Coned hemipelvis reconstruction for osteoporotic acetabular fractures in frail elderly patients.

AIMS: Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort. METHODS: We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59). RESULTS: The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d'Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions. CONCLUSION: The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155-161.

Outcomes of conservatively managed complex acetabular fractures in the frail and elderly one year post injury.

BACKGROUND: Acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Despite advances in operative techniques, there remains a cohort of elderly, extremely frail patients with comminuted fractures who are considered unfit for surgery and are treated conservatively. We aim to assess mortality, mobility and radiological outcomes one-year post injury in this challenging cohort. METHODS: We performed a review of the regional Fracture Outcome and Research Database for patients over 65 with associated type acetabular fractures which were treated conservatively. We collected data on demographics, fracture classification, pre-injury mobility and habitation, and length of acute hospital stay. Mobility status, habitation, radiographic result and mortality were also recorded at one-year post injury. RESULTS: There were 49 patients with a mean age of 80 years. The mean estimated American Society of Anaesthesiologist (ASA) score was 3.1. 92% sustained a low energy injury, and the most common fracture pattern was anterior posterior hemi-transverse (84%). Mean acute hospital stay was 20 days and mortality was 24% at one year. 56% of patients maintained habitation in their own home and 35% returned to their premorbid level of mobility. Of the surviving patients, 30% had an 'excellent/good' reduction on x-ray at one year, 70% had a 'fair/poor' reduction. There was no correlation between fracture reduction and either one year mobility status or maintenance of mobility. CONCLUSIONS: The data confirms that conservatively managed complex acetabular fractures in the elderly, frail patient are associated with a significant reduction in mobility and living independence, a high level of mortality and poor radiological outcomes. IMPLICATIONS: Conservative management of this cohort is associated with poor outcomes and current operative solutions are unsuitable for this frail cohort of patients. Future developments should focus on minimising surgical insult and allowing weight bearing mobilisation to maximise the rehabilitation potential in this frail cohort.

Total hip replacement in complex acetabular fractures using a coned hemipelvic acetabular component.

Acetabular fractures in the elderly are a challenging clinical problem due to both the complex nature of operative intervention, osteoporotic bone and the multiple comorbidities of the patients involved. They are associated with poor functional outcomes and high levels of morbidity and mortality. Treatment currently ranges from conservative treatment, open reduction internal fixation and variations of total hip arthroplasty. We present the surgical technique and early results of the use of a coned hemipelvic acetabular component in the primary treatment of these complex injuries. Five patients (six cases) with a mean age of 75 years have been followed up for 15 months. There were five minor post-operative complications: two patients suffered mild serous wound ooze, two sustained an acute kidney injury, and one a lower respiratory tract infection. One patient suffered pre-operative bilateral sciatic nerve injury, which has partially resolved. There have been no thromboembolic events, dislocations or infections. There have been no cases of prosthesis migration. Four of five patients were able to mobilise fully weight-bearing day one post-operatively, and at latest follow-up four of five mobilised independently with a walking aid. We feel that early weight-bearing mobilisation is essential to achieve a successful outcome in these patients, in a similar way to neck of femur fracture patients. The coned acetabular prosthesis bypasses the fracture, creating an immediately stable construct which allows mobilisation day one post-operatively. The early results of this new technique are promising. Although follow-up is short, there have been no serious complications, a high level of patient satisfaction and radiological evidence of fracture healing, with no prosthesis migration. We aim to continue utilising this technique, with close monitoring of longer-term results.