Solutions for failed osteosynthesis of the acetabulum

Abstract

Osteosynthesis of the acetabulum is complex and requires very careful planning and preoperative preparation. The goal is to achieve anatomical reduction without steps or gaps in the articular surface. If it has not been possible to achieve an optimal reconstruction, one has to consider whether it makes sense to carry out reosteosynthesis or revise the fixation. The risk of infection, heterotopic ossification, avascular necrosis of the femur and cartilage damage is much higher than with the primary procedure. Often, especially in older patients, it may make more sense to achieve fracture union and to implant a total hip prosthesis in due course. In younger patients, every attempt should be made to achieve optimum anatomical reduction and this may mean consideration of reosteosynthesis after careful planning and counselling of the patient. If reosteosynthesis is considered adequate imaging including a postoperative CT is essential as part of the planning. This article looks at the possible solutions for failed osteosynthesis of the acetabulum.

Keywords: Acetabulum; Arthrosis; Hip prosthesis; Incongruency; Plate osteosynthesis; Reosteosynthesis.

Fig. 1

3D reconstruction of a transverse fracture after surgical treatment via a Kocher Langenbeck approach. The 3D reconstruction, as well as the coronary and axial CT sections show the incomplete reduction of the fracture. Both columns are not reduced correctly. Revision throughout the same approach. The fracture can be anatomically reduced using the Jungbluth tong. The postoperative CT sections show no more step. Bottom left postoperative pelvic overview and follow-up after 3 years.

Fig. 2

25-year-old male after high speed road traffic collision with combined pelvic and acetabular injury. Transverse right acetabular fracture and APC left hemi pelvis injury. Smoker of 30 cigarettes per day. Upper row AP, Iliac and Obturator oblique views of post-operative pelvic and acetabular fracture fixation. Middle row AP, Iliac and Obturator oblique views of patient 18 months post fixation showing failure of both anterior and posterior column fixation with broken plate and screws. Bottom row: axial cuts through CT scan showing non-union of transverse fracture line. AP pelvic radiograph 1-year post revision anterior and posterior fixation and bone grafting right acetabular fracture non-union showing united fracture.

Fig. 3

38-year-old patient (BMI 47) with hip dislocation and pelvic ring injury. Due to severe lung contusion the hip joint fracture could only be reconstructed 5 weeks after the trauma due to the severe lung contusion. Despite the acceptable reconstruction, the patient developed massive ossification and necrosis of the femoral head in the further course. Therefore, a hip prosthesis then had to be implanted.