What are the treatment options for a 1-year-old traumatic acetabulum (hip socket) fracture in an adult patient with ongoing symptoms?

Management of 1-Year-Old Acetabular Fracture in Adults with Ongoing Symptoms

For an adult with persistent symptoms one year after acetabular fracture, total hip arthroplasty (THA) is the definitive treatment option, as it provides predictable pain relief and functional restoration when post-traumatic arthritis has developed. 1, 2

Initial Assessment

Diagnostic Evaluation

• Obtain comprehensive radiographic evaluation including AP pelvis and lateral hip views to assess current joint congruity, degree of post-traumatic arthritis, and bone integrity 1
• CT scan is essential to comprehensively diagnose the extent of bone lesions, residual displacement, and associated structural abnormalities that may have developed over the year 1
• Evaluate for specific complications including:
  • Post-traumatic arthritis (most common at 1 year post-injury) 2, 3
  • Avascular necrosis of the femoral head 3
  • Residual incongruence between acetabulum and femoral head 4, 5
  • Heterotopic ossification 2

Patient Factors to Document

• Current functional status: mobility level, use of assistive devices, ability to perform activities of daily living 6, 7
• Pain severity and impact on quality of life 7
• Comorbidities including diabetes, kidney disease, cardiac conditions that affect surgical candidacy 6
• Bone quality assessment for surgical planning 8

Treatment Algorithm Based on Findings

If Post-Traumatic Arthritis is Present (Most Likely at 1 Year)

Primary recommendation: Total Hip Arthroplasty 1, 2

Evidence Supporting THA:

• THA after acetabular fracture provides excellent outcomes with mean Harris Hip Scores of 84, minimal complications, and no infections or dislocations in specialized series 2
• Superior functional outcomes compared to living with post-traumatic arthritis, with 70-92 point Harris Hip Scores reported 9
• Predictable pain relief and return to ambulatory status for patients with established arthritis 1

Technical Considerations:

• Use cementless acetabular component with cemented femoral stem (note: current guidelines strongly support cemented stems in older adults) 6, 2
• Prophylactic low-dose radiation should be administered to prevent heterotopic ossification 2
• Prophylactic antibiotics (gentamicin with cefazolin or vancomycin) within one hour of incision 8, 2
• Expect technical challenges including scarring, contractures, and altered anatomy from previous injury 2, 3

If Residual Displacement Without Severe Arthritis

Consider revision open reduction and internal fixation (ORIF) only if:

• Patient is younger with good bone quality 9, 5
• Significant incongruence is correctable 4, 5
• Joint cartilage is still viable 6, 5

However, at 1 year post-injury, this scenario is uncommon as most symptomatic patients will have developed arthritis 2, 3

Perioperative Management

Anesthesia Selection

• Spinal or general anesthesia are both appropriate 6
• Consider peripheral nerve blocks (fascia iliaca compartment block) for multimodal pain control, particularly in elderly patients 6
• Spinal/epidural may reduce postoperative confusion in older adults 8

Pain Management Protocol

• Multimodal analgesia approach is mandatory 6
• First-line: IV acetaminophen every 6 hours 6
• Add peripheral nerve blocks to reduce opioid consumption 6
• Minimize opioid use with 20-25% dose reduction per decade after age 55 6
• Consider NSAIDs cautiously in severe pain, accounting for renal function and cardiovascular risk 6

VTE Prophylaxis

• Mandatory in all hip surgery patients 6
• Restart anticoagulation (if previously on it) by postoperative day 2 6

Postoperative Rehabilitation

Weight-Bearing Protocol After THA

• Immediate full weight-bearing is permitted in 53% of combined hip procedures (THA with fracture treatment) 9
• This contrasts sharply with isolated ORIF, which requires 6-12 weeks of partial weight-bearing 9
• Early mobilization improves outcomes and reduces complications 6, 9

Expected Outcomes

• Length of stay: 8-25 days (mean 17 days) for combined procedures 9
• Functional recovery: Mean Harris Hip Scores of 70-92 points 9
• Patient satisfaction: 74-90% 9
• Independent ambulation: Earlier than with ORIF alone 9

Potential Complications and Monitoring

THA-Specific Risks

• Dislocation rate: 8-11% (higher than primary THA due to altered anatomy) 9
• Implant loosening: up to 18% (particularly acetabular component in compromised bone) 9
• Infection risk: Minimized with prophylactic antibiotics 8, 2
• Nerve palsy: Transient in <5% of cases 2

Long-Term Mortality Considerations

• 1-year mortality: 0-14% for THA after acetabular fracture 9
• 5-year mortality can reach 70% in elderly patients, reflecting underlying comorbidities rather than surgical complications 9

Critical Pitfalls to Avoid

1. Do not delay definitive treatment if post-traumatic arthritis is established—conservative management will not improve outcomes at this stage 2, 5

2. Do not attempt revision ORIF if significant arthritis has developed—this leads to poor outcomes and delays appropriate THA 4, 5

3. Do not underestimate surgical complexity—these cases require experienced surgeons familiar with altered anatomy and scarring 2, 3

4. Do not restrict weight-bearing unnecessarily after THA—this delays rehabilitation and increases complications 9

5. Do not skip orthogeriatric co-management in elderly patients—this reduces complications and optimizes outcomes 6, 7

Special Considerations for Elderly Patients

• Age alone should not exclude THA if patient was previously independent and has rehabilitation potential 6, 7
• Bone health optimization is essential: evaluate for osteoporosis, supplement calcium/vitamin D, consider bisphosphonates 7
• Fall prevention strategies must be implemented given the initial traumatic mechanism 7
• Comprehensive geriatric assessment should address malnutrition, anemia, and cardiac/pulmonary optimization 7