Acetabular Peri-Prosthetic Fractures-A Narrative Review

Abstract

Acetabular peri-prosthetic fractures are rare but their incidence is rising due to the increased prevalence of total hip arthroplasty, the increasing life expectancy and the growing functional demand of an ageing population, the incidence of primary total hip arthroplasty is increasing. They are either intra-operative or post-operative and have various aetiologies. Several factors such as implant stability, bone loss, remaining bone stock, fracture pattern, timing, age and co-morbidities of the patients must be considered for adequate treatment. To date, the literature on this subject has been sparse and no universally recognized treatment algorithm exists. Their rarity makes them a little-known entity and their surgical management represents a challenge for most orthopaedic surgeons. This review aims to present an update on epidemiology, the diagnostic work up, existing classification systems, surgical approaches and therapeutic options for acetabular peri-prosthetic fractures.

Keywords: acetabulum; fracture; peri-prosthetic; revision surgery; total hip arthroplasty.

Figure 1

Modified 2003 Paprosky and Della Valle classification for periprosthetic acetabular fractures.

Figure 2

Intra-operative fracture of the left acetabulum recognized on immediate post-operative X-rays. It was treated non-operatively with 8 weeks of non-weight bearing with a favourable outcome. (A) postoperative CT scan showing the non-displaced fracture of the anterior column according to Judet and Letournel’s classification; (B) Immediate postoperative X-ray; (C) X-ray at 1 year follow-up.

Figure 3

Failure of a conservative treatment of an acute post-operative fracture (black arrow) (A,B), following a low energy trauma, at 6 months. (C): 3D CT scan showing a nonunion of a transverse fracture of the acetabulum (white arrow). (D): postoperative X-ray showing a plating of the posterior column and reconstruction with a Kerboull acetabular device and a cemented dual-mobility cup. Reaming to activate nonunion was performed and bone graft added. Septic non-union was ruled out with intraoperative samples.

Figure 4

Acute post-operative fracture, following a low energy trauma, of the anterior column in a 94-year-old patient (A,B) treated by one stage surgery. Reduction and ORIF of the anterior column through a Stoppa approach, and revision of the cup through a direct anterior approach with reconstruction of the acetabulum and a cemented dual-mobility cup (D). Reduction of the cup can be achieved from the Stoppa approach (C).

Figure 5

Late postoperative T-type fracture (A,B): ORIF of the anterior column using a Stoppa approach followed by ORIF of the posterior column and acetabular reconstruction using a Burch-Schneider Antiprotrusio cage via a Kocher-Langenbeck approach (C).

Figure 6

Authors preferred treatment algorithm for intra-operative fractures.

Figure 7

Authors preferred treatment algorithm for post-operative fractures.

Figure 8

Authors preferred treatment algorithm for pelvic discontinuity.