Which treatment in acetabular fractures of the elderly: Osteosynthesis, osteosynthesis-THA or orthopedic treatment? 2-years retrospective outcomes of a therapeutic algorithm.

Introduction: Acetabular fractures account for 7% of osteoporotic fractures, with an epidemiological peak between 75 and 80 years of age. The aim of this study is to evaluate the results of treatment of these fractures in a population aged over 65.

Hypothesis: Surgical treatment would lead to better survival and functional outcomes in the management of acetabular fractures in subjects aged over 65.

Material and methods: Patients over 65 years of age treated for acetabular fracture between January 2017 and May 2020 were included in this retrospective single-center study and divided into three treatment groups: osteosynthesis, osteosynthesis-THA (Osteosynthesis-THA) and orthopedic treatment. The choice of treatment was made according to an algorithm that considered the patient's co-morbidities, autonomy and bone lesions. The primary endpoint was patient survival at 12 and 24 months' follow-up.

Results: 94 patients (mean age 78.5 +/-8.4 years) were included: 29 patients treated with orthopedic therapy, 46 patients with osteosynthesis and 19 patients with osteosynthesis-THA. Mean follow-up was 32.7+/-14.9 months. Mortality rates were higher in the orthopedic and osteosynthesis-THA groups (20.7% and 21.1% respectively). Patients in the orthopedic and osteosynthesis-THA groups showed excess mortality, with hazard ratios (HR) of 3.4 ([1.02; 11.3], p < 0.05) and 3.3 ([0.9; 12.3], p = 0.08) respectively, compared with those treated with osteosynthesis. Mean PMA at 2 years, mean Harris score at 2 years and Parker score were significantly higher in the operated groups. The rate of conversion to THA (THA) was higher in the orthopedic treatment group (27.6%). The complication rate was 24% (11/46) for the osteosynthesis group, 42% (8/19) for the osteosynthesis-THA group.

Discussion: Applying our decision algorithm, orthopedic treatment is inferior to surgical treatment in terms of survival and functional results, with a higher re-intervention rate for THA than treatment with osteosynthesis. This study confirms the place of osteosynthesis, with higher functional scores, lower complication and revision rates, and a positive effect on mortality.

Level of evidence: IV; Retrospective cohort study.