Session X - Pelvis/Geriatrics

The Combined Hip Procedure: Open Reduction Internal Fixation with Concurrent Total Hip Arthroplasty for the Management of Acetabular Fractures in the Elderly

Dolfi Herscovici, Jr., DO; Brett R. Bohlhofner, MD; Eric Lindvall, DO; Julia M. Scaduto, ARNP, Orthopaedic Trauma Service, Tampa General Hospital, Tampa, FL

Purpose: The treatment of acetabular fractures in the elderly can be extremely challenging. Debates occur as to whether an open reduction internal fixation (ORIF) or a primary total hip arthroplasty (THA) should be performed. We assessed the treatment, complications, and outcomes of elderly patients who underwent a combined hip procedure for displaced acetabular fractures.

Methods: From September, 1987 to October, 2000, 24 elderly patients with displaced acetabular fractures were prospectively treated using a combined hip procedure. There were 14 men and 10 women with an average age of 75.3 years (range, 57 to 95). For inclusion in the study, the elderly patients with displaced acetabular fractures also had to have evidence of significant osteoarthritis, osteoporosis, or associated femoral head fractures. Inpatient records and complications were recorded. At follow-up, radiographs were used to evaluate union and the development of heterotopic bone, and physical examinations and the Harris Hip Score were used for clinical assessment.

Results: Surgical times averaged 232 minutes (range, 80 to 510 minutes) with blood losses of 1163 cc (range, 300 to 4500). All patients had transfusions averaging 3.5 units of packed red blood cells (PRBC). The THA portion of the procedure was performed through the same ORIF incision in 14 of the 18 cases, all through a Kocher-Langenbach approach, with an average surgical blood loss of 777 cc and an average of 2.9 units of PRBC transfused. Surgical times averaged 232 minutes (range, 80 to 510) with blood losses of 1163 cc (range, 300 to 4500). The remaining four cases had separate incisions for the acetabular ORIF and the THA, with an average blood loss of 2225 cc and an average of 5 units of PRBC transfused. Of the 24 patients, 4 died and 2 patients could not be located, leaving 18 patients available for evaluation. Follow-up averaged 24.4 months (range, 8 to 48). There were no implant failures and all fractures healed at and average of 3.1 months (range, 3 to 5) after the operation. The length of hospital stay was 8.1 days (range, 5 to 14), and progression to full weight bearing was seen at 2.2 months (range, 0 to 4 months). There were no postoperative infections, but nine complications were noted. One patient had a wound dehiscence treated nonoperatively, and three had hip dislocations, two of which eventually loosened and required a revision. The remaining five patients developed heterotopic bone, none requiring treatment. Postoperatively, nine patients were able to walk without aids, four required a cane, and five were using a walker at their last follow-up visit.

Discussion: The combined hip procedure appears to be a successful treatment option for certain displaced acetabular fractures in elderly patients. Although complications were noted in 50%, only two patients required surgical intervention. Blood losses, surgical times, and lengths of stay appear to be consistent with other ORIF acetabular studies, and the use of a single-incision technique produced less blood loss than the dual-incision technique. The problems with use of this technique appear to be the high rates of transfusion and lengthy anesthetic times in elderly patients. Aggressive medical workups may be needed preoperatively to clear patients for this procedure. Its can allow for a quicker return to painless hip range of motion and eliminate the need for future total hip arthroplasty for the management of an incongruent joint.