Secondary and delayed reconstruction of pelvic ring and acetabular fractures

Secondary or delayed reconstructions following mal-or nonunited fractures of the pelvic ring and acetabulum are challenging procedures. Three different healing problems have to be distinguished: malunion, nonunion, and fractures and/or dislocations that have healed incompletely. Combinations of these three pathologies are also possible. Delayed reconstructions have no chance of success unless the patient's signs and symptoms are clearly attributable to the malunion or nonunion. This means that extensive clinical and radiological evaluation is mandatory preoperatively. Risks involved and the results that can be expected must be discussed thoroughly with the patient once the surgery has been planned in detail. For the treatment of nonunion or delayed union, the unstable zone must be debrided, and autologous bone grafting with cancellous bone and stable internal fixation are then required. Malunion requires careful mobilization of the malunited fracture fragments, which is often a very demanding procedure. If there is already advanced damage to the acetabulum little functional improvement can be expected after a corrective osteotomy. Viable treatment alternatives are hip fusion and endoprosthetic joint replacement. Possible complications include damage to neurovascular structures, impaired wound healing, infections and implant failure. Extensive experience in the management of acute fractures of the pelvic ring and acetabulum is essential if delayed reconstruction is to be successful.