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The acetabulum is the cup-shaped part of the pelvis that forms the “socket” of the ball-and-socket hip joint. An acetabular fracture occurs when this socket is broken due to extreme trauma. Pelvic and acetabular fractures require rapid and precise treatment and, in some cases, one or more surgical procedures.
Through advances in surgical treatment of pelvic injuries, an experienced orthopaedic trauma surgeon like Dr Arunva Lala has the potential to intervene and improve outcomes from these potentially devastating injuries.
The severity of the injury depends on several factors, including:
• The number and size of the fracture fragments
• The amount each piece is out of place (displaced) — In some cases, the broken ends of bones line up adequately; in more severe fractures, there may be a large gap between the broken pieces, or the fragments may overlap each other.
• The injury to the cartilage surfaces of both the acetabulum and the head of the femur
• The injury to surrounding soft tissues, such as muscle, tendons, nerves, and skin.
A fractured acetabulum is almost always very painful. The pain is worsened with movement. If nerve damage has occurred with the injury, the patient may feel numbness, weakness, or a tingling sensation down the leg.
Nonsurgical treatment may be recommended for stable fractures where the bones are not displaced or for patients who are at higher risk for surgical complications like severe osteoporosis, heart disease, or other medical concerns.
Nonsurgical treatment may include walking aids, Positioning aids and medication.
Most acetabular fractures are treated with surgery. During surgery, the displaced bone fragments are first re-positioned (reduced) into their normal alignment. The doctor will then attach metal plates and screws to the outer surfaces of the bone to hold the fragments together while they heal.
In some cases, the acetabulum is so damaged that repair or reconstruction is unlikely to provide a good long-term result. In this situation, the 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.
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 may develop near the skin surface around an incision or deep in the surgical wound. Surface infections are typically treated with antibiotics for 1 to 2 weeks. Deeper infections usually require a surgical procedure to thoroughly cleanse the wound as well as a longer course of antibiotics, usually 4 to 6 weeks.
Mobility after surgery will be limited. This can slow the normal blood flow in the legs and increase risk for a blood clot. The 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, often leading to arthritis with increasing pain and stiffness.
Treatment with physical therapy, walking aids, medications, and lifestyle changes often helps. In severe cases that limit activity, a total hip replacement may be the best option to relieve symptoms.
Sciatic Nerve Injury
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.
Even with successful surgical repair to an acetabular fracture, if the normal blood flow and nutrition necessary to keep the femoral head as well as the acetabulum bone healthy is disrupted, the bone cells will die. This condition is called avascular necrosis. 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.
Recovery and Healing :
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. Medications are often prescribed for short-term pain relief after surgery. Most patients require crutches or a walker for a period of time. In many cases, a physical therapist will provide instructions on how to safely begin moving and use crutches or a walker.
It is important to follow the doctor’s specific instructions for weight bearing. Walking on the 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.
Due to the serious nature of acetabular fractures—as well as the likelihood of developing long-term complications—many patients have to incorporate changes in their lifestyle after the surgery, including physiotherapy, medications, exercises, restricted weight bearing and well-managed physical activity under the supervision of their doctor.