Fractures in the Elderly

Epidemiology

Acetabular fractures in elderly patients are becoming more important. Treatment decisions can be difficult in this age group as bone quality is often reduced, making operative procedures more demanding.

The demographic change leads to a strong increase in acetabular fractures in the elderly.¹^,²^,³^,⁴^,⁵^,⁶ The amount of elderly patients among patients with acetabular fractures, depending on age and study period, varied between 10% and 25%.¹^,²^,³^,⁶ Elderly fractures were variably defined, starting between 55 and 65 years.¹^,²^,³^,⁴^,⁵^,⁶^,⁷^,⁸^,⁹ The incidence of acetabular fractures is gender-dependent and primarily depends on the inclusion criteria of age.¹^,⁵^,⁷^,⁸^,⁹

Keller et al reported an incidence of acetabular fractures in elderly patients (> 65 years) after high-energy trauma as 10%.⁴ Based on data from the German Pelvic Registry, 14% of all pelvic injuries in this age group were acetabular fractures.¹⁰ Researchers agree that the proportion of older patients at least doubled over the past 20 years.¹^,²^,³^,⁴^,⁶ Ferguson et al reported on 235 patients older than 60 years. The proportion of these patients in the whole collective of acetabular fracture patients was 10% during 1980–1993 and increased to 25% between 1994 and 2007.²

Sullivan et al reported a 2.5-fold increase in patients > 65 years for the period 1993–2010.⁶

With increasingly aging societies in industrial countries, the average age of patients in this age group is > 60 years, which is a significant increase during the past decades.⁶ In a recent meta-analysis of 414 patients > 55 years with surgically treated acetabular fractures, a mean age of 71.8 years was reported.¹ Two-thirds of the elderly people with acetabular fractures were male.¹^,²^,⁴^,¹¹^,¹² In the age group > 60 years, as expected, many patients had additional preexisting comorbidities¹²^,¹³^,¹⁴^,¹⁵^,¹⁶^,¹⁷ (e.g., cardiovascular disease, metabolic disorders, chronic lung diseases, chronic liver and kidney disorders, neurological limitations with previous strokes, etc.), making the treatment decision more difficult.

Clinical Relevance

The demographic change during the last 30 years resulted in a marked increase of age fractures of the acetabulum.

18.2 Injury Mechanism

In contrast to the young patient, where a high-energy trauma during traffic accidents is often responsible for acetabular fractures, in nearly half of the cases, a simple fall caused acetabular fractures in the elderly.¹^,²^,¹²^,¹³^,¹⁸

Whether a fall from a height or a low-energy fall while standing or walking led to the fracture is not uniformly stated in all studies. A low-energy trauma is proposed to cause acetabular fractures in the elderly patient in 3–74%.¹^,²^,¹¹^,¹²^,¹⁷^,¹⁸^,¹⁹^,²⁰^,²¹^,²²^,²³

Approximately one-third of these fractures are due to high-energy trauma, with traffic accidents as the most frequent cause. Not all studies distinguish the type of traffic accidents (e.g., motor vehicle accidents, pedestrians, etc.), but car drivers have a higher risk sustaining an acetabular fracture.¹^,²^,¹²^,¹³^,¹⁴^,¹⁷^,²² Due to the overall lower trauma energy, acetabular fractures more often represent as isolated injuries. Concomitant injuries are reported in one-third of elderly patients, whereas in young patients approximately half of the patients sustained other injuries.²^,³^,¹³^,¹⁵^,²⁰

The most frequent additional injuries were injuries of the lower limb. Head or chest injuries were also frequent accompanying injuries.²^,⁴^,¹⁷^,²⁴

18.3 Fracture Characteristics

The fracture characteristics in elderly patient differs from younger patients.¹^,²^,¹⁸^,²⁵^,²⁶^,²⁷^,²⁸

Fracture classification is based on standard X-ray images (anteroposterior [AP] pelvis view, iliac view, and obturator oblique view) according to Letournel.²⁹ CT is recommended for detailed fracture evaluation.³⁰ In the elderly, a higher variability of the fracture pattern was observed.²⁸^,³¹ In simple fracture types, more fractures of the anterior column and wall are observed.²⁷ In associated fracture types, often associated anterior column plus posterior hemitransverse fractures were observed.¹^,²^,¹⁰^,¹⁴^,¹⁹^,²⁷^,³² Data from the German Trauma Registry also stated an increased presence of these fracture types in patients > 60 years old,³³ with an increase of associated anterior column plus posterior hemitransverse fractures from 3.1% in the early 1990 to presently almost 19%. In multiple injuries or polytraumatized patients, these fracture types were observed more rarely.

Due to age-related restricted bone quality, the integrity of the main load zone at the superior acetabulum and the quadrilateral surface is of major importance to avoid relevant subluxation or protrusion of the femoral head.¹⁰^,²³^,²⁵ Consequently, in elderly patients, marginal impactions are frequently observed involving the acetabular roof.²^,¹⁰^,²³^,²⁸^,³⁴^,³⁵^,³⁶ Falling from stance can lead to force transmission across the greater trochanter to a high pressure load at the anteromedial joint surface and at the quadrilateral surface.²^,¹⁰^,³² Anglen et al defined the radiological visible gull sign corresponding to superior marginal impactions.²⁵ It was identified as a relevant risk factor for rapid development of posttraumatic osteoarthritis.¹⁷^,²⁵^,³⁶ Anglen stated that the presence of a gull sign was 100% predictive for a secondary dislplacement.²⁵

Regarding displacement, some investigations reported a larger proportion of displaced fractures,²^,⁷ whereas other studies found a higher mean age in patients with undisplaced fractures.⁵^,²²

Additional injury to the femoral head was observed in up to 30% of acetabular fractures in the elderly—with 4% of the cases showing an accompanying femoral head fracture (Pipkin fracture).¹⁴

Clinical Relevance

Fractures involving the anterior column (especially associated anterior column plus posterior hemitransverse fractures) are typical fracture types in the elderly population. A reduced bone quality leads to a higher proportion of superomedial marginal impactions and of quadrilateral surface fractures.

18.4 Treatment Indications

Comorbidities play an important role for treatment decision, especially in elderly patients. There is a large variety between active best-agers to immobile high-aged patients. The biological age and the activity level before the injury form the basis for treatment decision. Many patients are in a reduced general condition.

Comorbidities such as metabolic diseases, cardiovascular diseases, obesity, and the presence of osteoporosis significantly influences the choice of treatment.²^,⁷^,¹⁷^,²⁸

Treatment options include conservative treatment, percutaneous screw osteosynthesis, open reduction and internal fixation with screws and plates, as well as endoprosthetic joint replacement with and without additional osteosynthesis.⁷^,¹⁴^,²⁶^,²⁸^,³¹

Several authors proposed specific treatment algorithms for acetabular fractures in the elderly.¹^,¹¹^,¹⁴^,¹⁷^,²⁸^,³¹^,³⁷^,³⁸^,³⁹^,⁴⁰^,⁴¹ The main matching indication criteria were the extent of displacement and the proposed fracture stability.

Undisplaced osteoporotic fractures without comminution zones are supposed to be stable fractures.⁷ In the presence of a congruent joint (no subluxation of the femoral head), these fractures can sufficiently be treated conservatively or by percutaneous osteosynthesis.

In patients in good general condition with displaced fractures, open reduction and internal fixation is generally recommended.³^,⁷^,¹⁷^,²⁵^,³¹ Similar to younger patients, the postoperative outcome is correlated to the quality of reduction.²^,⁷^,¹⁷^,¹⁹^,²⁵^,³⁷^,⁴²^,⁴³

Persistent displacement of the posterior wall often leads to a rapid degeneration of the joint.⁴³^,⁴⁴

In the presence of relevant primary cartilage injury to the femoral head or preexisting symptomatic coxarthrosis, joint reconstructions are associated with poorer outcome. Thus, primary joint replacement is recommended in these patients.¹⁷^,⁴³

The posterior column should be sufficiently stable for prosthetic insertion. In individual cases, an additional posterior column osteosynthesis can be necessary.¹⁴^,⁴⁵^,⁴⁶

Clinical Relevance

The biological age of the patient plays a crucial role in treatment decisions. The primary aim also in elderly patients is the anatomical acetabular reconstruction. Indications for a conservative treatment protocol and primary prosthetic replacement should be considered.

18.5 Conservative Treatment

Conservative treatment is indicated in nondisplaced or minor displaced fractures without subluxation of the femoral head.

Often, simple anterior column fractures, some anterior wall fractures, and fractures with a transverse fracture line can sufficiently be treated nonoperatively.³³ An indirect reduction via traction is often not possible, as the capsular parts between the femoral neck and the acetabulum allow no sufficient ligamentotaxis.⁷^,⁴⁰

Conservative treatment includes appropriate analgesia, mobilization under physiotherapeutic guidance, and an appropriate thrombosis prophylaxis. Partial weight bearing of approximately 20-kg body weight on the affected leg is recommended. In many high-aged elderly patients this will not be possible, thus, depending on the fracture configuration, a pain-adapted mobilization has to be accepted or even surgical stabilization has to be considered.

In the past, the indication for conservative treatment was generously stated especially in the multimorbid patient with reduced general condition and low functional demands.⁴⁷ Although 1-year mortality was only 16% compared to higher mortality rates after femoral neck fractures,¹¹^,¹³ a high proportion of poor functional results and subsequently a rise in posttraumatic morbidity and mortality was observed.⁷^,¹¹^,¹³^,⁴⁰^,⁴⁴^,⁴⁸^,⁴⁹^,⁵⁰

Spencer et al treated undisplaced fractures with traction and reported that 30% had unacceptable results with permanent pain.⁴⁰ Matta et al reported a > 33% unacceptable rate of functional long-term results after conservative treatment.⁵¹

With technical improvements, especially with the introduction of the percutaneous stabilization methods, indications for conservative treatment were reduced.⁴⁰^,⁵² Complications of conservative treatment include secondary displacement, development of posttraumatic arthrosis, nonunions, and even heterotopic ossifications.⁷^,²³^,³¹

In a retrospective epidemiological study, Bible et al found a higher comorbidity using the Charlson Index.¹³ Compared to younger patients with higher mortality rates in the operative group, older patients (> 60 years) presented with a higher mortality rates after conservative treatment.¹¹

Thus, the classical indications for conservative treatment are:

Minimal/undisplaced fractures without traction need
Some both-column fractures (secondary congruence potential⁵³)

Contraindication of conservative treatment are prolonged immobilization, potential need for traction treatment, unstable fractures, joint incongruence, and relevant comorbidities.²⁸

Clinical Relevance

Conservative treatment is only recommended in exceptional cases.

18.6 Operative Treatment

Depending on the general condition of the patient and concomitant injuries, surgical joint reconstruction should be favored in all unstable or displaced fractures with involvement of the weight-bearing acetabular.²^,⁷^,¹³^,²⁸^,²⁹^,³⁷^,⁴⁰^,⁴²^,⁵¹^,⁵⁴

The primary aim of surgery is the anatomical reconstruction of the joint surface and stabilization of the main weight-bearing areas of the acetabulum, especially the stable connection between the anterior and posterior column, which is the prerequisite of adequate weight bearing.

The choice of the operative approach also depends on patient age and the fracture morphology. In the 1990s, two-thirds of acetabular fractures were treated using the posterior Kocher-Langenbeck approach.³³ With the demographic change of the fracture morphology, and a higher proportion anterior column involvement, anterior approaches were further modified during the last decades.

As anterior column and wall involvement is frequently present, today, the majority of fractures in the elderly are treated using an anterior approach.³^,¹⁰^,¹¹^,¹⁹^,²⁵^,³⁶^,³⁷^,³⁸^,⁵⁵^,⁵⁶^,⁵⁷

Anatomical joint reconstruction primarily affects the outcome.²^,⁷^,¹⁷^,¹⁹^,²⁵^,²⁹^,³⁷^,⁴²^,⁴³ The quality of reduction is usually analyzed according to Matta’s criteria.¹^,¹⁴^,¹⁹^,²²^,²³^,²⁵^,³³^,³⁶^,⁴² Good results can be expected after anatomical joint reconstruction with congruent joints, no relevant femoral head and acetabular cartilage damage, and without superior dome impactions or postoperative complications.²⁵^,²⁸^,⁵⁸ Risk factors for a poor result are a central hip fracture dislocation, cartilage damage to the femoral head, and involvement of the posterior wall.¹⁷^,¹⁹^,⁵⁹ Transverse fractures show a reduced rate of anatomical reconstructions.²⁵

Intraoperative complications are described in the literature in up to 7% and mostly occur as bleeding complications or thromboembolic events.¹³^,¹⁴^,¹⁹^,²⁵^,⁵⁸

Early reports stated good to excellent results after osteosynthesis in 76–94%.²⁹^,⁵⁸

Clinical Relevance

Acetabular osteosynthesis, considering prognostic factors, is the primary treatment procedure in older patient populations.

18.6.1 Percutaneous Procedures

Percutaneous screw osteosynthesis (PSO) is recommended in older patients with non- or mildly displaced acetabular fractures. Gay et al described a technique of PSO in six patients with acetabular fractures.⁶⁰

In the meantime, the technique and the indications of PSO have been improved due to technical improvements and further development of implants and better fluoroscopy techniques.

The PSO is also a minimally invasive method, recommended for multimorbid patients, and those with impaired operability, as PSO has an average operating time of 70 minutes and an averaged blood loss of 100 mL.²²^,³⁴^,⁴⁹^,⁶¹ In a meta-analysis, Daurka et al reported a significantly higher mortality rate of 30.5% after PSO in patients > 55 years.¹ The follow-up period in the PSO group, however, was significantly longer and the procedure was more commonly performed in patients with a reduced general condition and more frequent comorbidities.

Multimorbid patients with reduced compliance, who are not able to perform partial weight bearing, can especially benefit from PSO.

Kazemi et al reported on 28 patients with anterior column and associated anterior column plus posterior hemitransverse fractures after PSO who were able to fully weight bear immediately postoperative (pain-dependent), had good functional results, and no secondary displacement.²²

Sufficiently stable implants should be used. Cannulated screw systems with 6.5–7.3 mm diameter have proven to be successful.¹^,²⁰^,²²^,⁴⁸^,⁴⁹

A typical PSO is performed as a retrograde upper pubic rami screw to stabilize the anterior column or as a supraacetabular screw starting from the lateral edge of the anteroinferior iliac spine in descending direction to fix the posterior column.⁴⁸

Moushine et al also describe a retrograde percutaneous posterior column screw stabilization starting from the ischial tuberosity.⁴⁹

Intraoperative three-dimensional imaging allows optimal intraoperative hardware control. Thus, indirect reduction procedures lead to an extended spectrum for PSO. König et al performed a percutaneous navigated balloon reduction of a displaced acetabular fracture.⁶²

The combination of a PSO together with a primary endoprosthetic hip replacement is possible in complex fractures involving the anterior column using a posterior approach.²⁰

Clinical Relevance

Percutaneous screw osteosyntheses represents a good, minimally invasive alternative in certain fracture types.

18.6.2 Open Reduction and Internal Fixation

Open reduction and internal fixation (ORIF) represents the gold standard treatment in the elderly population. ORIF is recommended in displaced fractures in younger patients.¹^,²^,¹¹^,¹²^,¹³^,¹⁴^,¹⁷^,²⁵^,³¹^,⁶³^,⁶⁴^,⁶⁵ Older patients often present with limited operability, therefore a detailed risk–benefit analysis regarding surgery is recommended. Preexisting symptomatic hip joint degeneration is a contraindication for ORIF.

Also, in older patients, the posterior Kocher-Langenbeck approach was most frequently favored.²⁹^,³³^,³⁷^,⁴²^,⁵¹ Over the past decades, with the significant increase of acetabular fractures in the elderly, the presence of anterior acetabular involvement led to using anterior approaches. Due to the changes in fracture morphology, anterior approaches were further modified.²³^,³⁵^,³⁶^,⁵⁵ For a long time the ilioinguinal was the standard approach dealing with anterior column, anterior wall, and complex fracture types, such as, associated anterior column plus posterior hemitransverse fractures.¹⁶^,²⁹^,³⁷^,⁴²^,⁵¹^,⁵⁴ Difficulties, however, arose during indirect reduction of fracture parts via the second window with a risk of injury to the external iliac vein.¹³^,¹⁴^,¹⁹^,²⁵^,⁵⁸ Minimizing blood loss and shortening the overall operation time are considered advantageous due to the reduced physiological reserve in older patients. Therefore, the ilioinguinal approach was often used in a limited form, only opening the first and the third window.¹⁶

Jeffcoat et al compared patients > 55 years who were treated via such a limited ilioinguinal approach with a control group using the classical three-window ilioinguinal approach and reported a significant reduction in the operating time and the intraoperative blood loss due to this limited access.¹⁶ The quality of reduction was comparable.

A further approach-specific risk of ilioinguinal approach is the iatrogenic lesion of the lateral cutaneus femoris nerve. Caroll et al reported a rate of up to 32% after ilioinguinal approach in patients > 55 years of age.¹⁴

Fractures with central acetabular impaction zones are observed more frequently in older patients.¹⁰^,²³^,²⁵^,³⁶ This joint part cannot be visualized directly using the ilioinguinal approach, making reduction more difficult.²³^,³⁵^,³⁶^,³⁸^,⁴²^,⁵⁴^,⁵⁵ In two-thirds of patients with a poor quality of reduction, Zha et al observed superomedial marginal impaction zones and a quadrilateral surface involvement.¹⁷

In recent analyses, reductions of the medial fracture fragments were performed using the intrapelvic approach, where the quadrilateral surface can be directly visualized and direct reduction of central impactions is possible.²³^,³⁵^,³⁶^,⁵⁵^,⁶⁶

Newer implants are designed to specifically address the quadrilateral area to prevent central displacement of the femoral head.¹⁰^,⁶⁷^,⁶⁸

Clinical Relevance

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