of Treatment Options for Acetabular Fractures in Older Patients

Study

Year

Patients

Results

Starr

2001

Harris Hip Score: 85

Mouhsine

2004

Good results in 17

Gary

2010

Only 25% convert to THA

Gary

2012

Hip scores = ORIF

Note: Three (Starr and both Gary articles) of the four studies are from the same group

One potential criticism of this technique is that perhaps if patients go on to posttraumatic arthritis and require arthroplasty, the limited fixation will have led to deformity of the acetabulum that will make the subsequent arthroplasty poorly functioning. Data on this point are limited, but a subset of 11 patients who went on to arthroplasty after percutaneous fixation had reasonable outcomes compared with previous acute arthroplasty studies [34].

Although these relatively small single-center series are encouraging, it is unknown whether the results can be replicated in other surgeons’ practices. One of the main criticisms of these techniques is that they are not currently in widespread use and it is unclear whether similar results would be obtained at other centers. Others have argued that the limited screw fixation is not mechanically effective in poor geriatric bone and that the treatment winds up being essentially similar to nonoperative treatment in terms of affecting the natural history of the healing process. Currently, clinicians have very little information to guide us on the outcomes of percutaneous treatment of geriatric acetabular fractures. Randomized trials would be helpful to determine the relative merits of this technique versus other operative treatments, but to our knowledge none are on the horizon.

Traditional ORIF

Traditional ORIF has been performed on geriatric patients with the hope of reducing the risk of posttraumatic arthritis or at least restoring enough bone stock to simplify a later arthroplasty should one be required. Letournel described the first ORIF experience in 58 geriatric patients and found 62% with “excellent and very good” outcomes [17]. In 1996, Matta et al. noted that reduction quality was worse in patients older than 60 years as only 44% were well reduced versus 75% in younger patients [22].

Several papers have been published specifically on the outcome of ORIF of geriatric acetabular fractures [1, 6, 12, 14, 26] (See Table 10.2). Helfet’s original report demonstrated a very low conversion to arthroplasty rate of 6% in 18 patients at 2.6 years. However, subsequent studies have tended to show higher conversion rates with longer follow-up, including Helfet’s group (Table 10.3). The average time to hip replacement was a little over 2 years in two series [6, 26], highlighting the need for longer follow-up to properly evaluate the rate of conversion to arthroplasty after ORIF. Outcome scores after ORIF have been reported to be reasonable with an average WOMAC score of 17, which is comparable to primary total hip replacement scores and much better than the scores of 50 or more for patients with osteoarthritis [26]. Similarly, the SF36 Physical Component Summary score has been reported to be an average of 48 compared with the population norm of 50, indicating good function [14].

Table 10.2

Summary of literature on “traditional” (as opposed to percutaneous) open reduction and internal fixation (ORIF) of geriatric acetabular fractures

Study		Patients	Validated outcome score
Helfet	1992	18	Harris Hip Score
Anglen	2003	38	SF-36
Carroll	2010	84	SF-36, FMA, SMFA
Jeffcoat	2012	41	SF-36, FMA, SMFA
O’Toole	2014	46	WOMAC, SF-8

SF short form FMA Fugl-Meyer Assessment SMFA Short Musculoskeletal Function Assessment WOMAC Western Ontario and McMaster Universities Osteoarthritis

Table 10.3

Comparison of the rate of conversion to total hip arthroplasty (THA) after open reduction and internal fixation (ORIF) of geriatric acetabular fractures in various studies

Study		n	Average follow-up (years)	Conversion to THA (%)
Helfet	1992	18	2.6	6
Anglen	2003	38	3.1	16
Carroll	2010	84	5.0	31^a
Jeffcoat	2012	41	5.3	27
O’Toole	2014	46	4.4	28^b

Note the increased rate of arthroplasty with increasing length of follow-up, even between the same surgeons (e.g., Helfet vs. Carroll, Jeffcoat)

THA total hip arthroplasty

^aThe average conversion to THA occurred at 2.3 years with a range of 0.3 to 11 years

^bThe average conversion to THA occurred at 2.2 years with a range of 0.4 to 6 years

Authors have tried to identify risk factors for failure of ORIF in geriatric acetabular fracture surgery. Proposed risk factors have included impaction of the dome [1], posterior wall involvement [26], femoral head involvement, and quadrilateral plate involvement. Some surgeons have argued that low-energy mechanisms increase the likelihood of failure with ORIF, and low-energy mechanism has been shown to lead to higher rates of being treated nonoperatively (45% vs. 62%, p = 0.03) [16]. However, one recent study demonstrated that failure rates as indicated by conversion to THA were actually higher in cases of geriatric acetabular fractures sustained after high-energy mechanisms compared with low-energy mechanisms [15], so this requires more work to determine.

The complication rates for THA that is performed later for cases of posttraumatic osteoarthritis developed after ORIF of a geriatric acetabular fracture are also unknown. The higher this complication rate is, the more one could argue against ORIF and toward acute arthroplasty for these patients. This has led to mixed results, with both high (18%–22%) [29, 36] and low [3, 4, 27] 10-year revision rates being reported. A systematic review assessed 10 late conversions for arthroplasty after a mix of operative and nonoperative treatments and demonstrated reasonable outcomes but a relatively high revision rate of 18% [19].

Although more data are available on ORIF of geriatric acetabular fractures than on nonoperative treatment or percutaneous treatment, the data are still limited. All studies are only level IV, and there are no prospective or randomized trials. Further work is needed to delineate which patients and fractures are at highest risk of early posttraumatic osteoarthritis and conversion to arthroplasty.

Acute Arthroplasty

If progression to arthritis and need for future arthroplasty are highly likely, it might be advantageous to perform acute arthroplasty after acetabular fractures in older patients. Unlike acetabular fractures in younger patients, arthroplasty is commonly used for arthritis in patients 60 years and older. But how does acute arthroplasty perform in the more complex setting of an acute acetabular fracture?

A host of papers have been published to date assessing outcomes of arthroplasty for geriatric acetabular fractures [2, 5, 7, 8, 13, 18, 20, 23–25, 28, 31, 35], all typically reporting good outcomes (See Table 10.4). The literature is limited in that only three of these studies have more than 30 patients in the series [18, 24, 31] and the largest has only 57 [24] (Table 10.4).

Table 10.4

Summary of literature on acute arthroplasty for geriatric acetabular fractures

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