Outcome After Open Reduction Internal Fixation of Acetabular Fractures in the Elderly

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.

Acetabular fractures in elderly patients are associated with high rates of complications during the initial admission

Background

Acetabular fractures among the elderly are common. Identification of risk factors predisposing elderly patients to in-hospital complications is critical to mitigating morbidity and mortality.

Methods

A retrospective cohort study was performed including 195 patients ≥60 years old who sustained acetabulum fractures treated at a single level 1 trauma center. Operative (n=110, 56.4%) or non-operative management was undertaken, and complications during the index hospitalization were defined.

Results

Seventy-three patients (37%) developed a complication during their hospitalization. Most common complications were acute respiratory failure: 13.3%, pneumonia: 10.3%, urinary tract infection: 10.3%, cardiac dysrhythmia: 9.7%, and acute kidney injury: 6.2%. On multivariable analysis, factors associated with in-hospital complications were increased age (adjusted OR (AOR): 1.06, 95% CI: 1.01 to 1.11, p=0.013), more comorbidities (AOR: 1.69, 95% CI: 1.07 to 2.65, p=0.024), operative management (AOR: 0.3, 95% CI: 0.12 to 0.76, p=0.011), and increased length of stay (AOR: 1.34, 95% CI: 1.2 to 1.51, p<0.001).

Conclusions

Acetabular fractures in the elderly are associated with high rates of in-hospital complications. Advanced age, more medical comorbidities and longer lengths of stay predicted higher risk of developing complications. Whereas operative management was associated with lower risk of developing complications during the initial admission, it is important to note the selection bias in which healthier patients with improved baseline functionality may be more likely to undergo operative management.

Level of evidence

Level III therapeutic.

Higher Rates of Readmission After Acute Total Hip Arthroplasty Versus Open Reduction Internal Fixation for Elderly Acetabular Fractures, a National Study From 2010 to 2019

OBJECTIVES

To evaluate the initial complications and short-term readmissions and reoperations after open reduction internal fixation (ORIF) versus acute total hip arthroplasty (THA) for elderly acetabular fractures.

DESIGN

Retrospective database review.

SETTING

All hospitalizations in the National Readmissions Database and National Inpatient Sample.

PATIENTS/PARTICIPANTS

Patients 60 years of age or older with closed acetabular fractures managed surgically identified from the National Readmissions Database or National Inpatient Sample between 2010 and 2019.

INTERVENTION

Acute THA with or without ORIF.

MAIN OUTCOME MEASUREMENTS

30-, 90-, and 180-day readmissions and reoperations and index hospitalization complications.

RESULTS

An estimated 12,538 surgically managed acetabular fractures in elderly patients occurred nationally between 2010 and 2019, with 10,008 (79.8%) undergoing ORIF and 2529 (20.2%) undergoing THA. Length of stay was 1.7 days shorter ( P < 0.001) and probability of nonhome discharge was reduced (OR 0.68, P = 0.009) for THA patients than for ORIF patients. THA was associated with lower rates of pneumonia (4.6 vs. 9.1%, P < 0.001) and other respiratory complications (10.2 vs. 17.6%) when compared with ORIF. At 30 days, THA patients had higher rates of readmission (13.9 vs. 10.1%, P = 0.007), related readmission (5.4 vs. 1.2%, P < 0.001), readmission for dislocation (3.1 vs. 0.3%, P < 0.001), and reoperations (2.9 vs. 0.9%, P = 0.002). At 180 days, THA patients had higher rates of related readmission (10.1% vs. 3.9%, P < 0.001), readmission for dislocation (5.1% vs. 1.3%, P < 0.001), and readmission for SSI (3.4 vs. 0.8%, P = 0.005).

CONCLUSIONS

Acute THA is associated with lower length of stay and certain index hospitalization complications, but higher rates of readmissions for related reasons and specifically for dislocation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Quality of life from return to work and sports activities to sexual dysfunction after surgical treatment of acetabular fractures

INTRODUCTION

To evaluate the outcomes of patients treated for acetabular fractures in terms of Quality of Life (QoL), return to work, functional outcome, sports activities, and post-operative sexual dysfunction.

MATERIALS AND METHODS

The database of a level 1 trauma center was used to investigate the results of patients treated for acetabular fractures from 2010 to 2020. The minimum patient follow-up was 12 months. QoL was evaluated with the SF-12 questionnaire, return to work with the Workplace Activity Limitation Survey (WALS), functional outcomes and sports activities with Harris Hip Score (HHS) and Tegner activity scores, respectively, and the sexual function damage with a 0-10 NRS.

RESULTS

Sixty-five patients (44 men, 21 women) were enrolled, mean age at surgery of 53.4 years (20-85 years). The HHS and Tegner scores were 79.0 ± 19.4 and 2.6 ± 1.5, respectively, and 18.5% of patients underwent THA after 21.3 ± 28.6 months. QoL evaluated with the SF-12 showed the worst results in terms of Bodily Pain and Role Physical; 35.4% of the patients who were working before the trauma lost their job, and one third was affected at sex functional level. Sex was found to influence significantly both Harris Hip Score (p < 0.05) and Tegner activity score (p < 0.05), with men reporting better scores. On the other hand, men presented a higher impact in terms of job loss and sexual dysfunction.

CONCLUSION

Acetabular fractures affect patients' life as a whole, beyond the mere functional outcomes, often leading to a high rate of job loss and a significant probability of sexual functional worsening, especially for men. A significant number of patients also underwent THA at an early follow-up. Further efforts should aim at optimizing the surgical management, to improve functionality and the entire QoL sphere of patients affected by acetabular fractures.

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

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.