Session IV - Pelvis

Limited Open Reduction and Percutaneous Screw Fixation of Acetabular Fractures in Elderly Patients

Michael T. Hay, MD; Adam J. Starr, MD; Drake S. Borer, MD; Charles M. Reinert, MD; Shelly N. Whitlock, CCRA; University of Texas Southwestern Medical Center, Dallas, Texas, USA

Purpose: The appropriate treatment of acetabular fractures in elderly patients is controversial. The purpose of this study was to report the results of limited open reduction and percutaneous screw fixation of displaced fractures of the acetabulum in a consecutive series of elderly patients.

Methods: Our first 18 patients over the age of 60 years whose displaced acetabular fractures were treated with limited open reduction and percutaneous screw fixation are reported in this series.* Six of the patients were women, and the average age was 71 (range, 62 to 85 years). Ten patients had significant medical problems, and 9 had associated traumatic injuries. Fifteen had complex or associated fracture patterns, and 3 had simple patterns. The average preoperative fracture displacement was 11 mm (range, 2 to 20 mm). The fractures of all 18 patients were successfully reduced with minimally invasive techniques and were stabilized percutaneously. For the acetabular fracture operations, the average estimated blood loss was 36 cc (range, 10 to 100 cc); the average operating room time was 92 minutes (range, 40 to 175 minutes); and the average fluoroscopy time was 10 minutes (range, 3.5 to 28 minutes). The average postoperative fracture displacement was 3 mm (range, 0 to 5). Four patients had minor losses of reduction in the early postoperative period. There were no other perioperative complications.

Results: Four patients died of causes unrelated to their acetabular fractures. These deaths occurred at 28 months after injury, on average (range, 3 to 83 months). Every surviving patient returned for follow-up examination and radiographs. The average follow-up time of the remaining 14 patients was 46 months (range, 27 to 94 months). Ten patients live independently; 4 live in a nursing home. Four patients have undergone total hip replacement. All hip replacements were performed through standard lateral approaches, through essentially virgin tissue. The average Harris Hip Score (HHS) for all the surviving patients was 91 (range, 68 to 100). Nine patients had excellent results (HHS 91 to 100), one had a good result (HHS 81 to 90), three had fair results (HHS 71 to 80) and one had a poor result (HHS less than 71). The average hip range of motion was as follows: flexion 115, extension 5, abduction 25, adduction 15, external rotation 30, and internal rotation 10. Each patient completed a Short Musculoskeletal Function Assessment (SMFA) questionnaire. The average daily activities score for the SMFA was 36 (range, 0 to 97); for emotional status, 17 (range, 0 to 57); for arm and hand function, 12 (range, 0 to 68); for mobility, 26 (range, 0 to 86); for the functional index 23 (range, 0 to 79); and for the bother index 21 (range, 0 to 89).

Discussion: Percutaneous stabilization of acetabular fractures is a demanding technique, with indications not yet fully delineated. The results of this series of patients are roughly equivalent to the results reported after more traditional techniques using open reduction and internal fixation, immediate total hip arthroplasty, or a combination of the two. The benefit of the percutaneous technique is that it results in fewer complications, has a lower blood loss, and a shorter operating-room time. These benefits may be important in the elderly population. Another advantage of the percutaneous technique is that it allows for later hip arthroplasty through virgin tissue, if hip replacement becomes necessary.

Conclusion: Elderly patients whose acetabular fractures are treated using percutaneous techniques will have outcomes similar to those seen after more traditional open methods of fixation. Limited open reduction and percutaneous screw fixation of acetabular fractures is a viable treatment option for this elderly group of patients.

*Early data on some of these patients has been previously reported. The current study was undertaken to obtain long term follow-up and functional outcome measures using the Harris Hip Score and the SMFA.