A study of orthopedic surgery patients found that open reduction and internal fixation plus joint replacement for displaced acetabular fractures in older patients led to similar outcomes and fewer reoperations compared with internal fixation alone, suggesting this combination of procedures is safe and effective in elderly patients.
This study was published in Injury.
This study is “the first prospective clinical trial to our knowledge, comparing open reduction and internal fixation (ORIF) versus ORIF + total hip arthroplasty (THA) for geriatric acetabular fractures,” wrote Theodore T. Manson, MD, and colleagues.
Acetabular Fractures, ORIF, and THA
Acetabular fracture is a type of fracture impacting the acetabular dome, or the “ball-and-socket” of the hip. These fractures are caused by the head of the femur being driven into the pelvis. In these kind of fractures, the sciatic and femoral nerves are vulnerable to injury due to their proximity to the fracture.
Open Reduction-Internal Fixation Surgery
Surgical treatments for fractures of the acetabulum include ORIF (open reduction–internal fixation), which is a two-step procedure. The first step is open reduction, which involves an orthopedic surgeon creating an incision to access the bone and realign it. The second part of the procedure, internal fixation, occurs when the surgeon pieces the bone fragments together.
Total Hip Arthroplasty for Hip Fracture
THA, or total hip replacement, is an emerging option for treatment of acetabular fracture. Hip replacement is a common orthopedic surgery in which the damaged bone and cartilage in the hip joint is replaced by a prosthetic implant.
However, the use of this procedure for acetabular fractures may be associated with a high risk of infection. A recent study published in the Journal of the American Academy of Orthopaedic Surgeons assessed identified several risk factors for 90-day surgical site infections or periprosthetic joint infections after THA for acetabular fractures. Significant risk factors for infection included: morbid obesity (odds ratios [ORs], 1.84 for SSIs and 1.70 for PJIs), pathologic weight loss (ORs, 1.64 and 1.72), and iron deficiency anemia (ORs, 1.59 and 1.97).
As older patients have increased risk of comorbidity and frailty, it is important to identify the safety parameters of treating these challenging fractures in this population. “The optimal treatment of elderly patients with an acetabular fracture is unknown,” wrote Manson, et al.
ORIF versus ORIF Plus THA
In this prospective clinical trial, the researchers assessed patients aged older than 60 years with acetabular fracture plus at least one of three fracture characteristics: dome impaction, femoral head fracture, or posterior wall component.
Fractures were managed with either ORIF plus THA performed in the same operation through same incision, or ORIF alone. Functional assessment measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Short Form 36 (SF-36), Harris Hip Score (HHS), and Patient Satisfaction Questionnaire Short Form scores. Unplanned reoperations within two years were also documented.
“Our hypothesis was that patients who had ORIF + THA would have better patient reported outcomes and lower reoperation rates postoperatively,” the researchers noted.
Population and Outcomes
Out of 165 eligible patients, 47 were included in the final analysis. The average age was 70.7 years.
At one year postoperatively, there were no clinically important differences between groups in WOMAC, SF-36, and Patient Satisfaction Questionnaire scores. There was a significantly significant difference in HHS in favor of ORIF plus THA. The average difference in HHS between ORIF plus THA and ORIF alone was 12.3 points (95% confidence interval -0.3-24.9; P = 0.07). Compared to ORIF alone, ORIF plus THA reduced the absolute risk of reoperation by 28% (95% confidence interval 13-44; P <0.01). There were no postoperative hip dislocations in either group.
In summary, the authors wrote, “In patients older than 60 years with an operative displaced acetabular fracture with specific fracture features (dome impaction, femoral head fracture, or posterior wall component), treatment with ORIF + THA resulted in fewer reoperations than treatment with ORIF alone. No differences in patient satisfaction and other validated outcome measures were detected.”
They concluded, “Our results confirm that a combined ORIF + THA strategy can be safely performed in these challenging injuries.”