Management of Acetabular Fractures in the...
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47 Bulletin • Hospital for Joint Diseases Volume 62, Numbers 1 & 2 2004 T he aging epidemic is upon us. The “baby boomer” generation is entering the ranks of senior citizens and seniors are living longer thanks to medical advances. This change in population demographics has caused a new awareness among orthopaedic surgeons. The orthopaedic specialty is now treating more than 300,000 fracture hips, 16,000 pelvic fractures, and 3000 acetabular fractures annually. Fractures of the hip are usually managed by surgical intervention to decrease pain, decrease medical co-morbidities, and to retain or improve function. 1-3 Acetabular fractures are uncommon compared to other fractures; however, they are increasing as people function to a later age. Fractures in the elderly differ from those in the younger adult acetabular trauma patient. Younger patients usually suffer injury through high velocity trauma. However, in the elderly the usual mechanism of injury is a fall from a low height with minimal velocity 4 and many of these fractures are called insufficiency fractures since they are associated with osteopenia and osteoporosis. The treatment of these fractures continues to undergo change with a trend to surgical intervention. Surgery is chosen when possible to decrease pain and improve function. 5 The goal is to offer the geriatric patient one procedure that has the highest expectation of success. The Orthopaedic Trauma Service at Mount Sinai has treated patients with simple and complex acetabular fractures where indicated. Our initial experience with complex fractures was unsatisfactory with open reduction and internal fixation. Patients required further interventions, with most needing total hip arthroplasty. This procedure proved to be complicated by previous procedures and our experience in other areas of the skeleton with primary arthroplasty led us to primary joint arthroplasty in certain acetabular fractures. Patient Selection Eleven patients were included in this series. The age of the patients ranged from 67 to 78 years. There were 3 males and 8 females. Fracture patterns were transverse in 5 (1 males and 4 females); posterior wall in 3 (1 male and 2 females); posterior column and wall in 1 (a female); one transverse and posterior wall (a female); and 1 with associ- ated femoral neck fracture. All patients were admitted to our hospital within 10 days of the injury. Six patients came through the Mount Sinai Emergency Department and the other five were transferred from other institutions for tertiary and definitive care. All patients had incongruity, instability, or both. No patient experienced dislocation. There were no nerve palsies de- tected. Basic preoperative trauma protocols were used. Hydra- tion, transfusion, and hematological review of platelet and cell morphology were instituted. Neurological examination was performed by the surgeon, orthopaedic house staff, as well as a board certified neurologist. Six of the 11 patients had Greenfield filters placed preoperatively. Indications for insertion of a filter included cardiac and pulmonary disease, obesity, and preoperative venous insufficiency. 6 Surgery was performed on 5 patients within 2 days of admission, 3 patients within 3 days, and 3 patients with 5 days. All patients were placed on low molecular weight heparin prior to surgery and continued postoperatively until discharged. One aspirin daily was prescribed after discharge for life. Indications for surgery were determined after standard radiographic evaluation. These studies included, plain radiographs [anteroposterior pelvis; anteroposterior and lateral of involved hip; and Judet views – obturator (in- Elton Strauss, M.D., is at the Mount Sinai Medical Center, New York, New York. Correspondence: Elton Strauss, M.D., Mount Sinai Medical Center, 5 East 98th Street, Box 1188, NewYork, NewYork 10029 Management of Acetabular Fractures in the Elderly Elton Strauss, M.D.
Transcript of Management of Acetabular Fractures in the...
47 Bulletin• Hospital for Joint Diseases Volume62,Numbers1&2 2004
Theagingepidemicisuponus.The“babyboomer”generationisenteringtheranksofseniorcitizensand seniors are living longer thanks to medical
advances.This change in population demographics hascausedanewawarenessamongorthopaedicsurgeons.Theorthopaedicspecialtyisnowtreatingmorethan300,000fracturehips,16,000pelvicfractures,and3000acetabularfracturesannually.Fracturesofthehipareusuallymanagedbysurgicalinterventiontodecreasepain,decreasemedicalco-morbidities,andtoretainorimprovefunction.1-3
Acetabularfracturesareuncommoncomparedtootherfractures;however,theyareincreasingaspeoplefunctiontoa laterage.Fractures in theelderlydiffer fromthosein theyoungeradultacetabular traumapatient.Youngerpatientsusuallysufferinjurythroughhighvelocitytrauma.However,intheelderlytheusualmechanismofinjuryisafallfromalowheightwithminimalvelocity4andmanyofthesefracturesarecalledinsufficiencyfracturessincetheyareassociatedwithosteopeniaandosteoporosis. Thetreatmentofthesefracturescontinuestoundergochange with a trend to surgical intervention. Surgeryischosenwhenpossible todecreasepainandimprovefunction.5Thegoalistoofferthegeriatricpatientoneprocedurethathasthehighestexpectationofsuccess.TheOrthopaedicTraumaServiceatMountSinaihastreatedpatientswith simple and complex acetabular fractureswhere indicated. Our initial experience with complexfractures was unsatisfactory with open reduction andinternalfixation.Patientsrequiredfurtherinterventions,withmostneedingtotalhiparthroplasty.Thisprocedureprovedtobecomplicatedbypreviousproceduresandourexperience inotherareasof theskeletonwithprimary
arthroplastyledustoprimaryjointarthroplastyincertainacetabularfractures.
Patient SelectionElevenpatientswereincludedinthisseries.Theageofthepatientsrangedfrom67to78years.Therewere3malesand8females.Fracturepatternsweretransversein5(1malesand4females);posteriorwall in3(1maleand2females);posteriorcolumnandwallin1(afemale);onetransverseandposteriorwall(afemale);and1withassoci-atedfemoralneckfracture. Allpatientswereadmittedtoourhospitalwithin10daysoftheinjury.SixpatientscamethroughtheMountSinaiEmergencyDepartmentandtheotherfiveweretransferredfromotherinstitutionsfortertiaryanddefinitivecare.Allpatientshad incongruity, instability,orboth.Nopatientexperienceddislocation.Therewerenonervepalsiesde-tected. Basicpreoperativetraumaprotocolswereused.Hydra-tion,transfusion,andhematologicalreviewofplateletandcellmorphologywereinstituted.Neurologicalexaminationwasperformedbythesurgeon,orthopaedichousestaff,aswellasaboardcertifiedneurologist.Sixofthe11patientshadGreenfieldfiltersplacedpreoperatively.Indicationsforinsertionofafilterincludedcardiacandpulmonarydisease,obesity,andpreoperativevenousinsufficiency.6
Surgerywasperformedon5patientswithin2daysofadmission,3patientswithin3days,and3patientswith5days.Allpatientswereplacedonlowmolecularweightheparin prior to surgery and continued postoperativelyuntil discharged.Oneaspirindailywasprescribedafterdischargeforlife. Indicationsforsurgeryweredeterminedafterstandardradiographic evaluation. These studies included, plainradiographs [anteroposterior pelvis; anteroposterior andlateralof involvedhip;andJudetviews–obturator (in-
EltonStrauss,M.D.,isattheMountSinaiMedicalCenter,NewYork,NewYork.Correspondence:EltonStrauss,M.D.,MountSinaiMedicalCenter,5East98thStreet,Box1188,NewYork,NewYork10029
Management of Acetabular Fractures in the Elderly
Elton Strauss, M.D.
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ternal)obliqueandiliac(external)oblique].Allpatientsunderwent computerized axial tomography with 3 mmcutsperformedthroughtheacetabulum.7-9Allradiographsyieldedpatternsofinstability,incongruity,orboth. All of the patients were treated through a posterior-lateral Kocher-Langenbeck approach.10 Cell saver wasutilizedonallcases.Prophylacticantibioticswereusedfor48hours.Thepatientswerepositionedonanimagetablewith a radiolucentpelvicholder.Base line imageswiththeimageintensifierweretakenandsaved.Atrochantericosteotomywasindicatedin5patients.Theosteotomywasusefulforexposureofthefractureaswellasidentificationofthesciaticnerve. The preoperative goals were: a stable rather than ananatomicalreduction,tosupportbonelosswithautograftor allograft, and to stabilize the anterior and posteriorcolumnswithcannulatedlongandlarge(greaterthan4.5mm)screws.
Primaryreductionwasmadeafterthefemoralheadwasremoved.Thereductionwasmadeandheldwithlargepel-vicandacetabularclamps.Cannulatedwiresweredrilledeitherfromtheinsideoroutsideof theacetabulum(Fig1).Thiswasmadeeasiersincetheheadwasremovedandtheshaftmobilizedoutoftheway. Oncethecolumnswererestoredthepatient’sacetabu-lumwastreatedasatotaljointarthroplasty.Revisionprin-cipleswereutilized.Theseincludedastablerimconstructthatwouldsupportanacetabularcup(Fig.2). This exposure and construct made joint replacementeasier.Theabilitytoworkinsideandoutsidetheacetabu-lumaidedthedecision-makingprocessforuncementedorcementedsupportcages.Despitesuggestionsmadebyotherinvestigators,11-13therewasnoattempttoreconstructthemedialwall,oncethesocketwasrestoredgraftmaterialandsmallerguidewireswereplaced.Insomecasesthewirescouldbeplacedfromwithinthefracturedsocket;pushed
Figure 1 AandB,Techniqueofacetabularreconstructionafterheadisremoved.Largeguidepinsforcannulatedscrewsareadded.C,Acetabularcageisinsertedafterprimaryfixationwithscrews.
A B
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retrogradeandthenantegradeafterplacementoftheshellorcage. Once the acetabulum was stabilized, an uncementedcuporacetabularshellwithacementedcupwaschosen.In 7 cases a multiple hole hydroxyapatite cup (Stryker,Allendale, N.J.) was used; a GAP shell with cementedpolyethyleneliner(Stryker,Allendale,N.J.)wasusedin4cases(Fig3). Thefemoralsidewastreatedwithanantibioticimpreg-natedcementandstem.TrochanterfixationwasperformedwithDall-Milescables(Stryker,Allendale,N.J.).
Case ExampleA74-year-oldfemalesufferedafallonalocalsidewalk.She struck her left knee with a force that resulted in atransversefractureoftheleftacetabulum.Herco-morbidi-tiesincludedhypertension,type2diabetesmellitus,andvenousstasis.After initial stabilization includingplace-
mentofaGreenfieldfilter,surgerywasperformedthroughaKocher-Langenbeckapproach.Atrochantericosteotomywasneeded(Fig.4).
ResultsAverage anesthesia time was 5 hours and the averagebloodlosswas3units.Nonervepalsieswereobserved.Alltrochantersunited.Everypatientwasabletosurvivesurgeryandambulatewithexternalsupport.At4monthspostoperatively,eightpatientsusedawalker,twopatientsusedacane,andonepatientwaswalkingwithoutsupport.(Subsequentlythreepatientsdiedfromcausesunrelatedtotheoperativeinterventionintheperiodrangingfrom6to14monthspost-injury). Theeightsurvivorsareallambulatingindependently.Sixcurrentlyusewalkers,threeuseacane,andoneam-bulateswithoutsupport. Theprosthesisboneinterfaceshaveremainedconstant.
Figure 2 Flowchart demonstrating the deci-sion-making process for acetabular fracturereconstruction.
Figure 3A,Acetabularshellforusewithcementedliner.B,Uncementedshellusedwithgoodrim(column)fit.
BA
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Norevisionshavebeenneededorsuggested.Theareasthatwerebonegraftedhaveconsolidated.Thescrewfixationhasremainedunchanged. Complicationshavebeenfew.Onedeepinfectionwasobservedatfourweekspostoperatively.Itwasinafemalepatientwithatransversefracturepatterntreatedwithanacetabularshell.Treatmentwasbyradicaldebridement,dislocationofthejoint,exchangeofapolytoaconstrainedliner.Postoperativesuppressionantibioticscontinueone-year postoperatively. She currently lives semi-indepen-dently in an adult community complex. She ambulateswithawalker. Surprisinglynocasesofheterotopicossificationhavebeen observed.14,15 Patients were not given radiation ornon-steroidalanti-inflammatorydrugs.
DiscussionAgingisallaboutfunction.Mostofourseniorsneedtomaintaintheirindependenceandlifestyle.Recentadvancesinprostheticreplacementofotherjointshaveencouragedthistreatmentofthedifficultacetabularfracture. Revision totalhipswithacetabulardeficiencycanbeproblematic.16-18ManyarthroplastysurgeonsusetheAAOSclassificationsystemforacetabulardeficiency.19Ourcon-clusionwasthatmanyofthesefracturesweresimilartoatype4pelvicdiscontinuity(Fig.5).
JolyandMearsstatedthat“certainacetabularfracturespossessanintrinsicallyabysmalprognosisirrespectiveoftheinitialmethodoftreatment.”20Openreductioninternalfixationispreferredandthoughttoofferthehighestchance
Figure 4A74-year-oldfemalethatsufferedalowvelocityfallwhilewalkingonthestreet;A,Transversefracturepattern;B,reconstruc-tionwithanacetabularcage,cementedliner,andcementedstem.
Figure 5IllustrationofanAAOStypeIVpelvicdiscontinuity;similartocolumndisruptionafteracetabularfracture.
B
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ofafavorablefunctionaloutcomeaftermostdisplacedac-etabularfractures.21However,prognosisispoorforcertaininjurypatternsandintheelderly.LetournelandJudetaswellasMattaattributedunfavorableoutcomesofanteriorandposteriorwallaswellasposteriorcolumnfracturestoelderlyosteoporoticbone.Theyobservedthebestresultsinyounghealthyadultsandtheworstoutcomesinpatientsovertheageof50(particularlyinfemales).22,23
Acetabularfracturesintheelderlyhavemarkedcom-minution,underlyingarthritis,impactionofarticularsur-faces,andassociatedfracturesofthepelvisandfemoralneck.Impactionofthearticularsurfacehasbeenshowntosignificantlyimpacttheprognosis.24,25
Morethan10millionAmericanssufferfromosteoporo-sisandosteopenia.Another18millionareatrisk.Tencerhasshownthatosteoporosissignificantlyaffectsfracturefixation.Thisisdemonstratedbyadecreaseinthediameteroftrabecularbone,lossofbonemassandshearstrength,andlossofinterconnectingstrutsaswellascompressivestrength.Screwpullout isaffectedby theabovemecha-nisms.26
Asalludedtopreviouslyinthisreview,Mears,Velyvis,Chang,andothersreviewedcausesofsuccessandfailureindisplacedacetabularfracturestreatedbyopenreductionandinternalfixation.Theyconcludedthatage,bonequality,impaction,underlyingarthritis,andcomorbidityplayedasignificantrole.Evenwithimprovedfixationtechniquessuchascables,Mearsandcolleaguesalludedtothefacttheprimaryreplacementmaybebetterforthepatient.Hisgroupreportedon63caseswith27patientshavingsevereosteoporotic bone. Supplementation of the fixation wasperformedaswellastheuseofamulti-screwedcupactingas“hemispherical”plate.Thegroupstressedmedialwallreconstruction for primary socket stability. Our successwithrevisionarthroplastyusingrimsupportnegatedtheabovepremiseinourpatientgroup. Late total hip arthroplasty after open reduction andinternal fixation can be complicated and unrewarding.Complications secondary to previous surgery includeheterotopicbone,proliferativescar,obstructivehardware,occult infection, ischemic muscle and poor soft tissue,nerveandvesselentrapment,bonedefectsandnonunion(especiallyinnon-operativetreatmentordelayedsurgery).Pooroutcomefunction(HarrisHipScore)hasbeenassoci-atedwiththisgroup.27
ConclusionSurgeryforacetabularfracturesneedstobeindividualized.Thinkingmustincludethepremisethatallosteopenicboneis pathological. Open reduction internal fixation mustimprovetheprognosisandnotcausecomplications.Think-ingthatprimaryopenreductionisthefirstofatwostageprocedureiscompromisingthegeriatricpatient.Primarytotaljointarthroplastycanbesuccessfulifthesocketcanbestabilizedeitherwitharim-fituncementedcuporwith
acementedacetabularcage.Timeoftheprocedureandco-morbiditiesmustbeconsidered.Immediatemobilizationofthepatientmustbethegoal. Thesefracturesaredifficultandchallengingfromallperspectives.Workinthisfieldcontinuestoevolve.Furtheroutcomestudiesareneeded,particularlyfrommulticenterlocations.However,theproblemisuponusandmustbeconfronted with a well planned and executed surgicalintervention.Thegoalisafunctioningpatientwhoisabletomaintainhisorherindependence.
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