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47 Bulletin• Hospital for Joint Diseases Volume62,Numbers1&2 2004

Theagingepidemicisuponus.The“babyboomer”generationisenteringtheranksofseniorcitizensand seniors are living longer thanks to medical

advances.This change in population demographics hascausedanewawarenessamongorthopaedicsurgeons.Theorthopaedicspecialtyisnowtreatingmorethan300,000fracturehips,16,000pelvicfractures,and3000acetabularfracturesannually.Fracturesofthehipareusuallymanagedbysurgicalinterventiontodecreasepain,decreasemedicalco-morbidities,andtoretainorimprovefunction.1-3

Acetabularfracturesareuncommoncomparedtootherfractures;however,theyareincreasingaspeoplefunctiontoa laterage.Fractures in theelderlydiffer fromthosein theyoungeradultacetabular traumapatient.Youngerpatientsusuallysufferinjurythroughhighvelocitytrauma.However,intheelderlytheusualmechanismofinjuryisafallfromalowheightwithminimalvelocity4andmanyofthesefracturesarecalledinsufficiencyfracturessincetheyareassociatedwithosteopeniaandosteoporosis. Thetreatmentofthesefracturescontinuestoundergochange with a trend to surgical intervention. Surgeryischosenwhenpossible todecreasepainandimprovefunction.5Thegoalistoofferthegeriatricpatientoneprocedurethathasthehighestexpectationofsuccess.TheOrthopaedicTraumaServiceatMountSinaihastreatedpatientswith simple and complex acetabular fractureswhere indicated. Our initial experience with complexfractures was unsatisfactory with open reduction andinternalfixation.Patientsrequiredfurtherinterventions,withmostneedingtotalhiparthroplasty.Thisprocedureprovedtobecomplicatedbypreviousproceduresandourexperience inotherareasof theskeletonwithprimary

arthroplastyledustoprimaryjointarthroplastyincertainacetabularfractures.

Patient SelectionElevenpatientswereincludedinthisseries.Theageofthepatientsrangedfrom67to78years.Therewere3malesand8females.Fracturepatternsweretransversein5(1malesand4females);posteriorwall in3(1maleand2females);posteriorcolumnandwallin1(afemale);onetransverseandposteriorwall(afemale);and1withassoci-atedfemoralneckfracture. Allpatientswereadmittedtoourhospitalwithin10daysoftheinjury.SixpatientscamethroughtheMountSinaiEmergencyDepartmentandtheotherfiveweretransferredfromotherinstitutionsfortertiaryanddefinitivecare.Allpatientshad incongruity, instability,orboth.Nopatientexperienceddislocation.Therewerenonervepalsiesde-tected. Basicpreoperativetraumaprotocolswereused.Hydra-tion,transfusion,andhematologicalreviewofplateletandcellmorphologywereinstituted.Neurologicalexaminationwasperformedbythesurgeon,orthopaedichousestaff,aswellasaboardcertifiedneurologist.Sixofthe11patientshadGreenfieldfiltersplacedpreoperatively.Indicationsforinsertionofafilterincludedcardiacandpulmonarydisease,obesity,andpreoperativevenousinsufficiency.6

Surgerywasperformedon5patientswithin2daysofadmission,3patientswithin3days,and3patientswith5days.Allpatientswereplacedonlowmolecularweightheparin prior to surgery and continued postoperativelyuntil discharged.Oneaspirindailywasprescribedafterdischargeforlife. Indicationsforsurgeryweredeterminedafterstandardradiographic evaluation. These studies included, plainradiographs [anteroposterior pelvis; anteroposterior andlateralof involvedhip;andJudetviews–obturator (in-

EltonStrauss,M.D.,isattheMountSinaiMedicalCenter,NewYork,NewYork.Correspondence:EltonStrauss,M.D.,MountSinaiMedicalCenter,5East98thStreet,Box1188,NewYork,NewYork10029

Management of Acetabular Fractures in the Elderly

Elton Strauss, M.D.


ternal)obliqueandiliac(external)oblique].Allpatientsunderwent computerized axial tomography with 3 mmcutsperformedthroughtheacetabulum.7-9Allradiographsyieldedpatternsofinstability,incongruity,orboth. All of the patients were treated through a posterior-lateral Kocher-Langenbeck approach.10 Cell saver wasutilizedonallcases.Prophylacticantibioticswereusedfor48hours.Thepatientswerepositionedonanimagetablewith a radiolucentpelvicholder.Base line imageswiththeimageintensifierweretakenandsaved.Atrochantericosteotomywasindicatedin5patients.Theosteotomywasusefulforexposureofthefractureaswellasidentificationofthesciaticnerve. The preoperative goals were: a stable rather than ananatomicalreduction,tosupportbonelosswithautograftor allograft, and to stabilize the anterior and posteriorcolumnswithcannulatedlongandlarge(greaterthan4.5mm)screws.

Primaryreductionwasmadeafterthefemoralheadwasremoved.Thereductionwasmadeandheldwithlargepel-vicandacetabularclamps.Cannulatedwiresweredrilledeitherfromtheinsideoroutsideof theacetabulum(Fig1).Thiswasmadeeasiersincetheheadwasremovedandtheshaftmobilizedoutoftheway. Oncethecolumnswererestoredthepatient’sacetabu-lumwastreatedasatotaljointarthroplasty.Revisionprin-cipleswereutilized.Theseincludedastablerimconstructthatwouldsupportanacetabularcup(Fig.2). This exposure and construct made joint replacementeasier.Theabilitytoworkinsideandoutsidetheacetabu-lumaidedthedecision-makingprocessforuncementedorcementedsupportcages.Despitesuggestionsmadebyotherinvestigators,11-13therewasnoattempttoreconstructthemedialwall,oncethesocketwasrestoredgraftmaterialandsmallerguidewireswereplaced.Insomecasesthewirescouldbeplacedfromwithinthefracturedsocket;pushed

Figure 1 AandB,Techniqueofacetabularreconstructionafterheadisremoved.Largeguidepinsforcannulatedscrewsareadded.C,Acetabularcageisinsertedafterprimaryfixationwithscrews.

A B

C


retrogradeandthenantegradeafterplacementoftheshellorcage. Once the acetabulum was stabilized, an uncementedcuporacetabularshellwithacementedcupwaschosen.In 7 cases a multiple hole hydroxyapatite cup (Stryker,Allendale, N.J.) was used; a GAP shell with cementedpolyethyleneliner(Stryker,Allendale,N.J.)wasusedin4cases(Fig3). Thefemoralsidewastreatedwithanantibioticimpreg-natedcementandstem.TrochanterfixationwasperformedwithDall-Milescables(Stryker,Allendale,N.J.).

Case ExampleA74-year-oldfemalesufferedafallonalocalsidewalk.She struck her left knee with a force that resulted in atransversefractureoftheleftacetabulum.Herco-morbidi-tiesincludedhypertension,type2diabetesmellitus,andvenousstasis.After initial stabilization includingplace-

mentofaGreenfieldfilter,surgerywasperformedthroughaKocher-Langenbeckapproach.Atrochantericosteotomywasneeded(Fig.4).

ResultsAverage anesthesia time was 5 hours and the averagebloodlosswas3units.Nonervepalsieswereobserved.Alltrochantersunited.Everypatientwasabletosurvivesurgeryandambulatewithexternalsupport.At4monthspostoperatively,eightpatientsusedawalker,twopatientsusedacane,andonepatientwaswalkingwithoutsupport.(Subsequentlythreepatientsdiedfromcausesunrelatedtotheoperativeinterventionintheperiodrangingfrom6to14monthspost-injury). Theeightsurvivorsareallambulatingindependently.Sixcurrentlyusewalkers,threeuseacane,andoneam-bulateswithoutsupport. Theprosthesisboneinterfaceshaveremainedconstant.

Figure 2 Flowchart demonstrating the deci-sion-making process for acetabular fracturereconstruction.

Figure 3A,Acetabularshellforusewithcementedliner.B,Uncementedshellusedwithgoodrim(column)fit.

BA


Norevisionshavebeenneededorsuggested.Theareasthatwerebonegraftedhaveconsolidated.Thescrewfixationhasremainedunchanged. Complicationshavebeenfew.Onedeepinfectionwasobservedatfourweekspostoperatively.Itwasinafemalepatientwithatransversefracturepatterntreatedwithanacetabularshell.Treatmentwasbyradicaldebridement,dislocationofthejoint,exchangeofapolytoaconstrainedliner.Postoperativesuppressionantibioticscontinueone-year postoperatively. She currently lives semi-indepen-dently in an adult community complex. She ambulateswithawalker. Surprisinglynocasesofheterotopicossificationhavebeen observed.14,15 Patients were not given radiation ornon-steroidalanti-inflammatorydrugs.

DiscussionAgingisallaboutfunction.Mostofourseniorsneedtomaintaintheirindependenceandlifestyle.Recentadvancesinprostheticreplacementofotherjointshaveencouragedthistreatmentofthedifficultacetabularfracture. Revision totalhipswithacetabulardeficiencycanbeproblematic.16-18ManyarthroplastysurgeonsusetheAAOSclassificationsystemforacetabulardeficiency.19Ourcon-clusionwasthatmanyofthesefracturesweresimilartoatype4pelvicdiscontinuity(Fig.5).

JolyandMearsstatedthat“certainacetabularfracturespossessanintrinsicallyabysmalprognosisirrespectiveoftheinitialmethodoftreatment.”20Openreductioninternalfixationispreferredandthoughttoofferthehighestchance

Figure 4A74-year-oldfemalethatsufferedalowvelocityfallwhilewalkingonthestreet;A,Transversefracturepattern;B,reconstruc-tionwithanacetabularcage,cementedliner,andcementedstem.

Figure 5IllustrationofanAAOStypeIVpelvicdiscontinuity;similartocolumndisruptionafteracetabularfracture.

B

A


ofafavorablefunctionaloutcomeaftermostdisplacedac-etabularfractures.21However,prognosisispoorforcertaininjurypatternsandintheelderly.LetournelandJudetaswellasMattaattributedunfavorableoutcomesofanteriorandposteriorwallaswellasposteriorcolumnfracturestoelderlyosteoporoticbone.Theyobservedthebestresultsinyounghealthyadultsandtheworstoutcomesinpatientsovertheageof50(particularlyinfemales).22,23

Acetabularfracturesintheelderlyhavemarkedcom-minution,underlyingarthritis,impactionofarticularsur-faces,andassociatedfracturesofthepelvisandfemoralneck.Impactionofthearticularsurfacehasbeenshowntosignificantlyimpacttheprognosis.24,25

Morethan10millionAmericanssufferfromosteoporo-sisandosteopenia.Another18millionareatrisk.Tencerhasshownthatosteoporosissignificantlyaffectsfracturefixation.Thisisdemonstratedbyadecreaseinthediameteroftrabecularbone,lossofbonemassandshearstrength,andlossofinterconnectingstrutsaswellascompressivestrength.Screwpullout isaffectedby theabovemecha-nisms.26

Asalludedtopreviouslyinthisreview,Mears,Velyvis,Chang,andothersreviewedcausesofsuccessandfailureindisplacedacetabularfracturestreatedbyopenreductionandinternalfixation.Theyconcludedthatage,bonequality,impaction,underlyingarthritis,andcomorbidityplayedasignificantrole.Evenwithimprovedfixationtechniquessuchascables,Mearsandcolleaguesalludedtothefacttheprimaryreplacementmaybebetterforthepatient.Hisgroupreportedon63caseswith27patientshavingsevereosteoporotic bone. Supplementation of the fixation wasperformedaswellastheuseofamulti-screwedcupactingas“hemispherical”plate.Thegroupstressedmedialwallreconstruction for primary socket stability. Our successwithrevisionarthroplastyusingrimsupportnegatedtheabovepremiseinourpatientgroup. Late total hip arthroplasty after open reduction andinternal fixation can be complicated and unrewarding.Complications secondary to previous surgery includeheterotopicbone,proliferativescar,obstructivehardware,occult infection, ischemic muscle and poor soft tissue,nerveandvesselentrapment,bonedefectsandnonunion(especiallyinnon-operativetreatmentordelayedsurgery).Pooroutcomefunction(HarrisHipScore)hasbeenassoci-atedwiththisgroup.27

ConclusionSurgeryforacetabularfracturesneedstobeindividualized.Thinkingmustincludethepremisethatallosteopenicboneis pathological. Open reduction internal fixation mustimprovetheprognosisandnotcausecomplications.Think-ingthatprimaryopenreductionisthefirstofatwostageprocedureiscompromisingthegeriatricpatient.Primarytotaljointarthroplastycanbesuccessfulifthesocketcanbestabilizedeitherwitharim-fituncementedcuporwith

acementedacetabularcage.Timeoftheprocedureandco-morbiditiesmustbeconsidered.Immediatemobilizationofthepatientmustbethegoal. Thesefracturesaredifficultandchallengingfromallperspectives.Workinthisfieldcontinuestoevolve.Furtheroutcomestudiesareneeded,particularlyfrommulticenterlocations.However,theproblemisuponusandmustbeconfronted with a well planned and executed surgicalintervention.Thegoalisafunctioningpatientwhoisabletomaintainhisorherindependence.

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