Open reduction and internal fixation of acetabular fractures in patients of old age

Increased risk of adverse events following the treatment of associated versus elementary acetabular fractures: a matched analysis of short-term complications

PURPOSE

This retrospective cohort study aims to compare short-term complication rates between patients receiving open reduction and internal fixation (ORIF) for associated versus elementary acetabular fractures, with a secondary objective of identifying independent risk factors for adverse outcomes.

METHODS

The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) codes to identify patients that underwent ORIF for associated acetabular (CPT 27228) or elementary acetabular fractures (CPT 27226, 27227) from 2010 to 2021. Propensity score matching was employed to account for baseline differences and the short-term complication rates were compared between the cohorts.

RESULTS

We identified 1,330 patients who underwent ORIF for an acetabular fracture between 2010 and 2021, including 868 patients with elementary fractures and 462 with associated fractures. After matching, there were 462 patients in each cohort. The matched associated acetabular fracture group experienced higher rates of any adverse event (AAE, p = 0.029), transfusion (p = 0.010), and reoperation (p = 0.049). Increased age, increased operative time, higher body mass index (BMI), and prolonged hospital length of stay (LOS) augmented the risk of any complication.

CONCLUSION

The findings of this study identify areas of greater risk of postoperative complications after ORIF in individuals with associated versus elementary acetabular fractures. Discussion of these heightened risks is critical to appropriate patient care. Understanding these risks plays an important role in the clinical decision-making process and may identify areas to monitor patients postoperatively.

Similar Medium-Term Revision Rates Following Acute Total Hip Arthroplasty Versus Open Reduction and Internal Fixation for Acetabular Fractures in the Elderly

BACKGROUND

The management of elderly acetabular fractures is complex, with high rates of conversion total hip arthroplasty (THA) after open reduction and internal fixation (ORIF), but potentially higher rates of complications after acute THA.

METHODS

The California Office of Statewide Health Planning and Development database was queried between 2010 and 2017 for all patients aged 60 years or older who sustained a closed, isolated acetabular fracture and underwent ORIF, THA, or a combination. Chi-square tests and Student t tests were used to identify demographic differences between groups. Multivariate regression was used to evaluate predictors of 30-day readmission and 90-day complications. Kaplan-Meier (KM) survival analysis and Cox proportional hazards model were used to estimate the revision surgery-free survival (revision-free survival [RFS]), with revision surgery defined as conversion THA, revision ORIF, or revision THA.

RESULTS

A total of 2,184 surgically managed acetabular fractures in elderly patients were identified, with 1,637 (75.0%) undergoing ORIF and 547 (25.0%) undergoing THA with or without ORIF. Median follow-up was 295 days (interquartile range, 13 to 1720 days). 99.4% of revisions following ORIF were for conversion arthroplasty. Unadjusted KM analysis showed no difference in RFS between ORIF and THA (log-rank test P = 0.27). RFS for ORIF patients was 95.1%, 85.8%, 78.3%, and 71.4% at 6, 12, 24 and 60 months, respectively. RFS for THA patients was 91.6%, 88.9%, 87.2%, and 78.8% at 6, 12, 24 and 60 months, respectively. Roughly 50% of revisions occurred within the first year postoperatively (49% for ORIF, 52% for THA). In propensity score-matched analysis, there was no difference between RFS on KM analysis ( P = 0.22).

CONCLUSIONS

No difference was observed in medium-term RFS between acute THA and ORIF for elderly acetabular fractures in California. Revision surgeries for either conversion or revision THA were relatively common in both groups, with roughly half of all revisions occurring within the first year postoperatively.

LEVEL OF EVIDENCE

III.

Epidemiology of acetabular fractures in elderly patients and the effect of various management options on the outcomes. A comprehensive narrative review

Owing to the expected increase in the world's elderly population (>65 years old), and the concomitant osteoporosis in this particular population, fragility fractures of the pelvis and the acetabulum is becoming a real concern, which could be life-threatening. In the current review, we aimed to discuss the various epidemiological characteristics of geriatric acetabular fractures, management options, and the outcomes. For the review synthesis, we searched PubMed to select the most relevant and updated articles published from various areas and institutions. Geriatric acetabular fractures are mainly caused by trivial trauma, constitute about 1.5%-3% of all skeletal injuries, and showed a 2.4-fold increase over the past three decades. Furthermore, these fractures' associated one-year mortality rate ranges from 14% to 25%. Management options differ largely according to the type and severity of the injury if there is an associated skeletal or non-skeletal injury, and preexisting patient comorbidities. These options could be nonoperative or operative (including surgical fixation and acute total hip arthroplasty), and both carry a specific risk in this vulnerable age group. There is controversy among various reports regarding the best management option leading to better function and health-related quality of life (HRQoL) outcomes. In conclusion, the incidence of acetabular fractures in elderly patients is rising. The decision-making on the best management option should consider the patient's fragility, injury severity, poor bone quality, and multiple medical comorbidities. The outcomes related to function, quality of life, and mortality are comparable between operative and nonoperative management options.

The outcome of conversion total hip arthroplasty following acetabular fractures: a systematic review and meta-analysis of comparative studies

BACKGROUND

Conversion total hip arthroplasty (THA) is considered the main treatment plan for patients with first-line treatment failure of acetabulum fracture. This meta-analysis aims to assess the effect of the type of initial treatment and timing of surgery on the outcomes of conversion THA.

METHODS

Using PRISMA guidelines, MEDLINE/PubMed, Scopus, Web of Science, and CENTRAL Cochrane were searched for articles published before October 14, 2022. Comparative studies investigating the outcome of THA following treatment failure of acetabular fracture were included. These articles were categorized into three groups, and the outcomes of treatment plans in each group were compared: (A) primary THA vs. conversion THA, (B) THA following conservative treatment vs. THA following ORIF, and (C) acute THA vs. delayed THA following prior treatment failure. Review Manager (RevMan, version 5.3) software was utilized to perform the statistical analysis.

RESULTS

Twenty-four comparative studies met the inclusion criteria (reported the data of 13,373 patients). Concerning group (A), the following complications were significantly higher in conversion THA: Infection (OR [95% CI] 3.19 [2.12, 4.79]; p value < 0.00001), dislocation (OR [95% CI] 4.58 [1.56, 13.45]; p value = 0.006), heterotopic ossification (OR [95% CI] 5.68 [3.46, 9.32]; p value < 0.00001), and Revision (OR [95% CI] 2.57 [1.65, 4.01]; p value < 0.00001). Postoperative HHS (SMD [95% CI] - 0.66 [- 1.24, - 0.08]; p value = 0.03) was significantly lower and operation time (SMD [95% CI] 0.88 [0.61, 1.15]; p value < 0.00001), blood loss (SMD [95% CI] 0.83 [0.56, 1.11]; p value < 0.00001), and bone graft need (OR [95% CI] 27.84 [11.80, 65.65]; p value < 0.00001) were significantly higher in conversion THA. Regarding group (B), bone graft need (OR [95% CI] 0.48 [0.27, 0.86]; p value = 0.01) was considerably higher in patients with prior acetabular fracture conservative treatment, while other outcomes were comparable. Respecting group (C), there were no significant differences in analyzed outcomes. However, systematically reviewing existing literature suggested a higher incidence rate of DVT following acute THA.

CONCLUSION

There were significantly higher postoperative complications and lower functional outcomes in conversion THA compared to primary THA. While complications and functional outcomes were comparable between ORIF and the conservative groups, the bone graft need was significantly higher in the conservative group. There were no significant differences between aTHA and dTHA. These results can assist surgeons in designing treatment plans based on each patient's clinical situation. Prospero registration code: CRD42022385508.

LEVEL OF EVIDENCE

III/IV.

Surgical outcomes of acetabular fracture of elderly patients with superomedial dome impaction

This study aimed to investigate the outcomes of elderly acetabular fractures according to the reduction of impacted dome fragments. A retrospective cohort study was performed in two institutions. Fifty-four patients aged ≥ 60 years with acetabular fractures were enrolled. Data for dome impaction and postoperative reduction was collected. Patients were divided into the good reduction group (displacement ≤ 3 mm) and poor reduction group (displacement > 3 mm). Postoperative osteoarthritis (OA), Harris hip score (HHS), total hip arthroplasty conversion, good/poor outcomes were compared between the two groups. The good reduction group (N = 45) demonstrated a lower proportion of radiographic OA (18 vs. 77%, P = 0.001), higher HHS (82.1 vs. 68.6, P = 0.022), and higher proportion of good outcomes than the poor reduction group (N = 9) (89 vs. 22%, P < 0.001). In a subgroup analysis of the patients with dome impaction, the good reduction group had a higher proportion of good outcomes (80 vs. 20%, P = 0.031). On comparing within the good reduction group, dome impaction did not influence clinical outcomes. Elderly acetabular fractures demonstrated favorable outcomes when adequate reduction was achieved even with dome impaction. Well-reduced dome impaction could achieve satisfactory outcomes in elderly acetabular fractures.

Locating an iliac cortical window for reduction of an acetabular dome impaction: A computed tomography and cadaveric study

This study aimed to determine the optimal location of the iliac cortical window (ICW) for the direct reduction of acetabular dome impactions using a reference bony landmark.

Methods

In the first part of the study, computed tomography scans of 10 normal acetabula, the femoral head weight bearing area, were projected through the superior iliac cortical surface perpendicular to the plane of the true pelvis to show the area that corresponds to the acetabular dome. A line connecting each pair of anterior inferior iliac spines (AIIS) was drawn then reflected in the superior surface of the acetabulum and a reference point (RP) was marked on the line halfway between the AIIS and the pelvic brim. A 12-point 1-cm interval grid with horizontal and vertical axes labeled A, B, C and 1 to 4, respectively, overlying the acetabular surface projection was created to identify the location of the acetabular dome. In the second part of the study, the 12-point grid was marked on eight fresh cadavers (16 acetabula) and the same acetabular dome reference point was identified. K-wires were drilled into the acetabula using a parallel drill guide at each of the twelve grid points. An arthrotomy was carried out and the locations of the K-wires which penetrated the acetabular dome were recorded.

Results

The average distance from the AIIS to the medial pelvic brim in the CT scans and cadaveric study were 47.7 and 45.9 mm, respectively. The K-wires at grid points B2 and C1 had a 100% correlation to the dome area. The A2, B1, and C2 grid points had a correlation with the dome area of >80%. The remaining grid points had joint penetrations ranging from 6.25% to 62.5%.

Conclusion

The proposed RP, which can be easily identified intraoperatively, and the area 1 cm2 around the RP (except in the posterior direction) can be used as reliable reference landmarks and for identification of the location of the ICW for the reduction of an acetabular dome impaction.

Transverse posterior wall acetabular fracture pattern is associated with increased risk of periprosthetic joint infection after conversion total hip arthroplasty

INTRODUCTION

Acetabular fracture subtypes are associated with varying rates of subsequent conversion total hip arthroplasty (THA) after open reduction internal fixation (ORIF) with transverse posterior wall (TPW) patterns having a higher risk for early conversion. Conversion THA is fraught with complications including increased rates of revision and periprosthetic joint infections (PJI). We aimed to determine if TPW pattern is associated with higher rates of readmissions and complications including PJI after conversion compared to other subtypes.

METHODS

We retrospectively reviewed 1,938 acetabular fractures treated with ORIF at our institution from 2005 to 2019, of which 170 underwent conversion that met inclusion criteria, including 80 TPW fracture pattern. Conversion THA outcomes were compared by initial fracture pattern. There was no difference between the TPW and other fracture patterns in age, BMI, comorbidities, surgical variables, length of stay, ICU stay, discharge disposition, or hospital acquired complications related to their initial ORIF procedure. Multivariable analysis was performed to identify independent risk factors for PJI at both 90-days and 1-year after conversion.

RESULTS

TPW fracture had higher risk of PJI after conversion THA at 1-year (16.3% vs 5.6%, p = 0.027). Multivariable analysis revealed TPW independently carried increased risk of 90-day (OR 4.89; 95% CI 1.16-20.52; p = 0.03) and 1-year PJI (OR 6.51; 95% CI 1.56-27.16; p = 0.01) compared to the other acetabular fracture patterns. There was no difference between the fracture cohorts in 90-day or 1-year mechanical complications including dislocation, periprosthetic fracture and revision THA for aseptic etiologies, or 90-day all-cause readmission after the conversion procedure.

CONCLUSION

Although conversion THA after acetabular ORIF carry high rates of PJI overall, TPW fractures are associated with increased risk for PJI after conversion compared to other fracture patterns at 1-year follow-up. Novel management/treatment of these patients either at the time of ORIF and/or conversion THA procedure are needed to reduce PJI rates.

LEVEL OF EVIDENCE

Therapeutic Level III (retrospective study of consecutive patients undergoing an intervention with analyses of outcomes).

OUTCOMES OF SURGICAL TREATMENT FOR DISPLACED BOTH-COLUMN ACETABULAR FRACTURES

Complex both-column acetabulum fractures are severe injuries, often with associated injuries and complications with uncertain clinical and functional outcome. Modern traumatological protocols point to early surgical treatment, with anatomical reduction and stable internal fixation of fragments as a prerequisite for achieving a good treatment outcome. This retrospective-prospective multicenter cohort study was conducted during the 2014-2020 period and included 24 cases that met the input parameters, using the Letournel and Judet classification, and application of a combined surgical approach, a modified Stoppa and Kocher-Langenbeck approach. The results of treatment with complications, associated injuries and functional outcome are described. Fractures were caused by high kinetic energy trauma, and the cause was traffic accident in 17/24 (70.84%), fall from a height in 5/24 (20.83%) and crash injuries in 2/24 (8.33%) cases. The sample included 18 (75.00%) male and 6 (25.00%) female, with 10/24 (41.67%) right sided and 14/24 (58.33%) left sided fractures. Their mean age was 45.06 (range, 24-62) years. The mean follow-up time was 2.8 (range, 1-5) years. Postoperative complications were detected in 14/24 (58.33%) cases, including wound infection in 4/24 (16.67%), deep vein thrombosis in 2/24 (8.33%), heterotopic ossification in 2/24 (8.33%), hip osteoarthrosis in 3/24 (12.50%), avascular necrosis of femoral head in 2/24 (8.33%), total hip arthroplasty procedures in 3/24 (12.50%), abdominal complications in 2/24 (8.33%), urologic complications in 2/24 (8.33%), iatrogenic nerve lesion in 3/24 (12.50%), and fatal pulmonary embolism in 2/24 (8.33%) cases; there was no loss of reduction or non-union acetabular fracture. Associated injuries that we recorded as major trauma were presented in 13/24 (54.17%) study patients. The final functional results according to the Harris Hip Score (HHS) were excellent in 7/22 (31.82%), good in 10/22 (45.45%), moderate in 4/22 (18.18%) patients, and poor in 1/22 (4.55%) patient. The mean HHS was 84 (range 34-98). Complications and results have led us to a conclusion that primary injuries significantly affect the clinical and functional results. A good diagnostic procedure, assessment of the general condition and application of the trauma scoring system, surgical treatment that includes early hip reduction, open reduction internal fixation and physical rehabilitation are necessary.

Biomechanical evaluation of a healed acetabulum with internal fixators: finite element analysis

BACKGROUND

Treatment of complicated acetabular fracture with internal fixation usually has high risk of failure because of unbefitting fixation. However, evaluation of the biomechanical effect of internal fixation under physiological loading for fracture healing is still generally rarely performed. The purpose of this study is to analyze the biomechanical characteristics of a healed acetabulum with designed internal fixators under gait and to explore the biomechanical relationship between the healed bone and the internal fixator.

METHODS

A patient-specific finite element model of whole pelvis with designed internal fixators was constructed based on the tomographic digital images, in which the spring element was used to simulate the main ligaments of the pelvis. And the finite element analysis under both the combination loading of different phases and the individual loading of each phase during the gait cycle was carried out. The displacement, von Mises stress, and strain energy of both the healed bone and the fixation were calculated to evaluate the biomechanical characteristics of the healed pelvis.

RESULTS

Under the combination loading of gait, the maximum difference of displacement between the left hip bone with serious injury and the right hip bone with minor injury is 0.122 mm, and the maximum stress of the left and right hemi-pelvis is 115.5 MPa and 124.28 MPa, respectively. Moreover, the differences of average stress between the bone and internal fixators are in the range of 2.3-13.7 MPa. During the eight phases of gait, the stress distribution of the left and right hip bone is similar. Meanwhile, based on the acetabular three-column theory, the strain energy ratio of the central column is relatively large in stance phases, while the anterior column and posterior column of the acetabular three-column increase in swing phases.

CONCLUSIONS

The acetabular internal fixators designed by according to the anatomical feature of the acetabulum are integrated into the normal physiological stress conduction of the pelvis. The design and placement of the acetabular internal fixation conforming to the biomechanical characteristics of the bone is beneficial to the anatomical reduction and effective fixation of the fracture, especially for complex acetabular fracture.

Total hip arthroplasty for posttraumatic osteoarthritis secondary to acetabular fracture: An evidence based on 1,284 patients from 1970 to 2018

BACKGROUND

Posttraumatic osteoarthritis (PTOA) can be a crippling sequela of acetabular fracture (AF), and total hip arthroplasty (THA) is often necessary to alleviate the clinical progression of symptoms. The purpose of this study was to summarize the existing clinical evidence concerning the surgical management of AF with THA through meta-analyses.

METHODS

Databases were searched for articles published between 1995 and January 2022 that contained the keywords "acetabular," "fracture," "arthroplasty," and "osteoarthritis." Our study was registered in PROSPERO under number CRD42022314997.

RESULTS

We screened 3,125 studies and included data from 31 studies with 1,284 patients. The median patient age at the time of THA was 52 years and ranged from 19 to 94 years. The pooled overall survival rate was 88% [86%-90%, 95% confidence interval (CI)] and could reach 83% at ≥15-year follow-up. For the Harris Hip Score, we pooled 22 studies with an overall mean difference of 43.25 (40.40-46.10, 95% CI; P < 0.001), indicating a large clinical effect. The pooled complications (incidence rates) across studies were: heterotopic ossification (22.53%), implant dislocation (4.66%), implant infection (3.44%), and iatrogenic nerve injury (1.07%).

CONCLUSION

THA in patients with PTOA following AF leads to significant improvement in symptoms and function at ≥15-year follow-up. Survival rates of implants free from re-operation or revision after THA decreased with follow-up time and could still reach 83% at ≥15-year follow-up. THA might be an effective therapeutic method for patients with PTOA due to AF.

Primary stability of multi-hole cups compared to plate osteosynthesis in osteoporotic anterior column and posterior hemi-transverse acetabular fractures—A biomechanical comparison

Introduction

Acetabular fractures pose high demands on the surgeon and in the case of osteosynthetic treatment, anatomical reconstruction has the highest priority to achieve a good outcome. However, especially in older patients with poor bone quality, even anatomical reconstruction is no guarantee for a good clinical outcome and may nevertheless end in early osteoarthritis. Primary arthroplasty therefore has an increasing importance in the treatment of these patients. The aim of this study was to biomechanically compare fracture gap displacement and failure load as an assessment measure of the primary stability of conventional plate osteosynthesis with the treatment using a sole multi-hole cup for acetabular fractures.

Methods

Six hemi-pelvises each with anterior column and posterior hemi-transverse (ACPHT) fracture were treated with either plate osteosynthesis or a multi-hole cup. The tests were carried out in a standardised test set-up with cyclic loading in various stages between 150 N and 2500 N. The fracture gap displacement was recorded with optical 3D measuring and the failure load was determined after the cyclic measurement.

Results

With increasing force, the fracture gap displacement increased in both procedures. In each group there was one treatment which failed at the cyclic loading test and a bone fragment was broken out. The primary stability in arthroplasty was comparable to that of the standard osteosynthesis.

Conclusions

The results found seem promising that the primary arthroplasty with a sole multi-hole cup and corresponding screw fixation achieves an initial stability comparable to osteosynthesis for typical ACPHT fractures. However, further clinical studies are needed to prove that the cups heal solidly into the bone.

What's New in Geriatric Acetabular Fractures

The incidence of acetabular fractures in the geriatric population is growing, yet the optimal treatment algorithm remains a controversial topic among orthopaedic surgeons. This review highlights key studies published over the past 5 years on the outcomes of various treatment options for geriatric acetabular fractures. Topics include surgical timing, mortality and risk factors, nonoperative treatment, open reduction internal fixation, and acute total hip arthroplasty.

The use of Verbrugge forceps for reduction of the posterior column element in displaced acetabular fractures: clinical and radiological evaluation

PURPOSE

Different reduction techniques and tools are described to facilitate anatomical reduction of acetabular fractures. However, maintenance of reduction, plate placement, and fracture fixation remain a challenge owing to the large surface area occupied by the available reduction tools. This study aims at radiological and functional assessment of the effectiveness of a novel reduction technique for the posterior column element in displaced acetabular fractures.

METHODS

A prospective study was conducted for evaluation of a novel reduction technique; the use of the conventional large holding Verbrugge forceps for reduction of posterior column and transverse, with or without posterior wall, fractures. Intra-operative safety and reduction time were evaluated. The immediate postoperative quality of reduction was assessed using Matta radiographic criteria. The functional outcome was evaluated at the latest follow-up visit using the modified Merle d'Aubigne and Postel (MDP) score.

RESULTS

Thirty patients with a mean follow-up of 18.1 months were included. Fifteen had transverse/posterior wall, ten had transverse, and five had posterior column fractures. All fractures were displaced ≥ 2 mm on anteroposterior and/or Judet views of the pelvis without traction. The average operative time was 100.4 min with 12.5 min reduction time. No intra-operative complications were encountered. Twenty-three patients (76.6%) had anatomical while seven (23.3%) had imperfect reduction. The functional outcome score was excellent in three patients, good in 18, fair in four, and poor in five patients at the latest follow-up.

CONCLUSION

The use of the conventional large Verbrugge bone-holding forceps for the reduction of the posterior column element in displaced acetabular fractures using the Kocher-Langenbeck approach is a safe, effective, time-saving, and technically undemanding procedure.

Medial buttressing of the quadrilateral surface in acetabular and periprosthetic acetabular fractures

Background

In geriatric acetabular fractures, the quadrilateral plate is often involved in the fracture pattern and medially displaced. Open reduction and internal fixation (ORIF) includes reduction of the quadrilateral plate and securing its position. In this study, the concept of medial buttressing in acute and periprosthetic acetabular fractures is evaluated.

Materials and methods

Patients, who sustained an acetabular fracture between 2012 and 2018, in whom ORIF with a specific implant for medial buttressing was performed, were included in the study. Patients were divided in two groups; acute acetabular fractures (group 1) and periprosthetic acetabular fractures (group 2). Demographics, type of fracture, surgical approach, type of implant for medial buttressing, comorbidities, general and surgical in-hospital complications and length of hospital stay were recorded retrospectively. The following data were collected from the surviving patients by telephone interview: EQ-5D-5L, SF-8 physical and SF-8 mental before trauma and at follow-up, UCLA activity scale, Parker Mobility Score and Numeric Rating Scale.

Results

Forty-six patients were included in this study, 30 males (65.2%) and 16 females (34.8%). Forty patients were included group 1 and six patients in group 2. The median age of patients of group 1 was 78 years. Among them, 82.5% presented with comorbidities. Their median length of in-hospital stay was 20.5 days. 57.5% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all but one patient. ORIF together with primary total hip arthroplasty (THA) was carried out as a single stage procedure in 3 patients. Secondary THA was performed in 5 additional patients (5/37 = 13.5%) within the observation period. Among surviving patients, 79.2% were evaluated after 3 years of follow-up. Quality of life, activity level and mobility dropped importantly and were lower than the values of a German reference population. SF-8 mental did not change. The median age of patients of group 2 was 79.5 years, all of them presented with one or several comorbidities. The median length of in-hospital stay was 18.5 days. 50% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all patients. 5 of 6 patients (83.3%) could be evaluated after a median of 136 weeks. In none of these patients, secondary surgery was necessary. Quality of life, activity level and mobility importantly dropped as well in this group. SF-8 mental remained unchanged.

Conclusion

In geriatric acetabular fractures with involvement and medial displacement of the quadrilateral plate, medial buttressing as part of ORIF proved to be reliable. Only 13.5% of patients of group 1 needed a secondary THA within 3 years of follow-up, which is lower than in comparable studies. Despite successful surgery, quality of life, activity level and mobility dropped importantly in all patients. The loss of independence did however not influence SF-8 mental values.

Total hip arthroplasty in acetabular fractures

Total Hip Arthroplasty (THA) is a well-accepted treatment for established hip arthritis following acetabular fractures. If a conservatively managed or operated case progresses to non-union/mal-union failing to restore the joint integrity, it may eventually develop secondary arthritis warranting a total hip arthroplasty. Also, in recent years, acute total hip arthroplasty is gaining importance in conditions where the fracture presents with pre-existing hip arthritis, is not amenable to salvage by open reduction and internal fixation, or, a poor prognosis is anticipated following fixation. There are several surgical challenges in performing total hip arthroplasty for acetabular fractures whether acute or delayed. As a separate entity elderly patients pose a distinct challenge due to osteoporosis and need stable fixation for early weight bearing alleviating the risk of any thromboembolic event, pulmonary complications and decubitus ulcer. The aim of surgery is to restore the columns for acetabular component implantation rather than anatomic fixation. Meticulous preoperative planning with radiographs and Computed Tomography (CT) scans, adequate exposure to delineate the fracture pattern, and, availability of an array of all instruments and possible implants as backup are the key points for success. Previous implants if any should be removed only if they are in the way of cup implantation or infected. Press fit uncemented modern porous metal acetabular component with multiple screw options is the preferred implant for majority of cases. However, complex fractures may require major reconstruction with revision THA implants especially when a pelvic discontinuity is present.