How is an acetabular fracture treated?
Your provider will consider several things when planning your treatment, including:
- The specific pattern of the fracture
- How much the bones are displaced
- Your overall health condition
Nonsurgical treatment may be recommended for stable fractures in which the bones are not displaced. It may also be recommended for patients who are at higher risk for surgical complications. For example, patients with severe osteoporosis, heart disease, or other medical concerns may not be able to tolerate surgery.
Nonsurgical treatment may include:
- Walking aids. To avoid bearing weight on your leg, your doctor may recommend that you use crutches or a walker for up to 3 months—or until your bones are fully healed.
- Positioning aids. If your doctor is concerned about joint instability—the ball of your hip sliding within or popping out of the socket— he or she may restrict the position of your hip, limiting how much you are allowed to bend it. A leg-positioning device, such as an abduction pillow or knee immobilizer, can help you maintain these restrictions.
- Medications. Your doctor may prescribe medication to relieve pain, as well as an anti-coagulant (blood thinner) to reduce the risk of blood clots forming in the veins of your legs.
Most acetabular fractures are treated with surgery. Because acetabular fractures damage the cartilage surface of the bone, an important goal of surgery is to restore a smooth, gliding hip surface.
During the operation, your doctor will reconstruct the normal anatomy of the hip joint—aligning the bone fragments to restore the surface of the acetabulum, and fitting the femoral head into the hip socket.
Timing of surgery
Most acetabular fractures are not operated on right way. Your doctor may delay your surgery a few days to make sure your overall condition is stable and you are prepared for the procedure.
During this time, your doctor may place your leg in skeletal traction to immobilize the fracture and prevent additional injury or damage to the hip socket. In skeletal traction, a metal pin is implanted in the femur or tibia bone. Weights attached to the pin gently pull on the leg, keeping the broken bone fragments in as normal a position as possible. For many patients, skeletal traction also provides some pain relief.
Open Reduction and Internal Fixation
During surgery, the displaced bone fragments are first repositioned (reduced) into their normal alignment. Your doctor will then attach metal plates and screws to the outer surfaces of the bone to hold the fragments together while they heal.
Depending upon the location of your fracture, your doctor will make an incision along the front, side, or back of your hip. Occasionally, a combination of approaches or an alternative approach is used.
Total Hip Replacement
In some cases, the acetabulum is so damaged that repair or reconstruction is unlikely to provide a good long-term result. In this situation, your doctor may recommend total hip replacement. In this procedure, the damaged bone and articular cartilage are removed and replaced with artificial parts (prosthesis).
Whenever possible, the doctor will reposition the bones into their normal alignment using screw and plate fixation before performing the total hip replacement. However, if this is not feasible, the doctor may delay the procedure for a period of time to allow the fracture to first heal in its unaligned position. He or she will then perform the total hip replacement— replacing the irregular hip socket with the total hip prosthesis.
Your doctor will consider many factors, including your age and activity level, in determining whether total hip replacement is the most appropriate treatment.
After surgery, you will feel some pain. This is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover from surgery faster.
Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.
Be aware that although opioids help relieve pain after surgery, they are a narcotic and can be addictive. Opioid dependency and overdose has become a critical public health issue in the U.S. It is important to use opioids only as directed by your doctor. As soon as your pain begins to improve, stop taking opioids. Talk to your doctor if your pain has not begun to improve within a few days of your surgery.
Most patients require crutches or a walker for a period of time. For some patients, partial weight bearing may be allowed after 6 to 8 weeks. Full weight bearing will not be allowed until your bones are fully healed, which usually takes from 3 to 4 months. You may require the use of a cane or a walking aid for a longer period of time.
It is important to follow your doctor's specific instructions for weight bearing. Walking on your injured leg prior to healing or participating in physical activities too soon may cause the fracture to shift. This can lead to unevenness in the hip socket or recurrent instability in the hip joint.
Despite weight-bearing restrictions, your doctor may encourage early movement. This means getting up out of bed and doing as much as feasible within specific weight-bearing limitations. In many cases, a physical therapist will provide instructions on how to safely begin moving and use crutches or a walker.
Over time you will learn other exercises to help you build strength and endurance so that you are better able to perform your daily activities.
Sports and Fitness Activities
If your goal is to resume sports or fitness activities, your doctor will guide you in a gradual progression to more vigorous activities. It is important to be aware that due to the complicated nature of many acetabular fractures, many patients arenot be able to return to pre-injury levels of activity.
Your doctor will tell you when it is safe to begin low-impact activities, such as swimming and/or riding a stationary bicycle. However, it can take from 6 to 12 months to return to more vigorous sports activities.
It typically takes from 9 to 12 months for an acetabular fracture to completely heal. The outcomes of treatment will vary from patient to patient, depending on the following:
- Pattern and severity of the fracture
- Other injuries associated with the trauma Patient's age and bone quality
- Patient's general health, including smoking status. Research indicates that smoking can slow down bone healing and increase the risk for other complications
Due to the serious nature of acetabular fractures—as well as the likelihood of developing long-term complications—many patients are not able to return to the same level of activity they had before their injury.
Even when surgery is successful, some patients will experience complications that may lead to the need for additional surgery.
Although advances in treatment and sterile surgical techniques continue to help prevent infections following surgery, surgical site infections do sometimes occur.
These infections may develop near the skin surface around an incision or deep in the surgical wound. Surface infectionsare typically treated with antibiotics for 1 to 2 weeks. Deeper infections can cause further healing complications and may lead to infections that are difficult to cure. They usually require a surgical procedure to thoroughly cleanse the wound as well as a longer course of antibiotics, usually 4 to 6 weeks.
Your mobility after surgery will be limited. This can slow the normal blood flow in your legs and increase your risk for a blood clot. In some cases, a blood clot can break free from the vein wall and travel to the lungs. This is called a pulmonary embolism and it can be life-threatening.
Your doctor may prescribe a blood thinner to help prevent blood clots from forming in the deep veins of your legs.
Even when treated successfully, acetabular fractures can damage the smooth surface of the joint, making it more likely that arthritis will develop during recovery or even years after an injury. Over time, the articular cartilage that protects the joint wears away, leading to increasing pain and stiffness.
Posttraumatic arthritis can be treated like other forms of osteoarthritis — with physical therapy, walking aids, medications, and lifestyle changes. In severe cases that limit activity, a total hip replacement may be the best option to relieve symptoms.
Sciatic Nerve Injury
The sciatic nerve is a large nerve that passes near the back of the hip socket. It supports motion and sensation in the leg and foot. The sciatic nerve can be injured or damaged during the initial injury or during surgery.
Most often, injury to the sciatic nerve results in "foot drop," a condition in which the patient is not able to lift the ankle or toes from the floor when walking. Nerve injuries can range in severity and the amount of recovery can be variable.
A rare problem that may occur after surgery is the growth of bone in the muscles, tendons and ligaments around the hip socket. This is called heterotopic ossification. When this happens, bone grows where it should not be and can cause stiffness not directly related to the condition of the hip socket cartilage. In cases where the amount of extra bone is great enough to interfere with flexibility and function, surgical removal may be required.
Blood supply to the bone can be disrupted at the time of the injury. Even with successful surgical repair, if the normal blood flow and nutrition necessary to keep bone healthy is disrupted, the bone cells will die. This condition is called avascular necrosis.
An acetabular fracture can lead to avascular necrosis in the femoral head as well as the acetabulum. As the bone cells die, the bone gradually crumbles and collapses, along with the smooth cartilage protecting it. Without this smooth cartilage, bone rubs against bone, leading to increased pain, arthritis, and loss of motion and function.