As the population of developed countries ages, new challenges are facing orthopaedic surgeons, and this ageing trend is predicted to continue [
The senior author’s preference (MR) for management of elderly/osteoporotic acetabular fractures is simultaneous internal fixation and primary total hip arthroplasty. The technique has previously been described in detail, along with decision making processes [
Pre- and post-op images of a typical case involving fractures of both columns. (a, b) Initial AP pelvis and film of right hip. (c) Axial CT scan of the fracture showing displacement of both columns. (d) Postoperative X-ray. Both columns have been reduced and plated, and a hip replacement was performed.
Images of patients 4 and 25, who sustained bilateral fractures at different time points. (a) Initial fracture in January 2010. (b) Postoperative view in January 2010. (c) Postoperative X-ray after second surgery in January 2012. (d) Most recent X-ray in June 2015.
In line with the senior authors’ standard practice, none of the patients in this series were actively discharged from follow-up but were seen yearly for clinical and radiographic review—this facilitated recent reviews of most patients. Those who had not attended clinic routinely were contacted and reviewed again, although 2 patients could not be found and were lost to follow-up. In line with standard protocols, patients underwent clinical review and plain radiographs, scores were calculated for the Harris Hip Score [
The study group contained 25 hips in 24 patients. Nine patients had died since surgery and 2 were lost to follow-up, leaving a cohort of 14 hips in 13 patients. The mean time to follow-up of the surviving patients was 49 months, range 33 to 69. The patient details and outcomes are shown in Table
Details of surviving patients.
Patient | Age | Sex | Walking aids | Harris Hip Score | Merle D’A Score | Months to present follow-up |
---|---|---|---|---|---|---|
3 | 79 | M | None | 96 | Excellent | 57 |
4 | 75 | M | 1 stick | 90 | Good | 65 |
5 | 65 | M | None | 100 | Excellent | 49 |
6 | 71 | M | None | 100 | Excellent | 50 |
11 | 70 | M | None | 65 | Fair | 51 |
12 | 73 | M | None | 100 | Excellent | 69 |
14 | 86 | M | 1 stick | 90 | Good | 47 |
15 | 87 | M | 1 stick | 84 | Good | 45 |
16 | 77 | F | None | 96 | Excellent | 45 |
17 | 64 | M | None | 100 | Good | 40 |
18 | 75 | F | None | 84 | Good | 50 |
19 | 72 | M | None | 96 | Excellent | 38 |
21 | 84 | F | Lost | Lost | Lost | Lost to follow-up |
22 | 92 | F | Wheelchair | n/a | n/a | 33 |
23 | 84 | M | Lost | Lost | Lost | Lost to follow-up |
25 | 77 | M | 1 stick | 96 | Good | 41 |
The mean overall age at surgery for the group was 77.4 years (range 62 to 92). The age at surgery of patients now deceased was 78.8 (range 63 to 90) compared to 76.9 (range 64 to 92) for those still surviving. Similarly there was no detectable difference in ASA grade, comorbidities, or mechanism of injury between those patients living and deceased. No patients underwent revision surgery prior to death (or reported any problems with the operated hip), and the single reoperation which was performed for a superficial infection was described in the previous paper.
The mean Harris Hip Score was 92 (range 65 to 100), and 13 of 14 hips rated as excellent or good on the Merle d’Aubigné rating system. One patient has become wheelchair-bound secondary to general poor health and severe dementia, and thus no score was recorded for this patient. Radiologically, all fractures were healed with well-fixed acetabular components, and no cup migration was seen in any case. Radiologically no cup appeared to be at risk of loosening or revision surgery for any reason. No new complications had occurred since the perioperative period in any patient.
This paper shows encouraging outcomes at a mean of 49 months after surgery, both in terms of implant survival and clinical results. No new complications have been seen since the perioperative period, and we therefore conclude that the use of acetabular column stabilisation and simultaneous total hip replacement with subsequent immediate full weight bearing can give excellent results, even in the longer term.
There are limitations to this paper. Firstly, the cohort is small, with only 14 surviving patients at the time of writing. Secondly, although the authors have not seen any cup migration in this series, this has only been judged on plain radiographs which may not be as accurate as using RSA technology [
Our results are based on outcomes from 14 hips, with 9 patients having died within the study period. Using standardised mortality rates for the UK, it would be expected that approximately 5 patients would have died within this time; there is clearly an impact on mortality as a result of this injury. The presumed logic behind performing such large procedures on elderly patients comes at least in part from evidence around neck of femur fracture patients. It is now widely accepted that in that elderly population long periods of forced immobility lead to high rates of morbidity and mortality. Surgical strategies for management of neck of femur fractures in the elderly therefore almost always aim for early surgery that allows immediate full weight bearing. Evidence that the same factors affect the elderly acetabular fracture population in the same way does not exist, however tempting it may be to assume that the same applies. In addition, very few patients from the neck of femur population are deemed unfit for surgery, whereas for elderly patients with acetabular fractures it is much more likely that they will be labelled “unfit” and thus managed nonoperatively. This results in a selection bias, with published series of surgically managed elderly acetabular fractures being inherently healthier than those of neck of femur fractures. Gary et al. attempted to look at mortality with a retrospective review of cases from 3 level 1 trauma centres, cases being stratified into nonoperative, percutaneous fixation, open reduction and internal fixation, or acute total hip replacement [
The real difficulty remains however in deciding when to choose acute arthroplasty over the other options available for this difficult group of fractures. Risk factors for failure of more conventional methods are poorly defined within the literature but almost certainly include marginal impaction [
Patients considered for surgery in this age group will fall into one of 3 broad groups: those who would not survive the perioperative period, those who will die within a year, and those who will live for a substantial period of time. In an ideal world, accurate prediction of this grouping would allow the surgeon to manage patients accordingly, and in all probabilities the first group is best managed nonoperatively and the second with internal fixation. The third group however ideally requires a single long-lasting surgical procedure—the inherent problem being the high revision rate of internal fixation in this group, especially beyond 1 year.
This is the first report that the authors are aware of showing midterm outcomes for elderly patients undergoing acute total hip replacement for acetabular fractures, using trabecular metal and allowing immediate full weight bearing. No cups were loose at a mean of 49 months and late complications have not been seen. We conclude that THR is a viable long-term solution in this situation provided that the acetabular columns are stabilised prior to implantation, but more research is needed to aid overall management decision making.
The authors declare that they have no competing interests.