Injury, Int. J.

Care Injured (2007) 38, 497—508

www.elsevier.com/locate/injury

Treatment options of pelvic and acetabular

fractures in patients with osteoporotic bone
P. Vanderschot *

Department of Traumatology, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium

Accepted 16 January 2007

KEYWORDS Summary The incidence of pelvic ring and acetabular fractures in the elderly is
Elderly; climbing relentlessly. This increase is attributed to a greater longevity and a decrease
Acetabulum; in the incidence of alcohol-related trauma in younger adults. Often, the elderly
Pelvic ring; trauma patient has compromised physiological reserve and healing capacity due to
Osteoporosis; concomitant morbidities, resulting in a less favourable clinical outcome. The pre-
Fracture; sence of osteopenic or osteoporotic bone and other treatments for existing comor-
Surgery; bidities hamper some treatment alternatives, especially those designed for younger
Total hip arthroplasty; patients.
Cables; Diverse clinical presentations include minor trauma, major polytrauma and insuf-
Minimal invasive; ficiency fractures. An assessment of the general health and functional status of the
Conservative patient is of utmost importance to determine the optimal treatment. The different
treatment options of pelvic and acetabular fractures in the presence of osteoporosis
vary mainly according to the clinical presentation and include: conservative methods,
percutaneous or minimally invasive procedures, open reduction and fixation, and
primary total hip arthroplasty.
Whichever treatment is chosen, even for elderly people, the aim is a rapid
mobilisation of the patient in order to reduce complications to some extent inherent
to this age group.
# 2007 Elsevier Ltd. All rights reserved.

Introduction related pelvic and acetabular fractures during the

Pelvic ring or acetabular fractures in the elderly
represent the most rapidly growing segment of the
spectrum of pelvic trauma. This is partially the
result of the relative decrease in motor vehicle-
* Tel.: +32 16344277; fax: +32 16344614.
E-mail address: Paul.vanderschot@uz.kuleuven.ac.be.
past decade.28
The incidence of fractures of the pelvis in the
elderly is climbing relentlessly,10 with a marked
predominance in women.40 In Finland from 1970
to 1997, the age-adjusted incidence of pelvic frac-
tures increased from 31/10,000 to 103/100,000 in
women and from 13/100,000 to 38/100,000 in men,
i.e., by 23% per year. The mean age at the time of

0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2007.01.021
498
injury increased from 74 to 80 years. In addition, the
proportion of pelvic fractures related to osteoporo-
sis increased from 18% to 64% overall and from 65%
to 94% among individuals older than 60 years off
age.23 A fall, mainly due to an ‘‘age-associated
multifactorial gait disorder’’ described by Runge55
was by far the most common trauma in 83% of cases.
In 47% no other fractures were diagnosed. A mor-
tality rate of 7.6% was noted during the immediate
post-fracture period, 27% after 1 year and 10% per
year subsequently; after 3 years the survival rate
was 50%. Among survivors, 70.9% were able to return
home (with home help in 84.3%) and 29.1% required
institutionalisation. Dependency was consistently
greater after than before the fracture.41
Some fracture patterns are the result of exces-
sive force exerted on relatively normal bone. These
are the fracture types we are most familiar with and
described by Tile,65 Letournel and Judet.21,27 How-
ever, most pelvic or acetabular fractures in the
elderly are pathological fractures through osteo-
porotic bone and are the result of minimal trauma.
Reconstructive surgery by means of open reduc-
tion and internal fixation becomes less important in
severe osteoporosis. Salvage procedures on the
other hand, which enable elderly people to continue
their normal daily life within acceptable time limits
are preferable. The purpose of this paper is to
review the different treatment options of pelvic
ring and acetabular injuries in osteoporotic bone,
taking into account the different types of injuries as
well as the prior health and functional status of the
patient.
Pelvic ring injuries
Low-energy pelvic ring fractures
Low-energy pelvic ring fractures in the elderly fre-
quently result from a fall while walking, and espe-
cially involve stable fractures of the pelvic ring.
Insufficiency fractures also occur in elderly patients,
typically of the sacrum and anterior pelvic ring.
Closed pelvic ring fractures
Fractures of the pelvic ring in the elderly are the
result of low energy trauma, a fall. Falls, defined as
any accident in which the patient unintentionally
ends up on the floor,71 become more common with
increasing age.2 Low energy trauma in this sense
implies that the forces applied to the bony struc-
tures in the process of injury are those arising only
from the dissipation of potential energy in the
change of position from standing height or less to
the ground level. Thirty percent of persons over the
P. Vanderschot
age of 65 will fall each year.2,49 This rate rises to 40%
for those over 80.49 Between 10% and 25% of falls
result in serious injury and up to 6% culminate in a
fracture.1,67 Such fractures are considered as stable
fractures (usually of the pubic rami) without disrup-
tion of the pelvic ring65 and hence, are treated
conservatively.
Morris et al.41 reported on 148 patients (mean
age: 83) who suffered a pelvic fracture in low energy
trauma, treated conservatively. Adequate quality
radiographs were available in 115 patients of which
107 had a Singh index59 of four or less, indicating
osteoporosis. Single breaks of the superior or infer-
ior pubic ramus accounted for 47.2% of all fractures
and 47.9 were found to have sustained fractures at
multiple pelvic sites.
These fractures, if isolated and not associated
with other major system injuries, can be treated by
means of bed rest until the patient is comfortable.
Analgesia may be required, which in this situation
should be minimal. All of the aggressive measures
necessary to prevent thromboembolic diseases and
other complications of bed rest should be vigorously
pursued, including turning in bed and deep breath-
ing exercises.
Insufficiency fractures of the pelvis
Patients with insufficiency fractures of the pelvic
ring present with groin or coxofemoral pains,
which may produce limping or functional disability
of joint movement.8,18,48,56 There may also be
pelvic pains and ill-defined pain in the lower
limbs. Fractures may be asymptomatic and dis-
covered accidentally.56 Risk factors include osteo-
porosis, rheumatoid arthritis, corticosteroid
treatment and mechanical constraint resulting
from total hip replacement.18,31,56 Radiographs
are often normal, in which case a bone CT scan
is useful to make the diagnosis. A CT scan may
show bone destruction with a pseudotumour
appearance.58 Diagnosis of fracture should be
considered when there are predisposing factors
and if radiographs show an osteolytic area sur-
rounded by osteosclerosis.58 Finally, MRI imaging
can demonstrate an insufficiency fracture. MRI
characteristically shows high signal intensity in a
mass on T2-weighted sequences surrounded by a
ring with low signal intensity.17
Most insufficiency fractures of the sacrum occur
in women (94.3%) of advanced age (mean age: 70.6
years).6 The most common risk factor is osteoporo-
sis. Patients have often undergone prolonged corti-
costeroid treatment.57 Other risk factors mentioned
by Finiels et al.6 include radiotherapy, osteomala-
cia, rheumatoid arthritis hip arthroplasty and fluor-
ide treatment.
Osteoporotic pelvic and acetabular fractures 499

In about 30%, trauma is cited as a causative
factor. Clinical expression is low back pain and groin
pain in presence of associated pelvic fractures.44
Truncated sciatica and sciatica of S1 distribution
may be observed. Furthermore, neurological com-
plications, such as motor deficit of the lower limbs
and urinary incontinence have been rarely
reported.63
A delay of diagnosis of 1 month61 and 2.07
months6 is reported in the literature. Plain radio-
graphs are usually unhelpful or may be misleading. A
sensitivity of 37%61 and 34.3%6 has been reported.

Figure 1 Woman of 74 years old treated for a rectal carcinoma by means of radiotherapy (50.4 gy) and chemotherapy. A
few months later she experienced an incapacitating low back pain irradiating to the both lower extremities (S1
topography). Plain radiographs of the pelvis were unhelpful (a) as well as an axial CT with coronal and sagittal
reconstructions (b). Bone scan using 99mTc-MDP tracer showed an increased uptake at the level of the sacro-iliac joint,
more pronounced on the right side (c). T1 weighted images of the MRI revealed hypointens regions at the level of the
sacral ala bilaterally (d). After administering gadolinium, an intense uptake was visible at the same regions of the sacrum,
indicating insufficiency lesions (e). A TISIB-procedure has been performed since the pathology occurred bilaterally.
Postoperative anteroposterior (f), inlet (g) and outlet (h) views showed a well positioned bar at the level of S1.
500
Scintigraphy has a very high sensitivity of 92.6%61
and 97.3%6 and 100%9. A complete or partial H-
shaped pattern, described by Ries,50 is the most
common pattern and the combination of concomi-
tant sacral and parasymphyseal uptake is considered
as characteristic of insufficiency fractures.46 CTscan
shows the fracture line with a diagnostic sensitivity
of 95.9%6 and a vacuum phenomenon at the level of
the insufficiency fractures of the sacrum and/or in
the sacroiliac joints.46 MRI sensitivity is estimated at
97.2%.6 It is especially useful for excluding pre-
existing metastatic lesions, not for the diagnosis
of a fracture.30
Gotis-Graham et al.9 reported on 20 patients, 19
female with sacral insufficiency fractures. Their
mean age was 74 years and the diagnosis was made
at a mean of 5 weeks after the onset of pain. No
neurological abnormalities were recorded. All were
treated conservatively. Fourteen patients required
admission to hospital for a mean of 21 days. At 6—9
months follow-up only three patients required mild
analgesics for occasional recurrences of pain and
none required narcotic drugs. The other 17 patients
had complete resolution of local pain. No patient
lost any significant independence in daily living.
Although not reported in other articles, it is the
practice of the author to treat patients with inca-
pacitating back pain, radiating to the buttocks or
legs due to sacral insufficiency fractures, rather
with a minimally invasive procedure instead of a
conservative treatment. Because the insufficiency
fracture is often bilateral, a trans-iliac-sacral-iliac-
bar (TISIB-procedure)69 is placed at the level of S1
(Fig. 1a—h). Since, this is not always possible, a
screw fixation uni- or bilaterally at the sacro-iliac
joint can be considered.70 Indeed, the complexity
and variability of the sacrum is reflected in the
individually common safe area of the iliac-sacral-
iliac path. Preoperative planning of the iliac-sacral-
iliac path by means of 3D reconstructions and tri-
axial reformats is mandatory to understand the
unique location of the path in a given patient.
Our first experience indicates a sudden relief of
the patient’s complaints in the post-operative per-
iod. Discharge is usually one or two days after the
intervention with only minor analgesics.
High-energy pelvic ring fractures
High-energy pelvic ring fractures in the elderly are
less frequent and the causes are comparable to
those of young people. As a result of the impact,
the pelvic ring can be stable or unstable (horizon-
tally or vertically). The choice of treatment should
be based not only on the long-term outcome but
perhaps even more directed by the specific pro-
P. Vanderschot
blems of elderly people. Bed rest, postural reduc-
tion, closed manipulation, slings, casting
techniques, turnbuckles and traction apparatus
have all been mentioned in the literature.3,16,72
External and/or internal fixation in some cases
has the potential benefits of better reduction, more
rapid mobilisation, easier nursing care, increased
patient comfort, diminished blood loss, and fewer
complications such as pneumonia, decubitus ulcera-
tions, and deep venous thrombosis.68,74
Whichever treatment is chosen, a severe vertical
displacement at the level of the posterior sacro-iliac
complex (>1 cm on plain AP radiographs) should be
avoided at any time. Henderson13 reported on long
term results of major pelvic disruptions in young
people (mean follow-up: 8 years), non-operatively
treated by means of bed rest, skeletal traction,
pelvic sling or casting. Frequent or daily low back
pain was reported in 50% of patients, compared with
25% in a group of 100 normal adult controls.73 Of
those 50%, 80% of patients were treated for an
unstable pelvic injury. All patients with severe ver-
tical displacement were having frequent or daily
episodes of low back pain. Furthermore, a perma-
nent, objective neurological injury was found in
67%, dysaesthesias in 86% and some degree of dis-
ability to work in 83%. Finally, 60% were found to
have a limp which was most commonly attributed to
a residual pelvic obliquity. Also Fell et al.5 also
recommended operative reduction and internal sta-
bilisation for all unstable pelvic fractures. The clin-
ical outcome in his series of 114 non-operatively
treated patients who suffered a pelvic fracture was
not acceptable. Although no patients with type A
lesions had any complaints, 55% of patients with a
type B lesion complained of pain or showed an
impaired functional result, and only 15% of patients
with a type C lesion did not suffer any pain and 10%
had no functional deficit.
At our institution, we also feel that unstable
pelvic ring injuries even in the elderly should be
treated according to the principles of the ASIF and
described by Tile65 and others. In this way, it is
possible to start early mobilisation and to reduce
the time of hospitalisation. Furthermore, complica-
tions inherent to this age group can be avoided to
some extent. External rotational instabilities and
lateral compression injuries of the pelvic ring (type
B injuries according Tile65) can be managed by
external fixation. However, when an urgent lapar-
otomy is inevitable, an internal reduction and fixa-
tion in the presence of a type B1 lesion (open book)
should be managed at the same time. If not, it is
important to choose an external fixator which offers
the best stability. Kim et al.24 compared the stability
of an anterosuperior (into the iliac crest) external
Osteoporotic pelvic and acetabular fractures 501

fixator, the AO tubular system versus an anteroin-
ferior (into the supraacetabular dense bone) exter-
nal fixator, the Orthofix system on Tile types B1
(open book) and C (vertical unstable) pelvic inju-
ries65 using cadaveric pelves (mean age: 68 years).
Although there were no significant differences
between the two frames, the biomechanical tests
showed evidence of a potential increased stability
of fixation when the pins where placed anteroinfer-
ior, into the supraacetabular area. Gansslen et al.7
retrospectively analysed 64 supraacetabular exter-
nal fixator applications to stabilise the pelvic ring in
20 type B and 44 type C injuries. No secondary
displacements were noted of the anterior or poster-
ior pelvic ring in type B nor for type C, sacral
fractures associated with fractures of the pubic
ramus injuries. There was one pseudarthrosis of
the pubic and ischial ramus, requiring surgery,
and no pin site infection. Iatrogenic lesions of the
lateral femoral cutaneous nerve was noted in 4.5%,
which completely reversed within 1 year.
In selected cases, lateral compression injuries
can also be managed minimally invasively. When
there is no major displacement initially or after
closed reduction, sacroiliac screws and/or single
screws into the iliopubic ramus can be inserted to
stabilise the pelvic ring. In this way the discomfort
of an external fixator can be avoided (Fig. 2a—e).

Figure 2 Woman of 72 years old hit by a car while walking. Plain anteroposterior radiograph shows a lateral compression
injury of the pelvic ring, type B2-1 according M. Tile (a). An axial CT-image indicates a fracture of the ilium posterior,
running into the sacroiliac joint (c). Through the same minimal approach (4 cm) two fractures were stabilized: at the
level of the ilium posterior (2 lag screws) and the ipsilateral iliopubic ramus (cortical screw) AP- (b), inlet- (d) and outlet
view (e).
502
Major displaced pelvic ring injuries (type C inju-
ries) can be treated initially by means of external
fixation in polytrauma patients to stabilise the pel-
vic injury and to diminish blood loss. If a residual
vertical displacement or a diastases at the fracture
site of the posterior sacro-iliac complex is still pre-
sent, a well planned open reduction and internal
fixation is mandatory. In these cases an ilioanterior
approach (Pfannenstiel or lower midline incision
combined with an incision at the iliac crest),
described by Hirvensalo et al.15 is a recommended
approach, because all lesions in the symphysis,
rami, and in the sacroiliac region can be reduced
and fixed with reconstruction plates and screws.
Using this approach, Hilversano reported on eigh-
teen patients who presented with a horizontally or
vertically unstable pelvic fracture. No intraopera-
tive complications occurred. The obtained reduc-
tion was maintained in all but one sacral fracture.
All fractures united. The functional recovery was
uneventful in all the patients.
Acetabular injuries
Elderly patients who sustained a displaced fracture
of the acetabulum are frequently treated non-
operatively by means of traction.35,47,62 The ratio-
nale for this approach is that they are candidates for
total hip arthroplasty if and when these patients
have decreased function, increased pain, or
increased deformity from post-traumatic arthritis.
The reluctance to operate on fractures of the acet-
abulum, especially in the elderly patients, is due to
several factors, including problems with the opera-
tive exposure, osteopenic bone, and the major
anaesthesia-related and medical risks of such a
procedure.
However, the alternatives are not without their
own risks and complexity. Prolonged traction treat-
ment for the elderly is fraught with medical com-
plications,11,29,53 and the likelihood of attainment
of an acceptable reduction of the displaced acet-
abulum by traction alone is small.4,25,26,34,35,45,62
Primary total hip arthroplasty necessitates the same
open reduction of the unstable acetabulum before
the insertion of the prosthetic components and is
often a prolonged and technically difficult proce-
dure. Delayed total hip arthroplasty for a displaced,
healed fracture of the acetabulum is made more
difficult by the acetabular deformity and the lack of
acetabular bone-stock.4,35,52
Nevertheless, the goal of acetabular fracture
care should be a preservation of the hip joint rather
than reconstructing bone stock to make a better
subsequent total hip replacement possible. New
P. Vanderschot
imaging and fixation techniques, bone substitutes,
as well as a better understanding of cartilage, all
potentially benefit our future treatment of acetab-
ular fractures.33,51
Nowadays, the spectrum of treatment options for
acetabular fractures in the elderly includes: non-
operative treatment, minimally invasive techni-
ques, conventional open surgical procedures and
primary THA with or without cable fixation of the
acetabular fracture.
Conservative treatment
Some clinicians believe that the best treatment for
acetabular fractures in the elderly is non-surgical,35
because a stable anatomic reduction was more
difficult to achieve, especially in those with osteo-
porotic bone.37
It is difficult to decide whether conservative
treatment by means of skeletal traction is appro-
priate for displaced unstable fractures in the
elderly. Ligamentotaxis by the capsular attach-
ments of the femoral head to the acetabulum is
not effective in achieving significant realignment of
the displaced fragments.34 Traction is unlikely to
achieve correction because the typical deformity is
rotational rather than translational. The use of
traction through a threaded greater trochanter
pin along the axis of the femoral neck has been
notoriously unsuccessful in the elderly. The
threaded pin typically disengages prematurely from
the bone with an increased risk of osteomyelitis in
the pin track. Longitudinal traction also has a lim-
ited role because of the obligatory enforced recum-
bency and resultant socio-economic cost.
In 1989, Spencer62 reported on 25 patients of 65
years or older with unilateral acetabular fractures,
non-operatively managed by means of traction. At
follow-up (range: 9—52 months) 16 of the 23 surviv-
ing patients returned to their previous level of
activity while 7 (30%) had an unacceptable func-
tional result. Factors which carried a poor prognosis
were: displaced posterior column fractures; osteo-
porosis, femoral head fracture, delayed diagnosis,
inadequate traction and early weight bearing. Even
so, Hesp et al.14 concluded that no optimal result
can be expected when in dorsal column or roof
fractures the achieved reposition was insufficient.
In this series, 79% of patients had a moderate or bad
result when the dorsal column or roof of the acet-
abulum was involved.
So, in cases of non-dislocation, dislocated acet-
abular fractures with anterior column involve-
ment14 or an intrinsically stable injury such as a
transverse type fracture,36 conservative treatment
can be considered. Furthermore, conservative
Osteoporotic pelvic and acetabular fractures
treatment can also be an option in cases of a dis-
placed comminuted fracture, in a patient with
osteopenic bone (e.g. both column fracture) when
secondary congruency by means of traction can be
achieved and maintained.66
Minimally invasive fixation techniques
In selected cases with fracture characteristics
showing no or mild displacement, no step in the
articular surfaces, and if no more than two main
fragments have to unite, one can consider percu-
taneous- or computed tomography-navigated fixa-
tion. Using computer-navigation, Jacob et al.19
reported on four cases with an excellent outcome.
However, computed tomography-navigated proce-
dures are time-consuming and a long learning curve
is needed With the new generation of image inten-
sifiers with high resolution covering a large field and
the availability of cannulated-screws, a percuta-
neous procedure without navigation has proved
valuable for limited displaced fractures in the
elderly. The role of percutaneous fixation of super-
ior pubic ramus fractures with cannulated screws
has been assessed by Routt.54 This method is parti-
cularly attractive for use in the presence of a
minimally displaced fracture with an unstable pos-
terior or superior fracture line, such as an anterior
Figure 3 Undisplaced T-type fracture in a 61-year-old male. Coronal (a) and axial (b) CT images showing the fracture
lines. Antegrade stabilization of the anterior column using a 3.5 mm cortical screw and posterior column fixation by
means of a 4.5 mm cannulated screw insertion into the ischial tuberosity. Plain anteroposterior (c), ala- (d) and obturator
view (e).
503
column, posterior hemi-transverse, isolated high
posterior column, selected T-type (Fig. 3a—e), or
high anterior column fracture, in which a displace-
ment is likely to occur.36 Mouhsine et al.43 reported
on 21 consecutive elderly patients with a minimal or
undisplaced fracture of the acetabulum. All under-
went fluoroscopic-guided percutaneous fixation
by means of two cannulated cancellous 7.3 mm
screws, inserted in a retrograde fashion to stabilise
the posterior and the anterior column. At follow-
up, clinical results were satisfactory in 17 patients.
All fractures healed at a mean time of 12 weeks
with no radiographical evidence of secondary dis-
placement. They concluded that percutaneous
screw fixation under fluoroscopic control is a safe
technique in selected acetabular fractures.
Open reduction and internal fixation
It is important to determine which patient is a
candidate for a conventional treatment by open
reduction and internal fixation. To be considered as
a candidate, Helfet et al.12 mentioned that the
patient should be an independent walker and not
have medical problems that would make the risk-
benefit ratio of anaesthesia and operative treat-
ment a contra-indication. In addition, the acetab-
ular fracture should have at least 5 mm of
504 P. Vanderschot

displacement of the 458-arc of the acetabular roof
on either the anteroposterior radiograph of the
pelvis or the Judet radiographs, or persistent sub-
luxation of the femoral head relative to the acet-
abulum. These criteria are however less stringent
than those currently recommended for younger
people.25,26,34,35 Furthermore, the ability to attain
stable fixation at the time of the operation, which
negates the need for post-operative immobilisa-
tion, is essential to eliminate the risk of prolonged
bed rest and traction.11,29,47,60,62 Finally, lag
screws alone should never be relied on to maintain
fixation. Reduction and fixation of the fracture by
means of buttress-plating through of a single ante-
rior or posterior approach is recommended
(Fig. 4a—d).
Helfet et al.12 reported on 18 patients with an
average age of 67 years, managed for an acute
displaced fracture by means of an open reduction
and fixation. Only one patient had a partial loss of
reduction. Seventeen patients, followed for at least
2 years had an average Harris hip-score of 90 points.
The treatment was regarded as having failed in only
one patient.
Letournel and Judet27 documented good to excel-
lent results for only 7 of 9 anterior wall fractures, 74
of 101 transverse—posterior wall fractures, and 8 of
17 posterior wall-posterior column fractures, in
marked contrast to 18 of 19 transverse fractures,
7 of 9 anterior column fractures, and 10 of 11
posterior column fractures. They attributed the
unfavourable outcome of the anterior wall and
posterior wall-posterior column fractures to the
higher percentage of elderly osteoporotic patients
who sustained these injuries. In an analysis of out-
come by patient age, Letournel and Judet27
observed the best results in their teenage and young
adult patients and the poorest results in patients
over the age of 50, with the results progressively
deteriorating with increasing age. A similarly unfa-
vourable effect of aging on clinical outcome was
reported by Matta.32

Figure 4 (a) 3D-image of a left sided acetabular fracture in a male of 63 years. A classic geriatric acetabular fracture.36
The anterior column and wall and the quadrilateral surface is fractured with protrusion of the femoral head. Post-
operative radiographs of the acetabulum: anteroposterior (b), ala- (c) and obturator view (d). The fracture at the level of
the quadrilateral area is reduced by means of a pre-bent reconstruction plate which pushed the displaced fragment in an
anatomical position while tightening the screws.
Osteoporotic pelvic and acetabular fractures
Cable fixation of acetabular fractures with
or without THA
The use of cerclage wires or cables is an effective
and minimally invasive stabilisation procedure for
an acetabular fracture, especially in the elderly
and in cases complicated by comminution with
osteoporosis.38 The cable fixation technique is
usually indicated if the fracture line extends high
into the greater sciatic notch. This procedure is
especially useful for high posterior column frac-
tures, transverse fractures with high anterior or
posterior limbs, and both column fractures.20,38
Mears and Shirahama38 reported on a technique,
modified by Mouhsine et al.42 (Fig. 5a—c) to
stabilise the fracture primarily with cables, fol-
lowed by a primarily THA during the same proce-
dure. The advantage of this technique is to
provide good initial reduction and stability of
the fracture even in osteoporotic bone so that
the prosthetic cup may be inserted and used as
a hemispheric buttress which completes fracture
stabilisation.
Figure 5 (a) A B3-2 type fracture in a 66-year-old male.
(b) Fracture stabilization by means of screws and a cable.
The prosthetic cup is inserted and acts as a hemispheric
buttress which completes fracture stabilization.
505
Kang and Min22 reported on 21 acetabular frac-
tures in young people treated by means of a cable
alone (Dall-Miles cables: Stryker-Howmedica,
Kalamazoo, MI, USA) or with an additional plate
and screws. Mean age was 34 (range 16—69 years)
No intraoperative complication occurred. Post-
operative complications included 2 cases each of
posttraumatic arthrosis and avascular necrosis of
the femoral head. At the latest follow-up, the
clinical results were excellent in 13 cases, good
in 3, fair in 3 and poor in 2. Mouhsine et al.42
reported on 12 patients treated with a cable
fixation and primary THA. One patient died. The
mean age was 79 years and all patients were
followed for 2 years after surgery. The clinical
outcome score according to Matta35 was excellent
in 7 patients and good in the remaining 4. The
radiographic outcome showed a satisfactory align-
ment of the acetabular cup and no signs of loosen-
ing in all cases.
Primarily total hip arthroplasty
While the preferred treatment of most acetabular
fractures is open reduction and internal fixation, the
prognosis is poor for certain injury patterns, notably
in patients with osteopenic bone. In cases of intra-
articular comminution, full thickness abrasive loss
of articular cartilage, impaction of the femoral
head, and impaction of the acetabulum that
involved >40% of the joint surface and including
the weight-bearing region, an THA should be con-
sidered to achieve a painless, mobile hip. Using
these indications, Mears et al.39 reported on 57
unilateral displaced fractures managed with a pri-
mary total hip arthroplasty. The mean age at the
time of surgery was 69 years. Following the proce-
dure, each patient used a touchdown gait with
crutches or walker for 6 weeks. Thereafter, weight
bearing was increased as tolerated, with the patient
using a cane beginning at 10 weeks. After a mean
follow-up of 8.1 years, they measured a mean Harris
hip score of 89 points. Forty-five (79%) had an
excellent or good outcome. The younger patients
had the highest score, and there is a progressive
decrease in the scores with advancing age. These
scores appeared to be related to a general func-
tional impairment in the elderly. An average medial
displacement of the cup of 3 mm and an average
vertical displacement of 2 mm was measured. No
cup or stem had late clinical or radiographic signs of
loosening. A similar clinical outcome has been
reported by Tidermark et al.64 after primary THA
with a Burch-Schneider antiprotrusion cage and
autologous bone grafts for acetabular fractures in
elderly patients.
506
Discussion
The majority of pelvic ring fractures in the presence
of osteoporosis are the result of low energy trauma
and are typically stable fractures. These can be
managed conservatively by means of bed rest and
analgesics.41 However, the clinical expression of
insufficiency fractures of the sacrum can be vari-
able. Some patients experience low back pain, other
truncated sciatica and sciatica of S1 topography
requiring moderate analgesics. The time to resolu-
tion for these patients can be quite long, certainly
with concomitant fractures of the pelvic ring.61 It is
the personal conviction of the author to consider, in
selected cases, a minimally invasive procedure by
means of a trans-iliac-sacral-iliac bar69 whenever
possible.70 High energy pelvic ring injuries may be
stable or unstable. Conservative treatment carries a
high percentage of unsatisfactory clinical out-
comes.5,13 Stabilisation of the pelvic ring is pre-
ferred since it has the potential benefits of better
reduction, more rapid mobilisation, easier nursing
care, increased patient comfort, diminished blood
loss and fewer complications. Many unstable, B and
C type fractures in the elderly can be managed by
means of an external fixation alone,7 placed ante-
roinferior into the supraacetabular area.24 An exter-
nal fixation can be avoided in some cases where an
urgent explorative laparotomy is required. An open
book injury (type B1) can be internally stabilised at
the time of the laparotomy. Type B fractures, initi-
ally almost undisplaced or after closed reduction
can be managed by means of a minimally invasive
procedure: sacroiliac screws (if necessary) and/or
an antegrade screw osteosynthesis to stabilise the
iliopubic ramus. Only in cases of a residual vertical
displacement or diastases of the fracture at the
level of the posterior sacroiliac complex, should
an open reduction an internal fixation be considered
by means of an ilioanterior approach.15
The decision to undertake non-operative care of
an acetabular fracture can be made when a satis-
factory outcome can be reasonably predicted, not
because other options are not available. In cases of
non-dislocation, dislocated acetabular fractures
with anterior column involvement14 or an intrinsi-
cally stable injury such as a transverse type frac-
ture,36 conservative treatment can be the
treatment of choice. In our current cost-conscious
healthcare environment such fractures can be trea-
ted at home or in a suitable nursing facility despite
the obvious risk of late displacement.62 If fracture
displacement occurs after 1 week, an alternative
treatment plan can be considered. If not, one may
expect the fracture to unite at 6 weeks and con-
solidation to take place at 12 weeks.62 Typically,
P. Vanderschot
such a fracture becomes asymptomatic with full
weight bearing in 4—8 weeks.36 Conservative treat-
ment can also be an option in cases of a displaced
comminuted fracture, in a patient with osteopenic
bone (e.g. both column fracture) when secondary
congruency by means of traction can be achieved
and maintained.66
In selected minimally displaced fractures in
which displacement is likely to occur in association
with transfer of the patient, a percutaneous internal
screw fixation, as assessed by Routt et al.54 may be
considered. Although this method may be feasible in
experienced hands, for most surgeons the complex-
ities of acetabular anatomy and the small target
zones for proper insertion of screws have militated
against widespread enthusiasm. Nevertheless, for
an elderly patient, rapid relief of fracture pain,
prompt initiation of active or active assisted trans-
fers, and the potential for early discharge are
favourable attributes of this method.
When an open procedure is planned for a dis-
placed acetabular fracture in an elderly patient, a
single standard acetabular exposure (Kocher—Lan-
genbeck or ilioinguinal approach) is the method of
choice. The degree of devascularisation of the sur-
gical field, produced by extensile approaches (trir-
adiate, extended iliofemoral or two simultaneous
approaches) in elderly patients has been an impor-
tant concern. Indeed, complications such as wound
dehiscence and fulminant post-operative infections
are discouraging for the applications of these
approaches.12 Increasing experience of the surgeon
and technical improvements make it possible to
reduce and to stabilise portions of an acetabular
fracture that are remotely situated with respect to
the surgical field.27 Open reposition and internal
fixation should be considered when the posterior
column or acetabular roof is involved when insuffi-
cient reposition can be achieved by other
means.14,62
A primary THA should be considered in the pre-
sence of osteoporotic bone when dealing with an
anterior wall or posterior wall-posterior column
fracture,27 and also when intra-articular comminu-
tion, full thickness loss of articular cartilage, impac-
tion of the femoral head or acetabulum is present.39
Primary THA has hardly been used because of the
difficulty in stabilising the acetabular fracture suffi-
ciently for adequate fixation of the cup in the pre-
sence of osteoporosis and comminution.20,38 For this
reason, it is important to choose an appropriate
approach which enables stabilising column- or trans-
verse fractures by means of a screw-osteosynthesis
or braided cables to correct a protruding medial
wall.38,43 In cases of posterior wall fractures, a
structural autograft should be used to restore the
Osteoporotic pelvic and acetabular fractures
posterior aspect of the acetabulum, and morselised
femoral head autografts should be impacted into
residual gaps of the acetabulum. Finally a cup, 2 mm
larger than the diameter of the final reamer should
be used for an interference fit. An uncemented stem
is the first choice in younger individuals, whereas in
elderly patients with osteopenia a cemented stem is
still preferred.39
The management of acetabular fractures in
young adults remains a technical challenge for
the surgeon in charge. Open reduction and internal
fixation in this age group carries a high percentage
of excellent results and should be generally
accepted. Acetabular fractures in the elderly are
more demanding. The presence of osteoporotic
bone, comorbidities, and functional status of the
patient will influence the clinical outcome. Should
we consider operative treatment or not? If surgery is
considered, the surgical approaches are preferably
limited to a single ilioinguinal or posterior
approach. But the real problem remains; to predict
for a given patient, which treatment will result in
the best clinical outcome. Since there are no gen-
erally accepted treatment protocols, and since
these fractures are rising relentlessly, we should
focus more on this topic in the following decade to
improve our understanding of the pathology, in
order to launch other treatment options which
finally improve the clinical outcome in this age
group.
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