What is the treatment for intraoperative acetabular fracture during total hip arthroplasty (THA)?

From the Guidelines

Intraoperative acetabular fractures during total hip arthroplasty require immediate assessment and management based on fracture characteristics, with the goal of minimizing morbidity, mortality, and optimizing quality of life.

Treatment Approach

For stable, non-displaced fractures, protected weight-bearing for 6-12 weeks with close radiographic monitoring is recommended, while continuing with the primary implant 1. For unstable or displaced fractures, surgical fixation with plates and screws is necessary, followed by either continuing with the primary implant if stability can be achieved or converting to a cage construct or revision components with augments for better fixation.

Intraoperative Management

Intraoperatively, the surgeon should obtain multiple fluoroscopic views to assess fracture extent and stability, and may need to adjust component positioning or use specialized implants like jumbo cups or trabecular metal components to achieve stability.

Postoperative Care

Postoperatively, patients typically require protected weight-bearing for 6-12 weeks depending on fracture severity and fixation quality. These fractures occur due to excessive reaming, press-fit cup impaction, or bone quality issues, particularly in osteoporotic patients.

Prevention Strategies

Prevention strategies include careful preoperative planning, gentle reaming techniques, appropriate implant sizing, and consideration of cemented components in high-risk patients with poor bone quality. The most recent and highest quality study 1 supports these recommendations, prioritizing morbidity, mortality, and quality of life as the primary outcomes.

From the Research

Treatment of Intraoperative Acetabular Fracture

The treatment of intraoperative acetabular fracture during total hip arthroplasty (THA) depends on the timing of the diagnosis and the stability of the implants.

• Fractures detected intraoperatively should be treated with appropriate stabilisation 2.
• The stability of the implants as well as the fracture pattern determine whether a conservative treatment is initially feasible 2.
• Most acetabular fractures diagnosed intraoperatively are to be treated with a multi-hole cup, with additional screws anchoring in the different acetabular regions 2.
• In cases of large posterior wall fragments or pelvic discontinuity, plate osteosynthesis of the posterior column is indicated 2.
• Alternatively, cup-cage reconstruction can be utilised 2.

Surgical Procedures

Various surgical procedures can be carried out to treat intraoperative acetabular fractures, including:

• Supplemental screw fixation 3, 4
• Steel plate fixation 3
• Use of femoral heads as a graft 3
• Replacement of the original cup with a design that allows for supplemental screw fixation 4

Outcomes

The outcomes of intraoperative acetabular fractures can be affected by various factors, including:

• The anatomic location of the fracture 3, 4
• The cause of the fracture 3, 4
• The treatment method used 3, 4
• The presence of associated complications 5
• The functional outcomes can be poor, with a high risk of associated complications 5