Clinical comment

The incidence of acetabular fractures has increased 2.4 times over the past decade. They are associated with a mortality rate of between 8 and 25%.² The main purpose of surgical treatment is to restore the function of the hip, accelerate recovery, and avoid future complications.

Deciding which is the best treatment of these fractures requires considering several factors. Apart from fracture pattern and the surgeon’s ability to achieve the best possible reduction, there are also important patient‐related factors to consider. In addition, an aging population with multiple co‐morbidities might mean that some patients are not ideal candidates for surgical treatment.

Available literature and quality of the evidence

• Level II: 1 study
  
• Level III: 9 studies
  
• Level IV: 1 study.

Findings

When operative management is required for anterior column fractures, minimally invasive techniques result in lower mortality, morbidity, and complications, compared to open surgery.³ With operative treatment compared to nonoperative treatment, the recovery of function is much faster, allowing early weightbearing in elderly patients.⁴ Sixty‐five percent of patients recover their previous functional level, although in many cases with persistent pain.⁵ Conversely, results obtained by Daurka et al. showed that results are worse for percutaneous osteosynthesis when compared with open reduction and internal fixation (ORIF).⁶

Fractures compromising the acetabular roof are usually managed surgically. In older patients it will depend on the medical condition.⁷ In patients with low functional demands or those who are at high surgical risk because of co‐morbidities, nonsurgical treatment can be chosen, followed by THA if secondary osteoarthritis develops. Patients should be mobilized as soon as possible if pain management allows, to avoid prolonged periods of rest or traction in bed. Optimal outcomes are achieved when patients start with flat foot weightbearing for 6–8 weeks, and then progress gradually from there to full weightbearing.⁸

Posterior wall fractures are the most frequent acetabular fractures, representing around 30–47%.¹ They are generally associated with poorer prognosis, particularly when associated with a posterior dislocation, which is often associated with femoral head damage as well.

Other fractures that occur more inferiorly in the acetabulum that do not affect the weightbearing surface can be treated conservatively. Similarly, bi‐columnar fractures can be successfully treated nonoperatively if secondary congruence of the femoral head respect to the acetabular roof is maintained without traction.

Ryan et al. reported similar functional results in patients with high surgical risk who were treated nonoperatively and those who underwent ORIF. No differences were found in overall Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) or Short Form 8 (SF‐8) scores at one‐year follow‐up.⁸

Resolution of clinical scenario

• In older or younger patients with co‐morbidities and surgical risk, nonsurgical treatment of acetabular fractures is associated with worse outcomes in terms of pain and morbidity.
  
• Mortality is similar in patients with high risk who undergo nonsurgical treatment compared to those in which surgical treatment was performed.
  
• In older patients with high surgical risk, it is reasonable to opt for nonoperative management and reserve arthroplasty as a rescue alternative. Patients should be counselled about this possibility at time of injury.