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Coned hemipelvis reconstruction for osteoporotic acetabular fractures in frail elderly patients
Samuel E McMahon1, Owen J Diamond1, Laurence A Cusick1
1Royal Victoria Hospital Belfast, Belfast, UK.
Insights
This study shows that a coned hemipelvis reconstruction with total hip arthroplasty (THA) is a safe and effective treatment for elderly patients with complex acetabular fractures, allowing immediate weight-bearing and maintaining mobility.
Area of Science:
- Orthopedic Surgery
- Geriatric Trauma
- Arthroplasty
Background:
- Complex displaced osteoporotic acetabular fractures in the elderly present significant morbidity and mortality risks.
- Surgical options for these fractures include open reduction internal fixation or total hip arthroplasty (THA).
- Severely comorbid patients often receive conservative treatment due to unfitness for extensive surgery.
Purpose of the Study:
- To evaluate the outcomes of a coned hemipelvis reconstruction and THA as a primary treatment for high-risk elderly patients with complex displaced acetabular fractures.
- To assess the safety and efficacy of this surgical approach in a vulnerable patient population.
Main Methods:
- A prospective study of 22 cases (21 patients) with a mean age of 79 years and a mean ASA score of 3.3.
- Patients underwent a coned hemipelvis reconstruction and THA via a posterior approach.
- Follow-up averaged 32 months, with assessments of mobility, functional scores, and complications.
Main Results:
- Mean operative time was 93 minutes, with 20 out of 21 patients achieving full weight-bearing on postoperative day 1.
- Mean hospital stay was 12 days, and preoperative mobility was maintained in 13 patients.
- One-year mortality was 9.5%, with no reported revisions, deep infections, or thromboembolic events.
Conclusions:
- Coned hemipelvis reconstruction bypasses the fracture, creating a stable construct for immediate full weight-bearing.
- The posterior approach minimizes operative time and physiological insult in frail elderly patients.
- This technique offers a safe surgical option for medically frail elderly patients with complex displaced acetabular fractures.
Aims:
Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.
Methods:
We have prospectively monitored a series of 22 cases (21 patients) with a mean follow-up of 32 months (13 to 59).
Results:
The mean patient age was 79 years (67 to 87), and the mean ASA score was 3.3 (3 to 5). Three patients had high-energy injuries and 18 had low-energy injuries. All cases were associated fractures (Letournel classification: anterior column posterior hemitransverse, n = 13; associated both column, n = 6; transverse posterior wall, n = 3) with medialization of the femoral head. Mean operative time was 93 minutes (61 to 135). There have been no revisions to date. Of the 21 patients, 20 were full weight-bearing on day 1 postoperatively. Mean length of hospital stay was 12 days (5 to 27). Preoperative mobility status was maintained in 13 patients. At one year, mean Merle d'Aubigné score was 13.1 (10 to 18), mean Oxford Hip Score was 38.5 (24 to 44), mean EuroQol five-dimension five-level (EQ-5D-5L) health score was 68 (30 to 92), and mean EQ-5D-5L index score was 0.68 (0.335 to 0.837); data from 14 patients. Mortality was 9.5% (2/21) at one year. There have been no thromboembolic events, deep infections, or revisions.
Conclusion:
The coned hemipelvis reconstruction bypasses the fracture, creating an immediately stable construct that allows immediate full weight-bearing. The posterior approach minimizes the operative time and physiological insult in this vulnerable patient population. Early results suggest this to be a safe addition to current surgical options, targeted at the most medically frail elderly patient with a complex displaced acetabular fracture. Cite this article: Bone Joint J 2020;102-B(2):155-161.
