OTA 2013 Posters

Scientific Poster #37 Geriatric OTA 2013

Acetabulum Fractures in Elderly Patients: Which Injury and Treatment Characteristics Are Associated With the Best Outcomes?

Nicholas R. Scarcella, BS; Erik Schnaser, MD; Heather A. Vallier, MD;
MetroHealth Medical Center, Cleveland, Ohio, USA

Background/Purpose: In the United States, the elderly population is rapidly increasing. Acetabulum fractures are life-altering and possibly life-threatening injuries for these patients. Few prior studies have addressed acetabulum fractures in this population, often subject to treatment challenges including poor bone quality, preexisting arthrosis, and underlying medical conditions. The best course of action would promote efficient return to ambulation while minimizing complications. The purpose of this study is to review a large series of acetabulum fractures in this group and to identify favorable injury and treatment characteristics.

Methods: Records of 171 patients over 60 years of age with acetabulum fractures were reviewed. This included 124 men and 47 women. Mechanism of injury was low-energy fall in 85 and high-energy mechanisms in 86, most commonly motor vehicle collision (n = 69). Mean age was 71.2 years (range, 60-94). Fracture patterns included OTA 62A (n = 53), 62B (n = 42), 62C (n = 76) with associated both-column (ABC) in 58 (34%), and posterior wall in 30 (18%), most common. Treatment characteristics, complications, hospital stay, and secondary procedures were documented. Early complications included infections (wound, urinary, other), pneumonia, deep venous thrombosis (DVT), and pulmonary embolism. Sequential radiographs were reviewed for arthrosis and osteonecrosis.

Results: Open reduction and internal fixation (ORIF) was performed in 91 patients (53%): 53 Kocher-Langenbeck and 38 ilioinguinal approaches. Posterior fracture dislocations were most likely to be treated surgically. One patient had a primary total hip arthroplasty (THA). Seven nonoperative patients died within the first few days of hospitalization, and the overall 1-year mortality rate was 8.8% (n = 15). Other complications occurred in 24% of all patients. Nonoperatively treated patients had less pneumonia: 7.0% versus 14.3% in surgical patients (P = 0.10). However, nonoperative patients had more DVTs (14.1% vs 8.8%, P = 0.29), resulting in no differences in total complication rates between the two groups. The highest complication rate was seen after ilioinguinal approach (29%). Mean hospital stay was longer in patients treated with ORIF: 15.3 days versus 10.2 (P = 0.002). 51 patients were over 75 years of age. Seven of them had ORIF with mean blood loss of 830 cc, and a 71% complication rate. The majority of patients in this group had ABC patterns, and the THA conversion rate after nonoperative management was 4.5%. Secondary THA was done in 9.8% of all patients at mean 31 months after injury, with 44% of these occurring within 1 year after injury. 19% of patients with late THA had initial nonoperative care; thus 15.4% of operative and 4.2% of nonoperative patients had secondary THA (P = 0.013).

Conclusion: Half of the acetabulum fractures in patients over 60 years of age were due to low-energy falls and were treated nonoperatively with low rate of secondary THA. However, unstable posterior patterns with associated dislocations were more often treated surgically, likely to avoid prolonged bed rest and traction. Hospital stays in this group were longer and more developed pneumonia. Complications and large surgical blood loss were most common after ilioinguinal approaches. Conversion to THA was more likely after initial ORIF, suggesting the need for careful patient selection for ORIF and warranting further study into alternative treatment options including less-invasive fixation or acute THA.

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.