Fri., 10/9/09 Hip & Geriatric, Paper #43, 10:54 am OTA-2009
Protrusio Fractures of the Acetabulum in Patients 70 Years and Older
Michael T. Archdeacon, MD, MSE (4-Smith &Nephew; 4, 5A, 7-Stryker, AO;
5A-CardioMEMS);
University of Cincinnati Academic Health Center, Cincinnati, Ohio, USA
Purpose: The purpose of this investigation is to evaluate a prospective protocol for the treatment of protrusion-type acetabulum fractures in a senior patient population (≥70 years of age). We propose that this acetabulum fracture variant in the senior population can be successfully managed with modifications of the standard treatment protocols typically used for younger patients. Fractures of the acetabulum that result in a protrusio of the hip comprise several of the traditional Letournel acetabulum fracture types including the anterior column (AC), anterior column posterior hemitransverse (ACPHT), and the both-column (BC) fractures. Oftentimes, a fall from standing height is responsible; however, high-energy trauma is becoming more frequent in the senior population. Concomitant comorbidities, significant injury severity, minimal physiologic reserve, and decreased functional demands necessitate alternative treatment strategies for this patient population.
Methods: We retrospectively reviewed a prospective treatment protocol with the goals of preoperative optimization, minimizing operating room (OR) time and blood loss, achieving immediate hip stability with congruency, and employing a modified Stoppa window with an infrapectineal plate to buttress the protrusio in a consecutive series of patients ≥70 years of age with a protrusion-type acetabulum fracture.
Results: We identified and enrolled 18 patients who met inclusion criteria from a series of 432 operatively treated acetabulum fractures (4.2 %). Patient demographics included: age, 81 ± 6 years (range, 70-93); gender, 11 male and 7 female; preinjury activity 2 employed, 13 community ambulation, and 3 with assistive devices. Fracture classification included 1 AC, 11 ACPHT, and 6 BC. Three patients had bilateral acetabulum fractures and 15 of the 18 had significant medical comorbidities. Average time from injury to OR was 6 days, OR time averaged 216 ± 75 minutes, and estimated blood loss (EBL) was 1065 ± 2062 cc (excluding 1 case with 9000-cc EBL, EBL averaged 558 ± 254). Average follow-up was 11.3 months (range, 4-38), with a minimum of 6 months follow-up in 13 patients who had a mean d’Aubigne and Postel Score of 15.3. In the 13 patients with minimum 6-month follow-up, the radiographic evaluation grade was excellent (7), good (2), and poor (4). Three of the 18 patients underwent total hip arthroplasty.
Conclusions: In the senior patient with a protrusio acetabulum fracture variant, a treatment strategy that optimizes preoperative conditions, minimizes OR time and EBL, and achieves a stable and concentric hip using an infrapectineal buttress plate can result in reasonable outcomes with acceptable morbidity. If future total hip arthroplasty is required, a posterior approach is essentially a primary approach, with bone stock and cup stability achieved by the infrapectineal buttress plate.
• 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