Open Reduction Internal Fixation

That there are various surgical approaches for the management of acetabular fractures in the elderly is not unexpected given the differences in the strength and structure of their bones, their physical needs and expectations, the fracture patterns of their injuries, their comorbidities, and the experience and skills of the treating surgeon. Without performing an exhaustive review of the literature, most surgeons providing routine care to the elderly intuitively know that there is a significant difference in treating patients who present after high-energy injuries versus those presenting after a low-energy injury. In the former, the bone stock of the acetabulum may be similar to that seen in younger patients so that the use of established open reduction techniques to fix the acetabulum may be used. In these patients successful outcomes can be expected to be similar to those reported for younger patients (45). It should be noted however that post-traumatic arthritis has been reported in up to 30% of all patients due to imperfect reductions, chondrolysis of the cartilage from the initial trauma, osteochondral defects, or the development of vascular necrosis of the head or acetabulum (44,64,70-72,73) (Fig. 7 A-D), all of which will affect outcomes.

In those patients sustaining fractures from low-energy traumas, age-related bone loss or bone loss occurring secondary to osteoporosis will result in diminished bone stock. This is seen at the microstructural level, resulting in a reduction in the bone mineral density and a change in the trabecular orientation of the bone. Studies have demonstrated that these structural changes narrow the tolerable loading directions of the bone, increasing the risk of a fracture (74,75). In addition, these patients may also have already have pre-existing arthritis of the hip so that the additional insult of an acetabular fracture may produce displaced, unrecognizable fracture patterns with severe comminution, erosion of the articular surfaces, and associated fractures of the femoral head (65,73) (Fig. 8A-F). The combination of the four factors of osteoporosis, comminution, associated head fractures, and arthritis may ultimately produce bone that does not allow any anchorage of the fixation devices, or ultimately results in loosening and failure of the applied fixation or collapse of the hip joint.

When evaluating outcomes by age, using traditional surgical approaches and techniques, studies have demonstrated that the numbers of anatomic reductions and the ability to obtain a successful outcome decreases with advancing age (8,70,76). Therefore, an alternative to standard approaches should be considered. One alternative may be the use of minimally invasive or percutaneous approaches for the management of these injuries (46,77-83). Since the goal may not be an absolute anatomic reduction of the joint, this approach may allow for a rapid relief from the pain of the fracture and allow early mobilization of the patient. However, these are difficult techniques to learn, may require specialized instruments to obtain the reduction, have potentially life-threatening complications if the screws are misplaced, and may work best with minimally displaced or unstable but congruent fractures. Because some malalignment of the joint may persist, one needs to remember that even though small incisions or percutaneous screw placements are used, significant post-traumatic arthritis or avascular necrosis of the femoral head may still occur similar to those seen after open techniques (46,70,76,78).

Therefore, prior to using open reduction internal fixation or percutaneous techniques to repair the fracture in an elderly patient, it is important to differentiate fractures occurring from high- or low-energy mechanisms of injury. If after the radiolo-gic evaluation pre-existing arthritis of the hip is identified, fractures are not easily classifiable, demonstrate associated femoral head fractures, or present with severe displacement of the fragments, then other surgical options should be considered for use in the management of these patients. If the decision is made to fix the fracture, then one should remember that, regardless of the fixation technique, posttraumatic arthritis may develop in up to 30% of these patients.

Acetabular Fracture Repair

Figure 7 (A) Antero-posterior (AP) radiograph of a 69-year-old female who fell from a standing height. The fall produced an acetabular fracture along with a posterior hip dislocation on the right side. (B) AP radiograph three months after fixation. The joint space has become narrowed and the femoral head is starting to lose its spherical shape. (C) At nine months, the femoral head has collapsed as a result of avascular necrosis. In addition, some the areas of the acetabulum have also developed some avascularity, resulting in severe posttraumatic arthritis of the hip joint. (D) Salvage achieved through the use of a total hip arthroplasty performed at 15 months postinjury.

Figure 7 (A) Antero-posterior (AP) radiograph of a 69-year-old female who fell from a standing height. The fall produced an acetabular fracture along with a posterior hip dislocation on the right side. (B) AP radiograph three months after fixation. The joint space has become narrowed and the femoral head is starting to lose its spherical shape. (C) At nine months, the femoral head has collapsed as a result of avascular necrosis. In addition, some the areas of the acetabulum have also developed some avascularity, resulting in severe posttraumatic arthritis of the hip joint. (D) Salvage achieved through the use of a total hip arthroplasty performed at 15 months postinjury.

Figure 8 (A) Antero-posterior (AP) radiograph of the pelvis in a 71-year-old male who sustained a fracture of the acetabulum and a posterior dislocation of the hip as a result of a motor vehicle accident. (B) AP view after reduction of the hip dislocation. Note the impaction of the joint, as the femoral head appears to be penetrating through the acetabulum. (C) Lateral view of the hip joint after the closed reduction of the dislocation. Note the impaction of the femoral head superiorly, at the roof of the acetabulum. (Continued)

Figure 8 (A) Antero-posterior (AP) radiograph of the pelvis in a 71-year-old male who sustained a fracture of the acetabulum and a posterior dislocation of the hip as a result of a motor vehicle accident. (B) AP view after reduction of the hip dislocation. Note the impaction of the joint, as the femoral head appears to be penetrating through the acetabulum. (C) Lateral view of the hip joint after the closed reduction of the dislocation. Note the impaction of the femoral head superiorly, at the roof of the acetabulum. (Continued)

Acetabular Fractures With Dislocation

Figure 8 (Continued) (D) Two-dimensional CT scan demonstrating comminution of the weight-bearing dome of the acetabulum. (E) Fixation was performed to provide stability to the acetabulum. At three months postfixation, notice that there is continued protrusion of the femoral head. (F) Subsequent degeneration of the hip joint produced a femoral head and neck that became locked within the acetabulum, allowing no motion of the hip joint. Eventually the patient sustained a low-energy injury, which produced an ipsilateral subtrochanteric femur fracture. Salvage was with a calcar total hip replacement.

Figure 8 (Continued) (D) Two-dimensional CT scan demonstrating comminution of the weight-bearing dome of the acetabulum. (E) Fixation was performed to provide stability to the acetabulum. At three months postfixation, notice that there is continued protrusion of the femoral head. (F) Subsequent degeneration of the hip joint produced a femoral head and neck that became locked within the acetabulum, allowing no motion of the hip joint. Eventually the patient sustained a low-energy injury, which produced an ipsilateral subtrochanteric femur fracture. Salvage was with a calcar total hip replacement.

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