Delayed fixation of neglected acetabular fractures: clinical challenges and mid-term outcomes of a prospective case series.

Objective: Neglected acetabular fractures, defined as those not addressed surgically within three weeks of injury, pose significant technical and prognostic challenges due to chronic displacement, malunion, and soft tissue contracture. This study aimed to evaluate radiological and functional outcomes of open reduction and internal fixation (ORIF) in a large prospective cohort managed at a tertiary trauma center.

Methods: Between 2009 and 2019, patients aged 14 years and older with displaced, neglected acetabular fractures (> 3 weeks post-injury) were enrolled at a high-volume Level I pelvic trauma center. Exclusion criteria included pathological fractures, fresh fractures, unreconstructable articular surfaces, and patients who did not complete the minimum follow-up period. Of the total cohort, 94 patients underwent ORIF and were analyzed. Preoperative evaluation included CT imaging, and fractures were classified using the Letournel-Judet system. Radiological reduction quality was graded by Matta's criteria, and functional recovery was assessed using the modified Merle d'Aubigné-Postel score. Secondary outcomes included complication rates and conversion to THA. For subgroup analysis, patients were stratified into early-late presenters (3-5 weeks) and very-late presenters (> 5 weeks). Statistical analysis employed chi-square tests for categorical variables, Student's t-test or Mann-Whitney U test for continuous variables, and multivariate logistic regression to identify predictors of outcome, with significance set at p < 0.05.

Results: Among the 94 patients analyzed, anatomical reduction (≤ 1 mm displacement) was achieved in 59.6%, with imperfect and poor reductions in 26.6% and 13.8%, respectively. Quality of reduction (β = 0.44, p < 0.001) and surgical delay (β = - 0.32, p = 0.006) independently predicted functional outcome, while fracture type and femoral head condition were not significant.On subgroup comparison, early-late presenters (3-5 weeks) showed a trend toward better outcomes compared with very-late presenters (> 5 weeks), although differences did not reach statistical significance. Major complications included heterotopic ossification (12.8%), post-traumatic arthritis (14.9%), avascular necrosis (9.6%), and conversion to THA during follow-up (10.6%).

Conclusion: This study represents one of the largest prospective series on neglected acetabular fractures with midterm follow-up. Despite delayed presentation, ORIF achieved satisfactory anatomical and functional results in most cases. Early surgical intervention within the neglected window was associated with superior outcomes, while subgroup analysis highlighted a gradual adverse effect of increasing delay. These findings underscore the importance of individualized surgical strategies, meticulous planning, and experienced surgical execution in optimizing results for this challenging patient population.