Total hip replacement for neglected acetabular fractures

Total hip replacement for neglected acetabular fractures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Total hip replacement for neglected acetabular fractures Vlad-Alexandru Georgeanu, Radu Fleaca, Mihai Roman, Bogdan Obada, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5908140/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Neglected acetabular fracture can be approached by different surgical methods, but the optimal treatment is represented by total hip replacement (THR), which theoretically should ensure a stable, painless hip, with almost-normal mobility and a hope of survival as long as possible. This study aims to evaluate the outcomes of THR in patients with neglected acetabular fractures. Methods By analyzing clinical and radiological outcomes, surgical challenges, and complication rates, we aim to provide insights into the efficacy and limitations of this approach. This is a retrospective study, 8 patients who underwent THR for neglected acetabular fractures between 2020 and 2024. All patients were assessed at 6 weeks, 6 months, 1 year and 2 years after surgery. Results As expected, regardless of the fracture type and the interval between initial trauma and index procedure, Harris hip score showed continuous improvement in successive examinations at 3, 6, 12, and 24 months; younger patients had the best preoperative scores and the fastest postoperative progression. The lowest preoperative score and the lowest rate of improvement was observed in elderly patients. The results of our case series suggest that THR might be an effective treatment for neglected acetabular fractures. The critical challenge is how to approach the acetabular defect to obtain a stable hip. Conclusions Neglected fractures are more difficult to repair and have poorer surgical outcomes. Successful outcomes are expected if a solid bone stock is achieved using various surgical techniques. total hip replacement arthroplasty acetabular fractures complications results Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Acetabular fracture become more frequent in the last period due to the increased number of high velocity trauma like high-speed car accidents, falls from heights, and sport events in which especially young peoples are involved; another direction is represented by elderly patients with osteopenia or osteoporosis who suffered accidental falls on the hip. The incidence of this type of facture is around 3 per 100000 people per year. ( 1 ) According to the type of acetabular fracture, the initial treatment can be conservative for undisplaced or minimally displaced fracture and by percutaneous fixation or most of the time by ORIF for displaced or complex fractures. A neglected acetabular fracture refers to an acetabular fracture that has remained untreated or inadequately treated for a prolonged period, typically beyond the acute phase of injury (3 weeks or more), leading to complications such as malunion, nonunion, respectively post-traumatic arthritis. ( 2 ) Total hip replacement (THR) is most often addressed to the complications of hip joint fractures, both for femoral neck fractures (posttraumatic aseptic necrosis, pseudarthrosis), femoral head fracture (posttraumatic arthritisis), but also for complications of treated or neglected acetabular fractures. Neglected acetabular fracture can be approached by different surgical methods, but the optimal treatment is represented by THR, which theoretically should ensure a stable, painless hip, with almost-normal mobility and a hope of survival as long as possible. Theoretically, THR results in patients with neglected acetabular fractures are less favourable compared to THR for other different conditions like osteoarthritis, ANCF or inflammatory arthritis. ( 3 ) These poorer outcomes are due to pelvic deformities resulting from fracture displacement or remodeling, impaired bone quality in and around the acetabulum and retraction of the soft tissue around the hip. ( 3 ) This study aims to evaluate the outcomes of THR in patients with neglected acetabular fractures. The subject is not often addressed in the literature because the standard treatment of these fractures is surgical, the percentage of untreated ones being less and less. By analyzing clinical and radiological outcomes, surgical challenges, and complication rates, we aim to provide insights into the efficacy and limitations of this approach. Material and methods Material and method s This is a retrospective study, 8 patients who underwent total hip replacement (THR) for neglected acetabular fractures between 2020 and 2024. Ethical approval was obtained from the institutional review board. The inclusion criteria for this study were: patients diagnosed with neglected acetabular fractures (at least 6 months post-injury) presenting significant hip joint dysfunction requiring THR, adequate pre-operative imaging, including radiographs and CT scans, a minimum follow-up of 12 months post-THR. The exclusion criteria were acute acetabular fractures, patients with surgically treated acetabular fracture which necessitates THR, patients lost to follow-up or with incomplete data. The study group included 8 cases (6 men and 2 women) who presented a neglected fracture of the acetabulum for at least 6 months from the time of the trauma. (table I) The patients' ages ranged from 26 to 72 years, all of whom were involved in traffic accidents as drivers or passengers. In three cases, the patients' initial conditions contraindicated surgical treatment of the acetabular fracture. In the remaining cases, surgical intervention was not performed because the orthopedic services at the initial hospitals did not undertake procedures of the magnitude required for acetabular fractures. Three of the eight patients received initial treatment with continuous transfemoral traction, which retrospectively proved ineffective, as all these cases subsequently required total hip replacement (THR). Table I. Epidemiology of the study cohort sex age mechanism of injury associated lesions interval trauma - THR initial treatment 1 F 39 traffic accident left radial shaft fracture; ribs fractures 11 months none 2 F 73 traffic accident cranial trauma 23 months femoral traction 3 M 28 traffic accident sacroilac dislocation 18 months ORIF (plate) of SI dislocation 4 M 60 traffic accident humerus fracture 12 months none 5 M 42 traffic accident cranial trauma 24 months none 6 M 71 traffic accident sacroilac dislocation 26 months ORIF (plate) of SI dislocation 7 M 32 traffic accident cranial trauma 16 months femoral traction 8 M 64 traffic accident cranial trauma 24 months femoral traction ORIF = open reduction internal fixation / SI = sacroiliac The interval between the accident and the THR ranged from 9 to 26 months, with an average of 15 months. This duration was primarily influenced by the patient’s clinical progression. Persistent pain, significant limitation of hip range of motion, and a noticeable limping gait were the most important aspects in patients’ decision for hip replacement. Preoperative assessment included both clinical and radiological evaluations. Neurological examination of the lower limb was conducted to identify any deficits secondary to the fracture; just one of the patients exhibited neurological disorders related to the initial trauma at the time of evaluation. Laboratory tests, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, were performed to rule out subclinical joint infections. In case of elevated inflammatory tests, is mandatory a needle fluid aspiration for microbiological analysis and complete cell count ( 24 ). No one of our cases fell into this category. Radiological evaluated fracture healing, bone quality, pelvic deformities, and classification of the previous fracture according to the Letournel and Judet system for acetabular fractures. Imaging studies included standard radiographs (anteroposterior, lateral, inlet, and outlet views) and long-length X-rays to document preoperative leg length discrepancies. Additionally, 3D computed tomography (CT) scans were performed in all cases to provide a more accurate assessment of local bone deformity and to evaluate the size and location of bone defects (Fig. 1 ). In the absence of the documents and the imaging examination of the cases that would allow a correct classification of the cases in the Judet - Letournel classification, this was evaluated based on the imaging examinations from the moment immediately preceding the THR and approximated according to the location of the bone changes. According to this, 1 case was appreciated like T-shaped, 3 cases posterior wall, 2 cases transverse and posterior wall, 2 cases posterior column and posterior wall. Surgical approaches varied based on the specific case. A modified Hardinge approach in the lateral decubitus position was utilized, or a posterior approach was chosen if the bone defect was located at the posterior column. Tranexamic acid was used on regular basis. The resected femoral head can be used as either a structural or morselized graft, depending on the type of defect. In our series, bone graft from femoral head was used only for cases with contained defects which necessitates morselized graft for filling (Fig. 2 ). For the cases with uncontained defects, central or defects of the postero-superior wall, we did not used structural grafts fixed with screws, but trabecular metal augments. In one case with nonunion secondary to a transverse fracture, a distraction technique was applied, and the space created between the fragments was filled with bone chips. All cases involved the use of uncemented multi-hole cups with screws; notably, in 6 cases, including the one where the distraction technique was performed, trabecular metal cups were implanted. For the rest of the cases, hydroxyapatite coated cups were used. In none of the cases was there a need for a combined technique, of plate and screw fixation and THR in a single surgical stage. Postoperatively, the patient’s received deep venous thrombosis prophylaxis according to the accepted protocols. Mobilization was individualized according to the reconstructive procedure performed; non-weight bearing was recommended for the first six weeks with gradually increased weight-bearing after this period. For all the cases, complete weight-bearing was achieved at 3 months. All patients were assessed at 6 weeks, 6 months, 1 year and 2 years after surgery. Clinically, the functional status was appreciated according to Harris Hip Score (HHS). Another clinical aspect was limb length discrepancy. HHS analysis was performed in Python version 3.7.12 using the libraries NumPy (version 1.19.5) and Matplotlib (version 3.2.2). Results As expected, regardless of the fracture type and the interval between initial trauma and index procedure, HHS showed continuous improvement in successive examinations at 3, 6, 12, and 24 months; younger patients had the best preoperative scores and the fastest postoperative progression. (Table II) The lowest preoperative score and the lowest rate of improvement was observed in elderly patients. The longer the time interval between the initial trauma and THR, the lower the preoperative HHS, and its progression in the first 6 months is slower. Its highest rate of progress is in the range of 6–12 months (Fig. 3 ). Table II. Treatment of neglected fractures. Evolution of Haris hip score Post-operative radiographs were analyzed in terms of implant positioning, loosening or displacement. Positioning of the cup was appreciated in 7 cases at a normal high, near the center of rotation of the hip, restoring the limb length as well. In one case, the cup was positioned in a high hip manner, a situation in which hip stability was not obtained, causing repeated dislocations even though a dual-mobility cup was used. In one case intrapelvic protrusion of the construct was noted. Two cases were appreciated like failure of the initial treatment; first, the case of a 60-year-old patient with a cavitary defect, located centrally and posterior, at 1 year after acetabular fracture. The initial arthroplasty was done by using a trabecular metal augment and a trabecular metal cup; after 3 months an intrapelvic migration of the construct was noted and a revision arthroplasty using 2 augments in footing manner and a trabecular metal cup fixed with additional screws (Fig. 4) The evolution was good without displacement of the construct. The second was a 39-year-old female with a massive posterosuperior wall fracture, at 2 years after initial trauma. A trabecular metal augment and a hydroxyapatite coated dual mobility cup was used. Due to the high position of the cup, repetitive dislocations were noted. The final solution was a bigger posterosperior trabecular metal augment, trabecular metal dual mobility cup Discussion This was a single surgeon series of 8 hips that underwent THA for neglected acetabular fractures. They were managed with different acetabular reconstruction techniques to achieve stable cup placement. Selecting an appropriate surgical technique to achieve stability depends on the type, size, and location of the acetabular fracture and the defect if it is present. We hypothesised that stable cup placement and acetabular bone conservation allows use of the primary hip component; this improves prosthesis longevity by osteointegration and predicts good results. Poor initial stability and cage use may have increased the risk of later revision. Acetabular fractures have a bimodal age distribution. In younger patients, high-energy trauma such as motor vehicle accidents and falls from significant heights are the leading causes. Specific scenarios include dashboard injuries where the knee strikes the dashboard, forcing axial load through the femur into the posterior acetabulum. This mechanism often results in posterior wall or posterior column fractures. Another mechanism was lateral compression when a lateral blow to the pelvis can transmit forces medially, causing fractures of the anterior wall or column. Another common cause are falls from height; vertical axial loading can lead to complex fractures, often involving both acetabular columns and associated pelvic injuries. ( 4 ) Conversely, in the elderly, acetabular fractures are increasingly attributed to low-energy trauma, such as ground-level falls, often compounded by underlying osteoporosis. These typically involve dome collapse or impaction fractures of the acetabulum. Such injuries are associated with significant morbidity. ( 5 ) Depending to the direction of the impact forces and secondary to the type and size of acetabular bone defect, the femoral head can migrate posterosuperiorly or medially. According to Matta 50% of the cases with this kind of trauma is associated with other organ injuries (35% extremity injury, 19% head injury, 18% chest injury, 13% nerve injry, 8% abdominal injury, 6% genitourinary, and 4% spine injury) which makes it difficult to treat in emergency. ( 6 ) This fact means that in the absence of specialized services in the complex management of such cases, the acetabular fracture is neglected, saving life often being paramount. Acetabular fractures represent real therapeutic challenges, both in terms of initial and delayed treatment of their complications. Initial treatment of acetabular fractures by open reduction and internal fixation, in the conditions where they are often accompanied by other post-traumatic pathological conditions, requires complex multidisciplinary teams and surgeons well trained in this kind of fractures surgery. The aim is a precise bone alignment, just like any other joint fractures, and it has been demonstrated that establishing better alignment leads to more favorable clinical outcomes even if a THR is required like a final treatment method. ( 7 ) The surgical treatment of acetabular fractures reduces the incidence of those complication, but it remains high. The necessity for a THR increases with insufficient acetabular reduction. Different papers reporting between 11 and 44% posttraumatic arthritis, regardless of the surgical treatment of the fracture by ORIF. ( 6 , 7 ) The prognosis is related on several factors, especially fracture pattern (T-type having the worst prognosis), and associated condition of the hip (femoral head lesions, dislocation, stability of the joint after treatment). Neglected fractures are, by definition, fractures that have not benefited from treatment in the first 3 weeks after the accident. ( 2 ) The main complications are represented by non-unions and malunions associated with the formation of a hypertrophic callus that led in a very short time to the appearance of post-traumatic osteoarthritis. They can be addressed through several treatment methods. Reduction and internal fixation (ORIF), total hip replacement (THR) and associated procedure (ORIF and THR). The results of the delayed ORIF, are influenced by the time onset between trauma and surgical procedure. Achieving anatomical reduction and good functional outcome reduces significantly fractures as time to surgery increases. ( 7 ) More than 11 days delay is associated with poor reduction, deficient fixation and poor functional results. ( 8 ) The main reason of ORIF is to restore as much as possible the normal anatomy of the hip joint and the articular surfaces congruency as well. These theoretical aims are very difficult to achieve in most of the case but can be improved with a positive effect on a late arthroplasty. Sometimes, these aims cannot be achieved, so the only option remains THR. Association of ORIF and THR in a single procedure can be a solution in very few cases due to the difficulty of intraoperative appreciation of the stability of the implant in a complex environment like a freshly reduced and fixed malunited or nonunited fractures which requires special surgical techniques. ( 9 ) Another strategy for neglected acetabular fractures is represented by THR, which should ensure a stable, painless hip, with almost-normal mobility and a hope of surviveal as long as possible. In fact, the results are not as good as for another common indications for hip replacement. ( 10 , 11 ) Both cemented and non-cemented prostheses can be used, but non-cemented ones are preferred. ( 12 ) The main technical problems for THR are the management of bone defects, fixation of the acetabular component in a right position and restoration of the center of rotation of the hip. ( 12 ) Management of the bone defects is very important to achieve a good bone stock for acetabular component. For cases without significant bone defects, standard cemented or noncemented cups are used in a standard manner. Uncemented cups were used in all cases of our series, and the results were satisfactory. Management of acetabular defect can be done by different techniques, depending to the type of defect. Bone autograft, allograft, oblong or jumbo acetabular cups, trabecular metal augments with or without reinforcement cages or personalized devices are the most used methods. ( 13 , 14 ) For malunions with cavitary bone defects, morselized bone graft is used, most of the time the autograft being obtained from the femoral head ( 15 ). Depending on the geometry of the acetabulum, either cemented cups with cages or reinforcing rings are used to protect the graft until integration in the case of irregular acetabulum, or uncemented cups with or without screws in the case that a retention and a primary satisfactory press-fit can be obtained. Bone grafting is the preferred method for protrusion deformity as well, associated with antiprotrusio mashes to protect the bone graft until integration. This type of reconstruction is useful only if an appropriate contact, respectively a good quality press-fit of the cup on the periphery of the acetabulum can be obtained; otherwise, the graft cannot ensure the content of the cup that will migrate intrapelvic, even if it was cemented or additionally fixed with screws in the case of non-cemented cups. For these cases, an additional reinforcement device like Kerboul ring or Burch-Schneider cage can be used, associated with a cemented cup. Trabecular metal augments and cups is another very popular technique. In the case of malunions with segmental defects, it is necessary to restore the acetabular contour. This can be done either with autografts from the iliac crest, allografts or by trabecular metal augments. The main advantage of structural grafts is the restoration of the hip center of rotation and improvement of bone stock. Uncontained defects involving < 50% of the acetabulum (type 3 Paprosky) can be managed by this technique. ( 14 ) Acetabular reconstruction with structural grafts associated with total hip arthroplasty demonstrated 88% respectively 76% cup survival rate at 10- and 20-years follow-up. ( 13 ) Resorption of bone grafts can be a long-term problem, so the use of trabecular metal augments is an effective solution. Oblong cups can restore the native center of rotation but did not improve the local bone stock. ( 16 ) Jumbo cups can create sometime high hip or near-normal hip center, which can lead to potential abnormal hip biomechanics with subsequent problems at the level of the lumbar spine as well as to an early degradation of the arthroplasty. ( 17 ) The most used method in the case of nonunion is the classic technique with careful debridement and freshening of bone ends for biologic stimulation, addition of morselized bone graft, and fixation of one or both columns with reconstruction plates, depending on the fracture pattern. Sometimes, when non-union is associated with an important bone defect, a bulk acetabular allograft can be used. A multi-hole cup with screws in different columns can be used for the reconstruction The concern related to the use this type of massive bone graft is about their resorbtion and subsequent instability of the entire construct. of the acetabulum. ( 18 ) The acetabular distraction is a relative new technique used for treatment of acetabular nonunion. It was first introduced by Sporer in 2012 for revision surgery. ( 19 ) This technique addresses acetabular discontinuity with distraction by expanding the defect and creating elastic recoil forces to compress the porous metal cup or a construct of cup and augments. The large diameter, porous metal cup, acting as an “internal plate”, the discontinuity or the fracture being bridged and stabilized. Bone ingrowth up to the cup or augments on the superior and inferior borders of the discontinuity, resulting in stable construct. The porous metal cups are the first option in this technique, due to its high coefficient of friction against cancellous bone and excellent biologic fixation via bony ingrowth which leads to long- term implants’ stability and surviveal especially in presence of acetabular defects. ( 20 ) In cases of nonunion with pelvic discontinuity, cup - cage construct is the preferred method. The cage acts like a plate, fixing the discontinuity, and by bridging the cup and augments which are fixed in the acetabulum protects them until their integration. This method is extr emely useful both in cases of pelvic discontinuity and in cases of nonunion with important acetabular defects. ( 21 ) Another technique for nonunions with pelvic discontinuity is custom triflange component, which appear to work at least as well as jumbo cups and cup/cage constructs in the setting of extensive erosion of acetabular bone, but this method is limited by high costs. ( 22 ) Proper positioning of an acetabular cup in a deformed acetabulum aasociate wih hypertrophic callus can be very difficult d0ue to the modification of local anatomy and identification of the bony landmarks. Robotic hip replacement surgery can aid in the accurate positioning of the pelvis in these cases. ( 23 ) Retraction of the soft tissue around the affected hip is another problem. It reduces the mobility of the affected hip and makes reduction of the prosthesis difficult. Most of the time this condition requiring tenotomy of the retracted muscles (rectus femoris, hamstrings), and trochanterotomy or femoral shortening to correct gluteus medius shortening. Preoperatively, is mandatory to check the condition of these muscles to establish a clear surgical strategy. ( 24 ) The postoperative complications as early implant loosening, nerve injury, vascular injury, infection, and dislocation are reported in the literature much more frequent than after primary hip arthroplasty for common conditions. ( 25 ) Neglected acetabular fracture is a fracture that has remained untreated for a prolonged period, typically beyond the acute phase of injury (3 weeks). Even though there is no ideal treatment for this, THR is an extremely efficient solution obtaining ensure a stable, painless hip, with almost-normal mobility and a long surviveal. To achieve these goals, each case must be evaluated preoperatively extremely carefully, clinically, imaging and by laboratory test. Preoperative imaging investigation (Xrays, CT) are particularly important to appreciate the local bone changes as accurately as possible to adapt the surgical approach to them. The management of bone defects is the most important aspect to obtain a bone stock that allows the best possible fixation of the acetabular cup in a correct position, with the restoration of the femoral center of rotation. Our approach consisted in the use of morcellated bone autograft from the femoral head in the case of contained defects and trabecular metal augments in the case of uncontained defects. In all cases, we used non-cemented cups, either trabecular metal or covered with hydroxyapatite; the fixation was always completed by screws. Our results were good, with a marked improvement in the functional score, except 2 cases where the restoration of the center of rotation was not achieved, respectively the correct management of the bone defect. Conclusions The results of our case series suggest that THA might be an effective treatment for neglected acetabular fractures. The critical challenge is how to approach the acetabular defect to obtain a stable hip. Neglected fractures are more difficult to repair and have poorer surgical outcomes. Successful outcomes are expected if a solid bone stock is achieved using various surgical techniques. Limitation of this study: The main weakness of the study is the small number of cases. This small number is because most cases with acetabular fractures are operated on in the first days after the accident, and our paper considered only the cases in which no surgical intervention was performed before. A second limitation is the relatively short follow-up interval, of a maximum of 4 years. Declarations Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This research study was conducted retrospectively from data obtained for clinical purpose. Approval from the ethical committee of Orthopedics and Trauma Surgery Department, St. Pantelimon Hospital, Bucharest, Romania and written informed consent were obtained from all the patients prior to initiating data collection. Informed consent Informed consent was gathered before any clinical and pictorial data were collected. Consent to publish any personal data was also obtained before manuscript drafting. Funding The authors declare that no funds, grants or other support were received during the preparation of this manuscript. Author Contribution All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by V.A. G., R. F., M. R., B. O. and V. P. The first draft of the manuscript was written by V.A. G. and all authors commented on previous versions of the manuscript. All authors read, reviewed and approved the final manuscript. References Hoge S, Chauvin BJ Acetabular Fractures. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544315/ Mears DC, Velyvis JH, Chang C-P (2003) Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res 407:173–186 Ranawat A, Zelken J, Helfet D, Buly R (2009) Total hip arthroplasty for posttraumatic arthritis after acetabular fracture. 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PMID: 36958713 Fontalis A, Raj RD, Kim WJ et al (2023) Functional implant positioning in total hip arthroplasty and the role of robotic-arm assistance. Int Orthop (SICOT) 47:573–584 Aali Rezaie A, Blevins K, Kuo FC, Manrique J, Restrepo C, Parvizi J (2020) Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern. J Arthroplasty 35(9):2619–2623 Obada B, Georgeanu V, Iliescu M, Popescu A, Petcu L, Costea DO (2024) Clinical outcomes of total hip arthroplasty after femoral neck fractures vs. osteoarthritis at one year follow up-A comparative, retrospective study. Int Orthop 48(9):2301–2310. 10.1007/s00264-024-06242-0 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5908140","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":411329095,"identity":"1e03790b-79b0-4cc6-ba35-fcba190947a8","order_by":0,"name":"Vlad-Alexandru Georgeanu","email":"","orcid":"","institution":"Carol Davila University of Medicine and Pharmacy","correspondingAuthor":false,"prefix":"","firstName":"Vlad-Alexandru","middleName":"","lastName":"Georgeanu","suffix":""},{"id":411329096,"identity":"7e1c327b-bee8-494f-99fa-6db8fc9bac55","order_by":1,"name":"Radu Fleaca","email":"","orcid":"","institution":"Lucian Blaga University of Sibiu","correspondingAuthor":false,"prefix":"","firstName":"Radu","middleName":"","lastName":"Fleaca","suffix":""},{"id":411329097,"identity":"594a63ef-23cf-4761-a4d9-b2d5db4ae5c2","order_by":2,"name":"Mihai Roman","email":"","orcid":"","institution":"Lucian Blaga University of Sibiu","correspondingAuthor":false,"prefix":"","firstName":"Mihai","middleName":"","lastName":"Roman","suffix":""},{"id":411329098,"identity":"6a367176-4a69-4461-aab9-e26595154f91","order_by":3,"name":"Bogdan Obada","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4klEQVRIiWNgGAWjYBACAyCWAOIEIGJ8wMBwgDQtzAYka2GTIEqLOXv7xRs/d9jk8bcnP6vmqbkjx8/A/PDRDTxaLHvOFFv2nkkrljjzzOw2z7FnxpINbMbGOfgcdiMnTYK37XBiw40EoBa2w4kbDvCwSRPSIvkXqGX+jfRvxTz/iNKSfkwaZMuGGzlmzGAGIS1AvzBby7alFRueeVMsObfvsLFkMwG/AEPs4c23bTZ5csfTN3548+2wHD9788PH+LQwMPAYwJlMPCCSGa9yEGB/AGcy/iCoehSMglEwCkYiAADECVTXXxMmOAAAAABJRU5ErkJggg==","orcid":"","institution":"Ovidius University","correspondingAuthor":true,"prefix":"","firstName":"Bogdan","middleName":"","lastName":"Obada","suffix":""},{"id":411329099,"identity":"841149a2-b672-42b5-a51f-d7d7f2f4834a","order_by":4,"name":"Vlad Predescu","email":"","orcid":"","institution":"Ponderas Academic Hospital","correspondingAuthor":false,"prefix":"","firstName":"Vlad","middleName":"","lastName":"Predescu","suffix":""}],"badges":[],"createdAt":"2025-01-26 19:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5908140/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5908140/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75592223,"identity":"eee62e34-a3af-4e38-ae34-f1ec0ea1efa9","added_by":"auto","created_at":"2025-02-06 07:20:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":505502,"visible":true,"origin":"","legend":"\u003cp\u003e3D CT is useful in assessing the bone defect and the displacement of the fragments\u003c/p\u003e\n\u003cp\u003ea. posterior view shows the displacement of a fragment of the posterior wall while maintaining the continuity of the posterior column\u003c/p\u003e\n\u003cp\u003eb. same fracture from antero-lateral view after rotation of the picture\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5908140/v1/52ea8def675ddb72ce788edf.png"},{"id":75592240,"identity":"cab9ce26-b44b-47ff-be47-b42e77df58ba","added_by":"auto","created_at":"2025-02-06 07:20:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":293569,"visible":true,"origin":"","legend":"\u003cp\u003eMalunion after T-shaped fracture in which morcellated grafts were impacted in the central defect.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5908140/v1/d7fe98f757009f80747fa65f.png"},{"id":75592249,"identity":"5e5852d7-1872-4b3a-8025-fb6685e1b51e","added_by":"auto","created_at":"2025-02-06 07:20:31","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":15798,"visible":true,"origin":"","legend":"\u003cp\u003eEvolution of Harris hip score\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5908140/v1/ac501445a5cf5dd6384a9541.png"},{"id":75592224,"identity":"861edf4d-adfe-4766-bdc6-7b85774270bb","added_by":"auto","created_at":"2025-02-06 07:20:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":410038,"visible":true,"origin":"","legend":"\u003cp\u003ea. Intrapelvic protrusion after first procedure; b. revision arthroplasty with 2 augments in footing manner and trabecular metal cup.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5908140/v1/c8a333e21c40e2da94b9fa97.png"},{"id":77149597,"identity":"feb0c474-9a70-4f7e-a35b-3838fb39b315","added_by":"auto","created_at":"2025-02-25 14:53:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1839446,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5908140/v1/1525b98d-a97d-4a17-aec2-fa49db12ba57.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Total hip replacement for neglected acetabular fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcetabular fracture become more frequent in the last period due to the increased number of high velocity trauma like high-speed car accidents, falls from heights, and sport events in which especially young peoples are involved; another direction is represented by elderly patients with osteopenia or osteoporosis who suffered accidental falls on the hip. The incidence of this type of facture is around 3 per 100000 people per year. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAccording to the type of acetabular fracture, the initial treatment can be conservative for undisplaced or minimally displaced fracture and by percutaneous fixation or most of the time by ORIF for displaced or complex fractures.\u003c/p\u003e \u003cp\u003eA neglected acetabular fracture refers to an acetabular fracture that has remained untreated or inadequately treated for a prolonged period, typically beyond the acute phase of injury (3 weeks or more), leading to complications such as malunion, nonunion, respectively post-traumatic arthritis. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eTotal hip replacement (THR) is most often addressed to the complications of hip joint fractures, both for femoral neck fractures (posttraumatic aseptic necrosis, pseudarthrosis), femoral head fracture (posttraumatic arthritisis), but also for complications of treated or neglected acetabular fractures.\u003c/p\u003e \u003cp\u003eNeglected acetabular fracture can be approached by different surgical methods, but the optimal treatment is represented by THR, which theoretically should ensure a stable, painless hip, with almost-normal mobility and a hope of survival as long as possible. Theoretically, THR results in patients with neglected acetabular fractures are less favourable compared to THR for other different conditions like osteoarthritis, ANCF or inflammatory arthritis. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) These poorer outcomes are due to pelvic deformities resulting from fracture displacement or remodeling, impaired bone quality in and around the acetabulum and retraction of the soft tissue around the hip. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThis study aims to evaluate the outcomes of THR in patients with neglected acetabular fractures. The subject is not often addressed in the literature because the standard treatment of these fractures is surgical, the percentage of untreated ones being less and less. By analyzing clinical and radiological outcomes, surgical challenges, and complication rates, we aim to provide insights into the efficacy and limitations of this approach.\u003c/p\u003e"},{"header":"Material and methods ","content":"\u003cdiv class=\"Heading\"\u003e\u003cb\u003eMaterial and method\u003c/b\u003es\u003c/div\u003e \u003cp\u003eThis is a retrospective study, 8 patients who underwent total hip replacement (THR) for neglected acetabular fractures between 2020 and 2024. Ethical approval was obtained from the institutional review board.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for this study were: patients diagnosed with neglected acetabular fractures (at least 6 months post-injury) presenting significant hip joint dysfunction requiring THR, adequate pre-operative imaging, including radiographs and CT scans, a minimum follow-up of 12 months post-THR.\u003c/p\u003e \u003cp\u003eThe exclusion criteria were acute acetabular fractures, patients with surgically treated acetabular fracture which necessitates THR, patients lost to follow-up or with incomplete data.\u003c/p\u003e \u003cp\u003eThe study group included 8 cases (6 men and 2 women) who presented a neglected fracture of the acetabulum for at least 6 months from the time of the trauma. (table I) The patients' ages ranged from 26 to 72 years, all of whom were involved in traffic accidents as drivers or passengers. In three cases, the patients' initial conditions contraindicated surgical treatment of the acetabular fracture. In the remaining cases, surgical intervention was not performed because the orthopedic services at the initial hospitals did not undertake procedures of the magnitude required for acetabular fractures. Three of the eight patients received initial treatment with continuous transfemoral traction, which retrospectively proved ineffective, as all these cases subsequently required total hip replacement (THR).\u003c/p\u003e \u003cp\u003eTable I. Epidemiology of the study cohort\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003esex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003emechanism of injury\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eassociated lesions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003einterval trauma - THR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003einitial treatment\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eleft radial shaft fracture; ribs fractures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecranial trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e23 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003efemoral traction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003esacroilac dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eORIF (plate) of SI dislocation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ehumerus fracture\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecranial trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003enone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003esacroilac dislocation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eORIF (plate) of SI dislocation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecranial trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003efemoral traction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003etraffic accident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ecranial trauma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003efemoral traction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eORIF\u0026thinsp;=\u0026thinsp;open reduction internal fixation / SI\u0026thinsp;=\u0026thinsp;sacroiliac\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe interval between the accident and the THR ranged from 9 to 26 months, with an average of 15 months. This duration was primarily influenced by the patient\u0026rsquo;s clinical progression. Persistent pain, significant limitation of hip range of motion, and a noticeable limping gait were the most important aspects in patients\u0026rsquo; decision for hip replacement.\u003c/p\u003e \u003cp\u003ePreoperative assessment included both clinical and radiological evaluations. Neurological examination of the lower limb was conducted to identify any deficits secondary to the fracture; just one of the patients exhibited neurological disorders related to the initial trauma at the time of evaluation.\u003c/p\u003e \u003cp\u003eLaboratory tests, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, were performed to rule out subclinical joint infections. In case of elevated inflammatory tests, is mandatory a needle fluid aspiration for microbiological analysis and complete cell count (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). No one of our cases fell into this category.\u003c/p\u003e \u003cp\u003eRadiological evaluated fracture healing, bone quality, pelvic deformities, and classification of the previous fracture according to the Letournel and Judet system for acetabular fractures. Imaging studies included standard radiographs (anteroposterior, lateral, inlet, and outlet views) and long-length X-rays to document preoperative leg length discrepancies. Additionally, 3D computed tomography (CT) scans were performed in all cases to provide a more accurate assessment of local bone deformity and to evaluate the size and location of bone defects (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the absence of the documents and the imaging examination of the cases that would allow a correct classification of the cases in the Judet - Letournel classification, this was evaluated based on the imaging examinations from the moment immediately preceding the THR and approximated according to the location of the bone changes. According to this, 1 case was appreciated like T-shaped, 3 cases posterior wall, 2 cases transverse and posterior wall, 2 cases posterior column and posterior wall.\u003c/p\u003e \u003cp\u003eSurgical approaches varied based on the specific case. A modified Hardinge approach in the lateral decubitus position was utilized, or a posterior approach was chosen if the bone defect was located at the posterior column. Tranexamic acid was used on regular basis. The resected femoral head can be used as either a structural or morselized graft, depending on the type of defect. In our series, bone graft from femoral head was used only for cases with contained defects which necessitates morselized graft for filling (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). For the cases with uncontained defects, central or defects of the postero-superior wall, we did not used structural grafts fixed with screws, but trabecular metal augments. In one case with nonunion secondary to a transverse fracture, a distraction technique was applied, and the space created between the fragments was filled with bone chips. All cases involved the use of uncemented multi-hole cups with screws; notably, in 6 cases, including the one where the distraction technique was performed, trabecular metal cups were implanted. For the rest of the cases, hydroxyapatite coated cups were used.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn none of the cases was there a need for a combined technique, of plate and screw fixation and THR in a single surgical stage.\u003c/p\u003e \u003cp\u003ePostoperatively, the patient\u0026rsquo;s received deep venous thrombosis prophylaxis according to the accepted protocols. Mobilization was individualized according to the reconstructive procedure performed; non-weight bearing was recommended for the first six weeks with gradually increased weight-bearing after this period. For all the cases, complete weight-bearing was achieved at 3 months.\u003c/p\u003e \u003cp\u003eAll patients were assessed at 6 weeks, 6 months, 1 year and 2 years after surgery. Clinically, the functional status was appreciated according to Harris Hip Score (HHS). Another clinical aspect was limb length discrepancy.\u003c/p\u003e \u003cp\u003eHHS analysis was performed in Python version 3.7.12 using the libraries NumPy (version 1.19.5) and Matplotlib (version 3.2.2).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAs expected, regardless of the fracture type and the interval between initial trauma and index procedure, HHS showed continuous improvement in successive examinations at 3, 6, 12, and 24 months; younger patients had the best preoperative scores and the fastest postoperative progression. (Table II) The lowest preoperative score and the lowest rate of improvement was observed in elderly patients. The longer the time interval between the initial trauma and THR, the lower the preoperative HHS, and its progression in the first 6 months is slower. Its highest rate of progress is in the range of 6\u0026ndash;12 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTable II. Treatment of neglected fractures. Evolution of Haris hip score\u003c/p\u003e \n\u003cp\u003e\u003cimg 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\" width=\"629\" height=\"572\"\u003e\u003c/p\u003e\u003cp\u003ePost-operative radiographs were analyzed in terms of implant positioning, loosening or displacement. Positioning of the cup was appreciated in 7 cases at a normal high, near the center of rotation of the hip, restoring the limb length as well. In one case, the cup was positioned in a high hip manner, a situation in which hip stability was not obtained, causing repeated dislocations even though a dual-mobility cup was used. In one case intrapelvic protrusion of the construct was noted.\u003c/p\u003e \u003cp\u003eTwo cases were appreciated like failure of the initial treatment; first, the case of a 60-year-old patient with a cavitary defect, located centrally and posterior, at 1 year after acetabular fracture. The initial arthroplasty was done by using a trabecular metal augment and a trabecular metal cup; after 3 months an intrapelvic migration of the construct was noted and a revision arthroplasty using 2 augments in footing manner and a trabecular metal cup fixed with additional screws (Fig.\u0026nbsp;4) The evolution was good without displacement of the construct. The second was a 39-year-old female with a massive posterosuperior wall fracture, at 2 years after initial trauma. A trabecular metal augment and a hydroxyapatite coated dual mobility cup was used. Due to the high position of the cup, repetitive dislocations were noted. The final solution was a bigger posterosperior trabecular metal augment, trabecular metal dual mobility cup\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis was a single surgeon series of 8 hips that underwent THA for neglected acetabular fractures. They were managed with different acetabular reconstruction techniques to achieve stable cup placement. Selecting an appropriate surgical technique to achieve stability depends on the type, size, and location of the acetabular fracture and the defect if it is present. We hypothesised that stable cup placement and acetabular bone conservation allows use of the primary hip component; this improves prosthesis longevity by osteointegration and predicts good results. Poor initial stability and cage use may have increased the risk of later revision.\u003c/p\u003e \u003cp\u003eAcetabular fractures have a bimodal age distribution. In younger patients, high-energy trauma such as motor vehicle accidents and falls from significant heights are the leading causes. Specific scenarios include dashboard injuries where the knee strikes the dashboard, forcing axial load through the femur into the posterior acetabulum. This mechanism often results in posterior wall or posterior column fractures. Another mechanism was lateral compression when a lateral blow to the pelvis can transmit forces medially, causing fractures of the anterior wall or column. Another common cause are falls from height; vertical axial loading can lead to complex fractures, often involving both acetabular columns and associated pelvic injuries. (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eConversely, in the elderly, acetabular fractures are increasingly attributed to low-energy trauma, such as ground-level falls, often compounded by underlying osteoporosis. These typically involve dome collapse or impaction fractures of the acetabulum. Such injuries are associated with significant morbidity. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eDepending to the direction of the impact forces and secondary to the type and size of acetabular bone defect, the femoral head can migrate posterosuperiorly or medially.\u003c/p\u003e \u003cp\u003eAccording to Matta 50% of the cases with this kind of trauma is associated with other organ injuries (35% extremity injury, 19% head injury, 18% chest injury, 13% nerve injry, 8% abdominal injury, 6% genitourinary, and 4% spine injury) which makes it difficult to treat in emergency. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) This fact means that in the absence of specialized services in the complex management of such cases, the acetabular fracture is neglected, saving life often being paramount.\u003c/p\u003e \u003cp\u003eAcetabular fractures represent real therapeutic challenges, both in terms of initial and delayed treatment of their complications. Initial treatment of acetabular fractures by open reduction and internal fixation, in the conditions where they are often accompanied by other post-traumatic pathological conditions, requires complex multidisciplinary teams and surgeons well trained in this kind of fractures surgery. The aim is a precise bone alignment, just like any other joint fractures, and it has been demonstrated that establishing better alignment leads to more favorable clinical outcomes even if a THR is required like a final treatment method. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe surgical treatment of acetabular fractures reduces the incidence of those complication, but it remains high. The necessity for a THR increases with insufficient acetabular reduction. Different papers reporting between 11 and 44% posttraumatic arthritis, regardless of the surgical treatment of the fracture by ORIF. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe prognosis is related on several factors, especially fracture pattern (T-type having the worst prognosis), and associated condition of the hip (femoral head lesions, dislocation, stability of the joint after treatment).\u003c/p\u003e \u003cp\u003eNeglected fractures are, by definition, fractures that have not benefited from treatment in the first 3 weeks after the accident. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) The main complications are represented by non-unions and malunions associated with the formation of a hypertrophic callus that led in a very short time to the appearance of post-traumatic osteoarthritis. They can be addressed through several treatment methods. Reduction and internal fixation (ORIF), total hip replacement (THR) and associated procedure (ORIF and THR).\u003c/p\u003e \u003cp\u003eThe results of the delayed ORIF, are influenced by the time onset between trauma and surgical procedure. Achieving anatomical reduction and good functional outcome reduces significantly fractures as time to surgery increases. (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) More than 11 days delay is associated with poor reduction, deficient fixation and poor functional results. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e) The main reason of ORIF is to restore as much as possible the normal anatomy of the hip joint and the articular surfaces congruency as well. These theoretical aims are very difficult to achieve in most of the case but can be improved with a positive effect on a late arthroplasty. Sometimes, these aims cannot be achieved, so the only option remains THR. Association of ORIF and THR in a single procedure can be a solution in very few cases due to the difficulty of intraoperative appreciation of the stability of the implant in a complex environment like a freshly reduced and fixed malunited or nonunited fractures which requires special surgical techniques. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAnother strategy for neglected acetabular fractures is represented by THR, which should ensure a stable, painless hip, with almost-normal mobility and a hope of surviveal as long as possible. In fact, the results are not as good as for another common indications for hip replacement. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) Both cemented and non-cemented prostheses can be used, but non-cemented ones are preferred. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe main technical problems for THR are the management of bone defects, fixation of the acetabular component in a right position and restoration of the center of rotation of the hip. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) Management of the bone defects is very important to achieve a good bone stock for acetabular component. For cases without significant bone defects, standard cemented or noncemented cups are used in a standard manner. Uncemented cups were used in all cases of our series, and the results were satisfactory.\u003c/p\u003e \u003cp\u003eManagement of acetabular defect can be done by different techniques, depending to the type of defect. Bone autograft, allograft, oblong or jumbo acetabular cups, trabecular metal augments with or without reinforcement cages or personalized devices are the most used methods. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFor malunions with cavitary bone defects, morselized bone graft is used, most of the time the autograft being obtained from the femoral head (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Depending on the geometry of the acetabulum, either cemented cups with cages or reinforcing rings are used to protect the graft until integration in the case of irregular acetabulum, or uncemented cups with or without screws in the case that a retention and a primary satisfactory press-fit can be obtained. Bone grafting is the preferred method for protrusion deformity as well, associated with antiprotrusio mashes to protect the bone graft until integration. This type of reconstruction is useful only if an appropriate contact, respectively a good quality press-fit of the cup on the periphery of the acetabulum can be obtained; otherwise, the graft cannot ensure the content of the cup that will migrate intrapelvic, even if it was cemented or additionally fixed with screws in the case of non-cemented cups. For these cases, an additional reinforcement device like Kerboul ring or Burch-Schneider cage can be used, associated with a cemented cup. Trabecular metal augments and cups is another very popular technique.\u003c/p\u003e \u003cp\u003eIn the case of malunions with segmental defects, it is necessary to restore the acetabular contour. This can be done either with autografts from the iliac crest, allografts or by trabecular metal augments. The main advantage of structural grafts is the restoration of the hip center of rotation and improvement of bone stock. Uncontained defects involving\u0026thinsp;\u0026lt;\u0026thinsp;50% of the acetabulum (type 3 Paprosky) can be managed by this technique. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) Acetabular reconstruction with structural grafts associated with total hip arthroplasty demonstrated 88% respectively 76% cup survival rate at 10- and 20-years follow-up. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Resorption of bone grafts can be a long-term problem, so the use of trabecular metal augments is an effective solution. Oblong cups can restore the native center of rotation but did not improve the local bone stock. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Jumbo cups can create sometime high hip or near-normal hip center, which can lead to potential abnormal hip biomechanics with subsequent problems at the level of the lumbar spine as well as to an early degradation of the arthroplasty. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe most used method in the case of nonunion is the classic technique with careful debridement and freshening of bone ends for biologic stimulation, addition of morselized bone graft, and fixation of one or both columns with reconstruction plates, depending on the fracture pattern. Sometimes, when non-union is associated with an important bone defect, a bulk acetabular allograft can be used. A multi-hole cup with screws in different columns can be used for the reconstruction The concern related to the use this type of massive bone graft is about their resorbtion and subsequent instability of the entire construct. of the acetabulum. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe acetabular distraction is a relative new technique used for treatment of acetabular nonunion. It was first introduced by Sporer in 2012 for revision surgery. (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) This technique addresses acetabular discontinuity with distraction by expanding the defect and creating elastic recoil forces to compress the porous metal cup or a construct of cup and augments. The large diameter, porous metal cup, acting as an \u0026ldquo;internal plate\u0026rdquo;, the discontinuity or the fracture being bridged and stabilized. Bone ingrowth up to the cup or augments on the superior and inferior borders of the discontinuity, resulting in stable construct. The porous metal cups are the first option in this technique, due to its high coefficient of friction against cancellous bone and excellent biologic fixation via bony ingrowth which leads to long- term implants\u0026rsquo; stability and surviveal especially in presence of acetabular defects. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIn cases of nonunion with pelvic discontinuity, cup - cage construct is the preferred method. The cage acts like a plate, fixing the discontinuity, and by bridging the cup and augments which are fixed in the acetabulum protects them until their integration. This method is extr emely useful both in cases of pelvic discontinuity and in cases of nonunion with important acetabular defects. (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) Another technique for nonunions with pelvic discontinuity is custom triflange component, which appear to work at least as well as jumbo cups and cup/cage constructs in the setting of extensive erosion of acetabular bone, but this method is limited by high costs. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eProper positioning of an acetabular cup in a deformed acetabulum aasociate wih hypertrophic callus can be very difficult d0ue to the modification of local anatomy and identification of the bony landmarks. Robotic hip replacement surgery can aid in the accurate positioning of the pelvis in these cases. (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eRetraction of the soft tissue around the affected hip is another problem. It reduces the mobility of the affected hip and makes reduction of the prosthesis difficult. Most of the time this condition requiring tenotomy of the retracted muscles (rectus femoris, hamstrings), and trochanterotomy or femoral shortening to correct gluteus medius shortening. Preoperatively, is mandatory to check the condition of these muscles to establish a clear surgical strategy. (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe postoperative complications as early implant loosening, nerve injury, vascular injury, infection, and dislocation are reported in the literature much more frequent than after primary hip arthroplasty for common conditions. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eNeglected acetabular fracture is a fracture that has remained untreated for a prolonged period, typically beyond the acute phase of injury (3 weeks). Even though there is no ideal treatment for this, THR is an extremely efficient solution obtaining ensure a stable, painless hip, with almost-normal mobility and a long surviveal.\u003c/p\u003e \u003cp\u003eTo achieve these goals, each case must be evaluated preoperatively extremely carefully, clinically, imaging and by laboratory test. Preoperative imaging investigation (Xrays, CT) are particularly important to appreciate the local bone changes as accurately as possible to adapt the surgical approach to them. The management of bone defects is the most important aspect to obtain a bone stock that allows the best possible fixation of the acetabular cup in a correct position, with the restoration of the femoral center of rotation.\u003c/p\u003e \u003cp\u003eOur approach consisted in the use of morcellated bone autograft from the femoral head in the case of contained defects and trabecular metal augments in the case of uncontained defects. In all cases, we used non-cemented cups, either trabecular metal or covered with hydroxyapatite; the fixation was always completed by screws. Our results were good, with a marked improvement in the functional score, except 2 cases where the restoration of the center of rotation was not achieved, respectively the correct management of the bone defect.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe results of our case series suggest that THA might be an effective treatment for neglected acetabular fractures. The critical challenge is how to approach the acetabular defect to obtain a stable hip. Neglected fractures are more difficult to repair and have poorer surgical outcomes. Successful outcomes are expected if a solid bone stock is achieved using various surgical techniques.\u003c/p\u003e\n\u003ch3\u003eLimitation of this study:\u003c/h3\u003e\n\u003cp\u003eThe main weakness of the study is the small number of cases. This small number is because most cases with acetabular fractures are operated on in the first days after the accident, and our paper considered only the cases in which no surgical intervention was performed before. A second limitation is the relatively short follow-up interval, of a maximum of 4 years.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthical approval\u003c/h2\u003e \u003cp\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This research study was conducted retrospectively from data obtained for clinical purpose. Approval from the ethical committee of Orthopedics and Trauma Surgery Department, St. Pantelimon Hospital, Bucharest, Romania and written informed consent were obtained from all the patients prior to initiating data collection.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003eInformed consent was gathered before any clinical and pictorial data were collected. Consent to publish any personal data was also obtained before manuscript drafting.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe authors declare that no funds, grants or other support were received during the preparation of this manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by V.A. G., R. F., M. R., B. O. and V. P. The first draft of the manuscript was written by V.A. G. and all authors commented on previous versions of the manuscript. All authors read, reviewed and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHoge S, Chauvin BJ Acetabular Fractures. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK544315/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK544315/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMears DC, Velyvis JH, Chang C-P (2003) Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res 407:173\u0026ndash;186\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRanawat A, Zelken J, Helfet D, Buly R (2009) Total hip arthroplasty for posttraumatic arthritis after acetabular fracture. J Arthroplasty 24(5):759\u0026ndash;767\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManson TT et al (2015) Acetabular fractures: Surgical approaches and fixation techniques. J Am Acad Orthop Surg 23(4):180\u0026ndash;191\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhandari M et al (2014) Management of osteoporotic acetabular fractures: Challenges and solutions. J Orthop Trauma 28(Supplement 1):S34\u0026ndash;S40\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatta JM (1996) Fractures of the acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surgery-American Volume 78(11):1632\u0026ndash;1645\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMadhu R (2006) Outcome of surgery for reconstruction of fractures of the acetabulum. J Bone Joint Surg [Br] 9:1197\u0026ndash;1203. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1302/0301-620X.88B9.17588\u003c/span\u003e\u003cspan address=\"10.1302/0301-620X.88B9.17588\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. 88-B.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMears DC, Velyvis JH, Chang C-P (2003) Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res 407:173\u0026ndash;186\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManson TT (2020) Open Reduction and Internal Fixation Plus Total Hip Arthroplasty for the Acute Treatment of Older Patients with Acetabular Fracture: Surgical Techniques. Orthop Clin North Am 51(1):13\u0026ndash;26\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorison Z, Moojen DJF, Nauth A et al (2016) Total Hip Arthroplasty After Acetabular Fracture Is Associated with Lower Survivorship and More Complications. Clin Orthop Relat Res 474(2):392\u0026ndash;398\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStibolt RD, Patel HA, Huntley SR, Lehtonen EJ, Shah AB, Naranje SM (2018) Total hip arthroplasty for posttraumatic osteoarthritis following acetabular fracture: A systematic review of characteristics, outcomes, and complications. Chin J Traumatol - Engl Ed 21(3):176\u0026ndash;181\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerry DJ, Halasy M (2002) Uncemented acetabular components for arthritis after acetabular fracture. Clin Orthop Relat Res 405(405):164\u0026ndash;167\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSternheim A, Abolghasemian M, Safir OA, Backstein D, Gross AE, Kuzyk PR (2013) A long-term surviveorship comparison between cemented and uncemented cups with shelf grafts in revision total hip arthroplasty after dysplasia. J Arthroplasty 28:303\u0026ndash;308\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGross AE, Goodman S (2004) The current role of structural grafts and cages in revision arthroplasty of the hip. Clin Orthop Relat Res 429:193\u0026ndash;120\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchreurs BW, Bolder SBT, Gardeniers JWM, Verdonschot N, Slooff TJJH, Veth RPH (2004) Acetabular revision with impacted morsellised cancellous bone grafting and a cemented cup. J Bone Jt Surg - Ser B 86\u0026ndash;B(4):492\u0026ndash;497\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eK\u0026ouml;ster G, Willert G-H, K\u0026ouml;hler H-P, D\u0026ouml;pkens K (1998) An oblong revision cup for large acetabular defects: Design rationale and two- to seven-year follow-up. J Arthroplast 13(5):559\u0026ndash;569\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGustke KA, Levering MF, Miranda MA (2014) Use of Jumbo Cups for Revision of Acetabula with Large Bony Defects. J Arthroplast 29(1):199\u0026ndash;203 ISSN 0883\u0026ndash;5403. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.arth.2012.11.010\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2012.11.010\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatil VS, Shevate I, Pervez FR, Bhakare D (2024) A Neglected Fracture of Acetabulum Treated with Total Hip Replacement. Cureus 16(6):e61778. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.7759/cureus.61778\u003c/span\u003e\u003cspan address=\"10.7759/cureus.61778\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 38975433; PMCID: PMC11227437\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSporer SM, Bottros JJ, Hulst JB et al (2012) Acetabular distraction: an alternative for severe defects with chronic pelvic discontinuity? Clin Orthop Rela Res 470:3156\u0026ndash;3163\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArgyropulou E, Sakellariou E, Galanis A, Karampinas P, Rozis M, Koutas K, Tsalimas G, Vasiliadis E, Vlamis J, Pneumaticos S (2024) Porous Tantalum Acetabular Cups in Primary and Revision Total Hip Arthroplasty: What Has Been the Experience So Far? A Systematic Literature Review. Biomedicines 12:959. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003edoi.org/10.3390/biomedicines12050959\u003c/span\u003e\u003cspan address=\"10.3390/biomedicines12050959\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaudhry F, Daud A, Greenberg A, Braunstein D, Safir OA, Gross AE, Kuzyk PR (2024) Cup-Cage Construct for Treatment of Severe Acetabular Bone Loss in Revision Total Hip Arthroplasty: Clinical and Radiographic Outcomes at a Mean Follow-Up of 7.7 Years. J Arthroplasty. ;39(10):2555\u0026ndash;2560. doi: 10.1016/j.arth.2024.07.010. Epub 2024 Jul 11. PMID: 39002767\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeding JB, Meding LK (2023) Custom Triflange Acetabular Implants: Average 10-Year Follow-Up. J Arthroplasty. ;38(7S): S201-S205. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.arth.2023.03.035\u003c/span\u003e\u003cspan address=\"10.1016/j.arth.2023.03.035\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2023 Mar 21. PMID: 36958713\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFontalis A, Raj RD, Kim WJ et al (2023) Functional implant positioning in total hip arthroplasty and the role of robotic-arm assistance. Int Orthop (SICOT) 47:573\u0026ndash;584\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAali Rezaie A, Blevins K, Kuo FC, Manrique J, Restrepo C, Parvizi J (2020) Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern. J Arthroplasty 35(9):2619\u0026ndash;2623\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eObada B, Georgeanu V, Iliescu M, Popescu A, Petcu L, Costea DO (2024) Clinical outcomes of total hip arthroplasty after femoral neck fractures vs. osteoarthritis at one year follow up-A comparative, retrospective study. Int Orthop 48(9):2301\u0026ndash;2310. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00264-024-06242-0\u003c/span\u003e\u003cspan address=\"10.1007/s00264-024-06242-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"total hip replacement, arthroplasty, acetabular fractures, complications, results","lastPublishedDoi":"10.21203/rs.3.rs-5908140/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5908140/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eNeglected acetabular fracture can be approached by different surgical methods, but the optimal treatment is represented by total hip replacement (THR), which theoretically should ensure a stable, painless hip, with almost-normal mobility and a hope of survival as long as possible. This study aims to evaluate the outcomes of THR in patients with neglected acetabular fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBy analyzing clinical and radiological outcomes, surgical challenges, and complication rates, we aim to provide insights into the efficacy and limitations of this approach. This is a retrospective study, 8 patients who underwent THR for neglected acetabular fractures between 2020 and 2024. All patients were assessed at 6 weeks, 6 months, 1 year and 2 years after surgery.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAs expected, regardless of the fracture type and the interval between initial trauma and index procedure, Harris hip score showed continuous improvement in successive examinations at 3, 6, 12, and 24 months; younger patients had the best preoperative scores and the fastest postoperative progression. The lowest preoperative score and the lowest rate of improvement was observed in elderly patients. The results of our case series suggest that THR might be an effective treatment for neglected acetabular fractures. The critical challenge is how to approach the acetabular defect to obtain a stable hip.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eNeglected fractures are more difficult to repair and have poorer surgical outcomes. Successful outcomes are expected if a solid bone stock is achieved using various surgical techniques.\u003c/p\u003e","manuscriptTitle":"Total hip replacement for neglected acetabular fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-06 07:20:25","doi":"10.21203/rs.3.rs-5908140/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ef7a2ec4-7420-4e82-b11e-00766a4adc51","owner":[],"postedDate":"February 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-12T02:08:10+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-06 07:20:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5908140","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5908140","identity":"rs-5908140","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}