Session X - Pelvis/Geriatrics

Operative Results and Functional Outcomes of Acetabular Fractures in Geriatric Patients

Jeffrey O. Anglen, MD; Timothy A. Burd, MD; Kelly Hendricks, MD; Paula Harrison, CST, University of Missouri Hospitals and Clinics, Columbia, MO

Purpose: Operative treatment of displaced acetabulum fractures in the elderly population remains a difficult challenge for the orthopaedic traumatologist because of their osteopenic bone and medical co-morbidities. Treatment options are open reduction and internal fixation (ORIF), and early or delayed total hip arthroplasty. We assessed the intermediate-term functional outcomes of elderly patients with displaced acetabulum fractures undergoing ORIF.

Methods: From July 1992 to August 1999, 48 patients more than 60 years of age with displaced acetabulum fractures were treated with ORIF by one surgeon. Preoperative and postoperative radiographs and CT scans were obtained. Twenty-five of the patients completed the short musculoskeletal functional assessment survey (SMFA) and the SF-36; 21 patients returned for follow-up examination and radiographs. The average age at the time of surgery for the 26 patients who completed questionnaires and/or returned for a follow-up examination was 69 years (range, 61 to 89) with an average follow-up of 53 months (range, 20 to 98). There were 17 elemental and 9 associated fractures, 11 patients had dislocation, and 11 patients had associated traumatic injuries. The mechanism was motor vehicle accident, 15; fall to floor, 9; and blunt trauma, 2. The Injury Severity Score mean was 13 (range, 9 to 34). Surgical approaches included Kocher-Langenbeck (n = 19), ilioinguinal (n = 3), and both approaches (n = 4). There were no perioperative deaths or serious postoperative complications.

Results: Of the 26 patients, 85% were community ambulators and 15% were household ambulators only. Twenty of the 26 patients (77%) had no hip pain; 6 (23%) had occasional hip pain, 4 of whom needed acetaminophen or NSAIDs for relief. The average range of motion for the 21 patients examined were flexion, affected side 114° vs. unaffected 121°; external rotation, affected side 44° vs. unaffected side 53°; internal rotation, affected side 14° vs. unaffected side 19°; and abduction, affected side 38° vs. unaffected side 44°. Manual muscle testing revealed that 20 of the 21 patients had equal strength on both sides. Five patients had a slight limp, three with a Trendelenburg gait. Nine of the 21 patients (43%) used some type of assistance device for walking. There were 13 excellent (34.2%), 12 good (31.6%), 3 fair (8%), and 10 poor (26.2%) outcomes, according to the radiographic classification of Matta, among the 38 patients for whom there was radiographic follow-up. Of the 10 with poor outcomes, 8 patients were very osteopenic and had high transverse fractures and central/superior dome impaction with medial displacement of the fracture. These failures all occurred in the early postoperative period, within 1 to 2 months. Grade I heterotopic ossification was noted in 9 patients, grade II in 4, and grade III in 2 of the initial 48 patients; the overall incidence was 31.3% with 4.1% considered significant. The average daily activities score for the SMFA was 27.7 (range, 2.5 to 68.75); for emotional status, 27.07 (range, 3.57 to 53.57); arm and hand category, 7.81 (range, 0 to 40.63); mobility category, 33.33 (range, 0 to 80.56); dysfunctional index, 23.97 (range, 0.74 to 51.84); and bother index, 20.08 (range, 0 to 72.91). The average scores for the SF-36 were as follows: mental component summary, 57.38 (range, 37.93 to 75.44); physical component summary, 37.26 (range, 20.19 to 56.51).

Discussion and Conclusion: Patients over 60 years of age can expect functional outcomes after acetabular fracture fixation that are comparable to age-matched cohorts. Good-to-excellent radiographic results can be obtained in approximately two-thirds of patients. Although bone quality, nonunion, and implant failure or loss of fixation are potentially devastating outcomes, we did not experience these problems in this group except for those patients with significant osteopenia and high transverse fracture patterns involving superior and medial articular impaction. Alternative treatment such as early total hip arthroplasty may result in better long-term success in this group of patients.