The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients

Archives of Orthopaedic and Trauma Surgery https://doi.org/10.1007/s00402-021-03829-9 TRAUMA SURGERY The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients Dietmar Krappinger1 · Herbert Resch2 · Richard A. Lindtner1 · Johannes Becker3 · Marian Mitterer2 · Thomas Freude2 Received: 9 November 2020 / Accepted: 8 February 2021 © The Author(s) 2021 Abstract Introduction Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA. Materials and methods Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures. Results The mean age was 80.5 years (range 65–98 years). The average time from injury to surgery was 8.5 days (range 1–28). Mean time of surgery was 167 min (range 100–303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification. Conclusions The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group. Keywords Acetabular fracture · Osteoporosis · Elderly · Full weight bearing · Reinforcement ring · Antiprotrusion cage · Total hip arthroplasty Introduction * Thomas Freude 1 Department of Trauma Surgery, Medical University of Innsbruck, Innsbruck, Austria 2 Department of Orthopaedics and Traumatology, Paracelsus Medical University Salzburg, Muellner Hauptstrasse 48, 5020 Salzburg, Austria 3 Department of Trauma Surgery, BG Unfallklinik Murnau, Murnau, Germany Open reduction and internal fixation (ORIF) is considered the gold standard of treatment for displaced acetabular fractures. The prerequisites for a favorable outcome after ORIF, however, are anatomical reduction and maintenance of reduction until healing. Over the last years the number of patients with osteoporotic acetabular fractures has increased with fractures commonly caused by low energy trauma from a ground standing position [1, 2]. While the typical fracture pattern in younger patients involves the posterior column and posterior wall, the typical fracture pattern in older patients involves the anterior column and the quadrilateral 13 Vol.:(0123456789) Archives of Orthopaedic and Trauma Surgery plate (QLP) with concomitant medial dislocation of the femoral head [1, 3, 4]. Fractures in this age group are frequently complex and comminuted with superomedial dome impaction and femoral head lesions [5, 6]. Whereas outcomes after ORIF usually are satisfying in younger patients, outcomes with ORIF alone have been mixed in elderly patients [7, 8]. Subcortical impaction makes anatomic reduction difficult to achieve with the risk of postoperative arthritis and the necessity for secondary total hip arthroplasty (THA) [6, 9–13]. As elderly patients often suffer from several comorbidities and a limited physiological tolerance, a long surgical procedure and a subsequent limited mobility due to restricted weight bearing represent considerable health risks. Due to the special features of osteoporotic acetabular fractures, the desire for primary implantation of a THA has increasingly arisen in recent years [9, 11, 13–15]. The question of stable anchorage of the implant in the fractured acetabulum was in the focus of interest. Authors recommended a cabling reinforcement technique [16], an antiprotrusion cage with additional plating [9, 11, 17, 18] or a two-incision approach technique [13]. The acetabular roof reinforcement plate (ARRP) presented in this study was designed with the intention to achieve a stable fixation that allows full weight bearing (FWB) immediately after surgery without any additional fixation technique. The stability is achieved by an angular stable anchoring technique in the intact iliac bone. The goal of this study is to present the clinical and radiological results of a series of 59 patients with displaced osteoporotic acetabular fractures who were treated with the ARRP and hip arthroplasty. Materials and methods This retrospective study was approved by the local ethics committee and no concerns were raised regarding the use of the ARRP. From 2009 to 2019, eighty-four patients with displaced fractures of the acetabulum were treated with the ARRP as an antiprotrusion cage [19, 20]. Eighty-three were acute fractures and one a non-union after open reduction and internal fixation (ORIF). All 84 patients except 3 were treated in two level-one trauma centers. Inclusion criteria for the insertion of this implant were a displaced acetabular fracture with or without a previous hemi- or total hip arthroplasty, age above 65 years, osteoporotic fracture as identified by a low-energy trauma such as a ground-level fall, significant marginal impaction and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 11 had died due to cardiac failure within the first 6 months after surgery. Another 13 patients were seen only at the 3 months but not at the 6-month follow-up visit and one patient was excluded due to failed former osteosynthesis, leaving 59 patients for full clinical 13 and radiographical examination after 6 months (Table 1). Thirty-four were males and 25 females. The mechanism of injury included a simple ground level fall in 51, a level fall (tractor, ladder) in 3, a ski accident in 3 and a bicycle accident in 2 patients. The fractures were classified according to Letournel and Judet [21]. Twenty-five were anterior column posterior hemitra (...truncated)