Management of acetabular fractures in the geriatric patient

Abstract

Introduction: Open reduction and internal fixation (ORIF) is standard care for most acetabular fractures. With increasing numbers of acetabular fractures in the elderly, the risk of revision surgery and conversion to total hip replacement (THR) is increasing. Alarmingly, about 20-25% of acetabular fractures in the elderly following ORIF needed revision and conversion to delayed THR.

Methods: Recently, prognostic factors have been identified, which correlate with an increased risk of worse outcomes following ORIF of acetabular fractures in the elderly patient. Patient risk factors include, for example, age, comorbidities, and degree of osteoporosis. Injury risk factors mainly include the fracture pattern.

Results: The concept of primary THR following acetabular fractures is an alternative to ORIF, especially in the elderly patient. Satisfactory outcomes have been reported in different studies for primary THR following acetabular fractures in the elderly. The surgeon should be aware of strict selection criteria in order to achieve these satisfactory outcomes. Therefore, an individualized treatment plan has to be defined for elderly patients following acetabular fractures.

Discussion: Here, the advantages and disadvantages of ORIF versus THR following acetabular fractures in the elderly are discussed.

Figure 1.

Moribund 81-year-old patient following low energy fall. Besides cardiomyopathy, significant lung fibrosis excluded extensive surgical therapy. The individualized treatment plan was defined as minimal invasive ORIF of the anterior column + posterior hemi-transverse fracture. Minimal invasive surgery was conducted using a cannulated 7.3 mm screw. The postoperative AP view was acquired on the intensive care unit (ICU). No additional follow-up could be conducted, the patient passed away two months following surgery in the rehabilitation unit.

Figure 2.

Two-column fracture of the left acetabulum following a bicycle accident in a 76-year-old male. Significant premorbidities included cardiomyopathy with s/p myocardial infarction nine years ago, recurrent DVTs with warfarin anticoagulation, lower limb atherosclerosis with s/p femoro-popliteal bypass, and s/p viral encephalitis with residual impaired gait and presence of suprapubic catheter. Due to s/p multiple abdominal surgeries, the anterior approach was no option. The individualized treatment plan was defined as ORIF via one singular Kocher-Langenbeck approach, aiming to convert the two-column fracture into a stable fracture pattern with secondary congruence of the hip joint. Computed tomography (CT) scans show the two-column fracture in frontal, axial views and 3D reconstruction (column A1–A3), postoperative conventional radiographs display the reduced joint line at two weeks (column B) and at three months follow-up (column C).

Figure 3.

Due to a low energy fall a 84-year-old female patient presented with a Pipkin-IV fracture. The femoral head and the acetabular rim were fractured, the patient presented with a dislocation of the hip. Due to atrial fibrillation permanent anticoagulation with warfarin was present. Following bridging, the individualized treatment included acute total hip replacement (THR) with a Müller acetabular reinforcement ring.

Figure 4.

Fracture of the right acetabulum of a 67-year-old female. The patient reported to the emergency room four weeks delayed, upon admission impaction of the femoral head and the pattern of a two-column fracture was visible (column A). Significant comorbidities were missing, the individualized treatment plan was defined as acute total hip replacement (THR) with application of the Burch-Schneider reinforcement ring. Follow-up X-rays at two weeks (column B) and at three months (column C) are shown.

Figure 5.

Algorithm for individualized treatment of acetabular fractures in the elderly. Prognostic injury and patient factors have to be considered prior to determining the treatment.