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. 2026 Jul 10;7(7):907–915. doi: 10.1302/2633-1462.77.BJO-2026-0106.R1

Super-acute massive osteolysis of the femoral head after acetabular fracture fixation

a comparative study with conventional post-traumatic osteonecrosis requiring total hip arthroplasty

Yi-Hsun Yu 1,✉, Chih-Yang Lai 1, I-Jung Chen 1, Yung-Heng Hsu 1, Ying-Chao Chou 1
PMCID: PMC13349589  PMID: 42425534

Abstract

Aims

Super-acute massive osteolysis of the femoral head (MOFH) is a rare but devastating complication following acetabular fracture, characterized by rapid femoral head destruction within weeks. This study aimed to characterize and compare the clinical and radiological features of super-acute MOFH with those of conventional post-traumatic osteonecrosis of the femoral head (ONFH) requiring total hip arthroplasty (THA).

Methods

This retrospective study included adult patients who underwent acetabular fracture osteosynthesis at a single Level I trauma centre between January 2021 and December 2025 and subsequently required THA. Patients were classified into super-acute MOFH or conventional ONFH groups. Demographic data, injury patterns, surgical variables, and radiological findings were reviewed. Reduction quality was assessed using postoperative radiographs and CT-based articular gap and stepoff measurements. Groups were compared using non-parametric and exact tests; Firth penalized logistic regression identified factors independently associated with super-acute MOFH.

Results

Overall, 31 patients met the inclusion criteria: 12 with super-acute MOFH and 19 with conventional ONFH. Patients with super-acute MOFH were significantly older (p = 0.010). Fracture pattern, hip dislocation, recurrent dislocation, time to reduction, time to fixation, surgical approach, revision fixation, and overall reduction quality showed no association with super-acute MOFH. CT-based articular gap measurements were similar between groups. Greater postoperative axial stepoff in posterior wall fractures occurred in the super-acute MOFH group but were not independently predictive. Multivariable analysis showed increasing age was independently associated with super-acute MOFH (odds ratio 1.14 per year; 95% CI 1.01 to 1.29; p = 0.037).

Conclusion

Super-acute MOFH is a distinct, aggressive post-traumatic entity that can occur despite satisfactory acetabular reduction and fixation. Its development is unrelated to fracture morphology or surgical factors, but associated with older age in middle-aged trauma patients, suggesting host-related biological vulnerability. Early recognition, close postoperative imaging surveillance, and timely THA preparation are recommended for at-risk patients.

Cite this article: Bone Jt Open 2026;7(7):907–915.

Keywords: Acetabular fracture, Femoral head osteonecrosis, Massive osteolysis, Post-traumatic complication, Total hip arthroplasty, massive osteolysis, femoral head, acetabular fracture fixation, acetabular fractures, Osteonecrosis of the femoral head (ONFH), hip dislocation, orthopaedic trauma, total hip arthroplasty (THA), osteosynthesis, recurrent dislocation

Introduction

Osteonecrosis of the femoral head (ONFH) is a well-recognized complication of acetabular fractures, particularly after high-energy trauma with associated hip dislocation.1,2 Post-traumatic ONFH mostly follows a prolonged course, with subchondral collapse and symptomatic degeneration emerging months to years after injury. Reported intervals to radiological or clinical manifestation typically range from six months to > five years.3,4 During this conventional course, radiological changes progress gradually, with preservation of femoral head sphericity until advanced collapse.

In contrast, several case reports describe an unusually aggressive pattern characterized by rapid femoral head destruction, sometimes progressing to near-complete disappearance within months.5-8 This phenomenon, termed massive osteolysis of the femoral head (MOFH), differs from classical post-traumatic osteonecrosis in temporal evolution and radiological appearance.9 Reported features include abrupt subchondral bone loss, fragmentation originating at the weightbearing dome, and secondary structural failure, including femoral neck collapse. Although the underlying mechanisms remain unclear, proposed explanations include severe vascular injury at trauma, occult subchondral insufficiency fractures, inflammatory osteolytic activation, and increased vulnerability in osteoporotic bone.10-12

An even more extreme presentation has been observed in a small patient subset, with femoral head destruction occurring within the first month after acetabular fracture or fracture dislocation. This pattern, termed super-acute MOFH, is characterized by radiological collapse or massive osteolysis progressing to end-stage femoral head failure within four weeks. Such rapid deterioration cannot be explained by conventional post-traumatic osteonecrosis or osteoarthritis and suggests distinct biological or mechanical factors.9 Currently, no comparative study has systematically examined differences between super-acute MOFH and the typical delayed form of post-traumatic ONFH following acetabular fracture.

Therefore, this study aimed to characterize the clinical and radiological features of super-acute MOFH in patients requiring total hip arthroplasty (THA) and compare these features with those of conventional post-traumatic ONFH requiring THA. Identifying the distinguishing features of this rare but devastating complication may improve recognition, inform postoperative surveillance, and advance understanding of its underlying mechanisms.

Methods

Study population and enrolment protocol

This retrospective study was conducted at a single Level I trauma centre and included only patients who underwent acetabular fracture osteosynthesis at our institution. The institutional orthopaedic trauma database was queried to identify all adult patients who eventually underwent THA for post-traumatic femoral head failure between 2021 and 2025. Prior acetabular fixation surgeries were retrospectively reviewed for these patients, and only those with index acetabular fracture surgery performed at our hospital were included to ensure consistency in surgical technique, implant selection, postoperative care, and radiological follow-up. Electronic medical records, operative reports, and imaging archives were cross-referenced to identify patients who underwent ipsilateral THA during the study period. This study was approved by the Institutional Review Board (IRB no: 202600029B0).

Exclusion criteria applied to isolate patients with post-traumatic ONFH included age > 60 years at the time of acetabular fracture (as treatment strategies in this age group often differ from those for younger patients because simultaneous osteosynthesis and acute arthroplasty are considered for severe injury patterns); end-stage post-traumatic osteoarthritis; and evidence of deep infection or septic arthritis. In all patients undergoing THA, intraoperative evaluation included three sets of tissue cultures (joint fluid, acetabular tissue, and femoral tissue), and only those with negative culture results were included in the analysis.

After criteria application, 31 patients remained eligible and were included in the final analysis (Figure 1). All enrolled patients had undergone acetabular osteosynthesis at our centre, demonstrated radiological progression to post-traumatic ONFH, and ultimately required THA.

Fig. 1.

Flowchart shows selection of 31 eligible patients from 450 surgeries, with exclusions listed, then classification into super-acute MOFH (n = 12) and conventional ONFH (n = 19) based on timing of femoral head failure. This figure is a flow diagram outlining patient selection and classification. It begins with 450 acetabular fracture surgeries performed during the study period. Of these, 73 patients underwent total hip arthroplasty after fracture. A side box lists excluded cases, including older patients, end-stage osteoarthritis without femoral head collapse, infection-related procedures, and acute arthroplasty, leaving 31 eligible patients with end-stage femoral head necrosis after acetabular osteosynthesis. These 31 patients are then classified according to timing of femoral head failure into two groups: super-acute massive osteolysis of the femoral head with 12 patients and conventional osteonecrosis of the femoral head with 19 patients. The diagram shows a clear stepwise filtering process from the initial cohort to final subgroup classification.

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Flow diagram illustrating patient selection and cohort allocation. MOFH, massive osteolysis of the femoral head; ONFH, osteonecrosis of the femoral head; THA, total hip arthroplasty.

Patient characteristics

During the study period, 31 patients were analyzed. A total of 12 patients were classified into the super-acute MOFH group, and 19 into the ONFH group. Baseline demographic details are summarized in Table I.

Table I.

Patient demographic details and baseline injury characteristics.

Variable Super-acute MOFH (n = 12) ONFH (n = 19) p-value
Median age, yrs (IQR) 50.0 (40.2 to 54.5) 36.0 (24.5 to 46.5) 0.010*
Sex, n
Male 10 19 0.140
Female 2 0
Median BMI, kg/m2 (IQR) 26.1 (25.1 to 30.4) 26.7 (24.0 to 35.8) 0.570
Median Injury Severity Score (IQR) 9.0 (9.0 to 21.8) 9.0 (9.0 to 17.0) 0.980
Median new Injury Severity Score (IQR) 17.0 (13.8 to 24.0) 17.0 (13.0 to 24.5) 0.840
Hip dislocation, n 9 18 0.270
Hip relocation performed, n (%) 9/12 (75.0) 18/19 (94.7) 0.270
Median time from injury to relocation, hrs (IQR) 7.0 (3.8 to 30.0) 10.0 (7.0 to 23.5) 0.580
Recurrent dislocation after closed reduction, n (%) 5/12 (41.7) 7/19 (36.8) > 0.999
Median time from injury to definite surgery (IQR) 5.5 (3.8 to 10.2) 6.0 (3.0 to 9.0) 0.840
Transcatheter angioembolization, n 1 1 > 0.999
Median surgical time, mins (IQR) 176.5 (142.8 to 225.0) 240.0 (173.5 to 329.5) 0.080
Median estimated blood loss, ml (IQR) 350 (237.5 to 1,150.0) 650 (450.0 to 850.0) 0.360
ICU admission, d, n (%) 4/12 (33.3) 6/19 (31.6) > 0.999
Median time to ONFH, mins (IQR) 1.0 (1.0 to 1.0) 10.0 (5.0 to 13.0) < 0.001*
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*

Statistical significance.

MOFH, massive osteolysis of the femoral head; ONFH, osteonecrosis of the femoral head.

Classification of super-acute MOFH compared with conventional ONFH

Patients were categorized into two groups to evaluate the phenomenon of extreme early femoral head destruction, based on the interval between the index acetabular surgery and the first radiological evidence of femoral head collapse: 1) super-acute MOFH, defined as radiological collapse, fragmentation, or massive osteolysis occurring within four weeks of acetabular osteosynthesis (Figure 2); or 2) conventional ONFH, defined as femoral head collapse occurring more than four weeks after surgery, consistent with the typical delayed progression of post-traumatic osteonecrosis (Figure 3).

Fig. 2.

Series of pelvic radiographs and CT images labeled a–f show an acetabular fracture, detailed fracture views, surgical fixation, and later hip replacement in the same patient. This figure is a six‑panel composite of medical images labelled a to f, showing the progression of an acetabular fracture and its management. Panels a and b are pelvic radiographs demonstrating the initial fracture with disruption of the hip socket. Panels c and d are CT images providing closer detail of the fracture pattern and joint involvement. Panel e shows a postoperative radiograph with fixation hardware stabilizing the fractured acetabulum. Panel f shows a later radiograph with a total hip replacement prosthesis in place following failure or complications of the native joint. The sequence illustrates injury assessment, surgical repair, and eventual joint replacement.

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An illustration of super-acute massive osteolysis of the femoral head. A 57-year-old male patient sustained a right hip fracture-dislocation. a) Initial anteroposterior (AP) pelvic radiograph showing the injury. b) AP pelvic radiograph and c) axial CT images after hip reduction demonstrating impaction injuries of the acetabulum and femoral head. d) Postoperative AP pelvic radiograph obtained three days after injury following acetabular fixation. e) Follow-up AP pelvic radiograph four weeks after fixation demonstrating complete femoral head osteolysis. f) Postoperative AP pelvic radiograph after total hip arthroplasty.

Fig. 3.

Six-panel imaging series shows acetabular fracture on radiograph and CT, followed by fixation with hardware and later conversion to total hip replacement after joint deterioration. This figure is a six-panel composite labeled a through f, showing imaging of an acetabular fracture and its treatment course. Panel a is an initial pelvic radiograph demonstrating disruption of the hip socket consistent with fracture. Panel b is a CT image that provides a detailed view of the fracture fragments and their position within the joint. Panel c is a postoperative radiograph showing internal fixation of the acetabulum with plates and screws. Panel d is a follow-up CT image showing the fixation hardware in place and the relationship of the repaired bone to the joint surface. Panel e is a later radiograph suggesting progression toward joint deterioration despite fixation, with hardware still present. Panel f is a final radiograph showing conversion to a total hip replacement, with a prosthetic joint replacing the native hip. The sequence illustrates initial injury, surgical stabilization, and eventual joint replacement due to failure or degeneration.

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An illustration of conventional post-traumatic osteonecrosis of the femoral head. A 21-year-old male sustained an acetabular fracture with associated hip dislocation. a) Initial anteroposterior (AP) pelvic radiograph demonstrating the injury. b) Coronal CT image after reduction showing the acetabular fracture. c) Postoperative AP pelvic radiograph following acetabular fixation. d) Coronal CT image confirming fracture reduction and fixation. e) Follow-up AP pelvic radiograph several months after injury demonstrating gradual femoral head collapse consistent with post-traumatic osteonecrosis. f) Postoperative AP pelvic radiograph after total hip arthroplasty.

Radiological assessment

All fractures were classified according to the Judet and Letournel system13 using a combination of preoperative anteroposterior (AP), iliac oblique, and obturator oblique radiographs, supplemented by axial, coronal, and sagittal CT reconstructions. Preoperative imaging was reviewed to document fracture pattern, presence of hip dislocation, marginal and dome impaction, femoral head impaction, and initial displacement parameters. When a hip dislocation was present, radiological and CT assessments were repeated after the hip was successfully reduced.

All patients also underwent postoperative CT scanning as part of routine assessment.14 Axial, coronal, and sagittal CT reconstructions were reviewed to quantify residual gaps (defined as linear separation between articular fragments) and stepoffs, defined as vertical incongruity of the joint surface. Measurements were made at the site of greatest displacement on any plane and recorded to the nearest 0.1 mm using Picture Archiving and Communication System (PACS; GE Healthcare, USA) digital calipers; when multiple displaced regions were present, the largest gap and stepoff values were used for analysis.

All CT measurements were performed by two fellowship-trained orthopaedic trauma surgeons (C-YL, I-JC) independently. If discrepancies existed, measurements were repeated and resolved by consensus.

Standard radiological follow-up included imaging performed immediately after surgery and again at approximately four weeks postoperatively. Additional images were obtained earlier if patients reported unexpected hip pain or presented earlier than scheduled.

Surgical management and perioperative protocol

All procedures were performed or supervised by dedicated pelvic trauma surgeons at a high-volume trauma centre managing over 200 pelvic and acetabular injuries annually. The three primary surgeons had more than three, five, and ten years of independent experience with pelvic and acetabular surgeries, respectively.

All patients were initially evaluated in the Emergency Department (ED) according to institutional trauma protocols. When a hip dislocation was identified on presentation, urgent closed reduction was performed either under procedural sedation in the ED or under general anaesthesia in the operating theatre, depending on the patient’s condition and concomitant injuries. Following successful relocation, the injured limb was placed in skin or skeletal traction to maintain hip joint stability, and to reduce contact pressure across the femoral head and acetabular cartilage, while awaiting definitive fixation.

Osteosynthesis of the acetabular fracture was performed as soon as the patient’s physiological status permitted operative intervention. The choice of surgical approach was determined by the specific fracture pattern according to the Letournel classification, and the fragments requiring direct visualization and reduction.

Standard surgical principles aimed at preserving femoral head vascularity, including careful soft-tissue handling, minimization of unnecessary posterior soft-tissue stripping, preservation of the short external rotators where feasible, and adherence to established surgical exposure techniques, were routinely followed.

Postoperative rehabilitation and prophylaxis protocol

Postoperatively, all patients followed a standardized rehabilitation protocol. Non-weightbearing ambulation was maintained for the first six weeks, followed by a gradual progression to partial and then full weightbearing with crutch assistance, aiming for independent ambulation by three months, provided there were no contraindications to crutch or walker use (e.g. concomitant upper limb fractures, or significant head, chest, or abdominal injuries). For venous thromboembolism prophylaxis, all patients were prescribed compression stockings for a duration of three months after surgery. Heterotopic ossification prophylaxis was individualized based on intraoperative findings; in cases with substantial gluteal muscle injury or extensive soft-tissue trauma, indometacin (25 mg twice daily) was administered for four weeks postoperatively, unless contraindicated.

Statistical analysis

Statistical analyses were performed using SPSS Statistics v. 25.0 (IBM Corp, USA) and R statistical software v. 4.6 (R Foundation for Statistical Computing, Austria). Continuous variables were compared between groups using the Mann-Whitney U test, and categorical variables were analyzed using Fisher’s exact test. Variables showing significance on univariate analysis were included in multivariable analysis. Multivariable analysis was conducted using Firth penalized logistic regression, and results were expressed as odds ratios (ORs) with 95% CIs. Analyses were performed using available data, with no imputation for missing values. All tests were two-tailed, and statistical significance was defined as a p-value < 0.05.

Results

Patients in the super-acute MOFH group were significantly older than those in the ONFH group (p = 0.010). Table II compares fracture patterns and surgical variables between the two groups. No significant differences were observed between the two groups in fracture characteristics or operative variables.

Table II.

Fracture pattern and operative variables in super-acute massive osteolysis of the femoral head (MOFH) compared with conventional osteonecrosis of the femoral head (ONFH).

Variable Super-acute MOFH (n = 12) ONFH (n = 19) p-value
Elementary fracture type 6 10 > 0.999
AC involvement 4 6 > 0.999
PC involvement 5 8 > 0.999
PW involvement 10 17 0.630
Surgical approach     0.540
Anterior approach alone 2 1  
Posterior approach alone 9 13  
Combined approaches 1 5  
Revision osteosynthesis* 1 3 > 0.999
Acetabulum impaction 11 18/19 > 0.999
Femoral head impaction 8 14/19 0.700
Combined femoral head fracture 0 5/19 0.130
Combined femoral neck fracture 1 4/19 0.620
Combined femoral intertrochanteric fracture 1/12 1/19 > 0.999
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*

Revision osteosynthesis indicates secondary acetabular surgery performed after initial surgery at another institution.

AC, anterior column; PC, posterior column; PW, posterior wall.

Table III and Table IV summarize CT-based articular gap and stepoff measurements before and after acetabular fracture fixation, stratified by column and wall involvement. Overall, preoperative displacement severity and postoperative reduction quality were comparable between the two groups across most parameters. A significant difference was observed only in postoperative axial stepoff for posterior wall fractures, which was greater in the super-acute MOFH group (p = 0.004). No other CT-based gap or stepoff measurements differed significantly between groups. Overall, postoperative CT measurements demonstrated generally satisfactory articular reduction in both groups, with most residual gaps and stepoffs within ranges considered acceptable in clinical practice.

Table III.

CT-based gap measurements stratified by column and wall involvement. Data are shown as median (IQR).

Variable Super-acute MOFH ONFH p-value*
Anterior column involvement
Preoperative CT scan
Axial view 13.0 (8.0 to 17.7) 13.5 (7.6 to 18.2) 0.630
Coronal view 12.6 (6.6 to 17.8) 12.9 (7.1 to 18.0) 0.250
Sagittal view 9.2 (7.7 to 16.4) 9.8 (7.5 to 16.9) 0.910
Postoperative CT scan
Axial view 2.7 (0 to 6.4) 3.0 (0 to 6.6) 0.250
Coronal view 3.8 (0 to 7.1) 3.5 (0 to 7.0) 0.890
Sagittal view 0 (0 to 4.0) 0 (0 to 4.2) 0.910
Posterior column involvement
Preoperative CT scan
Axial view 12.5 (7.5 to 19.5) 13.1 (8.0 to 20.1) 0.690
Coronal view 9.8 (5.2 to 17.2) 10.2 (5.6 to 17.8) 0.570
Sagittal view 11.0 (5.4 to 18.9) 11.4 (5.8 to 19.2) 0.640
Postoperative CT scan
Axial view 2.3 (0 to 5.3) 2.6 (0 to 5.7) 0.570
Coronal view 2.5 (0 to 6.0) 2.8 (0 to 6.2) 0.780
Sagittal view 0 (0 to 4.1) 0 (0 to 4.3) 0.590
Posterior wall involvement
Preoperative CT scan
Axial view 17.6 (10.9 to 31.4) 18.2 (11.3 to 32.1) 0.690
Coronal view 13.7 (8.2 to 19.8) 14.1 (8.5 to 20.4) 0.640
Sagittal view 13.7 (7.8 to 22.0) 14.0 (8.1 to 22.6) 0.430
Postoperative CT scan
Axial view 1.8 (0 to 5.0) 2.0 (0 to 5.3) 0.570
Coronal view 1.0 (0 to 4.8) 1.2 (0 to 5.0) 0.780
Sagittal view 0 (0 to 1.9) (0 to 2.1) 0.710
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*

Mann-Whitney U test.

MOFH, massive osteolysis of the femoral head; ONFH, osteonecrosis of the femoral head.

Table IV.

CT-based stepoff measurements stratified by column and wall involvement. Data are shown as median (IQR).

Variable Super-acute MOFH ONFH p-value
Anterior column involvement
Preoperative CT scan
Axial view 5.5 (0 to 9.6) 5.2 (1.2 to 9.1) 0.250
Coronal view 4.9 (2.2 to 7.4) 4.6 (2.0 to 7.2) 0.630
Sagittal view 3.8 (0 to 6.7) 3.6 (0 to 6.5) 0.910
Postoperative CT scan
Axial view 0 (0 to 0.5) 0 (0 to 0.8) 0.890
Coronal view 2.0 (0 to 3.6) 1.8 (0 to 3.4) 0.250
Sagittal view 0 (0 to 1.1) 0 (0 to 1.3) 0.910
Posterior column involvement
Preoperative CT scan
Axial view 4.9 (1.0 to 9.0) 4.6 (1.4 to 8.7) 0.780
Coronal view 4.0 (1.9 to 7.0) 3.8 (2.0 to 6.8) 0.590
Sagittal view 3.8 (0 to 7.0) 3.6 (0 to 6.8) 0.380
Postoperative CT scan
Axial view 0 (0 to 1.0) 0 (0 to 1.2) 0.720
Coronal view 1.2 (0 to 2.8) 1.1 (0 to 2.6) 0.710
Sagittal view 0 (0 to 2.1) 0 (0 to 2.3) 0.710
Posterior wall involvement
Preoperative CT scan
Axial view 7.2 (4.2 to 10.6) 6.8 (4.0 to 10.2) 0.140
Coronal view 5.1 (2.7 to 7.8) 4.9 (2.5 to 7.6) 0.590
Sagittal view 6.4 (2.4 to 8.7) 6.1 (2.2 to 8.5) 0.380
Postoperative CT scan
Axial view 0 (0 to 3.2) 0 (0 to 2.8) 0.004
Coronal view 0 (0 to 2.3) 0 (0 to 2.1) 0.720
Sagittal view 0 (0 to 2.1) 0 (0 to 2.0) 0.710
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MOFH, massive osteolysis of the femoral head; ONFH, osteonecrosis of the femoral head.

Univariate analysis showed that patients in the super-acute MOFH group were significantly older than those in the ONFH group (p = 0.014). No significant inter-group differences were identified in injury severity scores, intensive care unit admission, hip dislocation or recurrent dislocation, time from injury to reduction, time from injury to osteosynthesis, fracture pattern based on the Letournel classification, or reduction quality on postoperative radiographs and CT (all p > 0.05). Sub-group analysis showed higher postoperative axial stepoff in posterior wall fractures for the super-acute MOFH group, but this was not significant when using a single value per patient (p = 0.250).

Exploratory Firth penalized logistic regression showed age was independently associated with super-acute MOFH (OR 1.14 per year, 95% CI = 1.01 to 1.29, p = 0.037), whereas postoperative posterior wall axial stepoff was not (OR 1.18 per ml, 95% CI = 0.84 to 1.67, p = 0.330).

Discussion

In this study, we compared patients who developed super-acute MOFH after acetabular fracture fixation with those who progressed to conventional post-traumatic osteonecrosis requiring THA. All patients in the super-acute MOFH group underwent rigorous pre-diagnostic evaluation for infection to rule out deep infection or septic arthritis, which can mimic rapid femoral head destruction. Comparative analysis showed that super-acute MOFH, aside from its association with older age, did correlate with differences in fracture pattern, surgical variables, timing of fixation, or reduction quality. CT-based assessment showed comparable preoperative displacement and postoperative reduction between groups, except for greater postoperative axial stepoff in posterior wall fractures. Exploratory multivariable analysis suggested a potential association between increasing age and super-acute MOFH.

Super-acute MOFH displayed a highly aggressive and reproducible radiological pattern distinct from classical post-traumatic osteonecrosis and degenerative post-traumatic arthritis. Four characteristic imaging findings were consistently observed, including early collapse of the superior weightbearing femoral head, often within two to four weeks; rapid fragmentation and femoral head contour loss; secondary femoral neck collapse or fracture due to structural insufficiency; and near-complete femoral head disappearance with relative acetabular preservation.

These features resemble those of previously reported rapidly destructive hip disease and MOFH, but the extremely short timeline indicates a more accelerated, catastrophic process.9

The pathophysiology of super-acute MOFH remains unclear and likely multifactorial, involving a combination of vascular compromise, mechanical insult, and accelerated osteolytic activity.15-17 Severe hip dislocation or femoral head impaction during injury may cause immediate subchondral plate disruption, while concomitant retinacular vessels injury can precipitate extensive femoral head ischaemia.18-23 Additionally, traumatic haemarthrosis, synovial inflammation, and cytokine activation may promote rapid osteoclastic bone resorption, resembling mechanisms proposed in rapidly destructive hip disease.11,24,25 Unlike classical post-traumatic osteonecrosis, which typically progresses through a prolonged sequence of marrow necrosis, subchondral fracture, and delayed collapse, super-acute MOFH exhibits a hyper-accelerated destructive phenotype, suggesting the presence of a distinct biological process initiated at or shortly after the index injury.

Among the variables examined, increasing age was the only factor independently associated with the development of super-acute MOFH. Although the absolute age difference between groups was modest, this finding suggests that relative host-related vulnerability, rather than advanced age per se, may contribute to the rapid structural failure observed in this condition. Patients with super-acute MOFH were older within a middle-aged trauma population, which may reflect subtle differences in bone quality, regenerative capacity, or tolerance to ischaemic or inflammatory stress following high-energy acetabular injury.15,16 Age-related shifts in bone remodelling, together with declines in vascularization and cellular repair capacity, have been shown to impair structural integrity and recovery from subchondral injury, potentially predisposing the femoral head to rapid collapse after trauma.16,17 One potential contributor to vascular compromise in this setting is transcatheter arterial embolization (TAE), which is occasionally required for haemostasis in patients with severe pelvic injury.26 However, TAE was not associated with the development of super-acute MOFH in the present study, suggesting that this intervention alone does not account for the observed rapid femoral head osteolysis.

In contrast to traditional assumptions, factors commonly implicated in post-traumatic osteonecrosis, such as hip dislocation, irreducible dislocation, or recurrent dislocation after reduction, were not associated with the development of super-acute MOFH in the present study. Although prolonged femoral head displacement has been considered a major contributor to vascular compromise,27-29 these findings suggest that such mechanical factors alone do not account for the rapid femoral head destruction observed in this condition. Revision acetabular surgery after initial fixation at another institution was likewise not associated with super-acute MOFH, indicating that initial technical inadequacy or fracture complexity was not a determining factor. Aside from an isolated difference in postoperative axial stepoff in posterior wall fractures, overall reduction quality was comparable between groups, with consistently good to near-anatomical restoration of acetabular components. Most patients in both groups achieved postoperative reductions within thresholds generally considered acceptable for acetabular fracture fixation. These observations support the concept that super-acute MOFH can occur despite satisfactory joint congruity and is unlikely to be driven primarily by mechanical or technical factors.

Building on the observation that reduction quality was not a determinant of super-acute MOFH, fracture configuration and operative variables were likewise not contributory in this cohort. Traditionally, complex acetabular fracture patterns, posterior wall involvement, extensile surgical approaches, and associated proximal femoral fractures have been considered potential risk factors for post-traumatic osteonecrosis due to their presumed impact on femoral head vascularity.4,30-32 However, in the present study, fracture characteristics based on the Letournel classification, specific column or wall involvement, surgical approach, and the presence of associated proximal femoral fractures did not differ between patients with super-acute MOFH and those with conventional ONFH. In addition, revision fixation following initial surgery at another institution was not associated with this condition. Together with the consistently satisfactory postoperative reduction achieved across groups, these findings reinforce the concept that super-acute MOFH cannot be explained by fracture morphology or operative strategy alone, and is more likely related to host- or biology-driven factors. These findings should not be interpreted as evidence supporting preference for acute arthroplasty; rather, they reflect the outcomes of joint-preserving strategies in patients with fractures considered reconstructible at index surgery.

This study has some limitations. First, the small number of super-acute MOFH cases limited the statistical power and precluded more extensive multivariable modelling and definitive identification of risk factors. In addition, exclusion of older patients limited the generalizability of the findings, particularly to populations where acute arthroplasty is more frequently considered. Second, the heterogeneous acetabular fracture patterns may have obscured fracture-specific effects despite stratification. Third, this single-centre retrospective study incurs unavoidable selection bias; patients with rapid femoral head destruction managed elsewhere or without THA may have been missed. Detailed assessment of cumulative hip dislocation duration and vascular insult was also limited by the retrospective design and incomplete documentation of transient re-dislocation events. Larger multicentre or prospective studies can better define the predictors of and mechanisms underlying super-acute MOFH. Future studies comparing these patients with the broader acetabular fracture population may further clarify injury-related risk factors for early femoral head failure. Moreover, postoperative weightbearing protocol adherence could not be verified objectively; early mechanical loading may have occurred, but likely without differences between groups. Finally, although systematic radiological and CT evaluations were performed, occult chondral injury, subchondral microfracture, or early femoral head vascular insult could not be reliably identified without obvious impaction or advanced imaging such as MRI, limiting elucidation of initial pathological events in super-acute MOFH. In addition, surgeon-specific technical factors and soft-tissue handling that may influence femoral head vascularity could not be fully quantified.

In summary, super-acute MOFH is a rare but aggressive complication after acetabular fracture fixation, characterized by rapid femoral head destruction despite satisfactory reduction and fixation. This condition was not associated with fracture pattern, surgical approach, or reduction quality, but it may be associated with increasing age within a middle-aged trauma population. Patients with this risk profile warrant close early radiological follow-up, education on potential rapid joint failure, and preparation for timely THA upon progressive femoral head collapse.

Take home message

- Super-acute massive osteolysis of the femoral head is a rare but catastrophic complication that may occur within weeks of acetabular fracture fixation despite satisfactory reduction and fixation.

- Older patients should undergo close early radiographic surveillance, and surgeons should recognize this entity to facilitate timely patient counselling and preparation for total hip arthroplasty when rapid femoral head collapse develops.

Author contributions

Y. Yu: Conceptualization, Supervision, Writing – review & editing

C. Lai: Formal analysis, Investigation, Writing – review & editing

I. Chen: Formal analysis, Investigation, Writing – review & editing

Y. Hsu: Writing – original draft, Writing – review & editing

Y. Chou: Writing – original draft, Writing – review & editing

Funding statement

The authors received no financial or material support for the research, authorship, and/or publication of this article.

ICMJE COI statement

The authors have no conflicts of interest to disclose.

Data sharing

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

Ethical review statement

This study was performed in accordance with the principles of the Declaration of Helsinki. This study was approved by the Institutional Review Board of Chang Gung Memorial Hospital (IRB No: 202401217B0).

Open access funding

The open access fee was self-funded.

© 2026 Yu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/

Data Availability

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.

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