Fragility Fractures of the Acetabulum: Current Concepts for Improving Patients' Outcomes

Abstract

The incidence of fragility fractures of the acetabulum (FFA) is constantly increasing. Generally, these fractures are related to a fall on the greater trochanter involving the anterior column. The management of FFA is extremely difficult considering both patients' comorbidities and poor bone quality. Both non-operative and several operative treatment protocols are available, and the choice among them is still ambiguous. The proposed surgical techniques for FFA [namely open reduction and internal fixation (ORIF), percutaneous fixation and total hip arthroplasty (THA)] are associated with a high complication rate. The treatment with the higher early mortality is the ORIF + THA, while the one with the lowest is the non-operative. However, at longer follow-up, this difference dreadfully change is becoming the opposite. Frequently ORIF, percutaneous fixation, and non-operative treatment need a subsequent re-operation through a THA. This latter could be extremely difficult, because of poor bone quality, acetabular mal union/non-union, bone gaps and hardware retention. However, the outcomes of each of the proposed treatment are mostly poor and controverted; therefore, a comprehensive patient evaluation and an accurate fracture description are required to appropriately manage acetabular fracture in the elderly.

Keywords: Acetabular fracture; Elderly; Fragility fracture; Hip fracture; Mortality; Open reduction and internal fixation; Osteoporosis; Percutaneous fixation; Plate; Total hip arthroplasty.

Fig. 1

a A 3D reconstruction of a two columns fracture with the involvement of the quadrilateral plate occurred in a 75-year-old male. b Coronal reconstruction of a CT scan. Please note in red the “gull sing” that represent the result of the supero-medial impaction of the femoral head

Fig. 2

a Anteroposterior X-ray view of a fragility both column fracture occurred in an 84-year-old female. Please note the degree of fracture fragmentation and the involvement of the quadrilateral plate. b and c Anteroposterior and oblique postoperative X-rays. Because of the patient started to complain respiratory failure during the procedure, a non-anatomic reduction of the quadrilateral plate was accepted. d Anteroposterior X-ray at 1 month of the surgery showing reduction loosening of the quadrilateral plate and femoral head medialization

Fig. 3

An anteroposterior X-ray in a 78-year-old lady. As opposite of the previous case, note the anatomical reduction of the quadrilateral plate that led to fracture healing without the further development of the osteoarthritis

Fig. 4

Antero-posterior standard X-ray, showing the three corridors for the percutaneous fixation of the acetabular fractures. In Blue, the iliac-pubic corridor (in retrograde fashion) for the anterior column. In Yellow, the iliac-ischiatic corridor for the fixation for the posterior column. In Red, the dome corridor

Fig. 5

Treatment algorithm for a practical approach to FFA