Acetabulum fractures in elderly: A systematic review of fracture pattern and treatment

Treatment Trends and Epidemiologic Changes in Acetabular Fracture Management over the Course of 10 Years: An Analysis Based on 2853 Patients as Treated by the German Pelvic Multicenter Study Group

Background/Objectives: Acetabular fractures, traditionally linked to high-impact trauma in younger adults, are increasingly observed in the elderly due to falls and poor bone quality. This demographic shift necessitates updated treatment approaches. This study analyzes demographic trends and treatment evolution over a decade using the German pelvic fracture registry. Methods: Data on acetabular fractures were analyzed from the German pelvic fracture registry of the German Trauma Society. Parameters included classification, demographics, treatment methods, and surgical details. Trends were assessed by grouping patients based on treatment intervals and age, comparing treatment methods, surgical approaches, and reduction quality across these groups, considering fracture types and treatment volume. Results: The study included 2853 unilateral acetabular fractures with a mean patient age of 61.5 years, showing an increasing age trend. A shift from simple to complex fractures involving the anterior acetabular column was observed. Operative treatment was performed in 62.5% of cases, more common in non-geriatric patients and those with posterior column involvement. The use of anterior intrapelvic approaches increased over time, replacing the Ilioinguinal extrapelvic approach. Anatomical reduction was achieved in 47.4% of cases, with 31.7% having imperfect reductions and 20.9% poor reductions. High-volume centers had significantly better reduction outcomes, particularly for simple fractures. Geriatric patients exhibited worse reduction quality compared to younger patients. In-hospital mortality was stable at 3.3%. Conclusions: The study highlights a demographic shift towards an older patient population, leading to more complex fracture patterns. Despite advancements in surgical techniques and new implant technologies, these demographic changes have resulted in lower reduction quality for complex fractures. Emphasis is placed on careful patient selection for reconstructive surgery or endoprosthetic replacement to ensure high-quality outcomes.

Similar Medium-Term Revision Rates Following Acute Total Hip Arthroplasty Versus Open Reduction and Internal Fixation for Acetabular Fractures in the Elderly

BACKGROUND

The management of elderly acetabular fractures is complex, with high rates of conversion total hip arthroplasty (THA) after open reduction and internal fixation (ORIF), but potentially higher rates of complications after acute THA.

METHODS

The California Office of Statewide Health Planning and Development database was queried between 2010 and 2017 for all patients aged 60 years or older who sustained a closed, isolated acetabular fracture and underwent ORIF, THA, or a combination. Chi-square tests and Student t tests were used to identify demographic differences between groups. Multivariate regression was used to evaluate predictors of 30-day readmission and 90-day complications. Kaplan-Meier (KM) survival analysis and Cox proportional hazards model were used to estimate the revision surgery-free survival (revision-free survival [RFS]), with revision surgery defined as conversion THA, revision ORIF, or revision THA.

RESULTS

A total of 2,184 surgically managed acetabular fractures in elderly patients were identified, with 1,637 (75.0%) undergoing ORIF and 547 (25.0%) undergoing THA with or without ORIF. Median follow-up was 295 days (interquartile range, 13 to 1720 days). 99.4% of revisions following ORIF were for conversion arthroplasty. Unadjusted KM analysis showed no difference in RFS between ORIF and THA (log-rank test P = 0.27). RFS for ORIF patients was 95.1%, 85.8%, 78.3%, and 71.4% at 6, 12, 24 and 60 months, respectively. RFS for THA patients was 91.6%, 88.9%, 87.2%, and 78.8% at 6, 12, 24 and 60 months, respectively. Roughly 50% of revisions occurred within the first year postoperatively (49% for ORIF, 52% for THA). In propensity score-matched analysis, there was no difference between RFS on KM analysis ( P = 0.22).

CONCLUSIONS

No difference was observed in medium-term RFS between acute THA and ORIF for elderly acetabular fractures in California. Revision surgeries for either conversion or revision THA were relatively common in both groups, with roughly half of all revisions occurring within the first year postoperatively.

LEVEL OF EVIDENCE

III.

Epidemiology of acetabular fractures in elderly patients and the effect of various management options on the outcomes. A comprehensive narrative review

Owing to the expected increase in the world's elderly population (>65 years old), and the concomitant osteoporosis in this particular population, fragility fractures of the pelvis and the acetabulum is becoming a real concern, which could be life-threatening. In the current review, we aimed to discuss the various epidemiological characteristics of geriatric acetabular fractures, management options, and the outcomes. For the review synthesis, we searched PubMed to select the most relevant and updated articles published from various areas and institutions. Geriatric acetabular fractures are mainly caused by trivial trauma, constitute about 1.5%-3% of all skeletal injuries, and showed a 2.4-fold increase over the past three decades. Furthermore, these fractures' associated one-year mortality rate ranges from 14% to 25%. Management options differ largely according to the type and severity of the injury if there is an associated skeletal or non-skeletal injury, and preexisting patient comorbidities. These options could be nonoperative or operative (including surgical fixation and acute total hip arthroplasty), and both carry a specific risk in this vulnerable age group. There is controversy among various reports regarding the best management option leading to better function and health-related quality of life (HRQoL) outcomes. In conclusion, the incidence of acetabular fractures in elderly patients is rising. The decision-making on the best management option should consider the patient's fragility, injury severity, poor bone quality, and multiple medical comorbidities. The outcomes related to function, quality of life, and mortality are comparable between operative and nonoperative management options.

Uncemented hip revision cup as an alternative for T-type acetabular fractures: A cadaveric study

BACKGROUND

The current rise in elderly patients with compromised bone quality complicates the surgical treatment of acetabular T-type fractures (AO type 62B2 fractures). There is on ongoing discussion about the treatment options, mostly consisting of an open reduction and internal fixation (ORIF) with or without primary or secondary total hip arthroplasty (THA). Yet, these patients are oftentimes unable to fulfil weight-bearing restrictions and mostly present with an unavailability of a stable anchor site. Consequently, this study investigates the feasibility of a cementless hip revision cup for acetabular T-type fractures and compares its biomechanical properties to ORIF.

HYPOTHESIS

The cementless hip revision cup provides sufficient biomechanical stability under the simulation of full weight-bearing.

PATIENTS AND METHODS

The study compared two groups of human cadaveric hip bones with T-type fractures, of whom 6 subjects were treated with ORIF (6 male; mean age: 62±17years; mean body weight: 75±15) versus 6 subjects treated with a cementless hip revision cup (2 male; 69±12 years; 73±15kg). The group-assignment was controlled for comparable BMD results (mean BMD: ORIF 110±37 mg Ca-Ha/mL versus hip revision cup 134±32 mg Ca-Ha/mL). To compare for biomechanical stability cyclic loading was applied measuring the force and dislocation of the fracture gap at standardized bone loci using an all-electric testing machine and a 3D-ultrasound measuring system.

RESULTS

Comparing superior pubic ramus versus iliac wing (cementless hip revision cup versus ORIF [mean±standard deviation]: 5.8±2.0 versus 7.0±3.2; p=0.032) as well as sacral ala versus iliac wing (4.6±2.2 versus 6.4±3.7; p=0.002), the cementless revision cup achieved a significantly higher stability than the plate osteosynthesis.

CONCLUSION

Revision cup and ORIF withstood biomechanical loading forces exceeding full weight-bearing in this biomechanical study. The results of our study suggest that the cementless hip revision cup might be promising alternative to the current standard care of ORIF with or without primary THA.

LEVEL OF EVIDENCE

III; case control experimental study.

Early Stabilization Does Not Increase Complication Rates in Acetabular Fractures of the Elderly: A Retrospective Analysis from the German Pelvis Registry

Background: The incidence of acetabular fractures in geriatric patients has increased. Although there are strong data supporting the early operative treatment of hip fractures in geriatric patients, the optimal timing for acetabular fractures remains unclear and for several reasons, delayed treatment after trauma is common. Methods: A retrospective analysis of the German Pelvis Registry between 2008 and 2017 was performed. Ultimately, 665 patients with fractures of the anterior column or anterior column and posterior hemitransverse were enrolled. Patients above and below 65 years of age with these fracture types were analyzed regarding surgery day (within 48 hours, between 2 and 4 days, after 4 days), complication rate, reduction quality, and hospital stay. Results: The complication rate of the geriatric group was twice as high as that of younger patients; however, this finding was independent of the timing of surgery. Reduction quality and hospital stay were independent of surgical timing. Conclusions: In contrast to other fracture types, such as proximal femur fractures, the timing of surgery for acetabular fractures does not have a significant impact on the patient's outcome. The optimal time for surgery cannot be determined using the current data. However, as expected, there is a significantly higher risk for postoperative complications in the geriatric population.

Treatment of Acetabulum Anterior Wall Fractures Using the Modified Stoppa Approach

Introduction The objective of this study was to describe the modified Stoppa approach for anterior wall fracture fixation and to present our radiological and functional results of this approach. Materials and methods Between April 2013 and December 2019, 256 acetabular fractures operated with the modified Stoppa approach in our clinic were retrospectively reviewed, and 11 patients who were operated for anterior acetabular wall fractures with at least two years of follow-up were included in the study. Results The median amount of bleeding during surgery was found to be 450 ml (200-800), and the median operation time was 120 minutes (90-180). The modified Merle d'Aubigné and Postel Hip Score (MDS), modified Harris Hip Score (HHS), Matta's Reduction Criteria (MRC), and Kellgren-Lawrence Classification (KLC) outcomes are similar to the anterior surgical approach. Conclusion We suggest that the modified Stoppa approach can be safely used in the surgical treatment of isolated anterior acetabular fractures due to its short operative duration, low amount of bleeding, low complication rate, and favorable radiological and clinical results. The modified Stoppa procedure is a considerable alternative to the ilioinguinal approach in anterior acetabular fractures.

Outcomes of acetabular fractures treated with acute fix and replace versus open reduction and internal fixation in elderly population: a multicentric retrospective study

Purpose

The optimal operative treatment for displaced acetabular fractures in elderly population is still object of debate. Acute fix and replace procedure, the so called “combined hip procedure” (CHP), was introduced because of the poor results of the open reduction and internal fixation (ORIF) alone. The aim of the study is to compare clinical outcomes of CHP and ORIF alone for the treatment of acetabular fractures in elderly patients.

Methods

This is the largest multicentric retrospective analytical study, with a case–control design on the issue. Hospital records and clinical notes were reviewed to collect demographic, peri-operative, and clinical data.

Results

A total of 45 patients met the inclusion criteria: 24 patients entered the CHP group whereas 21 entered the ORIF control group. The mean age was 69.5 +  − 1.12 years in the ORIF group and 73.4 +  − 1.84 in the control group. The most frequent traumatic mechanism was the fall from same level in both groups (37.5% CHP; 42.9% ORIF). Operating time was significantly lower in the CHP group compared to the ORIF group (207 +  − 11.0 ORIF; 175 +  − 9.16 CHP; p < 0.05). Moreover, full weight-bearing was allowed significantly earlier in the CHP group compared to ORIF alone (37.3 +  − 1.59 ORIF; 32.5 +  − 1.69 CHP; p < 0.05). Among the clinician-completed scores, the HHS at three months was higher in the CHP group (66.3 +  − 1.83 ORIF;73.6 +  − 2.09 CHP; p < 0.05). All the other clinical outcomes were similar in both study groups.

Conclusion

CHP is desirable treatment option in elderly patients with acetabular fracture when there are poor expected outcomes in terms of joint survival with ORIF alone.

Team Approach: Management of Geriatric Acetabular Fractures

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Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase.

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An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention.

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Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.

What's New in Geriatric Acetabular Fractures

The incidence of acetabular fractures in the geriatric population is growing, yet the optimal treatment algorithm remains a controversial topic among orthopaedic surgeons. This review highlights key studies published over the past 5 years on the outcomes of various treatment options for geriatric acetabular fractures. Topics include surgical timing, mortality and risk factors, nonoperative treatment, open reduction internal fixation, and acute total hip arthroplasty.

Biomechanical comparison of acetabular fracture fixation with stand-alone THA or in combination with plating

PURPOSE

A common surgical treatment in anterior column acetabular fractures with preexisting osteoarthritis is THA, which is commonly combined with plate osteosynthesis. Implantation of a solitary revision cup cranially fixed to the os ilium is less common. The purpose of this study was to compare the stabilization of anterior column acetabular fractures fixed with a cranial socket revision cup with flange and iliac peg or with a suprapectineal plate osteosynthesis combined with an additional revision cup.

METHODS

In 20 human hemipelves, an anterior column fracture was stabilized by either a cranial socket revision cup with integrated flange (CF = Cup with Flange) or by a suprapectineal plate combined with a revision cup (CP = Cup and Plate). Each specimen was loaded under a stepwise increasing dynamic load protocol. Initial construct stiffness, interfragmentary movements along the fracture line, as well as femoral head movement in relation to the acetabulum were analyzed.

RESULTS

Both groups showed comparable initial construct stiffness (CP: 3180 ± 1162 N/mm and CF: 3754 ± 668 N/mm; p = 0.158). At an applied load of 1400 N, interfragmentary movements at the acetabular (p = 0.139) and the supraacetabular region (p = 0.051) revealed comparable displacement for both groups and remained below 1 mm. Femoral head movement in relation to the acetabulum also remained below 1 mm for both test groups (p = 0.260).

CONCLUSION

From a biomechanical point of view, both surgical approaches showed comparable fracture reduction in terms of initial construct stiffness and interfragmentary movement. The potential benefit of the less-invasive cranial socket revision cup has to be further investigated in clinical studies.

Outcomes of Primary Total Knee Arthroplasty in Fractures Around the Knee in the Elderly: A Systematic Review and Pooled Analysis of 212 Patients Across 11 Studies

BACKGROUND

Treatment of fractures around the knee in the elderly is somewhat controversial with primary total knee arthroplasty (TKA) gaining prominence over the past decade or so, as an alternative for open reduction and internal fixation. The present review was conceptualized to review the published literature and evaluate outcomes of TKA in these patients, and to understand whether this is a viable treatment option for these fractures. We have further tried to identify complications and the challenges faced while performing this surgery.

METHODS

PRISMA guidelines were followed and search was conducted on three databases-PubMed, EMBASE and SCOPUS. Studies evaluating multiple factors related to outcomes and complications in primary TKA performed for fractures around the knee in the elderly were included. Cadaveric studies, conference abstracts, case reports, and any studies that included non-traumatic cases or revision after failed internal fixation, were all excluded.

RESULTS

Eleven studies, published between 2011 and 2021 were included in our review. There was significant female preponderance in the study population (M:F = 1:3). Implants with higher constraint (high post, hinged prosthesis) were frequently required to compensate for ligamentous laxity due to the fractures. On pooled analysis the mean Knee Society Score (KSS) knee score was 84.62 (excellent), and mean knee range of motion was 107.25°. However, the mean KSS function score was 56.71 (poor), which could have been due to co-morbid conditions and pre-operative status. Overall complication rate was 14.6%; surgical site infection was the most commonly reported.

CONCLUSION

There remains limited evidence for the use of TKA as a primary treatment option for these injuries. In the presence of specific conditions, and in expert hands-it may be a viable alternative to osteosynthesis with comparable outcomes. More focused studies are needed to compare the two treatment options and to formulate guidelines.

Pubic root fractures are commonly misread as anterior column fractures by radiologists: Single-institution study from a level 1 trauma center

BACKGROUND

We sought to determine how frequently pubic root fracture is incorrectly identified as anterior column fracture by radiologists and describe differences in characteristics and outcomes between injury patterns.

METHODS

We identified 155 patients who sustained pelvic or acetabular fractures at a single, level 1 trauma academic institution. Pelvis computed tomography (CT) scans were evaluated to determine whether patients sustained an anterior column fracture or pubic root fracture. Demographic and clinical factors such as mortality, ambulatory status, type of treatment (nonoperative/surgery), and mechanism of energy were assessed.

RESULTS

There were a total of 83 patients in the anterior column group and 72 patients in the pubic root cohort. Eighty-five percent of pubic root fractures were read as anterior column fractures by radiologists. A total of 77.8% of pubic root fractures had posterior ring involvement. Patients with true anterior column acetabular fracture were more likely to need surgery (63.86% vs 41.70%, P = 0.01) and be discharged to skilled nursing or inpatient rehabilitation (59.04% vs 40.27%, P = 0.02) compared to patients with pubic root fracture.

CONCLUSION

Pubic root fractures are frequently misread as anterior column fractures in radiology reports. Correctly diagnosing pubic root fractures and differentiating them from anterior column acetabular fractures can have significant impact on patients.

LEVEL OF EVIDENCE

III, Therapeutic.

Is non-operative management of acetabular fracture a viable option for older patients? A systematic review of the literature for indication, treatments, complications and outcome

There is no consensus about the best treatment for acetabular fracture in older patients. The purpose of this study was to review the current literature looking for indication, perioperative information and outcome of nonoperative management for acetabular fractures in elderly.A systematic review of literature was performed on different research database by using various combination of the keywords "acetabular fracture", "elderly patients", "60 years", "nonoperative", "nonsurgical" and "conservative treatment".Six articles met our inclusion criteria, 315 patients aged 60 or more treated nonoperatively for acetabular fracture were included in the analysis. The average age was 78.1 years, the average follow-up length was 48.7 months. The main criteria for indication of nonoperative management for acetabular fractures were, old age (75 years or more), two or more important medical comorbidities, and minimally or undisplaced fracture. The most frequent fracture pattern was anterior column in 25.3% of cases. Fall from standard height was the most frequent causative mechanism in 80% of patients. A conversion total hip arthroplasty was performed after 8.3% of cases. A 1-year mortality of 18% was reported, an overall mortality of 33.1% at last follow-up was reported.The management of acetabular fractur in elderly is a challenging problem and there is no consensus about the best treatment. Currently, multiple treatment options have been suggested, depending on fracture pattern and patients' general conditions. Although operatively treatment allow for an early recovery, there is not an high level of evidence about the superiority in terms or complications and mortality rate compared to nonoperative treatment.