The Journal of Bone & Joint Surgery

Introduction

After a displaced acetabular fracture, a patient may be predisposed to the development of symptomatic posttraumatic degenerative arthritis of the hip joint or avascular necrosis of the femoral head. In selected patients, a total hip arthroplasty may eventually be necessary irrespective of the method of initial management^1-3. On the basis of a review of the results described by Letournel and Judet² and Matta⁴ and on the basis of our experience, we determined that the likelihood that treatment will culminate in an arthroplasty is related to the initial type of fracture; the magnitude of the provocative force; the age and weight of the patient; and, when the initial management of the fracture was open reduction and internal fixation, the duration of the delay from the injury to the surgical procedure. When the initial acetabular deformity is relatively minor and when the acetabulum unites, especially following nonoperative treatment, a conventional arthroplasty is likely to lead to an uncomplicated recovery and a satisfactory outcome. Nevertheless, in selected cases, one or more complicating factors may be encountered. Following nonoperative treatment of an acetabular fracture, residual displacement may hamper a subsequent arthroplasty because of an occult or frank nonunion of the acetabulum or possibly because of a malunion or a malaligned nonunion⁵. When the initial management of an acetabular fracture was surgical, a belated arthroplasty performed to manage posttraumatic arthritis may be impeded by dense scar tissue, heterotopic bone, avascularity of the hip muscles or the acetabulum, obstructive hardware, or occult infection⁶. On the basis of a review of the few prior studies in the literature^7-10, we found that the overall prognosis for a patient managed with a total hip arthroplasty after an acetabular fracture is less favorable than that for one managed with an arthroplasty performed because of primary degenerative arthritis. In the present study, we address the principal concerns regarding management with total hip arthroplasty after initial treatment of an acetabular fracture with closed or open reduction.

In view of the principal shortcoming of acute management with total hip arthroplasty following an acetabular fracture - namely, the vulnerability to premature failure and the subsequent need for one or more surgical revisions - the potential therapeutic alternatives merit serious consideration. For example, young male laborers or other young, exceptionally active individuals are highly susceptible to premature failure of an arthroplasty¹¹. In such patients, one therapeutic alternative is arthrodesis of the hip, which is mainly indicated if there is relative preservation of the osseous architecture of the hip joint. The other criteria for an arthrodesis - namely, a normal contralateral hip, normal knees, and an asymptomatic lower back - also must be met¹². Currently, most individuals in North America are reluctant to consider arthrodesis. When a patient has avascular necrosis of the femoral head, loss of acetabular bone stock, marked osteoporosis, or a persistent acetabular nonunion that impairs the mechanical stability of a hip fusion and hampers the healing of the bone, the likelihood of achieving a solid fusion is considerably compromised. In such complex cases, the main practical alternative is a resection arthroplasty, with or without the use of a cement spacer¹³.

Certain other symptomatic acetabular fractures may be associated with secondary problems that can be addressed by reconstruction of the hip, thus preserving the hip as a functional joint. Examples of the problems include heterotopic bone leading to hip stiffness; symptoms related to the hardware; a symptomatic nonunion or malunion of the acetabulum and/or hemipelvis; and, occasionally, a localized and indolent infection. In each of these situations, all relevant diagnostic clinical and radiographic methods are used in an attempt to determine whether the hip joint has intact and congruent bearing surfaces. Whenever it is technically possible, and especially in a younger patient, every attempt should be made to salvage a functional hip joint¹⁴.

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Fig. 1-A:: Figs. 1-A, 1-B, and 1-C: The structural importance of acetabular defects is related to their size, location, and characterization as a cavitary or segmental lesion.
Fig. 1-A: Oblique three-dimensional computed tomographic scan, made one year after a fracture-dislocation of the posterior wall, showing a large segmental defect of the posterior wall secondary to failed fixation.

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Fig. 1-B:: Anteroposterior radiograph of a hip, made two years after a transtectal transverse fracture that was treated nonoperatively, showing a central segmental defect of moderate size with a principal axis of more than ten millimeters but less than twenty-five millimeters.

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Fig. 1-C:: Anteroposterior radiograph of a pelvis, made two years after a transtectal T-type fracture that was treated nonoperatively, showing progression to a large central segmental defect with a principal axis of approximately fifty millimeters.

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Fig. 2-A:: Figs. 2-A and 2-B: A forty-eight-year-old man sustained a T-type acetabular fracture, which was managed with limited internal fixation. Subsequent symptomatic posttraumatic arthritis was complicated by an excessively large superocentral acetabular defect and necrotic bone in the roof. Three years after the injury, as part of a total hip arthroplasty, the necrotic bone was removed and a structural autograft from the femoral head was used to obliterate the acetabular defect.
Fig. 2-A: Anteroposterior radiograph of the right hip, made three years after the injury, showing the large acetabular defect.

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Fig. 2-B:: Anteroposterior radiograph made after the total hip arthroplasty, showing the large defect obliterated by a jumbo cup.

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Fig. 3-A:: Figs. 3-A through 3-D: Illustrations showing the surgical approaches commonly used in total hip arthroplasty for late reconstruction of acetabula with various defects and accompanying deformities.
Fig. 3-A: The modified Hardinge (anterolateral) incision is useful for hips with posttraumatic arthritis, cavitary lesions, or most limited segmental defects, including ones that involve the posterior wall. Our preferred modification of the approach includes an orientation of 30 degrees from the long axis of the limb so that more direct visualization of the acetabulum is achieved with a shorter incision.

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Fig. 3-B: The Kocher-Langenbeck incision is useful for fractures involving the posterior wall and column.

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Fig. 3-C: The modified triradiate incision, with preservation of the greater trochanter, is an extensile approach that is useful for complete visualization of both the anterior and posterior columns and the hip joint. The incision is appropriate for exposure of a large central defect, a displaced ipsilateral sacroiliac joint, or a hip with grade-IV heterotopic bone that completely surrounds the hip joint.

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Fig. 3-D: The limited extended iliofemoral incision is an extensile approach that is useful for visualization of the entire hemipelvis and allows for a corrective pelvic osteotomy. The approach is modified by extending the incision to the posterior inferior iliac spine and by preserving the insertions of the gluteal muscles and piriformis tendons on the greater trochanter.

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Fig. 4-A:: Figs. 4-A, 4-B, and 4-C: A forty-one-year-old pilot sustained a displaced iliac-wing, or so-called crescent, fracture of the left hip and a T-type acetabular fracture of the right hip in a free fall in his helicopter from 200 feet (sixty-one meters). Two years after nonoperative treatment, he was referred to us with bilateral pelvic pain and a persistent and highly displaced nonunion of both the left iliac fracture and the right acetabular fracture. A partial realignment and stabilization of the left hemipelvis was performed with a right total hip arthroplasty and open reduction and internal fixation of the right acetabulum. In order to improve the patient's sitting balance, the right ischial tuberosity was osteotomized and partly resected so that his weight rested on the inferior end of the posterior column.
Fig. 4-A: A three-dimensional computed tomography scan, made at the time of presentation, showing a persistent vertical and rotational deformity of the left hemipelvis and a displaced nonunion of the right T-type acetabular fracture with distal displacement of the inferior half of the acetabulum.

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Fig. 4-B:: Postoperative anteroposterior radiograph showing a partial correction of the left pelvic deformity and a right cementless total hip replacement with immobilization of the acetabulum.

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Fig. 4-C:: Anteroposterior radiograph of the right hip, made eleven years after the arthroplasty, showing a successful long-term result. The patient had no pain.

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Fig. 5:: A T-type fracture of the posterior wall that initially was managed nonoperatively progressed to a nonunion with deformity and degenerative change. Two years later, the posterior column was stabilized, through a Kocher-Langenbeck approach, with a reconstruction plate while the defective wall was replaced with a precisely fitting structural autograft and lag screws. This intraoperative photograph was made after a metal-backed cup was secured to the pelvis while the autograft was secured with multiple screws.

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Fig. 6-A:: Figs. 6-A and 6-B: A twenty-eight-year-old man sustained a transverse fracture of the posterior wall of the left acetabulum. Open reduction and internal fixation was performed with use of a triradiate incision. Within two weeks, the posterior wall fragment had displaced; subsequently, the hip progressed to posttraumatic arthritis with grade-IV heterotopic bone formation. Two years later, a total hip arthroplasty was performed and augmented with a MÂ¸ller ring to stabilize the wall defect.
Fig. 6-A: Anteroposterior radiograph, made two years after the open reduction and internal fixation, showing grade-IV heterotopic bone formation and a fusion of the hip.

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Fig. 6-B:: Anteroposterior radiograph, made five years after the total hip arthroplasty, showing stable fixation of the ring along with a cemented polyethylene cup and a cementless stem.

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Fig. 7-A:: Figs. 7-A, 7-B, and 7-C: Drawings showing multiple designs of cages with diverse extension plates that are available for use with a cemented cup.
Fig. 7-A: MÂ¸ller ring with a smaller posterosuperior flange.

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Fig. 7-B:: Ganz ring with a superior flange and an inferior hook for anchorage in the obturator foramen.

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Fig. 7-C:: Burch-Schneider cage with large superior and inferior flanges for anchoring screws.

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Fig. 8-A:: Figs. 8-A, 8-B, and 8-C: A fifty-three-year-old man who had a fracture of the posterior wall was managed with an acute open reduction and internal fixation with use of a plate. Within two weeks, the fixation failed, with the initiation of rapid, abrasive destruction of the femoral head. When the patient was referred to us four weeks after the injury, a hybrid total hip arthroplasty was performed with a structural autograft from the femoral head to buttress the posterior wall.
Fig. 8-A: Anteroposterior radiograph of the right hip, made at the time of the injury, showing the fracture-dislocation of the posterior wall.

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Fig. 8-B:: Transaxial computed tomographic scan, made four weeks after the injury, showing erosive damage to more than 30 percent of the femoral head. This finding was not visualized on plain radiographs made at that time.

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Fig. 8-C:: Iliac oblique radiograph, made after the total hip arthroplasty, showing the structural autograft secured with two cancellous screws.

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Fig. 9-A:: Figs. 9-A and 9-B: A thirty-five-year-old man sustained a fracture of the posterior wall and posterior column of the right acetabulum and was managed initially with limited internal fixation. The fixation rapidly failed, which provoked secondary degenerative change. Two years later, the patient was referred to us with marked erosive damage to the femoral head, an absent posterior wall, and a partial defect of the posterior column. A total hip arthroplasty with a custom cup that had a large posterior flange with drill-holes to permit effective screw fixation to the pelvis was performed.
Fig. 9-A: Transaxial three-dimensional computed tomographic reconstruction with a template of the custom cup.

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Fig. 9-B:: Anteroposterior radiograph of the right hip, made six years after the total hip arthroplasty, showing continued stable fixation of the cup in a superior position.

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Fig. 10:: Photograph showing the modular bilobed cup (Mars; Biomet, Warsaw, Indiana), which allows application of a lobe of three different sizes to obliterate corresponding acetabular defects. The polyethylene liner is secured mechanically to the bilobed cup, in contrast to the case with a conventional cage.

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Fig. 11-A:: Figs. 11-A, 11-B, and 11-C: A fifty-six-year-old man who had failure of fixation of a transverse acetabular fracture of the right hip was managed with a total hip arthroplasty with use of central mesh, morselized bone graft, and lag screws.
Fig. 11-A: Anteroposterior radiograph, made before the total hip arthroplasty, showing failure of internal fixation solely with lag screws and marked abrasive destruction of the femoral head.

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Fig. 11-B:: Schematic drawings of the central mesh and morselized impacted bone chips.

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Fig. 11-C:: Obturator oblique radiograph, made after the hybrid total hip arthroplasty, showing a central mesh and a metal-backed cup secured with three screws.

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Fig. 12-A:: Figs. 12-A, 12-B, and 12-C: Cables can be used for reconstruction of the inner pelvic table in a so-called geriatric acetabular fracture pattern in which the quadrilateral plate is displaced medially. As displayed in Fig. 1-C, a sixty-two-year-old woman with osteopenic bone sustained a T-type acetabular fracture with marked displacement of the posterior column, including most of the quadrilateral surface. Following nonoperative treatment, she was seen two years later with marked protrusion of the femoral head through the site of the nonunion. Cables were used to reduce and immobilize the displaced posterior column and to buttress the quadrilateral surface. After the application of a structural femoral head autograft, a hybrid total hip arthroplasty was performed.
Fig. 12-A: Photograph of an intact anatomical pelvic model, showing the position of the cables on the inner pelvic table.

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Fig. 12-B:: Photograph of an intact anatomical pelvic model, showing the position of a cable on the outer pelvic table.

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Fig. 12-C:: Anteroposterior radiograph made after total hip arthroplasty with two cables that buttress the crucial quadrilateral surface.

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Fig. 13:: Increased radiodensity of the acetabular roof on the left side is a subtle but important finding of acetabular avascular necrosis. This twenty-eight-year-old woman sustained a transverse fracture that was managed acutely with open reduction and was managed one year later with removal of the metal. Three years after the injury, a total hip arthroplasty was performed to manage posttraumatic arthritis. Within another two-year period, the patient complained of recurrent hip pain, and an aspiration arthrogram confirmed an aseptically loose cup. This anteroposterior radiograph shows superior migration of the failed cup into the necrotic acetabular roof.

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Fig. 14-A:: Figs. 14-A, 14-B, and 14-C: A twenty-four-year-old woman sustained a fracture of both columns of the left acetabulum, which was initially treated with open reduction through a triradiate approach and dissection on the outer and inner pelvic tables. Six years later, she underwent a total hip arthroplasty without cement to manage posttraumatic arthritis. Within two years, severe aseptic osteolysis of the acetabulum culminated in a transverse dissociation.
Fig. 14-A: Anteroposterior radiograph made ten months after the open reduction and internal fixation.

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Fig. 14-B:: Anteroposterior radiograph made soon after the total hip arthroplasty and six years after the initial injury.

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Fig. 14-C:: Iliac oblique radiograph, made two years after the total hip arthroplasty, showing a completely loose cup and a transverse dissociation secondary to marked osteolysis of the anterior and posterior columns.

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Fig. 15:: Three-dimensional computed tomographic scan of the hip of a seventy-three-year-old woman who had complete, traumatic loss of the posterior acetabular column. This acetabular defect presents one of the most challenging reconstruction problems, as it can be very difficult to achieve a stable acetabular component that will resist the forces that are imposed by sitting and sitting transfers as well as standing and walking.

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TABLE I: Classification of Acetabular Deficiencies in Total Hip Arthroplasty According to the System of the American Academy of Orthopaedic Surgeons21

Type	Deficiency
I	Segmental deficiencies
IA	Peripheral
IB	Central (medial wall absent)
II	Cavitary deficiencies
IIA	Peripheral
IIB	Central (medial wall intact)
III	Combined deficiencies
IV	Pelvic discontinuity
V	Arthrodesis

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TABLE I: Classification of Acetabular Deficiencies in Total Hip Arthroplasty According to the System of the American Academy of Orthopaedic Surgeons21

Type	Deficiency
I	Segmental deficiencies
IA	Peripheral
IB	Central (medial wall absent)
II	Cavitary deficiencies
IIA	Peripheral
IIB	Central (medial wall intact)
III	Combined deficiencies
IV	Pelvic discontinuity
V	Arthrodesis

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TABLE II: Classification of Acetabular Deficiencies in Total Hip Arthroplasty According to the System of Gross et al.22

Type	Deficiency
I	Contained cavitary defect (protrusio)
II	Uncontained (structural rim defect)
IIA	Minor column (shelf defect) with >50%of cup coverage
IIB	Major column (acetabular defect) with >50% loss of cup contact and loss of one or both columns

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TABLE II: Classification of Acetabular Deficiencies in Total Hip Arthroplasty According to the System of Gross et al.22

Type	Deficiency
I	Contained cavitary defect (protrusio)
II	Uncontained (structural rim defect)
IIA	Minor column (shelf defect) with >50%of cup coverage
IIB	Major column (acetabular defect) with >50% loss of cup contact and loss of one or both columns

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TABLE III: Guidelines for Surgical Strategies to Address Pelvic and Acetabular Deformities as Part of a Total Hip Arthroplasty

Type of Defect	Treatment
Intrinsic acetabular defects
Small superior acetabular defect	Morselized impaction grafting if contained defect, supplementary mesh if uncontained defect, cementless cup
Large superior acetabular defect	Structural or morselized grafting, cementless cup, jumbo cup, bilobed cup, protrusio cage
Medial acetabular defect	Central mesh, morselized impaction grafting, cage
Posterior acetabular defect	Structural or morselized grafting, posterior plate, mesh, standard cup, cage
Associated deformities of pelvic ring
Iliac defect, nonunion, malalignment	Open reduction and internal fixation of ilium, standard cup
External rotational deformity of ipsilateral or contralateral sacroiliac joint	Open reduction and internal fixation of sacroiliac joint, standard cup
Unstable, windswept pelvis	Open reduction and internal fixation of both sacroiliac joints, standard cup
Vertical defect
Ipsilateral	Reduction of hemipelvis, long-stemmed component
Contralateral	Reduction of hemipelvis, standard cup

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TABLE III: Guidelines for Surgical Strategies to Address Pelvic and Acetabular Deformities as Part of a Total Hip Arthroplasty

Type of Defect	Treatment
Intrinsic acetabular defects
Small superior acetabular defect	Morselized impaction grafting if contained defect, supplementary mesh if uncontained defect, cementless cup
Large superior acetabular defect	Structural or morselized grafting, cementless cup, jumbo cup, bilobed cup, protrusio cage
Medial acetabular defect	Central mesh, morselized impaction grafting, cage
Posterior acetabular defect	Structural or morselized grafting, posterior plate, mesh, standard cup, cage
Associated deformities of pelvic ring
Iliac defect, nonunion, malalignment	Open reduction and internal fixation of ilium, standard cup
External rotational deformity of ipsilateral or contralateral sacroiliac joint	Open reduction and internal fixation of sacroiliac joint, standard cup
Unstable, windswept pelvis	Open reduction and internal fixation of both sacroiliac joints, standard cup
Vertical defect
Ipsilateral	Reduction of hemipelvis, long-stemmed component
Contralateral	Reduction of hemipelvis, standard cup

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TABLE IV: Devices to Manage a Large Defect and Indications for Their Use

Device	Indication
Mesh	Superior or middle central defect or superior posterior wall defect (remaining acetabulum must be intact)
Bilobed cup	Superior wall and dome defect
MÂ¸ller ring	Central, superior defect
Ganz ring with hook in obturator foramen	Nonunion of transverse fracture
Burch-Schneider cage	Large superior and central defect; nonunion of transverse, T-type fracture; large posterior defect; transverse dissociation with central bone loss to anterior inferior iliac spine

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TABLE IV: Devices to Manage a Large Defect and Indications for Their Use

Device	Indication
Mesh	Superior or middle central defect or superior posterior wall defect (remaining acetabulum must be intact)
Bilobed cup	Superior wall and dome defect
MÂ¸ller ring	Central, superior defect
Ganz ring with hook in obturator foramen	Nonunion of transverse fracture
Burch-Schneider cage	Large superior and central defect; nonunion of transverse, T-type fracture; large posterior defect; transverse dissociation with central bone loss to anterior inferior iliac spine

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Dana C. Mears, John H. Velyvis; Primary Total Hip Arthroplasty After Acetabular Fracture*. The Journal of Bone & Joint Surgery. 2000 Sep;82(9):1328-1328.

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