ORIGINAL ARTICLE

The Combined Hip Procedure: Open Reduction Internal Fixation Combined With Total Hip Arthroplasty for the Management of Acetabular Fractures in the Elderly
Dol Herscovici, Jr, DO,* Eric Lindvall, DO, Brett Bolhofner, MD, and Julia M. Scaduto, ARNP*

Objective: The objective of this study was to evaluate acetabular

fractures in elderly patients treated with open reduction internal xation combined with acute total hip arthroplasty during the same anesthetic.

but a single posterior surgical procedure will avoid the wait-andsee approach often used for these patients. Key Words: fracture, acetabulum, elderly, combined hip (J Orthop Trauma 2010;24:291296)

Design: The authors conducted a retrospective analysis of a treatment. Setting: Level I and Level II trauma centers. Patients: Between September 1995 through January 2005, 22 elderly patients were treated using the combined hip procedure. There were nine transverse/posterior wall patterns, seven anterior column/posterior hemitransverse patterns, and six presented as a both column injury. Six patients had hip dislocations and 14 patients demonstrated some impaction. Patients underwent medical evaluations and clearance before surgical intervention. Intervention: Standard open reduction internal xation techniques
followed by immediate total hip arthroplasty during the same anesthesia. Ilioinguinal patients were repositioned and redraped for total hip placement.

INTRODUCTION
Fractures of the acetabulum are usually the result of high-energy trauma. They occur predominantly in patients younger than age of 40 years1,2 and, if displaced, are managed with open reduction and internal xation. Restoration of the joint has been shown to decrease the development of posttraumatic arthritis35; however, even with an anatomic reduction, degenerative changes and avascular necrosis of the femoral head can occur.510 Despite these and other potential complications, the ability to anatomically restore displaced acetabular fractures has been accepted as the treatment of choice for most displaced fractures.57,913 In elderly patients, fractures of the acetabulum can also occur as a result of a high-energy injury. However, in the presence of osteoporosis or osteopenia, fractures may also result from moderate- or low-energy injuries such as a fall to the ground from a standing position.1,14,15 These falls can produce similar patterns of displacement and comminution along with impaction of the acetabulum and the femoral head. If the acetabular fracture in these patients is combined with pre-existing arthritis or any substantial associated medical comorbidity,16 management other than open reduction and internal xation may be used. This may consist of conservative or nonoperative care, insertion of a primary or acute total hip arthroplasty, the use of a delayed total hip arthroplasty, or even the potential use of an open reduction internal xation technique.14,1722 Although nonoperative care,23,24 acute total hip arthroplasty,25,26 a delayed total hip replacement,17,27,28 and the use of an open reduction internal xation technique11 have all been described as treatment options, poor outcomes may occur as a result of poor bone quality or unstable pelvic column injuries. To improve outcomes, a complex approach may be necessary to address elderly patients presenting with these injuries.14,15,21,22,25,29 The purpose of this article is to present a retrospective review on the management and outcomes of the combined hip procedure (CHP), consisting of open reduction internal xation (ORIF) of the acetabulum combined with an acute total hip arthroplasty (THA), during the same anesthetic,
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Main Outcome Measurements: Complications, physical examinations, and Harris hip scores assessed outcomes. Radiographs evaluated union and stability of the femoral and acetabular components, osteolysis, or the development of any heterotopic bone. Results: Follow up averaged 29.4 months. Surgeries averaged 232 minutes with 1163 mL average blood loss. Hospital stays approximated 8 days with full weightbearing occurring at 3 months. Hip motion averaged 102 of exion, 32 of abduction, and 16 of adduction. Harris hip scores averaged 74. Four patients developed heterotopic ossication, and ve underwent revisions as result of osteolysis or multiple hip dislocations. Conclusions: The combined hip procedure is an option for
acetabular fractures in elderly patients. Complications, surgical times, and hospitalizations are consistent with open reductions or belated total hip arthroplasties. Aggressive medical workups may be needed,
Accepted for publication June 5, 2009. From the *Orthopedic Trauma Service, Florida Orthopaedic Institute, Tampa, FL; University Medical Center, Fresno, CA; and Bayfront Medical Center, St. Petersburg, FL. The authors have no nancial disclosures to report regarding this manuscript. Reprints: Dol Herscovici, Jr, DO, 13020 Telecom Parkway, N. Tampa, FL 33637 (e-mail: xbones@AOL). Copyright 2010 by Lippincott Williams & Wilkins

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for the management of specic (see inclusive criteria) acetabular fractures in elderly patients.

PATIENTS AND METHODS Patient Criteria

Using the trauma registry of two institutions, and after obtaining approval through the Institutional Review Board of both centers, we identied 2333 patients who presented with an acetabular fracture from September 1995 through January 2005. Fractures were classied using the descriptions of Letournel30 and of these, 482 patients (21%) were identied who were 60 years of age or older at the time of their injury. In this subset of patients, 223 (46%) underwent operative management for their acetabular fractures with 24 patients (24 fractures) treated using the CHP. Patients were considered for a CHP if they met the following criteria: elderly patients who also presented with signicant osteoarthritis of the hip,31 osteoporosis producing poor bone stock,32 or those presenting with associated femoral head fractures. Patients were excluded if they were bedridden preoperatively, presented with previous xation of the proximal femur, had a pathologic fracture, previous infections about the hip, a previous total or hemiarthoplasty of the hip, had such severe medical comorbidities such as severe senile osteoporosis33 that it precluded any structural repair of the pelvic ring, or any surgical intervention or evaluations of the medical service precluded any surgical intervention. After using multiple methods to nd missing patients,34 two patients were lost leaving 12 males and 10 females with an average age of 75.3 years (range, 6095 years). Five patients were injured secondary to a motor vehicle accident, whereas the remaining 17 sustained fractures as a result of a low-energy fall. All 22 patients had at least one pre-existing medical problem. All underwent standard anteroposterior, iliac, and obturator oblique radiographs, computed tomography and three-dimensional computed tomography scans, medical evaluation, and medical optimization before surgical intervention and only ve presented with an isolated acetabular fracture. Six patients had documented hip dislocations at the time of their injury, 14 patients demonstrating some impaction of the their fracture; all 22 had one or more of the inclusion criteria necessary for enrollment and no patient presented with an injury to the sciatic nerve. Evaluating the fractures demonstrated that all patients had signicant (more than three fragments) comminution with ve demonstrating apparent bone loss of the acetabulum. Nine patients had involvement of the femoral head. Fractures were classied30 as nine transverse/posterior wall patterns, seven anterior column/posterior hemitransverse patterns, and six presented as a both column injury.

been scheduled but was converted intraoperatively to a CHP as a result of inadequate bone stock precluding xation. The operative management consisted of stabilization of the fracture using standard open reduction internal xation techniques30 followed by immediate THA during the same anesthesia. All acetabular fractures were approached using either a KocherLangenbeck (KL) or an ilioinguinal approach. (IL-L).30 Although infrequent, the decision to use an IL-L approach was based on the preoperative decision that a posterior approach would not provide sufcient stability of the columns to allow implantation of the acetabular component.13,35 Patients who had their fractures managed through an ilioinguinal approach then repositioned and redraped to allow for the placement of a THA using a posterior or posterolateral approach. A Ganz ring acetabular component (Protek, Berne, Switzerland) and Sultzer (Austin, TX) femoral component were used in six patients, whereas the Osteonics Total Hip Arthroplasty (Stryker, Kalamazoo, MI) was used in the remaining 16 patients. As a result of acetabular deciencies, six patients were bone-grafted using the femoral head. Based on surgeon preference, all but two femoral components were cemented, whereas half the patients had cemented acetabular components and postoperatively, three patients were given low-dose radiation and one was given Indocin, whereas the remaining patients were treated without heterotopic prophylaxis. The patients undergoing CHP were treated combining the total hip and postxation protocols. All patients began physical therapy on the rst postoperative day and were placed on partial weightbearing regimens for the rst 3 postoperative months. Patients unable to comply with a partial weightbearing regimen were initially managed with bed to chair transfers along with the use of a wheelchair until physical therapists felt they had achieved ample stamina to safely progress to gait training. Inpatient records were reviewed for the lengths of stay, lengths of surgery, intraoperative blood loss, and perioperative complications. At the nal follow up, all perioperative complications were recorded; physical examinations and the Harris hip scores36 were used to clinically assess patients. Radiographs were taken to evaluate union and stability of the femoral and acetabular components, the development of any osteolysis,37 or the development of any heterotopic bone.38

RESULTS
Follow up averaged 29.4 months (range, 1367 months) and all patients were found to have healed their acetabular fractures at an average of 3.1 months (range, 35 months). There were no cases of postoperative sciatic nerve injuries, intraoperative complications, hardware failures, or postoperative infections. Surgical times (skin-to-skin) for all patients averaged 232 minutes (range, 80510 minutes) with an average blood loss of 1163 mL (range, 3004500 mL). Although a cell saver was used during the entire length of surgery (Cell Saver 3 Plus or Cell Saver 5; Haemonetics, Braintree, MA), all patients had intraoperative transfusions averaging 3.5 units of packed red blood cells. Hospital stay for all patients averaged 8.1 days (range, 514 days) and the ability to bear full weight occurred at approximately 3.2 months
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Surgical Management
All patients underwent medical evaluations and clearance before surgical intervention. The CHP was performed by two surgeons (D.H. and B.B.) at an average of 5.1 days (range, 3322 days) from the initial injury. During this time, patients were placed into skeletal traction through the distal femur. Preoperative evaluations led to 19 patients scheduled for a primary CHP. In the remaining three patients, an ORIF had

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(range, 24 months). Hip motion for both groups averaged 102.2 of exion (range, 70120), 32 of abduction (range, 1040), and 16 of adduction (range, 530), whereas Harris hip scores averaged 74 (range, 4286). Nineteen of the 22 patients were treated using a KL approach. In these patients, treated through a single approach, the surgical times averaged 121 minutes (range, 96390 minutes), blood loss averaged 777 mL (range, 3502700 mL), with 2.9 units of packed red blood cells (range, 24 units) intraoperatively transfused, and lengths of stay averaging 7.7 days (range, 514 days). In the remaining three cases, treated using an IL-L approach, surgical times averaged 427 minutes (range, 375510 minutes), blood losses averaged 2225 mL (range, 8004500 mL), with an average of 5 units of packed red blood cells transfused (range, 48 units), and lengths of stay averaged 10.5 days (range, 514 days). Thirteen patients (59%) had postoperative complications; 10 related to their orthopaedic surgery. The three medical complications consisted of two patients developing urinary tract infections and a third patient who developed a transient ischemic attack. All were managed effectively using conservative means. The KL group had eight complications in 19 patients. Four patients developed heterotopic bone, two Grade I ossication, one developed Grade II, and the fourth had Grade IV. All were managed conservatively. In the remaining four patients, all underwent revision of both components. The rst reported thigh pain and had signicant osteolysis on radiographs of the femur in Zones 2 through 7.37 Suspicion was also present for some mild osteolysis of the acetabular component and at the time of revision; the acetabular component was loose and was also replaced. In the second patient, a fall produced loosening of the components requiring a revision of both. The last two patients had irreducible hip dislocations as a result of entrapment of the femoral head on the acetabular fracture that even with an open technique, we were unable to reduce. As a result of the demonstrated instability, both underwent revisions and were treated with a constrained-type THA (SROM ZTT; DePuy Orthopaedics, Division of Johnson and Johnson, Warsaw, IN). At nal follow up, the ranges of hip motion for all patients undergoing KL averaged 106.6 of exion (range, 85120); 33of abduction (range, 1040), 15 of adduction (range, 1020), and three patients lacked 5 to full extension. Gait demonstrated that ve ambulated without any aids; four required the use of a cane, four used a walker with one requiring an abduction brace, and one, as a result of dementia and a stroke, was wheelchair-bound. Harris hip scores for this group averaged 78.6 (range, 4286). In the IL-L group, there were two complications in three patients. One patient developed wound dehiscence of the total hip approach along with a contracture of the knee. Both problems were treated nonoperatively. The second patient sustained multiple (three) hip dislocations along with the identication of a Grade I heterotopic ossication. No osteolysis was noted, but a recommendation was made for a revision of the acetabular component in which the patient and family both declined. This group had 97.8 of hip exion (range, 70110), 31.3 of abduction (range, 1040), 17.5
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of adduction (range, 530) with only one patient lacking full extension. At follow up, two ambulated without any aids, one required a cane, and the last wore an abduction brace and used a walker. The Harris hip scores averaged 69.3 (range, 4282).

DISCUSSION
Good to excellent outcomes3,4,6 have been reported after using ORIF techniques for the management of displaced fractures of the acetabulum. Some authors have even described good results using an ORIF technique11 in the management of certain fractures in the elderly. However, not all acute acetabular fracture in elderly patients can or should be managed through ORIF. Some studies4,10,12,39,40 have reported that pre-existing arthritis, associated fracture patterns, marginal impaction, intra-articular fragments, lesions of the femoral head, suboptimal reductions of the fracture, with or without the presence of osteoporosis, and patients older than 55 years of age have demonstrated poor clinical outcomes when compared with other surgically managed acetabular fractures. However, elderly people are not necessarily household ambulators or wheelchair-bound patients; some perform at a high level of activity before their injury. Therefore, the goal in such patients is to salvage a functional way of life by restoring them to their preinjury level of activity. Acute THA may appear to be an attractive approach for the management of these patients. However, the fracture and the presence of osteoporosis may make it impossible to obtain adequate xation using hip replacements alone. Even if xation is obtained, hip arthroplasty components may subside as a result of instability at the fracture site.25,26 When a delayed THA is used for the management of these injuries, it is often viewed as a salvage procedure, because patients often present with posttraumatic arthritis and malreduction of the acetabulum with or without the development of avascular necrosis of the femoral head and/or the acetabulum. The reported outcomes of these patients have varied greatly. In patients who had undergone a closed treatment of their fracture, studies have shown that the presence of residual pelvic deformities, occult or frank nonunions, and bone loss41 can contribute to subsequent loosening of the prostheses. This results in poor outcomes with 30% and 40% of patients demonstrating radiographic loosening of femoral and acetabular components, respectively. This yields higher rates of failure than reported for patients treated with a THA for degenerative arthritis.20,27,28 Better results were reported by Bellabarba et al, who demonstrated that they were able to obtain good to excellent results in 90% of their patients who underwent THA after conservative management of an acetabular fracture.18 This wide variation in reported outcomes also exists in patients who have undergone a THA after a previous ORIF. Three separate studies have reported high rates of complications, including infections, development of heterotopic bone, and aseptic loosening, resulting in 36% to 51% of patients undergoing a revision of one or both components.17,19,42 In contrast, others have noted high rates of success in patients treated with THA after previous xation of acetabular fractures.18,28,43,44 Regardless of whether the initial management of the acetabular fracture was closed or through
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an open technique, the common ndings are that a THA can be more difcult to perform after an acetabular fracture, resulting in longer surgical times and greater amounts of blood loss.17,18,20,42 This study presents a different approach for acute acetabular fractures in the elderly. Although the majority sustained their injury as a result of a low-energy fall, the use a CHP was an attempt to avoid the difculties in dealing with the expected posttraumatic arthritis, the formation of dense scar tissue, heterotopic bone, and the atrophic or avascularity of the hip muscles.20,29,36 The surgical approach was one of aggressive management to stabilize the pelvic injury, which would decrease pelvic deformities and avoid bone loss, while performing an acute THA. Although the overall surgical times, intraoperative blood losses, and transfusion requirements were higher with patients undergoing a CHP than for patients undergoing THA as a result of degenerative arthritis,45,46 they appear to be fairly consistent for those patients who underwent a THA after an acetabular fracture.17,18 If the data are stratied to those patients who were treated through a single approach (KL), all three variables approximate those reported in a series of nontraumatic patients with arthritis. It is the treatment of the patients managed through two surgical exposures that tended to prolong surgeries, producing greater blood losses and higher needs for transfusions. The two-incision approach was used because there was concern that both the anterior column and quadrilateral plate could not be stabilized using a posterior approach. However, given the outcomes of these three patients and the options now available for cup xation of the acetabulum, avoidance of the IL-L approach and the use of a single posterior approach, augmented with the resected femoral head when necessary, has become the preferred treatment of choice at our center. In addition, the use of an arthroplasty surgeon for the placement of the total hip may also decrease operative times. Few articles discuss the management of acetabular fractures in the elderly using combined techniques. Although Weber et al17 and Bellabarba et al18 discussed the benet of restoring the osseous anatomy of the acetabulum, despite the subsequent development of osteoarthritis, and the use of plate xation for recognized nonunions, a few published series have discussed the use of cable xation for the management of acetabular fractures in the elderly.15,29 We do not have any personal experience using this technique, but the concern is that this technique may not be capable of managing column injuries or acetabular fractures in patients who present with signicant osteopenia.33 There are some concerns with using the CHP technique. First, such patients may require medical workups before surgery, which may prolong their lengths of stay. Although age is not necessarily a factor, consideration should be given to octogenarians and older regarding whether they can tolerate such an extensive approach. Second, the combination of these surgeries can be difcult even for surgeons familiar with the approach and management of acetabular fractures. Certainly, elective arthroplasty for osteoarthritis of the hip produces lower complications rates, but these are not routine surgeries. The displacement of the pelvic columns, with or without any history of osteoporosis (Figs. 14), may prevent the use of

FIGURE 1. Anteroposterior view of the pelvis in an 81-year old woman who fell at home after tripping on her carpet. Although the appearance suggests it, this patient did not dislocate her hip.

a limited approach. Therefore, surgeons attempting a CHP should recognize that higher complications rates can occur and that surgical times can be prolonged.1416,29 Third was the inconsistent xation of the acetabular cup. Using either cement or a press-t did not allow us to make any rm conclusions. However, use of a press-t acetabulum, augmented with the femoral head and the use of a reconstruction cup when necessary, has become our treatment of choice. Lastly was the short period of follow up for the THA. Therefore, it is unknown whether the use of a CHP will mimic the longevity seen in standard THA populations treated for osteoarthritis. However, using this single surgical approach for the management of certain acetabular fractures in the elderly

FIGURE 2. Computed tomographic scan demonstrating comminution and impaction of the acetabulum. q 2010 Lippincott Williams & Wilkins

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FIGURE 3. Anteroposterior view after performing the combined hip procedure with a cemented stem through a KocherLangenbeck approach.

fractures. Although complications were noted, blood losses, surgical times, and lengths of stay appear to be consistent with either ORIF acetabular studies or belated THA in patients with previous acetabular fractures. The use of a single-incision technique resulted in shorter surgical times, less blood loss, and fewer transfusions than the dual-incision technique and given the options now available for cup xation of the acetabulum, a single posterior approach, augmented with the resected femoral head when necessary, has become the preferred treatment of choice when performing this procedure. The problems with use of this technique appear to be the high rates of transfusion, lengthy anesthetic times, and the technical difcultly in performing this approach in elderly patients. Aggressive medical workups should be performed preoperatively to optimize patients before this procedure. These select patients may undergo a single surgical procedure and avoid the wait for a future THA resulting from a painful joint as a result of the development of avascular necrosis or posttraumatic arthritis of the hip. REFERENCES

demonstrated that all of the patients healed their fractures, a good range of motion of the hip was obtained, most were able to return to preinjury levels of activity, and that this form of treatment avoided the wait-and-see approach frequently used for these patients. Indeed, if the data are stratied to exclude the patients undergoing IL-L, then the Harris hip scores would have averaged 82.6. In summary, CHP appears to be a treatment option for acetabular fractures presenting in elderly patients who have concurrent osteoarthritis of the hip, associated femoral head fractures, signicant osteopenia, or nonreconstructible

FIGURE 4. Obturator oblique view of the patient postoperatively demonstrating that stability of both columns was obtained when the total hip arthroplasty was placed into the patient. Note that three plates were used to obtain stability of the pelvic columns. Given the newer xation strategies currently available for cup xation, it may be possible to obtain the same xation without the need for such extensive plate xation. q 2010 Lippincott Williams & Wilkins

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