# Acute total hip arthroplasty with concomitant surgical fixation in delayed acetabular fractures: functional and radiological outcomes in a prospective cohort

## TL;DR

This study shows that combining hip replacement with surgical repair can effectively treat complex hip fractures, leading to significant recovery and stability.

## Contribution

The study provides new evidence on the effectiveness of combined open reduction and internal fixation with acute total hip arthroplasty for delayed acetabular fractures.

## Key findings

- Mean Harris Hip Score improved significantly from 42.3 preoperatively to 86.1 at final follow-up.
- 82% of patients achieved good-to-excellent outcomes, with over 75% exceeding the minimal clinically important difference.
- Functional improvement correlated positively with radiological stability (r = 0.42, p = 0.04).

## Abstract

Delayed or neglected acetabular fractures present complex challenges due to comminution, osteoporotic bone, and joint incongruity. Optimal management remains controversial, and data on combined reconstruction with acute total hip arthroplasty (THA) are limited. This study aimed to evaluate the clinical, functional, and radiological outcomes of combined open reduction and internal fixation (ORIF) with acute THA in patients with delayed, unreconstructible acetabular fractures.

This prospective study was conducted at a tertiary university referral center between February 2018 and January 2022. Patients aged > 50 years with fractures diagnosed or treated > 3 weeks post-injury and deemed unreconstructible by ORIF alone (based on multidisciplinary review and intraoperative confirmation) were included. Exclusion criteria included active infection, pathological fractures, prior hip arthroplasty, or medical contraindications. ORIF was performed to restore acetabular geometry, using autologous bone grafts or trabecular metal as required, followed by THA with cemented or cementless components according to preoperative planning and intraoperative judgment. Functional outcomes were assessed using Harris Hip Score (HHS, including MCID), WOMAC, and EQ-5D. Radiographs evaluated implant stability, graft incorporation, and complications. Reliability testing was performed for fracture classification and radiographic assessment.

Twenty-two patients completed a mean follow-up of 30 months (range 24–48 months). Fracture patterns included anterior column–posterior hemitransverse (n = 7), posterior wall (n = 6), both-column (n = 5), and transverse posterior wall (n = 4). Mean operative time was 185 min, with 850 mL blood loss. Complications occurred in 4 patients (18%), including infection, transient neuropraxia, and dislocation. Mean HHS improved significantly from 42.3 preoperatively to 86.1 at final follow-up (p < 0.001), with 82% achieving good-to-excellent outcomes and > 75% exceeding MCID. Patients aged ≤ 65 years demonstrated slightly higher functional recovery (HHS 88.6 vs 84.2, p = 0.05) and lower complication rates compared with those > 65 years. Early surgery (≤ 8 weeks) showed trends toward higher HHS gain, greater WOMAC and EQ-5D improvement, and lower complication rates. Functional improvement correlated positively with radiological stability (r = 0.42, p = 0.04).

Combined ORIF with acute THA provides substantial functional recovery, durable implant stability, and acceptable complication rates. Early intervention and careful acetabular reconstruction optimize functional and radiological outcomes, supporting this approach as an effective strategy for delayed acetabular fractures in patients.