Coned hemipelvis reconstruction for osteoporotic acetabular fractures in frail elderly patients

Acute treatment of elderly patients with acetabular fractures by open reduction, internal fixation, and total hip arthroplasty: a 1-10-year follow-up of 48 patients

BACKGROUND AND PURPOSE

 Acetabular fractures in osteoporotic bone are associated with substantial joint impaction and comminution, previously shown to be prognostic for a poor result. A combined procedure of open reduction, internal fixation (ORIF), and total hip arthroplasty (THA) can be a good option, allowing for immediate weightbearing as tolerated. We report short- to medium-term outcome and complications of the results of patients treated with this combined procedure.

METHODS

 48 cases treated with ORIF and acute THA from 2000 to 2019 were identified from our local pelvic fracture registry, from which follow-up data was extracted. Descriptive statistics were used and Kaplan-Meier survival curves were calculated. Primary outcome was HHS at 1 year. Secondary outcomes were implant survival, complications requiring surgery, and mortality at 3 months.

RESULTS

 There were 37 men and 11 women treated in the study period. Mean age was 68 (37-87) years. 6 patients died within 3 months of surgery, leaving 42 cases available for follow-up. Mean follow-up (FU) was 2.8 (1-16) years. The most common mechanism of injury was fall from standing height (n = 36). Medical comorbidities were common. Mean Harris Hip Score (HHS) was 83 (51-100) at 1-year follow-up. There were 7 reoperations: 6 for postoperative infection and 1 closed reduction of implant dislocation. 38 had their implant intact at latest FU. At the latest FU, 28 patients were ambulatory without a walking aid.

CONCLUSION

 Our results indicate that ORIF and acute THA can be performed with good functional results in patients with unreconstructable displaced acetabular fractures, but with a significant risk of infection and revision.

Outcomes Following Pedestal Cup Reconstruction of (Impending) Pathological Fractures of the Acetabulum due to Metastatic Bone Disease

Management of periacetabular metastatic bone disease (MBD) is challenging, specifically if associated with bone loss or fracture. The aim of this study was to evaluate the complications and outcomes after undergoing peri-acetabular reconstruction using an 'ice-cream cone' pedestal cup endoprostheses for the most severe cases of (impending) pathological acetabular fractures. Fifty cases with severe periacetabular disease were identified. Acetabular defects were classified using the Metastatic Acetabular Classification (MAC). Pre- and post-operative mobility was assessed using the Eastern Cooperative Oncology Group (ECOG) Performance Status. Pain levels were assessed using a verbal rating scale. Surgical complications and patient survival were analysed; the Prognostic Immune Nutritional Index (PINI) was applied retrospectively to survival. There were 32 females and 18 males with a median age of 65 (41-88). Median post-operative follow-up was 16 months (IQR 5.5-28.5 months). Thirty-nine had complete, and 11, impending pathological fractures. The observed five-year survival was 19%, with a median survival of 16 months (IQR 5.8-42.5 months). Significantly worse survival was observed with PINI scores < 3.0 (p = 0.003). Excluding three perioperative deaths, 13 complications occurred in 12 patients: Implant failure in six patients (four aseptic loosening, one dislocation and one infection). At the final follow-up, mobility and pain levels were improved in 85% and 100%, respectively. Reconstruction of significant pelvic MBD with the 'ice-cream cone' reduces pain and improves mobility. Whilst the mortality rate is high, it remains a reasonable option for bed-bound, immobile patients. We advocate the use of an 'ice-cream cone' prosthesis for selected patients balancing the reported risks with the observed benefits.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01917-x.

Health economic evaluation of blended collaborative care for older multimorbid heart failure patients: study protocol

BACKGROUND

Integrated care, in particular the 'Blended Collaborative Care (BCC)' strategy, may have the potential to improve health-related quality of life (HRQoL) in multimorbid patients with heart failure (HF) and psychosocial burden at no or low additional cost. The ESCAPE trial is a randomised controlled trial for the evaluation of a BCC approach in five European countries. For the economic evaluation of alongside this trial, the four main objectives were: (i) to document the costs of delivering the intervention, (ii) to assess the running costs across study sites, (iii) to evaluate short-term cost-effectiveness and cost-utility compared to providers' usual care, and (iv) to examine the budgetary implications.

METHODS

The trial-based economic analyses will include cross-country cost-effectiveness and cost-utility assessments from a payer perspective. The cost-utility analysis will calculate quality-adjusted life years (QALYs) using the EQ-5D-5L and national value sets. Cost-effectiveness will include the cost per hospital admission avoided and the cost per depression-free days (DFD). Resource use will be measured from different sources, including electronic medical health records, standardised questionnaires, patient receipts and a care manager survey. Uncertainty will be addressed using bootstrapping.

DISCUSSION

The various methods and approaches used for data acquisition should provide insights into the potential benefits and cost-effectiveness of a BCC intervention. Providing the economic evaluation of ESCAPE will contribute to a country-based structural and organisational planning of BCC (e.g., the number of patients that may benefit, how many care managers are needed). Improved care is expected to enhance health-related quality of life at little or no extra cost.

TRIAL REGISTRATION

The study follows CHEERS2022 and is registered at the German Clinical Trials Register (DRKS00025120).

Integrated care for older multimorbid heart failure patients: protocol for the ESCAPE randomized trial and cohort study

ESCAPE

Evaluation of a patient-centred biopsychosocial blended collaborative care pathway for the treatment of multimorbid elderly patients.

THERAPEUTIC AREA

Healthcare interventions for the management of older patients with multiple morbidities.

AIMS

Multi-morbidity treatment is an increasing challenge for healthcare systems in ageing societies. This comprehensive cohort study with embedded randomized controlled trial tests an integrated biopsychosocial care model for multimorbid elderly patients.

HYPOTHESIS

A holistic, patient-centred pro-active 9-month intervention based on the blended collaborative care (BCC) approach and enhanced by information and communication technologies can improve health-related quality of life (HRQoL) and disease outcomes as compared with usual care at 9 months.

METHODS

Across six European countries, ESCAPE is recruiting patients with heart failure, mental distress/disorder plus ≥2 medical co-morbidities into an observational cohort study. Within the cohort study, 300 patients will be included in a randomized controlled assessor-blinded two-arm parallel group interventional clinical trial (RCT). In the intervention, trained care managers (CMs) regularly support patients and informal carers in managing their multiple health problems. Supervised by a clinical specialist team, CMs remotely support patients in implementing the treatment plan-customized to the patients' individual needs and preferences-into their daily lives and liaise with patients' healthcare providers. An eHealth platform with an integrated patient registry guides the intervention and helps to empower patients and informal carers. HRQoL measured with the EQ-5D-5L as primary endpoint, and secondary outcomes, that is, medical and patient-reported outcomes, healthcare costs, cost-effectiveness, and informal carer burden, will be assessed at 9 and ≥18 months.

CONCLUSIONS

If proven effective, the ESCAPE BCC intervention can be implemented in routine care for older patients with multiple morbidities across the participating countries and beyond.

The iliac stemmed cup in reconstruction of the acetabular defects secondary to tumor resection: a systematic review of literature

INTRODUCTION

Stemmed acetabular cups are suitable for reconstruction in case of important bone loss. Nevertheless, their use is not so common, because generally judged very invasive and technically difficult to implant. The aim of the present review is to verify the results of their use and to evaluate indications and complications.

MATERIALS AND METHODS

Literature research was performed in the main healthcare databases; indications, surgical technique, related complications, functional results and implant survival were valued and analyzed for every selected paper.

RESULTS

13 studies were selected, for a population of 424 patients and 428 hips. The main indication was reconstruction after tumor removal; the primary non-oncologic indication was revision for aseptic loosening. The most frequent complications were aseptic loosening and implant failure (16.2%), followed by deep infection (11.3%) and dislocation (9.8%). The average MSTS score was 65.9%; while data regarding functional results for degenerative cases are quite fragmented. The 5-years implant survival was 73.6%.

CONCLUSIONS

Data regarding SAC prostheses are quite rare in the literature; no prospective studies with comparisons with other reconstruction techniques are available so their use is mainly based on the experience of single centers. While data for tumors are more consistent and supported by studies, information on revisions of hip prosthesis implanted for degenerative problems is quite scarce. Preliminary results on the SAC prosthesis as a valid alternative both for tumoral and degenerative revision cases are encouraging. Prospective randomized studies are advocated to value results compared to alternative techniques.

A novel and secure technique of stemmed acetabular cup implantation in complex hip reconstructions: a comparative study and technical note

PURPOSE

The stemmed acetabular cup (SAC) can be considered in several complicated situations. This type of prosthesis uses the iliac isthmus, which is most often preserved, thus allowing solid anchorage. Its implantation is prone to mechanical complications intraoperatively, such as extra-isthmic effraction, fracture, and early aseptic loosening. The aim of our study was to compare a new technique using a flexible motorized reamer combined with isthmus catheterization (Group A) versus the standard technique deploying a rigid reamer alone (Group B).

MATERIALS AND METHODS

A retrospective analysis was carried out of the SACs implanted at our hospital. The main evaluation criterion was visualization of extra-isthmic effraction (EIE) of the stem.

RESULTS

Fifty-six SACs (Integra Lepine®, Genay, France) were implanted, 31 in group A and 25 in group B. The mean follow-up was 21.6 months ± 22.3. This study found fewer EIEs using a flexible motorized reamer (0 versus 5, p = 0.014), less perioperative bleeding (p = 0.054), and less aseptic loosening in group A (p = 0.034). There was no difference in terms of infection or other mechanical complications post-operatively between the two groups.

CONCLUSION

Using iliac catheterization combined with a flexible motorized reamer when implanting a SAC helps to avoid EIE and it also appears to reduce complications such as peri-operative bleeding and early aseptic loosening. We recommend use of this surgical technique rather than a rigid reamer alone, and this new technique should allow widespread and more accessible use of this specific type of implant.

Current concepts: managing acetabular fractures in the elderly population

The aim of this review is to summarise the current concepts in the management of acetabular fractures in the elderly population. A literature review of the evidence regarding the management of elderly acetabular fractures was performed utilising PubMed and Ovid. The predominant causes and fracture patterns of acetabular fractures are changing as populations age. Consequently, the operative management has had to change also. Judet and LeTournel did not offer operative treatment to any patients older than sixty. However, in the present time, according to the German Pelvic Registry, over half the patients aged sixty or over, sustaining acetabular fractures underwent operative fixation. We find that the increasing age of the population raises particular challenges for the operating surgeon. Postoperative rehabilitation should be focused on early mobilisation. More research needs to be focussed on standardised treatment protocols and long-term outcomes for this cohort of patients.

The management of osteoporotic acetabular fractures: Current methods and future developments

Acetabular fractures in the elderly are challenging. Management is complicated by patients' poor physiological status and osteoporotic bone. Analysis of the management of these patients must be separated from the treatment of younger patients. Conservative management continues to have a role in patients who sustain fractures that are non-displaced and are considered stable with weight bearing mobilisation, and in those patients considered too medically frail to undergo surgical intervention. The mainstay of current surgical intervention is open reduction and internal fixation (ORIF) and variations of ORIF and total hip arthroplasty (THA), or fix and replace. Fix and replace is being increasingly favoured in those patients who display poor prognostic factors for long term joint survival after ORIF. Percutaneous fixation has the theoretical benefits of minimally invasive surgery and the potential to make any subsequent THA less complicated. However, it requires specialised fluoroscopic skills and is not suitable for all fracture patterns. There are a number of developments being reported. The use of a reinforcement ring and THA in has been reported in a number of centres, as has the use of trabecular metal acetabular implants. A coned hemi pelvic prosthesis and THA has been described in our centre, with promising early results. The potential for 3D printing to improve preoperative planning and reduce intra-operative time is also being explored. The aim of this review is to provide a summary of the literature supporting current and future treatment methods, tips on reduction techniques and an overview of the treatment algorithm of these patients in our unit.

Outcomes of Total Hip Arthroplasty After Acetabular Open Reduction and Internal Fixation in the Elderly-Acute vs Delayed Total Hip Arthroplasty

BACKGROUND

Optimum management for the elderly acetabular fracture remains undefined. Open reduction and internal fixation (ORIF) in this population does not allow early weight-bearing and has an increased risk of failure. This study aimed to define outcomes of total hip arthroplasty (THA) in the setting of an acetabular fracture and compared delayed THA after acetabular ORIF (ORIF delayed THA) and acute fixation and THA (ORIF acute THA).

METHODS

All acetabular fractures in patients older than 60 years who underwent ORIF between 2007 and 2018 were reviewed (n = 85). Of those, 14 underwent ORIF only initially and required subsequent THA (ORIF delayed THA). Twelve underwent an acute THA at the time of the ORIF (ORIF acute THA). The ORIF acute THA group was older (81 ± 7 vs 76 ± 8; P < .01) but had no other demographic- or injury-related differences compared with the ORIF delayed THA group. Outcome measures included operative time, length of stay, complications, radiographic assessments (component orientation, leg-length discrepancy, heterotopic ossification), and functional outcomes using the Oxford Hip Score (OHS).

RESULTS

Operative time (P = .1) and length of stay (P = .5) for the initial surgical procedure (ORIF only or ORIF THA) were not different between groups. Four patients had a complication and required further surgeries; no difference was seen between groups. Radiographic assessments were similar between groups. The ORIF acute THA group had a significantly better OHS (40.1 ± 3.9) than the ORIF delayed THA group (33.6 ± 8.5) (P = .03).

CONCLUSION

In elderly acetabulum fractures, ORIF acute THA compared favorably (a better OHS, single operation/hospital visit, equivalent complications) with ORIF delayed THA. We would thus recommend that in patients with risk factors for failure requiring delayed THA (eg, dome or roof impaction) that ORIF acute THA be strongly considered.

Does use of a quadrilateral surface plate improve outcome in elderly acetabular fractures?

BACKGROUND

Acetabular fractures in the elderly frequently involve segmental quadrilateral plate injury, yet no consensus exists on how to best control the femoral head medial displacement. Quadrilateral surface plates (QSP) were developed to help buttress these challenging fractures. The study aims to 1) Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2) Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome.

METHODS

This was a retrospective study conducted at a level-1 trauma centre. . All patients over 60-years that sustained an acetabular fracture between 2007 and 2019 were reviewed. Pre-operative pelvic radiographs and CT imaging were reviewed for 96 patients, to assess for SQPF. From the 96 patients reviewed, over one third of patients (n = 40, 41.6%) sustained a SQPF. Patients that had an acute-THA (n = 7) were excluded as were patients that underwent an ORIF but did not have a QSP or an anterior column buttress plate (n = 3). The remaining 30 formed the study's cohort. We assessed the ability to achieve and maintain reduction in this elderly population, and compared outcomes using traditional anterior column buttress plates (ilioingual or intra-pelvic approach) versus an intra-pelvic pre-contoured buttress suprapectineal plate (QSP). Outcome measures included: fracture reduction using the Matta classification (desirable: anatomical/imperfect and poor), re-operations, conversion to THA and Oxford Hip Score (OHS) (for the preserved hips).

RESULTS

Ten patients had an ORIF with utilization of a QSP (QSP-group), and 20 had an ORIF but did not have the QSP (non-QSP-group). There was no difference in patient demographics between groups. Fracture patterns were also similar (p = 0.6). Postoperative fracture reduction was desirable (anatomical/imperfect) in 17 patients and poor in 13. Improved ability to achieve a desirable reduction was seen in the QSP-group (p = 0.02). Conversion to THA was significantly lower in patients that had a desirable fracture reduction (appropriate: 3/17; poor: 7/13). No patients in the QSP-group have required a THA to-date, compared to 10/20 patients in the non-QSP-group (p = 0.01). The mean time to THA was 1.6 ± 2.1 year. There was no difference in OHS between the two groups (34.4 ± 10.3).

CONCLUSION

Elderly acetabulum fractures have a high incidence (approaching 40%) of segmental QPF. Desirable (anatomical/imperfect) fracture reduction was associated with improved outcome. The use of a QSP was associated with improved ability to achieve an appropriate reduction. A QSP should be considered as they are both reliable and reproducible with a significantly improved fracture reduction and lower conversion to THA.

Total hip arthroplasty in acetabular fractures

Total Hip Arthroplasty (THA) is a well-accepted treatment for established hip arthritis following acetabular fractures. If a conservatively managed or operated case progresses to non-union/mal-union failing to restore the joint integrity, it may eventually develop secondary arthritis warranting a total hip arthroplasty. Also, in recent years, acute total hip arthroplasty is gaining importance in conditions where the fracture presents with pre-existing hip arthritis, is not amenable to salvage by open reduction and internal fixation, or, a poor prognosis is anticipated following fixation. There are several surgical challenges in performing total hip arthroplasty for acetabular fractures whether acute or delayed. As a separate entity elderly patients pose a distinct challenge due to osteoporosis and need stable fixation for early weight bearing alleviating the risk of any thromboembolic event, pulmonary complications and decubitus ulcer. The aim of surgery is to restore the columns for acetabular component implantation rather than anatomic fixation. Meticulous preoperative planning with radiographs and Computed Tomography (CT) scans, adequate exposure to delineate the fracture pattern, and, availability of an array of all instruments and possible implants as backup are the key points for success. Previous implants if any should be removed only if they are in the way of cup implantation or infected. Press fit uncemented modern porous metal acetabular component with multiple screw options is the preferred implant for majority of cases. However, complex fractures may require major reconstruction with revision THA implants especially when a pelvic discontinuity is present.