Introduction <p>The number of acetabular fractures in the elderly population is increasing. Non-surgical treatment in these patients have been associated with poor outcomes. A primary total hip arthroplasty (THA) in combination with additional acetabular fixation (“fix and replace”) has been suggested to prevent complications associated with inactivity and to allow an active independent life. Although the reported results are promising, most of the so far published series are relatively small and with short follow-up times.</p> Materials and methods <p>All patients aged from 60 years that underwent an acute primary THA with additional fixation (plate and/or cage) due to an acetabular fracture at the Karolinska University Hospital in Stockholm, Sweden from 2017 to 2023 were identified. Medical records including radiographs were manually reviewed and follow-up was a minimum of 1 year.</p> Results <p>A total of 70 patients were included. The median age was 78 (60–95) years, and 26% (<i>n</i> = 18) were females. Six patients (8.6%) underwent an open reoperation due to infection (<i>n</i> = 4, 5.7%) or recurrent dislocations of the THA (<i>n</i> = 2, 2.9%). Four patients (5.7%) had a dislocation of the THA. The dislocation rate was 19% (<i>n</i> = 3/16) for THA via a posterior approach, and 1.9% (<i>n</i> = 1/54) for an anterolateral approach (<i>p</i> = 0.04). A total of 24 patients (34%) had at least one other adverse event. Logistic regression analysis showed that female gender was associated with an increased risk for other adverse events in both uni- (OR 4.7, 95% CI 1.5–15, <i>p</i> = 0.008) and multivariable (OR 5.3, 95% CI 1.6–18, <i>p</i> = 0.008) analysis. The 30-day mortality was 7.1% (<i>n</i> = 5), and the 1-year mortality was 13% (<i>n</i> = 9) for all patients.</p> Conclusions <p>The reoperation rate and the mortality was moderate, whereas the rate of other adverse events was considerable. The posterior surgical approach was associated with an increased risk for dislocation.</p>