Workup of the Geriatric Patient with an Acetabular Fracture

Radiographic workup of geriatric acetabular fractures is the same as that in the younger population. Standard anteroposterior (AP), iliac, and obturator oblique radiographs should be obtained in the emergency department. CT scan is also recommended to better evaluate bone quality and other associated injuries, such as femoral head impaction that could change treatment. Because of significant osteopenia in the elderly population, fracture patterns may not strictly adhere to those described by Letournel and Judet [12]. If the fracture pattern is amenable to nonoperative treatment based on plain radiographs, but more information is needed to determine definitive treatment, a reduction maneuver with distal femoral traction and a lateral force on the proximal femur is beneficial prior to obtaining a CT scan. Always obtain an AP pelvis radiograph after performing a reduction maneuver or adding skeletal traction.

As with geriatric hip fracture patients, a medical consultation is recommended to obtain a risk stratification if the patient were to undergo operative fixation as this risk is used to help determine treatment. For example, if a fracture pattern requires an extensile or dual approach, but the patient cannot tolerate substantial anesthetic time or blood loss, nonoperative treatment may be the best treatment option.

Authors’ Preferred Treatment Method for Treating Patients Nonoperatively

Once the decision is made by surgeon, patient, and/or family, the immediate goal is pain control and mobilization. If skeletal traction is placed, it should be removed as prolonged traction is not an acceptable form of treatment. Immediate mobilization is necessary in both displaced and non-displaced fracture patterns. This avoids the complications of being bedridden. The medical or geriatric service can help guide the pain management regimen to minimize narcotics and the risk of delirium.

Patients are made toe-touch weight-bearing on the affected extremity and the advancement of weight-bearing is based primarily on the patients’ symptoms. First follow-up radiographs (AP and Judet views) are obtained at 2 weeks post-injury to assess for further displacement; however, the primary purpose of the first clinical visit is to determine the comfort level of the patient with nonoperative management. For those patients who cannot yet mobilize and have significant pain, it is reasonable to offer surgical stabilization in the form of fixation, arthroplasty, or both. Patients who are mobilizing and whose pain is well controlled may continue with nonoperative care. Patients with non- or minimally displaced fractures can advance weight-bearing as early as 4 weeks after injury and more displaced fracture patterns as early as 6–8 weeks after injury. This may seem counterintuitive because most patients treated with fixation of acetabular fractures have restricted weight-bearing for 8–12 weeks, but the elderly population treated nonoperatively is different. Advancement is based on patient comfort and often patients will advance weight-bearing on their own as the fracture heals. Elderly patients often have difficulty complying with partial weight-bearing, and advancement is made from toe-touch weight-bearing to protected weight-bearing as tolerated with a walker at the time of advancement. Repeat radiographs (AP and Judet views) are performed at 6 weeks and then again at 12, 26, and 52 weeks. Determining the healing of comminuted, displaced acetabular fractures in osteoporotic bone is difficult. Groin pain could be caused by a fracture that has not yet fully healed, symptomatic arthritis or both. However, clinical symptoms, not radiographic results, are the driver of this form of treatment. Improvement in pain, callous at the fracture site, and medialization of the femoral head that is unchanged on follow-up radiographs are all signs of healing. Obtaining long-term follow-up in this patient population is difficult, and after 1 year if patients are doing well, they are instructed to follow up as needed.

Chemoprophylaxis against thromboembolic events is also crucial. Extrapolating from the hip fracture and joint replacement literature, chemoprophylaxis is continued at least 1 month and extended until the patient is mobilizing well [6]. Type of anticoagulant is left up to the treating surgeon. Many elderly patients with these types of injuries are on Coumadin or other types of anticoagulants, and if nonoperative treatment is undertaken, then these medications can be continued as long as a complete blood count is followed during admission to watch for bleeding from the fracture from the baseline anticoagulant.

Patients should expect a leg length discrepancy in displaced fracture treated nonoperatively as the limb is shortened because of the femoral head medialization. This can easily be corrected with a shoe lift. In addition, patients should expect hip stiffness and may need to use a walking aid.

Outcomes

Patient-reported outcomes such as pain and physical function in the elderly with acetabular fractures treated nonoperatively have not yet been published, but preliminary data are encouraging [14, 24], despite poor radiographic results. In this patient population, objective findings (e.g., radiographic parameters) often do not correlate with symptom intensity and magnitude of disability. Self-reported measures of symptoms and disability are increasingly important in the shift toward value-based care. In a retrospective study of 27 patients over the age of 60 with displaced acetabular fractures treated nonoperatively, most reported surprisingly good outcomes, as determined by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)––a widely used score in the evaluation of pain, stiffness, and physical function associated with hip osteoarthritis––and the SF-8 score (a health-related quality of life instrument) [24]. However, there is selection bias with this patient population as those treated nonoperatively tend to be older and lower demand. Another retrospective study of 29 patients over the age of 65 found that nonoperatively treated patients (n = 15) had earlier return to baseline ambulation status compared with patients treated with ORIF (n = 14) [14].

Several older studies that are often quoted when discussing the results of treating elderly patients nonoperatively do not use modern functional outcomes or utilize outdated treatment methods. Spencer [27] reviewed the results of nonoperative treatment in 25 elderly patients with acetabular fractures and found that nearly one-third had unacceptable outcomes. The exact outcome measures reported were unclear, however. Additionally, the author had difficulty assessing the types of fractures because of inadequate radiographs, and nine patients were treated in traction. A study by Matta et al. [17] of 64 displaced acetabular fractures, 21 of which were treated nonoperatively in prolonged traction, found that 12 (51%) of the 21 patients had poor clinical results. The authors did not specifically comment on the outcomes of patients older than 50 years and did not specify the rate of nonoperative treatment in this patient group. Furthermore, the clinical outcome used was a modification of a non-validated scoring system that was originally intended to assess outcomes of acrylic hip prostheses. Interestingly, a 1994 study by Ruesch et al. [23] concluded that operative treatment of acetabular fractures provides results that are superior to those achieved with nonoperative treatment; yet, this study only included patients treated operatively. Based on these studies, one cannot conclude that elderly patients with displaced acetabular fractures have poor clinical outcomes.

It is reasonable to offer fixation for pain relief; however, a comparison of early pain scores in an operative versus a nonoperative group has not yet been reported. The rationale for offering fixation for pain relief is that lower pain levels could result in improved mobility, which could decrease mortality, but surprisingly, a recent retrospective study including 454 patients from three level I trauma centers in the United States showed that, after controlling for patient (e.g., comorbidity burden) and fracture (e.g., fracture patterns) characteristics, there was no difference in 1-year mortality between operative versus nonoperative treatment [8]. This finding is in contradiction with previous smaller studies, which were underpowered and lacked advanced statistics such as survival analysis using Cox proportional hazards modeling.

Not surprisingly, Schnaser et al. [25] demonstrated that patients older than 60 years who underwent delayed conversion to total hip arthroplasty for acetabular fractures initially treated operatively (n = 91) or nonoperatively (n = 80) had worse functional outcomes (higher Musculoskeletal Function Assessment scores and lower Harris Hip scores) when compared with control patients who underwent primary total hip arthroplasty for osteoarthritis. However, the rate of conversion rate to THA of the nonoperative cohort was lower (3.8%) compared to that of the operative cohort (15%), despite the nonoperative group being older (73 vs. 69 years; p < 0.05). It remains unclear whether delayed THA following initial operative fixation of acetabular fractures yields improved outcomes compared with THA following nonoperative treatment.

Conclusions

The treatment of displaced acetabular fractures in the geriatric population is controversial. Each form of operative and nonoperative treatment has its advantages and disadvantages. The treatment plan should be individualized, based on patient factors and fracture characteristics. Because of the lack of current data on functional outcomes of nonoperative treatment, one cannot assume that results are poor. In fact, early evidence suggests that, among infirm elderly patients with displaced acetabular fractures, nonoperative treatment may be associated with functional outcomes and mortality comparable to those seen in healthier, younger patients who undergo operative fixation. Future prospective studies on treatment of these injuries in this patient population should include a nonoperative group because the results may not be as suboptimal as once thought.