Case Report

Reconstruction of posterior acetabular wall bone defect using a fibular autograft: A case report

Reconstrucción de defecto óseo en la pared posterior del acetábulo con autoinjerto de peroné: reporte de caso

Nestor Augusto Orozco-Castaño1,2 Luis Felipe Correa-Lopez² Alejandro Castaño-Duque³

1 Clínica Ospedale, Department of Orthopedics, Manizales, Colombia.

2 Clínica Santillana, Department of Orthopedics, Manizales, Colombia.

Open access

Received: 07/03/2025

Accepted: 30/06/2026

Correspondence: Luis Felipe Correa-Lopez, Clínica Santillana, Department of Orthopedics, Manizales, Colombia. Email: luisfelipecorrealopez@hotmail.com

How to cite: Orozco-Castaño NA, Correa-Lopez LF, Castaño-Duque A. Reconstruction of posterior acetabular wall bone defect using a fibular autograft: A case report. Rev. colomb. ortop. traumatol. 2026;40:e583. https://doi.org/10.58814/01208845.583

Cómo citar: Orozco-Castaño NA, Correa-Lopez LF, Castaño-Duque A. [Reconstrucción de defecto óseo en la pared posterior del acetábulo con autoinjerto de peroné: Reporte de caso]. Rev. colomb. ortop. traumatol. 2026;40:e583. https://doi.org/10.58814/01208845.583

Copyright: ©2026 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, as long as the original author and source are credited.

Abstract

Introduction: The use of various bone grafts for acetabular defects has been described in the literature. This case report describes the use of a fibular graft to manage secondary hip instability following a posterior hip dislocation associated with a posterior wall acetabular fracture.

Case presentation: A patient sustained a traumatic hip dislocation in 2020, underwent initial management with closed reduction, followed by open reduction and capsular repair with placement of a titanium bone-anchoring system. Residual hip instability persisted, and three years after the initial trauma, the patient sustained a new dislocation due to low-energy trauma. The patient was admitted to a tertiary care center, where a posterior wall acetabular fracture with resorption of the bone fragments and a post-traumatic bone defect was documented, the latter was reconstructed through the novel use of a non-vascularized structural fibular diaphyseal autograft. At the 12-month follow-up, good outcomes were observed.

Conclusion: It is important to maintain a high index of suspicion to rule out acetabular fractures associated with hip dislocations. It is fundamental to restore the bony structural support of the acetabulum to prevent or treat hip instability. The use of fibular bone autograft represents an appropriate option to provide stability to the hip and posterior wall acetabular fractures.

Keywords: Hip Dislocation; Fibula; Bone Transplantation; Acetabulum; Joint Instability; Case Reports (MeSH).

Resumen

Introducción: se ha descrito en la literatura el uso de diversos injertos óseos para el manejo de defectos del acetábulo. Se presenta un caso de utilización de un injerto de peroné para manejo de inestabilidad de cadera secundaria seguido por una luxación posterior asociada a una fractura de la pared posterior del acetábulo.

Presentación del caso: paciente con luxación traumática de cadera en 2020, se realizó manejo inicial con reducción cerrada, seguida de una reducción abierta y reparación de la cápsula con colocación de un sistema de anclaje óseo de titanio. Persistió inestabilidad residual de la cadera y tres años después del trauma inicial presentó una nueva luxación por un trauma de baja energía. El paciente fue ingresado a una institución de tercer nivel donde se documentó una fractura de la pared posterior del acetábulo con reabsorción de los fragmentos óseos y un defecto óseo postraumático, el cual se reconstruyó mediante el uso novedoso de un autoinjerto no vascularizado estructural de peroné diafisario. En el seguimiento a los 12 meses, se observaron buenos resultados.

Conclusión: es importante mantener un alto índice de sospecha para descartar fracturas acetabulares asociadas a luxaciones de cadera. La restauración del soporte estructural óseo del acetábulo es fundamental para prevenir o tratar la inestabilidad de la cadera. El uso del autoinjerto óseo de peroné representa una opción adecuada para proporcionar estabilidad a la cadera y a las fracturas de la pared posterior del acetábulo.

Palabras clave: Luxación de la Cadera; Peroné; Trasplante Óseo; Acetábulo, Inestabilidad de la Articulación; Informes de Casos (DeCS).

Introduction

Traumatic hip dislocations, defined as the separation of the femoral head from the acetabulum caused by a significant external force, typically result from high-energy trauma, primarily from motor vehicle accidents (up to 95%).1-3 Posterior dislocations are the most common type of injury (80–90%). Furthermore, traumatic hip dislocations are frequently associated with concomitant injuries, particularly acetabular and pelvic fractures.1-3 In the general population, the cumulative incidence of acetabular fractures is 5.6 (95% CI 3.3–9.7) per 100 000 person-years.4 Furthermore, patients with traumatic dislocation are at risk of developing complications such as post-traumatic osteoarthritis, avascular necrosis of the femoral head, sciatic nerve injury, and joint instability.3,5 Closed reduction is usually the standard treatment for hip dislocation; however, patients with fractures or delayed presentation may require surgical management.3 Given that the presence of multifragmentary fractures of the posterior acetabular wall, the association with hip dislocation, and delayed reduction are associated with an increased risk of avascular necrosis,5-8 early and effective management is essential to restore hip function and prevent complications.3

According to Beebe et al.,8 following reduction of the dislocation or in cases of irreducible dislocation, a CT scan is recommended to avoid delays in surgical management. Likewise, in cases of comminuted and multifragmentary fractures of the posterior acetabular wall, the use of various types of bone grafts has been described to restore joint congruity and hip stability.9-13 In this context, we present the case of a young man with a bony defect of the posterior acetabular wall not associated with joint replacement, in whom favorable clinical outcomes were achieved following reconstruction with a fibular autograft.

Case Presentation

A 30-year-old male patient presented to the emergency department of a tertiary care hospital in Manizales, Colombia, with severe pain, functional limitation, and shortening of the left lower limb following a fall from standing height two hours prior to arriving at the emergency department. A history of posterior dislocation of the left hip and a fracture of the posterior wall of the acetabulum was documented, resulting from a traffic accident in which he was riding a motorcycle three years earlier. These injuries were initially treated with closed reduction, followed by open reduction of the dislocation and repair of the joint capsule with suture anchors. During open reduction, a fracture of the femoral head was identified and managed conservatively. Additionally, a history of hip dislocation following a low-energy trauma two years prior was reported, which had been managed with closed reduction.

On physical examination, shortening, internal rotation, and adduction of the left lower extremity were noted. In addition, the hip X-ray revealed a posterior dislocation of the left hip (Type V according to the Thompson-Epstein classification),14 so three hours after the injury, closed reduction was performed (under general anesthesia), with satisfactory results and no signs of neurological or vascular injury.

During his stay in the emergency department, a CT scan of the hip with three-dimensional reconstruction was performed, revealing a chronic fracture of the femoral head (Type IV according to the Pipkin classification and Type 1B according to the Brumback classification)15 and a chronic fracture of the posterior wall of the left acetabulum with multiple bone fragments undergoing resorption, the largest of which measured 2x3 cm (Figure 1). Joint instability was considered to be present due to recurrent dislocations associated with low-energy trauma. Based on the CT findings, the recurrent dislocations, and the presence of a chronic femoral head fracture, the patient was admitted for surgical management, which consisted of hip-preserving surgery with reconstruction using a fibular autograft, reduction of bone fragments, and internal fixation.

Figure 1. CT scan with three-dimensional reconstruction showing a fracture of the posterior wall of the acetabulum and a fracture of the femoral head.

Source: Image obtained during the patient’s treatment.

On the first day of hospitalization, the patient underwent surgery, during which a Kocher-Langenbeck approach, dissection by anatomical planes, longitudinal fasciotomy, and a transgluteal approach were performed; a bony defect was found in the upper part of the posterior wall of the acetabulum. In addition, joint instability was assessed through intraoperative mobilization using hip flexion, internal rotation, and adduction maneuvers. Multiple small bone fragments undergoing resorption and loss of joint capsule integrity were also identified.

However, no evidence of avascular necrosis was found in the femoral head, as assessed by a 2 mm puncture in a non-weight-bearing area that resulted in active bleeding; nor were there any signs of osteoarthritis, as determined by direct inspection. Next, through a lateral incision over the distal fibula of the left leg, a 2x3x1 cm tricortical bone graft was harvested, which was then placed in the defect of the posterior wall of the acetabulum and secured with two 3.5 mm cannulated screws with washers (Figure 2). Subsequently, the acetabular bone fragments were reduced, and a preformed 3.5 mm straight reconstruction plate with 8 holes was positioned to compress the bone autograft; this was fixed with 5, 3.5 mm cortical screws (Figure 3). The remaining joint capsule was sutured; the stability of the acetabulum and hip was verified through intraoperative maneuvers of hip flexion, internal rotation, and adduction under fluoroscopic guidance; and the surgical wound was closed in layers. The X-ray taken immediately postoperatively showed congruent reduction of the fracture of the posterior wall of the acetabulum, adequate reduction of the hip dislocation, and the osteosynthesis hardware in the correct position (Figure 4).

Figure 2. Fixation of a fibular bone autograft. The fluoroscopic image also shows a suture anchor from a previous surgery.

Source: Image obtained during the patient’s treatment.

Figure 3. Intraoperative image. The femoral head (blue), the fibular bone autograft (yellow), and the osteosynthesis hardware (green) are visible.

Source: Image obtained during the patient’s treatment.

Figure 4. Postoperative X-ray showing adequate hip reduction and osteosynthesis hardware in the correct position.

Source: Image obtained during the patient’s care.

Following the procedure, the patient remained in a general inpatient ward for 48 hours. Prophylactic antibiotics were administered in the form of three 1 gram doses of cefazolin, along with analgesia consisting of 1 gram of acetaminophen every 6 hours and two 25 mg doses of tramadol. No complications occurred. The patient was discharged with instructions to limit weight-bearing on the limb and to use crutches for six weeks.

Follow-up examinations were conducted at 15 days, 5 months, and 12 months. At these follow-up visits, there was no loss of joint alignment, no loss of osteosynthesis fixation, and no resorption of the bone autograft. At each follow-up visit, full ranges of pain-free motion were assessed, and follow-up X-rays were taken; however, due to migration and the hospital’s radiology system overhaul, access to these postoperative follow-up X-rays is not available. Thus, follow-up visits were conducted at 15 days, 5 months, and 12 months. At the follow-up visits, there was no loss of joint space, no loss of osteosynthesis fixation, and no resorption of the autologous bone graft. At each follow-up visit, full ranges of motion without pain were assessed, and follow-up X-rays were taken; however, due to changes and system updates in the hospital’s radiology department, access to these postoperative follow-up X-rays is not available.

At the 12-month follow-up, the following was reported: walking with full support, full range of motion in the hips, symmetrical limbs, and no signs of instability or pain (Figure 5). The patient expressed satisfaction with the treatment received, and follow-up X-rays were requested; however, he did not continue to attend follow-up appointments.

Figure 5. Patient at the 12-month postoperative follow-up.

Source: Image obtained during the patient’s care.

Discussion

Traumatic hip dislocations are serious injuries resulting from high-energy trauma, frequently associated with traffic accidents. Posterior dislocation is the most common type and is associated with acetabular fractures in up to 53.9% of cases.1 In the case presented, the patient’s instability at the time of the initial trauma was due to components that had not been addressed during previous treatment, including fractures of the acetabular rim and the femoral head. For this reason, treatment of hip dislocation fractures must be comprehensive, taking into account the bony, capsular, and ligamentous structures, to achieve joint congruity and definitive hip stability.16 It is of the utmost importance to assess hip stability intraoperatively, taking into account the multiple methods described for this evaluation, including the ease of hip distraction, assessment of the thickness and quality of the capsule, the presence of specific chondral and labral injury patterns, and the identification of focal capsular defects.17

We present the case of a young, active male patient with recurrent hip dislocation and instability secondary to a bony defect in the posterior wall of the acetabulum and a chronic fracture of the femoral head, with no indication for arthroplasty. Open reduction, osteosynthesis, and bone grafting of the residual acetabular defect were performed. The treatment of sequelae from hip dislocation-fractures is determined based on the condition of the joint; in cases of avascular necrosis or advanced osteoarthritis, hip arthroplasty is the treatment of choice.18,19 However, given the joint viability observed despite the chronic nature of the condition, a reconstructive approach was chosen, involving open reduction, osteosynthesis, and autologous bone grafting, an alternative described in the literature as effective for resolving post-traumatic bone defects.20

There is extensive experience with the use of autologous cortical bone grafts to correct various bone defects.9-13,21 These grafts possess osteoconductive, osteoinductive, osteogenic, and osseointegrative properties; furthermore, they provide structural support and are non-immunogenic.22 In hip pathology, this type of bone graft has been used with good results in the reconstruction of acetabular defects during primary arthroplasties.22-24 Likewise, various autologous bone grafts have been used for the reconstruction of posterior acetabular fractures, ranging from pedicled grafts from the intertrochanteric crest or greater trochanter to free grafts from the iliac crest.9-13

The use of structural fibular bone grafts has been reported in the treatment of bonedefects in segments such as the tibia, radius, humerus, and ilium,25 as well as in thosethat bear high mechanical loads, such as the femur.26 The biological potential ofavascular fibular grafts has been demonstrated in various studies in which they havebeen used to treat osteonecrosis of the femoral head, achieving adequateosseointegration and favorable long-term clinical outcomes.27 Consequently, in surgeriesrequiring structural support in the acetabulum, the use of structural cortical bone graftswith osteointegration potential is preferred; in this scenario, avascular fibula graftsrepresent an attractive alternative.13

Although a literature search was conducted in PubMed and Google Scholar, no reports were found on the use of a non-vascularized structural fibula autograft for the reconstruction of acetabular bone defects not associated with joint replacement. Although the use of structural fibular autografts has been well studied in other traumatic and non-traumatic conditions,25,28 this case report represents a novel application of the fibular autograft for a defect in the posterior wall of the acetabulum, with satisfactory results. Furthermore, some of the benefits of this technique include reduced costs and the fact that it does not require other types of materials for defect management, such as cortical bone allografts or demineralized bone matrix.

According to the literature, iliac crest bone grafts have been used in other cases for the reconstruction of bone defects; however, their harvesting is not without complications such as infection, iliac fracture, lateral femoral cutaneous nerve neuropraxia, chronic pain, abdominal injuries, incisional hernias, and gait disturbances.17,21,29-31 These complications may be associated with the size of the graft and the residual defect in the iliac bone.4 In large acetabular bone defects, it may be necessary to harvest large amounts of bone graft; In a study by Katz et al.,31 a statistically significant association was found between graft volume and length of hospital stay, with an average graft volume of 8.39 cm³ in young patients and 13.32 cm³ in elderly patients (p<0.01).3,4 Harvesting bone grafts from the fibula is a suitable alternative in cases requiring structural support for large post-traumatic defects.3-5

The use of a fibular autograft was considered an appropriate option due to its biological viability, the need for a tricortical graft, its ability to withstand high loads, and the potential complications associated with harvesting grafts from the iliac crest. In this case, the patient had a defect in the posterior wall of the acetabulum that required a 6 cm³ bone graft, which, together with a reconstruction plate, provided structural support and integrated adequately, stabilizing the hip and allowing for weight-bearing and early rehabilitation.

Conclusion

The non-vascularized fibular bone autograft, combined with open reduction and osteosynthesis, resulted in an anatomical, congruent, and stable reduction of the hip, which facilitated the patient’s early rehabilitation. This, coupled with the cortical graft’s ability to withstand short-term mechanical loads and its biological properties, provides a biomechanical advantage for long-term stability. Thus, restoring the structural bony support of the acetabulum is essential for preventing or treating hip instability, as capsular repair without stabilizing the bony support is insufficient. The use of this autograft for managing bone defects in hip dislocation-fractures is a suitable alternative that yielded good results in this case. Further studies are needed to evaluate outcomes in a larger group of patients and to compare this approach with other techniques for managing these bone defects, such as the use of other bone autografts, allografts, or metal implants, with long-term follow-up.

Informed Consent

Informed consent signed by the patient presented in this case is on file.

Conflict of Interest

None declared by the authors.

Funding

None declared by the authors.

Acknowledgments

None declared by the authors.

Use of Artificial Intelligence

None declared by the authors.

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