Fragility Fractures of the Acetabulum: Current Concepts for Improving Patients’ Outcomes

Indian Journal of Orthopaedics https://doi.org/10.1007/s43465-022-00653-0 REVIEW ARTICLE Fragility Fractures of the Acetabulum: Current Concepts for Improving Patients’ Outcomes Giuseppe Toro1,2 · Adriano Braile1 · Annalisa De Cicco1 Antonio Benedetto Cecere1 · Alfredo Schiavone Panni1 · Raffaele Pezzella3 · Francesco Ascione4 · Received: 18 July 2021 / Accepted: 4 May 2022 © The Author(s) 2022 Abstract The incidence of fragility fractures of the acetabulum (FFA) is constantly increasing. Generally, these fractures are related to a fall on the greater trochanter involving the anterior column. The management of FFA is extremely difficult considering both patients’ comorbidities and poor bone quality. Both non-operative and several operative treatment protocols are available, and the choice among them is still ambiguous. The proposed surgical techniques for FFA [namely open reduction and internal fixation (ORIF), percutaneous fixation and total hip arthroplasty (THA)] are associated with a high complication rate. The treatment with the higher early mortality is the ORIF + THA, while the one with the lowest is the non-operative. However, at longer follow-up, this difference dreadfully change is becoming the opposite. Frequently ORIF, percutaneous fixation, and non-operative treatment need a subsequent re-operation through a THA. This latter could be extremely difficult, because of poor bone quality, acetabular mal union/non-union, bone gaps and hardware retention. However, the outcomes of each of the proposed treatment are mostly poor and controverted; therefore, a comprehensive patient evaluation and an accurate fracture description are required to appropriately manage acetabular fracture in the elderly. Keywords Acetabular fracture · Elderly · Fragility fracture · Open reduction and internal fixation · Total hip arthroplasty · Percutaneous fixation · Osteoporosis · Hip fracture · Mortality · Plate Introduction The constant increase in life expectancy led to a growing incidence of fragility fractures [1–4]. Recently, a constant increase of fragility fractures of the acetabulum (FFA) has been observed [5]. Particularly, a 2.4-fold increase in the incidence of acetabular fractures in patients over 60 years of age during the last 3 decades was observed, making this * Giuseppe Toro 1 Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy 2 Department of Clinical Sciences and Translational Medicine, University of Rome Tor Vergata, 00133 Rome, Italy 3 Unit of Orthopedics and Traumatology, AORN San Giuseppe Moscati, 83100 Avellino, Italy 4 Department of Orthopaedic and Traumatology Surgery, Ospedale Buon Consiglio Fatebenefratelli, 80123 Naples, Italy population one of the most commonly affected (about 24% of all acetabular fractures) [6]. As a definition, FFA are due to a fall from a standing height, with a subsequent impact on the greater trochanter. The resulting anteromedial force commonly leads to a fracture of the anterior column and/or the quadrilateral plate with a medialization of the femoral head and a supero-medial roof impaction [6]. The management of FAA is still a matter of debate. Particularly, indications for non-operative versus operative treatment, the reliability of surgical fixation in an osteoporotic bone and the safety of complex joint reconstructive procedures (i.e., revision arthroplasties) are some of the unmet needs. Moreover, regardless of the treatment choice, final outcomes are mostly poor both in terms of function and mortality (Table 1). The aim of the present study is to aid the orthopaedic surgeon in the treatment decision making for fragility acetabular fractures through a comprehensive literature review, focusing on the technical tips that may aid to improve patient’s outcomes. 13 Vol.:(0123456789) Indian Journal of Orthopaedics Table 1  Treatment-related mortality risk. Adapted from Daurka et al.9 Procedure Mortality rate (%) Mortality follow-up (months) Conservative ORIF ORIF + THA Percutaneous Fixation 12 15.3 13.15 30.5 52 42.2 33.3 121.8 ORIF open reduction and internal fixation, THA total hip arthroplasty Fig. 1  a A 3D reconstruction of a two columns fracture with the involvement of the quadrilateral plate occurred in a 75-year-old male. b Coronal reconstruction of a CT scan. Please note in red the “gull sing” that represent the result of the supero-medial impaction of the femoral head Patient Evaluation and Fracture Pattern FFA presents some differences from acetabular fractures observed in the young. In fact, in the elderly, most of acetabular fractures are related to a lateral compression force on the greater trochanter transmitted antero-medially to the anterior column, the anterior wall and the quadrilateral plate (Fig. 1) [6–8]. This characteristic mechanism of fracture explains the high incidence anterior column fractures both elementary and associated [4]. Furthermore, because of poor bone quality, the FFA is associated to an increased incidence of both femoral head injury and posterior hip dislocation related to a more severe posterior wall involvement (i.e. marginal impaction or comminution) [5, 9, 10]. These observations underline the troublesome need of both appropriately diagnose and treat fragility acetabular fractures. As a rule, a comprehensive evaluation of an elderly patient after a fall from a standing height is mandatory, 13 investigating on both the femoral neck and the acetabulum, and to adequately manage the patient an appropriate evaluation of pre-fracture patients’ walking ability is recommendable. The clinics of a patient with an acetabular fracture depend on the fracture displacement, varying from the absence of pain and normal range of motion (ROM) to intractable pain, lower limb discrepancy and restricted ROM. In case of a suspected acetabular fracture, a standardized radiograph protocol, based on an anteroposterior (AP) and Judet oblique views (both obturator and iliac), must be obtained [11]. These X-rays are generally able to identify and classify the fracture. However, CT scan is useful to improve fracture diagnosis and classification. In fact, some characteristics of the fractures (i.e., articular incongruities, nondisplaced fractures, intra-articular fragments, femoral head subluxation or quadrilateral plate impaction) are easily observed using a CT scan. Moreover, CT with 3D reconstructions can help to visualize complex fractures and to plan the surgical procedure, being able to enhance diagnostic and therapeutic accuracy [12]. However, considering the mechanism of fracture and the poor bone quality, fragility acetabular fractures might be nondisplaced and difficult to diagnose. Therefore, in case of high suspicious of FFA with inconclusive X-ray and CT scans, an MRI or a bone scan should be used to identify the fracture [11, 13, 14]. The Management of FFA In the elderly, the appropriate management o (...truncated)