Operative vs non-operative management of geriatric acetabular fractures: persisting clinical challenges in decision-making and outcome reporting

Geriatric acetabular fractures (GAFs) have become an increasingly familiar problem for practicing orthopedic trauma surgeons. Once considered relatively uncommon, these injuries are now encountered with growing frequency as life expectancy increases, and older adults maintain active, independent lifestyles well into advanced age. Unlike hip fractures of the proximal femur, which are managed along well-established treatment pathways, acetabular fractures in elderly patients retain much of the biological and mechanical complexity seen in younger individuals. What changes is the host in which these fractures occur: osteoporotic bone, limited physiologic reserve, multiple medical comorbidities, and heightened vulnerability to complications.

In daily practice, surgeons are increasingly confronted with patients who are both medically fragile and functionally demanding. Many wish to return to preinjury levels of independence, mobility, and social participation. This tension between fragility and expectation has become one of the defining features of modern geriatric trauma care and is particularly pronounced in the management of GAFs.

The core clinical dilemma: to operate or not to operate

Despite decades of surgical progress, there remains no universally accepted algorithm to guide treatment decisions for GAFs. If several experienced trauma surgeons are asked to independently evaluate the same elderly patient with a displaced acetabular fracture, their recommendations will often differ. Each opinion may be supported by published data, yet the decision-making process remains highly individualized. At its core, the debate continues to revolve around whether to proceed with operative management or to pursue non-operative care.

Clinical variables that drive decision-making

In real-world practice, treatment selection for GAFs is rarely dictated by the fracture pattern alone. Instead, surgeons must integrate multiple layers of information before committing to a course of action. Patient-related variables such as age, baseline mobility, cardiopulmonary reserve, frailty burden, and cognitive status weigh heavily in the decision process. At the same time, fracture-specific considerations—including displacement, comminution, dome impaction, posterior wall involvement, and the presence of associated pelvic injuries—directly influence both the technical feasibility of fixation and the likelihood of durable joint preservation.

Equally important is the condition of the preinjury hip joint. The presence of established osteoarthritis, femoral head injury, or cartilage damage may shift the balance toward arthroplasty rather than fixation.

Finally, system-level factors must be acknowledged. The availability of surgeons experienced in acetabular reconstruction, access to arthroplasty expertise, intensive care capabilities, and structured geriatric rehabilitation programs all shape what is realistically achievable for a given patient. In many centers, especially outside major tertiary referral hospitals, these constraints are impossible to ignore.

Strengths and limitations of non-operative management in current practice

Non-operative management (NOM) has traditionally been reserved for patients with minimally displaced fractures, substantial medical comorbidity, or limited functional demand. For some frail and non-ambulatory patients, this approach remains appropriate. Avoidance of anesthesia-related risks, surgical wounds, infection, and implant-related complications can be decisive advantages in carefully selected cases.

However, the real-world limitations of NOM are well recognized by clinicians who follow these patients beyond the acute hospital stay. Prolonged bed rest and restricted weight-bearing expose elderly individuals to a predictable cascade of complications, including pneumonia, pressure injuries, venous thromboembolic events, deconditioning, and loss of independence. Moreover, by leaving residual joint incongruity uncorrected, NOM carries a substantial risk of post-traumatic osteoarthritis, persistent pain, dissatisfaction, and eventual conversion to delayed total hip arthroplasty under less favorable medical conditions. Thus, while NOM may appear safer in the short term, it often transfers risk from the perioperative period to the months and years that follow.

Operative management: promise, complexity, and surgeon-dependent outcomes

Operative management (OM) remains the standard of care for displaced acetabular fractures in younger patients, and its theoretical advantages apply equally to selected elderly individuals. By restoring articular congruity and mechanical stability, surgery can facilitate earlier mobilization, improve pain control, and potentially reduce the risk of long-term degenerative change. For many high-functioning older adults, the possibility of regaining independent ambulation is a compelling reason to consider surgery despite elevated medical risk.

At the same time, OM in the geriatric population is inherently demanding. Osteoporotic bone challenges fixation quality and increases the risk of implant failure. Prolonged operative times and higher blood loss place additional strain on limited physiologic reserves. Postoperative care often requires close coordination between surgical, anesthesia, geriatric, and rehabilitation teams. From both a clinical and systems perspective, OM represents a resource-intensive commitment whose success depends heavily on surgical expertise and institutional support.

What does the best available evidence actually show?

In an effort to clarify the relative merits of OM and NOM, we conducted a systematic review and meta-analysis during my AO ITC research fellowship in 2023 in collaboration with members of the AO ITC team Lyndsey J Kostadinov, Dimitri D Hauri, and Tracy Yaner Zhu, focusing primarily on health-related quality of life (HRQoL) assessment, functional outcomes, complications, and mortality rates

Thirteen studies comprising 5,680 patients were analyzed. The mean patient age was 74.1 years, and the majority were male.

Non-operative management was employed in 58.3% of cases, while 41.7% underwent operative treatment. Among surgically treated patients, ORIF represented the predominant strategy, followed by CRPIF and, in a small minority, acute THA. In contrast, the details of NOM were inconsistently reported and typically consisted of partial weight-bearing or traction with bed rest for approximately six weeks. This lack of uniformity already illustrates one of the fundamental problems in interpreting the existing literature.

The persistent problem: inconsistent and inadequate outcome reporting

Perhaps the most striking finding from this review was the lack of consistent, patient-centered outcome reporting. Health-related quality of life (HRQoL), arguably one of the most relevant endpoints for elderly patients, was reported in only four studies, each using a different assessment tool. Functional outcomes were likewise assessed with a variety of instruments, including the Harris Hip Score, Postel-Merle d’Aubigne score, and the Musculoskeletal Function Assessment.

Only two studies directly compared HRQoL between OM and NOM. One reported no difference between treatment strategies, while the other found significantly better HRQoL in the operative group after two years. This degree of heterogeneity severely limits the ability of surgeons to provide evidence-based prognostic counselling to patients and their families.

Key quantitative findings relevant to clinical practice

When the available data were pooled, several trends of direct relevance to daily practice emerged. Length of hospital stay did not differ significantly between OM and NOM. This challenges the common assumption that surgical management necessarily leads to prolonged hospitalization in elderly patients.

Complications, defined as the occurrence of at least one adverse event, were significantly more frequent in the OM group. This increase likely reflects the burden of surgery-related problems such as infection, blood loss, implant failure, and perioperative medical complications.

The risk of conversion to total hip arthroplasty was also significantly higher following initial OM. This finding underscores the technical difficulty of achieving durable fixation in osteoporotic bone and the ongoing vulnerability of the elderly joint to mechanical failure.

Perhaps the most clinically provocative observation was that mortality—measured in-hospital, at 30 days, and at one year—was consistently lower in the OM group. At one year, operative treatment was associated with a 58% reduction in mortality. While causation cannot be established, this finding suggests that earlier mobilization and mechanical stabilization may confer a survival advantage in selected patients.

Can we declare one strategy superior?

Despite these trends, the certainty of the available evidence remains limited. According to GRADE assessment, mortality outcomes reached only moderate certainty, while HRQoL outcomes were supported by very low-quality evidence. Although OM was associated with higher complication rates and increased conversion to THA, it was also linked to substantially lower mortality. Functional recovery and quality-of-life advantages remain uncertain. Importantly, none of the included studies clearly defined the indications that guided selection of OM versus NOM, making it impossible to isolate treatment effect from selection bias.

Practical, clinically actionable principles for surgeons

In the absence of definitive evidence, several pragmatic principles may help guide clinical decision-making:

• First, management should be individualized through careful consideration of patient-related factors such as medical fitness, baseline function, and physiologic reserve, alongside fracture-specific characteristics and system-level resources.
• Second, while OM carries a higher risk of complications, its association with reduced mortality up to one year suggests that it should remain a strong consideration in elderly patients who are medically stable, cognitively intact, and functionally independent prior to injury.
• Third, NOM retains an important role in patients with minimally displaced fractures, profound frailty, multiple comorbidities, or limited life expectancy, where surgical risk clearly outweighs potential benefit.
• Finally, shared decision making is essential. Meaningful discussions should involve not only surgeons and anesthesiologists, but also geriatricians, rehabilitation specialists, patients, and their families. Expectations regarding pain control, independence, institutionalization, and caregiver burden must be openly addressed before a treatment path is chosen.

Future challenges that directly impact clinical practice

This body of evidence exposes several unanswered questions that will shape the future of geriatric acetabular fracture care. There is a clear need for treatment algorithms that incorporate not only fracture characteristics, but also frailty and physiologic reserve. Prospective comparisons between ORIF, acute THA, and NOM are urgently required, as are long-term assessments of HRQoL. Predictive models for failure of fixation and treatment selection may emerge as large datasets become available, potentially supported by advanced analytic tools. Cost-effectiveness, resource utilization, and system sustainability will also become increasingly important considerations as health care systems adapt to aging populations.

Call for realistic, patient-centered orthopedic care

Geriatric acetabular fractures represent far more than a technical challenge. They mark a vulnerable moment in an elderly patient’s trajectory, often determining whether independence can be regained or permanent dependency will follow. Whether treated operatively or non-operatively, the fundamental goal remains the same: to reduce pain, restore mobility as early as possible, minimize complications, and align treatment with the patient’s values and expected quality of life.

Progress in this field will depend on continued international collaboration among experienced pelvic trauma centers, multidisciplinary care models, and the generation of high-quality prospective data. Only then can surgeons move beyond debate and toward truly personalized, evidence-driven care for this rapidly growing patient population. 

International collaboration between expert trauma surgeons and tertiary centers specialized in the management of acetabular and pelvic trauma will be essential, and AO Trauma is an ideal platform to advance and organize such work.

Read more about Dr Ahmed A. Khalifa’s experience in Davos and the AO ITC Research fellowships here.