Types of acetabular fractures and their indications

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In the first part of this series, Rodrigo Pesantez from the Universidad de los Andes Medical School and Colegio Mayor de Nuestra Señora del Rosario, Bogotá, Colombia, explains the acetabular fracture patterns commonly seen in elderly patients, walks us through the definitions of and indications for acute and delayed total hip arthroplasty (THA) as a treatment for acetabular fractures, presents known (negative) prognostic factors, and looks at outcomes for both acute and delayed THA.

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Rodrigo Pesantez

Universidad de los Andes Medical School and Colegio Mayor de Nuestra Señora del Rosario, Bogotá, Colombia

Acetabular fracture patterns in the elderly

Acetabular fractures in elderly patients are increasing, with the incidence in patients over 60 years of age being 24% of all acetabular fractures [1]. The failure rate of open reduction and internal fixation (ORIF) as a treatment for these fractures in this population is high, leading to delayed THA in around 17‑30.4% of patients [2]. Acetabular fractures according to Letournel [3] are classically divided into elementary and associated patterns, with elementary patterns including posterior wall, posterior column, anterior wall, anterior column, and transverse fracture patterns; the associated patterns include T-shaped, posterior wall and posterior column, transverse and posterior wall, anterior and hemitransverse, and fractures of both columns [3]. It has been shown that the fracture pattern occurring in the elderly is different to that occurring in the younger population [1]. Ferguson et al [1]—in their epidemiological and radiological study of acetabular fractures in patients over 60 years of age—revealed that fractures characterized by displacement of the anterior column are more common in the elderly (64%) than in younger patients (43%). Here, the common fracture patterns in the elementary group were anterior column (19.2%) and posterior wall (13.2%), and in the associated group were both column (26.4%), anterior column posterior hemitransverse (14.9%), T-shaped (10.2%) and transverse posterior wall (8.1%) (Figure 1) [1].

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Figure 1. Most common acetabular fracture patterns observed in patients over 60 years of age, as reported by Ferguson et al [1].

Definition of acute versus delayed total hip arthroplasty

Total hip arthroplasty as a treatment for acetabular fractures can be used in different settings. According to Pesantez, surgeons are faced with performing a THA in an acute or in a delayed setting. When an acute THA is performed, it is either used as an immediate intervention or it can be staged by up to 3 weeks [4]. “On the contrary,” as Pesantez notes, “a delayed THA can be performed in different instances. The perhaps most extreme scenario is when a patient presents with an untreated acetabular fracture. This can also be referred to as a neglected fracture, which is discussed in more detail in Part 3  of this series of articles. Otherwise, a delayed THA can be performed after failure of acetabular fracture management be it nonoperative or ORIF”. Pesantez adds, “in some cases, the original ORIF was perhaps poorly executed resulting in a bad outcome for the patient, whereas in other cases the ORIF was well executed, but due to the severity of the injury the patient has a bad outcome with the development of osteoarthritis.” The following two cases describe classical situations in which an acute THA is performed as the immediate treatment for an acetabular fracture (Case 1), and in which a delayed THA is performed because of failure of the nonoperative treatment (Case 2).

Case 1: Acute total hip arthroplasty

An 84-year-old woman experienced a complex posterior wall and posterior column fracture with comminution and femoral head injury (Figure 2). The patient was treated with an acute THA through a direct anterior approach with antegrade column fixation.

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Figure 2. (a) AP x-ray of the pelvis showing a fracture dislocation of the left hip. (b) Computed tomography (CT) rendering showing the complex posterior wall and simple posterior column fracture. (c) Postoperative AP x-ray showing a multiple uncemented cup and posterior column and posterior wall screws outside the cup. (d) Obturator oblique view. (e) Iliac oblique view. (Images courtesy of Rodrigo Pesantez, Bogotá, Colombia.)

Case 2: Delayed total hip arthroplasty

A 67-year-old man sustained a transverse acetabular fracture of the right hip and a pelvic ring injury on the left side. He underwent treatment with a closed reduction and percutaneous fixation of his injuries (Figure 3). Nine months later, he presented with pain and radiographic examination revealed hip arthritis and heterotypic ossification (Figure 4). The patient was treated with acetabular reconstruction and a hybrid THA via the Kocher-Langenbeck approach.

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Figure 4. AP (a) and lateral (b) x-rays of the hip reconstruction using the femoral head as an autograft to reconstruct the posterosuperior defect and fixing it with 3.5 mm lag screws, and an uncemented cup fixed with screws and a cemented femoral stem. (Images courtesy of Rodrigo Pesantez, Bogotá, Colombia.)

Indications

According to Pesantez, acute THA is particularly indicated in elderly patients who present with fracture patterns such as complex posterior component comminution and/or impaction of the articular surface of the femoral head. Liang et al [4] identified in their systematic review and metaanalysis on acute versus delayed THA after acetabular fracture fixation a number of indications for performing acute THA from the studies included in their review. These comprised [4]:

  • Pathological fractures
  • Combined acetabular and femoral neck fractures
  • Increased age and extensive osteoporosis
  • Osteopenia/osteoporosis as evidenced by x-ray
  • Already existing severe hip osteoarthritis or femoral head avascular necrosis
  • Cartilage loss
  • Impaction or fracture at the femoral head
  • Involvement of the weight-bearing zone in acetabular impaction
  • Displaced acetabular fracture with intraarticular comminution and/or protrusion

In contrast, delayed THA for acetabular fracture is mainly indicated in posttraumatic osteoarthrosis and failure of fixation, notes Pesantez. Liang et al [4] similarly identified posttraumatic or postoperative arthritis or avascular necrosis of the femoral head as an indication for delayed THA, as well as postoperative dislocation, loss of implant fixation, fracture of the femoral neck, hardware breakage, and a Kellgren-Lawrence score of ≥ 3.

 

(Negative) prognostic factors

A number of factors have been shown to be associated with the development of posttraumatic osteoarthritis in patients with acetabular fractures [5, 6]. Studies show that in these patients age (older than 40 years), postoperative incongruence of the acetabular roof, femoral head cartilage lesion, impaction of the acetabular joint surface, anterior hip dislocation, severe posterior wall involvement, initial displacement of the articular surface over 20 mm, nonanatomical fracture reduction, and utilization of the extended iliofemoral approach lead to posttraumatic osteoarthritis [5, 6]. A study by Clarke-Jenssen et al [5] shows that after ORIF for displaced acetabular fractures, strong predictors of failure were acetabular impaction and injury to the femoral head particularly in patients over 60 years of age. According to Liang et al [4], there now exists consensus across multiple studies as to which negative prognostic factors strongly predispose patients to the need for THA after acetabular fracture. In addition to the above, preexisting osteoarthritis, marginal or dome impaction, femoral head damage, as well as more than a 2-week delay in surgery are noted as negative prognostic factors.

In their study on patients with posterior wall fractures, Firoozabadi et al [7] specifically identified five radiographic features of injury associated with conversion to THA. These are dislocation, wall comminution, intraarticular debris, acetabular impaction, and femoral head lesions. If five of the radiographic features were found to be present at the same time, then the conversion rate to THA was 50% in contrast to 11% if there were four or fewer [7]. When considering fracture reduction, in cases of diastasis and/or step-off on postoperative computed tomography (CT) scan, the conversion rate increased as these parameters increased [7]. Here, if more than 4 mm of malreduction was present, the conversion rate to THA was 54%, though if it was 1–4 mm the conversion rate was 10%, and 0% if less than 1 mm [7].

 

Treatment options and outcomes in patients with acetabular fractures

As noted above, for patients with acetabular fractures, THA can be used in an acute setting, particularly if there are indications that ORIF may fail [7]. Alternatively, patients with fracture patterns associated with a negative prognosis may undergo acute THA together with ORIF in one operation or staged up to 3 weeks [4]. This so-called “fix-and-replace” technique, or combined hip procedure, is seeing increased use in older patients with risk factors, yet as Liang et al [4] noted at the time of their study, the comparative evidence to justify the technique was limited.

 

Outcomes after acute THA

A number of studies [8-12] have looked at health-related quality of life, radiographic and clinical outcomes in patients who underwent acute THA for acetabular fractures. A prospective cohort study [8] assessed the use of acute THA using a Burch-Schneider reinforcement ring and autogenous bone graft in 15 elderly patients (average age of 76 years) with low-energy anterior column acetabular fractures (displaced anterior column, anterior column posterior hemitransverse, and transverse). Here, Enocson [8] looked at complications, reoperations, activities of daily living, functional scores (Harris Hip Score [HHS] and Short Form-36), EQ-5D score, and radiological evaluation. The HHS at 48 months was 88. The patients did not experience any prosthetic dislocations, periprosthetic fractures, or deep infections, and there were no signs of loosening on radiological evaluation. After the 48 month follow-up, the authors concluded that THA was a safe option with good functional and radiological outcomes in elderly patients with these types of anterior column fractures.

When comparing acute THA with ORIF in 70 elderly patients with acetabular fractures, Weaver et al [9] found that the reoperation rate was higher at 30% for patients who had undergone ORIF compared to 14% for those who had undergone THA, though this difference was not statistically significant. Furthermore, patients with ORIF had worse HHS and SF-36 scores compared with those patients treated with THA, where the latter patients showed improved function and better bodily pain scores [9]. However, the complication rate was similar with both treatments [9]. In this study [9], patients with ORIF had a high rate of conversion to THA within 2 years of acetabular fracture. Similarly, in a study by Nilssen et al [10], 13.5% of patients with ORIF were converted to THA. In this large study using the PearlDiver database [10], the risk of surgery after ORIF versus acute THA in geriatric acetabular fractures was compared in 120,032 patients with an acetabular fracture. Of those patients, 3.1% (3,768) underwent surgical treatment, out of which 39.3% (1,482) had THA and 60.7% (2,286) ORIF [10]. A matched cohort of 962 patients on each side was also compared [10]. Here, ORIF was associated with a longer length of stay, more transfusions, and a higher revision rate within 10 years (14.8% vs 6.2% in the matched ORIF cohort), although they were less likely to experience periprosthetic fractures or joint infection [10].

A high rate of conversion to THA was also found in patients with ORIF in another study investigating acute THA and ORIF for posterior wall fracture in patients aged 45–65 years [11]. Here, 16 patients underwent acute THA and 32 underwent ORIF. At an average of 6.2 years of follow-up (range: 1–15.2 years), the Oxford Hip Score (OHS) for patients with THA was 44 and for patients with ORIF 40. However, 37% of the hips (12 hips) in the ORIF group had either been referred for THA or had undergone THA at follow-up, compared with 13% (2 revisions) having a revision in the acute THA group. Although both procedures provided excellent results, THA achieved an improved survival of the index procedure and improved functional scores [11].

Jaregui et al [12] calculated in a metaanalysis of 21 studies including 430 acetabular fractures in elderly patients treated with acute THA a lower revision rate of 4.3%. Here, a mean HHS of 83.3 was reported, but there was an associated complication rate of approximately 20%. The most frequently reported complication was heterotopic ossification at 19.5%, followed by hip dislocation at 6.1%, venous thromboembolic event at 4.1%, deep infection at 3.8%, and neurological complication at 1.9%. The authors considered acute THA as a viable option in acetabular fracture treatment in elderly patients, with acceptable clinical outcomes and survivorship, but made note of the 20% complication rate.

 

Preferable use of acute total hip arthroplasty in older patients

Some studies [4, 13] have compared the outcomes of acute vs delayed THA in acetabular fractures. Nicol et al [13] evaluated 26 patients aged over 60 years with acetabular fractures. The patients were either treated with a combined procedure of ORIF with THA in an acute setting (12 patients) or underwent ORIF and a delayed THA (14 patients). The authors found that the patients who received ORIF with acute THA were older and had a better OHS than those in the delayed group [13]. The authors recommended that in patients with risk factors for failure requiring delayed THA, acute THA and ORIF should be strongly considered, given the better outcomes in terms of OHS, the need for only a single surgery and single hospital visit, and equivalent complications [13].

In the systematic review by Liang et al [4] comparing acute and delayed THA (after initial ORIF), five studies were found with 255 patients, of whom 54.1% were treated with acute and 45.9% with delayed THA. The delayed patients were found to be younger, with high energy injury patterns and a longer follow-up, but there were no differences in functional outcomes, complication, and mortality [4]. Delayed THA had a higher revision rate (17.1% vs 4.3% for acute THA) [4]. The “fix-and-replace” method, ie, acute THA, was concluded to be a good option for selected acetabular fractures in the elderly with lower revision rates [4].

 

Good outcomes with the combined hip procedure

The combined hip procedure of ORIF plus THA has been compared with ORIF alone in several studies [14-20]. The combined hip procedure appears to result in better clinical outcomes [18-20], better survival [14, 16, 18, 20] and fewer complications [20], although some studies have shown no difference in some outcomes [14, 15].

Denyer et al [15] compared the outcomes at 30 days of patients undergoing ORIF and THA versus ORIF alone using the American College of Surgeons National Surgical Quality Improvement Program database. They identified 184 patients who underwent a combined hip procedure and stratified them according to fracture pattern, with 99 wall, 45 elementary and 40 associated fractures. There were no differences in surgical site infection, thromboembolic events, transfusion rates, revision surgery, and readmission, regardless of fracture pattern and comorbidities. Borg et al [14] compared the short-term results of ORIF and THA (13 patients) with ORIF (14 patients) alone in elderly patients with acetabular fractures with severe acetabular impaction with or without concomitant femoral head injury. Despite not finding any differences in patient-reported outcomes, no revisions were required in patients who had undergone the combined hip procedure, giving ORIF and THA a 100% survival rate at 3 years compared with 28.6% for the ORIF group [14]. In displaced acetabular fractures in patients older than 75 years, a higher revision rate and lower 10-year survivorship was found for ORIF alone (25% and 45.8%, respectively) than for the combined ORIF and THA procedure (12.5% and 85.7%, respectively), with a time to conversion of 2.6 years for patients undergoing ORIF alone [16]. For elderly patients with acetabular fractures presenting with dome impaction, femoral head or posterior wall component fractures, the combined procedure resulted in better HHS and a 28% decrease in risk of reoperation compared with ORIF alone [18].

Looking further at patient-reported outcomes, in geriatric acetabular fractures better outcomes were found for patients with acute THA and ORIF [17], compared to those with ORIF alone [19, 20]. Additionally, fewer complications and lower reoperation rates [20] as well as shorter operating time [19] have been shown for acute THA and ORIF compared with ORIF alone.

 

Poorer outcomes for delayed THA compared with THA for primary osteoarthritis

As noted above, delayed THA is indicated in patients who have developed posttraumatic osteoarthritis after acetabular fracture. Some studies [21-23] have looked at the outcomes of such delayed THAs in comparison with THA for primary or nontraumatic osteoarthritis and have found that complication rates can be higher and patient-reported outcomes poorer.

A study by Scott et al [21] looked at the outcomes of cemented THA after acetabular fractures. Here, 49 patients underwent cemented THA after a mean of 6.5 years (0.1–25 years) after acetabular fracture; 38 patients were treated by ORIF and 11 nonoperatively [21]. They used an age-matched cohort of 98 patients undergoing THA for nontraumatic osteoarthritis to compare complications and patient-reported outcomes [21]. Initial fracture management, timing to THA, and age had no effect on the OHS or 10-year survival [21]. Six THAs were revised with a 10-year survival rate of 92% [21]. Complications rates were higher and OHS inferior for patients undergoing THA after acetabular fracture [21]. They conclude that cemented THA is an option for sequelae of acetabular fractures, but higher complication rates and poorer patient-reported outcome measures can be expected [21]. Similarly, lower survivorship (70% vs 90%) at 10 years and higher complication rates (infection, dislocation and heterotopic ossification) were found in delayed THA compared with THA after primary arthritis or avascular necrosis in a matched cohort study by Morison et al [23]. An increased rate of revision was also found for delayed THA in a matched cohort study of 552 cases from the Norwegian Arthroplasty register [22]. In this study, 224 patients had been treated with ORIF and 328 nonoperatively with a mean age of 58.8 years; follow-up was 8.7 years (1–29 years) [22]. Compared to the primary osteoarthritis cohort, the hazard ratio for revision was 1.38; survivorship was 79.7% at 10 years and 62.4% at 20 years.

Finally, to assess the effect of the initial treatment type and time of surgery on the outcomes of conversion THA for patients with failure of initial treatment of their acetabular fracture, Shaker et al [24] performed a systematic review and metaanalysis of 24 comparative studies. Here, the following groups were compared: a) primary vs conversion THA, b) THA after nonoperative treatment vs THA after ORIF, and c) acute vs delayed THA after treatment failure [24]. For the acute vs delayed THA group, no significant differences were found in terms of complication rate (dislocation, postoperative fracture, and heterotopic ossification), as well as postoperative OHS, intraoperative blood loss, and operating time [24]. Comparing primary vs conversion THA, it was found that the rate of infection, dislocation, heterotopic ossification and revision, as well as the operating time, blood loss, and need for bone graft were higher for patients undergoing conversion THA [24]. In contrast, the HHS was significantly higher in the primary THA group [24]. The comparison of ORIF or nonoperative treatment as the initial treatment revealed comparable rates of infection, heterotopic ossification, implant loosening, dislocation, and revision, as well as no differences in postoperative HHS, blood loss, or operating time [24]. However, the need for a bone graft was significantly higher in patients who had prior nonoperative treatment [24]. The authors conclude that higher complications and lower functional outcomes occur in conversion THA, and complications and functional outcomes were comparable after nonoperative treatment or ORIF [24].

 

Conclusion

In summary the outcomes of THA after acute acetabular fractures are better than ORIF alone in elderly patients, especially those with complex fracture patterns, comminution, impaction, femoral head injury, hip dislocation, nonanatomical reduction, and initial displacement over 20 mm. However, delayed THA after acetabular fractures has been shown to have worse outcomes and survival rates than THA after primary arthritis and avascular necrosis.

Pesantez concludes: “We should consider the use of combined hip procedure in acute acetabular fractures in the elderly”. Total hip arthroplasty is an option in acetabular fractures, and as Pesantez mentions, on the one hand, acutely it is a great option in patient with negative factors and complex fracture patterns, and it can be done alone or as a combined hip procedure (fix-and-replace) according to the fracture pattern. On the other hand, it can be used in a delayed setting to treat posttraumatic arthritis as a result of fractures without treatment or as a failure of fixation.

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Part 2 | Acute total hip arthroplasty

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Part 3 | Delayed total hip arthroplasty

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AO Recon resources

Contributing experts

This series of articles was created with the support of the following specialists (in alphabetical order):
Ashok S Gavaskar

Ashok S Gavaskar

Orthopedic Trauma and Arthroplasty Services, Rela Institute and Medical Centre, Chennai, India

Rodrigo Pesantez

Rodrigo Pesantez

Universidad de los Andes Medical School and Colegio Mayor de Nuestra Señora del Rosario, Bogotá, Colombia

Ramesh K Sen

Ramesh K Sen

Institute of Orthopedic Surgery,
Max Hospital, Mohali, India

This article was edited by Lyndsey Kostadinov, AO Innovation Translation Center, Clinical Science, Switzerland.

References

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