What is the optimal management approach for acetabular fractures?

Management of Acetabular Fractures

Open reduction and internal fixation (ORIF) through a single surgical approach is the primary treatment for displaced acetabular fractures in younger patients, while acute total hip arthroplasty combined with ORIF should be considered for elderly patients with joint impaction or femoral head damage. 1, 2

Initial Assessment and Surgical Timing

• Surgery should be performed within 2 weeks of injury, with 80% of cases ideally operated within this timeframe to optimize outcomes 3
• Preoperative planning requires plain radiographs and CT scanning with 3D reconstructions to assess fracture pattern, joint impaction, and femoral head damage 1
• Look specifically for the "gull sign" (acetabular dome impaction) or femoral head impaction on imaging—these indicate poor prognosis with isolated ORIF in elderly patients 1

Surgical Decision Algorithm

For Younger Patients (<65 years)

• ORIF is the standard treatment for displaced fractures, aiming for anatomic reduction with ≤2mm gap 4, 5
• 92% of cases can be managed through a single surgical approach: 3
  • Anterior ilioinguinal approach for anterior column/wall fractures
  • Posterior Kocher-Langenbeck approach for posterior column/wall fractures
• Only 5-6% require extensile triradiate or combined approaches 3
• Percutaneous fixation is appropriate for non-displaced or minimally displaced fractures, particularly in obese or osteoporotic patients 4

For Elderly Patients (≥65 years)

• Combined hip procedure (ORIF + acute THA) is preferred when: 1, 2
  • Joint impaction of acetabular dome is present (gull sign)
  • Femoral head impaction or damage exists
  • Severe comminution compromises joint surface
• Isolated ORIF in elderly patients has high failure rates: 16.5-45% require delayed THA conversion 2
• Use uncemented acetabular components with multiple screw fixation after restoring columnar continuity with plates 1
• Cemented acetabular components have high failure rates and should be avoided 1

Technical Surgical Principles

• Anatomic reduction (0-1mm displacement) is critical: gaps >2mm predict poor outcomes and post-traumatic arthritis 4, 5
• Plate the posterior column to provide continuity of the acetabular dome, quadrilateral plate, and ischium—this facilitates stable component implantation 1
• Use liberal autograft from the resected femoral head for acetabular defects 1
• Intramedullary cannulated screws are recommended for percutaneous techniques 4

Postoperative Weight-Bearing Protocols

After Isolated ORIF

• No immediate full weight-bearing is permitted 2
• Partial weight-bearing for 6-12 weeks is recommended in 62% of protocols 2
• This prolonged restriction aims to protect fixation but delays functional recovery 2

After Combined Hip Procedure (ORIF + THA)

• Immediate full weight-bearing is allowed in 53% of protocols, enabling earlier mobilization 2
• Superior functional outcomes with mean Harris Hip Scores of 70-92 points versus 63-82 for isolated ORIF 2
• Earlier independent ambulation and higher patient satisfaction (74-90%) 2

Expected Outcomes and Complications

Isolated ORIF Results

• Congruent reduction achieved in 89% of cases 3
• Clinical outcomes: 36% excellent, 52% good, 10% poor 5
• Deep infection rate: 2.7% 3
• Heterotopic ossification grade III: 4.1% 3
• Average Harris Hip Score: 85 at 3.5 years follow-up 3

Combined Hip Procedure Complications

• Dislocation risk: 8-11% 2
• Implant loosening: up to 18% 2
• These orthopedic complications are higher than isolated ORIF but offset by superior function 2

Risk Factors for Poor Outcomes

The following predict unsatisfactory results and should trigger consideration of primary arthroplasty: 5

• Age >55 years
• Delay >24 hours for hip dislocation reduction
• Residual fracture gap >1cm
• Severe intraarticular comminution

Mortality Considerations

• 1-year mortality: 0-25% for ORIF, 0-14% for combined procedures 2
• Long-term mortality increases dramatically: up to 42% at 5 years for ORIF, up to 70% for combined procedures 2
• This reflects the frailty of the elderly population rather than surgical technique 2

Critical Pitfalls to Avoid

• Do not use cemented acetabular components in acute fracture settings—failure rates are unacceptably high 1
• Do not attempt isolated ORIF in elderly patients with joint impaction—conversion to THA is nearly inevitable 1
• Postoperative CT is more accurate than plain radiographs: 44 of 59 patients (75%) had fracture gaps ≥2mm on CT despite appearing anatomic on X-ray 5
• Hardware that doesn't interfere with component placement can be left in situ during delayed THA 1