Surgical outcomes of acetabular fracture of elderly patients with superomedial dome impaction

www.nature.com/scientificreports OPEN Surgical outcomes of acetabular fracture of elderly patients with superomedial dome impaction Eic Ju Lim 1, Hyun‑Chul Shon 1, Jae‑Young Yang 1, Joosuk Ahn 2, Jung Jae Kim 3 & Ji Wan Kim 3* This study aimed to investigate the outcomes of elderly acetabular fractures according to the reduction of impacted dome fragments. A retrospective cohort study was performed in two institutions. Fifty-four patients aged ≥ 60 years with acetabular fractures were enrolled. Data for dome impaction and postoperative reduction was collected. Patients were divided into the good reduction group (displacement ≤ 3 mm) and poor reduction group (displacement > 3 mm). Postoperative osteoarthritis (OA), Harris hip score (HHS), total hip arthroplasty conversion, good/poor outcomes were compared between the two groups. The good reduction group (N = 45) demonstrated a lower proportion of radiographic OA (18 vs. 77%, P = 0.001), higher HHS (82.1 vs. 68.6, P = 0.022), and higher proportion of good outcomes than the poor reduction group (N = 9) (89 vs. 22%, P < 0.001). In a subgroup analysis of the patients with dome impaction, the good reduction group had a higher proportion of good outcomes (80 vs. 20%, P = 0.031). On comparing within the good reduction group, dome impaction did not influence clinical outcomes. Elderly acetabular fractures demonstrated favorable outcomes when adequate reduction was achieved even with dome impaction. Well-reduced dome impaction could achieve satisfactory outcomes in elderly acetabular fractures. With general population aging, the incidence of acetabular fractures in elderly patients increases1,2. Although open reduction and internal fixation (ORIF) is the gold standard for younger populations, no consensus on the ideal treatment for elderly acetabular fractures has been established. Because elderly patients have several vulnerabilities to be considered such as pre-injury health status and poor bone quality, several alternative treatments include conservative treatment, ORIF including percutaneous fixation, total hip arthroplasty (THA) with concomitant column fixation, and planned delayed THA3–6. Considering patient factors and injury factors, treatment for acetabular fractures should be highly individualized7. Patient factors include pre-injury ambulatory function; medical state such as whether surgery can be tolerated; and injury factors including injury mechanism, associated injury, and fracture characteristics. Regarding fracture characteristics, previous studies have emphasized negative predictive factors such as concomitant femoral head fracture, articular comminution, and articular impaction involving the weight-bearing dome8,9. Rommens et al. described ORIF as a way of reconstructing a stable socket for later safe-cup implantation when negative predictive factors present in elderly p atients10. Among those negative predictive factors, superomedial dome impaction (dome impaction), described as ‘gull sign’ by Anglen et al., was initially reported as the inability to obtain reduction and stable fixation11 (Fig. 1). They have reported that early loss of reduction occurred in 7 of 10 patients with dome impaction despite reduction of the dome fragment, and dome impaction was 100% predictive of failure of reduction and/or fixation. Subsequently, reduction techniques for dome impaction have been reported with relatively successful o utcomes12. Laflamme et al. have demonstrated direct reduction through an intrapelvic approach, reporting 33% (3 out of 9 patients) of overall conversion rate to T HA13. However, studies on the comparative outcomes of reduction of dome impaction in elderly patients are few. Therefore, we hypothesized that despite dome impaction, adequate reduction would improve clinical outcomes. The present study aimed to investigate the outcomes of elderly acetabular fractures according to reduction of impacted dome fragments. 1 Department of Orthopedic Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea. 2Department of Orthopedic Surgery, Korean Armed Forces Capital Hospital, Gyeonggi‑do, Republic of Korea. 3Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic‑ro, 43‑gil, Songpa‑gu, Seoul, Republic of Korea. *email: Scientific Reports | (2023) 13:19091 | https://doi.org/10.1038/s41598-023-46652-5 1 Vol.:(0123456789) www.nature.com/scientificreports/ Figure 1.  Case of acetabular fracture with dome impaction. (a) A 72-year-old woman had an injury associated with a column fracture with dome impaction (white arrow). (b) Surgery was performed without reduction and fixation of the impacted dome fragment. (c) Five years postoperatively, the patient presented with posttraumatic osteoarthritis and severe pain. (d) Total hip arthroplasty was performed. Materials and methods This study was performed in line with the principles of the Declaration of Helsinki. This study was approved by our institutional review board and a waiver of the requirement for written informed consent was granted (Asan Institute for Life Science, approval no.: 2021–3165-0003). Data collection was performed in accordance with relevant guidelines and regulations issued by the committee. Patient selection This retrospective comparative study was conducted in two university teaching hospitals. The inclusion criteria were as follows: patients aged ≥ 60 years, patients with acute acetabular fractures, and patients who had received surgical treatment. Initially, 127 patients were enrolled from the pelvis and acetabular fracture cohort database from 2003 to 2020. Then, we excluded 73 patients with fracture patterns unrelated with dome impaction (anterior wall, posterior wall, posterior column, and posterior column with posterior wall), who were treated conservatively or with acute THA, had concomitant pelvic ring injury, had periprosthetic fractures, and were followed up for < 12 months. Fracture patterns which can contain dome impaction include anterior column, transverse, transverse and posterior wall, T-type, anterior column and posterior hemitransverse, and both column fractures. Finally, 54 patients were enrolled in the present study (Fig. 2). Surgical technique for reduction of dome impaction The surgeries were performed by three operators (H.-C.S., J.J.K, and J.W.K.) with more than 10 years of experience performing pelvic and acetabular fracture surgeries. The patient was placed in a supine position with silicone padding under the knee to flex the hip and knee joints so that the iliopsoas muscle, external iliac vessel, and Figure 2.  Flowchart of patient enrollment and grouping. THA, total hip arthroplasty. Scientific Reports | Vol:.(1234567890) (2023) 13:19091 | https://doi.org/10.1038/s41598-023-46652-5 2 www.nature.com/scientificreports/ femoral nerve could relax. Skeletal traction at the distal fe (...truncated)