Management of intraoperative acetabular fracture in primary total hip arthroplasty

Abstract

Background: Intraoperative acetabular fracture(IAF) is a rare complication of primary total hip arthroplasty(THA). The previous reports have lacked a sufficiently large number of subjects to allow for an analysis of the causes and appropriate treatment of this problem.

Methods: Between 2015 to 2018, 4888 primary THA were enrolled. We retrospectively reviewed the records in our Total Joint Registry Database and found that 24 patients (24 hips) had sustained intraoperative acetabular fractures. Twenty-four patients(16 females and 8males)were all treated with a posterolateral approach using uncemented components. Twenty patients(83.3%)underwent supplemental screw fixation, of which 2 patients were treated with steel plate fixation. Two patients' femoral heads were used as a graft. In 4 patients(16.7%), the acetabular components were judged to be stable despite the fracture and no additional treatment was performed. All patients were evaluated clinically with Harris Hip Scores (HHS) and radiographically with serial X-rays which follow up for a mean period of 34.0 ± 12.6 months. We evaluated the anatomic locations, causes, treatments, and outcome of the fractures to study the treatment method and effect of intraoperative acetabular fracture during operation.

Results: The fracture rate associated with uncemented components was 0.49%. In 17(70.8%) of these patients, the fracture was noted during the impaction of the real acetabular component. Six patients(25%)with Ankylosing Spondylitis had fractures, 4 in the anterior wall, and 1 in the anterior column, because the patient with hip joint fusion needs a to pre-osteotomy before the dislocation. The HHS score increased from 30.8 ± 9.7 preoperatively to 90.2 ± 4.2 postoperatively. All the latest x-ray showed that the fracture did not move, and there is no translucent line formed in the acetabular cup bone interface.

Conclusion: Intraoperative acetabular fractures are rare complications of THA, and most commonly occur during the implantation of the acetabular components. It is necessary to prevent the occurrence of fractures as much as possible even if the fractures are found during the operation. It should be noted that patients with ankylosing spondylitis involving hip joints during THA surgery must be careful to prevent IAFs during dislocation and pre-osteotomy.

Keywords: Ankylosing spondylitis involving hip joints; Intraoperative acetabular fracture; Primary total hip arthroplasty.

Fig. 1

a Patient 1, Preoperative x-rays with double hip fusion. b The full-screw screws were nailed into the fracture ends, and the screw caps were replaced with steel wires in the form of cross-shaped bundling and compression

Fig.2

a Patient 5,Preoperative x-ray. b X-ray after operation for 3 days, posterior column fracture, internal fixation with steel plate screws. c X-ray 2 months after operation. d X-ray 3 years after operation, the component is stable

Fig. 3

a Patient 17, severe DDH on the left side. b X-rays after operation for 3 days. c review after 3 year, the position of the component is stable

Fig. 4

a Patient 20,Preoperative x-ray. b X-ray after operation 3 days.The femoral tuberosity was split during the operation and tied with steel wire. c X-ray after 2 year, the fracture heals

Fig. 5

unhealed skin after left hip arthroplasty 45 days.