Intraoperative acetabular periprosthetic fracture (IAPF) in total hip arthroplasty: a systematic review of outcomes and complications in conservative and surgical treatment.

BACKGROUND

Total hip arthroplasty (THA) is a widely performed and highly successful orthopedic procedure; however, intraoperative acetabular periprosthetic fractures (IAPF) remain a significant yet underreported complication. The increasing prevalence of THA, coupled with rising cases of osteoporosis, necessitates a better understanding of the incidence, risk factors, and long-term impact of these fractures. Despite advances in surgical techniques and implant designs, IAPFs present considerable challenges, affecting implant stability and patient outcomes. The aim of this study is to analyze the complications, reoperation rates, and functional outcomes associated with both conservative and surgical treatments of IAPF.

METHODS

A systematic review was conducted following PRISMA guidelines to evaluate studies published between 1999 and 2024 on the management and outcomes of IAPF. A comprehensive search of PubMed, Cochrane Library, and Web of Science identified 104 relevant studies, of which 11 met the inclusion criteria. Data extraction focused on fracture classification, treatment approaches, postoperative complications, reoperation rates, and functional outcomes. The quality of included studies was assessed using the Modified Coleman Methodology Score (mCMS).

RESULTS

A total of 323 THAs were analyzed, with 225 fractures managed conservatively and 98 requiring surgical intervention. Conservative treatment was associated with higher complication (15.5%) and reoperation rates (14.2%) compared to surgical treatment (5.1% and 3%, respectively; p = 0.015 and p = 0.006). The most common complication in the conservative group was aseptic cup loosening, whereas surgical patients experienced fewer mechanical failures. Functional outcomes, as measured by the Harris Hip Score (HHS), Postel Merle d'Aubigné (PMA) score, and Japanese Orthopaedic Association (JOA) Hip Score, demonstrated significant postoperative improvements across both treatment groups. However, study heterogeneity and methodological limitations restricted direct comparisons.

CONCLUSION

IAPFs remain a complex complication in THA, necessitating individualized treatment based on fracture stability and implant fixation. While conservative management is viable in stable cases, surgical intervention may lead to better long-term outcomes in select patients. Standardized classification systems and treatment protocols are needed to improve clinical decision-making and optimize patient care. Future research should focus on refining management strategies and incorporating patient-specific risk factors such as bone mineral density and implant design.