Acetabular fractures: the role of arthroplasty

Acetabular fractures are generally treated with open reduction and internal fixation, with the goals of anatomic reduction and preservation of the native hip joint. Modern techniques of internal fixation have resulted in good to excellent outcomes in the vast majority of patients when anatomic reduction can be obtained. Total hip arthroplasty (THA) has a role in the treatment of these injuries in 2 general situations: the acute fracture in the elderly patient with joint impaction, and for the sequelae of acetabular fracture, namely posttraumatic arthritis or osteonecrosis. Preoperative planning with plain radiographs and computed tomography (CT) scanning, including 3-dimensional reconstructions, is recommended. Recent data show that fractures in the elderly that exhibit joint impaction of the acetabular dome (the so-called gull sign) or impaction of the femoral head generally did not benefit from internal fixation attempts. Restoration of columnar continuity, typically with plates and uncemented acetabular components with multiple screw fixation, remains the preferred strategy. Cemented acetabular components have demonstrated a high failure rate in this setting and should be avoided. Plating of the posterior column will usually provide continuity of the acetabular dome, the quadrilateral plate, and ishium, which will facilitate stable uncemented acetabular component implantation. Rarely, an antiprotrusio device is necessary. Liberal use of autograft from the resected femoral head is recommended for acetabular defects. For posttraumatic sequelae, the surgeon must be prepared for heterotopic bone, scarring, bony defects, and retained hardware. Preoperative CT scanning can help localize heterotopic bone or bony defects. Hardware that does not interfere with acetabular component implantation can generally be left in situ.