Session VI - Geriatrics

Friday, October 13, 2000 Session VI, Paper #35, 10:16 am

Outcomes of Operatively Treated Acetabulum Fractures in the Elderly Population

Walter W. Virkus, MD; Pamela Williams-Russo, MD, MPH; Jeremy Sussman, BS; Allison Gill, RN; David L. Helfet, MD, The Hospital for Special Surgery, New York, NY

Introduction: The treatment of acetabulum fractures in elderly patients remains controversial, with some authors favoring open reduction with internal fixation (ORIF), and others favoring initial nonoperative treatment and early total hip arthroplasty (THA). The goals of this study were to assess the number of acetabulum fractures in elderly patients that result in THA and to assess the outcome of these treatment options with various outcome measures.

Methods: Fifty-five patients over 55 years of age with an operatively treated fracture of the acetabulum were identified. Preoperative and immediate postoperative radiographs and computed tomography scans were assessed for fracture type and adequacy of reduction, and follow-up radiographs were evaluated for the presence of arthrosis and, if applicable, any prosthetic loosening. Clinical follow-up included physical examination, Harris Hip Score and d'Aubigne Hip Rating, the Six-Minute Walk, and the Get-Up-and-Go evaluation. Finally, patients were asked to fill out 4 outcome measures: the SF-36, the short form Musculoskeletal Function Assessment Score (MFA), the AAOS Modems Hip Module, and a global assessment questionnaire designed for this study. The outcomes of patients were compared to each other (THA vs. ORIF), to a separate cohort of primary THA patients available at our institution, and to national age-specific population norms when available.

Five patients died with insufficient follow-up, 3 were lost to follow-up, and 2 had less than 6 months of follow-up at the time of data collection, leaving 45 patients with adequate follow-up data, with an average age of 63 years (range 55-85). Mean length of follow-up was 3.4 years (range .5-7). There were 31 complex and 14 simple fracture patterns according to the classification system of Letournel. Twenty-four patients had high-energy mechanisms of injury, and 21 had low-energy injuries. Three patients had acute THA performed due to severe femoral head injury, and all others had ORIF. Twenty-two patients had a reduction graded as anatomic, 8 imperfect, and 11 poor. Twenty-three patients (51%) suffered a complication related to surgery.

Results: At final follow-up, 8 additional patients had undergone a THA, one was awaiting THA, and THA had been recommended for 2. In total, 14 of 45 patients (31%) had undergone or were imminently undergoing THA.

Of the 34 patients available for follow-up without THA, radiographic assessment of arthrosis was graded as excellent (no signs of arthrosis) in 5, good in 7, fair in 11, and poor (severe arthrosis) in 9, with two patients not having available radiographs. Statistical analysis showed no association between fracture type and quality of reduction (P = .23). There was a significant association between a non-anatomic reduction and radiographic arthrosis (P = .05), non-anatomic reduction and subsequent THA (P = .03), and between femoral head injury and ultimate THA (P = .02). When comparing patients with THA to those with ORIF and without subsequent THA, no significant differences were seen in any of the outcome measures. Comparison of ORIF patients with a cohort of primary THA patients a year after surgery also showed no significant difference in outcome. Overall, 24 of 37 patients (65%) categorized themselves as the same, better, or only slightly worse off than prior to injury, with no significant difference between the THA and ORIF groups.

Discussion and Conclusion: Treatment of acetabular fractures in the older population is often difficult due to poor bone quality, other health problems, associated injuries, and poorer physical condition. While acute THA after fracture can lead to a good outcome with a single operative procedure, studies have shown that loosening problems occur in a higher percentage than in primary THA patients. Our results show that acetabulum fractures that include a femoral head injury often result in THA, and consideration should be given to this option initially. If a good reduction can be obtained, however, both patient and physician-based results for ORIF appear equal to THA patients. Regardless of treatment, most patients with these injuries can be returned to good function.