➢ In the physiologically compromised elderly patient with an acetabular fracture, nonoperative treatment is associated with functional outcomes (as indicated by the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] scores) similar to those seen in healthier patients who undergo open reduction and internal fixation, with similar mortality and lesser need for late conversion to total hip arthroplasty.
➢ Open reduction and internal fixation of displaced acetabular fractures in patients older than 60 years of age is an excellent option provided that the patient does not have risk factors for failure such as acetabular dome (roof) impaction, femoral-head impaction, or a posterior-wall component. Specific techniques to treat quadrilateral plate involvement and dome impaction are necessary to ensure a durable result. More limited operative approaches and percutaneous fixation have a role in this patient population to minimize the morbidity associated with more extensive exposures.
➢ The clinical and radiographic outcome of posterior-wall acetabular fractures that have associated comminution, marginal impaction, and/or femoral-head impaction fractures is predictably poor, with rapid onset of posttraumatic arthritis. Immediate total hip arthroplasty in this population is simple and has outcomes equivalent to those of total hip arthroplasty for coxarthrosis. Total hip arthroplasty should be considered for patients who are ≥60 years of age and have posterior-wall acetabular fractures and perhaps even in younger patients when there are multiple injury factors that predict a poor outcome.
➢ The published clinical results of the use of acetabular reconstruction rings, bone graft, and revision arthroplasty techniques appear to be similar to the results of combined internal fixation and insertion of uncemented acetabular components. Surgeons should choose an operative plan that is appropriate to their particular training and skills, the patient’s particular fracture, and hospital resources.
The goals of treatment of acetabular fractures are to optimize the eventual hip function of the patient and to treat the patient in a manner that minimizes the total period of disability and the risk of short-term and long-term complications. Such fractures may be treated nonoperatively by one of many possible methods of fracture repair or by arthroplasty (often combined with fracture stabilization). Physiologically compromised older patients are at a higher risk for perioperative morbidity, may have lower functional demands, and often have more challenging fracture patterns to treat, so the decision to operate in older patients with an acetabular fracture must be made judiciously. Because the gold standard for treatment of hip pathology in the geriatric patient is hip replacement, if another surgical option (such as open reduction and internal fixation) is chosen for treatment of a fracture, it should minimize the need for later hip replacement compared with nonoperative treatment; otherwise, the procedure is not benefitting the patient. Finally, the role of immediate total hip arthroplasty after acetabular fracture is becoming clearer.
Investigations of the operative indications for older patients with an acetabular fracture who have compromised physiology and/or bone density are limited, and there is also little information regarding the long-term outcomes of patients managed nonoperatively. Nonoperative treatment is the primary method of treatment of nondisplaced acetabular fractures in older patients with a stable hip.
Fractures Involving the Inferior Acetabulum
Displaced fractures in the elderly should be assessed using the same operative indications used in younger patients. If the patient has an intact superior acetabulum (defined as roof arc measures of at least 45° on the anteroposterior and Judet radiographic views as well as an intact subchondral ring in the superior 10 mm of the acetabulum as seen on computed tomography [CT]), there is good evidence to suggest that the patient would do well with nonoperative treatment1. In addition, the femoral head must remain congruent with the acetabulum on anteroposterior and Judet views taken out of traction. We consider the hip to be congruent when the hip joint space is of equal width and the subchondral bone of the superior femoral head completely parallels the acetabular sourcil throughout its width. Therefore, fractures of the inferior portion of the acetabulum (those completely outside the weight-bearing dome) may be treated nonoperatively provided that the hip is congruent, with no subluxation visible on any radiographic view.
Displaced Fractures Involving the Weight-Bearing Dome of the Acetabulum
Displaced acetabular fractures resulting in an incongruent joint or violation of the superior roof of the acetabulum (defined above) are typically treated operatively in the younger patient population. Carroll et al. proposed an algorithm for the treatment of displaced acetabular fractures in patients older than 55 years that begins with a medical evaluation for perioperative risk assessment2. Patients in this age group who are considered to be at high operative risk when they initially present can be managed nonoperatively; delayed total hip arthroplasty can be performed if and when their medical condition improves so that operative intervention is safer2. Similarly, patients who are not ambulatory at baseline, have severe osteopenia, or require walking aids for mobility are probably best treated nonoperatively, followed by delayed total hip arthroplasty if symptomatic posttraumatic osteoarthritis develops (Fig. 1)2. Ryan et al. studied 95 older patients with displaced acetabular fractures and found that those who met standard operative criteria but had physiologic contraindications to a surgical procedure had results similar to those of a comparison cohort of patients who had undergone open reduction and internal fixation and were healthier overall3. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)4 function scores were similar in both groups of patients at the time of the latest follow-up. The mortality in the nonoperative group was 24% compared with 25% in the operative group. The rate of late conversion to total hip arthroplasty was 15% in the nonoperative group and 28% in the operative group3. In an older patient who is physiologically unsuitable for a surgical procedure, medical optimization followed by delayed total hip arthroplasty several months after injury (if needed) may be a safer approach for treatment.
Previous reports of nonoperative treatment of displaced acetabular fractures showed relatively poor results and utilized cumbersome treatments such as distal femoral and lateral trochanteric traction for ≥6 weeks followed by gradual advancement of weight-bearing5,6. Ryan et al. used no traction and early immobilization with foot-flat weight-bearing for a period of 6 to 8 weeks followed by gradual advancement to full weight-bearing, achieving good results even in elderly patients with displaced fractures3.
Both-Column Fractures in the Elderly
Both-column fractures are common in older patients and, despite marked displacement, may be amenable to nonoperative treatment if secondary congruence is present. Secondary congruence is said to be present when, on anteroposterior and Judet radiographs out of traction, the femoral head is congruent with the acetabular roof; in this circumstance, nonoperative treatment with protected weight-bearing has been shown to be an effective strategy7. The surgical exposure to repair both-column acetabular fractures is, in most cases, rather extensive, so the decision to operate, particularly in the view of secondary congruence, must be carefully considered.
Posterior-Wall Acetabular Fractures in the Elderly
Nonoperative treatment of posterior-wall fractures is an accepted treatment for fractures involving the periphery of the acetabulum (<20% of the posterior wall involved)8. However, fracture pattern and hip joint stability are often difficult to discern in posterior-wall acetabular fractures. In general, fractures involving the weight-bearing dome are more unstable, but wall fragment size or location of the fracture alone does not reliably predict stability9.
Like younger patients, elderly patients with a fracture involving the posterior wall may benefit from stress examination under anesthesia and, if the fracture is unstable, may undergo operative treatment8. Posterior-wall fractures can be difficult to treat nonoperatively, and strong consideration should be given to operative treatment in an unstable fracture pattern in all patients, including the elderly.
Operative Treatment of Displaced Acetabular Fractures in the Elderly
Although nonoperative treatment of physiologically compromised older patients may be acceptable, healthy older patients with displaced fractures should be treated operatively to maximize the patient’s long-term native hip survival and function.
Many studies have shown that anatomic reduction of acetabular fractures in young and old patients protects against the need for later total hip replacement10-15. Unfortunately, acetabular fractures in patients older than 60 years of age often have several factors that make an anatomic reduction more difficult to achieve, including roof (or dome) impaction (Fig. 2)10,12,14-17, medial-wall (quadrilateral-plate) involvement and protrusio acetabuli12,13,17, and femoral-head impaction15,18-20. In posterior-wall fracture patterns, comminution and marginal impaction are also more common than in younger patients11,15,17,18.
Anterior Fracture Patterns
Fractures involving the anterior column including anterior column fractures, anterior column posterior hemitransverse fractures, both-column fractures, and fractures involving the quadrilateral surface are more common in elderly patients. In younger patients, these are typically reconstructed using ilioinguinal or modified anterior intrapelvic (Stoppa)21 and lateral window approaches; however, the elderly patient may be less physiologically tolerant of large and/or multiple surgical approaches.
Jeffcoat et al.12 reviewed a series of older patients with acetabular fractures who had undergone open reduction and internal fixation through either a standard ilioinguinal approach or a limited approach involving the middle and lateral windows only. They emphasized reduction of any dome impaction using a cortical window bone graft and raft screws (screws placed immediately below, and parallel to, the subchondral bone, as if the articular surface is supported on a raft of screws), as necessary. In addition, they recommended reduction and fixation of the quadrilateral surface using long screws parallel to the quadrilateral surface through the reconstruction plate on the pelvic brim directed from proximally to distally. This strategy for preventing later medial femoral head displacement (protrusio acetabuli) leaves long screws just medial to or slightly within the cotyloid fossa, parallel to the quadrilateral surface. With the limited ilioinguinal approach treatment, there was significantly less blood loss (572 mL compared with 904 mL, p = 0.02) and operative time (207 compared with 273 minutes, p = 0.002) compared with a standard ilioinguinal approach and equivalent reductions12.
To limit secondary fixation failure and protrusio acetabuli, other authors have advocated an infrapectineal reconstruction plate13,21-23 that is placed inferior to the pelvic brim along the inner aspect of the quadrilateral surface. These infrapectineal plates can be placed through the modified Stoppa approach alone in an effort to minimize operative time and blood loss. To effectively control late medial displacement, these plates are undercontoured to push laterally on the quadrilateral surface and typically have 2 to 3 screws on either side of the fracture.
As mentioned before, acetabular roof or dome impaction, radiographically manifest as the “gull sign,” is more common with anterior acetabular fracture patterns in older patients (Fig. 2)16. In 2003, Anglen et al. reported dome roof impaction as a harbinger for failure, with 100% of their patients with dome impaction requiring later total hip arthroplasty16. Impaction of the acetabular dome may persist after reduction and fixation of the anterior column (Fig. 3).
Recently, specific techniques of reduction and fixation of dome impaction have been reported. Laflamme and Hebert-Davies reduced the impacted joint surface under direct vision through a modified Stoppa approach by rotating the quadrilateral plate fragment posteroinferiorly to visualize the dome impaction directly14. The joint surfaces were then reduced using the femoral head as a template, much as would be done in a posterior-wall acetabular fracture. The results were reported in a small series of 9 patients with a mean follow-up of 2.8 years14. The reduction of the dome was within 3 mm in 7 patients (78%). One-third of the patients underwent conversion to total hip arthroplasty; all of these patients either had initial malreduction or suffered an early loss of reduction. Based on their experience, Laflamme and Hebert-Davies concluded that good reduction of superomedial dome impaction can be obtained and maintained using their approach14. Jeffcoat et al. addressed dome impaction with a cortical window, cancellous grafting, and raft screws as needed12. Casstevens et al. used a periosteal elevator and fluoroscopic visualization to shoehorn the impaction into reduction, using the femoral head as a template, using radiographic control24. In their series, the impaction could sometimes be accessed through the quadrilateral surface, but many times a secondary cortical osteotomy window had to be used. After reduction of the impaction, medial to lateral raft screws stabilized the fragments24.
Comminution and marginal impaction are common in posterior-wall fractures in patients older than 60 years of age, and associated femoral-head impaction is more common as well (Fig. 4). During open reduction and internal fixation, marginal impaction should be specifically addressed and fragment-specific fixation with lag screws and a supplemental buttress plate should be used. If there is extensive marginal impaction and comminution or there is substantial concomitant femoral-head damage, consideration of an acute total hip arthroplasty, with or without fixation of the fragments, should be considered in a patient older than 50 years of age18.
Outcomes of Open Reduction and Internal Fixation
Late Conversion to Total Hip Arthroplasty
Most studies of open reduction and internal fixation of acetabular fractures in patients older than 60 years of age have shown close to a 30% rate of late conversion to total hip arthroplasty. Posterior-wall fractures are difficult to treat nonoperatively and may be especially prone to posttraumatic arthritis after open reduction and internal fixation. Kreder et al. evaluated 128 patients with a posterior-wall fracture treated surgically and found that 54% of the patients older than 50 years of age with marginal impaction and comminution of the posterior wall required early hip replacement18. Similarly, O’Toole et al. reported on 46 patients older than 60 years of age who underwent surgical repair of an acetabular fracture and found that 36% of those with a posterior-wall component underwent late conversion to total hip arthroplasty compared with only 17% of patients without posterior-wall involvement15. In this series, posterior-wall fracture was an independent predictor for later conversion to total hip arthroplasty15.
Fractures predominantly involving the anterior column may be more forgiving than posterior-wall injuries, but they still present challenges for the long-term survival of the hip. In a study of fractures predominantly involving the anterior column, Jeffcoat et al. studied 41 patients who were ≥55 years of age and underwent a surgical procedure using the ilioinguinal approach and reported that 27% had undergone conversion to total hip arthroplasty at the 2-year follow-up12. Similarly, in a study of 59 anterior fractures repaired using a modified Stoppa approach, Bastian et al. reported that 29% required late conversion to total hip arthroplasty and found femoral-head impaction, central hip dislocation, reduction quality, and inability to reduce dome impaction predictive for later hip replacement10.
Dome impaction raises the risk of late hip replacement following open reduction and internal fixation, even when reduced. Laflamme and Hebert-Davies reported a 33% rate of conversion to total hip arthroplasty in these patients whose mean age was 64 years, despite their specific method to reduce dome impaction14. Casstevens et al. also showed good ability to reduce the dome impaction, but mortality remained high at 30% within the first year and the rate of secondary total hip arthroplasty within the first year was 19%24.
Operative techniques are now available to reliably address the medial protrusio acetabuli often present in an elderly patient with an acetabular fracture. Archdeacon et al. studied 39 patients older than 70 years of age with acetabular fractures with a protrusio component22. Treatment consisted of standard anterior approaches with an infrapectineal reconstruction plate supplemented in some cases with a standard pelvic brim plate and screws placed parallel to the quadrilateral surface. Archdeacon et al. did not report the ability to limit later protrusio, but 19% had been converted to total hip arthroplasty at the 18-month follow-up. Twenty-five percent of patients died within the first year after the surgical procedure. Similarly, Laflamme et al., also using infrapectineal reconstruction plates, found a 9.5% total hip arthroplasty conversion rate at the 4-year follow-up13.
To our knowledge, very few studies have shown 1-year mortality rates for patients who were older than 60 years of age and had an operatively treated acetabular fracture. One large multicenter study found an overall 1-year mortality of 16% for patients older than 60 years of age with an acetabular fracture25. Patients treated nonoperatively had a 21% mortality rate compared with 13% for patients managed with a surgical procedure (open reduction and internal fixation, percutaneous fixation, total hip arthroplasty). However, after adjusting for comorbidities, operative treatment was not protective against death. This contrasts with mortality data in older patients with a femoral neck fracture, in whom a surgical procedure does confer a mortality benefit. This may be because the same emphasis on medical optimization prior to the surgical procedure as well as early postoperative mobilization was not realized in the patients in that study. Further research is needed to clarify factors that affect mortality in physiologically compromised patients with an acetabular fracture.
The 2 most common outcome scores used in studies of open reduction and internal fixation of elderly acetabular fractures include the WOMAC4 and the Harris hip score26. WOMAC scores of 10 points (anterior acetabular patterns10) to 17 points (all fracture patterns15) have been reported for elderly patients following acetabular open reduction and internal fixation. This range is equivalent to that for patients who have undergone hip arthroplasty for osteoarthritis. Similarly, Harris hip scores have ranged from 80 points10,14 to 90 points27, slightly less than in a comparable patient population who have undergone total hip arthroplasty for osteoarthritis.
Percutaneous Acetabular Fracture Fixation
As older patients are less able to physiologically tolerate an extensive surgical procedure, many surgeons have adopted less invasive procedures for open reduction and internal fixation of these fractures, including percutaneous methods of acetabular fracture fixation.
Percutaneous methods utilize small 1-cm incisions for judiciously placed reduction clamps and cannulated lag screws. In some cases, a 3-cm incision over the iliac crest is used to make a small lateral window of the ilioinguinal (subiliacus) approach for placement of clamps and/or screws along the pelvic rim and iliac crests. This approach is directly amenable to the anterior column fractures, anterior column posterior hemitransverse fractures, and both-column fractures that are commonly seen in older patients. In many cases, reduction of the anterior column is hindered by plastic deformation of the bone, and osteotomy of the innominate bone at the iliac crest may facilitate reduction. In contrast to when definitive open reduction and internal fixation is performed, the need for extensive exposure to reduce the fracture is less important when total hip arthroplasty is going to be performed at the same time; the goal is restoration of the mechanical integrity of the anterior column rather than anatomic reduction. Long screws can be placed in the proximal iliac wing to stabilize an anterior or both-column fracture line. In addition, long screws can be placed from the anterior inferior iliac spine above the sciatic buttress into the posterior iliac spine to stabilize anterior column, transverse, and both-column fracture lines. Screws can also be placed to stabilize the posterior column. Posterior column screws are placed using either a retrograde approach by flexing the hip up and carefully avoiding the sciatic nerve or an antegrade approach through the same small lateral window of the ilioinguinal subiliacus approach.
Although this form of fixation is excellent for stabilization of the anterior column to the posterior column, there is less ability to stabilize quadrilateral plate injuries and to safely stabilize the posterior-wall component.
Gary et al. detailed the Parkland Hospital experience in 79 patients consecutively treated with minimally invasive fixation28,29. Seventy-five percent of the patients were treated with the limited lateral window exposure for clamp and screw placement, whereas 25% of the patients were treated with percutaneous clamp application and screw fixation alone28,29. The mean blood loss was 60 mL and the 1-year mortality was 13.9%. Nearly one-third of patients had undergone conversion to total hip arthroplasty at the time of the latest follow-up28.
Despite difficulties with stabilization of posterior-wall fractures and fractures with extensive quadrilateral plate damage, the results obtained with minimally invasive techniques are associated with 1-year mortality that is lower than that associated with standard open reduction and internal fixation, and blood loss that is lower than that associated with either standard or limited open reduction and internal fixation. In addition, conversion rates to total hip arthroplasty were equivalent to those after standard open reduction and internal fixation28. A functional analysis showed Harris hip scores26 of 77 points, comparable with those of patients who had open reduction and internal fixation alone or with total hip arthroplasty29.
Immediate Total Hip Arthroplasty
Many elderly patients with acetabular fractures, whether treated nonoperatively or by one of the various methods of fracture reduction and stabilization, develop posttraumatic arthritis and undergo eventual total hip arthroplasty. Treatment failure often occurs within the first 2 years19, so that patients who undergo secondary total hip arthroplasty often do so fairly quickly. Therefore, it seems reasonable to consider total hip arthroplasty as a primary method of management of the physiologically compromised patient with an acetabular fracture, especially one who presents with factors predictive of a poor outcome, such as posterior-wall marginal impaction11,15,17,18, dome impaction10,12,14-17, and/or associated femoral head lesions15,18-20.
Total Hip Arthroplasty without Fracture Fixation
Standard techniques of revision total hip arthroplasty, such as the use of multihole cups and bone-grafting, may be suitable for simple acetabular fractures, but more complex methods of reconstruction such as pelvic cage constructs may be necessary in more complex fractures30-32. Regardless of technique, the goal of the surgical procedure is to achieve initial fixation of the acetabular component that is sufficient to allow the patient to mobilize without risk of cup migration or compromise of the longevity of implant fixation. For that reason, many surgeons perform supplemental fracture fixation of some sort when performing total hip arthroplasty. Primary total hip arthroplasty techniques and components are suitable for biomechanically inconsequential fractures of the anterior or posterior walls. Whether revision-type total hip arthroplasty techniques with bone grafts and/or reconstruction rings or open reduction and internal fixation of the acetabulum combined with more standard total hip arthroplasty components is better and which is more cost-effective remain unanswered questions.
Anterior or Posterior-Wall Fractures: Total Hip Arthroplasty with Multiple-Screw Fixation of the Cup
Insertion of an acetabular component in patients with an isolated anterior or posterior-wall fracture may be possible using standard techniques while essentially ignoring the fracture fragments. This would be true for almost all anterior-wall fractures (Fig. 5). Fractures of the posterior wall can be problematic and can affect the stability of the acetabular component, depending on the size and location of the fracture fragment(s). Smaller, more inferior fragments are less likely to affect the stability of fixation of the cup, whereas larger fragments that are located in a more cranial position, closer to the weight-bearing dome, can create challenges to gaining appropriate cup stability. In general, reduction and buttress plate fixation of displaced posterior-wall fractures is the best approach, but in some patterns, fixation of a larger fragment with screws alone, similar to how a bulk allograft is stabilized during complex or revision total hip arthroplasty, may be possible.
In posterior-wall fractures, our practice is to perform a posterior approach and to directly evaluate whether the posterior-wall fracture is large enough to compromise cup stability. If so, it is repaired with a posterior buttress plate, as described later.
Cage Reconstruction for Fractures Involving the Columns
Acetabular cages or reconstruction rings are an established technique for acetabular reconstruction in cases of severe acetabular bone loss and, as such, may be used for immediate reconstruction of the pelvis after acetabular fracture (Fig. 6)30-32. Although well suited to prevent medialization of the acetabular component when the medial wall (quadrilateral plate) is compromised, cages may not be as biomechanically suited for maintenance of anterior or posterior column reduction as a proper buttress plate would be. Cages can also be difficult to use in true both-column fractures, wherein, by definition, no part of the acetabulum is in continuity with the innominate bone. Thus, although biomechanical studies are absent, such considerations would seem to dictate that reconstruction rings are best suited for cases with medial wall compromise but with an intact posterior column.
Reconstruction with Burch-Schneider or Kerboul Cages
The procedure is performed via the surgeon’s standard arthroplasty approach31,32. The femoral head is resected, facilitating exposure of the acetabulum. The acetabular cartilage is removed, but no attempt is made to reduce the articular fracture. Autologous bone from the femoral head can be morselized and can be placed into any acetabular defects. A reconstruction ring is affixed to the intact ilium with multiple screws (Fig. 6). Some designs (Burch-Schneider lineage) have an inferior flange that is impacted into a slot in the ischium, whereas others (Kerboul lineage) have an inferior hook that wraps around the radiographic teardrop into the obturator foramen. Depending on the design of the components, a polyethylene liner is cemented or is press-fit into the ring, and the femoral stem is inserted according to the surgeon’s preference. Typically, weight-bearing is restricted for 6 weeks to allow for some bone consolidation.
Chana-Rodríguez et al.30 reported what is essentially the reverse of the above technique, in which a Trabecular Metal cup (Zimmer) is first placed into the acetabular defect, followed by a cage placed inside the cup. The difference with this technique is the use of the porous tantalum cup, which provides a broad surface for long-term biologic fixation. However, the tantalum cup is an additional component and dramatically adds to the cost of the procedure.
The hip is exposed by the surgeon’s standard operative approach. The acetabulum is gently reamed. Defects are grafted with morselized autologous bone from the femoral head. A porous tantalum cup is inserted and is fixed to host bone where possible with 6.5-mm screws placed through the cup. A contoured cage is then fit to the ilium and ischium and is fixed to the pelvis with additional screws, some drilled through the acetabular shell. Finally, a polyethylene component is cemented into the cup-cage construct.
Mears Total Hip Arthroplasty with Cable Fixation Technique
One of the pioneers of the technique of performing immediate total hip arthroplasty in patients with acetabular fractures, Dr. Dana Mears, utilized a cerclage cabling technique with insertion of a standard acetabular component fixed with screws33. The rationale for the development of this simple technique was the need for adjunctive bone support to prevent subsidence of the acetabular component in unstable fracture patterns, while avoiding the complications associated with more extensile approaches typically used for formal open reduction and internal fixation33. The technique is done with the patient in the lateral decubitus position using a standard Hardinge34 or a posterolateral approach for total hip arthroplasty. After excision of the femoral head, one or two 2-mm-diameter braided cables are carefully placed using long pointed clamps in a manner to buttress the quadrilateral surface, typically through a drill-hole made in the anterior inferior iliac spine and passed through the lesser sciatic notch33.
Outcomes of Total Hip Arthroplasty Alone
One of the largest series of acute total hip arthroplasties for the treatment of acetabular fractures was reported by Mears and Velyvis in 200235. Among 57 patients, a variety of techniques were used, including lag screw fixation of displaced column fractures, structural autograft from the femoral head for large posterior-wall fractures, and cable fixation33 of low transverse or comminuted anterior column fractures with quadrilateral plate involvement35. All patients had an uncemented acetabular cup inserted with screw fixation. Patients were mobilized but kept toe-touch weight-bearing for 6 weeks. All fractures healed, with subsidence of the cups noted only in the first 6 weeks; mean subsidence was 3 mm medially and 2 mm vertically. All cups stabilized after 6 weeks, and none needed to be revised. Patients had a mean follow-up of 8 years (range, 2 to 12 years), and, at the time of the latest follow-up, 86% had no pain or just mild pain and 68% walked normally. Reported complications included 6 cases of heterotopic bone formation (of which 1 was symptomatic). Six cases had excessive medialization of the cup, but none had late loosening or osteolysis. At the time of the latest follow-up, 9 cups (16%) had polyethylene wear, although none required revision. One patient had late revision of a malaligned cup associated with recurrent dislocations, 1 patient had removal of the implant from the greater trochanter, and 1 patient underwent excision of symptomatic heterotopic bone.
Mouhsine et al. reported on 18 patients with a mean age of 76 years managed with cable fixation of the acetabulum and acute total hip arthroplasty36. Again, all fractures healed, and patients experienced good results at 1 to 4 years of follow-up, except for 1 patient who experienced recurrent dislocations36. The majority of patients (14 [78%] of 18) demonstrated some migration of the acetabular component within the first 3 months after the surgical procedure. The mean migration was 2.3 mm (range, 1 to 3.2 mm) superiorly and 2 mm (range, 1 to 3 mm) medially36.
With respect to the use of reconstruction cages, Enocson and Blomfeldt reported on their series of 15 elderly patients31. The overall complication rate was low, and the most common complication was heterotopic ossification in 4 patients. These investigators performed a functional assessment of the 11 patients who were alive 48 months after the surgical procedure, and all 11 patients were walking independently; just 3 patients used a walking aid when outdoors. However, all 11 patients demonstrated persistent deficits in health-related quality-of-life and functional outcome scores compared with their pre-fracture scores31. Malhotra et al. also reported on 15 patients managed with a specific acetabular ring that allows the polyethylene liner to be snap-fit into the acetabular ring32. There were 2 minor wound infections and 1 patient with a postoperative dislocation. All fractures had healed at the time of the latest follow-up, and all patients were walking independently32. Chana-Rodríguez et al. reported on a small series of 6 elderly patients treated with a cup-cage construct30. At the 2-year follow-up, all 6 patients reported minimal pain and radiographs showed healing of the fracture and no loosening of the acetabular components. One patient fell 3 months after the index surgical procedure and sustained a dislocation, which was treated with revision and insertion of a longer neck. One other patient developed Brooker stage-II37 heterotopic ossification.
Combined Open Reduction and Internal Fixation and Total Hip Replacement
The primary challenge with performing immediate total hip arthroplasty in patients with acetabular fractures is obtaining sufficient fracture stability to achieve ingrowth of the acetabular component. For posterior-wall fractures, simple fixation of the posterior wall with a contoured buttress plate, prior to insertion of the acetabular component, is a relatively simple technique. For more complex fractures involving the anterior and/or posterior column, as well as the associated fracture patterns, more sophisticated techniques of acetabular repair may be needed. Fixation techniques of acetabular repair include traditional formal open approaches, limited open approaches, and percutaneous methods of reduction and fixation.
Traditional Combined Techniques
Formal open reduction and internal fixation techniques can be combined with total hip arthroplasty using one or more surgical approaches38-40. Posterior-wall, posterior-column, and some transverse fractures can be treated through a posterior approach. Displaced, high anterior-column fractures are simple to reduce and to plate using the lateral window of the ilioinguinal approach, and lower anterior-column fractures and displacements of the quadrilateral plate are very well treated by fixation using the modified anterior intrapelvic approach.
When planning a combined procedure, careful assessment of the fracture pattern is done first, followed by the development of the optimum strategy to best reduce and to repair the fracture. Consideration of the specific characteristics of the geriatric acetabular fracture is needed, including the more frequent involvement of the quadrilateral plate, the frequent comminution of the anterior column, and the degree of osteopenia present. Fracture fixation should not be compromised by the need to perform total hip arthroplasty, and vice versa, and, in some cases, 2 approaches may be needed. The specific tactic employed may vary depending on the surgeon’s preferred approaches to a specific fracture pattern and for performing total hip arthroplasty. Anterior approaches (either ilioinguinal or anterior intrapelvic) are needed for displaced fractures of the anterior column. Surgeons who are comfortable with anterior approaches to total hip arthroplasty may safely perform such procedures using a single anterior incision (Fig. 7)41. For surgeons using a traditional posterior approach, the treatment of such fractures may require dual incisions. Fractures of the posterior column, posterior-wall fractures, many transverse fractures, and some associated fracture patterns can be addressed through the Kocher-Langenbeck approach42, followed by immediate total hip arthroplasty from the same posterior approach (Fig. 8). When using a single-incision approach, whether anterior or posterior, femoral-head excision provides increased access to the acetabulum. In some cases, reduction can be done from within the acetabulum using screws and a Farabeuf clamp and held while fixation is inserted. It is even possible, when needed, to apply a plate within the acetabulum for fixation, followed by cup insertion42.
The goal of such fixation is to reduce and stabilize the anterior and/or posterior columns, to buttress the quadrilateral plate if needed, and to restore the peripheral rim of the acetabulum. Anatomic reduction of all fracture lines is not necessary. Instead, the goal of fixation is to create a stable osseous foundation with mechanically competent acetabular bone stock that will support an acetabular component. Once these goals have been achieved, acetabular preparation is fairly straightforward. Often, contained bone defects in the anterior or posterior column will remain; these are filled with autologous cancellous bone taken from the patient’s resected femoral head. Many authors have reported the successful use of uncemented cups, usually fixed with additional screws39,40.
Percutaneous Fixation and Total Hip Arthroplasty
Surgeons who are facile with methods of closed reduction and percutaneous fixation of acetabular fractures have found these techniques to be of benefit when total hip arthroplasty is needed43. Percutaneous reduction and fixation of the anterior or posterior column, for example, might prevent the need for a dual-incision technique or at least might minimize the need for a more extensive exposure, might reduce blood loss, and might shorten operative time.
Such techniques require expertise in intraoperative imaging. Under general anesthesia, with the patient positioned supine, the ability to achieve an appropriate reduction of the acetabular fracture by manipulation and longitudinal traction of the ipsilateral leg is confirmed with fluoroscopy. Once adequate fracture reduction is achieved, 1 or 2 percutaneous 6.5-mm cannulated screws are used for fixation of the displaced column(s). The total hip arthroplasty is then accomplished per the surgeon’s usual technique.
Outcome of Open Reduction and Internal Fixation with Total Hip Arthroplasty
In the last 20 years, there has been increasing interest in treating selected acetabular fractures with early open reduction and internal fixation with concomitant total hip arthroplasty. However, the literature is difficult to synthesize, because the published reports are on a variety of fixation methods33,35,38-41,43-46. A summary of the published articles of combined open reduction and internal fixation and total hip arthroplasty indicates that complications are relatively common, occurring in 13%40 to 45%38 of patients. One of the largest series reported to date is also one of the earliest: the report by Mears and Velyvis of 57 patients, with a mean age of 69 years, treated with acute total hip arthroplasty and screw and cable fixation35, a technique that many surgeons today would consider outdated. Nevertheless, at a mean follow-up of 8 years, the mean Harris hip score26 was 89 points, consistent with a good outcome.
In 2009, Boraiah et al. analyzed the results of 18 patients who underwent internal fixation and total hip arthroplasty with ≥1 year of follow-up44. Fifteen of the patients (83%) had posterior-wall fractures, many associated with femoral-head impaction fractures. The surgical procedures were performed by both a trauma surgeon and an arthroplasty surgeon. One acetabular component failed at 3 weeks and required revision. The authors noted some minimal subsidence of the acetabular components, with a mean medial displacement of 1.2 mm (range, 0 to 3 mm) and a mean vertical displacement of 1.3 mm (range, 0 to 4 mm) noted at the time of the latest follow-up. Despite this, no acetabular components appeared loose.
Herscovici et al. reported the results of combined open reduction and internal fixation and total hip arthroplasty in 22 patients with acetabular fractures who were older than 60 years of age, with 4 revisions at a mean follow-up of 2.5 years38. Patients were treated with standard techniques of open reduction and internal fixation; 19 patients were treated via a Kocher-Langenbeck approach and 3 patients had an ilioinguinal approach prior to total hip arthroplasty. Six patients had their acetabulum reconstructed with a reinforcement ring or cage, and the other 16 patients had a standard cup (half with cemented cup fixation). Patients were kept on protected weight-bearing for 3 months. Three patients had minor medical complications, 4 patients demonstrated heterotopic ossification, and 4 patients required revision of their hip components. Two revisions were for loosening of the femoral stem, although at the time of the surgical procedure, 1 of the acetabular components was also loose. Two other revisions were for irreducible dislocations. At a mean follow-up of about 2.5 years (range, 1.1 to 5.5 years), the Harris hip scores26 were 79 points in the posterior approach group and 69 points in the group that required dual exposures.
Most recently, Lin et al. reported on 33 patients with a mean follow-up of 5 years (range, 1 to 14 years), all treated by a similar protocol of formal open reduction and plate fixation of the acetabulum as indicated by the fracture pattern, and immediate uncemented total hip arthroplasty using a posterior approach39. Six patients experienced minor medical complications. There was 1 early wound infection in a morbidly obese patient that was managed by serial irrigation and debridement procedures and successful salvage of the total hip arthroplasty. There were 2 early and 2 late prosthesis-related complications. Both of the early complications were instances of cup loosening. The first early complication occurred in a posterior-wall fracture that had undergone a plate fixation; this complication was considered to be due to the use of an undersized cup placed without supplemental screw fixation. The posterior-wall repair healed and at 6 weeks a successful hip revision to a larger cup was performed. The second early complication was loss of fixation of a low transverse acetabular fracture in a patient with severe osteopenia and roof impaction, leading to early movement of the cup. However, in this instance, the fracture healed and the cup stabilized, and the patient was able to walk with minimal pain despite the radiographic failure. The late complications were a single dislocation in 1 patient >1 year after the surgical procedure and a late hematogenous infection presenting 12 years after the surgical procedure. Patients in this series reported excellent functional outcomes, with Oxford Hip Scores47 equivalent to those published after primary total hip arthroplasty for degenerative joint disease. Furthermore, the hip scores remained stable with time, and follow-up radiographs showed no prosthetic subsidence39. Rickman et al. used traditional open reduction and internal fixation techniques to stabilize both columns in their series of 24 elderly patients. In contrast to other reports in which dual incisions were rarely used, these authors performed anterior column stabilization in 20 of their 24 patients40. They also plated the posterior column in all, and used a Trabecular Metal cup fixed with 2 to 3 screws. They cemented the polyethylene liner into the Trabecular Metal cup and used a cemented stem. With this technique, they allowed their patients to fully weight-bear, and by hospital discharge only 1 patient was using a walker. Despite this more aggressive rehabilitation protocol, all fractures were healed and no prosthetic complications were seen at a time of follow-up of 8 to 38 months.
Several investigators have reported results of specific techniques of total hip arthroplasty and/or fracture fixation in certain types of injuries. Beaulé et al. reported 10 cases of open reduction and internal fixation and immediate total hip arthroplasty performed using the Levine anterior surgical approach for anterior-wall or column fractures in the elderly associated with impaction involving more than half of the acetabular roof41. The mean follow-up of the patients in this series was 36 months (range, 24 to 53 months), and all fractures united, with no acetabular component migration or loosening noted. One patient developed heterotopic ossification, and 1 patient sustained a postoperative anterior dislocation that was treated by closed reduction and spica cast immobilization41.
Chakravarty et al. reported their results of using percutaneous screw fixation prior to total hip arthroplasty in 19 patients, most of whom were injured in low-energy falls43. Forty-two percent of patients experienced a perioperative complication of some sort, and 26% died within a year of injury, attesting to the frailty of these patients. At a relatively short-term follow-up, there was only 1 arthroplasty-related complication, which was a dislocation. In that series, only 20% of the patients survived more than 4 years, and prosthetic longevity was not an issue.
Sermon et al. compared a cohort of 64 patients (mean age of 78 years) undergoing early total hip arthroplasty for primary treatment of an acetabular fracture with a cohort of 57 patients (mean age of 53 years) undergoing late total hip arthroplasty for posttraumatic arthritis (51 of the 57 patients had undergone prior open reduction and internal fixation of the fracture)45. There was a larger proportion of good-to-excellent Harris hip scores26 in the late group compared with the early group. However, the incidences of both heterotopic ossification and the need for a revision surgical procedure were less in the early total hip arthroplasty group45.
Acetabular fractures in the elderly are increasing in frequency. Nonoperative treatment with delayed total hip arthroplasty if needed, immediate percutaneous reduction and fixation, immediate open reduction and internal fixation with attention to addressing the problems of acetabular dome impaction and quadrilateral plate involvement, and immediate total hip arthroplasty (often combined with open or percutaneous fixation) are all appropriate methods to treat these complex injuries (Table I). Surgeons treating these patients should have an understanding of the unique features of acetabular fractures in the elderly, as well as the many methods of management.
Disclosure: No funding was received in support of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work.
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