Injury, Int. J.

Care Injured 49S3 (2018) S65–S73

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Periprosthetic acetabular fractures: A New classification proposal

R. Pascarellaa , P. Sangiovannia,* , S. Cerbasia , R. Fantasiaa , O. Consonnib , V. Zottolab ,
A. Panellac , B. Morettic
a
Department of Orthopedic and Trauma Surgery, Ospedali Riuniti, Ancona, Italy
b
Department of Orthopedic Surgery and Traumatology, Sant Anna Hospital, Como, Italy
c
Orthopedic, Trauma and Spine Unit, Department of Basic Medical Sciences, Neuroscience and Sense Organs, School of Medicine, AOU Policlinico Consorziale,
University of Bari “Aldo Moro”,Bari, Italy

A R T I C L E I N F O A B S T R A C T

Article history: Introduction: Acetabulum periprosthetic fractures are rare, but are increasing, due to increase in high-
Received 29 June 2018 energy trauma and a decrease in mortality index.
Received in revised form 30 September 2018 Reconstruction of an acetabular fracture, in the presence of hip arthroplasty can be very complex and
Accepted 30 September 2018
represents a real challenge for orthopedic surgeon.
Aim of this multicentric study is to classify periprosthetic acetabulum fractures and to propose a
Keywords: treatment algorithm.
Acetabular fractures
Materials and methods: 24 cases of acetabular periprosthetic fracture were treated surgically from
New classification
Periprosthetic fractures
01.01.2010 to 31.04.2017 in three different hospitals; 4 males and 20 females, average age 76 years (range
56–90 years).
Treatment: 4 cases treated conservatively, 8 cases ORIF, 2 cases treated with acetabular ring and screws, 9
cases ORIF and acetabular cup revision, 1 implant removal without revision.
Results: All cases were reviewed at minimum 12 months follow-up.
In 22 cases, there was no need for new surgical procedures and radiographically all implants appeared
stable and with good bone integration.
In a case of a type 1b fracture, a dislocation of prosthetic implant was observed after 3 months.
In a case prosthesis was explanted and it was not possible to perform a revision.
Discussion and conclusions: Fracture classification systems must facilitate communication between
surgeons and encourage documentation and research. However, they should also have prognostic value,
so from them should come directly a treatment algorithm.
In our experience, most important factors as prognostic and therapeutic predictors were: implant
stability and timing of fracture: intraoperative or postoperative. In postoperative fractures CT is
mandatory to evaluate cup mobilization and fracture patterns.
Our classification proposal is simple and easy to remember for daily use. From it is derived a simple
treatment plan.
© 2018 Elsevier Ltd. All rights reserved.

Introduction There has been an increase in the population of hip prostheses

Acetabulum periprosthetic fractures are rare [1,2] and occur in
0.8% of patients with THR (Total Hip Replacement), in spite of 7.8%
of femoral periprosthetic fractures.
A statistically significant increase of incidence is to be found in
the use of non-cemented, press-fit elliptical cups [3,4].
* Corresponding author at: Department of Orthopedic and Trauma Surgery,
Ospedali Riuniti, via Conca 71, Ancona, Italy.
E-mail address: c.sangiovanni@libero.it (P. Sangiovanni).
in the last 10 years with an increase in high energy trauma and a
decrease in the mortality index.
The cause is due to the progressive update about construction of
vehicles, more protective than in past, and to greater diffusion of
seat belt use.
These fractures are divided in intraoperative [2,5) more
common, and postoperative, usually related to high energy [2,6]
trauma or low energy trauma in osteoporotic bone.
Reconstruction of an acetabular fracture, in the presence of hip
arthroplasty can be very complex and represents a real challenge
for orthopedic surgeon. He must have both trauma and orthopedic
skills as often a revision of acetabular cup is required and an
internal fixation too.

https://doi.org/10.1016/j.injury.2018.09.061
0020-1383/© 2018 Elsevier Ltd. All rights reserved.
S66 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73

In preoperative planning it must consider fracture type, that is
involvement of one or both columns, prosthetic implant stability,
timing, age and general condition of patient.
Aim of this study is to classify periprosthetic acetabulum
fractures and to propose a treatment algorithm.
Previous classification
Petersen and Lewallen [7] in 1996 were the first authors to
propose a classification of these fractures. They studied 11 patients
with a mean of 6.2 years after a total hip arthroplasty between
1985 and 1991 and distinguished fractures into two types
according to acetabular component stability:
- Type I Stable Cup
- Type II Unstable cup.
Authors included injuries that were not traumatic but so
forcibly defined;
At point 4 and 5, in fact, it talks about osteolytic lesions.
These are complications of prosthetic procedure, due in most
cases to implant loosening, which occurs before or often without
traumatic event.
This system, has already been slated and surpassed in 2008 by
Darin Davidson [10],
who proposed, in addition to the Vancouver Classification of
periprosthetic femoral fractures, three types of acetabular fracture:
- type I, undisplaced fracture not compromising the stability of
reconstruction;
- type II, undisplaced fracture that may compromise the stability
of reconstruction;
- type III, displaced fracture.

This classification is simple and easy to be clinically used, but, in our In his study, the factors mainly discriminating were the
point of view, the use of a single biomechanical parameter (stability) is displacement of the fracture and implant stability.
reductive, little oriented to specific therapeutic indication and it is Limit: the total exclusion of postoperative fractures.
referred only to postoperative acetabular fractures. In 2014 Ducan and Haddad [11], proposed overcoming
Callaghan [8] in 1998 proposed a classification, which consid- individual classifications for each anatomical region, and the use
ered as parameter stability and fracture pattern, studying the of what they called: Unified Classification System (UCS) for
affected anatomical region. Periprosthetic Fractures.
He identified four types of fractures: This classification, unique pattern for all joints, was later
adopted by AO.
1 Anterior wall It considers as prominent factors: anatomical pattern of
2 Transverse fracture and prosthetic implant stability (whatever it is).
3 Inferior lip It is made by 12 schemes, 2 for each of 6 joint. (Table1)
4 Posterior wall Each of these 12 schemes is ulterior divided in 6 groups from A
to F with other subgroups. (Table 2)
It is totally based on an in vitro investigation of the acetabulum As you can see, this classification system is very complex,
forces discharge using press-fit vs cemented techniques to fix the verbose, difficult to storage and daily use.
acetabular component. Then, once a fracture is hardly classified, it doesn’t give any
It results in a list of anatomical injured areas, without taking therapeutic indication.
account of traumatic postoperative periprosthetic fractures.
W.Paprosky and C.J. Della Valle [9] in 2003 proposed a new Classification proposal
classification, today the most widely used.
This classification is particularly complete and detailed, and Fracture classification systems have multiple purposes:
considers fractures timing, (intraoperative and postoperative), They must facilitate communication between surgeons and
implant stability and bone osteolysis. encourage documentation and research.
Use of press-fit non-cemented cups was recognized as risk However, to be clinically significant, they should also have
factors for intra-operative fracture and increasing risk of implant prognostic value, and primarily from them should come directly a
loosening due to high prevalence of periacetabular osteolysis using treatment algorithm.
this kind of cup. In our experience, most important factors as prognostic and
therapeutic predictors were: implant stability in combination with
1 Intraoperative during a component insertion timing of fracture, that is: intraoperative or postoperative/
a Recognized, stable component, undisplaced fracture traumatic. In postoperative fractures Ct is mandatory to evaluate
b Recognized, displaced fracture, cup unstable cup mobilization and fracture patterns.
c Not recognized intraoperatively So we attempted to summarize these parameters in a new
2 Intraoperative during a removal classification proposal:
a Less than 50%bone stock loss
b Greater than 50% bone stock loss
Table 1
3 Traumatic 2014 Ducan and Haddad classification: step 1.
a component stable
b Component unstable I Shoulder I,1 Glenoid/scapula
I,2 Humerus, proximal
4 Spontaneous II Elbow II,1 Humerus, distal
a Less than 50% bone stock loss II,2 Ulna/radius, proximal
b Greater than 50% bone stock loss III Wirst III,1 Radius/ulna, distal
5 Pelvic discontinuity III,2 Carpus/metacarpals
IV Hip IV,1 Acetabulum/pelvis
a Less than 50% bone stock loss
IV,2 Femur, proximal
b Greater than 50% bone stock loss V Knee V,1 Femur, distal
c Associated with pelvic radiation V,2 Tibia, proximal
V,3 Patella
This cumbersome classification system results very complex VI Ankle VI,1 Tibia, distal
VI,2 Talus
and difficult to apply.
 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73 S67

Table 2
2014 Ducan and Haddad classification: step 2 subgroup IV.1.

A: Apophyseal or extraarticular/ periarticular A1: Avulsion of Anterior inferior and superior iliac spine
A2: Avulsion of Ischial tuberosity
B: Bed of the implant or around the implant B1: Prosthesis stable, good bone: Acetabular rim or floor, good bone
B2: Prosthesis loose, good bone: Loose cup, good bone
B3: Prosthesis loose, poor bone or bone defect: Loose cup,poor bone,
defect; Pelvic discontinuity
C: Clear of or distant to the implant Pelvic/acetabular fractures distant to the implant
D: Dividing the bone between two implants or interprosthetic or intercalary Pelvic fracture
between bilateral total hip arthroplasties
E: Each of two bones supporting one arthroplasty or polyperiprosthetic Pelvis and femur
F: Facing and articulating with a hemiarthroplasty Fracture of the acetabulum articulating with
the femoral hemiarthroplasty

Table 3
Acetabulum periprosthetic fractures classification by Pascarella 2018.

Timing Prosthesis stability

1. Intraoperative fractures a. Prosthesis stable
b. Prosthesis unstable
2. Postoperative/Traumatic fractures a. Prosthesis stable
b. Prosthesis unstable, mobilized simultaneously trauma
c. Prosthesis unstable, mobilized before trauma (osteolysis/bone loss)

According to the traumatic event timing, we divided acetabu- Intraoperative fractures

lum periprosthetic fractures into two groups (Table 3):
1 fractures occurred intraoperatively
2 fractures due to trauma occurred postoperatively.
According to second parameter : acetabular implant stability
we divided the 1 st group in
a) Prosthesis stable and b) Prosthesis unstable.
Then 2nd group in:
a a Prosthesis stable;
b Prosthesis unstable, mobilized simultaneously trauma;
c Prosthesis unstable, mobilized before trauma.
In 1a type stable implant fractures: conservative treatment consists
of 8 weeks of complete discharge or add screws to increase primary
stability trough the acetabular component. Case 1 (Fig. 1a–c).
In 1b type fractures, with unstable implants, if there is more
than 2 cm displacement, fracture reduction and internal fixation is
indicated. Goal of fixation will be implant stability. In some cases it
is possible to use prosthetic rings with screws and cemented cups
or implant revision. Case 2 (Fig. 2a and b).
Post-traumatic fractures

Anyway, the fracture is always preceded by a traumatic event,
even at low energy, without neglecting possibility that this should
acts on a bone suffering from an osteolytic lesion or presence of
bone loss. This information has still a high prognostic and
therapeutic value.
Therapeutic algorithm
As mentioned above, a classification that has a practical value,
should also give clear guidance to the surgeon about treatment to
be undertaken once studied the lesion.
In this regard, from our classification is derived a simple
treatment plan, storable and easy to use.
Each group and subgroup corresponds to a specific therapeutic
approach (Table 4; Diagram 1):
Type 2a treatment is conservative with discharge for 8 weeks.
ORIF may be necessary if fragment can cause impingement with
prosthetic implant as in Case 3 (Fig. 3a–d).
Type 2b treatment (prosthetic mobilization contextual to
trauma): Prosthetic revision possibly associated to synthesis if
necessary. Case 4 (Fig. 4a–e).
Type 2c treatment (implant mobilization prior to trauma).
Prosthetic revision with bone loss restoration if necessary. Case 5
(Fig. 5a–c).
Material and methods
24 cases of acetabular periprosthetic fracture were treated from
01.01.2010 to 31.04.2017 in three different hospitals; 4 males and
20 females, average age 76 years (range 56–90 years).

Table 4
Therapeutic Algorithm.

Timing Prosthesis stability Treatment

1. Intraoperative fractures
2. Postoperative/Traumatic
fractures
a. Prosthesis stable Conservative treatment / increase primary stability with screws
b. Prosthesis unstable ORIF if displacement > 2 cm / acetabular ring with screws/ Implant
revision
a. Prosthesis stable Conservative treatment/ ORIF
b. Prosthesis unstable, mobilized simultaneously trauma Implant revision/ acetabular ring /ORIF
c. Prosthesis unstable, mobilized before trauma (osteolysis/ Implant revision/ acetabular ring /ORIF /bone graft
bone loss)
S68 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73
Diagram 1.
There were 16 cases of intraoperative fracture during insertion
of a press-fit cup. 8 cases occurred in post-operative period of
which 2 cases was a cemented cup.
Authors did not include injuries, which occur before or often
without traumatic event that were not traumatic but only
osteolytic lesions, complications of the prosthetic procedure.
Classification:
- 6 cases 1a: intraoperative fracture with stable implant
- 10 cases 1b: intraoperative fracture with unstable implant
- 3 cases 2a: post-traumatic fracture with a stable implant
- 4 cases 2b: post-traumatic fracture with implant mobilization
contextually to the trauma
- 1 case 2c: post-traumatic fracture with implant mobilization
before trauma
Treatment:
- Type 1a: 3 cases of conservative treatment including 1 anterior
wall fracture (Case 1), 3 cases of stability increase with screws
- Type 1b: 3 cases ORIF, 2 cases treated with acetabular ring and
screws, 5 cases treated with ORIF and acetabular cup revision
(Case 2)
- Type 2a: 1 case treated conservatively. 1 case of fracture of
anterior column was treated with ORIF (Case 3), 1 case of
transverse fracture, was treated with ORIF.
- Type 2b: 3 cases of osteosynthesis with revision of cemented
acetabular cup (Case 4), 1 case of implant removal without
revision.
- Type 2c: 1 case of osteosynthesis with revision of acetabular cup
(Case 5)
Results
All cases were reviewed at minimum 12 months follow-up.
In a case of a type 1b fracture, a dislocation of prosthetic implant
was observed after 3 months, it was treated with closed reduction.
In the case where prosthesis was explanted, it was not possible
to perform a contextual revision because fracture was too
comminuted with poor bone. Screws did not have sufficient bone
grip.
Subsequently, a revision was not performed after consolidation
to due bad general patient conditions.
In remaining cases, there was no need for new surgical
procedures.
Radiographically all implants appeared stable and with good
bone integration.
Discussion and conclusions
Periprosthetic acetabulum fractures are rare, but can occur
during clinical practice [1]. Their incidence will inevitably
tend to rise in coming years, due to exponential increase in
number of implanted prostheses and progressive aging of
population.
In these cases it is very important, after accurate imaging, to
proceed with the lesion’s classification in order to study fracture
type and choose appropriate treatment [2].
Due to the anatomical complexity of the pelvis and the presence
of prosthesis, over the years numerous classifications have been
proposed.
Each of these were based on different variables for example
timing (preoperative / postoperative) anatomical pattern or
lesion mechanism, often limited to in vitro studies (Callaghan
[8]) or very complex, verbose, difficult to remember (Ducan and
Haddad [11]).
However no classification of those mentioned, directly indi-
cates a therapeutic algorithm.
Once the fracture has been classified, a clear indication of
treatment should emerge from the scheme.
In our experience, a simple, easy-to-remember and precise
indication of the treatment helps surgeon to make decisions in any
case.
In particular in these rare and complex fractures, for which it is
difficult to have a lot of experience, even the less experienced
surgeon has an aid in order not to make mistakes in decision-
making.
Our classification proposal is simple and easy to be storage and
daily used.
It also gives clear guidance to the surgeon about treatment once
studied the lesion.
In intra-operative fractures, it is very important to check
prosthetic implant stability.
 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73 S69

Fig. 1. a) Preoperative X-ray. b) Transverse fracture in 64 years old patient. Classification: 1a type. Implant stable Conservative treatment as therapeutic algorithm based on
classification. c) 1 year follow up.
S70 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73

Fig. 2. a) Femoral neck fracture in 77 y.o. lady. b) Intraoperative fracture. Classification: 1b type. Implant unstable. ORIF and first implant cup.
 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73 S71

Fig. 3. a) Preoperative X-ray. 79 years old man, who fell after ten days from hip arthroplasty revision surgery. Classification: 2a type. Implant stable. b) Ct 3d. c) Ct 3d. d)
Treatment: ORIF without cup revision.

If stable, it may be sufficient to keep patient in discharge for 8
weeks, or increase primary stability of implant with screws.
If implant appears unstable it may be necessary to remove it,
perform fracture reduction and internal fixation, then insert a first
implant or use a ring and cemented cup.
In post-traumatic fractures, if displacement is minimal it may
not affect implant stability and therefore surgical treatment may
not be necessary. Ct is mandatory in all cases.
When implant is mobilized it is necessary to define whether
mobilization is consequent or preceding trauma. In these cases
acetabular cup has to be removed, fracture reduced if more two cm
dislocation and new cup is re-implanted.
In extreme cases, when prosthesis is mobilized but fracture
does not allow a revision, due to local conditions, prosthesis can be
explanted and, once consolidated fracture, to perform new cup re-
implantation.
Reconstruction of an acetabular fracture, in the presence of hip
arthroplasty can be very complex and represents a real challenge
for orthopedic surgeon. He must have both trauma and orthopedic
skills as often a revision of acetabular cup is required and an
internal fixation too.
In the preoperative planning it must consider fracture type that
is involvement of one or both columns, prosthetic implant stability,
timing, age and general condition of patient.
S72 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73

Fig. 4. a) Preoperative X-ray. 72 years old lady. Classification: 2b type. Implant unstable. b) Ct scan. c) Ct scan. d) Intraoperative picture: fracture-mobilized cup, which was
instable. e) 1 year follow up: ORIF and cup revision with cemented cup.
 R. Pascarella et al. / Injury, Int. J. Care Injured 49S3 (2018) S65–S73 S73

Fig. 5. a) Preoperative X-ray. 86 years old lady, who made total hip replacement 12 years before. She suffered a car accident. Classification: 2c type. b) Ct scan, cup
mobilization: Acetabular component was mobilized before trauma. c) 1 year follow up: acetabular ring, cemented cup.

Conflict of interest
All authors must disclose any financial and personal relation-
ships with other people, or organisations, that could inappropri-
ately influence (bias) their work, all within 3 years of the beginning
the work submitted.
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