Acetabular fractures treated with ORIF in geriatric population have reasonable outcomes

Issue: July 2010

A retrospective review of geriatric patients with acetabular fractures treated at a single level I trauma center found that open reduction and internal fixation provided reasonable outcome scores and rate of conversion to arthroplasty of 28% amongst those that survived.

Primary study author Robert V. O’Toole, MD, an assistant professor and director of clinical research in the Department of Orthopaedics at the University of Maryland School of Medicine, noted there are four main treatments for geriatric acetabular fractures: nonoperative, percutaneous reduction and fixation, traditional open reduction with internal fixation (ORIF) and combined ORIF/arthroscopy.

“Although these treatments are different, clinicians have little data regarding the outcomes and relative merits of each option,” O’Toole said.

WOMAC scores used

The study involved 147 consecutive patients, aged 65 and older, who were seen between 2001 and 2006. The investigators used WOMAC scores to assess the outcomes. O’Toole reported that the ORIF patients had an average score of 17.3, which is similar to results after elective arthroplasty for arthritis and substantially better than patients with established arthritis.

During the study period, O’Toole’s institution had a protocol in place of performing ORIF on nearly all healthy patients. “We rarely performed a primary arthroplasty in these patients,” O’Toole told Orthopedics Today. “This gave us the opportunity to study the outcome of this protocol without having a subgroup of patients who were treated with hip replacement at the time of injury.”

Eventual THA

The investigators’ primary question was, “How many of these patients end up needing hip replacement anyway?” O’Toole said. “If that number is high, then it questions the strategy of trying to preserve the hip in those patients who are already old enough to be good candidates for hip replacement.”

The outcomes, which were presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) in New Orleans, found that of the 61 living patients in the study (after exclusionary criteria), 52 (85%) were treated operatively (46 with ORIF and six with percutaneous fixation only). In the ORIF group who survived, 28% went on to hip arthroplasty, at an average of 2.5 years after injury.

Despite favorable WOMAC score results for ORIF patients, 39% reported some difficulty walking long distances and 45% indicated some degree of hip pain. “Certain fracture patterns appear to almost double your risk of failure, although this trend did not reach statistical significance,” O’Toole said. “Fracture patterns that contain a posterior wall did particularly poorly, and perhaps would be better treated with primary arthroplasty in these geriatric patients.”

Average follow-up was 4.3 years and O’Toole noted a 1-year mortality rate of 25%, similar to death rates after low energy hip fractures.

O’Toole and his colleagues have begun a pilot study contrasting ORIF to combined ORIF/arthroplasty “This will help us advise our patients about the relative merits of these two strategies,” O’Toole said. Limitations of the current study include small sample size, loss to follow-up and a retrospective review. “Still, we hope our study encourages other centers to publish their experience with their treatment algorithms.,” he said. – by Bob Kronemyer

Reference:
O’Toole, RV, Hui, E, Chandra A. Does ORIF of geriatric acetabular fractures lead to hip arthroplasty and poor mid-term outcomes? Paper 223. Presented at the 2010 Annual Meeting of the American Academy of Orthopaedic Surgeons. March 9-13. New Orleans.

Robert V. O’Toole, MD, University of Maryland Affiliated Hospitals, 22 S. Green St., Room T3R62; Baltimore, MD 21201; 410-328-6280; e-mail: rotoole@umoa.umm.edu.