In the senior author's Level I trauma center's database, for the period from 2002 to 2017, we identified 461 complete datasets of patients with acetabular fractures that were treated. Two patients were excluded because they underwent a primary THR after reconstruction of a comminuted posterior wall as part of a planned two-stage acute surgery. The mean age of the remaining 459 patients was 57.0 ± 20.6 years (range 13–99 years). And 78.2% of the patients with a fracture of the acetabulum were male. Of all patients admitted to the senior author's institution, 348 (75.8%) were treated by ORIF of their acetabular fracture (Table 3).
In the cohort from the senior author's clinic, 232 (50.6%) patients had an age of 60 years or more (Table 3). The mean age in this elderly subgroup was 74.0 ± 9.2 years. Comparable to the total trauma center cohort, 75.9% of the patients were male. Of the patients with an age of at least 60 years, 155 (66.8%) were treated operatively (Table 3). In the subgroup of patients younger than 60 years of age, 193 (85.0%) were operated on. Similar to the overall findings (Table 2), this difference in operative and nonoperative treatment relative to patient age was significantly different (P < 0.001).
Among patients treated at the senior author's institution, the in-hospital mortality was 3.7%. For patients aged 60 years or over, the mortality was 6.0%, whereas in the group of patients younger than 60 years of age, it was 1.3%, which proved to be significantly lower than the elderly subgroup (P = 0.02). The in-hospital mortality of elderly patients after surgical treatment (3.9%) was lower than the mortality of elderly patients who received nonoperative treatment (10.4%), but these numbers were not significantly different (Table 4).
Of the 232 patients with an age of 60 years or over who had been treated at the senior author's trauma center, 71 did not visit the outpatient department again after discharge and therefore were lost to follow up. Of the remaining 161 patients, 18 (11.2%) died within the first year after sustaining the acetabular fracture. After excluding patients with a follow-up of less than 12 months (n = 22), 121 patients remained for potential further analyses.
We were able to collect complete follow-up information for 96 (79.3%) of those patients (Table 5), because 8 patients had visited outpatient departments of other medical specialties of the hospital and therefore had not been asked to fill out the EQ-5D questionnaire, 10 patients did not consent to fill out the questionnaire, and 7 patients returned an incomplete questionnaire. The mean age when sustaining the injury was 71.3 ± 7.7 years and the mean follow-up was 4.75 years (range 12–193 months). In the follow-up cohort, 77 patients (80.2%) had been treated by ORIF (Table 5).
The analysis of fracture patterns showed that in both subgroups of elderly patients, those who had been treated with ORIF and those who were managed nonoperatively, fractures of the anterior column together with anterior column plus posterior hemitransverse fractures made up the majority of all fractures. Transverse fractures were significantly more frequent in the nonoperative group. The distribution of all other fracture types was not significantly different comparing the ORIF to the nonoperative group (Table 6).
Of all patients aged 60 years or over, 22.9% needed a secondary THR at any time after their injury (mean 11.8 months, range 2–60 months). And 77.2% of secondary hip replacements were necessary within the first 12 months after the fracture. Of the patients originally treated with ORIF, 24.7% had to undergo a secondary THR, whereas for patients after nonoperative management, posttraumatic osteoarthritis led to a secondary THR in 15.8% of the cases. The difference in rate of secondary THR after either ORIF or nonoperative treatment was not significantly different (P = 0.55, Table 5).
The EQ-5D questionnaire was used to assess the quality of life after either ORIF or nonoperative management of acetabular fractures. Patients for whom no EQ-5D score before a secondary THR was available (n = 14 for the ORIF group and n = 2 for the nonoperative group) were excluded. The mean EQ-5D score of the elderly patients in our follow-up cohort was 0.57 with no significant differences between the operative treatment and nonoperative treatment subgroups (Table 5).
In the 1960s, Émile Letournel excluded patients aged 60 years and over from surgical treatment for acetabular fractures.1 This was probably due to comorbidities and reduced bone stock and indicates that in those days, elderly people did most probably not represent a relevant cohort among patients with fractures of the acetabulum.
Even in 2005, when Giannoudis et al20 published a meta-analysis of 3670 acetabular fractures, the average age of patients was no higher than 39 years. However, it has been demonstrated that elderly persons are currently the fastest growing cohort of patients sustaining acetabular fractures.13,14 In the present study, we demonstrated that currently, the mean age in a large central European cohort of patients with a fracture of the acetabulum is 58.6 years and, therefore, has increased by nearly 20 years since Giannoudis' published his analysis in 2005. We conclude that elderly people represent a growing subgroup among patients with fractures of the acetabulum and might become the predominant cohort in acetabular surgery in the not too distant future.
Although among the elderly, women represent the vast majority of patients with insufficiency fractures of the pelvic ring, our data indicate that fractures of the acetabulum are more common in male individuals.21 This is consistent with the sex distribution in previously published analyses of younger cohorts and might be explained by the fact that severe osteoporosis, being a risk factor for fragility fractures of the pelvic ring, is more common in women.1,20,22,23
Bearing in mind that more than half the patients in our registry cohort had an age of 60 years or over when sustaining their injury and knowing that the age peaked at 75–80 years, it becomes obvious that at the present time elderly patients cannot be categorically excluded from surgical treatment for acetabular fractures. Although Letournel originally did not operate on any person aged 60 or over, more than 50% of those elderly patients in our registry cohort were treated with ORIF. However, nonoperative management was still significantly more frequent for patients over 60 years of age than younger patients. This might be explained by the fact that in older patients, severe comorbidities influence the indication for operative treatment more often than in younger individuals.
Our analysis has shown that elderly patients are at significantly higher risk to die during the hospital stay after sustaining a fracture of the acetabulum, when compared to younger individuals. Although in the regional cohort of the senior author's trauma center, the mortality did not differ significantly between surgically and nonoperatively treated elderly patients, the in-hospital mortality of elderly patients from the large registry cohort was significantly lower for patients treated with ORIF. This effect can most probably be explained by surgical selection bias, with the assumption that severe comorbidities of elderly patients are frequently a main contraindication for operative treatment. We therefore hypothesize that seriously multimorbid patients are more likely to be found in the subgroups of nonoperative treatment.
At the senior author's Level I trauma center, ORIF of an acetabular fracture was chosen for as much as 67% of patients aged 60 years or over. As mentioned above, surgical treatment did not prove to have a significant influence on in-hospital mortality in this subcohort. Furthermore, we found no significant differences in elderly patients' quality of life after operative or nonoperative treatment of acetabular fractures. The mean quality of life as indicated by the EQ-5D score was 0.57 for patients who had received treatment with ORIF after sustaining a fracture of the acetabulum at an age of 60 years or over (Table 5). When compared to the EQ-5D population norms (0.84 up to an age of 74 years and 0.77 for an age of 75 years and over), the quality of life decreased less than expected.24 Previously published data demonstrated a more drastic drop of the quality of life in elderly patients who had sustained an acetabular fracture.25
Our analysis of fracture patterns in the follow-up cohort showed a predominance of anterior fracture types in elderly patients. This is in line with current literature and emphasizes that the distribution of fracture types in geriatric patients differs markedly from the distribution in younger cohorts.20,26,27
The rate of secondary THR because of osteoarthritis for patients aged 60 years or over treated at the senior author's institution was 23% and therefore almost identical to the overall rate in the large cohort analyzed by Giannoudis et al.20 There was no significant difference in the rate of secondary THR comparing patients who had initially been treated with ORIF to patients who had been managed nonoperatively. This might be due to the fact that except for transverse fractures, the distribution of fracture types did not differ significantly in both groups and that most probably, less displaced fractures are more likely to be treated nonoperatively. Furthermore, we found that the 1-year mortality of elderly patients who had sustained a fracture of the acetabulum was 11%, which is considerably lower than the mortality after fractures of the proximal femur.28
In our opinion, the above-mentioned findings from the senior author's department emphasize that elderly patients with fractures of the acetabulum can and should be treated with ORIF if there is a surgical indication to do so. However, there are no universal treatment guidelines.29 Treatment decisions should be made strictly individually, taking into account the patients' comorbidities, functional needs, and previous level of activity.
We conclude that over the years, demographic change and medical advances have led to a completely new situation in the field of surgery for fractures of the acetabulum. Letournel's original aversion to operative treatment of geriatric acetabular fractures is no longer up to date. Today's acetabular fracture surgeons need to operate on patients older than 60 years with a reduced bone quality if they do not want to miss the best treatment mode for a relevant number of elderly patients.30 The presently high and still increasing number of geriatric acetabulum fractures in combination with increasing patients' demands and activity levels requires new strategies and an adaptation of surgical techniques to enable adequate surgical reduction and stabilization even for those patients with poor bone stock. The relatively low 1-year mortality with a low rate of conversion to secondary THR, comparable to series of younger patients, and the surprisingly high quality of life after 1 year justify intensified research, to enable even wider surgical indications after acetabulum fractures in the geriatric patient group.
Today, elderly persons represent the dominant cohort among patients with fractures of the acetabulum. Fifty-five years after the publication of Letournel's original case series, data indicate that currently, ORIF is a common and necessary option in the therapy of acetabular fractures in elderly patients.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
acetabular fracture; geriatric patients; surgical treatment; contraindications; demographic change