Sat., 10/15/11 Peds, Ger, Hip, Femur & IP, Paper #71, 10:34 am OTA-2011
Functional Outcomes of Nonoperative Treatment of Geriatric Acetabular Fractures Meeting Operative Criteria
Scott P. Ryan, MD; Theodore T. Manson, MD; Christopher T. LeBrun, MD;
Jason W. Nascone, MD; Marcus F. Sciadini, MD; Renan C. Castillo, PhD;
Robert V. O’Toole, MD;
R Adams Cowley Shock Trauma Center, Dept. of Orthopaedics, University of Maryland
School of Medicine, Baltimore, Maryland
Purpose: Controversy exists regarding the best treatment for displaced geriatric acetabular fractures. The purpose of this study is to report the functional outcomes in patients older than 60 years, who sustained an acetabular fracture and were treated nonoperatively despite having fracture patterns that would be treated operatively in younger, healthier patients. Our hypothesis is that this treatment results in worse outcomes than open reduction and internal fixation (ORIF).
Methods: We contacted 24 patients 60 years of age or older who sustained an acetabular fracture and were treated nonoperatively with early mobilization over a 7-year period at one Level 1 trauma center. No patients were treated in traction. Radiographic review (at least 3 of 5 independent traumatologists agreed that based on fracture pattern alone that the patient would have qualified for operative treatment if the patient were young and healthy) determined that 15 patients (average follow-up 2.2 years) would have been treated with ORIF if young. Reasons for nonoperative treatment included advanced age, medical comorbidities, and preexisting arthritis. Our control group (n = 46, average follow-up 4.6 years) was a previously reported group of patients older than 60 years, who sustained an acetabular fracture and were treated operatively at the same institution over the same time period. The primary validated outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) hip and Short Form–8 (SF-8) scores. Secondary outcome was failure of nonoperative treatment, defined as conversion to ORIF or total hip arthroplasty and 1-year mortality.
Results: Patients in the nonoperative group were significantly older (74 vs 68 years; P <0.05) and had more medical comorbidities per patient (1.76 vs 1.13; P <0.05). There was no statistical difference in the overall, or any subsets, of the WOMAC or SF-8 (P >0.05; 80% power to detect differences between 15% and 20% in functional outcomes). This remained true when analyzing patients treated nonoperatively with fracture patterns that met traditional operative criteria and when controlling for fracture pattern. There were no differences in the failure rates (16% vs 28%; P = 0.38) or 1-year mortality (24% vs 21%; P >0.05) between the groups.
Conclusion: Elderly patients with a fracture pattern that would qualify for operative treatment in a younger patient had surprisingly good outcome scores when treated nonoperatively. These scores were similar to our control group of geriatric patients treated operatively and to historic controls after primary total hip replacement. These data further cloud the debate on the best treatment for these fractures and argue for the importance of a randomized trial to delineate the best treatment for this growing cohort of complex patients.
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• 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.