The Journal of Arthroplasty 29 (2014) 19831990

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The Journal of Arthroplasty

journal homepage: www.arthroplastyjournal.org

Total Hip Arthroplasty after Acetabular Fracture: Incidence of

Complications, Reoperation Rates and Functional Outcomes:
Evidence Today
Konstantinos G. Makridis, MD, MSc, PhD.c , Oghor Obakponovwe, MD, MBBS, MRCS,
Peter Bobak, MD, Peter V. Giannoudis, MD, FRCS (Ortho), PhD
Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General Inrmary, Clarendon Wing Level A, Leeds, UK

a r t i c l e i n f o a b s t r a c t

Article history: The outcome of THA following acetabular fracture was analyzed on 654 patients with a systematic review
Received 20 April 2014 approach. An uncemented acetabular and femoral component was used in 80.1% and 59.8% of the cases
Accepted 1 June 2014 respectively. The median Harris hip score was 88 points. In the early THA group, KaplanMeier survivorship
analysis with any loosening, osteolysis or revision as the end point revealed that the 10-year cup survival
Keywords:
was 81% whereas in the late THA group was 76% (P = 0.287). The 10-year survival was 95% for the early
acetabular fractures
total hip replacement
stems and 85% for the late ones (P = 0.001). Due to their complexity these fractures should be managed in
treatment outcome highly specializing units where the expertise of arthroplasty and trauma reconstruction is available.
implant survival 2014 Elsevier Inc. All rights reserved.
systematic review

Acetabular fractures are severe injuries which commonly present
in young adults after high-energy trauma, usually secondary to road-
trafc collisions. During such incidents, the femoral head may
be driven into the acetabulum leading to both bony and neurovascular
injuries [1,2]. Open reduction and internal xation is considered
the gold standard of treatment for displaced fractures, while non-
displaced or minimally displaced (b 2 mm) fractures can be treated
with non-operative methods with satisfactory results [2]. Restoration
of congruency of the joint plays an important role in treatment
outcome, although development of post-traumatic osteoarthritis can
occur even after anatomical reconstruction [35].
Contrary to young adults, in the elderly population, low-energy
trauma is responsible for a high percentage of acetabular fractures,
due to the frequency of falls and increased prevalence of osteopenia
and osteoporosis. Several authors have reported that open reduction
and internal xation in the elderly patients is associated with
poor prognosis and higher rate of long-term complications [68].
Consequently, the role of acute (early) or delayed (late) total
hip arthroplasty in combination with surgical reconstruction of the
acetabular fracture has lately attracted an increased interest with
Conict of Interest: Each author certies that he has no commercial associations
(eg, consultancies, stock ownership, equity interest, patent/licensing arrangements,
etc.) that might pose a conict of interest in connection with the submitted article.
The Conict of Interest statement associated with this article can be found at http://
dx.doi.org/10.1016/j.arth.2014.06.001.
Reprint requests: Konstantinos G. Makridis, MD, MSc, PhD.c, Academic Department
of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds General
Inrmary, Clarendon Wing Level A, Great George Street, LS1 3EX Leeds, UK.
clearly dened indications and promising results [7,911]. On the
other hand, regardless of the timing of intervention, complications
can still develop including dislocation, nerve palsies, infection,
heterotopic bone formation and loosening of the prosthesis [611].
The literature regarding the outcome of total hip arthroplasty following
acetabulum fracture is sparse.
A systematic review of the literature therefore was undertaken in
order to (a) determine the existing evidence concerning the
classication, indications and surgical management of acetabular
fractures that were treated with total hip arthroplasty (THA); (b) to
analyze the clinical outcomes and the incidence of complications; and
(c) to evaluate the impact of the timing of intervention (early versus
delayed hip arthroplasty) as well as the type of prosthesis used
(uncemented versus cemented) on the long-term treatment outcome.
Materials and Methods
Literature Search
We searched the Medline databases using PubMed, Scopus, and
Cochrane library search engines, from January 1990 to January 2014,
in order to retrieve all relevant articles reporting on the management
of post-traumatic arthritis of the hip following acetabular fractures
with the use of late total hip arthroplasty and articles where
acetabular fractures were treated with early total hip arthroplasty.
The keywords used in the subject headings search included: total hip
replacement and acetabular fracture. Full texts of the articles were
retrieved and assessed for their suitability for inclusion in this study.

http://dx.doi.org/10.1016/j.arth.2014.06.001
0883-5403/ 2014 Elsevier Inc. All rights reserved.
1984 K.G. Makridis et al. / The Journal of Arthroplasty 29 (2014) 19831990
The reference list of the articles was also screened manually to ensure
that no appropriate studies for inclusion were omitted as well as the
related articles options in Medline databases.
Criteria for Eligibility
The studies selected were original articles fullling the following
criteria: (1) studies on adult subjects; (2) studies with a minimum
median of 12-month follow-up; (3) publications with inclusion of
more than 10 patients; (4) articles in English. All articles that did not
meet the above criteria were excluded, including case reports and
editorial comments.
Extraction of Data
Articles were evaluated regarding the type of study, whether
prospective or retrospective clinical review or a case series. Data were
extracted, examined and analyzed to attain information such as,
patient demographics, mechanism of injury, type of fracture, time
interval from the acetabular fracture to total hip arthroplasty, type of
implant used, operative approach, and early and late complications
and functional outcome. For each of the analyzed factors, the number
of available studies and the number of relevant patients were
recorded (Table 1).
Statistical Analysis
Comparison of data between the groups was performed on a
personal computer using SPSS (17.0.1 for Windows, SPSS Inc., Chicago,
Illinois). Qualitative data were compared using the chi-squared test.
KaplanMeier survival analysis was used to calculate the survival
probabilities of implants at 10 years. The end point for survival was
dened as aseptic loosening whether the component was changed
or not. Survival analyses were conducted for total hip arthroplasties
(cup and stem separately) and comparison was performed between
cemented and uncemented arthroplasties. Differences were considered
signicant at P b 0.05.
Results
Literature Search
Our original electronic search yielded 55 manuscripts, which were
reviewed after obtaining the full text. However, 19 articles met the
inclusion criteria [7,8,1228] (Fig. 1). In total 654 patients were reviewed
(659 hips) with a median follow-up 5.4 years (range 12 months
20 years). Median follow-up was 3.9 years (range 12 months12 years)
in acute THA group and 6.3 years (range 12 months20 years) in
delayed THA group.
Demographic Data
The median age of patients at the time of total hip arthroplasty
was 60.45 years (1795) and 433 of them (66.2%) were male. Overall, 71.2%
of the fractures were the result of high-energy mechanism. Associated
injuries and Injury Severity Score (ISS) were poorly documented.
Classication of Acetabular Fractures
Three types of classication were commonly used to classify
the initial acetabular fractures and these were the Letournel, Judet and
Letournel and Tile classications [2,29,30]. The frequency of each
fracture pattern is listed at Table 2.
Table 1
Factors Recorded and Analyzed.
Demographics Age (years)
Gender
Mechanism of injury
Mortality
Fracture Classication Letournel
Judet
Tile
Other
Initial Surgery Time from injury to total hip arthroplasty
Surgical approach
Removal of metalwork
Early Complications Intra-operative fractures
Nerve palsies
Medical complications
Thromboembolism
Local infections
Dislocation
Follow-Up Period of follow-up (months)
Late Complications Dislocation
Deep infection
Heterotopic ossication
Implant loosening
Revision Surgery Revision arthroplasty
Functional Outcome Harris hip score
Type of Treatment
One study did not report on the initial treatment of acetabular
fractures [13]. From the remaining 625 fractures, forty-hundred
seventy three (75.7%) [7,8,12,14,1628] were treated with open
reduction and internal xation (ORIF) and 152 (24.3%) with non-
operative methods [8,12,15,1719,22,23,25,26,28]. The majority of
the studies reported no failure of initial treatment of acetabular
fractures [7,8,12,1521,24,25,28]. Two studies mentioned compli-
cations of initial ORIF such as infection and non-union [22,27] and 4
gave no data [13,14,23,26]. Thirty-six percent of patients (237) were
treated with acute total hip arthroplasty [7,8,1416,20,21,24,26].
Detailed reports of the surgical approaches utilized were mentioned
in 15 studies [7,8,1218,20,21,2528] (Table 3).
Both acute and delayed total hip arthroplasties were performed in
only one manuscript that involved 121 patients [26]. Delayed total hip
arthroplasty was performed in the remainder of the reviewed articles
following either operative or non-operative management of the initial
acetabular fracture [12,13,1719,22,23,25,27,28]. In the early-THA
cases, the median interval between time of injury and total hip
arthroplasty was 10 days (129). In the delayed cases, the average
time from injury to THA was 6.6 years (2 months45 years). All but
one studies [23] reported on the implants used. Thus out of the data
available of 604 hips, an uncemented acetabular component was used
in 80.1% (484) of patients [7,1215,1722,2427] and a cemented one
was used in 19.9% (120) [8,15,16,20,2427]. Three studies did not
report on the kind of femoral stem used [14,21,23]. From the data
available of 569 hips, an uncemented femoral component was used in
59.8% (340) of cases [7,12,13,1620,22,24,26,27] and a cemented one
in 40.2% (229) [7,8,12,13,15,16,22,2428]. An anti-protrusion acetabular
cage was used in 3 studies [7,24,28]. Acetabular bone graft was used in
all cases [7,8,1228].
Clinical Outcome
Harris hip score was used to describe the functional outcome in 15
of the reviewed studies [7,8,12,1420,22,2528] with a median value
of 88 points (Table 4). Regardless the type of treatment, and according
to Harris hip score, younger patients achieved better clinical outcomes
than older patients (92.94 4.48 versus 81.68 4.58, respectively)
(P b 0.001). Comparison between different types of fracture was
made in two studies [7,8]. Fracture patterns such as posterior wall
 K.G. Makridis et al. / The Journal of Arthroplasty 29 (2014) 19831990 1985

Records identified through database

Identification
searching
(n = 2326)

Records after duplicates removed

Screening (n = 1678)

Records screened Records excluded

(n = 1678) (n = 1630)
Eligibility

Full-text articles excluded, (no report

Full-text articles assessed for of clinical outcomes, revision
eligibility rate/implant survival not in English)
(n = 55) (n = 36)

Studies included in
qualitative synthesis
(n = 19)
Included

Fig. 1. Flow diagram demonstrating the systematic review protocol.

fractures, transverse fractures and anterior column/posterior hemi-
transverse fractures were compared in relation to the clinical outcome.
No statistical signicant difference was detected between the three
fracture patterns. The mean Harris hip score after xation of posterior
wall, transverse and anterior column/posterior hemi-transverse frac-
tures was 89.3 5.96, 84.38 10.55 and 84.55 8.79, respectively
(P = 0.21).
Available data comparing acute with delayed total hip arthroplasty
were found in Sermon's et al study, where 53% of patients were
treated with primary and 47% of them with delayed total hip
arthroplasty [26]. Fifty-eight percent of patients who were treated
with primary joint arthroplasty had an excellent or good Harris hip
score in contrast to 76% who had delayed joint arthroplasty (P b 0.01).

Complications
Table 2
Classication of Acetabular Fractures in 16 Studies [7,8,1317,1924,2628].
Complications following acute or delayed total hip arthroplasty
Letournel Judet and Letournel Tile were mentioned in all 19 studies [7,8,1228]. Only one study did
Anterior wall: 0 Anterior wall: 2 Anterior wall: 0 not report the incidence of heterotopic ossication after total hip
Posterior wall: 0 Posterior wall: 140 Posterior wall: 20 arthroplasty [13]. The general complications are listed in Table 5.
Posterior column: 0 Posterior column: 13 Posterior wall/column: 7 Overall, the incidence of major complications was within the range of
Transverse: 5 Transverse: 37 Transverse: 13
Both columns: 6 Both columns: 49 Anterior column: 1
Posterior column/posterior Posterior column/posterior Posterior column: 10
Table 3
wall: 0 wall: 51
Surgical Approaches Described in 15 Studies [7,8,1218,20,21,2528].
Transverse/posterior Transverse/Posterior Posterior wall/
column: 9 wall: 63 transverse: 3 Surgical Approach Frequency (Percentage in 659 Fractures)
T-type: 0 T-shaped: 33 T-shape: 0
Comminuted anterior Anterior column: 33 Transverse/wall: 0 Antero-lateral 247 (37.5%)
column/wall: 0 Trans-trochanteric 45 (6.8%)
Anterior column/posterior Anterior wall/posterior Double column: 0 Postero-lateral 181 (27.5%)
hemi-transverse: 12 hemi-transverse: 21 Kocher-Langenbeck 55 (8.3%)
Anterior wall/column Modied anterior approach 21 (3.2%)
or transverse: 0 Other 10 (1.5%)
1986 K.G. Makridis et al. / The Journal of Arthroplasty 29 (2014) 19831990

that reported in primary THA. Only the percentage of infection Table 5

was higher after replacement following acetabular fractures, however General Complications after THA in Patients Sustained Acetabular Fracture [7,8,1228].

this was similar to those reported after primary hip arthroplasties on Complication Number of Patients
the literature. Ossication 196/654
In the early THA group, 13 cups (7.5%) and 8 stems (4.6%) out Infection 37/654 (supercial: 23, deep: 14)
of 173 implants were revised. Four cups were revised for aseptic Dislocation 29/654 (9 required revision)
loosening (1 had also osteolysis), 1 for traumatic loosening, 6 for Nerve injuries 14/654
Intraoperative periprosthetic fracture 4/654
dislocation and 2 for infection. Two stems were revised for aseptic
DVT 3/654
loosening (1 had also osteolysis), 1 for traumatic loosening, 3 for Bilateral paresthesia 1/654
dislocation and 2 for infection. It was not possible to clarify how many Femoral artery injury 1/654
of them were uncemented or cemented because 2 studies did not Nonunion of trochanteric osteotomy site 1/654
report such details [6,24]. In the late THA group, 35 cups (9.6%) and 30 Hip pain due to prominent metalwork 1/654

stems (8.2%) out of 365 implants were revised. Sixteen cups (45.7%)
were uncemented (13 were revised for aseptic loosening, 1 for
traumatic loosening and 2 for infection). Nineteen cups (54.3%) were
cemented (17 were revised for aseptic loosening, 1 for dislocation and
1 for infection). Twelve stems (40%) were uncemented (10 were
revised for aseptic loosening, 1 for periprosthetic fracture and 1 for
infection). Fourteen stems (46.7%) were cemented (all were revised
for aseptic loosening). For the rest 4 stems, there is no report about
the method of xation (2 were revised for aseptic loosening and 2
for infection) [22].
In the early THA group, KaplanMeier survivorship analysis
with any loosening, osteolysis or revision as the end point revealed
that the 10-year cup survival was 81%. In the late THA group, this
percentage was 76%. The log-rank test showed that this difference was
not signicant (P = 0.287) (Fig. 2).
In the early THA group, KaplanMeier survivorship analysis with
any loosening, osteolysis or revision as the end point revealed that the
10-year stem survival was 95%. In the late THA group, this percentage
was 85%. The log-rank test showed that this difference was signicant
(P = 0.001) (Fig. 3).
In the late THA group where the proportion of uncemented and
cemented implants were available, KaplanMeier survivorship analysis
with any loosening, osteolysis or revision as the end point revealed
that the 10-year survival was 86.7% for the uncemented cups and 81% for
the cemented. The log-rank test showed that this difference was not
signicant (P = 0.163) (Fig. 4). For the uncemented stems, the 10-year
survival was 91% and for the cemented was 89%. No difference was
noted (P = 0.652) (Fig. 5).
Further analysis was made to compare revision rates between
THAs performed 20 years ago (before 1995) and those performed
within the last 20 years. In the rst group, ve studies with late THA
were found with a total of 203 cases [12,13,17,23,27]. Twenty-six cups
(12.8%) and 25 stems (12.3%) were revised. In the second group, eight
studies were found with a total of 205 cases. Early THAs were
performed in 5 of them [1416,20,21] and late THAs in 3 [18,22,28].
Eight cups (3.9%) and 10 stems (4.9%) were revised in this group.
Descriptive statistical analysis using Pearson chi-square test showed
signicant differences between the 2 groups for both cups (P = 0.001)
and stems (P = 0.007). The rest 6 studies reported on procedures
performed before and after 1995 so safe conclusions could not be made
[7,8,19,2426].
Thirty-three patients died and the overall mortality rate was 5%.
No patient died in the acute peri-operative phase. The minimum
time of postoperative mortality was 4 months after surgery [15] and
maximum within 10 years after surgery [13]. Only in 8 papers the
causes of death were mentioned and these were unrelated diseases to
the THA [7,8,13,18,21,23,25,26].
Discussion
Acetabular fractures represent complex injuries of the hip joint
associated with high morbidity. Restoration of joint congruency plays
an important role in treatment outcome. However, development
of post-traumatic osteoarthritis can occur even after anatomical
reconstruction. Development of post-traumatic arthritis leads to
painful stimuli and impairment of function. In such cases further
surgery in the form of THA is recommended. Several authors have
proposed that in cases where long-term longevity of the hip joint
could not be guaranteed after reconstruction, primary hip arthro-
plasty should be considered as an alternative option allowing early
patient ambulation and sparing the need for secondary surgery in the
form of THA [7,14,16,21,31].

Table 4
Clinical Outcomes and Re-Operation Rates in Studies Reviewed [7,8,1228].

Author Study Number of Fractures Reviewed Median Follow-Up (years) Type of THA Average Harris Hip Score Total Revision Rate (%)

Romness (1990) [29] Retrospective 55 7.3 Delayed 21.8

Weber (1998) [37] Retrospective 63 9.6 Delayed 93 26
Huo (1999) [11] Retrospective 21 5.4 Delayed 90 4.7
Bellabara (2001) [1] Prospective 30 5.2 Delayed 88 17
Berry (2002) [2] Prospective 34 11.9 Delayed 26.5
Moushine (2002) [23] Prospective 17 3 Acute 0
Mears (2002) [22] Prospective 57 8.1 Acute 89 1.75
Tidermark (2003) [35] Retrospective 10 3.1 Acute 85 0
Sarkar (2004) [30] Retrospective 19 6 Acute 42
Schreurs (2005) [31] Retrospective 20 9.5 Delayed 93 15
Sermon (2008) [32] Retrospective 121 2.6 Acute (64) 58% excellent-good 6
Delayed (57) 76% excellent-good 31.5
Boraiah (2009) [5] Retrospective 18 3.9 Acute 88 5.5
Ranawat (2009) [27] Retrospective 32 4.7 Delayed 82 19
Herscovici (2010) [10] Retrospective 22 2.45 Acute 74 22.7
Lai (2011) [15] Retrospective 31 6.3 Delayed 89 0
Zhang (2011) [38] Retrospective 55 5.3 Delayed 90.1 1.8
Lizaur-Utrilla (2012) [17] Prospective 24 8.4 Delayed 77 16.7
Malhotra (2013) [18] Retrospective 15 6.8 Acute 91.1 0
Econson (2013) [9] Prospective 15 4 Acute 87.6 0
 K.G. Makridis et al. / The Journal of Arthroplasty 29 (2014) 19831990 1987

Fig. 2. KaplanMeier procedure comparing cup survival between early and late THA.
Fig. 4. KaplanMeier procedure comparing survival between uncemented and cemented
cups in late THA.

Limitations of this systematic review are the lack of high

quality randomized prospective control studies and the absence of
and the survival analysis in correlation with the rates reported in the
homogenous validated outcome assessment tools in order to extract
most validated hip registries.
robust conclusions regarding the long-term efcacy of early versus
Finally, a comparison of revision rates between THA performed
delayed arthroplasty.
20 years ago and those in recent years was made and a treatment
However, an extensive research of the literature was performed
algorithm was recommended.
including a large population of patients to be analyzed. Moreover,
Most of the studies in this review used the classication of
different parameters that could critically affect the treatment outcome
Letournel and Judet for the initial acetabular injuries giving important
were recorded, while survival analysis was separately performed
information regarding the fracture patterns [7,8,1317,1924,2628].
for acetabular and femoral implants as well as for the early and late
Comparing different fracture patterns no statistical signicance was
THA groups.
detected regarding the nal Harris hip score and the corresponding
Another additional strength of this review is the comparison of the
fracture pattern. We cannot however reach rm conclusions with
complication and revision rates with those of primary hip arthroplasty

Fig. 5. KaplanMeier procedure comparing survival between uncemented and cemented

Fig. 3. KaplanMeier procedure comparing stem survival between early and late THA. stems in late THA.
1988 K.G. Makridis et al. / The Journal of Arthroplasty 29 (2014) 19831990
regard to this matter as the number of patients analyzed was small
(type II statistical error). Letournel and Judet documented good to
excellent results for 47% of posterior wallposterior column fractures,
in marked contrast to 95% of transverse fractures and 91% of posterior
column fractures. They attributed the unfavorable outcomes of the
posterior wallposterior column fractures to the higher percentage of
elderly osteoporotic patients who sustained such injuries [29].
In this study, the main indications for acute THA included severe
intra-articular comminution, impaction/fracture of the femoral head,
impaction of the acetabulum involving signicant portion of the
weight-bearing area, and pre-existing symptomatic hip arthritis
[7,14]. In one study, an additional indication reported was patients
older than 65 years of age [31]. When performing an acute THA, the
fracture is primarily reduced and internally xed, followed by joint
arthroplasty. The primary objective when performing the reduction is to
achieve a stable construct rather than a truly anatomical restoration, a
strategy that helps to limit the need for extensive operative expo-
sure [21]. Mears published late results of acute THA in 49 patients.
Seventy-nine percent of them had an excellent or good Harris hip score
and good survival rate of the implants. Only minimal cavitary acetabular
osteolysis or peripheral resorption was observed on the late follow-
up radiographs [7].
The indications for delayed total hip arthroplasty are post-
traumatic arthritis of the hip, avascular necrosis of the femoral head
and its use as a salvage procedure in response to failed open reduction
and internal xation [32]. The authors who favor late intervention in
the form of THA argue that stability and secure xation of the fracture
is compromised when attempting a simultaneous hip arthroplasty.
Furthermore, it is believed that the medical burden on the patient is
high and morbidity is increased. Pritchett and Bortel evaluated 19
patients who underwent late hip arthroplasty and they found
excellent results without any complication [32]. On the contrary,
Carnesale et al reviewed 39 patients showing good results, although a
high rate of complications was reported [1].
One of the main conclusions of the herein study is that better
clinical outcomes are observed in younger patients compared to
elderly patients over 70 years of age, regardless of the timing of total
hip arthroplasty. This is in accordance with many studies, which
report difculties in achieving anatomical and stable reduction of the
affected hip joint in older patients with osteoporotic bones [7,8,21].
Matta reported that anatomic reduction was achieved in 74% of
patients under the age of 60, whereas this was feasible in 44% of
patients older than 60 years old [4]. One analysis of the postoperative
outcomes in relation to the age showed better results in younger
patients and a deterioration of outcome with increasing age [29].
Mears et al performed acute joint arthroplasties in 57 patients and
after 8-years of follow-up reported that the functional outcomes for
the elderly patients deteriorated with age. The mean Harris hip score
was 87 points for patients in their eighth decade of life and 75 points
for those in their ninth decade [7]. However, the revision rates were
higher in younger patients compared to older ones.
Romness et al reported a revision rate of 17.2% in patients less than
60 years of age with delayed joint arthroplasty that was signicantly
higher than that of patients over 60 years old (7.7%) [23]. Similarly,
Berry et al mentioned that age of less than 50 years is a signicant risk
factor for aseptic loosening after a 10-year follow-up and this probably is
correlated with the higher activity level of younger patients [13].
Table 6
Complications Reported after THA.
Present Review Conventional Primary THA [3336]
Infection 5.6% 0.94.6%
Dislocation 4.4% 0.27%
Heterotopic ossication 30% 590%
Nerve injuries 2.1% 03%
Other investigators have also highlighted that in patients less than
60 years of age there is an increased risk of revision rates secondary to
high level activities of younger patients that leads to aseptic loosening and
osteolysis around acetabular and femoral implants [8,13,17,22,23,31,32].
One study also reported that patients with N80 kg in weight and
severe acetabular defects are at greater risk for acetabular loosening
[28], while another study mentioned that creating a stable acetabular
construct, grafting the posterior acetabular wall and avoiding
medialization of acetabular cup reduces the risk of revision [7].
The risk of infection in THA following acetabular fractures is higher
than conventional hip arthroplasty, especially in patients with
multiple prior surgeries and retained hardware from previous
acetabular reconstruction. In this review, the overall infection rate
was 5.6% with 2.1% involving deep infections. Only 1 study was found
in which preoperative screening for infection was made and the
infection rate remained high [22]. It seems to be imperative to
perform a staged procedure (blood tests, hip aspiration, tissue
cultures) before THA in order to minimize the possibility of a potential
underlying low-grade infection. Moreover, removal of metalwork
must be always considered in patients with prior history of infection.
Other authors reported the need to remove the metalwork when
difculties with the placement of the acetabular component were
encountered during surgery. The ve authors who reported such details
performed occasional total or selective removal of the metalwork in
order to restore the reconstructed hip center [12,17,22,25,28].
THA secondary to acetabular fractures is often more difcult than
routine THA due to extensive scarring, retained internal xation
devices, and residual deformity of the acetabular bone [26]. Patients
with comorbidities are more prone to develop complications [26].
The most common intraoperative complication reported in this study
was iatrogenic nerve injuries (2%) [15,17,18,22,26,28] followed by
periprosthetic femoral fractures (0.8%) [13,17]. In all but one study [22]
the nerve injuries were palsies and spontaneous recovery of patients
was reported, while all intraoperative periprosthetic fractures involved
placement of uncemented femoral stems.
Other common postoperative complications noted were hetero-
topic ossication [7,8,12,13,1518,2022,25,26] and hip dislocation
[7,8,13,16,21,22,24,26,28]. However, the formation of ectopic bone
did not require any intervention except for one patient with Brooker IV
heterotopic ossication [7]. Moreover, there was no statistically
signicant difference of heterotopic ossication development between
the early and late arthroplasty group (P = 0.373). Another complica-
tion like femoral head collapse and osteonecrosis was reported in
several studies [17,19,23,27]. According to Mears [7], this may develop
following non-operative treatment or internal xation of an acetabular
fracture even after anatomical reduction and under these circum-
stances, a THA is often used later as a salvage procedure. In general,
complication rates in this review were similar to those after conven-
tional primary THA [3336] (Table 6).
Bellabarba et al concluded that THA is a more severe intervention
in patients with posttraumatic arthritis, especially if an internal
xation of the acetabulum was previously performed. The authors
Table 7
Revision Rates Reported in Present Review and in Different Registries (Primary THA)
[37,38].
Revision Rate (%) Mean Follow-Up (Years)
Present review acute THA 8.66 3.9
Present review delayed THA 16.4 6.3
Denmark 3.35 10
Finland 4.06 10
Norway 1.67 20
Sweden 0.72 27
Australia 0.81 3.11
New Zealand 3.76 8
England and Wales 1.2 3
 K.G. Makridis et al. / The Journal of Arthroplasty 29 (2014) 19831990
Fig. 6. Treatment algorithm based on the present systematic review.
reported that the operating time is longer, there is a higher
transfusion need, more patients need bone grafting and there is a
higher incidence of intra-operative hip instability, but no statistical
signicance was found in the nal outcome [12]. Similarly, Weber et al
reported that although prolonged operative times are required in THA
following acetabular fractures previously treated with ORIF (difcult
exposure due to scar tissue, need to excise heterotopic bone and
remove hardware), the type of ORIF, type and any possible non-union
of acetabular fracture do not signicantly affect the treatment
outcome [27]. Finally, Lai et al reported more blood loss, surgical
time and transfusion requirements in ORIF group, but no signicant
differences in nal Harris hip score [18]. All the other studies report no
correlation between the extent of initial injury and the nal outcome
following THA.
In all 19 studies reviewed, bone graft was used to ll acetabular
bone stock deciencies [7,8,1228]. Bone graft was used to ll cavitary
defects whereas bulk graft was used to ll segmental defects.
The graft used was either autogenous from resected femoral head
and acetabular reamings or allograft (morcellized and bulk). Great
care was given in reconstruction of posterior acetabular wall to
achieve stable structural support for the acetabular implants. Only
two studies did not mention any details regarding posterior wall
insufciency [12,13]. The use of an interference t with a cup that is
oversized by 2 mm compared with the largest reamer appears to
augment the stability of the bone graft and the acetabular fracture
fragments [7]. Also a reinforcement ring could be used to improve the
component stability and avoid medialization of the cup [12,15].
Tidermark et al suggested that acute THA with a reinforcement ring
and bone grafting of the acetabulum offers immediate mobilization of
the patient with adequate pain relief [8].
Another objective of this study was to analyze the long-term
treatment outcome in early and late THA and survival rates of the
implants used. Acetabular shells were proved to perform in a similar
way in both groups, but femoral stems showed signicant better
results in the early THA. Further investigation revealed that the
majority of the stems (56%) with revision or loosening in the late THA
were cemented and included procedures that have been performed
more than 20 years ago using early cementing techniques [23,27].
Indeed revision rates of cups and stems were signicant higher in all
studies reporting on THA before 1995. Comparison between unce-
1989
mented and cemented implants in the early THA group was not
feasible because there were no details about the nature of the implant
in all studies reviewed. However, this was possible in the late THA
group. Nevertheless, it was proved that although the uncemented
prostheses can perform better, the difference with the 10-year survival
rates of the cemented implants was not signicant.
Despite the promising results and satisfactory functional and
radiological outcomes that have been reported, there are no
prospective studies to compare directly the outcomes following
acute or delayed total hip arthroplasty secondary to acetabular
fractures. The few data available in the literature indicate that the
clinical outcomes, revision rates and implant survivorship do not
differ when either an early or a late THA is performed in patients with
prior acetabular fractures. The only study with large series of patients,
which compared these two different treatment modalities, showed
that 58% of patients who were treated with acute hip arthroplasty had
an excellent or good Harris hip score in contrast to 76% of patients
who had delayed hip arthroplasty. Nevertheless, the revision rate in
this study was higher in the delayed arthroplasty group: 18% versus
4% in the acute arthroplasty group. According to the authors, this
could be secondary to the previous open reduction and internal
xation procedure of the acetabular fracture which could lead to
instability of the involved hip joint [26]. Overall, it was noted that
revision rates after THA following acetabular fractures are substan-
tially higher than those following a conventional primary THA [37,38],
thus justifying a multispecialty treatment approach of these
complex injuries (Table 7). Based on the currently available evidence,
an algorithm of management has been compiled (Fig. 6).
Further studies are desirable to through more light into the factors
inuencing functional outcomes and longevity of THA after acetabular
fracture reconstruction.
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