Management of acetabular fractures in the elderly patient

Abstract

Operative management of displaced acetabular fractures yields better results than nonoperative management. Over the past decade, surgical approaches to the acetabulum and the surgical tactic for repair of common fracture patterns have been advanced. Excellent outcomes after repair of these injuries can be achieved. In some cases, as in the elderly, or in those cases in which there is significant destruction of the articular cartilage, primary total hip arthroplasty may provide the best solution. Removal of the femoral head allows for excellent exposure of the acetabulum, making it possible to stabilize most fractures without the need for extensile or intrapelvic approaches. The surgical technique that has been successfully used calls for gaining primary stability of the acetabular columns by open reduction and internal fixation and then using the acetabular component to replace the articular surface. The columns need not be anatomically reduced. Multiholed acetabular shells can be used as internal fixation devices by placing screws into the columns enhancing the stability of the repair. In older individuals with severe osteoporosis, a typical fracture pattern results in intrapelvic dislocation of the femoral head with a blowout fracture of the anterior column and medial wall. Reinforcement rings with cemented acetabular fixation can be used in these cases. The femoral head can be used as bulk bone graft to replace and reinforce the reconstruction. Techniques common to revision of failed acetabular components are helpful in this setting. The results of reconstruction of severe acetabular fractures with total hip replacement have been reported to be similar to those achieved for reconstruction of osteoarthritis.

Figures

Fig. 1

Acetabular exposure from the posterior approach after excision of the femoral head. The shaded area indicates the region accessible by this approach

Fig. 2

a A radiograph of the pelvis of a 75-year-old man who suffered a both-column acetabular fracture after falling from a tree. b A radiograph of the pelvis after ORIF of the columns with implantation of a multiholed acetabular component and femoral head graft

Fig. 3

a A radiograph of the pelvis of an 88-year-old woman who fell, suffering a central fracture dislocation of the hip with displaced fracture of the anterior wall. b A radiograph of the hip after primary total hip arthroplasty using a reinforcement ring, femoral head bone graft, and cemented all-poly cup. c A radiograph at 1 year demonstrating stability of the cup with incorporation of the femoral head graft. d A radiograph taken 5 years after total hip replacement using an antiprotrusion cage for a central acetabular fracture dislocation for a 91-year-old man. The bone graft has fully incorporated, restoring acetabular bone stock