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Good results seen with conventional fixation of geriatric acetabular fractures
Early research on the limited ilioinguinal approach indicates less blood loss vs. traditional approach.
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DENVER — Research indicates that acute open reduction and internal fixation may lead to good outcomes in carefully selected elderly patients with displaced acetabular fractures.
“I think that acute open reduction and internal fixation (ORIF) of displaced fractures in the elderly is feasible,” David L. Helfet, MD, said during his presentation at the annual meeting of the Orthopaedic Trauma Association. “You can do it with low complications if you pick and prepare your patients well. We showed a satisfactory outcome with 2- to 18-years follow-up.”
He noted that there are many treatment options for elderly patients with acetabular fractures. His current treatment algorithm focuses on whether the patient can ambulate and tolerate surgery.
“If the patient is a functional ambulator and you can do his or her surgery in less than 3 hours and you expect to get a good reduction, then you go ahead and do ORIF, as long as the patient medically can have it done,” Helfet said.
He recommends acute ORIF with total hip arthroplasty (THA) in cases where the patient has a femoral head injury, the expected operating time would be too great and the surgery too complicated, or if the surgeon believes that the fracture is irreducible using a single nonextensile approach. He suggests delayed THA for nonambulating patients, those who are not surgical candidates acutely or patients who had a failed acute ORIF.
Fixation studies
In a case series of 93 elderly patients with displaced acetabular fractures who were treated with ORIF, Helfet and colleagues discovered that 70% of patients had a lasting reconstruction without the need for a secondary procedure at 5-years follow-up. They found that the remaining 30% subsequently underwent a THA. “You might say that is terrible. But in fact, all of them have gone on to a relatively primary simple THA because their bone stock has been restored,” Helfet said.
Their study showed no significant link between delayed THA and commonly associated factors such as age, gender or smoking. “The No. 1 factor was the quality of the reduction,” Helfet said. He also cited injury to the femoral head and “die punch” acetabular impactions as predictors for poor outcomes of acute ORIF.
Limited ilioinguinal approach
Emerging research using a limited ilioinguinal approach for acetabular fractures in the elderly indicates less blood loss and surgical time compared to the traditional ilioinguinal approach. Helfet noted that the limited technique for ORIF uses only the two lateral windows of the ilioinguinal approach as opposed to the three windows used for the traditional technique.
In a comparison of 41 elderly patients who underwent ORIF with the traditional or limited ilioinguinal technique, Helfet and colleagues discovered that both groups had similar postoperative complications rates and overall rates for secondary THA. In addition, the groups showed similar functional outcome scores.
“There was less blood loss and less operative time with the limited ilioinguinal technique,” Helfet said.
Regardless of the chosen technique, he noted that surgeons should ensure that the initial ORIF must allow for early mobilization. “I also believe that the restoration of alignment and bone stock has value even if they have post-traumatic arthritis or not a great hip. This allows for simple primary THA,” he said.
For more information:
- David L. Helfet, MD, can be reached at Hospital for Special Surgery, 535 East 70th St., New York, NY 10021; 212-774-2686; e-mail: HelfetD@HSS.edu.
References:
- Carroll EA, Huber FG, Goldman R, et al. Operative treatment of acetabular fractures in an older population through a limited ilioinguinal approach. J Orthop Trauma. In press. 2009.
- Helfet DL. Borrelli J Jr., Dipasquale T, et al. Stabilization of acetabular fractures in elderly patients. J Bone Joint Surg. (Am).1992;74(5):753-765.
- Helfet DL. Conventional fixation of geriatric acetabular fractures. Mini symposia #F-10. Geriatric acetabular fractures. Presented at Presented at the 24th Annual Meeting of the Orthopaedic Trauma Association. Oct. 16-18, 2008. Denver.