Peri-operative outcomes for ORIF of acetabular fracture in the elderly: Comparison with displaced intracapsular hip fractures in a national pelvic and acetabular referral centre over 5 years

Epidemiology of acetabular fractures in elderly patients and the effect of various management options on the outcomes. A comprehensive narrative review

Owing to the expected increase in the world's elderly population (>65 years old), and the concomitant osteoporosis in this particular population, fragility fractures of the pelvis and the acetabulum is becoming a real concern, which could be life-threatening. In the current review, we aimed to discuss the various epidemiological characteristics of geriatric acetabular fractures, management options, and the outcomes. For the review synthesis, we searched PubMed to select the most relevant and updated articles published from various areas and institutions. Geriatric acetabular fractures are mainly caused by trivial trauma, constitute about 1.5%-3% of all skeletal injuries, and showed a 2.4-fold increase over the past three decades. Furthermore, these fractures' associated one-year mortality rate ranges from 14% to 25%. Management options differ largely according to the type and severity of the injury if there is an associated skeletal or non-skeletal injury, and preexisting patient comorbidities. These options could be nonoperative or operative (including surgical fixation and acute total hip arthroplasty), and both carry a specific risk in this vulnerable age group. There is controversy among various reports regarding the best management option leading to better function and health-related quality of life (HRQoL) outcomes. In conclusion, the incidence of acetabular fractures in elderly patients is rising. The decision-making on the best management option should consider the patient's fragility, injury severity, poor bone quality, and multiple medical comorbidities. The outcomes related to function, quality of life, and mortality are comparable between operative and nonoperative management options.

Lower 1-Year Postoperative Mortality After Acetabular Versus Proximal Femoral Fractures in Elderly Patients

BACKGROUND

Geriatric acetabular fractures are becoming more common due to demographic changes. Compared with proximal femoral fractures, surgical treatment is more complex and often does not allow full-weight-bearing. The aims of this study were to compare operatively treated acetabular and proximal femoral fractures with regard to (1) cumulative 1-year mortality, (2) perioperative complications, and (3) predictive factors associated with a higher 1-year mortality.

METHODS

This institutional review board-approved comparative study included 486 consecutive surgically treated elderly patients (136 acetabular and 350 proximal femoral fractures). After matching, 2 comparable groups of 129 acetabular and 129 proximal femoral fractures were analyzed. Cumulative 1-year mortality was evaluated through Kaplan-Meier survivorship analysis, and perioperative complications were documented and graded. After confirming that the proportionality assumption was met, Cox proportional hazard modeling was conducted to identify factors associated with increased 1-year mortality.

RESULTS

The acetabular fracture group had a significantly lower cumulative 1-year mortality before matching (18% compared with 33% for proximal femoral fractures, log-rank p = 0.001) and after matching (18% compared with 36%, log-rank p = 0.005). Nevertheless, it had a significantly higher overall perioperative complication rate (68% compared with 48%, p < 0.001). In our multivariable Cox regression analysis, older age, perioperative blood loss of >1 L, and wheelchair mobilization were associated with lower survival rates after acetabular fracture surgery. Older age and a higher 5-item modified frailty index were associated with a higher 1-year mortality rate after proximal femoral fractures, whereas postoperative full weight-bearing was protective.

CONCLUSIONS

Despite the complexity of operative treatment and a higher complication rate after acetabular fractures in the elderly, the 1-year mortality rate is lower than that after operative treatment of proximal femoral fractures, even after adjustment for comorbidities.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Acetabular fractures in the elderly: modern challenges and the role of conservative management

Introduction 

The incidence of acetabular fractures in the elderly population is ever increasing. While management of acetabular fractures in young patients following high-energy trauma is well described, treatment of the elderly patient subgroup is complex and requires a unique, individualized approach. A variety of treatment strategies including operative and non-operative approaches exists to manage this vulnerable patient group. Conservative management of acetabular fractures in the elderly continues to play an important role in treatment of both stable fracture patterns and those medically unfit for surgery.

Aim 

This review assessing the current literature was undertaken with the purpose of summarising the challenges of management in this at-risk cohort as well as quantifying the role and outcomes following conservative management in the elderly.

 Conclusion

Our recommendation is that conservative management of acetabular fractures in the elderly can be considered as a treatment option on a case-by-case basis accounting for patient, injury, and surgical factors. If it is to be pursued, we advise a multidisciplinary approach focused on early mobility, minimisation of risk and regular follow-up to optimise patient outcomes.

Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery

BACKGROUND

Acetabular fracture open reduction and internal fixation (ORIF) is generally associated with high intraoperative blood loss. Hypotensive anesthesia has been shown to decrease blood loss and intraoperative transfusion in total joint arthroplasty and posterior spinal fusion. In this study, we assessed the effect of reduction in intraoperative mean arterial pressures (MAPs) during acetabular fracture surgery on intraoperative blood loss and need for transfusion.

METHODS

Three hundred and one patients with acetabular fractures who underwent ORIF at an academic Level 1 trauma center were retrospectively reviewed. Patients were separated based on mean intraoperative MAPs (<60 mmHg, 60-70 mmHg, >70 mmHg). Thirteen patients had mean intraoperative MAP <60 mmHg, 95 had MAP 60-70 mmHg, and 193 had MAP >70 mmHg. Rates of intraoperative and postoperative allogeneic blood transfusion were compared.

RESULTS

Mean intraoperative MAPs were significantly different between groups (p < 0.0001). Time from injury to surgery, estimated blood loss, operative time and intraoperative IV fluids were comparable. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively were similar between groups. Mean differences in preoperative and postoperative hemoglobin and hematocrit were also similar. There was no difference in hospital length of stay or perioperative complications between the groups. Multivariate logistic regression analysis demonstrated that body mass index > 30 (p < 0.05) and anterior surgical approach (p < 0.01) were independently associated with intraoperative transfusion and an anterior surgical approach (p < 0.001) was independently associated with postoperative transfusion.

CONCLUSION

Decreased intraoperative MAP during acetabular fracture surgery does not reduce blood loss or need for transfusion. On the other hand, no increased end-organ ischemia was seen with hypotensive anesthesia.

LEVEL OF EVIDENCE

Therapeutic Level III.

High- Versus Low-Energy Acetabular Fracture Outcomes in the Geriatric Population

Introduction:

High-energy mechanisms of acetabular fracture in the geriatric population are becoming increasingly common as older adults remain active later in life. This study compared outcomes for high- versus low-energy acetabular fractures in older adults.

Materials and Methods:

We studied outcomes of 22 older adults with acetabular fracture who were treated at a level-I trauma center over a 4-year period. Fourteen patients were categorized as low-energy mechanism of injury, and 8 were identified as a high-energy mechanism. We analyzed patient demographics with univariate logistic regressions performed to assess differences in high- and low-energy group as well as patient characteristics compared with surgical outcomes.

Results:

Most high-energy mechanisms were caused by motor vehicle collision (n = 4, 50.0%), with most having posterior wall fractures (50.0%). Among patient characteristics, the mechanism of injury, hip dislocation, fracture types, and fracture gap had the largest differences between energy groups effect size (ES: 2.45, 1.43, 1.36, and 0.83, respectively). The high-energy group was more likely to require surgery (odds ratio [OR] = 2.80, 95% CI: 0.26-30.70), develop heterotopic bone (OR = 4.33, 95% CI: 0.33-57.65), develop arthritis (OR = 3.60, 95% CI: 0.45-28.56), and had longer time to surgery (mean = 4.8 days, standard deviation [SD] = 5.8 days) compared to low-energy group (mean = 2.5 days, SD = 2.3 days).

Discussion:

The results of this case series confirm previous findings that patients with high-energy acetabular fractures are predominantly male, younger, and have fewer comorbidities than those who sustained low-energy fractures. Our results demonstrate that the majority of the high-energy fracture patients also suffered a concurrent hip dislocation with posterior wall fracture and experienced a longer time to surgery than the low-energy group.

Conclusion:

Geriatric patients who sustained high-energy acetabular fractures tend to have higher overall rates of complications, including infection, traumatic arthritis, and heterotopic bone formation when compared with patients with a low-energy fracture mechanism.

Annual case volume is a risk factor for 30-day unplanned readmission after open reduction and internal fixation of acetabular fractures

BACKGROUND

Surgical fixation of acetabular fractures is technically challenging, and quality of reduction directly correlates to patient outcomes. Considering the difficulty of open reduction and internal fixation (ORIF), increased case volumes may improve patient outcomes. No studies have investigated case volume as a risk factor for readmission after acetabular fracture ORIF. The present study sought to answer the question of whether annual case volume is a risk factor for 30-day unplanned readmission after acetabular fracture ORIF, if there is an identifiable threshold number of cases most predictive of a readmission, and if differences exist between reasons for readmission between high and low-volume centers.

HYPOTHESIS

Institutions with a lower annual case volume will have a higher incidence of 30-day unplanned readmissions.

MATERIALS AND METHODS

The national readmissions database (NRD) was queried for acetabular fractures that underwent ORIF during 2016. Comorbid conditions were summed, and annual hospital case volume was identified. A receiver operating characteristic (ROC) curve was generated and the Youden index identified threshold case volume most predictive of a 30-day readmission. A multivariable logistic regression was performed with 30-day readmission as the dependent variable and case volume below the threshold an independent variable.

RESULTS

A total of 3,407 cases were included with a median age of 43. The 30-day readmission for this cohort was 6.5% (220/3407). ROC curve analysis identified 22 annual cases as the threshold value most predictive of 30-day readmission. Multivariable logistic regression identified age (Odds Ratio (OR)=1.01, p=0.005), number of comorbidities (OR=1.35, p<0.0001), and ≤22 cases (OR=1.50, p=0.006) as statistically significant risk factors for 30-day readmission. The most common reason for readmission at both high and low-volume centers was surgical site infection.

DISCUSSION

Annual case volume is a statistically significant predictor of 30-day readmission after acetabular fracture ORIF. Performing ≤22 acetabular ORIFs places patients at greater risk for a readmission. Patients at low-volume centers may be predisposed to readmission, and it is paramount to optimize patients prior to discharge, and have appropriate surgeon and hospital resources to treat these complex injuries.

LEVEL OF EVIDENCE

III, Cross-sectional study.