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Open Reduction and Internal Fixation of Complex Geriatric Acetabular Fracture
Open Reduction and Internal Fixation of Complex Geriatric Acetabular Fracture Boris A. Zelle, MD,* and Peter A. Cole, MD† Management of complex acetabular fractures in the geriatric patient requires a better understanding of a different spectrum and frequency of fracture patterns, surgical techniques, and even treatment principles than in younger patients. Although joint replacement plays a role in certain elderly patients with acetabular fractures, open reduction internal fixation is the preferred treatment strategy, and must be executed even when combined with arthroplasty. Patient baseline functional status must be considered in choosing treatment goals, as well as their frailty and comorbidities. There are typical injury characteristics that must be recognized which require treatment-specific strategies. Lengthy reconstructions in this fragile patient population are to be avoided, and therefore single nonextensile approaches limiting blood loss are most appropriate, considering that the patient’s physiological reserve is lesser than younger counterparts. Although obtaining an anatomic reduction of the acetabulum is of paramount importance in the physiologically young who can withstand greater demands of surgery and who will require greater functional demands, the physiologically old patient requires stability to allow mobility and a surgery to mitigate their surgical risks. Oper Tech Orthop 21:286-292 © 2011 Elsevier Inc. All rights reserved. KEYWORDS acetabulum, fracture, elderly
A
s the absolute and relative population of elderly (⬎65) and geriatric (⬎80) patients increases in the United States,1 the orthopedic trauma surgeon is faced with the inherent challenges of treating an increasing number of geriatric acetabular fractures. Although acetabular fractures in the older patient can result from high-energy trauma, a common circumstance is a fragility fracture in compromised bone after a ground-level fall. Force transmission is typically generated through the greater trochanter or buttock and directed anteromedially, making the anterior column/wall and the quadrilateral plate vulnerable to injury.2 The femoral head is frequently driven through the fractured hip socket in a centrally dislocated position, the so-called intrapelvic dislocation. As a population, patients with these fracture patterns have been linked to poor outcomes after open reduction and internal
*Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX. †Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, St Paul, MN. Address reprint requests to Boris A. Zelle, MD, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MSC-7774, San Antonio, TX 78229. E-mail: boris. [email protected]
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fixation (ORIF) in the elderly and geriatric population.3 In the absence of bone density compromise, the physiologically younger patient will likely sustain patterns common to younger populations, but these are not the emphasis of this review. The focus of this chapter is on the management of fracture variants typical for the elderly and geriatric agegroups. Ferguson et al reviewed 235 patients aged ⬎60 years who presented with an acetabular fracture.2 They found that the fracture patterns in their elderly population differed from their younger patient (⬍60) cohort (n ⫽ 1074) and were characterized by displacement of the anterior column (64% vs 43%; P ⬍ 0.001), and often included a separate quadrilateral-plate component (51%), roof impaction (40%) in the anterior fractures as well as comminution (44%) and marginal impaction (38%) in the posterior wall fractures.2 Associated both-column fractures were also common in both the elderly (26%) and younger (28%) cohorts (P ⫽ 0.7), yet with different mechanisms. Demonstrating the poor bone quality in the older population, nearly half of the patients (49.8%) in the elderly cohort presented after a fall, whereas only 17.7% of the patients aged ⬍60 years had a similar mechanism of injury. The overall treatment goals in the elderly and geriatric
Reduction and internal fixation of complex geriatric acetabular fracture patients with these complex acetabular fractures require special consideration. Primary tenets of acetabular fracture management in the elderly patients are directed toward achieving hip stability and immediate mobilization while minimizing both systemic and/or local complications. However, management is plagued by both host and injury characteristics.4 Prolonged recumbency increases the risk for complications, especially in this older population with greater susceptibility for pulmonary compromise, deep vein thrombosis (DVT), and decubitus ulcers. Jain et al were able to document 30-day mortality rate as high as 73% in patients with severe comorbidities and hip fractures who were not able to mobilize effectively, whereas the mortality rate dropped to 19% in patients who were able to mobilize5. The overall physiology of the geriatric patient must be considered when determining the level of intervention required for optimal acetabular fracture management. As a rule, prolonged surgical interventions with excessive blood loss should be avoided. A surgical plan should be developed to give the patient a stable hip joint. Further, patient comorbidities that can be rapidly optimized should be addressed in conjunction with a geriatric internal medicine specialist, and a discussion with anesthetist before surgery to corroborate recommendations with findings of the geriatrician or internist being paramount. Perioperative management must continue until the patient achieves adequate mobility and can be discharged, as these patients often walk a thin line between hemodynamic stability and physiological liability. Past publications have documented that incorporating a team approach for elderly patients with hip fractures has resulted in improved results. Zuckerman et al reviewed 431 elderly cases with hip fractures who were included into an interdisciplinary program.6 Results from the study showed the patients included in the program had fewer complications, fewer intensive unit transfers, and improved ambulatory status when compared with a nonprogram agedmatched cohort.6 We advocate incorporating a similar management approach to elderly and geriatric patients with acetabular fractures, where this principle is even more important given that the greater scope of injury and surgery carry greater potential consequences. Preoperative planning should consider the specific personality of the acetabular fracture. The fracture pattern should be clearly delineated with standard and advanced imaging studies. Routine radiographs with anteroposterior and Judet views are more difficult to interpret in the elderly people owing to decreased bone quality and fracture pattern complexity7 as well as abdominal content patterns. Computed tomography (CT) scans allow for superior delineation of the articular surface, accuracy in classifying fracture patterns, and greater interrater reliability than radiographs alone.8 Attention should be focused on areas of articular impaction and fracture comminution that occurs to a greater degree in patients with poor bone density.3 Bone quality and preexisting coxarthrosis also need to be considered, as preexisting symptomatic degenerative conditions may lower the threshold to perform arthroplasty.
287 Because of the complexity of the elderly patient profile, treatment decisions must be highly individualized. The orthopedic surgeon should be equipped to perform any one of a number of options available for these patients with an acetabular fracture. Options include nonoperative care,9 traction, percutaneous pinning10,11 (Fig. 1), primary total hip arthroplasty,12-14 staged total hip arthroplasty, and ORIF.15,16 The indications for these treatment options remain controversial, and little comparative data are available in the literature. When feasible and the risks allow it, joint-preserving reconstruction and early patient mobilization are the preferred goals of treatment. It is only when host or injury factors preclude reliable ORIF that an alternative management solution be chosen.
Nonoperative Management The surgical indications for acetabular fractures have historically been based on younger patients’ outcomes after nonoperative care.17 Matta et al demonstrated that congruency of the femoral head to the weight bearing dome within 3 mm of displacement was crucial to obtain a good result.17 With the emergence of CT imaging, further indications followed: roof arc measurements ⬎45 degrees, intact subchondral bone on 2D CT scan 10 mm below the tectum, and a minimum of 50% of the posterior wall intact.18 Nonoperative management may be considered in patients not meeting these criteria, although prolonged bed rest in an effort to maintain congruent reduction is discouraged due to the high morbidity as previously described,5 although patients with highly displaced acetabular fractures rarely do well with nonoperative management. Sent et al reported on a subgroup of 14 patients with an acetabular fracture displaced ⬎20 mm.19 Only 2 of the 14 (14.3%) patients achieved good reduction on follow-up x-ray imaging.19 Letournel and Judet7 did describe a special subset of patients with both-column fractures that were able to be treated nonoperatively. These patients often develop a “secondary congruence” where the femoral head remains stable within a consolidated both-column fractures, in which the displaced acetabular articular pieces establish congruency with the head. This congruence is different from the circumstance of a posterior or anterior wall or column in which the femoral head follows one of the columns establishing congruency. In their study, 11 of the 13 (85%) of these both-column fracture patients managed nonoperatively had very good to excellent results after an average of 4.3 years of follow-up.7 If nonoperative treatment is chosen for the elderly patient, traction may be a dangerous option as demonstrated by Cross et al, in which the 3-month mortality rate of elderly patients from a Harborview series of patients placed in traction was more than 40% (2010 CrossOTA NationalMeeting) (personal communication, unpublished data). Furthermore, traction beds are more difficult than ever to accept and maintain in the current environment of shortening hospital stays and transitional care units and
B.A. Zelle and P.A. Cole
288
Figure 1 (A, B) Preoperative Judet radiographic images showing a minimally displaced transverse acetabular fracture and postoperative radiographs (C, D) after the patient was treated with a percutaneous pinning technique.
nursing homes, which do not accept patients with these apparatuses. Additionally, traction makes nursing care and patient positioning more difficult, predisposing patients to complications that must be avoided. Therefore, we have moved to a treatment strategy in our hospitals that renders some form of internal fixation or no traction at all, and one which allows a patient to be upright in a chair at a minimum.
Open Reduction Internal Fixation Both advances in surgical technique and orthopedic implants have empowered the orthopedic trauma surgeon with a more robust treatment armamentarium to perform reconstruction of most complex acetabular fractures in the geriatric patient population. In the past, despite the ability to impart a satisfactory reduction in the setting of poor bone quality, construct stability with traditional plate and screw constructs has led to fixation failure and dismal outcomes. Some of these failures have resulted from plate and screw pullout, as most surgeons treating this population will admit. Fortunately, locking technology can be used in regions of the acetabulum where poorer bone quality is expected, thus creating a more rigid mechanical environment for uneventful fracture healing and early patient mobilization. Combination plates that allow both locking and standard holes are ideally suited for ORIF of complex acetab-
ular fracture cases in the elderly patients. Examples of effective usage include brim plating of the anterior column and infrapectineal plating of the quadrilateral plate. Standard screws are frequently used in regions with better bone stock, including the posterior superior iliac spine and sciatic buttress. Fixed angle screws are more advantageous to secure the low anterior column where poorer osseous quality predominates. Previous studies have shown that across all age-groups, the best predictor for successful surgical outcomes is the quality of reduction.17,20 Importantly, however, recent literature has contradicted this previously accepted notion for the elderly population.21 Forty-five patients with a mean age of 67 years were followed, using 36-Item Short Form Health Survey forms to determine functional outcome after an average of 72.4 months.21 Radiographic results classified the reductions as anatomical in 58%, imperfect in 29%, and poor in 13%, whereas CT scans showed none as anatomical, 51% as imperfect, and 49% as poor. However, functional outcome scores were comparable with those of the general elderly population, with no correlation to the radiographic reduction.21 As orthopedic surgeons, we are now aware that failing to achieve anatomic reduction in this complex patient population will not seal their fate to have poor outcomes. This result likely is due to the low functional demands of some of these patients. Advances in surgical exposure/technique have made op-
Reduction and internal fixation of complex geriatric acetabular fracture
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Figure 2 (A, B) Injury Judet films of an elderly patient with an anterior column fragility fracture. Postoperative Judet films (C, D) after open reduction internal fixation through an ilioinguinal approach.
eration of complex acetabular fracture in the elderly patients less risky in some cases, allowing for mechanical stability and early mobilization. The concept of a single nonextensile exposure has been popularized for safe operation on the geriatric acetabular fracture. Host physiology typically precludes lengthy operation through either extensile or 2-approach techniques, particularly when associated with great blood loss. Recent reports have suggested that the overall rate of serious medical complications in geriatric patients undergoing ORIF of their acetabular fracture is relatively low (less than 4%), given the complexity of this problem.16 Clearly, however, this is going to be surgeon- and institution-dependent, and there is no question that vessel and tissue friability and coagulopathy common in this age-group make for greater blood losses than in younger patients, even with all other things being equal. Traditionally, the ilioinguinal approach has been the workhorse in most complex acetabular cases (associated both-column, anterior column ⫾ posterior hemitransverse patterns) of the elderly patients (Fig. 2), considering the predominance of anterior column and quadrilateral surface involvement. This approach has the potential for blood loss and morbidity,22 and avoidance of potential complications is critical in elderly patients with limited physiologic reserves.23 The traditional ilioinguinal exposure has since been modified to allow for more efficient, safe, and reliable fracture reduction and stabilization. A major modification includes the modification with the stoppa window.24 Initially described for repairing
complicated groin and inguinal hernias,24 Cole and Bolhofner25 described the exposure could be used safely and effectively for reducing acetabular fractures. This approach, also referred to as the anterior intrapelvic retroperitoneal approach, allows for excellent visualization of the intrapelvic portion of the anterior column, quadrilateral plate, and a good portion of the posterior column. Fracture reduction is facilitated and more rigid fixation can be used. Application of an infrapectineal plate is an advance technique described for providing biomechanical stability through fixation of the anterior column/quadrilateral plate, and it can be placed effectively through the stoppa approach. Adhering to similar guidelines of minimizing operative time and intraoperative blood loss, Jeffcoat et al recently described treatment of acetabular fractures in an older population by using a limited ilioinguinal approach.23 In their article, Jeffcoat et al described the technique as using only the lateral 2 windows of the ilioinguinal approach. They compared 17 patients (mean age ⫽ 70 years) with acetabular fracture treated through the limited approach vs 24 patients (mean age ⫽ 65 years) treated through the traditional ilioinguinal exposure. All comparative results with respect to functional outcome and radiographic reduction were not significantly different, except that the surgical time (P ⫽ 0.02) and estimated blood loss (P ⫽ 0.002) were both found to be significantly less using the limited approach.23 Although no deaths resulted from either procedure, we can assume that
B.A. Zelle and P.A. Cole
290 less surgical insult in the fragile elderly patient can only be beneficial.
Postoperative Care Incorporating the interdisciplinary team through the whole process of preoperative assessment and postoperative rehabilitation is crucial in managing these patients. They may remain labile perioperatively until their diet has resumed. Fluid loss through postoperative bleeding, and third spacing, particularly through large open approaches, are more common in the elderly patients and must be monitored. Encouraging mobilization should be the focus postoperative day 1 if possible, beginning with sitting up in bed, pivoting on the uninvolved side, and learning to transfer to a chair. Pre- and postoperatively, a patient with an acetabular fracture should have an overhead trapeze apparatus attached to the bed to give the patient more independence. This adjunct is critical, and furthermore, should be supplemented with an upper body strength program with therabands in bed. The stronger and better conditioned the upper extremities are before going into surgery, the more likely the patient will be able to progress to the use of a walker with partial weight bearing after surgery. When the patient is strong enough, they should be changed from chair restrictions to ambulating with a walker under the supervision of physical therapist. As any
complex reconstruction of the acetabular joint surface dictates, immediate weight bearing should not be instituted as in hip fracture surgery. Loss of articular reduction and subsidence of previously impacted areas will fail with early weight. Similar to patients with fixed femoral neck fractures, toe-touch weight bearing is tolerated and aids in the rehabilitative process. Special attention should be paid to pain management, as postoperative pain has been shown to be a risk factor for delirium.26 Chemical and mechanical DVT prophylaxis is also extremely important during the phase of rehabilitation, and should be continued for no less than a month postoperatively, and even then only if the patient is mobilizing well. The risk of DVT is higher in elderly patients, and must be aggressively prophylaxed. We do not advocate the routine screening for DVTs. Following is a case example demonstrating management of an elderly patient who presented with an acetabular fracture.
Case Example-Both Column Geriatric Acetabular Fracture Safe, efficient, and effective operation is illustrated in this 69-year-old active man with an associated both-column acetabular fracture sustained as a result of a fall from his bicycle. Besides well-controlled type 2 diabetes and stable coronary artery disease, the patient reports no other sub-
Figure 3 (A) Geriatric both column acetabular fracture with protrusio (B,C) Post operative Judet views demonstrating anatomic reduction using locking brim and infrapectineal plating strategies (D) Post operative 3D CT.
Reduction and internal fixation of complex geriatric acetabular fracture stantial medical comorbidities. The geriatrician colleagues were consulted. After routine preoperative testing, the patient was deemed an optimal candidate for operative reconstruction. Primary medical recommendations included an aggressive postoperative nutrition protocol, tight perioperative glycemic control, as well as both mechanical and chemical DVT prophylaxis. The musculoskeletal workup revealed that his complex acetabular fracture was an isolated injury. After analysis of Judet plain radiographs, a CT scan with fine cuts was used to study his injury pattern for preoperative planning. The orthopedic trauma team elected to proceed with open reconstruction using a modified ilioinguinal exposure. With minimal articular impaction evident, an anatomic stable hip joint was deemed readily achievable. Operation commenced on admission day 2, once qualified personnel and resources were organized. A modified ilioinguinal exposure was performed. Iliac, middle, and stoppa windows were established. The vessels were isolated. The corona mortis was ligated. Care was taken to protect both the femoral and obturator nerves. The high anterior column fracture containing the acetabular dome was reduced through the iliac window. A Schanz pin placed in the ilium was used as a reduction tool to anatomically reduce the externally rotated anterior column. A brim plate was then applied. All windows were used to carefully negotiate the plate. Standard screws were placed into the posterior superior iliac spine achieving optimal purchase. Locking screws were placed into the anterior pelvic ring. Reduction of the quadrilateral surface/posterior column was then performed using primarily the stoppa exposure. Use of the middle window was limited, as prolonged retraction on the femoral vessels was deemed unsafe due to known calcific changes. Through the stoppa window, the bladder was retracted using a malleable. The femoral neurovascular structures were retracted using a deaver. The quadrilateral plate/ishiopubic segment was reduced under direct vision using a ball spike pusher. A retroacetabular screw was then placed to initially hold the reduction. An infrapectineal plate was then used to serve as a buttress. The plate was held with Kirschner wires. Standard screws achieved excellent purchase into the sciatic buttress. Anteriorly locking screws were placed into the superior pubic ramus (Fig. 3). Anatomic reduction was evident on postoperative CT imaging. The technical exercise was completed in ⬍3 hours. Uneventful inpatient recovery realized. Anatomic reduction was maintained until uneventful osseous union. Patient was mobilized in aggressive fashion and progressed to full weight bearing at the 6- week checkup. At 1 year, the patient was back to baseline functionality with minimal hip discomfort.
Conclusions Although arthroplasty options are available for the treatment of complex geriatric acetabular fractures, when possible,
291 ORIF is the preferred treatment plan. As described earlier, serious complication rates in elderly patients undergoing ORIF of their acetabular fracture are low (4%).16 Attempting to adequately restore the bone stock and achieving anatomic reduction should be the goal but not at the expense of increasing the mortality. We recommend performing the procedure through a single-incision nonextensile approach limiting the surgical insult. Locking technology is useful for construct rigidity in compromised bone. As well, adequate intrapelvic exposure is very useful for assisting with reduction and fixation.
References 1. Grazier KL, Holbrook TL, Kelsey JL, et al: The Frequency of Occurrence, Impact, and Cost of Selected Musculoskeletal Conditions in the United States. Chicago, IL, American Academy of Orthopaedic Surgeons, 1984, pp 24-72 2. Ferguson TA, Patel R, Bhandari M, et al: Fractures of the acetabulum in patients aged 60 years and older: An epidemiological and radiological study. J Bone Joint Surg Br 92:250-257, 2010 3. Anglen JO, Burd TA, Hendricks KJ, et al: The “gull sign”: A harbinger of failure for internal fixation of geriatric acetabular fractures. J Orthop Trauma 17:625-634, 2003 4. Pagenkopf E, Grose A, Partal G, et al: Acetabular fractures in the elderly: Treatment recommendations. HSS J 2:161-171, 2006 5. Jain R, Basinski A, Kreder HJ: Nonoperative treatment of hip fractures. Int Orthop 27:11-17, 2003 6. Zuckerman JD, Sakales SR, Fabian DR, et al: Hip fractures in geriatric patients. Results of an interdisciplinary hospital care program. Clin Orthop Relat Res 274:213-225, 1992 7. Letournel E, Judet R: Fractures of the Acetabulum (ed 2). Berlin, Springer-Verlag, 1993 8. O’Toole RV, Cox G, Shanmuganathan K, et al: Evaluation of computed tomography for determining the diagnosis of acetabular fractures. J Orthop Trauma 24:284-290, 2010 9. Spencer RF: Acetabular fractures in older patients. J Bone Joint Surg Br 71:774-776, 1989 10. Gary JL, Lefaivre KA, Gerold F, et al: Survivorship of the native hip joint after percutaneous repair of acetabular fractures in the elderly. Injury 42:1144-1155, 2011 11. Starr AJ, Reinert CM, Jones AL: Percutaneous fixation of the columns of the acetabulum: A new technique. J Orthop Trauma 12:5158, 1998 12. Mears DC: Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg 7:128-141, 1999 13. Mears DC, Shirahama M: Stabilization of an acetabular fracture with cables for acute total hip arthroplasty. J Arthroplasty 13:104-107, 1998 14. Mears DC, Velyvis JH: Acute total hip arthroplasty for selected displaced acetabular fractures: Two to twelve-year results. J Bone Joint Surg Am 84:1-9, 2002 15. Helfet DL, Borrelli J Jr, DiPasquale T, et al: Stabilization of acetabular fractures in elderly patients. J Bone Joint Surg Am 74:753-765, 1992 16. Carroll EA, Huber FG, Goldman AT, et al: Treatment of acetabular fractures in an older population. J Orthop Trauma 24:637-644, 2010 17. Matta JM, Mehne DK, Roffi R: Fractures of the acetabulum. Early results of a prospective study. Clin Orthop Relat Res 205:241-250, 1986 18. Olson SA, Matta JM: The computerized tomography subchondral arc: A new method of assessing acetabular articular continuity after fracture (a preliminary report). J Orthop Trauma 7:402-413, 1993 19. Sen RK, Veerappa LA: Long-term outcome of conservatively managed displaced acetabular fractures. J Trauma 67:155-159, 2009 20. Giannoudis PV, Grotz MR, Papakostidis C, et al: Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br 87:2-9, 2005
292 21. Miller AN, Prasarn ML, Lorich DG, et al: The radiological evaluation of acetabular fractures in the elderly. J Bone Joint Surg Br 92:560-564, 2010 22. Langford JR, Trokhan S, Strauss E: External iliac artery thrombosis after open reduction of an acetabular fracture: A case report. J Orthop Trauma 22:59-62, 2008 23. Jeffcoat DM, Carroll EA, Huber FG, et al: Operative treatment of acetabular fractures in an older population through a limited ilioinguinal approach. J Orthop Trauma (in press)
B.A. Zelle and P.A. Cole 24. Stoppa RE: The treatment of complicated groin and incisional hernias. World J Surg 13:545-554, 1989 25. Cole JD, Bolhofner BR: Acetabular fracture fixation via a modified stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res 305: 112-123, 1994 26. Juliebø V, Bjøro K, Krogseth M, et al: Risk factors for preoperative and postoperative delirium in elderly patients with hip fracture. J Am Geriatr Soc 57:1354-1361, 2009
A
s the absolute and relative population of elderly (⬎65) and geriatric (⬎80) patients increases in the United States,1 the orthopedic trauma surgeon is faced with the inherent challenges of treating an increasing number of geriatric acetabular fractures. Although acetabular fractures in the older patient can result from high-energy trauma, a common circumstance is a fragility fracture in compromised bone after a ground-level fall. Force transmission is typically generated through the greater trochanter or buttock and directed anteromedially, making the anterior column/wall and the quadrilateral plate vulnerable to injury.2 The femoral head is frequently driven through the fractured hip socket in a centrally dislocated position, the so-called intrapelvic dislocation. As a population, patients with these fracture patterns have been linked to poor outcomes after open reduction and internal
*Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX. †Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, St Paul, MN. Address reprint requests to Boris A. Zelle, MD, Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MSC-7774, San Antonio, TX 78229. E-mail: boris. [email protected]
286
1048-6666/11/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.oto.2011.10.001
fixation (ORIF) in the elderly and geriatric population.3 In the absence of bone density compromise, the physiologically younger patient will likely sustain patterns common to younger populations, but these are not the emphasis of this review. The focus of this chapter is on the management of fracture variants typical for the elderly and geriatric agegroups. Ferguson et al reviewed 235 patients aged ⬎60 years who presented with an acetabular fracture.2 They found that the fracture patterns in their elderly population differed from their younger patient (⬍60) cohort (n ⫽ 1074) and were characterized by displacement of the anterior column (64% vs 43%; P ⬍ 0.001), and often included a separate quadrilateral-plate component (51%), roof impaction (40%) in the anterior fractures as well as comminution (44%) and marginal impaction (38%) in the posterior wall fractures.2 Associated both-column fractures were also common in both the elderly (26%) and younger (28%) cohorts (P ⫽ 0.7), yet with different mechanisms. Demonstrating the poor bone quality in the older population, nearly half of the patients (49.8%) in the elderly cohort presented after a fall, whereas only 17.7% of the patients aged ⬍60 years had a similar mechanism of injury. The overall treatment goals in the elderly and geriatric
Reduction and internal fixation of complex geriatric acetabular fracture patients with these complex acetabular fractures require special consideration. Primary tenets of acetabular fracture management in the elderly patients are directed toward achieving hip stability and immediate mobilization while minimizing both systemic and/or local complications. However, management is plagued by both host and injury characteristics.4 Prolonged recumbency increases the risk for complications, especially in this older population with greater susceptibility for pulmonary compromise, deep vein thrombosis (DVT), and decubitus ulcers. Jain et al were able to document 30-day mortality rate as high as 73% in patients with severe comorbidities and hip fractures who were not able to mobilize effectively, whereas the mortality rate dropped to 19% in patients who were able to mobilize5. The overall physiology of the geriatric patient must be considered when determining the level of intervention required for optimal acetabular fracture management. As a rule, prolonged surgical interventions with excessive blood loss should be avoided. A surgical plan should be developed to give the patient a stable hip joint. Further, patient comorbidities that can be rapidly optimized should be addressed in conjunction with a geriatric internal medicine specialist, and a discussion with anesthetist before surgery to corroborate recommendations with findings of the geriatrician or internist being paramount. Perioperative management must continue until the patient achieves adequate mobility and can be discharged, as these patients often walk a thin line between hemodynamic stability and physiological liability. Past publications have documented that incorporating a team approach for elderly patients with hip fractures has resulted in improved results. Zuckerman et al reviewed 431 elderly cases with hip fractures who were included into an interdisciplinary program.6 Results from the study showed the patients included in the program had fewer complications, fewer intensive unit transfers, and improved ambulatory status when compared with a nonprogram agedmatched cohort.6 We advocate incorporating a similar management approach to elderly and geriatric patients with acetabular fractures, where this principle is even more important given that the greater scope of injury and surgery carry greater potential consequences. Preoperative planning should consider the specific personality of the acetabular fracture. The fracture pattern should be clearly delineated with standard and advanced imaging studies. Routine radiographs with anteroposterior and Judet views are more difficult to interpret in the elderly people owing to decreased bone quality and fracture pattern complexity7 as well as abdominal content patterns. Computed tomography (CT) scans allow for superior delineation of the articular surface, accuracy in classifying fracture patterns, and greater interrater reliability than radiographs alone.8 Attention should be focused on areas of articular impaction and fracture comminution that occurs to a greater degree in patients with poor bone density.3 Bone quality and preexisting coxarthrosis also need to be considered, as preexisting symptomatic degenerative conditions may lower the threshold to perform arthroplasty.
287 Because of the complexity of the elderly patient profile, treatment decisions must be highly individualized. The orthopedic surgeon should be equipped to perform any one of a number of options available for these patients with an acetabular fracture. Options include nonoperative care,9 traction, percutaneous pinning10,11 (Fig. 1), primary total hip arthroplasty,12-14 staged total hip arthroplasty, and ORIF.15,16 The indications for these treatment options remain controversial, and little comparative data are available in the literature. When feasible and the risks allow it, joint-preserving reconstruction and early patient mobilization are the preferred goals of treatment. It is only when host or injury factors preclude reliable ORIF that an alternative management solution be chosen.
Nonoperative Management The surgical indications for acetabular fractures have historically been based on younger patients’ outcomes after nonoperative care.17 Matta et al demonstrated that congruency of the femoral head to the weight bearing dome within 3 mm of displacement was crucial to obtain a good result.17 With the emergence of CT imaging, further indications followed: roof arc measurements ⬎45 degrees, intact subchondral bone on 2D CT scan 10 mm below the tectum, and a minimum of 50% of the posterior wall intact.18 Nonoperative management may be considered in patients not meeting these criteria, although prolonged bed rest in an effort to maintain congruent reduction is discouraged due to the high morbidity as previously described,5 although patients with highly displaced acetabular fractures rarely do well with nonoperative management. Sent et al reported on a subgroup of 14 patients with an acetabular fracture displaced ⬎20 mm.19 Only 2 of the 14 (14.3%) patients achieved good reduction on follow-up x-ray imaging.19 Letournel and Judet7 did describe a special subset of patients with both-column fractures that were able to be treated nonoperatively. These patients often develop a “secondary congruence” where the femoral head remains stable within a consolidated both-column fractures, in which the displaced acetabular articular pieces establish congruency with the head. This congruence is different from the circumstance of a posterior or anterior wall or column in which the femoral head follows one of the columns establishing congruency. In their study, 11 of the 13 (85%) of these both-column fracture patients managed nonoperatively had very good to excellent results after an average of 4.3 years of follow-up.7 If nonoperative treatment is chosen for the elderly patient, traction may be a dangerous option as demonstrated by Cross et al, in which the 3-month mortality rate of elderly patients from a Harborview series of patients placed in traction was more than 40% (2010 CrossOTA NationalMeeting) (personal communication, unpublished data). Furthermore, traction beds are more difficult than ever to accept and maintain in the current environment of shortening hospital stays and transitional care units and
B.A. Zelle and P.A. Cole
288
Figure 1 (A, B) Preoperative Judet radiographic images showing a minimally displaced transverse acetabular fracture and postoperative radiographs (C, D) after the patient was treated with a percutaneous pinning technique.
nursing homes, which do not accept patients with these apparatuses. Additionally, traction makes nursing care and patient positioning more difficult, predisposing patients to complications that must be avoided. Therefore, we have moved to a treatment strategy in our hospitals that renders some form of internal fixation or no traction at all, and one which allows a patient to be upright in a chair at a minimum.
Open Reduction Internal Fixation Both advances in surgical technique and orthopedic implants have empowered the orthopedic trauma surgeon with a more robust treatment armamentarium to perform reconstruction of most complex acetabular fractures in the geriatric patient population. In the past, despite the ability to impart a satisfactory reduction in the setting of poor bone quality, construct stability with traditional plate and screw constructs has led to fixation failure and dismal outcomes. Some of these failures have resulted from plate and screw pullout, as most surgeons treating this population will admit. Fortunately, locking technology can be used in regions of the acetabulum where poorer bone quality is expected, thus creating a more rigid mechanical environment for uneventful fracture healing and early patient mobilization. Combination plates that allow both locking and standard holes are ideally suited for ORIF of complex acetab-
ular fracture cases in the elderly patients. Examples of effective usage include brim plating of the anterior column and infrapectineal plating of the quadrilateral plate. Standard screws are frequently used in regions with better bone stock, including the posterior superior iliac spine and sciatic buttress. Fixed angle screws are more advantageous to secure the low anterior column where poorer osseous quality predominates. Previous studies have shown that across all age-groups, the best predictor for successful surgical outcomes is the quality of reduction.17,20 Importantly, however, recent literature has contradicted this previously accepted notion for the elderly population.21 Forty-five patients with a mean age of 67 years were followed, using 36-Item Short Form Health Survey forms to determine functional outcome after an average of 72.4 months.21 Radiographic results classified the reductions as anatomical in 58%, imperfect in 29%, and poor in 13%, whereas CT scans showed none as anatomical, 51% as imperfect, and 49% as poor. However, functional outcome scores were comparable with those of the general elderly population, with no correlation to the radiographic reduction.21 As orthopedic surgeons, we are now aware that failing to achieve anatomic reduction in this complex patient population will not seal their fate to have poor outcomes. This result likely is due to the low functional demands of some of these patients. Advances in surgical exposure/technique have made op-
Reduction and internal fixation of complex geriatric acetabular fracture
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Figure 2 (A, B) Injury Judet films of an elderly patient with an anterior column fragility fracture. Postoperative Judet films (C, D) after open reduction internal fixation through an ilioinguinal approach.
eration of complex acetabular fracture in the elderly patients less risky in some cases, allowing for mechanical stability and early mobilization. The concept of a single nonextensile exposure has been popularized for safe operation on the geriatric acetabular fracture. Host physiology typically precludes lengthy operation through either extensile or 2-approach techniques, particularly when associated with great blood loss. Recent reports have suggested that the overall rate of serious medical complications in geriatric patients undergoing ORIF of their acetabular fracture is relatively low (less than 4%), given the complexity of this problem.16 Clearly, however, this is going to be surgeon- and institution-dependent, and there is no question that vessel and tissue friability and coagulopathy common in this age-group make for greater blood losses than in younger patients, even with all other things being equal. Traditionally, the ilioinguinal approach has been the workhorse in most complex acetabular cases (associated both-column, anterior column ⫾ posterior hemitransverse patterns) of the elderly patients (Fig. 2), considering the predominance of anterior column and quadrilateral surface involvement. This approach has the potential for blood loss and morbidity,22 and avoidance of potential complications is critical in elderly patients with limited physiologic reserves.23 The traditional ilioinguinal exposure has since been modified to allow for more efficient, safe, and reliable fracture reduction and stabilization. A major modification includes the modification with the stoppa window.24 Initially described for repairing
complicated groin and inguinal hernias,24 Cole and Bolhofner25 described the exposure could be used safely and effectively for reducing acetabular fractures. This approach, also referred to as the anterior intrapelvic retroperitoneal approach, allows for excellent visualization of the intrapelvic portion of the anterior column, quadrilateral plate, and a good portion of the posterior column. Fracture reduction is facilitated and more rigid fixation can be used. Application of an infrapectineal plate is an advance technique described for providing biomechanical stability through fixation of the anterior column/quadrilateral plate, and it can be placed effectively through the stoppa approach. Adhering to similar guidelines of minimizing operative time and intraoperative blood loss, Jeffcoat et al recently described treatment of acetabular fractures in an older population by using a limited ilioinguinal approach.23 In their article, Jeffcoat et al described the technique as using only the lateral 2 windows of the ilioinguinal approach. They compared 17 patients (mean age ⫽ 70 years) with acetabular fracture treated through the limited approach vs 24 patients (mean age ⫽ 65 years) treated through the traditional ilioinguinal exposure. All comparative results with respect to functional outcome and radiographic reduction were not significantly different, except that the surgical time (P ⫽ 0.02) and estimated blood loss (P ⫽ 0.002) were both found to be significantly less using the limited approach.23 Although no deaths resulted from either procedure, we can assume that
B.A. Zelle and P.A. Cole
290 less surgical insult in the fragile elderly patient can only be beneficial.
Postoperative Care Incorporating the interdisciplinary team through the whole process of preoperative assessment and postoperative rehabilitation is crucial in managing these patients. They may remain labile perioperatively until their diet has resumed. Fluid loss through postoperative bleeding, and third spacing, particularly through large open approaches, are more common in the elderly patients and must be monitored. Encouraging mobilization should be the focus postoperative day 1 if possible, beginning with sitting up in bed, pivoting on the uninvolved side, and learning to transfer to a chair. Pre- and postoperatively, a patient with an acetabular fracture should have an overhead trapeze apparatus attached to the bed to give the patient more independence. This adjunct is critical, and furthermore, should be supplemented with an upper body strength program with therabands in bed. The stronger and better conditioned the upper extremities are before going into surgery, the more likely the patient will be able to progress to the use of a walker with partial weight bearing after surgery. When the patient is strong enough, they should be changed from chair restrictions to ambulating with a walker under the supervision of physical therapist. As any
complex reconstruction of the acetabular joint surface dictates, immediate weight bearing should not be instituted as in hip fracture surgery. Loss of articular reduction and subsidence of previously impacted areas will fail with early weight. Similar to patients with fixed femoral neck fractures, toe-touch weight bearing is tolerated and aids in the rehabilitative process. Special attention should be paid to pain management, as postoperative pain has been shown to be a risk factor for delirium.26 Chemical and mechanical DVT prophylaxis is also extremely important during the phase of rehabilitation, and should be continued for no less than a month postoperatively, and even then only if the patient is mobilizing well. The risk of DVT is higher in elderly patients, and must be aggressively prophylaxed. We do not advocate the routine screening for DVTs. Following is a case example demonstrating management of an elderly patient who presented with an acetabular fracture.
Case Example-Both Column Geriatric Acetabular Fracture Safe, efficient, and effective operation is illustrated in this 69-year-old active man with an associated both-column acetabular fracture sustained as a result of a fall from his bicycle. Besides well-controlled type 2 diabetes and stable coronary artery disease, the patient reports no other sub-
Figure 3 (A) Geriatric both column acetabular fracture with protrusio (B,C) Post operative Judet views demonstrating anatomic reduction using locking brim and infrapectineal plating strategies (D) Post operative 3D CT.
Reduction and internal fixation of complex geriatric acetabular fracture stantial medical comorbidities. The geriatrician colleagues were consulted. After routine preoperative testing, the patient was deemed an optimal candidate for operative reconstruction. Primary medical recommendations included an aggressive postoperative nutrition protocol, tight perioperative glycemic control, as well as both mechanical and chemical DVT prophylaxis. The musculoskeletal workup revealed that his complex acetabular fracture was an isolated injury. After analysis of Judet plain radiographs, a CT scan with fine cuts was used to study his injury pattern for preoperative planning. The orthopedic trauma team elected to proceed with open reconstruction using a modified ilioinguinal exposure. With minimal articular impaction evident, an anatomic stable hip joint was deemed readily achievable. Operation commenced on admission day 2, once qualified personnel and resources were organized. A modified ilioinguinal exposure was performed. Iliac, middle, and stoppa windows were established. The vessels were isolated. The corona mortis was ligated. Care was taken to protect both the femoral and obturator nerves. The high anterior column fracture containing the acetabular dome was reduced through the iliac window. A Schanz pin placed in the ilium was used as a reduction tool to anatomically reduce the externally rotated anterior column. A brim plate was then applied. All windows were used to carefully negotiate the plate. Standard screws were placed into the posterior superior iliac spine achieving optimal purchase. Locking screws were placed into the anterior pelvic ring. Reduction of the quadrilateral surface/posterior column was then performed using primarily the stoppa exposure. Use of the middle window was limited, as prolonged retraction on the femoral vessels was deemed unsafe due to known calcific changes. Through the stoppa window, the bladder was retracted using a malleable. The femoral neurovascular structures were retracted using a deaver. The quadrilateral plate/ishiopubic segment was reduced under direct vision using a ball spike pusher. A retroacetabular screw was then placed to initially hold the reduction. An infrapectineal plate was then used to serve as a buttress. The plate was held with Kirschner wires. Standard screws achieved excellent purchase into the sciatic buttress. Anteriorly locking screws were placed into the superior pubic ramus (Fig. 3). Anatomic reduction was evident on postoperative CT imaging. The technical exercise was completed in ⬍3 hours. Uneventful inpatient recovery realized. Anatomic reduction was maintained until uneventful osseous union. Patient was mobilized in aggressive fashion and progressed to full weight bearing at the 6- week checkup. At 1 year, the patient was back to baseline functionality with minimal hip discomfort.
Conclusions Although arthroplasty options are available for the treatment of complex geriatric acetabular fractures, when possible,
291 ORIF is the preferred treatment plan. As described earlier, serious complication rates in elderly patients undergoing ORIF of their acetabular fracture are low (4%).16 Attempting to adequately restore the bone stock and achieving anatomic reduction should be the goal but not at the expense of increasing the mortality. We recommend performing the procedure through a single-incision nonextensile approach limiting the surgical insult. Locking technology is useful for construct rigidity in compromised bone. As well, adequate intrapelvic exposure is very useful for assisting with reduction and fixation.
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