Highlights
- •Early mobilisation after acetabular fractures in the elderly is critically important.
- •A fix and replace strategy provides opportunity for early mobilisation.
- •Patient selection is key due to the high morbidity and mortality associated with these injuries.
- •High levels of support in the pre- peri‑ and postoperative period are essential.
Abstract
Introduction
Displaced acetabular fractures in the elderly present significant treatment challenges.
The ‘fix and replace’ concept involves open reduction and internal fixation of the
acetabulum, providing bony stability to accept the press-fit of an acetabular cup,
with a cemented femoral stem. This allows early mobilisation and the advantages this
confers. This study of 57 patients treated with fix and replace describes our technique,
outcomes, and survival analysis.
Methods
A retrospective review of 57 ‘fix and replace’ procedures in patients aged over 60
was performed. Data was collected on mechanism, fracture type, demographics, time
to surgery, comorbidity index, complications, EQ-5D and Oxford hip scores (OHS). Radiographs
were reviewed for fracture healing, implant loosening, cup migration, and heterotopic
ossification.
Results
57 patients aged 60 to 95 had fix and replace surgery. The median ASA score was 3.
The mean Charlson Index was 4.8. 45 patients had a low-energy fall, 6 had a road traffic
accident, 3 fell off a bicycle, and 1 mechanism was unclear. The fracture patterns
were anterior column posterior hemitransverse (67%), associated both columns (9%),
posterior column (9%), posterior column and posterior wall (9%), and transverse (2%).
The mean time to surgery was 8.4 days (0–14). 26 out of 57 (46%) received a blood
transfusion. Mean length of stay was 17.6 days (7–86). The mean follow-up was 35.5
months. 4 dislocations were treated with closed reduction, whilst 1 required excision
arthroplasty. 2 infections resolved with debridement, antibiotics, and implant retention
(DAIR), whilst 1 required a two-stage revision. 1 acetabular component had migrated
requiring revision. The median pre-injury OHS was 44 (26–48) compared to 37.3 (28–48)
at 1 year. There were no deaths at 30-days, whilst at 1 year 7 patients had died.
Kaplan Meier survival analysis showed mean survival was 1984.5 days. Implant survival
was 90% at 1 year.
Conclusion
While fix and replace is conceptually attractive, this medically complex patient group
requires considerable support peri‑ and post-operatively. Further studies are required
to provide clinicians with more information to decide on how best to provide a holistic
management strategy for such injuries in this frail patient cohort.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to InjuryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Treatment of acetabular fractures in an older population.J Orthop Trauma. 2010;
- Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures.J Bone Jt Surg - Ser A. 2012;
- Functional outcomes after total hip arthroplasty for the acute management of acetabular fractures: 1- to 14-year follow-up.J Orthop Trauma. 2015;
- Acetabular fractures clinical outcome of surgical management.Chirurg. 1999;
- Results of treatment of acetabular fractures.Clin Orthop Relat Res. 1980;
- Total hip arthroplasty after operative treatment of an acetabular fracture.J Bone Jt Surg - Ser A. 1998;
- Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury.J Bone Jt Surg - Ser A. 1996;
- The “Gull Sign”. A Harbinger of failure for internal fixation of geriatric acetabular fractures.J Orthop Trauma. 2003;
- Cementless acetabular reconstruction after acetabular fracture.J Bone Jt Surg - Ser A. 2001;
- Total hip arthroplasty after fracture of the acetabulum. Long-term results.J Bone Jt Surg - Ser B. 1990;
- Total hip replacement after acetabular fracture.Orthop Clin North Am. 1997;
- Acetabular fractures in the senior population-epidemiology, mortality and treatments.Arch Bone Jt Surg. 2017;
- Functional outcomes of elderly patients with nonoperatively treated acetabular fractures that meet operative criteria.J Orthop Trauma. 2017;
- Acetabular fractures in patients aged >55 years: a systematic review of the literature.Bone Joint J. 2014;
- Optimal care for the management of older people non-weight bearing after lower limb fracture: a consensus study.BMC Geriatr. 2021;
- Acute management of acetabular fractures by total hip arthroplasty using an anterior approach.Rev Española Cirugía Ortopédica y Traumatol (English editor), 2019
- Sequential ilioinguinal or anterior intrapelvic approach with anterior approach to the hip during combined internal fixation and total hip arthroplasty for acetabular fractures.Eur J Orthop Surg Traumatol. 2021;
- The levine anterior approach for total hip replacement as the treatment for an acute acetabular fracture.J Orthop Trauma. 2004;
- Cup-cage construct using porous cup with burch-schneider cage in the management of complex acetabular fractures.Hip Pelvis. 2019;
- Cup-cage construct for acute fractures of the acetabulum, re-defining indications.Injury. 2012;
- Primary total hip arthroplasty with a Burch-Schneider antiprotrusion cage and autologous bone grafting for acetabular fractures in elderly patients.J Orthop Trauma. 2003;
- Acetabular fractures in the elderly treated with a primary burch-schneider reinforcement ring, autologous bone graft, and a total hip arthroplasty: a prospective study with a 4-year follow-up.J Orthop Trauma. 2014;
- Fractures of the cotyloid cavity, study of a series of 75 cases.J Chir (Paris). 1961;
- Nonoperative treatment of hip fractures.Int Orthop. 2003;
- Optimal use of tranexamic acid for total hip arthroplasty: a network meta-analysis.PLoS ONE. 2018;
- The efficacy of tranexamic acid in total hip arthroplasty: a network meta-analysis.J Arthroplasty. 2018;
- The role of intra-operative cell salvage in patient blood management for revision hip arthroplasty: a prospective cohort study.Anaesthesia. 2020;
- Periprosthetic acetabular fractures: a New classification proposal.Injury. 2018;
- Determinants of functional outcome after simple and complex acetabular fractures involving the posterior wall.J Bone Jt Surg - Ser B. 2006;
- Total hip arthroplasty for post-traumatic arthritis after acetabular fracture.Minerva Ortopedica e Traumatologica. 2003;
Article info
Publication history
Published online: September 17, 2022
Accepted:
September 16,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
