1 Introduction

Acetabular fractures in the elderly represent the most rapidly growing segment of acetabular trauma [1]. Some predict that soon the elderly will be the largest subset of patients with acetabular fractures [1, 2]. This trend parallels the global aging demographic of the population susceptible to injury and trauma [3]. Treatment of acetabular fractures in younger individuals is well described [4, 5], indications are well defined [6], and factors associated with favorable outcome are widely reported [4, 7]. However, the same cannot be said for similar injuries in older individuals.

Fractures in younger populations are usually the result of high-energy trauma. This contrasts with the more uniform mechanism of injury seen in older populations. A study [8] that reported the epidemiological and radiographic characteristics of 1,300 acetabular fractures noted that a fall from standing height accounted for almost half of acetabular fractures in patients older than 60 years. This same study [8] noted a twofold increase in the incidence of these types of injuries in older individuals during the second half of the study period compared with the first, suggesting that the incidence is increasing. Others [9] corroborate these patterns and numbers.

This unique mechanism of injury results in fracture patterns morphologically more uniform than the variety of patterns sustained in high-energy trauma injuries. A direct load to the greater trochanter usually results in a fracture of the anterior column and quadrilateral plate, medial protrusion of the femoral head, and varying degrees of anteromedial dome impaction. In the above-mentioned series, 64% of patients older than 60 years with an acetabular fracture had anterior column displacement, which differed significantly from those younger than 60 years [8]. Other large series [9] that specifically examined acetabular fractures in the elderly showed a similar preponderance of anterior column, anterior column with posterior hemitransverse, and associated both-column injuries. Figure 2.12-1 demonstrates a typical fracture pattern seen in this patient population.

The goals of treatment in this population should not differ from those of their younger counterparts and should include rapid mobilization and attempts to return to baseline level of function. These goals, however, may be complicated by medical comorbidities, preexisting degenerative joint disease, and poorer bone quality.

Critical to successful management is early consultation with specialists in medical comanagement and geriatric care. The impact of a comanagement model that integrates orthopedic surgeons and geriatricians throughout all aspects of care has been well studied in people with hip fracture. Compared with patients managed in a traditional care model, those in the comanagement model experience shorter times to surgery, fewer postoperative infections, fewer complications overall, and shorter lengths of stay [10]. These benefits likely are realized on the acetabular side of the hip joint as well.

Older patients with acetabular fractures or those with medical comorbidities must be seen by a geriatrician immediately on arrival. Important to successful management is early medical optimization and risk stratification.

Patients with nondisplaced fractures should first be managed nonoperatively. Tornetta [11] outlined criteria for nonoperative management of acetabular fractures, and these criteria can help guide decision making in the elderly. Nonoperative management should consist of bed-to-chair transfers with pivoting on the unaffected side; alternatively, toe-touch weight bearing on the injured side may be allowed if the patient can comply with this regimen. Frequent x-rays are necessary to ensure that there is no fracture displacement.

Mobilization of elderly patients is of critical importance. Jain et al [12] demonstrated that the 30-day mortality of nonoperatively treated hip fractures was 19% compared with 11% in operatively managed injuries (odds ratio, 1.7). More important, the mortality rate increased to 73% in patients treated nonoperatively who were not able to mobilize effectively [12]. Others [13] have also underscored the importance of mobilization and the deleterious effects of prolonged immobilization in the elderly. We believe that prolonged bed rest and traction have no place in the management of patients with acetabular fractures. Moreover, operative stabilization of nondisplaced acetabular fractures should be considered if pain from pathological motion inhibits an elderly patient’s ability to mobilize effectively.

We assert that in elderly patients who are surgical candidates, most displaced acetabular fractures warrant surgical intervention ( Fig 2.12-2 ). Historical reports show disappointing results from nonoperative management of these injuries. Spencer [14] reviewed the results of nonoperative treatment of acetabular fractures in the elderly. In this cohort of 25 patients, 68% had no significant displacement initially, and the remainder had an acceptable reduction in traction. However, 30% had an unacceptable functional result. These results underscore the need for surgical treatment in all fractures except those with minimal displacement out of traction.

The exact roles of formal open reduction and internal fixation (ORIF), percutaneous or minimally invasive fixation, delayed total hip arthroplasty (THA), and acute THA remain controversial [9]. Although nonoperative management of acetabular fractures historically has yielded disappointing results [14], good outcomes in older populations have been elusive, even in the most experienced hands [2, 7, 15]. Figure 2.12-3 details a treatment algorithm for the elderly patient with an acetabular fracture.

2 Acute total hip arthroplasty

In response to the disappointing results of internal fixation, some authors have examined the role of combined ORIF and acute THA for elderly patients with selected acetabular fractures. Most of these procedures seek to restore gross column alignment and neutralize fracture instability to create an environment suitable for acute acetabular cup placement. Mears and Velyvis [16] recommend this procedure in fractures with extensive intraarticular comminution, substantial nonreconstructable loss of femoral head cartilage, impaction affecting more than 40% of the dome, preexisting osteoarthritis, displaced femoral neck fracture, and severe osteopenia. With these selection criteria, 57 patients with follow-up as long as 12 years achieved good to excellent outcomes in 79% of cases.

Some recent studies [17, 18] using similar inclusion criteria report acceptable results with acute THA for select acetabular fractures. However, a different pattern emerges if these results are stratified based on fracture type, specifically anterior versus posterior lesions, and approach used, Kocher-Langenbeck versus ilioinguinal.

Boraiah et al [17] reported 18 patients with fractures treated with acute THA. However, 16 of 18 patients had lesions localized primarily to the posterior acetabulum. Most (11 of 18) also had a femoral head injury. In patients with injuries to both the femoral head and posterior aspect of the acetabulum, acute THA appears to be a better option as the bony stabilization and arthroplasty portion of the procedure are done through the same approach (Kocher-Langenbeck). Note that lesions involving the anterior pelvis are more common in elderly patients. This study provided insufficient data to generalize to the more common anterior lesion treated with acute THA. Similarly, in another study [16] only 20 (35%) of 57 patients underwent acute THA for anterior acetabular lesions. These studies appear to support THA for posterior acetabular fractures but provide fewer data regarding its efficacy in the more common anterior lesions (eg, anterior column, anterior column with associated posterior hemitransverse, or associated both-column fracture patterns) seen in the elderly.

One study [18] reported that patients who required an ilioinguinal approach as part of the ORIF and acute THA procedure did significantly worse than those treated with a Kocher-Langenbeck approach alone. Although only 3 of 14 patients in this study required dual approaches, they had an operative time three times as long, lost three times as much blood, and had longer hospital stays and higher complication rates than those treated with a single approach. The authors [18] stated that the use of two surgical exposures tended to prolong surgery, produced greater blood loss, and had higher needs for transfusion.

We agree with the two aforementioned studies [1, 7] that a small subset of acetabular fractures is best managed with acute THA. As demonstrated in Fig 2.12-3 , our criteria for acute THA are similar to those outlined by others [1, 7]. Importantly, published literature points to its efficacy primarily in acetabular fractures involving the posterior acetabulum. In lesions that require an anterior approach for bony column stabilization, the surgeon should be cautious of an acute arthroplasty option requiring two approaches and should consider acute ORIF, followed by secondary arthroplasty options if they become necessary.

3 Minimally invasive techniques

Some authors have considered minimally invasive options to treat these fractures in the elderly. These methods have the obvious benefit of decreased blood loss, decreased surgical insult, and potentially less morbidity to the patient. A retrospective review [19] of acetabular fractures in elderly patients treated with percutaneous fixation over a 13-year period was published. A final study cohort of 75 patients (average age, 73 years) with a mean follow-up of 3.9 years was available for final review. Approximately 25% of patients were treated with closed reduction only, whereas the remaining patients underwent limited open reduction via a subiliacus approach. As expected, blood loss was less than most other reported series, averaging 70 mL. A 41% complication rate was reported, although most complications were medical. At final follow-up, 19 (25%) of 75 of patients required secondary THA at a mean of 1.4 years after index surgery.

These results compare with other series examining less invasive means of acetabular fracture fixation in this population. Some authors [20] reviewed their results using only the lateral two windows of the ilioinguinal approach for anterior acetabular fractures. This series is unique in two ways: it describes the use of the lateral two windows exclusively, and it is the only series we know that looks specifically at the more common anterior lesions (anterior column, anterior column with associated posterior hemitransverse or associated both-column fracture patterns) seen in the elderly population.

The ilioinguinal approach in general and the development of the traditional medial window in particular can be associated with morbidity and blood loss [21, 22]. In the abovementioned series, the authors hypothesized that use of the lateral two windows alone could potentially reduce these risks [20]. Indications for use of this less invasive approach are detailed in their study but included fracture patterns traditionally treated with an ilioinguinal exposure in which the distal extent of the anterior moiety of the fracture could be fixed through the lateral two windows alone and those patterns in which fixation of the symphysis or contralateral rami was not necessary. With these criteria, 17 patients treated only with the lateral two windows of the ilioinguinal approach were compared with a consecutive group of 24 patients in whom all three windows were developed. The mean age of the study group was 67 years, and all had follow-up for a minimum of 2 years. As expected, those treated with the less invasive approach experienced shorter operative times and less blood loss. The quality of reduction did not differ between the two groups. Figure 2.12-4 shows a patient treated through the lateral two windows of the ilioinguinal approach. The rate of conversion to secondary THA was similar to results reported by Gary et al [19] at 26.8%, occurring at an average of 2.5 years after the index surgery. The complication rate was 51% in this group, although most could be considered as minor or medical complications.

These two studies [21, 22] provide good evidence that less invasive means of stabilizing these injuries in the frail, elderly population may have merit. However, each is plagued by the problems faced with all retrospective studies, including a broad potential for bias. In particular it is conceivable that without randomization less severe fractures were treated with minimally invasive means, whereas more severe fractures were treated in a more traditional fashion. Caution is needed before drawing conclusions until better data are available. However, these studies highlight a critical concept that the elderly cohort is different than their younger counter parts and that they deserve careful attention to minimize morbidity and surgical insult.