Fixation Versus Acute Total Hip Arthroplasty for Acetabular Fracture: A Cost-Effectiveness Analysis

The optimal treatment of acetabulum fractures in elderly patients is unknown. The purpose of this study was to review outcomes of open reduction and internal fixation (ORIF) or acute total hip arthroplasty (aTHA) and to determine the age threshold based on treatment using a cost-effectiveness decision model.

The PubMed database was queried for clinical English language studies from 2002 to 2022 (N > 10), of acetabular fracture patients age >50 years treated with either ORIF or aTHA. Revision surgery and mortality rates were collected. Costs were obtained from the National Inpatient Sample database. Health state utilities were converted to quality-adjusted life years, and a Markov decision analysis model was constructed. Sensitivity analyses were done with regard to the quality of life and cost variables.

Thirty studies met inclusion criteria, including 16 ORIF studies (N = 909) and 18 aTHA studies (N = 403). The ORIF cohort had a mean age of 71 years, follow-up of 3.5 years, mortality rate of 11.7%, and a conversion arthroplasty rate of 19.6%. The aTHA cohort had a mean age of 73 years, follow-up of 3.2 years, mortality rate of 10.7%, and a revision rate of 4.5%. Our model demonstrated that ORIF was a more cost-effective treatment for patients aged 67 years or younger and that aTHA was more cost-effective for patients aged 68 years and older. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost of ORIF and aTHA but highly sensitive to functional outcome variables in the model.

A review of 30 studies demonstrated a conversion arthroplasty rate of 19.6% for patients older than 60 years compared with a revision rate of 4.5% for patients treated with aTHA. Without considering fracture pattern or patient factors, we found that aTHA is a more cost-effective treatment than ORIF for treatment of acetabulum fractures in patients aged 68 years and older.

Economic Level III.