Total Hip Arthroplasty for Acetabular Fracture Sequelae: Surgical Complexity and Technical Pitfalls in a Series of 16 Cases

Abstract

Total hip arthroplasty (THA) performed for sequelae of acetabular fractures remains one of the most technically demanding reconstructive procedures in hip surgery due to post-traumatic anatomical distortion, acetabular bone loss, heterotopic ossification, fibrosis, and altered biomechanical landmarks. These factors are associated with increased intraoperative complexity and higher complication rates compared with primary THA. The purpose of this study was to analyze the surgical challenges, technical pitfalls, complications, and mid-term functional outcomes of THA performed for post-traumatic acetabular sequelae. We conducted a retrospective study including 16 patients who underwent THA between January 2020 and January 2026 at Mohammed VI University Hospital, Oujda, Morocco. The cohort showed a marked male predominance in 14 cases (87.5%), with a mean age of 54.6 years (range, 31-79). According to the Judet and Letournel classification, posterior wall fractures in six cases (37.5%) and transverse fractures in three cases (18.75%) were the most frequent patterns, and in 10 cases (62.5%), patients had an associated hip dislocation. Initial fracture management was surgical in seven cases (43.75%) and conservative in nine cases (56.25%). The mean delay between acetabular fracture and development of degenerative sequelae was 97.5 months. Radiographic evaluation demonstrated post-traumatic osteoarthritis in 13 cases (81.25%), femoral head avascular necrosis in seven cases (43.75%), and acetabular non-union in six cases (37.5%). THA was performed using predominantly double-mobility implants with cemented, cementless, hybrid, or reverse hybrid fixation depending on bone quality and acetabular defects. Intraoperative technical difficulties were encountered in 12 cases (75%), mainly related to loss of anatomical landmarks, acetabular bone loss requiring bone grafting, heterotopic ossification, and fibrosis-related neurological vulnerability. Previous osteosynthesis hardware did not interfere with implant positioning and was preserved in all cases to limit operative time and infectious risk. Postoperative complications included periprosthetic fractures in two cases (12.5%), two reported cases of infections (12.5%), neurological complications in three cases (18.75%), and one prosthetic dislocation (6.25%). At a mean follow-up of 45 months, the Harris Hip Score improved significantly from a preoperative mean of 52.7 to 84.4 at final evaluation. Despite a high rate of surgical complexity and complications, THA for acetabular fracture sequelae provided satisfactory mid-term functional outcomes when meticulous preoperative planning and adapted surgical strategies were applied.