Management of elderly patients with acetabular fracture is challenging. As with all elderly patients with “hip” fractures, these patients demand and benefit from expert multidisciplinary co-management including input from geriatrics, internal medicine, orthopedic surgery, anesthesiology, and occasionally other medical and surgical subspecialties. Nonoperative management of these injuries results in unacceptable outcomes in 30% or more of patients [6]. Internal fixation of these complex fractures in patients with reduced bone quality and inability to “protect” the hip from loading following surgery make open reduction and internal fixation (ORIF) challenging. Many methods of surgical repair have been reported, including nonoperative management, formal ORIF [7], percutaneous fixation [8], total hip arthroplasty (THA) (often incorporating techniques otherwise used in revision THA) [9, 10], or THA combined with open or percutaneous ORIF [11, 12]. Although it has been reported that the geriatric acetabulum is more forgiving of non-anatomic reductions than the young hip [13, 14], it appears that between 10% [15] and 30% [16] of elderly patients undergoing ORIF are later converted to a total hip replacement. If either nonoperative management or initial surgical repair results in a poor outcome, late conversion to a total hip arthroplasty (THA) does not reliably lead to good results; the results of late THA following acetabular fracture are not as good as those of primary THA [17]. In an effort to reduce the morbidity of ORIF in these fragile patients, percutaneous techniques of internal fixation have been advocated [8]. Finally, acute THA, either alone or in combination with ORIF, has been recommended by many surgeons [11, 12], but controlled clinical trials are completely lacking at this time, and surgeons are faced with making treatment decisions for these challenging patients without much evidence to guide them.

In summary, the incidence of acetabular fractures in the geriatric population is increasing [1]. Surgeons caring for these patients have a variety of acceptable treatment options, as listed above. All methods have their advocates, and none has been “tested” against another by means of a controlled clinical trial. Until further data become available, surgeons treating these patients should be aware of all the possible treatment methods and their likely complications and expected outcomes, so that the optimum approach for a given patient can be selected.

As many treatment decisions start out with an assessment of the patient’s activities and frailty, we will start in the next chapter with formal methods of assessing patients for frailty and expected activity levels. Nonoperative treatment methods will then be addressed followed by open reduction and internal fixation techniques from various anterior and posterior approaches.

Next, open reduction plus concomitant hip replacement will be addressed. To conclude, conversion hip replacement for posttraumatic arthritis methods will be explored in detail.