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Geriatric Acetabular Surgery

Letournel's Contraindications Then and Now—Data From the German Pelvic Registry

Herath, Steven C. MD*; Pott, Hendrik*; Rollmann, Mika F. R. MD*; Braun, Benedikt J. MD*; Holstein, Jörg H. MD*; Höch, Andreas MD; Stuby, Fabian M. MD; Pohlemann, Tim MD*

Journal of Orthopaedic Trauma: February 2019 - Volume 33 - Issue - p S8–S13
doi: 10.1097/BOT.0000000000001406
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Objective: In his original series of 129 surgically treated acetabular fractures, Letournel did not operate on patients older than 60 years. Almost 30 years later, he still emphasized that no patients with reduced bone quality should be operated on. The aim of the study was to analyze epidemiologic characteristics and treatment modes for today's cohort of elderly patients with acetabular fractures.

Design: Retrospective analysis.

Setting: Multicenter registry/Level I trauma center.

Patients: Three thousand seven hundred ninety-three patients who had sustained a fracture of the acetabulum.

Intervention: Operative and nonoperative treatment of acetabular fractures.

Main Outcome Measurements: Epidemiologic characteristics, treatment mode, in-hospital mortality, rate of secondary hip arthroplasty, and quality of life indicated by EQ-5D score.

Results: For the multicenter registry, more than 50% of all patients with acetabular fractures had an age of 60 years or over. The age peak was found at 75–80 years. Fifty percent of the elderly patients were treated surgically. The in-hospital mortality was significantly higher in elderly patients than patients younger than 60 years. In our Level I trauma center, surgical treatment by open reduction and internal fixation did not influence in-hospital mortality or quality of life of elderly patients with acetabular fractures.

Conclusions: 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, surgical treatment is a common and necessary option in the therapy of acetabular fractures in elderly patients.

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

*Department of Trauma, Hand and Reconstructive Surgery, Saarland University, Homburg, Germany;

Department of Orthopaedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany; and

BG Trauma Center, Murnau, Germany.

Reprints: Steven C. Herath, MD, Department of Trauma, Hand and Reconstructive Surgery, Saarland University, Building 57, Kirrberger Str. 100, 66421 Homburg, Germany (e-mail: steven.herath@uks.eu).

The authors report no conflict of interest.

Accepted November 08, 2018

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INTRODUCTION

Émile Letournel, generally accepted as the pioneer of acetabular fracture surgery, introduced a comprehensive classification for those injuries in the 1960s, which with minor modification is still in current use.1,2 Together with Robert Judet, he defined surgical approaches and rules for open reduction of acetabular fractures, which remain as the mainstay procedures in acetabular surgery.1,3 Letournel's dedication to the pursuit of excellence in acetabular surgery led to the publication of the textbook Fractures of the Acetabulum, which has become a classic medical text and the main reference manual for all acetabular fracture surgeons.4

In their series of 129 surgically treated acetabular fractures that was reported in 1964, Letournel and Judet did not operate on any patients older than 60 years.1 In the second edition of his book, which was published in 1993, Letournel stated that age alone should no longer be seen as a contraindication for acetabular surgery; however, he still identified reduced bone quality, specifically defined as “osteopenia of the innominate bone” as a contraindication to surgery.5 In 1993, with more than 30 years of experience in acetabular surgery and reporting on 940 fractures treated, Letournel had operated on only 2 patients older than 80 years.5

Because of ongoing demographic change, today's orthopaedic surgeons are confronted with an increasing number of elderly patients who are still physically active. Their reduced bone stock, however, brings an increased risk to sustain trauma-related injuries.6,7 Currently, more than 70% of all pelvic fractures occur in geriatric patients.8,9 Furthermore, fractures of the pelvis, including the subset of acetabulum fractures, account for about 7% of all osteoporotic fractures.10 According to data from the German Pelvic Registry, acetabular fractures in patients of more than 65 years of age are the fastest growing entity among pelvic injuries.11,12 This is in line with international literature, stating that elderly persons represent the most rapidly growing group of patients sustaining fractures of the acetabulum.13,14

Given the demographic change and bearing in mind the fact that even small step-offs in the articular surface of the acetabulum and incongruity of the joint can lead to posttraumatic osteoarthritis, it may be hypothesized that at the present time, orthopaedic surgeons should no longer defer to Letournel's original aversion to the operative treatment of geriatric acetabular fractures.15–17

The aim of the present study was to analyze epidemiological data from the German Pelvic Registry to identify and further characterize the current cohort of patients with acetabular fractures and an age of 60 years or more with this age group serving as a marker for pelvic osteopenia. We hypothesized that the demographic changes over the last decades have led to a new situation in the field of geriatric acetabular surgery.

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METHODS

Data from the German Pelvic Registry was analyzed retrospectively.12 The registry is operated by a multicenter study group consisting of experts from the German Trauma Society (DGU). Each participating center commits to include consecutive annual series of admitted trauma patients with a pelvic fracture, which includes the subset of those with a fracture of the acetabulum, into the registry. For the present study, the search was limited to a 15-year time period from 2002 to 2017 and included all patients with a documented acetabulum fracture. We aimed to compare the cohort of patients aged 60 years and over to the cohort of younger patients, focusing on the rate of treatment with open reduction and internal fixation (ORIF) and in-hospital mortality. Furthermore, we compared elderly patients treated nonoperatively to those treated with ORIF regarding the in-hospital mortality.

In addition, we analyzed for the same time period (2002–2017) data of a subcohort of patients treated in the senior author's institution (a Level I trauma center according to the classification of the German Trauma Society, which is equivalent to the rating of the American College of Surgeons).18,19 These data from the senior author's hospital database were used to epidemiologically characterize the cohort of patients with acetabular fractures and the subgroup of patients aged 60 years and older, subdivided into ORIF and nonoperative treatment. We analyzed the fracture patterns, the 1-year mortality of geriatric patients with acetabulum fractures and the rate of secondary conversion to total hip replacement (THR). Using the EQ-5D score, we additionally assessed the quality of life for elderly patients at least 1 year after sustaining an acetabular fracture. All data were obtained from the registry or the senior author's hospital database and routine follow-up examinations.

For comparison of numeric values, Student t test was used after proving data for normal distribution (Kolmogorov–Smirnov test) and equal variance (F-test). The χ2 test and Fisher exact test for small sample sizes were used for nominal data. A P value less than 0.05 was considered to indicate a significant difference. All statistical analyses were performed using the SigmaPlot software package (SYSTAT Software Inc, San Jose, CA).

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RESULTS

A total of 3793 complete datasets of patients with acetabular fractures were identified in the German Pelvic Registry. The mean age of the patients was 58.6 ± 21.6 years (range 8–105 years). The detailed age distribution is shown in Figure 1. The majority of the patients were male (69.1%) and 2166 (57.1%) were treated operatively by ORIF.

FIGURE 1

FIGURE 1

Of these 3793 patients identified in the German Pelvic Registry, 1914 (50.5%) were 60 years of age or more when sustaining the injury (mean age 76.6 ± 9.5 years). Thousand one hundred ninety-three (62.3%) of those patients were men. In this subgroup of 1914 geriatric patients, 967 (50.5%) patients were treated by ORIF, although of the patients less than 60 years of age, 1199 (63.8%) underwent this surgery. The frequency of ORIF was significantly higher in patients younger than 60 years (P < 0.001).

The overall in-hospital mortality was 4.1%. In the group of patients aged 60 years and over, 5.3% died during the hospital stay. Among patients younger than 60 years, the in-hospital mortality was significantly lower (2.8%; P < 0.001). Of interest, the mortality of elderly patients treated surgically was significantly lower than the mortality of elderly patients who were treated nonoperatively (P = 0.01). A detailed comparison and statistical analyses of specific subgroups from the registry are shown in Tables 1 and 2.

TABLE 1

TABLE 1

TABLE 2

TABLE 2

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).

TABLE 3

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).

TABLE 4

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).

TABLE 5

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).

TABLE 6

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).

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DISCUSSION

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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REFERENCES

1. Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am. 1964;46:1615–1646.
2. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;151:81–106.
3. Judet R, Judet J, Lanzetta A, et al. Fractures of the acetabulum: classification and guiding rules for open reduction [in Italian]. Arch Ortop. 1968;81:119–158.
4. Letournel E, Judet R. Fractures of the Acetabulum. Berlin, Germany; New York, NY; Heidelberg, Germany: Springer-Verlag; 1981.
5. Letournel E, Judet R. Fractures of the Acetabulum. Berlin, Germany; New York, NY; Heidelberg, Germany: Springer-Verlag; 1993.
6. Champion HR, Copes WS, Buyer D, et al. Major trauma in geriatric patients. Am J Public Health. 1989;79:1278–1282.
7. Dechert TA, Duane TM, Frykberg BP, et al. Elderly patients with pelvic fracture: interventions and outcomes. Am Surg. 2009;75:291–295.
8. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37:691–697.
9. Fuchs T, Rottbeck U, Hofbauer V, et al. Pelvic ring fractures in the elderly: underestimated osteoporotic fracture [in German]. Unfallchirurg. 2011;114:663–670.
10. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005–2025. J Bone Miner Res. 2007;22:465–475.
11. Ochs BG, Marintschev I, Hoyer H, et al. Changes in the treatment of acetabular fractures over 15 years: analysis of 1266 cases treated by the German pelvic multicentre study group (DAO/DGU). Injury. 2010;41:839–851.
12. Pohlemann T, Tosounidis G, Bircher M, et al. The German multicentre pelvis registry: a template for an european expert network? Injury. 2007;38:416–423.
13. Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg. 1999;7:128–141.
14. Pagenkopf E, Grose A, Partal G, et al. Acetabular fractures in the elderly: treatment recommendations. HSS J. 2006;2:161–171.
15. Giannoudis PV, Tzioupis C, Papathanassopoulos A, et al. Articular step-off and risk of post-traumatic osteoarthritis. Evid Today Inj. 2010;41:986–995.
16. Brinckmann P, Frobin W, Hierholzer E. Stress on the articular surface of the hip joint in healthy adults and persons with idiopathic osteoarthrosis of the hip joint. J Biomech. 1981;14:149–156.
17. Carter DR, Rapperport DJ, Fyhrie DP, et al. Relation of coxarthrosis to stresses and morphogenesis: a finite element analysis. Acta Orthop Scand. 1987;58:611–619.
18. Aprahamian C, Wolferth CC Jr, Darin JC, et al. Status of trauma center designation. J Trauma. 1989;29:566–570.
19. Siebert H. White book of severely injured - care of the DGU. Recommendations on structure, organization and provision of hospital equipment for care of severely injured in the Federal Republic of Germany [in German]. Unfallchirurg. 2006;109:815–820.
20. Giannoudis PV, Grotz MR, Papakostidis C, et al. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. J Bone Joint Surg Br. 2005;87:2–9.
21. Rommens PM, Hofmann A. Comprehensive classification of fragility fractures of the pelvic ring: recommendations for surgical treatment. Injury. 2013;44:1733–1744.
22. Breuil V, Roux CH, Testa J, et al. Outcome of osteoporotic pelvic fractures: an underestimated severity: survey of 60 cases. Joint Bone Spine. 2008;75:585–588.
23. Melton LJ III, Chrischilles EA, Cooper C, et al. How many women have osteoporosis? JBMR anniversary classic: JBMR, volume 7, number 9, 1992. J Bone Miner Res. 2005;20:886–892.
24. Janssen B, Szende A. Population norms for the EQ-5D. In: Szende A, Janssen B, Cabases J, eds. Self-Reported Population Health: An International Perspective Based on EQ-5D. Dordrecht, The Netherlands: Springer Open; 2014:19–30.
25. Tosounidis G, Culemann U, Bauer M, et al. Acetabular fractures in the elderly: outcome of open reduction and internal fixation [in German]. Unfallchirurg. 2011;114:655–662.
26. Butterwick D, Papp S, Gofton W, et al. Acetabular fractures in the elderly: evaluation and management. J Bone Joint Surg Am. 2015;97:758–768.
27. Ferguson TA, Patel R, Bhandari M, et al. Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study. J Bone Joint Surg Br. 2010;92:250–257.
28. Cenzer IS, Tang V, Boscardin WJ, et al. One-year mortality after hip fracture: Development and validation of a prognostic index. J Am Geriatr Soc. 2016;64:1863–1868.
29. Manson TT, Reider L, O'Toole RV, et al. Variation in treatment of displaced geriatric acetabular fractures among 15 level-I trauma centers. J Orthop Trauma. 2016;30:457–462.
30. Rickman M, Varghese VD. Contemporary acetabular fracture surgery: treading water or swimming upstream? Bone Joint J. 2017;99-B:1125–1131.
Keywords:

acetabular fracture; geriatric patients; surgical treatment; contraindications; demographic change

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