What is the treatment approach for a patient with an acetabulum fracture?

Acetabulum Fracture Treatment

For displaced acetabular fractures in younger patients, open reduction and internal fixation (ORIF) with anatomic reduction is the definitive treatment, while elderly patients (>65 years) with joint impaction should undergo primary total hip arthroplasty (THA) rather than ORIF. 1, 2, 3

Treatment Algorithm Based on Patient Age and Fracture Characteristics

Younger Patients (<65 years)

• Displaced fractures in the weight-bearing area require ORIF to restore congruity and stability of the hip joint. 2, 4
• The goal is anatomic reduction—anything less than perfect reduction compromises outcomes. 2, 5, 4
• Non-displaced fractures or those with maintained congruence between the femoral head and acetabular roof may be managed conservatively. 4

Critical decision point: Total incongruence (fragments separated from femoral head on all three standard radiographs) mandates operative treatment. 4

Elderly Patients (≥65 years)

• Primary THA is preferred over ORIF when joint impaction is present (the "gull sign" on imaging) or when femoral head impaction exists. 6, 3
• ORIF attempts in elderly patients with joint impaction have demonstrated poor outcomes. 3
• THA allows immediate postoperative mobilization with full weight-bearing, which is critical for preventing recumbency complications in this population. 6

Preoperative Evaluation

• Obtain three standard radiographic views (AP pelvis, obturator oblique, iliac oblique) to identify fracture type. 5
• CT scan with 3D reconstruction is essential for detailed assessment of cartilage lesions, fracture configuration, and surgical planning. 1, 3, 5
• These imaging modalities are complementary, not redundant—each provides unique information necessary for surgical planning. 5

Surgical Approach Selection for ORIF

• The Kocher-Langenbeck (posterior) approach is used for posterior column and posterior wall fractures. 5
• The ilioinguinal (anterior) approach is used for anterior column and anterior wall fractures. 5
• Extended approaches carry higher complication rates and should be reserved for complex fractures not amenable to standard approaches. 5

Common pitfall: Attempting ORIF through an inadequate approach leads to suboptimal reduction. The fracture type dictates the approach, not surgeon preference. 5, 4

Technical Considerations for THA in Acute Fracture

• Restore columnar continuity first using plates before acetabular component implantation. 3
• Plating the posterior column provides continuity of the acetabular dome, quadrilateral plate, and ischium, facilitating stable component fixation. 3
• Use uncemented acetabular components with multiple screw fixation—cemented components have high failure rates in this setting. 3
• Antiprotrusion cages may be necessary for severe bone loss or instability. 6, 3
• Liberal autograft from the resected femoral head should fill acetabular defects. 3
• Average surgical time is 154 minutes, and mobilization with full weight-bearing is typically possible within 10 days. 6

Postoperative Management

• Active rehabilitation requires stable fracture fixation. 5
• For ORIF patients, weight-bearing restrictions depend on fracture stability and fixation quality. 5
• For THA patients, immediate full weight-bearing mobilization is the primary advantage and should be implemented. 6
• Monitor for complications including sciatic nerve palsy (Kocher-Langenbeck approach), vascular injury (ilioinguinal approach), avascular necrosis, and heterotopic ossification. 5

Special Considerations

• Open pelvic fractures with acetabular involvement have >50% mortality and require management in specialized referral centers with multidisciplinary teams. 1
• For pathologic acetabular fractures from malignancy, prosthetic replacement with curettage, protrusio cup, cement, and pin/screw fixation provides predictable pain relief. 1
• Minimally invasive techniques (percutaneous cementoplasty, osteosynthesis) are options for patients with limited life expectancy or those unfit for major surgery. 1

Outcomes

• With anatomic ORIF reduction, 74-85% of patients achieve excellent or good functional results. 5
• Poor results correlate directly with residual fracture displacement or perioperative complications. 2
• In elderly patients treated with THA and antiprotrusion cage, 70% achieve full weight-bearing within 10 days, and most regain pre-injury mobility. 6