Operative treatment of acetabular fractures in an older population through a limited ilioinguinal approach

Which treatment in acetabular fractures of the elderly: Osteosynthesis, osteosynthesis-THA or orthopedic treatment? 2-years retrospective outcomes of a therapeutic algorithm

INTRODUCTION

Acetabular fractures account for 7% of osteoporotic fractures, with an epidemiological peak between 75 and 80 years of age. The aim of this study is to evaluate the results of treatment of these fractures in a population aged over 65.

HYPOTHESIS

Surgical treatment would lead to better survival and functional outcomes in the management of acetabular fractures in subjects aged over 65.

MATERIAL AND METHODS

Patients over 65 years of age treated for acetabular fracture between January 2017 and May 2020 were included in this retrospective single-center study and divided into three treatment groups: osteosynthesis, osteosynthesis-THA (Osteosynthesis-THA) and orthopedic treatment. The choice of treatment was made according to an algorithm that considered the patient's co-morbidities, autonomy and bone lesions. The primary endpoint was patient survival at 12 and 24 months' follow-up.

RESULTS

94 patients (mean age 78.5 +/-8.4 years) were included: 29 patients treated with orthopedic therapy, 46 patients with osteosynthesis and 19 patients with osteosynthesis-THA. Mean follow-up was 32.7+/-14.9 months. Mortality rates were higher in the orthopedic and osteosynthesis-THA groups (20.7% and 21.1% respectively). Patients in the orthopedic and osteosynthesis-THA groups showed excess mortality, with hazard ratios (HR) of 3.4 ([1.02; 11.3], p < 0.05) and 3.3 ([0.9; 12.3], p = 0.08) respectively, compared with those treated with osteosynthesis. Mean PMA at 2 years, mean Harris score at 2 years and Parker score were significantly higher in the operated groups. The rate of conversion to THA (THA) was higher in the orthopedic treatment group (27.6%). The complication rate was 24% (11/46) for the osteosynthesis group, 42% (8/19) for the osteosynthesis-THA group.

DISCUSSION

Applying our decision algorithm, orthopedic treatment is inferior to surgical treatment in terms of survival and functional results, with a higher re-intervention rate for THA than treatment with osteosynthesis. This study confirms the place of osteosynthesis, with higher functional scores, lower complication and revision rates, and a positive effect on mortality.

LEVEL OF EVIDENCE

IV; Retrospective cohort study.

Radiographic bladder shift is a harbinger of intraoperative blood loss in acetabular surgical fixation

PURPOSE

The purpose of this study was to characterize the relationship between a novel radiographic measurement on initial AP pelvis radiograph (termed "bladder shift," BS) to intraoperative blood loss (IBL) during acetabular surgical fixation.

METHODS

All adult patients receiving unilateral acetabular fixation (Level 1 academic trauma; 2008-18) were reviewed. AP pelvis radiographs were reviewed for visible bladder outlines and then measured to determine the percentage deformation toward the midline. Hemoglobin & hematocrit data were then used to calculate quantitative blood loss between pre- and post- operative blood counts for data analysis.

RESULTS

371 patients with unilateral traumatic acetabular fractures requiring fixation were reviewed; 99 of these had visible bladder outlines, complete blood count and transfusion data (2008-2018; 66% associated patterns). Median bladder shift (BS) was 13.3%. Every 10% of bladder shift was associated with 123 mL greater IBL. Patients with full bladder shift to midline sustained a median 1.5L IBL (interquartile range [IQR] 0.8 to 1.6). Associated patterns had a threefold greater median BS (associated: 16.5% [15.4 to 45.9] vs. elementary: 5.6% [1.1 to 15.4], p < 0.05) and received intraoperative pRBC twice as frequently (57% vs. 24%, p < 0.01).

CONCLUSIONS

Radiographic bladder shift is an easily available visual marker, in patients sustaining acetabular fractures, that may predict intraoperative hemorrhage and need for transfusions.

Acetabular fractures in geriatric patients: epidemiology, pathomechanism, classification and treatment options

The incidence of geriatric acetabular fractures has shown a sharp increase in the last decades. The majority of patients are male, which is different to other osteoporotic fractures. The typical pathomechanism generally differs from acetabular fractures in young patients regarding both the direction and the amount of force transmission to the acetabulum via the femoral head. Geriatric fractures very frequently involve anterior structures of the acetabulum, while the posterior wall is less frequently involved. The anterior column and posterior hemitransverse (ACPHT) fracture is the most common fracture type. Superomedial dome impactions (gull sign) are a frequent feature in geriatric acetabular fractures as well. Treatment options include nonoperative treatment, internal fixation and arthoplasty. Nonoperative treatment includes rapid mobilisation and full weighbearing under analgesia and is advisable in non- or minimally displaced fractures without subluxation of the hip joint and without positive gull sign. Open reduction and internal fixation of geriatric acetabular fractures leads to good or excellent results, if anatomic reduction is achieved intraoperatively and loss of reduction does not occur postoperatively. Primary arthroplasty of geriatric acetabular fractures is a treatment option, which does not require anatomic reduction, allows for immediate postoperative full weightbearing and obviates several complications, which are associated with internal fixation. The major issue is the fixation of the acetabular cup in the fractured bone. Primary cups, reinforcement rings or a combination of arthroplasty and internal fixation may be applied depending on the acetabular fracture type.

Treatment of Geriatric Acetabular Fractures Using the Modified Stoppa Approach: A Review Article of Technique, Tips, and Pitfalls

The surgical treatment of geriatric acetabular fractures is becoming increasingly important due to a demographic change in age. While acetabular fractures used to occur more frequently in younger patients, they are currently more prevalent in geriatric patients. This change has also led to an increase in the frequency of anterior and combined anterior acetabular fractures. Surgery for geriatric acetabular fractures is very challenging, and surgeons need years of experience to be able to deal with the advantages and disadvantages of pelvic surgery. This is why a high level of surgical expertise is required. The aim of this article is to provide an insight into the topic of geriatric acetabular fractures with a critical narrative review of the current literature and a focus on minimally invasive surgical treatment using the modified Stoppa approach without patients' own assessment. The modified Stoppa approach offers excellent visibility of the anterior structures of the acetabulum and can address the quadrilateral surface effectively. Pelvic surgery, in particular acetabular surgery, offers patients many advantages, such as rapid mobilization and the quick relief of pain symptoms. Total hip arthroplasty is currently being discussed as an alternative with good results for certain types of acetabular fractures in older patients, though it requires clarification of studies and recommendations.

The infraacetabular screw versus the antegrade posterior column screw in acetabulum fractures with posterior column involvement: a biomechanical comparison

INTRODUCTION

Traditionally, plate osteosynthesis of the anterior column combined with an antegrade posterior column screw is used for fixation of anterior column plus posterior hemitransverse (ACPHT) acetabulum fractures. Replacing the posterior column screw with an infraacetabular screw could improve the straightforwardness of acetabulum surgery, as it can be inserted using less invasive approaches, such as the AIP/Stoppa approach, which is a well-established standard approach. However, the biomechanical stability of a plate osteosynthesis combined with an infraacetabular screw instead of an antegrade posterior column screw is unknown.

MATERIAL AND METHODS

Two osteosynthesis constructs were compared in a synthetic hemipelvis model with an ACPHT fracture: Suprapectineal plate + antegrade posterior column screw (APCS group) vs. suprapectineal plate + infraacetabular screw (IAS group). A single-leg stance test protocol with an additional passive muscle force and a cyclic loading of 32,000 cycles with a maximum effective load of 2400 N was applied. Interfragmentary motion and rotation of the three main fracture lines were measured.

RESULTS

At the posterior hemitransverse fracture line, interfragmentary motion perpendicular to the fracture line (p < 0.001) and shear motion (p < 0.001) and at the high anterior column fracture line, interfragmentary motion longitudinal to the fracture line (p = 0.017) were significantly higher in the IAS group than in the APCS group. On the other hand, interfragmentary motion perpendicular (p = 0.004), longitudinal (p < 0.001) and horizontal to the fracture line (p = 0.004) and shear motion (p < 0.001) were significantly increased at the low anterior column fracture line in the APCS group compared to the IAS group.

CONCLUSIONS

Replacing the antegrade posterior column screw with an infraacetabular screw is not recommendable as it results in an increased interfragmentary motion, especially at the posterior hemitransverse component of an ACPHT fracture.

Outcomes, risk factors, and conversion rate in acetabular fractures in patients over 65 years of age. Analysis at a mean follow-up of 6 years

INTRODUCTION

Acetabular fractures are devastating injuries that can affect patients of different ages, as well as being associated with high or low energy trauma. Conversion to total hip arthroplasty (THA) results in increased complication rates, resource use and costs compared to primary THA due to osteoarthritis. The aim of this paper is to describe a retrospective cohort of patients over 65 years of age who presented with an acetabular fracture and were treated with open reduction and internal fixation (ORIF).

METHODS

A retrospective cohort study was conducted from January 2002 to December 2017. The study identified all patients over 65 years of age who suffered an acetabular fracture and were treated primarily with ORIF. The quality of reduction, fracture pattern and associated poor prognostic factors for fracture were analyzed.

RESULTS

A total of 50 cases of acetabular fractures in patients over 65 years of age were included. Six of them required conversion to THA (12%). In 3 of these cases conversion surgery was performed because of pre-existing osteoarthritis, pain, and postoperative progression of osteoarthritis. The main factors involved in the conversion cases were intra-articular fragments, femoral head protrusion and posterior wall comminution. Postoperative intra-articular gap had a p = 0.01 in linear regression analysis for conversion to arthroplasty.

CONCLUSION

The conversion rate reported in our cohort of elderly patients is similar to that reported in the literature in patients of all age ranges. The quality of reduction was a significant factor in predicting progression to conversion to THA.

Comparison of Percutaneous Screw Fixation to Open Reduction and Internal Fixation in Acetabular Fractures: A Matched Pair Study Regarding the Short-Term Rate of Conversion to Total Hip Arthroplasty and Functional Outcomes

Closed reduction and percutaneous internal fixation (CRPIF) for acetabular fractures was introduced as a less invasive alternative to open reduction and internal fixation (ORIF) for moderately displaced fractures. Currently, comparisons of ORIF and CRPIF outcomes are rare. Twenty-three patients treated with CRPIF were matched with patients treated with ORIF based on sex, age, and fracture classification. Surgery-dependent and -independent factors of the in-hospital stay, the conversion rate to total hip arthroplasty (THA), and quality of life were assessed. The ORIF group had a higher preoperative fracture step (p = 0.04) and gull wing sign (p = 0.003) compared with the CRPIF group. Postoperatively, the gap and step size were not significantly different between the groups (p > 0.05). CRPIF required less time (p < 0.0001) and transfusions (p = 0.009) and showed fewer complications (p = 0.0287). Four patients were converted to THA (CRPIF, n = 1; ORIF, n = 3; p = 0.155) because of posttraumatic osteoarthritis. Functional outcomes and pain were similar in both groups (p > 0.05). The present study revealed less blood loss and a lesser extent of reduction in patients treated with CRPIF than in those treated with ORIF. The rates of conversion to THA and functional outcomes did not differ between CRPIF and ORIF. CRPIF appeared to be a valuable treatment option for selected patients.

Clinical application of the anterior pelvic wall locking plate (APWLP) in acetabular fractures involving the quadrilateral surface

BACKGROUND

The management of acetabular quadrilateral surface fractures remains challenging for surgeons, and the treatment options for such fractures remain controversial. Quadrilateral surface surgery is a complex procedure involving combined approaches, and the quality of fracture reduction closely depends upon the surgical procedure, as well as the skill and experience of the surgeon. This study aimed to explore the clinical effects of applying an anterior pelvic wall locking plate (APWLP) through the lateral-rectus approach for treating acetabular fractures involving the quadrilateral surface.

METHODS

This retrospective analysis was comprised of 35 patients with acetabular fractures involving the quadrilateral surface who were treated with an APWLP in our hospital between June 2016 and December 2020. The patients included 25 males and ten females, with an average age of 52.45 years. All the patients were exposed through the lateral-rectus approach, six patients were exposed with an additional iliac fossa approach, and the fractures were fixed by combining an APWLP with a reconstruction plate. The Matta imaging standard was used to assess the quality of the fracture reduction, and the final follow-up clinical outcome was classified as excellent (18 points), good (15-17), fair (13-14), or poor (< 13) according to the modified Merle d'Aubigné-Postel scoring standard.

RESULTS

All patients successfully completed the operation, and there was no blood vessel or nerve injury during any of the operations. The average follow-up period was 26.11 months. The mean time of resuming full-weight-bearing activities was 12.88 weeks. Hip flexion and extension and internal and external rotation ranges of motion significantly increased over time. At the last follow-up, Matta's imaging evaluation showed that 24 cases were anatomically reduced, seven cases were satisfactory, and four cases were unsatisfactory. The satisfaction rate was 88.6% (31/35). According to the modified Merle d'Aubigné-Postel scoring standard, the hip function was excellent, good, fair, and poor in 23, 6, 4, and 2 cases, respectively. The excellent and good rates represented 82.9% of the total cases (29/35).

CONCLUSION

The findings suggest that the APWLP for acetabulum quadrilateral surface fracture achieve good to excellent clinical and radiological outcomes, and an APWLP may be a new treatment option for these fractures involving the quadrilateral surface.

A Review on Management of Insufficiency Fractures of the Pelvis and Acetabulum

"Insufficiency fractures of the pelvis and acetabulum are occurring at increasing rates. Osteoporosis is the most prevalent risk fracture. Diagnosis begins with plain radiographs followed by advanced imaging with computed tomography and/or MRI. Pelvic ring fragility injuries are classified by the Fragility fractures of the pelvis system. Elderly acetabular fractures may be classified by the Letournel system. Management of these injuries is primarily nonoperative with early immobilization when allowed by fracture characteristics. When warranted, percutaneous fixation and open reduction internal fixation are options for both. Both acute and delayed total hip arthroplasty are options for acetabular fractures."

Fragility Fractures of the Acetabulum: Current Concepts for Improving Patients' Outcomes

The incidence of fragility fractures of the acetabulum (FFA) is constantly increasing. Generally, these fractures are related to a fall on the greater trochanter involving the anterior column. The management of FFA is extremely difficult considering both patients' comorbidities and poor bone quality. Both non-operative and several operative treatment protocols are available, and the choice among them is still ambiguous. The proposed surgical techniques for FFA [namely open reduction and internal fixation (ORIF), percutaneous fixation and total hip arthroplasty (THA)] are associated with a high complication rate. The treatment with the higher early mortality is the ORIF + THA, while the one with the lowest is the non-operative. However, at longer follow-up, this difference dreadfully change is becoming the opposite. Frequently ORIF, percutaneous fixation, and non-operative treatment need a subsequent re-operation through a THA. This latter could be extremely difficult, because of poor bone quality, acetabular mal union/non-union, bone gaps and hardware retention. However, the outcomes of each of the proposed treatment are mostly poor and controverted; therefore, a comprehensive patient evaluation and an accurate fracture description are required to appropriately manage acetabular fracture in the elderly.

The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients

INTRODUCTION

Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA.

MATERIALS AND METHODS

Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures.

RESULTS

The mean age was 80.5 years (range 65-98 years). The average time from injury to surgery was 8.5 days (range 1-28). Mean time of surgery was 167 min (range 100-303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification.

CONCLUSIONS

The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group.

Fatigue Acetabular Fracture after Lumbopelvic Instrumented Fusion in Elderly

Purpose

Only several cases of acetabular "fatigue"/insufficiency fractures have been reported in elderly patients with osteoporosis. However, fatigue acetabular fracture below lumbopelvic fixation has not been published. This review reports on the frequency and mechanisms of acetabular fatigue fractures in elderly individuals, including postmenopausal osteoporosis, and presents a case of an acetabular "fatigue" fracture in association with lumbopelvic fusion.

Methods

We report on a 71-year-old postmenopausal woman who underwent in our department a L2-pelvis instrumented fusion for failed lumbar decompression and interbody fusion performed in another institution. For at least one year, the patient was receiving antiosteoporotic treatment (Alendronate plus Calcium and Vitamin D) and was fully ambulatory without limping. Eighteen months following our surgery, the patient sought again our department because of increasing pain in her right hip and limping without trauma.

Results

The physical examination disclosed painful passive motion in her right hip. The roentgenograms and CT-scans disclosed a transverse acetabular fracture with radiolucencies around both iliac screw tips, particularly the right. Additionally, a severe compression fracture of the 12^th thoracic vertebral body and upper endplate of the L2 vertebra was disclosed. We recommended open stabilization of the acetabulum and T12 and L2 vertebrae. Immediately before the planned surgeries, the patient had a serious heart infarct, and thus, surgeries were canceled by the patient's cardiologist because of the high perioperative risk. The patient and relatives denied further surgeries because of the heart disease. In the final telephone call and CT and roentgenographic evaluation that went to us after request, there was an acetabular pseudarthrosis in the right hip without however associated complaints. Since surgery was not accepted, the patient was prescribed Denosumab injection therapy plus Vitamin and Calcium supplement.

Conclusion

This case report emphasizes the significance of follow-up observation of elderly patients with postmenopausal osteoporosis following lumbopelvic fusions, for possible fatigue acetabular and vertebral fractures. The authors speculate that this extremely rare acetabular "fatigue"/insufficiency fracture should be the result of increased repetitive mechanical forces acting around the acetabulum in association with osteoporosis.

A Bibliometric Analysis of Fragility Fractures: Top 50

Background and Objectives: The population is aging and fragility fractures are a research topic of steadily growing importance. Therefore, a systematic bibliometric review was performed to identify the 50 most cited articles in the field of fragility fractures analyzing their qualities and characteristics. Materials and Methods: From the Core Collection database in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to fragility fractures were identified in February 2021 using a multistep approach. Year of publication, total number of citations, average number of citations per year since year of publication, affiliation of first and senior author, geographic origin of study population, keywords, and level of evidence were of interest. Results: Articles were published in 26 different journals between 1997 and 2020. The number of total citations per article ranged from 12 to 129 citations. In the majority of publications, orthopedic surgeons and traumatologists (66%) accounted for the first authorship, articles mostly originated from Europe (58%) and the keyword mostly used was “hip fracture”. In total, 38% of the articles were therapeutic studies level III followed by prognostic studies level I. Only two therapeutic studies with level I could be identified. Conclusions: This bibliometric review shows the growing interest in fragility fractures and raises awareness that more high quality and interdisciplinary studies are needed.

Treatment modalities and outcomes following acetabular fractures in the elderly: a systematic review

PURPOSE

The treatment of geriatric acetabular fractures remains controversial. Treatment options include nonoperative management, open reduction and internal fixation (ORIF), total hip arthroplasty (THA) with or without internal fixation, and closed reduction with percutaneous pinning (CRPP). There is currently no consensus on the optimal treatment strategy for geriatric patients with acetabular fractures. The purpose of this study is to compare adverse event rates, functional and radiographic outcomes, and intraoperative results between the various treatment modalities in order to help guide surgical decision making.

METHODS

We performed a systematic review (registration number CRD42019124624) of observational and comparative studies including patients aged ≥ 55 with acetabular fractures.

RESULTS

Thirty-eight studies including 3,928 patients with a mean age of 72.6 years (range 55-99 years) and a mean follow-up duration of 29.4 months met our eligibility criteria. The pooled mortality rate of all patients was 21.6% (95% confidence interval [CI] 20.9-22.4%) with a mean time to mortality of 12.6 months, and the pooled non-fatal complication rate was 24.7% (95% CI 23.9-25.5%). Patients treated with ORIF had a significantly higher non-fatal complication rate than those treated with ORIF + THA, THA alone, CRPP, or nonoperative management (odds ratios [ORs] 1.87, 2.24, 2.15, and 4.48, respectively; p < 0.01). Patients that underwent ORIF were significantly less likely to undergo subsequent THA than these treated with CRPP (OR 0.49, 95% CI 0.32-0.77) but were more likely to require THA than patients treated nonoperatively (OR 6.81, 95% CI 4.63-10.02).

CONCLUSION

Elderly patients with acetabular fractures tend to have favorable functional outcomes but suffer from high rates of mortality and complications. In patients treated with internal or percutaneous fixation, there was a high rate of conversion to THA. When determining surgical treatment in this population, THA alone or concurrent with ORIF should be considered given the significantly lower rate of non-fatal complications and similar mortality rate. Nonoperative management remains a viable option and was associated with the lowest non-fatal complication rate.

LEVEL OF EVIDENCE

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Single column plate plus other column lag screw fixation vs. both column plate fixation for anterior column with posterior hemitransverse acetabular fractures - a biomechanical analysis using different loading protocols

OBJECTIVES

Open reduction and internal fixation of both columns is considered the treatment of choice for displaced anterior column with posterior hemitransverse (ACPHT) fractures in non-geriatric patients. Plate fixation of one column combined with lag screw fixation of the other column allows to decrease operative time and approach-related morbidity compared to conventional both column plating. The aim of this biomechanical study was to evaluate whether single column plate plus other column lag screw fixation confers similar stability to both column plate fixation. Physiological loads were simulated using both the single-leg stance (SLS) as well as the sit-to-stand (STS) loading protocols.

METHODS

A clinically relevant ACPHT fracture model was created using fourth-generation composite hemipelves. Fractures were stabilized with three different fixation constructs: (1) anterior column plate plus posterior column screw fixation (AP+PCS), posterior column plate plus anterior column screw fixation (PP+ACS) and anterior column plate plus posterior column plate fixation (AP+PP). Specimens were loaded from 50 to 750 N with a ramp of 100 N/s. Fracture gap motion (FGM) and relative interfragmentary rotation (RIFR) between the three main fracture fragments were assessed under loads of 750 N using an optical 3D measurement system.

RESULTS

STS loading generally resulted in higher mean FGM and RIFR than STS loading in the AP+PCS and AP+PP groups, while no significant differences were found in the PP+ACS group. Compared to conventional both column plate fixation (AP+PP), PP+ACS displayed significantly higher FGM and RIFR between the iliac wing and the posterior column during SLS loading. No significant differences in FGM and RIFR were identified between the AP+PCS and the AP+PP group.

CONCLUSION

Overall, single column plate plus other column lag screw fixation conferred similar stability to conventional both column plate fixation. From a clinical point of view, AP+PCS appears to be the most attractive alternative to conventional AP+PP for internal fixation of ACPHT fractures.

Medial buttressing of the quadrilateral surface in acetabular and periprosthetic acetabular fractures

Background

In geriatric acetabular fractures, the quadrilateral plate is often involved in the fracture pattern and medially displaced. Open reduction and internal fixation (ORIF) includes reduction of the quadrilateral plate and securing its position. In this study, the concept of medial buttressing in acute and periprosthetic acetabular fractures is evaluated.

Materials and methods

Patients, who sustained an acetabular fracture between 2012 and 2018, in whom ORIF with a specific implant for medial buttressing was performed, were included in the study. Patients were divided in two groups; acute acetabular fractures (group 1) and periprosthetic acetabular fractures (group 2). Demographics, type of fracture, surgical approach, type of implant for medial buttressing, comorbidities, general and surgical in-hospital complications and length of hospital stay were recorded retrospectively. The following data were collected from the surviving patients by telephone interview: EQ-5D-5L, SF-8 physical and SF-8 mental before trauma and at follow-up, UCLA activity scale, Parker Mobility Score and Numeric Rating Scale.

Results

Forty-six patients were included in this study, 30 males (65.2%) and 16 females (34.8%). Forty patients were included group 1 and six patients in group 2. The median age of patients of group 1 was 78 years. Among them, 82.5% presented with comorbidities. Their median length of in-hospital stay was 20.5 days. 57.5% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all but one patient. ORIF together with primary total hip arthroplasty (THA) was carried out as a single stage procedure in 3 patients. Secondary THA was performed in 5 additional patients (5/37 = 13.5%) within the observation period. Among surviving patients, 79.2% were evaluated after 3 years of follow-up. Quality of life, activity level and mobility dropped importantly and were lower than the values of a German reference population. SF-8 mental did not change. The median age of patients of group 2 was 79.5 years, all of them presented with one or several comorbidities. The median length of in-hospital stay was 18.5 days. 50% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all patients. 5 of 6 patients (83.3%) could be evaluated after a median of 136 weeks. In none of these patients, secondary surgery was necessary. Quality of life, activity level and mobility importantly dropped as well in this group. SF-8 mental remained unchanged.

Conclusion

In geriatric acetabular fractures with involvement and medial displacement of the quadrilateral plate, medial buttressing as part of ORIF proved to be reliable. Only 13.5% of patients of group 1 needed a secondary THA within 3 years of follow-up, which is lower than in comparable studies. Despite successful surgery, quality of life, activity level and mobility dropped importantly in all patients. The loss of independence did however not influence SF-8 mental values.

A new internal fixation technique for acetabular fractures involving the quadrilateral plate

BACKGROUND

The treatment of acetabular fracture involving the quadrilateral plate is a technical challenge, and the optimal management of the fracture remains controversial. We have designed a new implant (named acetabular fracture reduction internal fixator, AFRIF) for acetabular fractures involving the quadrilateral plate. This use of this new device was not investigated therefore we conducted a retrospective study aiming to determine whether the AFRIF can achieve satisfactory clinical and radiological outcomes for quadrilateral plate fracture.

HYPOTHESIS

The AFRIF for quadrilateral plate fracture is an acceptable option to treat acetabular fracture involving the quadrilateral plate.

MATERIALS AND METHODS

We performed a retrospective analysis of prospectively collected data on 24 patients (15 males and 9 females) with acute displaced quadrilateral plate fractures of the acetabulum who were treated by the AFRIF between August 2011 and May 2015. The mean age of the patients was 61.5±9.2 years (range, 31-82 years). All hips had protrusion of the femoral head, of these 5 hips with associated articular impaction of the medial roof. The type of fractures included anterior column in 4, anterior column+posterior hemitransverse in 3, associated both column in 11, T-shaped in 6 patients. The approaches included Limited Ilioinguinal (5 patients) and Limited Standard-Ilioinguinal combined with Kocher-Langenbeck (19 patients). Quality of reduction was evaluated and graded as anatomical (0mm to 1mm of displacement), imperfect (2mm to 3mm displacement) or poor (more than 3mm displacement) according to the residual displacement as defined by Matta. The final follow-up clinical outcome was classified as excellent (18 points), good (15-17 points), fair (13-14 points) or poor (<13 points) in terms to the modified Merle d'Aubigné-Postel score, and radiological outcomes evaluation were as excellent, good, fair, or poor based on Matta score.

RESULTS

The mean duration of follow-up was 45.7±13.0 months (range, 24-60 months). Average operative time and bleeding amount was 110.3±30.8min (range, 105-210min) and 950.6±348.6ml (range, 300-1500ml), respectively. There was anatomical reduction in 17 patients (17/24, 70.8%), imperfect in 5 patients (5/24, 20.8%), and poor in 2 patients (2/24, 8.3%). All of the quadrilateral plate fractures achieved anatomical except one imperfect reduction. No re-protrusion of the femoral head was observed at the final follow-up. The mean modified Merle d'Aubigné-Postel score was 16.9±2.0 points (range, 10-18 points), and 83.3% (20 of 24) have good or excellent radiological outcomes.

DISCUSSION

The findings suggest that the AFRIF for quadrilateral plate fractures may prevent protrusion of the femoral head and achieve good to excellent clinical and radiological outcomes.

LEVEL OF EVIDENCE

IV, retrospective study.

Open reduction and internal fixation of acetabular fractures in patients of old age

MATERIAL AND METHODS

There is an ongoing debate on which treatment for acetabular fractures in elderly patients is the most appropriate. This study was set up to identify the role of open reduction and internal fixation of acetabular fractures in persons of old age. We retrospectively reviewed the medical charts and radiological data of all patients older than 65 years, who suffered an isolated acetabular fracture and were admitted in our Department between 2010 and 2014 (5-year period). Complications, outcome and mortality were recorded. Of all surviving patients, quality of life (QoL), mobility and independence were graded with European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), European Quality of Life 5 Dimensions Visual Analogue Scale (EQ-5D-VAS), Numeric Rating Scale (NRS), Elderly Mobility Scale (EMS) and Tinetti Mobility Test (TMT).

RESULTS

Seventy patients could be identified. There were 52 men (74%) and 18 women (26%) with a median age of 79.0 years (range: 65-104 years). Forty-six patients (66%) had been treated with open reduction and internal fixation (ORIF), 24 (34%) conservatively. There were negative predictive factors-subchondral impaction, damage to the femoral head and multiple fragments-in 54% of the operative group. With ORIF, an anatomical reduction could be achieved in 27 patients (59%), an acceptable in 18 (39%) and a poor in one (2%). At follow-up, 18 patients (26%) had died and 23 (33%) were not able to participate. The follow-up rate of the surviving operatively treated patients was 77%. Eleven of 46 operated patients (24%) needed a conversion to a total hip arthroplasty (THA). All patients undergoing conversion had imperfect reduction after surgery. No patient in the non-operative group underwent conversion to THA during follow-up. The median follow-up time of operatively treated patients without conversion (n = 17) was 30 months (range, 16-73 months), of patients with THA (n = 9) 30 months after conversion (range, 17-55 months). Quality of reduction correlated to QoL, mobility and independence in all recorded parameters. Patients with secondary THA had similar good outcomes as patients after ORIF without later conversion. Men had better outcome than women.

CONCLUSION

ORIF of acetabular fractures in patients of old age results in excellent outcomes at short-term follow-up when anatomical reduction can be achieved. In case of negative predictive factors, ORIF cannot be regarded as a definitive solution, rather as the construction of a stable socket for secondary THA. The decision of therapy should be made dependent on pre-operative radiographic parameters.

Minimally displaced acetabulum fractures in geriatric patients: a comparison of open, percutaneous and non-operative treatment from the German Pelvic Injury Register data

Purpose

In elderly patients with minimally displaced acetabulum fractures, the patients’ inability to partially weight-bear and the need for early mobilisation may trigger the decision towards a treatment with higher primary stability. The purpose of this study was to compare open reduction and internal fixation (ORIF), closed reduction and percutaneous fixation (CRPIF) and non-operative treatment in geriatric minimally displaced acetabulum fractures with regard to complications and quality of reduction.

Methods

Data from the prospective German Pelvic Injury Register collected between 2008 and 2018 were used to evaluate 608 geriatric patients with isolated minimally displaced (≤ 5 mm) acetabulum fractures. In total, 429 received non-operative treatment, 117 ORIF and 62 CRPIF. Demographics, injury severity, fracture pattern, complications and fracture displacement before and after treatment were analysed.

Results

Both operative methods reduced fracture gap displacement. CRPIF was associated with lower blood loss and shorter operative time compared to ORIF (p < 0.001). Hospital stay was 12.9 days in the non-operative group, 16.8 with CRPIF and 23.6 with ORIF (p < 0.001). Non-surgical general complications were more likely to occur following ORIF (22.2%) compared to CRPIF (8.1%) and non-operative treatment (8.4%, p < 0.001). The rate of surgical complications was not different for ORIF and CRPIF (p = 0.122)

Conclusion

Both operative treatments improve fracture displacement and joint congruency in elderly patients with minimally displaced acetabulum fractures. Compared to ORIF, CRPIF achieves similar quality of reduction but is associated with fewer complications, smaller intraoperative blood loss, shorter operative time and shorter length of hospital stay.

Mortality, complications and long-term functional outcome in elderly patients with fragility fractures of the acetabulum

Background

Early operative treatment of acetabulum fractures in geriatric patients has been suggested to reduce pain and allow for earlier mobilization. The aim of this study was to determine mortality, complications and functional outcome after operative and non-operative treatment.

Methods

Patients aged ≥60 years with operative treatment of low-energy fragility fracture of the acetabulum from 2009 to 2016 and a follow-up of at least 24 months were identified. The patients were contacted by phone and a modified Merle d’Aubigné score was obtained. If patients or their relatives were not available for follow-up, mortality data was assessed using a national social insurance database.

Results

One hundred seventy-six patients (mean age 78, SD 10 years; 73 female) were available for analysis of mortality data. At final follow-up (68 months, SD 26, range, 24 to 129), 99/176 patients (56.3%) had deceased. One-year-mortality was 25.0% and 2-year mortality 35.8%. Type of treatment (non-operative vs. operative) did not affect mortality at 1 and 2 years (p = .65 and p = .10). Hospital-acquired infections were observed in 31/176 cases (17.6%), thromboembolic events and delirium in 6 patients (3.4%). In-hospital mortality was 5.7%. Patients who underwent operative treatment were more likely to have an in-hospital infection (p = .02) but less likely to sustain thromboembolic events (p = .03).

The mean hospital stay was 14 days (SD 10 days, range, 1 to 66). Patients with operative treatment were longer hospitalized than patients with non-operative treatment (p < .001).

The rate of secondary conversions to THA was 12.4%, this was not affected by initial treatment.

The mean modified Merle d’Aubigné Score of those patients available for a final follow-up (n = 47; follow-up 56 months, SD 28, range, 24 to 115) was 14/18 points, SD 3 (range 7 to 18). Functional results at final follow-up between operatively and non-operatively treated patients were without difference.

Conclusions

All-cause mortality and in-hospital complications are high among geriatric patients with low-energy fractures of the acetabulum even when treated operatively. Secondary conversion rates to THA are similar to those seen in younger patients. Mid-term functional outcome in those surviving is fair.

Fluoroscopically guided acetabular posterior column screw fixation via an anterior approach

Objective

Safe posterior column screw fixation via an anterior approach under two-dimensional fluoroscopic control.

Indications

Anterior column with posterior hemitransverse fractures (ACPHF); transverse fractures; two-column fractures and T‑type fractures without relevant residual displacement of the posterior column after reduction of the anterior column and the quadrilateral plate.

Contraindication

Acetabular fractures requiring direct open reduction via a posterior approach; very narrow osseous corridor in preoperative planning; insufficient intraoperative fluoroscopic visualization of the anatomical landmarks.

Surgical technique

Preoperative planning of the starting point and screw trajectory using a standard pelvic CT scan and a multiplanar reconstruction tool. Intraoperative fluoroscopically controlled identification of the starting point using the anterior–posterior (ap) view. Advancing the guidewire under fluoroscopic control using the lateral–oblique view. Lag screw fixation of the posterior column with cannulated screws.

Postoperative management

Partial weight bearing as advised by the surgeon. Postoperative CT scan for the assessment of screw position and quality of reduction of the posterior column. Generally no implant removal.

Results

In a series of 100 pelvic CT scans, the mean posterior angle of the ideal posterior column screw trajectory was 28.0° (range 11.1–46.2°) to the coronal plane and the mean medial angle was 21.6° (range 8.0–35.0°) to the sagittal plane. The maximum screw length was 106.3 mm (range 82.1–135.0 mm). Twelve patients were included in this study: 10 ACPHF and 2 transverse fractures. The residual maximum displacement of the posterior column fracture component in the postoperative CT scan was 1.4 mm (0–4 mm). There was one intraarticular screw penetration and one perforation of the cortical bone in the transition zone between the posterior column and the sciatic tuber without neurological impairment.

Paradigm shift in geriatric fracture treatment

The number of geriatric patients is increasing. These patients exhibit specific characteristics, which influence the type of fracture care. Many patients have comorbidities, which make them more vulnerable to surgical procedures. The soft tissue envelope around the fracture often is compromised due to pre-existing diseases such as diabetes, chronic venous insufficiency or peripheral vascular disease. Bone mineral density has decreased, which enhances the risk of implant loosening. The goals of treatment differ from those, which are valid for younger adults. Primary goal is preserving independency of the elderly patient in his activities of daily life. Advantages and drawbacks of surgical procedures have to be balanced with those of conservative treatment. Fractures of the lower extremities will more often need surgical treatment than fractures of the upper extremities. Patient´s autonomy is best obtained by creating high stability in the fracture plane, which enables motion and weight-bearing. Second priority is prevention of general and local post-operative complications by the use of less invasive surgical procedures. Restoring anatomy and optimal function are less important goals. The implants, which are used, are inserted through small incisions, placed deep under the skin and use long anatomic or osseous corridors. Intramedullary devices have important advantages. This paradigm shift takes the special challenges and requirements of geriatric patients into account.

Screw fixation of ACPHT acetabular fractures offers sufficient biomechanical stability when compared to standard buttress plate fixation

BACKGROUND

Geriatric acetabular fractures require fixation with sufficient primary stability to allow for immediate full-weight bearing. Minimally-invasive procedures would be desirable in order to keep perioperative morbidity low. The purpose of this study was to compare the biomechanical strength of lag screw-only fixation of anterior column posterior hemi-transverse (ACPHT) acetabular fractures to standard anatomical plate fixation.

METHODS

Standardized ACPHT fractures were created in fourth generation synthetic pelvis models and stabilized by either an anatomical buttress plate (n = 4) or by a screw-only construct (n = 4). In a validated setup, a cyclic loading protocol was applied with increasing axial force (3200 cycles, 175 N to 2250 N). Construct survival, acetabular fracture motion, and mode of failure were assessed.

RESULTS

The median number of cycles needed until failure of the construct occurred was 2304 cycles (range, 2020 to 2675) in the plate fixation group and 3200 cycles (range, 3101 to 3200) for the screw fixation constructs (p = .003). With regard to energy absorbed until failure, the plate fixation group resisted to 1.57 × 10⁶ N*cycles (range, 1.21 × 10⁶ to 2.14 × 10⁶) and the screw fixation group to 3.17 × 10⁶ N*cycles (range, 2.92 × 10⁶ to 3.17 × 10⁶; p = .001). All plate fixation specimens failed with a break-out of the posterior-column screw in the quadrilateral wing of the anatomical plate within a maximum load of 1750 N while the screw fixation constructs all survived loading of at least 2100 N. Acetabular fracture gap motion, acetabular rim angle, and medial femoral head subluxation as measures of fracture displacement were all not different between the two groups (p > 0.1).

CONCLUSIONS

In this in vitro biomechanical study, screw-only fixation of an ACPHT acetabular fracture resulted in at least as good construct survival as seen for standard buttress plate fixation. Both methods resisted sufficiently to forces that would be expected under physiologic conditions.

Computed tomography versus plain radiography assessment of acetabular fracture reduction is more predictive for native hip survivorship

INTRODUCTION

Computed tomography (CT) is more accurate than plain pelvic radiography (PXR) for evaluating acetabular fracture reduction. As yet unknown is whether CT-based assessment is more predictive for clinical outcome. We determined the independent association between reduction quality according to both methods and native hip survivorship following acetabular fracture fixation.

MATERIALS AND METHODS

Retrospectively, 220 acetabular fracture patients were reviewed. Reductions on PXR were graded as adequate or inadequate (0-1 mm or > 1 mm displacement) (Matta's criteria). For CT-based assessment, adequate reductions were defined as < 1 mm step and < 5 mm gap, and inadequate reductions as ≥ 1 mm step and/or ≥ 5 mm gap displacement. Predictive values and Kaplan-Meier hip survivorship curves were compared and risk factors for conversion to total hip arthroplasty (THA) were identified.

RESULTS

Mean follow-up was 8.9 years (SD 5.6, range 0.5-23.3 years), and 52 patients converted to THA (24%). Adequate reductions according to CT versus PXR assessment were associated with higher predictive values for native hip survivorship (92% vs. 82%; p = 0.043). Inadequate reductions were equally predictive for conversion to THA (33% for CT and 30% for PXR; p = 0.623). For both methods, survivorship curves of adequate versus inadequate reductions were significantly different (p = 0.030 for PXR, p < 0.001 for CT). Only age ≥ 50 years (p < 0.001) and inadequate reductions as assessed on CT (p = 0.038) were found to be independent risk factors for conversion to THA. Reduction quality as assessed on PXR was not found to be independently predictive for this outcome (p = 0.585).

CONCLUSION

Native hip survivorship is better predicted based on postoperative CT imaging as compared to PXR assessment. Predicting need for THA in patients with inadequate reductions based on both assessment methods remains challenging. While both PXR and CT-based methods are associated with hip survivorship, only an inadequate reduction according to CT assessment was an independent risk factor for conversion to THA.

Predictors for Long-Term Hip Survivorship Following Acetabular Fracture Surgery: Importance of Gap Compared with Step Displacement

BACKGROUND

Historically, the greatest residual (gap or step) displacement is used to predict clinical outcome following acetabular fracture surgery. Gap and step displacement may, however, impact the outcome to different degrees. We assessed the individual relationship between gap or step displacement and hip survivorship and determined their independent association with conversion to total hip arthroplasty.

METHODS

Patients who had acetabular fracture fixation (from 1992 through 2014), follow-up of ≥2 years (or early conversion to total hip arthroplasty), and postoperative computed tomography (CT) scans were included. Of 227 patients, 55 (24.2%) had conversion to total hip arthroplasty at a mean follow-up (and standard deviation) of 8.7 ± 5.6 years. Residual gap and step displacement were measured using a standardized CT-based method, and assessors were blinded to the outcome. Kaplan-Meier survivorship curves for the hips were plotted and compared (log-rank test) using critical cutoff values for gap and step displacement. These values were identified using receiver operating characteristic curves. Multivariate analysis was performed to identify independent variables associated with conversion to total hip arthroplasty. Subgroup analysis was performed in younger patients (<50 years old).

RESULTS

The critical CT cutoff value for total hip arthroplasty conversion was 5 mm for gap and 1 mm for step displacement. Hip survivorship at 10 years was 82.0% for patients with a gap of <5 mm compared with 56.5% for a gap of ≥5 mm (p < 0.001) and 80.0% for a step of <1.0 mm versus 65.5% for a step of ≥1.0 mm (p = 0.012). A gap of ≥5 mm (hazard ratio [HR], 2.3; p = 0.012) and an age of ≥50 years (HR, 4.2; p < 0.001) were independently associated with conversion to total hip arthroplasty in all patients. In the subgroup of younger patients, only a step of ≥1 mm (HR, 6.4; p = 0.017) was an independent factor for conversion to total hip arthroplasty.

CONCLUSIONS

Residual gap and step displacement as measured on CT scans are both related to long-term hip survivorship, but step displacement (1 mm) is tolerated less than gap displacement (5 mm). Of the 2 types of displacement, only a large gap displacement (≥5 mm) was independently associated with conversion to total hip arthroplasty. In younger patients who had less articular impaction with smaller residual gaps, only step displacement (≥1 mm) appeared to be associated with this outcome.

LEVEL OF EVIDENCE

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

Modified Stoppa approach for operative treatment of acetabular fractures: 10-year experience and mid-term follow-up

INTRODUCTION

The (modified) Stoppa approach for acetabular fracture surgery has gained significant popularity and early results have been encouraging but clinical outcome at extensive follow-up is scarce. The purpose of this study is to provide an update on our experience with this approach for operative treatment of acetabular fractures and to assess clinical outcome at mid-term follow-up.

METHODS

In this retrospective study, all patients treated operatively for an acetabular fracture using the Stoppa approach over a 10-year period were included. Surgery details were reviewed and patients were contacted and requested to return for follow-up. Primary outcome was native hip survivorship, secondary outcome measures included; functional outcome (Merle d'Aubiginé, Harris hip) scores, health-related quality of life (short-form 36) and radiographic outcome (heterotopic ossification, hip osteoarthritis).

RESULTS

Forty-five patients received operative fixation for 47 acetabular fractures using the Stoppa approach. Complications requiring surgical intervention were found in one patient (with a vascular lesion) intra-operatively and 3 patients (with wound infections (2) and diffuse bleeding (1)) post-operatively. Follow-up was 83% and 29/39 (74%) native hips survived at mean 59 months (SD 49) postoperatively. Excellent-good functional scores were found in 88% (Merle d'Aubiginé) and 76% (Harris hip) of patients who had retained their native hip. Most (6/8) short-form 36 indices in these patients were comparable to population norms. Of 29 native hips with radiographic follow-up (mean 59 months (SD 49), 4 (86%) had no-minimal radiographic abnormalities.

CONCLUSION

This study confirms that the Stoppa approach is a safe and effective technique for acetabular fracture fixation. Moreover, at mid-term follow-up, this approach is associated with satisfactory results in terms of hip survivorship as well as functional and radiographic outcome. As such, our findings reinforce the notion that this less invasive technique presents a valuable alternative to the ilioinguinal approach for the surgical treatment of acetabular fractures.

Functional Outcomes of Elderly Patients With Nonoperatively Treated Acetabular Fractures That Meet Operative Criteria

OBJECTIVES

To report functional outcomes of displaced acetabular fractures treated nonoperatively in the geriatric patient population.

DESIGN

Retrospective case series.

SETTING

Two Level I trauma centers.

PATIENTS

Twenty-seven patients 60 years of age or older who sustained displaced acetabular fractures during an 11-year period.

INTERVENTION

Nonoperative treatment.

MAIN OUTCOME MEASUREMENTS

Primary outcome measurements were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and Short Form 8 (SF-8) scores. Secondary outcome measurements were conversion to open reduction and internal fixation or total hip arthroplasty and 1-year mortality.

RESULTS

Twenty-six patients completed the WOMAC and SF-8 surveys. The overall WOMAC score was 12.9 ± 15.6 (range, 0-59.4). The average physical SF-8 was 51.1 ± 8.7 (range, 30.4-58.6), and the average mental SF-8 was 55 ± 6.2 (range, 30.4-58.6). The 1-year mortality rate was 24%. Conversion of treatment occurred in 15% of patients.

CONCLUSIONS

Elderly patients with fracture patterns that would qualify for operative treatment in younger healthy patients had surprisingly good outcome scores when treated nonoperatively.

LEVEL OF EVIDENCE

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

Postoperative CT Is Superior for Acetabular Fracture Reduction Assessment and Reliably Predicts Hip Survivorship

BACKGROUND

Postoperative pelvic radiographs are routinely used to assess acetabular fracture reduction. We compared radiographs and computed tomography (CT) with regard to their ability to detect residual fracture displacement. We also determined the association between the quality of reduction as assessed on CT and hip survivorship and identified risk factors for conversion to total hip arthroplasty (THA).

METHODS

Patients were included in the study who had undergone acetabular fracture fixation between 1992 and 2012, who were followed for ≥2 years (or until early THA), and for whom radiographs and a pelvic CT scan were available. Residual displacement was measured on postoperative radiographs and CT and graded according to Matta's criteria (0 to 1 mm indicating anatomic reduction; 2 to 3 mm, imperfect reduction; and >3 mm, poor reduction) by observers who were blinded to patient outcome. Kaplan-Meier survivorship curves were plotted and log-rank tests were used to assess statistical differences in survivorship curves between adequate (anatomic or imperfect) and inadequate reductions on CT. Cox proportional hazard regression analysis was used to identify risk factors for conversion to THA. Two hundred and eleven patients were included. At mean of 9.0 years (standard deviation [SD], 5.6; median, 7.9; range, 0.5 to 23.3 years) postoperatively, 161 patients (76%) had retained their native hip.

RESULTS

Compared with radiographs, CT showed worse reduction in 124 hips (59%), the same reduction in 79 (37%), and better reduction in 8 (4%). Of the 99 patients graded as having adequate reduction on CT, 10% underwent conversion to THA in comparison with 36% of those with inadequate reduction, and there was a significant difference between the survivorship curves (p < 0.001). Mean hip survivorship was shorter in patients ≥50 years of age (p < 0.001) and in those with an inadequate reduction on CT (p < 0.001). Independent risk factors for conversion to THA were age (hazard ratio [HR] = 4.46, 95% confidence interval [CI] = 2.07 to 9.62; p < 0.001), inadequate reduction (HR = 3.57, 95% CI = 1.71 to 7.45; p = 0.001), and posterior wall involvement (HR = 1.81, 95% CI = 1.00 to 3.26; p = 0.049). Sex, fracture type (elementary versus associated), and year of surgery did not influence hip survivorship.

CONCLUSIONS

CT is superior to radiographs for detecting residual displacement after acetabular fracture fixation. Hip survivorship is greater in patients with adequate (anatomic or imperfect) reduction on CT. Along with older age and posterior wall involvement, an inadequate reduction on CT is a risk factor for conversion to THA.

LEVEL OF EVIDENCE

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

Generating stability in elderly acetabular fractures-A biomechanical assessment

BACKGROUND & OBJECTIVES

As the overall health and life expectancy increases in the United States, the incidence of fragility fractures in elderly patients also continues to increase. Given their medical comorbidities and decreased bone mineral density, acetabular fractures in the elderly population present a significant challenge to the orthopaedic trauma surgeon. The anterior column posterior hemitransverse (ACPHT) fracture pattern is a common fracture pattern in this population, and is often associated with central subluxation/dislocation of the femoral head with articular impaction. This study sought to delineate the most stable fixation construct in ACPHT fracture patterns in the elderly population.

MATERIALS AND METHODS

The sample consisted of 3 groups of synthetic hemipelves (N=15), which were tested in order to compare stiffness by measuring motion at fracture lines under applied loads. The three groups of unique quadrilateral plate fixation were as follows: a specialty quadrilateral surface plate; 4 long peri-articular screws parallel to the quadrilateral surface into the ischium,; and an 8 hole infrapectineal buttress plate. Digital imaging system measured construct motion under load. Construct stiffness was estimated by linear regression of load between 50 and 850N versus average relative motion (average of relative motion at 200 points along the line of the osteotomy). Permanent deformation was estimated as the magnitude of relative motion upon unloading.

RESULTS

Using ANOVA with Tukey's test to determine construct stiffness in loading, the group long peri-articular screws was found to have significantly higher stiffness than either of the other groups. Maximal fracture displacement was located at the intersection of the low transverse fracture line in the posterior column and the free quadrilateral surface fragment.

CONCLUSIONS

Results indicate that the best fixation construct for this ACPHT acetabular fracture pattern includes independent lag screws across the anterior column and a pelvic brim plate with long periarticular screws maximizing posterior column fixation and preventing medialization of the free quadrilateral fragment. Although there are potential patient considerations that may complicate the placement of all 4 long screws, in most patients one or more of these screws can be safely placed in order to help prevent secondary displacement.

Management of Acetabular Fractures in the Elderly

The incidence of acetabular fractures in the elderly population is increasing. Fractures in this population differ from those in younger patients, with more frequent involvement of the anterior column, more comminution, and more severe articular impaction in elderly patients. Although acetabular fractures in geriatric patients are more likely the result of low-energy trauma, outcomes are generally poorer than those in young patients. Multiple management options have been proposed, but no intervention has become the standard of care for these fractures in the elderly. Patient characteristics (eg, prior ambulation status, functional capacity, bone quality), the nature of the fracture, and the experience of the treating orthopaedic surgeon all must be considered when choosing among nonsurgical treatment, percutaneous fixation, open reduction and internal fixation, and immediate or delayed arthroplasty. Each treatment option has the potential for satisfactory results in properly selected patients.

Minimally invasive plate osteosynthesis on anterior pelvic ring injury and anterior column acetabular fracture

INTRODUCTION

In performing surgery for fractures of the pelvis and acetabulum, various surgical approaches have been introduced with their own advantages and drawbacks. The extensile nature of ilioinguinal approach gives excellent exposure but was related to wound healing problems. Modified stoppa has a higher difficulty and poses a risk for neurovascular injury. In this study, we elaborate our experience using the Modified Stoppa approach with additional lateral window while adding few modifications to simplify the procedure and facilitate future implant removal.

METHODS

A prospective-retrospective cohort involving 30 anterior pelvic ring and/or anterior column acetabulum fracture patients were conducted from 2012-2016. Fifteen cases were prospectively treated using the modified approach since 2014, while the remaining fifteen cases that were treated using Ilioinguinal approach were retrospectively reviewed. Intraoperative parameters such as blood loss, duration of surgery, quality of reduction (Matta) and postoperative functional outcome (Majeed and Hannover score) at 12 months period were recorded and evaluated by a blinded reviewer.

RESULT

There were no significant differences between the two groups in mean age, sex and fracture type. The mean blood loss in the MIPO group were 325 ± 225 mL versus 710.67 ± 384.51 mL in the control group (p = 0.002). Duration of surgery were 149.33 ± 91.92 minutes in MIPO group versus 235.71 ± 65.79 minutes in ilioinguinal group (p = 0.014). There were no significant differences noted between the two groups in the quality of reduction and postoperative functional outcome, either by using Majeed or Hannover pelvic score. No complications were found after a 12-months follow up period. Two modified cases already had their implant removed and during the procedure, fibrotic tissue were minimal making the implant removal was less complicated and easier.

CONCLUSIONS

Modified stoppa and lateral window technique can be used as a safe and effective alternative approach for anterior pelvic ring fracture and/or anterior column acetabulum fracture. This approach decreased the duration of surgery and blood loss without compromising the quality of reduction and functional outcome in patients.

Surgical treatment of acetabular fractures in the elderly: a systematic review of the results

We performed a systematic review of the literature involving a number of databases to identify studies that included outcomes of surgical treatment of acetabular fractures in patients aged > 55 years. An initial search identified 1564 studies. After exclusion by two independent reviewers, 15 studies met the inclusion criteria. All studies were case series and the mean Coleman Methodology score for methodological quality assessment was 43.7 (standard deviation 12.3). There were 354 patients with acetabular fractures. Pooled analysis revealed a mean age of 71.6 years (55 to 96) and a mean follow-up of 43 months (20 to 188). Complex fractures were reported in 70.1% of patients.

Seven studies presented the results of open reduction and internal fixation (ORIF); in eight other studies a total hip arthroplasty (THA), alone or combined with different internal fixation techniques, was the chosen treatment. In the ORIF sub-group, conversion to THA was performed at a mean of 25.5 months with anatomical reduction in 11.6% and imperfect and poor reduction in 22.3%. In the THA sub-group, an acetabular ring or cage with a cemented acetabular component was used in four studies (52 patients) and a cementless acetabular component was implanted in five studies (78 patients). Six patients (4.9%) underwent revision at a mean of 39 months after the index procedure.

The analysis of intra-operative and post-operative parameters showed a statistical difference between the two sub-groups with regards to the mean operating time (236 mins ORIF vs 178 mins THA), the mean blood loss (707 mL ORIF vs 974 mL THA) and the mean mortality rate at one year (22.6% ORIF vs 8.8% THA).

Based on the current data available, acute THA (alone or in combination with internal fixation) may have a role in the treatment of older patients with complex acetabular fractures. Despite the wide heterogenecity of fracture types and patient co-morbidities, THA procedures were associated with lower rates of mortality and further surgery when compared with the ORIF procedures.

Cite this article: EFORT Open Rev 2017;2:97-103. DOI: 10.1302/2058-5241.2.160036

Patients undergoing surgical hip dislocation for the treatment of acetabular fractures show favourable long-term outcome

Aims

The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome.

Patients and Methods

We followed up 60 consecutive patients (61 hips; mean age 36.3 years, standard deviation (sd) 15) who underwent open reduction and internal fixation for a displaced fracture of the acetabulum (24 posterior wall, 18 transverse and posterior wall, ten transverse, and nine others) with a mean follow-up of 12.4 years (sd 3).

Results

Clinical grading was assessed using the modified Merle d’Aubigné score. Radiographic osteoarthritis was graded according to Matta. Kaplan-Meier survivorship and a univariate Cox-regression analysis were carried out using the following endpoints: total hip arthroplasty, a Merle d’Aubigné score of < 15 and/or progression of osteoarthritis.

Conclusion

The ten-year cumulative survivorship was 82% (95% confidence interval 71 to 92). Predictors for the defined endpoints were femoral chondral lesions, marginal impaction, duration of surgery, and age of patient. Cite this article: Bone Joint J 2017;99-B:508–15.

Variation in Treatment of Displaced Geriatric Acetabular Fractures Among 15 Level-I Trauma Centers

OBJECTIVES

To document the initial treatment of displaced acetabular fractures among older adults across multiple trauma centers and to investigate the factors that influence the decision to operate and the choice of operative procedure [open reduction internal fixation (ORIF) vs. total hip arthroplasty (THA)].

DESIGN

Retrospective observational study.

SETTING

Fifteen US level-I trauma centers participating in the Major Extremity Trauma Research Consortium.

PATIENTS/PARTICIPANTS

Overall, 269 patients aged 60 years or older admitted for the treatment of a displaced acetabular fracture.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Treatment.

RESULTS

Sixty percent of fractures (n = 162) were treated operatively. Younger age (<80 years), injury from high-energy mechanism, fractures with femoral head impaction, and fractures without hip congruency were significantly associated with receiving operative treatment (P < 0.05). Significant site variation in operative versus nonoperative treatment occurred even after accounting for these factors (P = 0.0044). Among operatively treated patients, 88% (n = 142) received ORIF and 12% (n = 20) received THA as the initial treatment. Women were more likely to be treated with initial THA compared with men; of the known risk factors for poor outcomes with ORIF (ie, dome or roof impaction, femoral head impaction, or posterior wall involvement), only dome impaction was significantly associated with receiving initial THA (P < 0.05).

CONCLUSIONS

Currently, no treatment guidelines exist for acetabular fractures in older adults, which likely explains the significant site variation in operative versus nonoperative treatment. This study identifies patient and injury factors that drive treatment decisions, which will be important in planning and designing future trials needed to determine the best treatment for these fractures.

Safety of modified Stoppa approach for Ganz periacetabular osteotomy: A preliminary cadaveric study

Objective

The aim of this cadaveric study was to investigate the efficacy of the modified Stoppa approach in Ganz periacetabular osteotomy (PAO).

Methods

The Ganz PAO was performed on 10 hemipelvises with normal hips, from 5 cadavers using the modified Stoppa approach through the Pfannenstiel incision. All of the osteotomies were performed under fluoroscopic control and direct visualizing the osteotomy site from the same incision. After the osteotomy, the acetabulum was medialized and redirected anterolaterally, and fixed with 2 screws. The neurovascular structures and the joints were examined by dissecting the soft tissues after fixation of the osteotomies. Outcome parameters were center-edge (CE) angle, the distances between the osteotomy and anterior superior iliac spine (ASIS), and between the osteotomy and the sciatic notch, neurovascular and joint penetrations.

Results

After the osteotomy, the mean CE angle was improved from 19.8° to 25.2°, mean distance between the osteotomy and ASIS was 3.1 cm, and the mean distance between the osteotomy and the sciatic notch was 10.2 mm. The neurovascular structures and the joints were examined by dissecting the soft tissues after fixation of the osteotomies. No damage to the joint, surrounding arteries, veins or nerves was detected in any of the cadavers.

Conclusions

Bilateral dysplastic hips can be treated with a 10 cm, cosmetically more acceptable incision in the same session using this approach. Quadrilateral surface of the acetabulum can be directly seen using this approach and the osteotomy can be safely performed.

Radiographic Measurement of Displacement in Acetabular Fractures: A Systematic Review of the Literature

OBJECTIVES

To report methods of measurement of radiographic displacement and radiographic outcomes in acetabular fractures described in the literature.

METHODS

A systematic review of the English literature was performed using EMBASE and Medline in August 2014. Inclusion criteria were studies of operatively treated acetabular fractures in adults with acute (<6 weeks) open reduction and internal fixation that reported radiographic outcomes. Exclusion criteria included case series with <10 patients, fractures managed >6 weeks from injury, acute total hip arthroplasty, periprosthetic fractures, time frame of radiographic outcomes not stated, missing radiographic outcome data, and non-English language articles. Basic information collected included journal, author, year published, number of fractures, and fracture types. Specific data collected included radiographic outcome data, method of measuring radiographic displacement, and methods of interpreting or categorizing radiographic outcomes.

DATA SYNTHESIS

The number of reproducible radiographic measurement techniques (2/64) and previously described radiographic interpretation methods (4) were recorded. One radiographic reduction grading criterion (Matta) was used nearly universally in articles that used previously described criteria. Overall, 70% of articles using this criteria documented anatomic reductions.

CONCLUSIONS

The current standard of measuring radiographic displacement in publications dealing with acetabulum fractures almost universally lacks basic description, making further scientific rigor, such as testing reproducibility, impossible. Further work is necessary to standardize radiographic measurement techniques, test their reproducibility, and qualify their validity or determine which measurements are important to clinical outcomes.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Assessment of functional outcomes of surgically managed acetabular fractures

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling.

Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results.

Cite this article: Bone Joint J 2016;98-B:690–5.

Effect of surgical treatment on mortality after acetabular fracture in the elderly: a multicenter study of 454 patients

OBJECTIVES

Controversy exists regarding the effect of operative treatment on mortality after acetabular fracture in elderly patients. Our hypothesis was that operative treatment would confer a mortality benefit compared with nonoperative treatment even after adjusting for comorbidities associated with death.

DESIGN

Retrospective study.

SETTING

Three University Level I Trauma Centers.

PATIENTS/PARTICIPANTS

All patients aged 60 years and older with acetabular fractures treated from 2002 to 2009 were included in the study. Four hundred fifty-four patients were identified with an average age of 74 years. Sixty-seven percent of the study group was male and 33% female.

INTERVENTION

One of 4 treatments: nonoperative management with early mobilization, percutaneous reduction and fixation, open reduction and internal fixation, acute total hip arthroplasty.

MAIN OUTCOME MEASUREMENTS

Kaplan-Meier survival curves were created, and Cox proportional hazards models were used to calculate unadjusted and adjusted hazard ratios (HRs) for covariates of interest.

RESULTS

In contrast to previous smaller studies, the overall mortality was relatively low at 16% at 1 year [95% confidence interval (CI), 13-19]. Unadjusted survivorship curves suggested higher 1-year mortality rates for nonoperatively treated patients (21% vs. 13%, P < 0.001); however, nonoperative treatment was associated with other risk factors for higher mortality. By accounting for these patient risk factors, our final multivariate model of survival demonstrated no significant difference in hazard of death for nonoperative treatment (0.92, P = 0.6) nor for any of the 3 operative treatment subgroups (P range, 0.4-0.8). As expected, we did find a significantly increased hazard for factors such as the Charlson comorbidity index [HR, 1.25 per point (95% CI, 1.16-1.34)] and age [HR, 1.08 per year of age more than 70 years (95% CI, 1.05-1.11)]. In addition, associated fracture patterns (compared with elementary patterns) significantly increased the hazard of death with a ratio of 1.51 (95% CI, 1.10-2.06).

CONCLUSIONS

The operative treatment of acetabular fractures does not increase or decrease mortality, once comorbidities are taken into account. The reasons for this are unknown. Regardless of the causes, the decision for operative versus nonoperative treatment of geriatric acetabular fractures should not be justified based on the concern for increased or decreased mortality alone.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A growing problem: acetabular fractures in the elderly and the combined hip procedure

Acetabular fractures in the elderly are most frequently the result of low-energy trauma and present unique management challenges to orthopedic surgeons. Evaluation and treatment should be performed in a multidisciplinary fashion with early involvement of internal medicine subspecialists and geriatricians. Distinct fracture patterns and pre-existing osteoarthritis and osteoporosis necessitate careful preoperative planning. The role of total hip arthroplasty should also be considered when surgical treatment is indicated. The outcomes of acetabular fractures in the elderly have improved, but complications remain higher and results less satisfactory than in younger individuals. The lack of randomized controlled trials has limited the ability to establish an evidence-based treatment algorithm.

Displaced acetabular fractures in the elderly: results after open reduction and internal fixation

BACKGROUND

The optimal management of elderly patients with displaced acetabular fractures remains controversial. This paper aims to summarize the clinical results of open reduction and internal fixation (ORIF) and the possible factors influencing them.

METHODS

Radiographic and clinical data on 52 elderly patients with displaced acetabular fractures that were treated by ORIF between May 2000 and May 2008 were retrospectively analysed. Data, such as fracture type (Letournel's classification system), quality of reduction, clinical outcomes (Harris hip score and modified Merle d'Aubigne-Postel score), and radiological outcomes (Matta score), were evaluated.

RESULTS

Good to excellent clinical and radiological outcomes were recorded in 43 (82.7%) and 37 patients (71.2%), respectively. Acetabular fractures without radiographic features, such as quadrilateral plate fracture, Gull sign, posterior dislocation of hip, posterior wall marginal impaction, comminuted posterior wall fracture, and femoral head injury, can still achieve good to excellent outcomes. However, patients with the abovementioned radiographic features tend to achieve fair or poor outcomes. When an acetabular fracture with the aforementioned features, except for femoral head injury, can achieve and maintain anatomic reduction until complete fracture healing, the difference between fractures with and without the radiographic features is no longer significant. The results indicate that the outcomes are more affected by reduction rather than radiographic features.

CONCLUSION

ORIF may be suggested for displaced acetabular fractures in the elderly. Good to excellent outcomes and a high degree of patient satisfaction can be achieved in majority of the patients. We recommend ORIF as the preferred treatment for displaced acetabular fractures without the abovementioned radiographic features.

LEVEL OF EVIDENCE

Therapeutic level IV.

Short-segment fixation through a limited ilioinguinal approach for treating anterior acetabular fractures: a historical-control study

PURPOSE

We evaluated the potential advantages of short-segment fixation of certain anterior acetabular fracture patterns through a limited ilioinguinal approach.

METHODS

Two patient groups were studied. The first group comprised 22 patients (20 men, two women; average age 36 years) treated using the short-segment fixation protocol through a limited ilioinguinal approach. We modified the use of short pelvic brim plates, spring plates and posterior-column screws as reduction and fixation tools (leaving the distal end of the fracture unfixed) to keep the dissection entirely lateral to the iliac vessels. The second (control) group comprised 31 patients with matched fracture patterns fixed through the standard ilioinguinal approach. All patients were followed up for a minimum of two years. The estimated amount of blood loss (primary outcome measure), operative time, postoperative radiographic assessment of reduction quality and functional score assessment (secondary outcome measures) were compared between groups.

RESULTS

The short-segment-fixation group had significantly less blood loss (p < 0.0001) and shorter operative time (p = 0.002) compared with the control group. However, there were no significant differences in the quality of fracture reduction and functional scores between groups at the final follow-up. No major complications were encountered in either group.

CONCLUSION

Short-segment fixation through a limited ilioinguinal approach is a safe and effective alternative for treating certain patterns of anterior acetabular fractures. Decreased blood loss and shorter operative time with less soft tissue dissection are the main advantages of this approach.

Acetabular fractures in patients aged > 55 years: a systematic review of the literature

The increasing prevalence of osteoporosis in an ageing population has contributed to older patients becoming the fastest-growing group presenting with acetabular fractures. We performed a systematic review of the literature involving a number of databases to identify studies that included the treatment outcome of acetabular fractures in patients aged > 55 years. An initial search identified 61 studies; after exclusion by two independent reviewers, 15 studies were considered to meet the inclusion criteria. All were case series. The mean Coleman score for methodological quality assessment was 37 (25 to 49). There were 415 fractures in 414 patients. Pooled analysis revealed a mean age of 71.8 years (55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven studies the results of open reduction and internal fixation (ORIF) were presented: this was combined with simultaneous hip replacement (THR) in four, and one study had a mixture of these strategies. The results of percutaneous fixation were presented in two studies, and a single study revealed the results of non-operative treatment. With fixation of the fracture, the overall mean rate of conversion to THR was 23.1% (0% to 45.5%). The mean rate of non-fatal complications was 39.8% (0% to 64%), and the mean mortality rate was 19.1% (5% to 50%) at a mean of 64 months (95% confidence interval 59.4 to 68.6; range 12 to 143). Further data dealing with the classification of the fracture, the surgical approach used, operative time, blood loss, functional and radiological outcomes were also analysed. This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients.

Comparative study of comminuted posterior acetabular wall fracture treated with the Acetabular Tridimensional Memory Fixation System

BACKGROUND

Posterior wall fractures are one of the most common acetabular fractures. However, only 30% of these fractures involve a single large fragment, and comminuted acetabular posterior wall fractures pose a particular surgical challenge. The purpose of this study was to compare outcomes between patients who received fixation for comminuted posterior wall fracture using the Acetabular Tridimensional Memory Fixation System (ATMFS) and patients who underwent fixation with conventional screws and buttress plates (Plates group).

METHOD

Between April 2003 and May 2007, 196 consecutive patients who sustained a comminuted posterior wall fracture of acetabulum were treated with ATMFS or conventional screws and buttress plates. Operative time, fluoroscopy time, blood loss, and any intra-operative complications were recorded. Plain AP and lateral radiographs were obtained at all visits (Matta's criteria). Modified Merle d' Aubigne-Postel score, and Mos SF-36 score were compared between groups.

RESULTS

Fifty patients were included in the analysis with 26 in the ATMFS group and 24 in the Plates group. The mean follow-up time was 57.5 months, ranging from 31 to 69 months. All patients had fully healed fractures at the final follow-up. There was no difference in clinical outcomes or radiological evaluations between groups.

CONCLUSION

Patients with comminuted posterior wall fractures of the acetabulum treated with the ATMFS or conventional screws and buttress plate techniques achieve a good surgical result. Both techniques are safe, reliable, and practical. Use of the ATMFS technique may reduce blood loss and improve rigid support to marginal bone impaction. The use ATMFS may need additional support when fractures involve the superior roof.

Geriatric fractures about the hip: divergent patterns in the proximal femur, acetabulum, and pelvis

Geriatric acetabular, pelvis, and subtrochanteric femur fractures are poorly understood and rapidly growing clinical problems. The purpose of this study was to describe the epidemiologic trends of these injuries as compared with traditional fragility fractures about the hip. From 1993 to 2010, the Nationwide Inpatient Sample (NIS) recorded more than 600 million Medicare-paid hospital discharges. This retrospective study used the NIS to compare patients with acetabular fractures (n=87,771), pelvic fractures (n=522,831), and subtrochanteric fractures (n=170,872) with patients with traditional hip fractures (intertrochanteric and femoral neck, n=3,495,742) with regard to annual trends over an 18-year period in incidence, length of hospital stay, hospital mortality, transfers from acute care institutions, and hospital charges. Traditional hip fractures peaked in 1996 and declined by 25.7% by 2010. During the same 18-year period, geriatric acetabular fractures increased by 67%, subtrochanteric femur fractures increased by 42%, and pelvic fractures increased by 24%. Hospital charges, when controlling for inflation, increased roughly 50% for all fracture types. Furthermore, transfers from outside acute care hospitals for definitive management stayed elevated for acetabular fractures as compared with traditional hip fractures, suggesting a greater need for tertiary care of acetabular fractures. Geriatric acetabular fractures are rapidly increasing, whereas traditional hip fractures continue to decline. Patients with these injuries are more likely to be transferred from their hospital of presentation to another acute care institution, possibly increasing costs and complications. This is likely related to their complexity and the lack of consensus regarding optimal management.