Primary Treatment for Pelvic Acetabular Surgery
Open reduction and internal fixation (ORIF) is the primary treatment for displaced acetabular fractures, with the goal of achieving anatomical reduction to restore hip joint congruity and stability. 1
Treatment Decision Framework
For Acute Traumatic Acetabular Fractures
Surgical indications:
- Displaced fractures in the weight-bearing area of the acetabulum require ORIF 1
- The primary goal is anatomical restoration of the acetabular surface—reduction takes priority over minimizing surgical approaches 2
- Non-displaced fractures or those outside weight-bearing zones may be managed non-operatively 1
Surgical approach:
- Open reduction remains the standard of care for most acetabular fractures, as anatomical reconstruction typically requires direct visualization 2
- Experienced surgeons may selectively use percutaneous techniques (anterior column screws, posterior column screws) as adjuncts to open approaches or in specific fracture patterns 2
- The complexity demands that only experienced acetabular surgeons perform these procedures 2, 1
Technical considerations:
- Anatomical reduction is mandatory for optimal outcomes—residual displacement correlates with poor results 1
- Robotic-assisted systems can improve screw placement accuracy and reduce radiation exposure in percutaneous fixation 3
- Combined pelvic ring and acetabular fractures require stabilization of the pelvic ring first, followed by acetabular fixation 4
For Metastatic/Pathologic Acetabular Fractures
Surgical options for cancer patients:
- Hip replacement with specialized techniques provides predictable pain relief and return to ambulation 5, 6
- Curettage with protrusio cup, cement, and pin/screw fixation achieves 76% reduction in narcotic use, though carries 22% complication rate 5
- Saddle prosthesis is an alternative with similar functional improvements but 20% complication rate 5
Patient selection is critical:
- The high morbidity (20-22% complication rate) necessitates careful assessment of life expectancy, mental status, mobility status, and overall medical condition before extensive surgery 5
- Minimally invasive options (percutaneous cementoplasty) should be considered for patients with limited life expectancy or those unfit for major surgery 6
For Revision Arthroplasty with Acetabular Deficiency
Reconstruction strategy:
- Porous-coated acetabular augments are preferred over structural allograft for segmental bone defects 7
- Severe bone loss or pelvic discontinuity may require plating combined with structural allografts, custom components, or reconstructive cages 7
- Antiprotrusio cages have fallen out of favor due to higher failure rates 7
Common Pitfalls to Avoid
- Attempting percutaneous fixation without adequate experience—only surgeons skilled in open acetabular surgery should use minimally invasive techniques 2
- Accepting non-anatomical reduction—even minor displacement in weight-bearing areas leads to poor outcomes 1
- Performing extensive surgery on metastatic disease without considering life expectancy and comorbidities—the 20-22% complication rate demands rigorous patient selection 5
- Fixing acetabulum before stabilizing pelvic ring in combined injuries—pelvic ring stability must be achieved first 4