Many older adults sustain a hip fracture every year. Increasing age combined with certain risk factors such as osteoporosis (decreased bone density) makes it more and more likely that an older adult will end up in the hospital with an acetabular fracture.
What’s an acetabular fracture? The acetabulum is the socket side of the hip joint. It is made of cartilage over bone just like every other joint. The reason it breaks is because the person falls (and lands) in such a way that the head of the femur (thigh bone) is driven up into the hip socket (acetabulum) with enough force to break bone.
When that happens, there can be a single break or fracture line but more often the acetabular bone breaks into many tiny pieces. That type of break is called a comminuted fracture. Older men are affected more often than women by this type of damage. Their femoral bones are thicker, stronger, and transfer a greater destructive force into the acetabulum. Women tend to develop a break in the neck of the femur — long before there is any force up into the socket.
Until recently, this type of fracture was always treated conservatively (without surgery). And many times, this is still the most appropriate treatment. The presence of dementia, poor health, severe bone loss, and nonambulatory status before the fracture are reasons why surgery may not be possible.
So long as the fracture isn’t displaced (shifted), those patients who could walk before the injury are allowed to walk with the support of a walker. But only minimal weight through the hip is allowed until healing occurs.
A physical therapist helps move the hip through its motions but with some limitations to protect it. Bedrest (even for displaced fractures) with tracton was once prescribed. But this is no longer recommended due to the many complications that arise with immobility in this age group (e.g., blood clots, bed sores, pneumonia, deconditioning).
Instead (with or without surgery), patients are encouraged to get up and move as early as possible. The goals of treatment for all acetabular fractures are four-fold: 1) restore the weight-bearing surface of the socket, 2) keep good bone stock (strength and density), 3) maintain joint stability, and 4) prevent deformities.
For those patients who will have to have surgery, there are several options. A procedure called open reduction and internal fixation (ORIF) pretty much describes what happens. The surgeon makes an incision to open up the hip, lines everything back up as much as possible, and uses plates, screws, pins, and/or wires to hold it all together until it heals.
The more closely the hip is restored to its normal shape and configuration, the better the results will be. The more bone fragments and the farther apart the bone fragments separate, the poorer the prognosis. If the patient is not a good candidate for ORIF (or if the ORIF procedure fails), then a total hip replacement may be the next step.
In some cases, it’s clear that the patient should have a hip replacement right from the start. The decision is made on a case-by-case (individual) basis. The surgeon evaluates the best way to reduce blood loss, minimize operative times, and prevent complications.
Of course, going right to a joint replacement surgery usually eliminates the need for a second surgery. Even so, whenever possible, the surgeon tries to save the joint by doing an ORIF first. Delaying the joint replacement by doing an ORIF first does not put the patient at increased risk for a poor result because of the two-stage surgery (ORIF then joint replacement). But it does increase the chances for additional complications along the way (e.g., infection, poor wound healing).
By reviewing all of the options, pros and cons, and factors in treating older adults with acetabular fractures, the authors of this article show us how complex and challenging the problem can be. The surgeon must take many things into consideration when developing the patient’s plan of care.
There have been enough studies done now to help guide the surgeon by providing prognostic factors. Being able to look back and see the final results for each treatment choice has helped pinpoint who should be treated by conservative (nonoperative) means, who needs surgery, and what type of surgery is best (ORIF, ORIF with delayed hip replacement, immediate hip replacement).