of 351 patients with acetabular fractures admitted to a single institution between January 1988 and December 2003. There was no significant change in the overall incidence of acetabular fractures, which remained at 3 patients/100 000/year. There was, however, a significant reduction in the number of men sustaining an acetabular fracture over the period (p < 0.02). The number of fractures resulting from falls from a height < 10 feet showed a significant increase (p < 0.002), but there was no change in those caused by motor-vehicle accidents. There was a significant reduction in the median Injury Severity score over the period which was associated with a significant decrease in mortality (p < 0.04) and a reduction in the length of hospital stay. The incidence of osteoarthritis noted during follow-up of operatively-treated fractures declined from 31% to 14%, reflecting improved results with increasing subspecialisation. Our findings suggest that there will be a continuing need for some orthopaedic surgeons to specialise in the management of these fractures. In addition, the reductions in the Injury Severity score and mortality may be associated with improved road and vehicle safety

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling. Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results. Cite this article: Bone Joint J 2016;98-B:690–5

Aims. Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone. Patients and Methods. A total of 27 patients with similar acetabular fractures (severe acetabular impaction with or without concomitant femoral head injury) with a mean age of 72.2 years (50 to 89) were prospectively followed for a minimum of two years. In all, 14 were treated with ORIF alone and 13 were treated with a CHP. Hip joint and patient survival were estimated. Operating times, blood loss, radiological outcomes, and patient-reported outcomes were assessed. Results. No patient in the CHP group required further hip surgery, giving THA a survival rate of 100% (95% confidence interval (CI) 100 to 100) after three years, compared with 28.6% hip joint survival in the ORIF group (95% CI 12.5 to 65.4; p = 0.001). No dislocations or deep infections occurred in the CHP group. No patient died within the first year after index surgery, but patient survival was lower in the CHP group after three years. There were no relevant differences in patient-reported outcomes. Conclusion. The CHP confers a considerably reduced need of further surgery when compared with ORIF alone in elderly patients with complex acetabular fractures. These findings encourage both further use of, and larger prospective studies on, the CHP. Cite this article: Bone Joint J 2019;101-B:478–483

Aims. Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort. Methods. We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59). Results. The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d’Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions. Conclusion. The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155–161

The February 2023 Trauma Roundup. 360. looks at: Masquelet versus bone transport in infected nonunion of tibia; Hyperbaric Oxygen for Lower Limb Trauma (HOLLT): an international multicentre randomized clinical trial; Is the T-shaped acetabular fracture really a “T”?; What causes cut-out of proximal femur nail anti-rotation device in intertrochanteric fractures?; Is the common femoral artery at risk with percutaneous fragility pelvis fixation?; Anterior pelvic ring pattern predicts displacement in lateral compression fractures; Differences in age-related characteristics among elderly patients with hip fractures

The December 2022 Hip & Pelvis Roundup. 360. looks at: Fix and replace: simultaneous fracture fixation and hip arthroplasty for acetabular fractures in older patients; Is the revision rate for femoral neck fracture lower for total hip arthroplasty than for hemiarthroplasty?; Femoral periprosthetic fractures: data from the COMPOSE cohort study; Dual-mobility cups and fracture of the femur; What’s the deal with outcomes for hip and knee arthroplasty outcomes internationally?; Osteochondral lesions of the femoral head: is costal cartilage the answer?

The increasing prevalence of osteoporosis in an ageing population has contributed to older patients becoming the fastest-growing group presenting with acetabular fractures. We performed a systematic review of the literature involving a number of databases to identify studies that included the treatment outcome of acetabular fractures in patients aged > 55 years. An initial search identified 61 studies; after exclusion by two independent reviewers, 15 studies were considered to meet the inclusion criteria. All were case series. The mean Coleman score for methodological quality assessment was 37 (25 to 49). There were 415 fractures in 414 patients. Pooled analysis revealed a mean age of 71.8 years (55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven studies the results of open reduction and internal fixation (ORIF) were presented: this was combined with simultaneous hip replacement (THR) in four, and one study had a mixture of these strategies. The results of percutaneous fixation were presented in two studies, and a single study revealed the results of non-operative treatment. With fixation of the fracture, the overall mean rate of conversion to THR was 23.1% (0% to 45.5%). The mean rate of non-fatal complications was 39.8% (0% to 64%), and the mean mortality rate was 19.1% (5% to 50%) at a mean of 64 months (95% confidence interval 59.4 to 68.6; range 12 to 143). Further data dealing with the classification of the fracture, the surgical approach used, operative time, blood loss, functional and radiological outcomes were also analysed. This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients. Cite this article: Bone Joint J 2014;96-B:157–63

Injury to the sciatic nerve is one of the more serious complications of acetabular fracture and traumatic dislocation of the hip, both in the short and long term. We have reviewed prospectively patients, treated in our unit, for acetabular fractures who had concomitant injury to the sciatic nerve, with the aim of predicting the functional outcome after these injuries. Of 136 patients who underwent stabilisation of acetabular fractures, there were 27 (19.9%) with neurological injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot and four had burning pain and altered sensation over the dorsum of the foot. Serial electromyography (EMG) studies were performed and the degree of functional recovery was monitored using the grading system of the Medical Research Council. In nine patients with a foot-drop, there was evidence of a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, the double-crush syndrome. At the final follow-up, clinical examination and EMG studies showed full recovery in five of the ten patients with initial muscle weakness, and complete resolution in all four patients with sensory symptoms (burning pain and hyperaesthesia). There was improvement of functional capacity (motor and sensory) in two patients who presented initially with complete foot-drop. In the remaining 11 with foot-drop at presentation, including all nine with the double-crush lesion, there was no improvement in function at a mean follow-up of 4.3 years

Total hip arthroplasty (THA) is frequently performed as a salvage procedure for the acetabular fracture when posttraumatic osteoarthritis, posttraumatic avascular necrosis, or fixation failure with subluxation develop. Special considerations for this situation include previous surgical exposure with dense scar tissue, the type and location of implants, the location and amount of heterotopic ossification, indolent infection, previous sciatic nerve palsy, and the pathoanatomy of existing acetabular defect. These factors can influence the choice of surgical exposure and the reconstructive method. The outcomes of THA after acetabular fracture are generally less favorable than those of the nontraumatic degenerative arthritis. Reason for this high failure is the low mean age and the high activity level of the patient. Other important reasons for failure include the problem of acetabular bone deficiency and compromised bone quality. We evaluated the results of cementless THA in patient who had previous acetabular fracture. We also compared this result with those of patients with posttraumatic avascular necrosis of the femoral head. Forty-five consecutive cementless THAs were performed for the treatment of post-traumatic osteoarthritis after acetabular fracture between December 1993 and December 2008. Of these patients, 15 patients were died or lost to follow-up monitoring before the end of the minimum one year follow-up period. This left 30 patients (30 hips) as the subjects of our retrospective review. We evaluated the clinical and radiographic results of these patients and compared with the results of THA in patients with post-traumatic AVN of the femoral head which had without acetabular damage. Two hips required revision of the cup secondary to early migration of the acetabular cup (1 hip) and postoperative deep infection (1 hip). There was no significant difference in clinical and radiographic results between two groups except implanted acetabular component size and required bone graft (p<0.05). The Kaplan-Meier ten-year survival rate, with revision as the end-point, was 90% and 96.7% with loosening of acetabular component as the end-point. Our series suggested that compared with cemented components, uncemented sockets may improve the results of arthroplasty after previous acetabular fracture. In conclusion, cementless THA following acetabular fracture presents unique challenge to the surgeon, careful preoperative assessment and secure component fixation with proper bone grafting is essential to minimize problems

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed. Cite this article: Bone Joint J 2017;99-B:1125–31

We have examined the accuracy of reduction and the functional outcomes in elderly patients with surgically treated acetabular fractures, based on assessment of plain radiographs and CT scans. There were 45 patients with such a fracture with a mean age of 67 years (59 to 82) at the time of surgery. All patients completed SF-36 questionnaires to determine the functional outcome at a mean follow-up of 72.4 months (24 to 188). All had radiographs and a CT scan within one week of surgery. The reduction was categorised as ‘anatomical’, ‘imperfect’, or ‘poor’. Radiographs classified 26 patients (58%) as anatomical,13 (29%) as imperfect and six (13%) as poor. The maximum displacement on CT showed none as anatomical, 23 (51%) as imperfect and 22 (49%) as poor, but this was not always at the weight-bearing dome. SF-36 scores showed functional outcomes comparable with those of the general elderly population, with no correlation with the radiological reduction. Perfect anatomical reduction is not necessary to attain a good functional outcome in acetabular fractures in the elderly

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (. sd. 2.6) vs 0.1 mm (. sd. 0.3), p < 0.001; and mean gap 11.5 mm (. sd. 6.5) vs 0.8 mm (. sd. 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access

We report the outcome of 161 of 257 surgically fixed acetabular fractures. The operations were undertaken between 1989 and 1998 and the patients were followed for a minimum of ten years. Anthropometric data, fracture pattern, time to surgery, associated injuries, surgical approach, complications and outcome were recorded. Modified Merle D’Aubigné score and Matta radiological scoring systems were used as outcome measures. We observed simple fractures in 108 patients (42%) and associated fractures in 149 (58%). The result was excellent in 75 patients (47%), good in 41 (25%), fair in 12 (7%) and poor in 33 (20%). Poor prognostic factors included increasing age, delay to surgery, quality of reduction and some fracture patterns. Complications were common in the medium- to long-term and functional outcome was variable. The gold-standard treatment for displaced acetabular fractures remains open reduction and internal fixation performed in dedicated units by specialist surgeons as soon as possible

Patients who are Jehovah's witnesses do not accept blood transfusions. Thus, total hip arthroplasty can be challenging in this group of patients due to the potential for blood loss. Multiple strategies have been developed in order to prevent blood loss. A 76-year-old female, Jehovah's witness medicated with a platelet antiaggregant, presented to the emergency department after a fall from standing height. Clinically, she had pain mobilizing the right lower limb and radiological examination revealed an acetabular fracture with femoral head protrusion and ipsilateral isquiopubic fracture. Skeletal traction was applied to the femur during three weeks and no weight bearing was maintained during the following weeks. Posteriorly, there was an evolution to hip osteoarthritis with necrosis of the femoral head. The patient was submitted to surgery six months after the initial trauma, for a total hip arthroplasty. The surgery was performed with hypotensive anaesthesia, careful surgical technique and meticulous haemostasis and there was no need for blood transfusion. Posteriorly, there was a positive clinical evolution with progressive improvement on function and deambulation. Total hip arthroplasty may be safely carried out with good clinical outcomes in Jehovah's witnesses, without the need for blood transfusion, if proper perioperative precautions are taken, as has already been shown in previous studies

Introduction: Factures of the acetabulum are the result of high-energy trauma. Long-term function of the hip joint is compromised in many cases as a result of imperfect reduction, chondral injuries to the acetabulum, femoral head lesion and post-traumatic avascular necrosis of the femoral head.Total hip arthroplasty is one of the treatment option for such patients who present with symptomatic post-traumatic arthritis or avascular necrosis with collapse of the femoral head following acetabular fractures. Materials and Methods: Twenty total hip arthroplasty were performed with use of a cementless cup in 17 patients and cemented cup in a cage in 3 patients for the treatment of posttraumatic osteoarthritis following acetabular fracture. The average age of the 4 women and 16 men was 49 (range, 26 to 86 years) at the time of the arthroplasty. The median interval between the time of injury and the total hip arthroplasty was 37 months (range, 8 to 144 months). The average operative time was 120 minutes and average intraoperative blood loss was 700 ml. Eight patients had previous open reduction and internal fixation of the acetabular fracture and twelve had been treated nonoperatively.Following total hip replacement,each patient was evaluated clinically and radiographically at six weeks, three months, six months and twelve months, and then yearly following total hip replacement. The average duration of clinical and radiographic follow-up was 40 months (range, 26 to 60 months). Results: At the time of final follow-up, of twenty acetabular components, 10 had no evidence of periacetabular radiolucency, 7 components had a partial radiolucency that was < 1 mm wide,2 had a complete radiolucency < 1 mm wide and 1 component was surrounded by a complete radiolucency of > 2 mm in width without showing component migration. According to Engh’s criteria,16 (80%) femoral stems had bony ingrowth and 4 (20%) stems had stable fibrous ingrowth. The average preoperative Harris hip score improved from 35 points to 78 points at the time of final followup. Conclusion: We conclude that total hip arthroplasty for degenerative arthritis following acetabular fractures,is a gratifying but often technically more difficult than a routine total hip arthroplasty because of extensive scarring, heterotopic bone, retained internal fixation devices, and residual deformity of the acetabulum

Introduction: Pelvic and acetabular fracture patients surgically treated have low patient reported outcome compared to a reference population. Our aim was to study quality of life changes during the first 2 years following injury. Methods: All 155 patients (110 male, 45 female, age 16–83) patients with pelvic and acetabular fractures surgically treated Sept 2004-April 2007 were prospectively followed at 6, 12 and 24 months with SF-36. There were 51 pelvic and 104 acetabular fractures. 124 patients answered the questionnaire (80%), and were compared to an age-and-gender matched reference population. Results: Pelvic fracture patients mean scores for physical function (PF) at 6–12–24 months were 59–66–74, and for role physical (RP) 28–47–62. This was below 1 SD from normative PF (mean 91, SD 28) and RP (mean 86, SD 41) at 6 months but not at 12 and 24 months. Acetabular fracture patients mean scores for PF were 51–56–61 and for RP 19–32–45. This was lower than 1 SD from normative PF (mean 85, SD 25) and RP (mean 79, SD 43) both at 6 and 12 months but not at 24 months. SF-36 scores were lower than the reference population in all domains for both fracture groups at the three time points. However mean scores were within 1 SD from normative for the other 6 domains BP, GH, VT, SF, RE and MH at all time points for both fracture groups. Hence improvement in the physical domains PF and RP was reported during the first year in both groups and during the second year for acetabular fractures. Discussion: and Conclusion: We found significant improvement in quality of life physical domains during the first year for both pelvic and acetabular fracture patients, and also during the second year for the latter group

Surgeons remain concerned that ceramic hip prostheses may fail catastrophically if either the head or the liner is fractured. We report two patients, each with a ceramic-on-ceramic total hip replacement who sustained high-energy trauma sufficient to cause a displaced periprosthetic acetabular fracture in whom the ceramic bearings survived intact. Simultaneous fixation of the acetabular fracture, revision of the cementless acetabular prosthesis and exchange of the ceramic bearings were performed successfully in both patients. Improved methods of manufacture of new types of alumina ceramic with a smaller grain size, and lower porosity, have produced much stronger bearings. Whether patients should be advised to restrict high-impact activities in order to protect these modern ceramic bearings from fracture remains controversial

Over a five-year period, adult patients with marginal impaction of acetabular fractures were identified from a registry of patients who underwent acetabular reconstruction in two tertiary referral centres. Fractures were classified according to the system of Judet and Letournel. A topographic classification to describe the extent of articular impaction was used, dividing the joint surface into superior, middle and inferior thirds. Demographic information, hospitalisation and surgery-related complications, functional (EuroQol 5-D) and radiological outcome according to Matta’s criteria were recorded and analysed. In all, 60 patients (57 men, three women) with a mean age of 41 years (18 to 72) were available at a mean follow-up of 48 months (24 to 206). The quality of the reduction was ‘anatomical’ in 44 hips (73.3%) and ‘imperfect’ in 16 (26.7%). The originally achieved anatomical reduction was lost in12 patients (25.8%). Radiologically, 33 hips (55%) were graded as ‘excellent’, 11 (18.3%) as ‘good’, one (1.7%) as ‘fair’ and 15 (25%) as ‘poor’. A total of 11 further operations were required in 11 cases, of which six were total hip replacements. Univariate linear regression analysis of the functional outcome showed that factors associated with worse pain were increasing age and an inferior location of the impaction. Elevation of the articular impaction leads to joint preservation with satisfactory overall medium-term functional results, but secondary collapse is likely to occur in some patients. Cite this article: Bone Joint J 2013;95-B:230–8

Objective. To investigate the relationship between the pattern of pelvic or acetabular fracture, and bladder injuries. Methods. A total of 173 patients admitted at our Academic Hospital from January 2006 to March 2012 with cystograms done for pelvic or acetabular fractures were studied retrospectively. Records of pelvic X-Rays, CT scans and cystograms were reviewed. Tile's classification and Young & Burgess classification were used for pelvic fractures and Judet & Letournel classification system for acetabular fractures. Results. Out of 173 patients 16% had bladder injuries of which 22% were intra-peritoneal and 70% were extra-peritoneal. The bladder injuries mostly occurred among male patients; 16 males compared to 9 female patients. Out of the 21 fractures of the acetabulum only 2 sustained bladder injury and they were secondary to gunshot wounds. Lateral compression fractures accounted for 67% of bladder injuries. Motor vehicle accidents were the leading mechanism of injury accounting for 117 patients in total and 81% of those with bladder injuries. Among the patients with bladder rupture 55% had at least 3 rami involved and only one patient (4%) with 1 ramus involved had a bladder injury. Overall 44 (34%) of patients with 3 or more rami fractured had bladder injury. Conclusion. Bladder injury appears to be related to the mechanism of injury. We recommend that a cystogram be done routinely when a patient presents with a type III lateral compression fracture. In isolated acetabulum fractures, single ramus fractures and lateral compression type I fractures, request for cystogram should be correlated with clinical signs and symptoms, and not done routinely. NO DISCLOSURES

The incidence of acetabular fractures within the UK is about 3 in 100,000 of the population per year. Since Letournel and Judet first proposed that operative reduction and rigid internal fixation of displaced fractures will likely lead to better outcome, operative management of such fractures has become standard management in major trauma centres. Long term outcome results following acetabular surgery have been reported sparingly. Two hundred and fifty-seven displaced acetabular fractures underwent an open reduction and internal fixation at St. George’s Pelvic Unit between 1992 and 1997. All surgery was performed by a single surgeon. 161 patients were followed up prospectively for a minimum of 10 years. Those lost to follow up were excluded. Anthropometric data, fracture pattern, time to surgery, associated injuries, approach, complication and outcome recorded on a database. Modified Merle D’ Auberge score was utilized as outcome measures. The mean age was 36 years (15 to 85). Road traffic accident was the commonest mechanism of injury. We observed simple fractures in 34 % and associated fractures in 66%. 52% suffered polytrauma. Average time to surgery was 11 days and anatomic reduction was achieved in 73.9%. Results were excellent 46.8 %, good 25.5 %, fair 7.5 %, and poor 19.2 %. Poor prognostic factors were increasing age, delayed surgery, poor reduction, and posterior column, transverse posterior wall and T-shaped fracture patterns. Acetabular surgery poses a major challenge to the trauma surgeon. Complications in the immediate, mid and long term are not rare. Our results compare to other series with shorter follow-up. We believe that the gold standard treatment for displaced acetabular fractures must be open reduction internal fixation performed by a dedicated pelvic surgeon at the earliest time possible. Moreover whether we are merely postponing the inevitable post-traumatic arthritis is still unknown

Introduction: Complex fracture of the acetabulum are difficult to treat. If an osteosynthesis is performed difficult surgery resulted in blood loss, long operating time, high risk of sepsis and failure. Even if the fracture is well operated and ideally stabilised there is a major risk of secondary osteoarthrosis. This can be related to bone necrosis , cartilage surface damage , bone loss. There are also intraoperative risks of neural damage: sciatic nerve as well as gluteus medius nerve. On the other hand , modern surgical technique including an alumina against alumina bearing could allow very long term survival without any activity limitation and this even in very young patients. Secondary procedure after a failed osteosynthesis provides statistically worse functional results than primary total hip. The surgery is more difficult because of hardware retrieval, nerve dissection, bone reconstruction and remaining muscular dysfunction. Materials and Methods: To address these issues we reviewed our results of total hip for acetabular fractures. 80 patients received a total hip for acetabular fracture. From 1980 to 1998: 58 acetabular fractures in 57 patients sustained a total hip: 39 males and 18 females. Mean age: 50 years (from 21 to 80). 35 had had a conservative treatment, 22 had had an osteosynthesis. Delay between fracture and total hip: operated: 10 years, non-operated: 6 years. All prosthesis had an alumina against alumina couple. The stem was always made of titanium alloy, it was smooth, collared and cemented. The socket was plain alumina cemented 8, cement less : 3, metal back alumlina insert: 29, screw in cup with alumina liner: 10, plain polyethylene cemented: 8. Results: Follow-up: from 6 months to 20 years (mean 5,5years). Last Postel Merle d’Aubigne rating: 16,1(8–18) 9 revisions : 1 bipolar aseptic loosening, 8 socket loosening : 2 septic , 6 aseptic. (2 screws in , 6 cemented). There were 22 neural disorder; 19 sciatic palsies; 13 post trauma; 4 post osteosynthesis; 2 post THR; 3 gluteus medius palsy. 7 sepsis: 4 post osteosynthesis, 3 post THR (including 2 post osteosynthesis). Discussion: The results presented were inferior to a regular total hip if an osteosynthesis have been performed previously. Reasons for these inferior results were limp due to previous palsy of gluteus medius nerve, sciatic sequellae, complications of previous sepsis and so on. In contrast cases who had at first orthopaedic treatment followed some weeks later by a total hip experienced very good results. It is difficult to conclude from this limited series. But we are actually on the way to modify our perspectives. Many weak results could have been avoided by doing fine primary surgery. We could expect better functional results with less complications regarding sepsis, nerve damage, muscle preservation if we perform a primary total hip in conjunctions with acetabular reconstruction. Osteosynthesis is still recommended for simple acetabular fracture with large displacement involvement of the posterior wall or one column not comminuted

The purpose of this study was to review the clinical and radiographic outcome in THRs done following acetabular fractures (fx). All patients undergoing conversion THR after previous acetabular fx between 1990 and 2006 at a single institution were identified. Clinical evaluation was done using the Harris hip scale. Radiographic evaluation was done using the system proposed by the Hip society. THRs as part of initial treatment for acute acetabular fx were excluded. There were 90 THRs (90 patients) performed in patients previously treated for an acetabular fracture. At the time of their acetabular facture, 67 had been treated with ORIF, 12 were treated with closed or limited open reduction and percutaneous fixation, and 11 were treated without surgery. The mean age at injury was 43.7 years, (range, 14–79). 68 patients sustained their fx from a high-energy mechanism (MVC, MPC, or MCC). Three patterns accounted for 52% of the fx: transverse posterior wall (20), both column (18), and T-Type (9). Associated pelvic fractures were present in 14 patients. Associated ipsilateral proximal femur fractures were present: femoral head (four), femoral neck (five), and femoral shaft (three). Among those treated with ORIF, marginal impaction was noted in 31 and osteo-chondral head damage in 32 hips. The mean interval between injury and THR was 42 months (range, two months to 32 years). Cement-less fixation was used in 81 of the 90 cups. Similarly, cementless stems were used in 80 stems. Bone graft was necessary in 26 patients (17 autograft, nine allograft). Two cases each required pelvic augments and reinforcement cage, respectively. Additional findings at THR included: femoral head erosion (53 hips), femoral head osteonecrosis (37 hips), osteonecrosis of the acetabulum (22 hips), and fx non-union (six hips). The average cup abduction angle was 440 (range, 28 to 60), the average cup height was 24 mm (range, 10 to 42), and the average medialization distance was 23 mm (range, 5 to 48). The mean EBL was 810 ml and mean operative time was 195 minutes. The mean F/U was 36 months (range, 6 months to 17 years). The median Harris hip score was 89 at the most recent F/U. Fifteen revisions (16%) have been done: aseptic loosening (seven hips), recurrent dislocation (six hips) and infection (two hips). Five of the six revisions for recurrent dislocation were performed in patients who had a posterior approach for both their acetabular fracture treatment and their THR. No revision was done in those who had been initially with percutaneous fixation. There was no infection in those who had been initially with percutaneous fixation either from the fx treatment or the THR. In contrast, 14 ORIF patients were complicated by infection. One of these developed infection following THR. Our data support the clinical efficacy and mid-term durability of THR in this patient group. Aseptic loosening and recurrent dislocation remain the primary reasons for revision surgery

Purpose: The purpose of this study was to evaluate total hip arthroplasty in the treatment of post-traumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation or conservative treatment of the acetabular fracture. Methods: Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from an acetabular fracture. The mean age at the time of hip arthroplasty was 49 years. The mean follow-up was eight years and nine months (range, 4–17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Twenty-three hips had been previously treated by open reduction and internal fixation and 12 hips had a conservatively treated fracture. An uncemented arthroplasty was performed in 31 hips, cemented arthroplasty in 2 patients and a hybrid replacement in 2 patients. Results: Only 16 patients achieved and maintained a good to excellent result over the course of the follow-up. The mean Harris hip score improved from 44.5 points preoperatively to 72.76 points for operatively treated fractures (23 patients). The mean Harris hip score improved from 44.2 points preoperatively to 78.7 points for conservatively treated fractures (12 patients) (p> 0.05). Ten out of 35 hips required revision; 9 were revised because of aseptic loosening and one for infection with a total revision rate of 29%. Femoral bone quality was significant in predicting revision. No femoral radiographic loosening was found at latest follow-up. On the acetabular side, the rate of radiographic loosening was higher. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (ORIF vs conservative treatment of acetabular fracture) (p> 0.05). Conclusions: Outcome following total hip arthroplasty in the treatment of post-traumatic arthritis following acetabular fracture is less favourable than following primary osteoarthritis. Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction and internal fixation. At long term follow-up, the main problem identified was osteolysis and acetabular wear

Background and Objective. Total hip arthroplasty (THA) has been applied to treat pain and disability in patients with post-traumatic arthritis after acetabular fracture for many years. However, the midterm and long-term results of THA for this unique population are still controversial. According to previous studies, we found that uncemented acetabular reconstructions were usually performed in patients who were most likely to have the best results and an abnormal acetabular structure was usually the reason for THA failure. In this study, we evaluated the midterm results of using uncement acetabular components to treat posttraumatic arthritis after acetabular fracture. In addition, we investigated the effects of different acetabular fracture treatments and fracture patterns on THA. Materials and Methods. Between January 2000 to December 2003, 34 uncemented acetabular reconstructions were performed in 34 patients for posttraumatic arthritis after acetabular fractures. Among them, 31 patients underwent complete clinical and radiographic follow-up for an average of 6.3 years (range, 3.1–8.4 years). There were 22 men and 9 women. The patients' average age was 51 ± 12 years (range, 27–74 years) at the time of arthroplasty. The average interval from fracture to THA was 5.58 ± 4.42 years (range, 0.75–17.5 years). Of the 31 patients, 19 had undergone ORIF (open-reduction group) and 12 had received conservative treatment for the acetabular fractures (conservative-treatment group). Then, 14 had simple pattern fractures (simple group) and 17 had complex pattern fractures (complex group). After midterm follow-up, the radiographic and clinic results of the different groups were compared. Results. During 6.3 years' follow up, no infection occurred and no revision was needed in the 31 patients. In the open-reduction and conservative-treatment groups, the respective averages for duration of surgery, intraoperative blood loss, and amount of blood transfused were 138 ± 29 minutes and 98 ± 16 minutes (P < .001), 726 ± 288 mL and 525 ± 101 mL (P = .01), and 1,130 ± 437 mL and 1,016 ± 422 mL (P = .62). In the complex group and the simple group, the respective averages for duration of surgery, intraoperative blood loss, and amount of blood transfused were 132 ± 28 minutes and 109 ± 31 minutes (P = .042), 741 ± 221 mL and 536 ± 248 mL (P = .02), and 1,100 ± 414 mL and 1,075 ± 456 mL (P = .91). The average Harris Hip Score increased from 49 ± 15 before surgery to 89 ± 5 in the latest follow up, and 29 patients (94%) had either excellent or good results. The average Harris Hip Score for the open-reduction group and the conservative-treatment group increased to 87 ± 6 and 91 ± 3 (P = .07), respectively, after surgery; for the complex group and the simple group, it increased to 88 ± 6 and 90 ± 4 (P = .25), respectively. There was no significant difference between the open-reduction group and the conservative-treatment group or between the complex group and the simple group regarding the number of hips with excellent and good results. Of our 31 patients, none had a change in acetabular component abduction of >4°. The average horizontal migration of cup was 1.48 ± 0.46 mm (range, 0.7–2.33 mm), and the average vertical migration was 1.41 ± 0.54 mm (range, 0.5–2.51 mm). The average rate of polyethylene liner wear was 0.25 ± 0.11 mm/y (range, 0.03–0.41 mm/y). Average wear rates were 0.25 ± 0.12 mm/y and 0.24 ± 0.11 mm/y for the open-reduction group and the conservative-treatment group (P = .72), respectively, and 0.24 ± 0.13 mm/y and 0.26 ± 0.10 mm/y in the complex group and the simple group (P = .67), respectively. The average rate of polyethylene wear for all patients was positively related to BMI (r = .36; P = .047). After THA, all 31 patients had a reconstructed hip center within 20 mm of vertical and horizontal symmetry compared with the contralateral hip, including 27 patients (87%) with anatomic restoration and 4 patients with reconstructed hip center between 10–20 mm of vertical and horizontal symmetry. Anatomic restoration was positively related to fracture treatment (r = .48; P = .006), but it had no relation to fracture pattern (r = .16; P = .40). Conclusion. Uncement acetabular reconstruction following acetabular fracture had favorable midterm results. Fracture treatments and patterns are associated with increased operative time and hemorrhage amount. Open reduction and internal fixation of fracture favours anatomic restoration of hip rotational center

Purpose: The purpose of this work was to analyse different techniques and outcome of total hip arthroplasty for acetabular degeneration after orthopaedically or surgically treated fracture of the acetabulum. Material and methods: This retrospective analysis of a consecutive series was conducted by an independent observer. Sixty-four arthroplasties in 63 patients performed between 1979 and 2000 were included. Twenty-eight acetabular fractures had been treated surgically and 36 orthopaedically. Five types of cups were implanted (25 cerafit, 3 cerapress, 17 cemented alumina, 11 screwed, 7 polyethylene). All patients were assessed preoperatively and at last follow-up with the Merle d’Aubigné clinical scale. The postoperative and last follow-up radiograms were assessed according to Charnley and De Lee. Operative difficulties were assessed in terms of operative time, blood loss, and analysis of the operation reports. Actuarial survival was calculated. Results: Mean follow-up was five years two months. Six patients were lost to follow-up early. Clinical outcome was satisfactory with significant improvement in the Merle d’Aubigné score. The 10-year survival rate was 81% taking aseptic loosening as the endpoint and 74% taking surgical revision as the endpoint. Operative time and blood loss were significantly related to loss of ace-tabular bone stock and to operator experience (p < 0.05). Survival was significantly related to acetabular bone defect (p < 0.05). There was no difference between the treatment modes used for the initial acetabular fracture for peroperative difficulty or survival. Discussion: Total hip arthroplasty for acetabular degeneration secondary to acetabular fracture has given good functional results. Long-term survival is below that for primary arthroplasty, the only unfavourable factor identified being loss of acetabular bone stock. The surgical procedure is more difficult and requires a certain experience. We did not find any difference related to the type of treatment (orthopaedic or surgical) used for the initial acetabular fracture. It was difficult to interpret the influence of cup type due to the wide range of cups used in this series

Isolated fractures of the anterior column and anterior wall are a relatively rare subgroup of acetabular fractures. We report our experience of 30 consecutive cases treated over ten years. Open reduction and internal fixation through an ilioinguinal approach was performed for most of these cases (76.7%) and percutaneous techniques were used for the remainder. At a mean follow-up of four years (2 to 6), 26 were available for review. The radiological and functional outcomes were good or excellent in 23 of 30 patients (76.7%) and 22 of 26 patients (84.6%) according to Matta’s radiological criteria and the modified Merlé d’Aubigné score, respectively. Complications of minor to moderate severity were seen in six of the 30 cases (20%) and none of the patients underwent secondary surgery or replacement of the hip

Aim: The purpose of this study was to compare patient outcome following THR after previous acetabular fracture versus replacement for idiopatic osteoarthritis. Methods: Patients with acetabular fractures that later required THR were matched by gender, age and year of THR to patients who received THRs for osteoarthritis. The patients function, complications, radiographic loosening and revision were documented. Results: 42 patients were in each of the 2 groups (62% male, mean age 51±11 years; mean follow-up was 6,1 (2–8) years. The average time from fracture to THR was 5,1 years, 28 patients were treated by ORIF and 14 non operativ. Patients with a previous acetabular fracture had lower WOMAC scores than arthritis patients, representing more pain and stiffness and worse function. There was no difference in the rate of acetabular component loosening (fracture group vs. arthritis group: 14,5% vs. 12,1%), femoral component loosening (7,0% vs. 9,4%), or acetabular (12,1% vs. 9,4%) or femoral (7,0% vs. 7,0%) revision. After adjusting for age, gender and length of follow-up, the time to revision was found to be shorter for the fracture group compared to the arthritis group (3,2± 4,0 vs. 5,9±3,7 years, p< 0,05). Conclusion: THR following previous acetabular fracture was associated with worse patient function than THR for osteoarthritis. Although loosening and revision rates were similar following THR in the two groups, revision total hip replacements occur earlier in patients with a previous acetabular fracture

Severe acetabular fractures are difficult to treat. Complications include blood loss, neural damage, long operating times, and a high risk of sepsis and failure. Even when the fracture is ideally stabilised, there is a major risk of secondary osteoarthritis. This can be related to bone necrosis, cartilage surface damage, bone loss. However, even in young patients modern surgical techniques, including use of an alumina-against-alumina bearing, may facilitate long-term survival without limitation of activity. Functionally, the results of secondary procedures after failed osteosynthesis are statistically worse than after primary total hip arthroplasty (THA). The surgery is difficult because of material retrieval difficulties, nerve dissection, bone reconstruction and remaining muscular dysfunction. We reviewed the results of 80 THA procedures done between 1980 and 1998 to treat 58 acetabular fractures. The mean age of our 57 patients (39 men and 18 women) was 50 years (21 to 80). The mean delay between fracture and THA was 10 years in 22 patients who had undergone osteosynthesis and six years in 35 patients who had been treated conservatively. The mean follow-up period was 5,5 years (6 months to 20 years). There were eight instances of socket loosening, two of which were septic and six aseptic. Two of these patients had screw-in prostheses and six had cemented. There were 19 sciatic palsies, 13 of which developed after trauma, four after osteosynthesis and two after THA. There were three cases of gluteus medius palsy. In two of four cases of sepsis that occurred after osteosynthesis, sepsis recurred after THA, and in one patient sepsis developed after THA. In this limited series, patients who underwent THA after osteosynthesis did not have as good an outcome as those in whom initial orthopaedic treatment was followed some weeks later by THA. We believe many poor results could have been avoided with better primary surgery. Functional results are likely to be better, and the incidence of complications lower, if primary THA is performed in conjunction with acetabular reconstruction. Of course, for treatment of simple acetabular fracture involving major displacement of the posterior wall, one column osteosynthesis is still recommended

Aims. The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome. Patients and Methods. We followed up 60 consecutive patients (61 hips; mean age 36.3 years, standard deviation (. sd. ) 15) who underwent open reduction and internal fixation for a displaced fracture of the acetabulum (24 posterior wall, 18 transverse and posterior wall, ten transverse, and nine others) with a mean follow-up of 12.4 years (. sd. 3). . Results. Clinical grading was assessed using the modified Merle d’Aubigné score. Radiographic osteoarthritis was graded according to Matta. Kaplan-Meier survivorship and a univariate Cox-regression analysis were carried out using the following endpoints: total hip arthroplasty, a Merle d’Aubigné score of < 15 and/or progression of osteoarthritis. . Conclusion. The ten-year cumulative survivorship was 82% (95% confidence interval 71 to 92). Predictors for the defined endpoints were femoral chondral lesions, marginal impaction, duration of surgery, and age of patient. Cite this article: Bone Joint J 2017;99-B:508–15

Retrospective review of 25 patients over 65 years of age with unilateral acetabular fractures managed conservatively showed that seven of the 23 survivors (30%) had an unacceptable functional result. Poor results were associated with: displaced posterior column fractures, osteoporosis, femoral head fracture, delayed diagnosis, inadequate radiographs, inappropriate or too brief traction, and early weight-bearing. In this age group acetabular fractures tend to be low-velocity injuries of osteoporotic bone and are not comparable with those in younger patients

To assess the stability of the hip after acetabular fracture, dynamic fluoroscopic stress views were taken of 41 acetabular fractures that met the criteria for non-operative management. These included roof arcs of 45°, a subchondral CT arc of 10 mm, displacement of less than 50% of the posterior wall, and congruence on the AP and Judet views of the hip. There were three unstable hips which were treated by open reduction and internal fixation. The remaining 38 fractures were treated non-operatively with early mobilisation and delayed weight-bearing. At a mean follow-up of 2.7 years, the results were good or excellent in 91% of the cases. Three fair results were ascribed to the patients’ other injuries. Dynamic stress views can identify subtle instability in patients who would normally be considered for non-operative treatment

Early total hip replacement (THR) for acetabular fractures offers accelerated rehabilitation, but a high risk of heterotopic ossification (HO) has been reported. The purpose of this study was to evaluate the incidence of HO, its associated risk factors and functional impact. A total of 40 patients with acetabular fractures treated with a THR weres retrospectively reviewed. The incidence and severity of HO were evaluated using the modified Brooker classification, and the functional outcome assessed. The overall incidence of HO was 38% (n = 15), with nine severe grade III cases. Patients who underwent surgery early after injury had a fourfold increased chance of developing HO. The mean blood loss and operating time were more than twice that of those whose surgery was delayed (p = 0.002 and p < 0.001, respectively). In those undergoing early THR, the incidence of grade III HO was eight times higher than in those in whom THR was delayed (p = 0.01). Only three of the seven patients with severe HO showed good or excellent Harris hip scores compared with eight of nine with class 0, I or II HO (p = 0.049). Associated musculoskeletal injuries, high-energy trauma and head injuries were associated with the development of grade III HO. The incidence of HO was significantly higher in patients with a displaced acetabular fracture undergoing THR early compared with those undergoing THR later and this had an adverse effect on the functional outcome. Cite this article: Bone Joint J 2013;95-B:95–100

We investigated whether patients who underwent internal fixation for an isolated acetabular fracture were able to return to their previous sporting activities. We studied 52 consecutive patients with an isolated acetabular fracture who were operated on between January 2001 and December 2002. Their demographic details, fracture type, rehabilitation regime, outcome and complications were documented prospectively as was their level and frequency of participation in sport both before and after surgery. Quality of life was measured using the EuroQol-5D health outcome tool (EQ-5D). There was a significant reduction in level of activity, frequency of participation in sport (both p < 0.001) and EQ-5D scores in patients of all age groups compared to a normal English population (p = 0.001). A total of 22 (42%) were able to return to their previous level of activities: 35 (67%) were able to take part in sport at some level. Of all the parameters analysed, the Matta radiological follow-up criteria were the single best predictor for resumption of sporting activity and frequency of participation

Purpose: The purpose of this study was to evaluate total hip arthroplasty (THA) in the treatment of posttraumatic arthritis following acetabular fracture and to compare the long-term outcome of THA after previous open reduction and internal fixation (ORIF) or conservative treatment of the acetabular fracture. Method: Thirty-four patients (thirty-six hips) underwent total hip arthroplasty for arthritis resulting from acetabular fractures. There were twenty-six males (27 hips) and eight females (9 hips). The mean age at the time of hip arthroplasty was 49 years (range, 25–78 years). The mean follow-up was eight years and nine months (range, 4–17 years). The mean interval from fracture to arthroplasty was 7.5 years (range, 5 months-29 years). Two patients died of unrelated causes and two patients were lost to follow up. Thirty patients (32 hips) were available for latest follow up. Twenty-one hips had been previously treated by open reduction internal fixation and 11 hips had conservative treatment. Results: Sixteen patients achieved and maintained a good to excellent result over the course of the follow-up. There was no difference in improvement of mean Harris Hip Score between both groups (p> 0.05). Ten out of 32 hips required revision; 9 acetabular components were revised because of aseptic loosening (3), osteolysis/excessive wear (4), instability (1) and infection (1) with a total revision rate of 28%. Eight patients needed acetabular revision alone, one femoral revision alone and one revision of both components. There was no significant difference in bone grafting, heterotopic bone formation, revision rate, operative time and blood loss between the two groups (p> 0.05). Conclusions: Those patients initially treated conservatively had similar long term results compared to those treated primarily by open reduction internal fixation. At long term follow-up the main problem identified was osteolysis and acetabular wear

There have been multiple approaches described for internal fixation of acetabular fractures. We discuss the results of acetabular fractures treated in our institution via a Stoppa intrapelvic approach. Between July 1997 to October 2002, the senior author surgically treated 14 acetabular fractures using this approach. Indications for utilizing this approach include displaced anterior column fractures, transverse fractures, T shaped fractures, both column fractures and anterior column or wall fractures associated with a posterior hemi transverse component. The fractures were classified according to Letournel and Judet. There were 10 males, 4 females with a mean age of 34 years (20–57 years). Patients were followed up for an average of 26 months (8–60 months). All fractures went on to union at an average of 12 weeks. There was one superficial wound infection, which was successfully treated with antibiotics. No patients suffered loss of fixation. There were no nerve or visceral injury in our series. Clinical results evaluated were based on the Harris Hip Score (out of 100). Our results show 13 patients had good to excellent results (Score 80–100), whereas one patient had a fair result. The Stoppa intrapelvic approach offers improved reduction and fixation techniques with a decrease in complications associated with extensile approaches

This study reports on the natural history of acetabular fracture dislocations. We retrospectively reviewed patients who sustained an acetabular fracture associated with a posterior hip dislocation from a prospective database. Patient characteristics, complications and the requirement for further surgery were recorded. Patient outcomes were measured using the Oxford Hip score and Short Form SF-12 health survey. A total of 99 patients were treated over a 24 year period. The mean age was 41 years. Open reduction and internal fixation was performed in the majority (n=87), 10 were managed conservatively following closed reduction and two underwent primary total hip replacement (THR). At a median follow up of 12.4 years (range 4–24 years) patient outcomes were available for 53 patients. 12 patients had died. 19 patients went onto have a THR as a secondary procedure, of which 11 had confirmed avascular necrosis. Median time to THR was 2 years (range 1–17 years). The mean Oxford hip score was 35 (range 2–48), SF-12 physical component score (PCS) was 40 and a third of the patients used a walking aid. In THR group the mean Oxford score was 32 (range 3–46), SF-12 PCS was 39 and almost all required a walking aid. This is the first study to present the long term outcomes following an acetabular fracture dislocation. Our study suggests there is considerable disability in this group of patients and the requirement for subsequent THR has inferior patient reported outcomes

Because there are a number of complicating factors, total hip arthroplasty (THA) performed following acetabular fractures has a less favourable prognosis than when done for primary degenerative arthritis. Patients who have had ace-tabular fracture and present for consideration of THA need careful clinical and radiological assessment. Investigation should include AP and lateral radiographs, 45° inlet/outlet views, obturator and iliac obliques, Judet views and CT scan, with or without 3D reconstruction. There are various classifications defining whether the bone deficiency is contained or uncontained and the extent of the structural defect. Treatment options include autograft, allograft together with mesh, screws, plates, rings, cages, etc. It is probably preferable to undertake THA sooner (as soon as there is radiological evidence of incongruent articular surfaces) rather than later, as this reduces the delay between fracture and recovery from THA, and any inadequate reduction can be minimised or corrected. The surgical approach must allow adequate access for the intended reconstruction. Small contained or uncontained defects can be treated with cemented or cementless implants and limited grafting. Large defects require structural reinforcement, bone grafting, a retaining cage and, unless a custom-made implant is used, cemented fixation. Potential problems at the time of surgery include sciatic nerve injury (beware the ‘double crush syndrome’) obstructive hardware, heterotopic ossification, avascular necrosis of the acetabulum and occult infection. Patients who are elderly or who present with markedly impacted fracture, extensive abrasion or fracture of the femoral head, displaced femoral neck fracture, and extensive acetabular comminution in the presence of osteopoenic bone, may warrant acute management with THA. Early experience of THA in the treatment of selected acute fractures is encouraging. However, the clinical results of THA after fractures of the acetabulum are often disappointing, and there is no current evidence that open reduction and internal fixation improves the success of the subsequent THA. THA following acetabular fractures is a challenging procedure with a high complication rate. Appropriate investigation and preoperative planning reduces the risk of complications

Specific radiological features identified by Brandser and Marsh were selected for the analysis of acetabular fractures according to the classification of Letournel and Judet. The method employs a binary approach that requires the observer to allocate each radiological feature to one of two groups. The inter- and intra-observer variances were assessed. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were analysed by a similar method. These factors were termed ‘modifiers’ and are generally considered when planning operative intervention and, critically, they may influence prognosis. Six observers independently assessed 30 sets of plain radiographs and CT scans on two separate occasions, 12 weeks apart. They were asked to determine the presence or absence of specific radiological features. This simple binary approach to classification yields an inter- and intra-observer agreement which ranges from moderate to near-perfect (κ = 0.49 to 0.88 and κ = 0.57 to 0.88, respectively). A similar approach to the modifiers yields only slight to fair inter-observer agreement (κ = 0.20 to 0.34) and slight to moderate intra-observer agreement (κ = 0 to 0.55)

We created virtual three-dimensional reconstruction models from computed tomography scans obtained from patients with acetabular fractures. Virtual cylindrical implants were placed intraosseously in the anterior column, the posterior column and across the dome of the acetabulum. The maximum diameter which was entirely contained within the bone was determined for each position of the screw. In the same model, the cross-sectional diameters of the columns were measured and compared to the maximum diameter of the corresponding virtual implant. We found that the mean maximum diameter of virtual implant accommodated by the anterior columns was 6.4 mm and that the smallest diameter of the columns was larger than the maximum diameter of the equivalent virtual implant. This study suggests that the size of the screw used for percutaneous fixation of acetabular fractures should not be based solely on the measurement of cross-sectional diameter and that virtual three-dimensional reconstructions might be useful in pre-operative planning

Purpose of the study: Correct implant position is one of the factors of long-term success of total hip arthroplasty (THA). Acetabular architectural defects caused by trauma can create difficult situations leading to potential complications and poor outcome. The purpose of this study was to examine retrospectively the results of THA implanted after fracture of the acetabulum treated surgically. The objective was to analyse the specific features and search for factors favouring poor outcome. Material and method: The series included 43 patients who had a THA implanted after treatment of an acetabular fracture. Mean age at trauma was 44.5 years (range 16–87). Five patients had a THA immediately, mean age 75 years (63–87). Thirty eight patients had osteosynthesis. According to the Letournel classification, the fracture was elementary in 12 cases and complex in 26. In ten patients, there was residual joint incongruence measuring more than 2 mm after osteosynthesis. The hips evolved to degenerated joint (n=34) and or necrosis (n=10). Results: Mean time from acetabular osteosynthesis to THA was 94.6 months (range 3–444), excluding those patients whose THA was implanted at the time of the osteosynthesis. Arthroplasty required removal of the osteosynthesis material (n=11), insertion of a supportive ring (n=14) associated with a bone graft (n=13). The acetabular implant was considered to be well positioned according to the Pierchon criteria in 16 hips and was lateralised (n=21) and/or ascended (n=17) in the other hips. Inclination was 42.8 on average, range 10–18. The five-year survival was 80%. Discussion: Arthroplasty after surgical treatment of an acetabular fracture is a difficult procedure. Complementary procedures are often necessary complicating the surgery and increasing the risk of perioperative complications, particularly infection. It is difficult to position the acetabular implant, increasing the risk of postoperative instability and early loosening. This study demonstrated the difficulties of implanting a THA in this context where the revision rate is significantly higher than in first-intention THA

Stable, anatomical fixation of acetabular fractures gives the best chance of a good outcome. We performed a biomechanical study to compare fracture stability and construct stiffness of three methods of fixation of posterior wall acetabular fractures. Two-dimensional motion analysis was used to measure fracture fragment displacement and the construct stiffness for each fixation method was calculated from the force / displacement data. Following 2 cyclic loading protocols of 6000 cycles, to a maximum 1.5kN, the mean fracture displacement was 0.154mm for the rim plate model, 0.326mm for the buttress plate and 0.254mm for the spring plate model. Mean maximum displacement was significantly less for the rim plate fixation than the buttress plate (p=0.015) and spring plate fixation (p=0.02). The rim plate was the stiffest construct 10962N/mm (SD 3351.8), followed by the spring plate model 5637N/mm (SD 832.6) and the buttress plate model 4882N/mm (SD 387.3). Where possible a rim plate with inter-fragmentary lag screws should be used for isolated posterior wall fracture fixation as this is the most stable and stiffest construct. However, when this method is not possible, spring plate fixation is a safe and superior alternative to a posterior buttress plate method

Background. Referral to centres with a pelvic service is standard practice for the management of displaced acetabular fractures. Hypothesis. The time to surgery: (1) is a predictor of radiological and functional outcome and (2) this varies with the fracture pattern. Methods. A retrospective case review of 254 patients over a ten year period with a minimum follow-up of two years. Patients were divided into two groups based on fracture pattern: elementary or associated. ‘Time to surgery’ was analysed as a continuous and a stratified variable. The primary outcome measures were the quality of reduction and functional outcome. Logistic regression analysis was used to test our hypothesis, while controlling for potential confounding variables. Results. For elementary fractures, an increase in the time to surgery on one day reduced the odds of an excellent/good functional result by 15% (p = 0.001) and of an anatomical reduction by 18% (p = 0.0001). For associated fractures, the odds of obtaining an excellent/good result were reduced by 19% (p = 0.0001) and an anatomical reduction by 18% (p = 0.0001) per day. When ‘time’ was measured as a categorical variable, an anatomical reduction was more likely if surgery was performed within 15 days (elementary) and five days (associated). An excellent/good functional outcome was more likely when surgery was performed within 15 days (elementary) and ten days (associated). Conclusion. The time to surgery is a significant predictor of radiological and functional outcome for both elementary and associated displaced acetabular fractures. The organisation of regional trauma systems must be capable of satisfying these time-critical targets to achieve optimal patient outcome

We have evaluated the functional, clinical and radiological outcome of patients with simple and complex acetabular fractures involving the posterior wall, and identified factors associated with an adverse outcome. We reviewed 128 patients treated operatively for a fracture involving the posterior wall of the acetabulum between 1982 and 1999. The Musculoskeletal Functional Assessment and Short-Form 36 scores, the presence of radiological arthritis and complications were assessed as a function of injury, treatment and clinical variables. The patients had profound functional deficits compared with the normal population. Anatomical reduction alone was not sufficient to restore function. The fracture pattern, marginal impaction and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement. It may be appropriate to consider immediate total hip replacement for patients aged > 50 years with marginal impaction and comminution of the wall, since 7 of 13 (54%) of these required early hip replacement

Certain acetabular fractures involve impaction of the weight-bearing dome and medialisation of the femoral head. Intra-operative fracture reduction is made easier by traction on the limb, ideally in line with the femoral neck (lateral traction). However, holding this lateral traction throughout surgery is very difficult for a tiring assistant. We detail a previously undescribed technique of providing intra-operative lateral femoral head traction via a pelvic reduction frame, to aid fixation of difficult acetabular fractures. The first 10 consecutive cases are reviewed (Group 1) and compared with a retrospective control (Group 2, n=18) of case-matched patients, treated prior to introducing the technique. The post-operative X-rays and CT scans were assessed to identify quality of fracture reduction according to the criteria of Tornetta and Matta. Operative time, blood loss and early complication rates were also compared. All cases in both groups were acute injuries with medial and/or superior migration of the femoral head. The majority were either associated both column or anterior column posterior hemi-transverse. There was no statistical difference between the groups in age, time to surgery, BMI or ASA grade. Fracture reduction was assessed as excellent in seven, good in three and poor in one. This was not significantly different from the control group (p=0.093). The mean operative time was 232 minutes in Group 1 and 332.78 minutes in Group 2 (p = 0.0015). There was no difference between the groups for blood loss or complication rates. We conclude that this new technique is at least equivalent to using manual traction and early results suggest it reduces operative time and technical difficulty in treating these complex acetabular fractures

A retrospective study of 23 acetabular fractures in patients up to 17 years of age is presented, with an average follow-up of eight years. Good or excellent functional results were achieved in 21 patients; radiographic results were good or excellent in 16. Conservative treatment gave consistently good results in fractures with minimal initial displacement, stable posterior fracture-dislocations and Salter-Harris type 1 and 2 triradiate cartilage fractures. Less favourable results were seen in type 5 triradiate cartilage fractures and in comminuted fractures, but operation was no better. Unstable posterior fracture-dislocations and irreducible central fracture-dislocations need operative treatment but the results may still be unsatisfactory

Introduction: The purpose of this retrospective study was to report on the minimal 5-year follow-up results of a consecutive series of cemented total hip arthroplasties following acetabular fracture. Materials and methods: Between January 1980 and December 1995, fifty-three total hip arthroplasties were performed in 53 patients (16 females and 37 males). The mean age of the patients at the time of the index arthroplasty was 53.1 years (range, 24–84 years). The initial fracture concerned one wall in 18 patients, one column in 7, and both columns in 6. It was a complex fracture in 11 patients, and was unknown in the remaining 11 patients. Twenty-three of the 53 fractures had had a non-operative treatment, while 30 had had a surgical treatment. The mean time between the fracture and the arthroplasty was 16.4 10.8 years. All prostheses were of Charnley-Kerboull design, combining a 22.2-mm femoral head and an all-polyethylene socket. Both components were cemented. Results: At the minimum 5-year follow-up evaluation, 35 patients were still alive and had not been revised at a mean of 12.4 3.8 years (range, 7–21 years), 6 patients had been revised, 5 patients had died from unrelated causes, and 7 patients were lost to follow-up. The mean Merle d’Aubigne hip score was 16.7 1.3 at the latest follow-up. Revision was performed for high polyethylene wear associated with periprosthetic osteolysis in 5 hips at a mean of 10.3 years, and for deep sepsis in one. The survival rate of the whole series at 15 years, using revision for any reason as the end-point, was 79.2 9.7 % (95% confidence interval, 60.3 to 98.2%). The survival rate at 15 years, using radiologic loosening as the end-point, was 94.7 % (95% confidence interval, 84.7 to 100%) for hips of which fracture had been treated non-operatively, versus 75.5 13.0% (95% confidence interval, 49.9 to 100%) for hips of which fracture had been surgically treated. The difference was not significant with the numbers available (log-rank test, p = 0.44). Discussion and conclusion: The results of this series indicated that the mechanical failure rate of total hip arthroplasty following acetabular fracture was high in the mid- to long-term. The young age of the patients, the predominantly male cohort, and the modifications of the acetabulum structure due to the fracture could account for this phenomenon

We report a retrospective study of 54 acetabular fractures treated by open reduction and internal fixation, with an average follow-up of 9.6 years (3 to 17). Reduction leaving displacement of less than or equal to 2 mm was achieved in 36 hips (67%); good or excellent functional results were obtained in 33 patients (61%). Early complications requiring re-operation included postoperative loss of reduction in one case and an intra-articular screw in another. Arthrodesis or total hip arthroplasty had been performed in 10 patients (19%) who had late symptomatic degenerative changes. Failure to obtain accurate reduction was the most important factor leading to a poor result, but heterotopic calcification caused poor results in seven patients, five of whom had had an anatomical reduction

We report a prospective, randomised, blinded clinical comparison of the use of indomethacin or radiation therapy for the prevention of heterotopic ossification (HO) in 75 adults who had open reduction and internal fixation of acetabular fractures through either a Kocher-Langenbeck, a combined ilioinguinal and Kocher-Langenbeck, or an extended iliofemoral approach. Indomethacin, 25 mg, was given three times daily for six weeks. Radiation with 800 cGy was delivered within three days of operation. Plain radiographs were reviewed and given Brooker classification scores by three independent observers who were unaware of the method of prophylaxis. One patient died from unrelated causes and two were lost to follow-up, leaving 72, 33 in the radiation group and 39 in the indomethacin group, available for evaluation at a mean of 12 months (6 to 48). There was no significant difference in the two groups in terms of age, gender, injury severity score, estimated blood loss, delay to surgery, head injury, presence of femoral head dislocation, or operating time, and no complications due to either method of treatment. The final extent of HO was already present by six weeks in all patients who were followed up. Three patients in the radiation group and five who received indomethacin developed HO of Brooker grade III. Two patients in the indomethacin group developed Brooker IV changes; both had failed to receive proper doses of the drug. Cochran-Armitage analysis showed no significant difference between the two treatment groups as regards the formation of HO. Indomethacin and single-dose radiation therapy are both safe and effective for the prevention of HO after operation for acetabular fractures. Radiation therapy is, however, approximately 200 times more expensive than indomethacin therapy at our institution and has other risks

The June 2023 Trauma Roundup³⁶⁰ looks at: Aspirin or low-molecular-weight heparin for thromboprophylaxis?; Lateral plating or retrograde nailing for distal femur fractures?; Sciatic nerve palsy after acetabular fixation: what about patient position?; How reliable is the new OTA/AO classification for trochanteric hip fractures?; Young hip fractures: is a medial buttress the answer?; When is the best time to ‘flap’ an open fracture?; The mortality burden of nonoperatively managed hip fractures.

It is widely recognised that pelvic disruption in association with high-energy trauma is a life-threatening injury. The potential morbidity and mortality associated with acetabular injuries are less well understood. Due to chronic underfunding and the absence of a comprehensive and coordinated national approach to the management of acetabular trauma throughout the UK, patients can incur prolonged recumbency. Prompt and appropriate referral for specialist management, thromboprophylaxis and venous thrombosis surveillance are important issues for the referring centre. We performed a postal questionnaire to establish the current clinical practice in the specialist centres throughout the UK in pelvic and acetabular trauma, with respect to time to surgery, thromboprophylaxis, and surveillance. We identified twenty-one units and thirty-seven surgeons in the NHS who deal with pelvic and acetabular injuries. The mean time to surgery from injury in the UK is 8.5 days (range 2-19 days). The larger units that accept and treat patients from outside their region experience the greatest delay to surgery. Mechanical thromboprophylaxis was used in 67% (14) of the units. 24% (5) use arterio-venous boots, 19% (4) use calf pumps, and 52% (11) use TEDS stockings. No unit routinely use prophylactic IVC filters in acetabular trauma. Chemical thromboprophylaxis is routinely used in 100% (21) of the units. 95% (20) used prophylactic doses of unfractionated heparin or low molecular weight heparin. Clinical surveillance alone for thromboembolism is employed in 90% (19) of the units. Only 2 (10%) units routinely perform radiological surveillance with ultrasound Doppler on its acetabular fracture cases pre-operatively. Currently there is no published directory of dedicated pelvic and acetabular surgeons in the UK. There is no general consensus on the approach to thromboprophylaxis and surveillance in acetabular trauma in the UK. There is no consensus approach to thromboprophylaxis and surveillance in the literature

Introduction. Acetabular fractures are a challenging problem. It has been published that outcome is dependent upon the type of fracture, the reduction of the fracture and concomitant injuries. The end-points of poor outcome include avascular necrosis of the femoral head, osteoarthritis. However, we lack definitive statistics and so counselling patients on prognosis could be improved. In order to achieve this, more outcome studies from tertiary referral centres are required. We present the first long term follow up from a large tertiary referral centre in Ireland. Methods. We identified all patients who were ten years following open reduction and internal fixation of an acetbular fracture in our centre. We invited all of these patients to attend the hospital for clinical and radiographic follow-up. As part of this, three scoring systems were completed for each patient; the Short-form 36 health survey (SF36), the Merle d'Aubigné score and the Short Musculoskeletal Functional Assessment (SMFA). Results. The data represents one year's activity at a new tertiary referral unit. We identified a total of 44 patients who were ten years following ORIF of acetabular fractures in our unit. 21 patients (48%) replied to written invitation and attended the hospital for clinical and radiographic follow-up. A further 7 patients were contacted by telephone and interviewed to gauge their rehabilitation. 3 patients had passed away. The remaining 13 patients were not contactable. Of those who attended in person for follow-up; 18 were male and 3 were female. The mean age at follow-up was 40.5 years (Range 27-60). In terms of fracture pattern epidemiology, 43% of patients sustained posterior column and wall fractures, 29% posterior wall, 14% posterior column alone, 9.5% transverse with posterior wall and 9.5% bicolumnar. 2 patients in the follow-up group had total hip replacements. Of the remaining patients the overall mean SF36 score was 78.8% (SD 16.4). The mean SMFA was 14.1% (SD 5). The mean Merle d'Aubigné score was 14.9 (SD 3.2) with 63% graded as good or excellent. Comparison of outcome between sub-groups according to fracture classification showed no significant difference. Traumatic sciatic nerve injury was sustained by four patients in the follow-up group and all patients continued to complain of ongoing weakness. Of the patients who were contacted via telephone, 2 had total hip replacements. The remaining 5 reported no significant problems with their hips and cited this as the reason for not attending follow-up. Conclusion. Overall the outcome of the patients was more favourable than expected. This was supported by the results of the clinical scoring systems. In some patients this also appeared to be despite poor radiographic findings. Our observations suggest that concomitant injuries, especially sciatic nerve injury have a profound negative influence on the patients' ability to fully rehabilitate. These data provide a valuable tool for the trauma surgeon in providing the patient with an educated prognosis

Introduction. Acetabular fractures are a challenging problem. It has been published that outcome is dependent upon the type of fracture, the reduction of the fracture and concomitant injuries. The end-points of poor outcome include avascular necrosis of the femoral head, osteoarthritis. However, we lack definitive statistics and so counselling patients on prognosis could be improved. In order to achieve this, more outcome studies from tertiary referral centres are required. We present the first long term follow up from a large tertiary referral Centre in Ireland. Methods. We identified all patients who were ten years following open reduction and internal fixation of an acetbular fracture in our centre. We invited all of these patients to attend the hospital for clinical and radiographic follow-up. As part of this, three scoring systems were completed for each patient; the Short-form 36 health survey (SF36), the Merle d'Aubigné score and the Short Musculoskeletal Functional Assessment (SMFA). Results. The data represents one years activity at a new tertiary referral unit. We idenfied a total of 44 patients who were ten years following ORIF of acetabular fractures in our unit. 21 patients (48%) replied to written invitation and attended the hospital for clinical and radiographic follow-up. A further 7 patients were contacted by telephone and interviewed to guage their rehabilitation. 3 patients had passed away. The remaining 13 patients were not contactable. Of those who attended in person for follow-up; 18 were male and 3 were female. The mean age at follow-up was 40.5 years (Range 27-60). In terms of fracture pattern epidemiology, 43% of patients sustained posterior column and wall fractures, 29% posterior wall, 14% posterior column alone, 9.5% transverse with posterior wall and 9.5% bicolumnar. 2 patients in the follow-up group had total hip replacements. Of the remaining patients the overall mean SF36 score was 78.8% (SD 16.4). The mean SMFA was 14.1% (SD 5). The mean Merle d'Aubigné score was 14.9 (SD 3.2) with 63% graded as good or excellent. Comparison of outcome between sub-groups according to fracture clasification showed no significant difference. Traumatic sciatic nerve injury was sustained by four patients in the follow-up group and all patients continued to complain of ongoing weakness. Of the patients who were contacted via telephone, 2 had total hip replacements. The remaining 5 reported no significant problems with their hips and cited this as the reason for not attending follow-up. Conclusion. Overall the outcome of the patients was more favourable than expected. This was supported by the results of the clinical scoring systems. In some patients this also appeared to be despite poor radiographic findings. Our observations suggest that concomitant injuries, especially sciatic nerve injury have a profound negative influence on the patients' ability to fully rehabilitate. These data provide a valuable tool for the trauma surgeon in providing the patient with an educated prognosis

We reviewed the outcome, at a mean follow-up of 14 months, of 21 two-column fractures of the acetabulum treated by operation through one or two non-extensile approaches. Eighteen procedures resulted in reduction of the articular surfaces to within 3 mm. The blood loss and operating time when two combined non-extensile approaches were used were similar to those reported for extended acetabular approaches. The incidence of heterotopic ossification which limited joint motion was low, and the average Harris hip score was 81 points. The use of non-extensile approaches for acetabular fractures in which both columns are involved avoids iatrogenic injury to the abductors, and reduces the incidence of complications

Acetabular fractures are amongst the most complex fractures. It has been suggested that pre-contouring the fixation plates may save intra-operative time, blood loss, reduce intra-operative fluoroscopy and improve the reduction. The purpose of this study was to assess if the contouring could be done reliably using the mirror image of the uninjured hemipelvis. Using the CT data of 12 specimens with no bony abnormality 3D models were reconstructed. Using computer software (AMIRA, Visage Imaging) the mirror image of the left hemipelvis and the right hemipelvis were superimposed based on landmarks. The distances between the surfaces were then calculated and displayed in the form of colour maps. The colour maps demonstrated that for the areas around were acetabular fixation plates would be placed the differences were small. For the anterior column plate 50% of the specimens had differences of less than 1mm, which based on the work of Letournel and Judet would represent an anatomical reduction. For the posterior column plate 58% had differences of less than 1mm. This study demonstrates that there is considerable symmetry between both hemipelvises and that precontouring on the mirror image of the uninjured side is an accurate, quick and reliable method for precontouring

Achieving precise open reduction and fixation of acetabular fractures by using a plate osteosynthesis is a complex procedure. Increasing availability of affordable 3D printing devices and services now allow to actually print physical models of the patient's anatomy by segmenting the patient's CT image. The data processing and printing of the model however still take too much time and usually the resulting model is rigid and doesn't allow fracture reduction on the model itself. Our proposed solution automatically detects relevant structures such as the fracture gaps and cortical bone while eliminating irrelevant structures such as debris and cancellous bone. This is done by approximating a sphere to the exterior surface of a classic segmented STL model. Stepwise, these approximated vertices are projected deeper into any structure such as the acetabular socket or fractures, following a specific set of rules. The resulting surface model finally is adapted precisely to the primary segmented model. Creating an enhanced surface reconstruction model from the primary model took a median time of 42 sec. The whole workflow from DICOM to enhanced printable 3D file took a median time of 13:25 min. The median time and material needed for the prints without the process was 32:25:36 h and 241,04 g, with the process 09:41:33 h and 65,89 g, which is 70% faster. The price of material was very low with a median of 2,18€ per case. Moreover, fracture reduction becomes possible, allowing a dry-run of the procedure and allowing more precise plate placement. Pre-contouring of osteosynthesis plates by using these 3D printouts was done for eleven patients prior to surgery. These printouts were validated to be accurate by three experiences surgeons and compared to classic segmented models regarding printing time, material cost and reduction ability. The pre-contouring of the plates was safely achievable. Our results show that improving the operative treatment with the help of enhanced 3D printed fracture models seems feasible and needs comparably little time and cost, thus making it a technique that can easily integrated into the clinical workflow

Acetabular fractures are amongst the most complex fractures to treat. It has been suggested that pre-contouring the fixation plates may save intra-operative time, blood loss, reduce intra-operative fluoroscopy and improve the reduction. The purpose of this study was to assess if the contouring could be done reliably using the mirror image of the uninjured hemipelvis. Using the CT data of 12 specimens with no bony abnormality 3D models were reconstructed. Using computer software (AMIRA, Visage Imaging) the mirror image of the left hemipelvis and the right hemipelvis were superimposed based on landmarks. The distances between the surfaces were then calculated. The results were collected in the form of mean distance and colour maps. The mean difference between surfaces ranged from 1.76mm and 8.47mm. The colour maps demonstrated that for the areas around were acetabular fixation plated would be placed the differences were small. For the anterior column plate 6 (50%) of the specimens had differences of less than 1mm, which based on the work of Letournel and Judet would represent an anatomical reduction. (None had a difference of more than 6mm.) For the posterior column plate 7 (58%) had differences of less than 1mm. (None had a difference of more than 3mm. This study demonstrates that there is considerable symmetry between both hemipelvises and that precontouring on the mirror image of the uninjured side is an accurate, quick and reliable method for precontouring. However the symmetry is not exact and the operating surgeon needs to be aware that fine-contouring may be required intra-operatively

We review the early results of 13 patients who underwent hip arthroplasty as the initial treatment following acetabular fracture. The indications for performing THA over open reduction and internal fixation included fractures of poor prognosis, dome comminution, femoral head damage and comorbidity. Fractures were fixed in a limited fashion and an uncemented Harris-Galante cup was inserted with bone grafting. All femoral components were cemented Exeters. There were two deaths. The first in the immediate post-operative period due to massive pulmonary embolism and the second in the early rehabilitation period due to pre-existing respiratory problems. The remaining 11 patients were assessed at an average of 37 months (13–68). The mean Charnley hip score was 15 (8–18) and the mean Harris hip score 82 (33–100). One acetabular cup had loosened accounting for the lowest scores and awaits revision. All fractures united by 6 months and all other components appeared stable at radiological review. Technical difficulties of this procedure will be discussed

Aims

The aim of this study was to record the incidence of post-traumatic osteoarthritis (OA), the need for total hip arthroplasty (THA), and patient-reported outcome measures (PROMS) after surgery for a fracture of the acetabulum, in our centre.

Total hip replacement (THR) after acetabular fracture presents unique challenges to the orthopaedic surgeon. The majority of patients can be treated with a standard THR, resulting in a very reasonable outcome. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining long-term acetabular component fixation. Indications for an acute THR include young patients with both femoral head and acetabular involvement with severe comminution that cannot be reconstructed, and the elderly, with severe bony comminution. The outcomes of THR for established post-traumatic arthritis include excellent pain relief and functional improvements. The use of modern implants and alternative bearing surfaces should improve outcomes further.

Cite this article: Bone Joint J 2013;95-B, Supple A:11–16.

Purpose: Twenty-one total hip arthroplasties after ace-tabular fracture were reviewed at a minimum two-year follow-up. The purpose of this analysis was to study operative difficulties and complications in implanting a total hip arthroplasty on a sequelar acetabulum. Material and methods: Ten acetabula had been treated surgically and eleven orthopaedically. Mean time interval between the initial trauma and the arthroplasty was 14 years (range 2 – 36). The posteriolateral approach was used in thirteen cases and the anterolateral approach in eight. Osteosynthesis material was totally removed in two patients and partially in three. Arthrolysis was performed in one patient who had grade IV heterotopic ossifications. Most of the cups were hydroxyapatite coated uncemented cups; two cups were cemented in a Postel Kerboul ring. Results: An autologous graft was required for nine of the eleven orthopaedically treated fractures versus two of the ten surgically treated fractures (p < 0 .05). Mean operative time was 136 minutes and mean blood loss was 1200cc. Postoperative complications included one superficial phlebitis, one infraperitoneal bladder wound, one superficial haematoma, one incomplete popliteal palsy, one dislocation and two heterotopic ossiications (1 Brooker I and 1 Brooker IV). At review, the mean Postel Merle d’Aubigné score was 16.5. Radiologically there was no evidence of loosening or defective fixation. Discussion: The operative difficulty was basically encountered in the group of orthopaedically treated acetabular fractures due to the callus (protrusion of the femroal head into the ovalised acetabulum. For these cases, an autologous graft was indispensable for reconstruction or defect filling (82% of the cases) to avoid excessive medialisation of the cup. For the fractures treated surgically, the osteo-synthesis material was only removed when it prevented proper cup position. An autologous graft was used to fill defects (18%) (wall or roof necrosis). Cup insertion without cement is the rule for first-intention treatment in these young patients, the supporting ring being used when required for second-intention treatment

Purpose: Preoperative planning forces the surgeon to understand the “fracture personality” and devise an operative plan. In our experience, trainees have difficulty in preparing for complex acetabular cases; these fractures are among the most difficult fractures to conceptualize and teach. As a result, these fractures are poorly understood as demonstrated by low interobserver agreement between trainees in the classification of acetabular fractures. We sought to determine whether the use of visou-haptic technology would help trainees to appreciate the “personality” of an Associated-Both-Column (ABC)fracture more accurately than trainees taught by conventional instruction. Method: Thirty senior medical students and PGY1 residents, were randomized into two groups. The control group studied an ABC fracture with the aid of a textbook excerpt and a 3D CT reconstruction of the fracture. The intervention group was given the same instructional materials, and a visuo-haptic CT model of the fracture. All other learning variables, including time on task were standardized. Participants were evaluated on their accuracy in drawing the fracture lines on a model pelvis. Results: There was no significant difference in gender, visuo-spatial ability, and training level between groups. The participants taught with the visuo-haptic model recalled an additional 26% anatomic relationships (p< 0.01) compared with the control group. Conclusion: These findings suggest that in addition to the benefits observed in the learning of motor skills, visuo-haptic input may improve the understanding of spatial relationships. This technology may be a useful adjunct for teaching anatomy, as well as preoperative planning

Background. Venous thromboembolism (VTE) is a common complication of pelvic and acetabular fracture fixation. There is, however, currently limited data to guide clinical decisions on thromboprophylaxis choice in these patients. Methods. This is a prospective study with retrospective analysis of all the patients who were admitted to the Northern General Hospital between August 2009 and March 2011. 2 consultants using same technique and peri-operative regime carried out all procedures. All patients were administered prophylactic enoxaparin and those who were admitted via another hospital had a pre-operative Doppler scan. Post-operatively all patients were commenced on warfarin, or low molecular weight heparin (enoxaprin) if warfarin was contra-indicated, and was continued for three months after discharge. Results. Eighty-nine patients were admitted during this period of which 25 were treated conservatively and were excluded from the study. The mean age of patients was 39.7 years (range 17 to 83) & 73% of those were men. 65% were involved in RTA and 49% had more than one injury. 46 patients were transferred from another hospital. Of those 3 had DVT confirmed on Dopplers and had IVC filters inserted preoperatively. 52 patients were treated with warfarin and 12 with Clexane. Two patients had warfarin related complications (thigh haematoma and small subdural haematoma). Both were treated conservatively and made a full recovery. Two of the warfarin-treated (3.8%) and one of enoxaparin-treated (8%) patients developed DVT/PE. One of the two warfarin-treated patients had a PE despite having an INR of 4.2 and the other patient upon transferring to local hospital had his warfarin stopped prematurely. Conclusions. The study shows that preoperative enoxaparin followed by postoperative warfarin is an effective thromboprophylaxis regime and is associated with low complication rate

There are unacceptable delays in the management of pelvic trauma in the United Kingdom. In 2003 this became a political issue after TV and radio coverage. Changes to the service were introduced, including trauma coordinators and a special tariff, but has it made a difference?

Introduction The results of THA in patients with post-traumatic arthritis are inferior to those in nontraumatic arthritis, both after cemented and noncemented THA. This increased failure rate is caused by the bone stock loss and the abnormal anatomy. We studied the outcome of acetabular bone impaction grafting and a cemented cup in 20 cases at 3 to 18 years follow-up. Materials and Methods Between January 1984 and January 2000 in 20 consecutive patients bone impaction grafting was used for arthritis after previous acetabular fracture, grafting was done in all for bone stock loss. There were 14 men and 6 women. The average age at THA was 53.3 years (range, 35 to 75 years). Defects were classified according to the AAOS acetabular defect classification (3 type I defects, 10 type II defects, 5 type III defects and 2 type V). Metal meshes were used in 6 medial wall and in 3 peripheral wall defects. In 15 cases autograft bone chips were used, in 5 both auto- and allograft was used. Grafts were impacted using impactors and a hammer and a PE cup was cemented. At review in January 2003 no patient was lost. Results Two patients died during follow up after 3 and 4 years respectively, deaths were not related to surgery and data are included. The mean follow up was 9.5 years (range, 3 to 18 years). The pre-operative Harris hip score was 44 (32–61). During follow up a cup revision was performed in two cases; one for a culture proven septic loosening 14.5 years after surgery and the other for aseptic loosening at 15.3 years after surgery. Both revised cups were radiologically loose at revision. At review the 16 surviving hips had an aver. Harris hip score of 93 points (range, 62 to 100 points). Fourteen hips were free of pain, one patient had slight and one had mild pain. Radiologically, none of these 16 cups was loose. However, two of the cups migrated more than 5 mm (e.g. 6 and 8 mm) relative to the initial post-operative X-ray. At review, both patients were symptom free. The Kaplan-Meier survival rate of the cup with endpoint revision for any reason was 100% at ten years and 80% (95% CI, 62–98%) after 15 years; with endpoint cup revision for aseptic loosening the survival was 100% both at 10 and 15 years. Conclusion The acetabular bone impaction grafting technique with a cemented cup is a biologically attractive technique to reconstruct the bone stock loss after posttraumatic arthritis with good long-term survival, even after long follow-up

Three middle-aged patients with diabetes sustained fractures of the acetabulum which were treated by open reduction and internal fixation. In each, rapid dissolution of the femoral head occurred with minimal discomfort, typical of a Charcot arthropathy. The patients had no other evidence of neuropathic arthropathy. Charcot changes may occur after high-energy trauma in patients with diabetes.

Purpose: The purpose of this retrospective study was to evaluate at minimal 5 years follow-up outcome in a consecutive series of total hip arthroplasties implanted for fracture of the acetabulum.

Material and methods: The series included 53 arthroplasties implanted between January 1980 and December 1995 in 53 patients, 16 women and 37 men, mean age 53.1 years (24–84). The initial fracture involved the acetabular wall in 18 patients, one column in seven and two columns in six. It was a complex fracture in eleven cases and classification was unknown in the eleven other hips. Orthopaedic treatment was used for 23 patients and surgery for 30. Mean time between fracture and arthroplasty was 16.4±10.8 years. Cemented Charnley-Kerboull implants with a metal-polyethylene bearing were used. The Postel-Merle-d’Aubigné (PMA) score was used to assess functional outcome. The actuarial survival was determined.

Results: At five years minimum follow-up, 33 patients were alive and had not undergone revision at mean follow-up of 12.4±3.8 years (7–21). Six patients had had revision of the acetabular and/or femoral element, five patients had died, and seven were lost to follow-up. Revisions were required for cup wear associated with periacetabular osteolysis. The mean preoperative functional score was 10.6±2.5 versus 16.2±2.8 (8–18) at last follow-up (Wilcoxon rank test, p< 0.0001). Cumulative survival, taking revision as failure, was 90.3±6.5% at 15 years (95%CI 77.6–100%) for hips treated orthopaedically versus 66.5±14.5 (95%CI 38.1–94.9%) for hips treated surgically. The difference for the analyzable hips was not significant (logrank, p=0.69).

Discussion: The results of this series confirm that the long-term risk of mechanical failure of total hip arthroplasty for fracture of the acetabulum is high.

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again.

The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply.

From 1987 to 1991, we treated 53 patients with 54 fractures of the acetabulum by reconstruction through a posterior or an extended iliofemoral surgical approach. For prophylaxis against heterotopic ossification we used perioperative irradiation and indomethacin. Indomethacin was given as daily doses of 25 mg started within 24 hours of operation and continued for four weeks. Irradiation was by either 1200 cGy in three daily doses or by a single 700 cGy dose on the first postoperative day. All patients were followed for at least one year postoperatively and the severity of heterotopic ossification was recorded using the Brooker classification and correlated with hip mobility. The combination therapy proved very effective; 44 fractures showed no heterotopic ossification and ten showed Brooker class I. The functional results were good and there were no complications of this therapy. Irradiation with 1200 cGy did not appear to offer any therapeutic advantage over the 700 cGy dose.

Using finely reconstructed helical pelvis CT scans of ninety-three cases and image analysis software, we define the “Safe Zone” for the extra-articular placement of screws during internal fixation of the acetabulum, using a Stoppa approach. Screws should be at most: 11mm from the top of the Sciatic notch, 23mm from the tip of the Ischial Spine, and at most 5mm posterior to the top of the Obturator canal, along the pelvic brim.

The purpose of this study was to identify a “safe zone” in the inner pelvis, to allow extra-articular screw placement using the Stoppa approach.

Acetabulum internal fixation screws can safely (extra-articular position) be placed through the Stoppa approach using three identifiable landmarks.

Surgeons can use these identifiable anatomic landmarks for the safe placement of screws along the inner aspect of the acetabulum.

Study Population: males:females 47%:53%, mean age: 51,3yrs (18–88). Reference measurements (means): Femoral Head (FH): 45,5mm (36–6), Inter-SI joint:177,9mm (102–34). Safe distance to joint: 1) from Sciatic notch: 11mm; 2) from Ischial Spine: 23mm; 3) from Obturator roof: 5mm. The Ischial Spine Distance (ISD) showed clustering (p< 0.05) into two groups according to Femoral Head diameter: FH< 47mm: Safe ISD=23mm ; FH≥47mm: Safe IS=28mm.

Ninety-three Helical Pelvis CT scans with fine reconstruction were done between July 1, 1999-June 30, 2000. Axial images were analyzed using GE Vox Tool® v.3.0.3 image analysis software. The femoral head diameter and the Inter-SI joint distance were used as reference. The distance between three identifiable bony landmarks and the point which would allow the placement of a 4mm screw outside the hip joint were measured. Inter and Intra-observer reliability study showed a difference < 1mm in > 90% of cases.

Surgical approaches which avoid extensive dissection and manipulation of the gluteal musculature are gaining in popularity. The Stoppa is such an approach which gives access to the medial acetabular wall and to the inner pelvis from the SI joint to the symphysis along the pelvic brim. This blind approach does not allow visualisation of the joint and confirmation of screw placement. The present paper offers surgeons these reference points.

Objective

The optimal positioning of the acetabular component is a relevant prognostic factor in total hip arthroplasty (THA). Because of substantial errors of manual technique in cup placement even with experienced surgeon, computer aided navigation system has been developed in recent years. However, existence of the hardware around acetabulum likely deteriorates the accuracy of the navigation system, namely in revision THA case and postoperative status of pelvic fracture. Here we report a case who we successfully performed THA using CT based navigation system although there were multiple hardware around acetabulum due to osteosynthesis for the previous pelvic fracture.

Aims. The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture. Methods. All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT. Results. A total of 191 patients were included. A DVT was found preoperatively in 12 patients (6.3%), of which six were proximal. A postoperative DVT was found in 42 patients (22%), of which 27 were proximal. Eight patients (4.2%) had a PE, which was secondary to a DVT in three. None of the 12 patients in whom a vena cava filter was implanted prophylactically had a PE. Multivariate logistic regression analysis indicated that the association with the need for spinal surgery (odds ratio (OR) 19.78 (95% confidence interval (CI) 1.12 to 348.08); p = 0.041), intramedullary nailing of a long bone fracture (OR 4.44 (95% CI 1.05 to 18.86); p = 0.043), an operating time > two hours (OR 3.28 (95% CI 1.09 to 9.88); p = 0.035), and additional trauma surgery (OR 3.1 (95% CI 1.03 to 9.45); p = 0.045) were statistically the most relevant independent predictors of a postoperative DVT. Conclusion. The acknowledgement of the risk factors for the development of a DVT and their weight is crucial to set a threshold for the index of suspicion for this diagnosis by medical staff. We suggest the routine use of the DUS screening for DVT in patients with a pelvic and/or acetabular fracture before and six to ten days after surgery. Cite this article: Bone Joint J 2022;104-B(2):283–289

The February 2024 Trauma Roundup. 360. looks at: Posterior malleolus fractures: what about medium-sized fragments?; Acute or delayed total hip arthroplasty after acetabular fracture fixation?; Intrawound antibiotics reduce the risk of deep infections in fracture fixation; Does the VANCO trial represent real world patients?; Can a restrictive transfusion protocol be effective beyond initial resuscitation?; What risk factors result in avascular necrosis of the talus?; Pre-existing anxiety and mood disorders have a role to play in complex regional pain syndrome; Three- and four-part proximal humeral fractures at ten years

Current treatment options for displaced acetabular fractures in elderly patients include non-surgical management, surgical fixation and surgical fixation with simultaneous hip replacement, the so-called “fix-and-replace”™. There remains a paucity of evidence to guide surgeons in decision making for these difficult injuries. The aim of this study was to assess the feasibility of performing an appropriately powered RCT between treatment options for acetabular fractures in older patients. This was an NIHR funded feasibility triple-arm RCT with participation from 7 NHS MTCs. Patients older than 60 were recruited if they had an acetabular fracture deemed sufficiently displaced for the treating surgeon to consider surgical fixation. Randomisation was performed on a 1:1:1 basis. The three treatment arms were non-surgical management, surgical fixation and fix-and-replace. Feasibility was assessed by willingness of patients to participate and clinicians to recruit, drop out rate, estimates of standard deviation to inform the sample size calculation for the full trial and completion rates to inform design of a future definitive trial. EQ-5D was the primary outcome measure at 6 months, OHS and Disability Rating Index were secondary outcome measures. Of 117 eligible patients, 60 were randomised whilst 50 declined study participation. Nine patients did not receive their allocated intervention. Analysis was performed on an intention to treat basis. During the study period 4 patients withdrew before final review, 4 patients died and 1 was lost to follow-up. The estimated sample size for a full scale study was calculated to be 1474 participants for an EQ-5D MCID of 0.06 with a power of 0.8. This feasibility study suggests a full scale trial would require international collaboration. This study also has provided observed safety data regarding mortality and morbidity for the fix-and-replace procedure to aid surgeons in the decision-making process when considering treatment options

Major orthopaedic fractures are an independent risk factor for the development of venous thromboembolism (VTE), which are significant causes of preventable morbidity and mortality in trauma patients. Despite thromboprophylaxis, patients who sustain a pelvic or acetabular fracture (PA) continue to have high rates of VTE (12% incidence). Thrombelastography (TEG) is a whole-blood, point-of-care test which provides an overview of the clotting process. Maximal amplitude (MA), from TEG analysis, is the measure of clot strength and values ≥65mm have been used to quantify hypercoagulability and increased VTE risk. Therefore, the primary aim was to use serial TEG analysis to quantify the duration of hypercoagulability, following surgically treated PA fractures. This is a single centre, prospective cohort study of adult patients 18 years or older with surgically treated PA fractures. Consecutive patients were enrolled from a Level I trauma centre and blood draws were taken over a 3-month follow-up period for serial TEG analysis. Hypercoagulability was defined as MA ≥65mm. Exclusion criteria: bleeding disorders, active malignancy, current therapeutic anticoagulation, burns (>20% of body surface) and currently, or expecting to become pregnant within study timeframe. Serial TEG analysis was performed using a TEG6s hemostasis analyzer (Haemonetics Corp.) upon admission, pre-operatively, on post-operative day (POD) 1, 3, 5, 7 (or until discharged from hospital, whichever comes sooner), then in follow-up at 2-, 4-, 6-weeks and 3-months post-operatively. Patients received standardized thromboprophylaxis with low molecular weight heparin for 28 days post-operatively. VTE was defined as symptomatic DVT or PE, or asymptomatic proximal DVT, and all participants underwent a screening post-operative lower extremity Doppler ultrasound on POD3. Descriptive statistics were used to determine the association between VTE events and MA values. For the primary outcome measure, the difference between the MA threshold value (≥65mm) and serial MA measures, were compared using one-sided t-tests (α=0.05). Twenty-eight patients (eight females, 29%) with a mean age of 48±18 years were included. Acetabular fractures were sustained by 13 patients (46%), pelvic fractures by 14 patients (50%), and one patient sustained both. On POD1, seven patients (25%) were hypercoagulable, with 21 patients (78%) being hypercoagulable by POD3, and 17 patients (85%) by POD5. The highest average MA values (71.7±3.9mm) occurred on POD7, where eight patients (89%) were hypercoagulable. At 2-weeks post-operatively, 16 patients (94%) were hypercoagulable, and at four weeks, when thromboprophylaxis was discontinued, six patients (40%) remained hypercoagulable. Hypercoagulability persisted for five patients (25%) at 6-weeks and for two patients (10%) by three months. There were six objectively diagnosed VTE events (21.4%), five were symptomatic, with a mean MA value of 69.3mm±4.3mm at the time of diagnosis. Of the VTE events, four occurred in participants with acetabular fractures (three male, 75%) and two in those with pelvic fractures (both males). At 4-weeks post-operatively, when thromboprophylaxis is discontinued, 40% of patients remained hypercoagulable and likely at increased risk for VTE. At 3-months post-operatively, 10% of the cohort continued to be hypercoagulable. Serial TEG analysis warrants further study to help predict VTE risk and to inform clinical recommendations following PA fractures

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome. This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF. Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome. The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF

The December 2022 Trauma Roundup. 360. looks at: Anterior approach for acetabular fractures using anatomical plates; Masquelet–Ilizarov for the management of bone loss post debridement of infected tibial nonunion; Total hip arthroplasty – better results after low-energy displaced femoral neck fracture in young patients; Unreamed intramedullary nailing versus external fixation for the treatment of open tibial shaft fractures in Uganda: a randomized clinical trial; The Open-Fracture Patient Evaluation Nationwide (OPEN) study: the management of open fracture care in the UK; Cost-utility analysis of cemented hemiarthroplasty versus hydroxyapatite-coated uncemented hemiarthroplasty; Unstable ankle fractures: fibular nail fixation compared to open reduction and internal fixation; Long-term outcomes of randomized clinical trials: wrist and calcaneus; ‘HeFT’y follow-up of the UK Heel Fracture Trial

The April 2024 Trauma Roundup. 360. looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?

Displaced acetabular fractures in the older patient present significant treatment challenges. There is evidence the morbidity and mortality associated is similar to the fractured neck of femur cohort. Despite growing literature, there remains significant controversy regarding treatment algorithms; varying between conservative management, to fracture fixation and finally surgical fixation and simultaneous THA to allow immediate full weight bearing. £250k NIHR, Research for Patient Benefit (Ref: PB-PG-0815-20054). Trial ethical approval (17/EE/0271). After national consultation, 3 arms included; conservative management, fracture fixation and simultaneous fracture fixation with THA. Statistical analysis required minimum 12 patients/3 arms to show feasibility, with an optimum 20/arm. Inclusion criteria; patients >60 years & displaced acetabular fracture. Exclusion criteria: open fracture, THA in situ, pre-injury immobility, polytrauma. Primary outcome measure - ability recruit & EQ-5D-5L at 6 months. Secondary outcome measures (9 months); OHS, Disability Rating Index, radiographs, perioperative physiological variables including surgery duration, blood loss, complications and health economics. 11 UK level 1 major trauma centres enrolled into the trial, commenced December 2017. Failure surgical equipoise was identified as an issue regarding recruitment. Full trial recruitment (60 patients) achieved; 333 patients screened. 66% male, median age 76 (range 63–93), median BMI 25 (range 18–37), 87% full mental capacity, 77% admitted from own home. 75% fall from standing height. 60% fractures; anterior column posterior hemi-transverse. Trial feasibility confirmed December 2020. Presented data- secondary outcomes that are statistically significant in improvement from baseline for only the fix and replace arm, with acceptable trial complications. Issues are highlighted with conservative management in this patient cohort. Our unique RCT informs design and sample size calculation for a future RCT. It represents the first opportunity to understand the intricacies of these treatment modalities. This RCT provides clinicians with information on how best to provide management for this medically complex patient cohort

Introduction. Severely comminuted, displaced acetabular fractures with articular impaction in the elderly population present significant treatment challenges. To allow early post-operative rehabilitation and limit the sequelae of immobility, treatment with acute total hip replacement (THA) has been advocated in selected patients. Achieving primary stability of the acetabular cup without early migration is challenging and there is no current consensus on the optimum method of acetabular reconstruction. We present clinical results and radiostereometric analysis of trabecular metal (TM) cup cage construct reconstruction in immediate THA without acetabular fracture fixation. Methods. Between 2011 and 2016, twenty-one acetabular fractures underwent acute THA with a TM cup cage construct. Patient, fracture and surgical demographics were collected. They were followed up for a mean of 24months (range 12–42months). Clinical and patient reported outcome measures were collected at regular post-operative intervals. Radiosterometric analysis (RSA) was used to measure superior migration and sagittal rotation of the acetabular component. Results. Thirteen fractures were classified as anterior column posterior hemi-transverse, two anterior column, two transverse and four associated both column acetabular fractures. There was one case of trochanteric fracture and transient foot drop. Mean Harris Hip Scores at 12months was 79 (range 33–98). The mean proximal migration of the acetabular components at 12months was 0.91mm (range 0.09–5.12 and mean sagittal rotation was 0.52mm (range 0.03–7.35). Conclusion. The TM cup-cage technique requires a single approach and provides immediate cup stability allowing full weight bearing day one post-op. To our knowledge this is the first study to accurately measure cup stability following THA for an acetabular fracture. Our promising early clinical and radiological outcomes suggest this technique may be an alternative to a fix and replace construct for immediate THA for acute acetabular fractures in the elderly

Since 1977 we did implant ceramic on ceramic THR in younger and active population. In 1991 we published (JBJS B N°4) data's in a consecutive group of patients under 50 years of age. What about the same patients for more than 30 years? Eighty-six hips in 75 patients, 41 males 34 females, mean age 43 (18 to 50), mean weight 68 kg (36 to 100), Charnley class: 38 A, 28 (38 hips) B, 9 patients (10 hips) C. Sixty-six primary procedures, 20 revisions (18 failed arthroplasties: 6 THR, 5 resurfacing, four single cup, two hemiarthroplasty, one bipolar), one after acetabular fractures. Four hips previously infected. Eight Patients deceased (8 hips) prosthesis still in place, ten lost to follow-up before 2 years, eight hips in 8 patients were revised before the review, partially followed: from 2 to 20 years: 35, completely followed: 25 hips in 23 patients resuming in: No pain in 20, slight pain in 2, severe disability in 3 not related to the hip, no radiolucent lines in 22, radiolucent lines in 3, no osteolysis in 25. Revision for: early sepsis in one, socket loosening in 8 (3 revisions cases), femoral head fractures in 2: one extra small head (22mm) for Crowe 3 DDH, one fractured at 24 years. Inertness, stability related to fibrous tissue generation, no noise

NICE Guidelines suggest patients should be offered a Total Hip Replacement (THR) rather than Hemiarthroplasty for a displaced intracapsular hip fracture. We investigated outcomes of patients aged 40–65 who received a THR or Hemiarthroplasty following a traumatic intracapsular hip fracture and had either high-risk (Group 1) or low-risk (Group 2) alcohol consumption (>14 or <14 units/week respectively). This was a retrospective study (April 2008 – December 2018) evaluating patients who underwent THR or Hemiarthroplasty in Greater Glasgow and Clyde. Atraumatic injuries, acetabular fractures, patients with previous procedures on the affected side and those lost to follow up were excluded. Analysis of length of admission, dislocation risk, periprosthetic fractures, infection risk, and mortality was conducted between both cohorts. Survival time post-operatively of Group 1 patients with a THR (61.9 months) and Hemiarthroplasty (42.3 months) were comparable to Group 2 patients with a THR (59 months) and Hemiarthroplasty(42.4 months). Group 1 patients with THR had increased risk of dislocation (12.9%; p=0.04) compared to those that received Hemiarthroplasty (2.5%). Group 1 Hemiarthroplasty patients had increased wound infection risk (11.6%) compared to Group 2 (3.7%). In conclusion, we found that amongst our population the life expectancy of a post-operative patient was short irrespective of whether they had high or low-risk alcohol consumption. A hip fracture may represent increased frailty in our study population. The Group 1 THR cohort presented a higher risk of hip dislocation and periprosthetic fracture. With this in mind, Hemiarthroplasty is a more cost-effective and shorter operation which produces similar results

Acetabulum fractures caused by civilian firearms represent a unique challenge for orthopaedic surgeons. Treatment strategies should include the assessment of infection risk due to frequently associated abdominal injuries and maintenance of joint function. Still, internationally accepted treatment algorithms are not available. The aim of the study was to increase knowledge about civilian gunshot fractures of the acetabulum by describing their characteristics and management at a high-volume tertiary hospital. All adult patients admitted to our hospital between January 2009 and December 2022 with civilian gunshot fractures of the acetabulum were included in this descriptive retrospective study. In total our institution treated 301 patients with civilian gunshot fractures of the hip joint and pelvis during the observation period, of which 54 involved the acetabulum. Most patients were young males (88,9%) with a mean age of 29 years. Thirty patients (55,6%) had associated intraabdominal or urological injuries. Fracture patterns were mostly stable fractures with minor joint destruction amenable to conservative fracture treatment (n=48, 88,9%). Orthopaedic surgical interventions were performed in 21 patients (38,9%) with removal of bullets in contact with the hip joint via arthrotomy or surgical hip dislocation as most frequent procedures. Most patients received antibiotics on admission (n=49, 90,7%). Fracture related infections of the acetabulum were noted in six patients (11,1%) while the mortality in the study population was low with one demised patient (1,9%) due to the trauma burden. Most civilian acetabulum gunshot fractures are associated with intraabdominal or urological injuries. In comparison to the literature on extremity gunshot fractures, there is an increased risk of infection in our study population. The decision for surgical wash-out and bullet removal should be based on contamination and anticipated joint destruction, while osteosynthesis or primary arthroplasty are rarely necessary for these injuries

We aimed to investigate the clinical consequences of intraoperative acetabular fractures. Between 2003 and 2012, a total of 3391 cementless total hip arthroplasties (THA) were performed at the Dept. of Orthopaedics, Innsbruck Medical University. Of those, a total of 160 patients underwent a CT scan within 30 days postoperatively. The scans of 44 patients were not suitable for analyse due to thick scan layers. Of the remaining 116 patients, 76 had a fracture. Reasons for CT-scans were suspected bleeding, hip pain, abdominal symptoms, etc. The fractures included 59 isolated acetabular fractures, the rest of fractures was in the superior or inferior pubic ramus or the tuber ischiadicum. Four cases out of the 59 acetabular fractures underwent revision surgery due to periprosthetic joint infection after 0, 2, 10 and 23 months. Four patients underwent revision due to cup loosening after 13 and 14 days as well as after 16 and 24 months. Of those, three showed a central acetabular fracture with protrusion. In 33 of the remaining 51 patients, a minimum of 3 x-rays was available for migration analysis with EBRA. In 6 patients, the x-rays were not comparable to each other. The 27 remaining acetabular fractures were categorised according to AO classification in 62A1 (1; posterior wall), 62A2 (16; posterior column), 62A3 (6; anterior wall), and others (4). Four hips showed initial migration of more than 3 mm in the first 6 months. One had a central fracture, and was lost for follow-up after 8 months. Two had an anterior column fracture and showed no further migration after 6 months. One showed also a radiolucency of more than 2 mm in all 3 zones and was lost for follow-up. We conclude that intraoperative acetabular fractures occur more often than we expected. Fractures of the acetabular ring involving one column do not seem to compromise the long-term stability of the implant. Central fractures required revision or showed loosening proved by high cup migration

Aims. To evaluate the outcomes of cemented total hip arthroplasty (THA) following a fracture of the acetabulum, with evaluation of risk factors and comparison with a patient group with no history of fracture. . Patients and Methods. Between 1992 and 2016, 49 patients (33 male) with mean age of 57 years (25 to 87) underwent cemented THA at a mean of 6.5 years (0.1 to 25) following acetabular fracture. A total of 38 had undergone surgical fixation and 11 had been treated non-operatively; 13 patients died at a mean of 10.2 years after THA (0.6 to 19). Patients were assessed pre-operatively, at one year and at final follow-up (mean 9.1 years, 0.5 to 23) using the Oxford Hip Score (OHS). Implant survivorship was assessed. An age and gender-matched cohort of THAs performed for non-traumatic osteoarthritis (OA) or avascular necrosis (AVN) (n = 98) were used to compare complications and patient-reported outcome measures (PROMs). Results. The mean time from fracture to THA was significantly shorter for patients with AVN (2.2 years) or protrusio (2.2 years) than those with post-traumatic OA (9.4 years) or infection (8.0 years) (p = 0.03). Nine contained and four uncontained defects were managed with autograft (n = 11), bulk allograft (n = 1), or trabecular metal augment (n = 1). Initial fracture management (open reduction and internal fixation or non-operative), timing of THA (> /< one year), and age (> /< 55 years) had no significant effect on OHS or ten-year survival. Six THAs were revised at mean of 12 years (5 to 23) with ten-year all-cause survival of 92% (95% confidence interval 80.8 to 100). THA complication rates (all complications, heterotopic ossification, leg length discrepancy > 10 mm) were significantly higher following acetabular fracture compared with atraumatic OA/AVN and OHSs were inferior: one-year OHS (35.7 versus 40.2, p = 0.026); and final follow-up OHS (33.6 versus 40.9, p = 0.008). . Conclusion . Cemented THA is a reasonable option for the sequelae of acetabular fracture. Higher complication rates and poorer PROMs, compared with patients undergoing THA for atraumatic causes, reflects the complex nature of these cases. Cite this article: Bone Joint J 2017;99-B:1399–1408

Intraoperative fractures although rare are one of the complications known to occur while performing a total hip arthroplasty (THA). However, due to lower incidence rates there is currently a gap in this area of literature that systematically reviews this important issue of complications associated with THA. Method: We looked into Electronic databases including PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), the archives of meetings of orthopaedic associations and the bibliographies of included articles and asked experts to identify prospective studies, published in any language that evaluated intra-operative fractures occurring during total hip arthroplasty from the year 1950-2020. The screening, data extraction and quality assessment were carried out by two researchers and if there was any discrepancy, a third reviewer was involved. Fourteen studies were identified. The reported range of occurrence of fracture while performing hip replacement surgery was found to be 0.4-7.6%. Major risk factors identified were surgical approaches, Elderly age, less Metaphyseal-Diaphyseal Index score, change in resistance while insertion of the femur implants, inexperienced surgeons, uncemented femoral components, use of monoblock elliptical components, implantation of the acetabular components, patients with ankylosing spondylitis, female gender, uncemented stems in patients with abnormal proximal femoral anatomy and with cortices, different stem designs, heterogeneous fracture patterns and toothed design. Intraoperative fractures during THA were managed with cerclage wire, femoral revision, intramedullary nail and cerclage wires, use of internal fixation plates and screws for management of intra operative femur and acetabular fractures. The main reason for intraoperative fracture was found to be usage of cementless implants but planning and timely recognition of risk factors and evaluating them is important in management of intraoperative fractures. Adequate surgical site exposure is critical especially during dislocation of hip, reaming of acetabulum, impaction of implant and preparing the femoral canal for stem insertion. Eccentric and increased reaming of acetabulum to accommodate a larger cup is to be avoided, especially in females and elderly patients as the acetabulum is thinner. However, this area requires more research in order to obtain more evidence on effectiveness, safety and management of intraoperative fractures during THA