Acetabular Fractures in Older Patients: Assessment and Management

© Springer Nature Switzerland AG 2020

T. T. Manson (ed.)Acetabular Fractures in Older Patientshttps://doi.org/10.1007/978-3-030-25105-5_1

1. Introduction and Scope of the Problem

Andrew H. Schmidt¹, ²  

(1)

Hennepin Healthcare, Minneapolis, MN, USA

(2)

University of Minnesota, Minneapolis, MN, USA

Andrew H. Schmidt

Email: [email protected]

Keywords

Acetabular fractureElderlyArthroplastyInternal fixation

Acetabular fractures in the elderly population are increasing in frequency, with the incidence of such fractures in patients over age 60 more than doubling in the past 25 years [1]. In younger patients, such fractures result from high-energy trauma. In older patients, acetabular fractures are just as likely to occur from low energy as a high-energy mechanism [1, 2]. Acetabular fractures that result from low-energy trauma (typically a fall from standing height) are associated with osteopenia and are considered a marker of significant frailty, and such patients tend to be older, have a lower body mass index, and have more comorbidities than patients with acetabular fractures from higher-energy trauma [2]. As might be expected given the differences in patient’s bone density and mechanisms of injury, acetabular fractures in the elderly have different fracture patterns than are seen in younger population, with a greater incidence of anterior column impaction, involvement of the quadrilateral plate, and articular impaction (Fig. 1.1) [3]. Like patients with fractures of the proximal femur, elderly patients who suffer an acetabular fracture have significant mortality, reported to be as high as 25% [4]. However, unlike proximal femur fractures, surgical repair of acetabular fractures in the elderly has not been shown to reduce mortality [5].

Fig. 1.1

Typical geriatric acetabular fracture demonstrating several common features of fractures in this age group: impaction of the dome of the acetabulum (note the different appearances of the sourcil compared to the opposite uninjured hip), involvement of the quadrilateral plate, and medialization of the femoral head

Management of elderly patients with acetabular fracture is challenging. As with all elderly patients with hip fractures, these patients demand and benefit from expert multidisciplinary co-management including input from geriatrics, internal medicine, orthopedic surgery, anesthesiology, and occasionally other medical and surgical subspecialties. Nonoperative management of these injuries results in unacceptable outcomes in 30% or more of patients [6]. Internal fixation of these complex fractures in patients with reduced bone quality and inability to protect the hip from loading following surgery make open reduction and internal fixation (ORIF) challenging. Many methods of surgical repair have been reported, including nonoperative management, formal ORIF [7], percutaneous fixation [8], total hip arthroplasty (THA) (often incorporating techniques otherwise used in revision THA) [9, 10], or THA combined with open or percutaneous ORIF [11, 12]. Although it has been reported that the geriatric acetabulum is more forgiving of non-anatomic reductions than the young hip [13, 14], it appears that between 10% [15] and 30% [16] of elderly patients undergoing ORIF are later converted to a total hip replacement. If either nonoperative management or initial surgical repair results in a poor outcome, late conversion to a total hip arthroplasty (THA) does not reliably lead to good results; the results of late THA following acetabular fracture are not as good as those of primary THA [17]. In an effort to reduce the morbidity of ORIF in these fragile patients, percutaneous techniques of internal fixation have been advocated [8]. Finally, acute THA, either alone or in combination with ORIF, has been recommended by many surgeons [11, 12], but controlled clinical trials are completely lacking at this time, and surgeons are faced with making treatment decisions for these challenging patients without much evidence to guide them.

In summary, the incidence of acetabular fractures in the geriatric population is increasing [1]. Surgeons caring for these patients have a variety of acceptable treatment options, as listed above. All methods have their advocates, and none has been tested against another by means of a controlled clinical trial. Until further data become available, surgeons treating these patients should be aware of all the possible treatment methods and their likely complications and expected outcomes, so that the optimum approach for a given patient can be selected.

As many treatment decisions start out with an assessment of the patient’s activities and frailty, we will start in the next chapter with formal methods of assessing patients for frailty and expected activity levels. Nonoperative treatment methods will then be addressed followed by open reduction and internal fixation techniques from various anterior and posterior approaches.

Next, open reduction plus concomitant hip replacement will be addressed. To conclude, conversion hip replacement for posttraumatic arthritis methods will be explored in detail.

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© Springer Nature Switzerland AG 2020

T. T. Manson (ed.)Acetabular Fractures in Older Patientshttps://doi.org/10.1007/978-3-030-25105-5_2

2. Life Expectancy and Assessment of Functional Status in Older Adults

Lisa Reider¹  

(1)

Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA

Lisa Reider

Email: [email protected]

Keywords

Older adultsLife expectancyFrailtyPhysical functionPresurgical assessments

Life Expectancy and Function

Men and women of age 65 years or older represent the fastest growing segment of the US population. Between 2004 and 2014, the number of older Americans increased by 28% compared with a 6.2% increase in younger Americans. In 2014, the census estimated that 46.2 million people were 65 years or older, which represents 14.5% of the total US population. This is projected to grow to be 21.7% of the population by 2040 [1]. Currently, the average life expectancy is 78.8 years. People reaching 65 years can expect to live an additional 19.1 years (20.5 years for women and 18 years for men) and people reaching 75 years can expect to live an additional 12.2 years (13 years for women and 11.1 years for men). Life expectancy has also increased for the oldest old. Octogenarians can expect to live on average 8 additional years, which is double their life expectancy from 30 years ago [2] (Fig. 2.1).

Fig. 2.1

Number of persons 65+, 1900 to 2060 (number of millions). (Source: U.S Census Bureau, Population Estimates and Projections publically available at https://​www.​acl.​gov/​aging-and-disability-in-america/​data-and-research/​profile-older-americans)

As the number of older adults continues to grow, trauma centers will experience an increase in the number of older patients that they treat. Compared to younger patients with similar injuries, older patients tend to have worse outcomes following surgery, which can be attributed, in large part, to preexisting comorbidity and disability. As many as two-thirds of older adults have two or more chronic conditions, [3] and according to the 2013 Medicare Current Beneficiary Survey, 30% of non-institutionalized beneficiaries reported difficulty in performing one or more activities of daily living (ADLs), which include bathing, dressing, eating, and getting around the house. An additional 12% reported difficulty with one or more instrumental activities (IADLs), which include preparing meals, shopping, managing money, using the telephone, doing housework, and taking medication [1].

Despite declines in overall function with age, there is notable heterogeneity in health and activity among older adults. According to data from the 2012–2014 National Health Interview Survey (NHS), 44% of non-institutionalized older adults reported excellent or very good health and many continue to participate in moderate-intensity physical activity even late in life. The 2001 Behavioral Risk Factor Surveillance System survey (BRFSS) found that only 21% of adults aged 65–74 were inactive based on measures of occupational, household, and leisure time physical activity, while 34% engaged in moderate activity and 18% engaged in vigorous activity. These percentages are slightly lower among adults 75 years and older, but even in this age group, 29% were engaging in moderate activity on a regular basis [4]. Another study using data from the 2001 NHS showed similar results—26.1% of older adults participate in regular light to moderate or vigorous aerobic activity [5]. Participation in the labor force is another marker of activity and many older adults are employed. The Bureau of Labor Statistics estimated that 8.8 million Americans 65 years or older were working or actively seeking work in 2015. This constitutes 5.6% of the labor force. In both men and women, the percentage of older adults that participate in the labor force has increased over the past 30 years (16–20% in men and 10% in women) [1]. With the expected growth of the aging population, these percentages are likely to rise.

There is growing evidence for a distinction between the third and fourth ages as supported by trends in disability and function. The third age (i.e., the young old) is characterized by increases in life expectancy, better physical and mental fitness, and high levels of emotional and personal well-being. Data from several longitudinal studies suggest that 70-year-olds today are comparable to 65-year-olds who lived 30 years ago. In general, the young old have fewer physical disabilities (e.g., ADL and IADL disability) than earlier cohorts, [6] and in fact some studies reported an annual decline in overall disability and functional limitation between 1990 and 2000 ranging from −1.52% to −0.92% [7]. Individuals who have reached old age over the past two decades have benefited from advances in medical care, improved economic situations, better education, and more psychological resources. These improvements in quality of life have no doubt contributed to overall well-being [6]. Unfortunately, these trends do not persist in the fourth age (i.e., the oldest old). The fourth age is characterized by prevalent dementia and high levels of multi-morbidity, physiologic dysfunction, and frailty. In developed countries, on average, individuals transition into the fourth age when they reach 85 years. However, this is a population-based threshold and the transition may actually vary quite a bit among individuals depending on a host of health and environmental factors. In other words, older adults can and do maintain good health and function well into their 80s.

Given the heterogeneity in health and function among older adults, age alone is not necessarily the best predictor of outcomes following surgery. There is growing evidence to support the use of frailty measures to identify older patients at risk of poor outcomes which may better inform treatment decisions. This chapter discusses the utility of frailty measures in older adults undergoing surgery. In addition, this chapter discusses the validated measures of physical performance that can be used to evaluate recovery and outcomes following surgery in older adults.

Frailty in Older Adults

Frailty is a clinical condition that results in loss of physiologic reserve and predisposes individuals to adverse health outcomes including death. While there is overlap with disability and comorbidity, frailty is considered a distinct clinical syndrome associated with increased vulnerability and functional impairment under minimal stress [8]. Because of the implications for clinical care, it is important to screen for frailty in older adults, particularly those undergoing surgery as they are more likely to have adverse outcomes if frailty also exists. Frail patients undergoing surgery may require alternative approaches to standard of care. If there are multiple options for surgical treatment, the less aggressive approach may yield better outcomes. Similarly, frail patients may do better if cared for by a multidisciplinary team that facilitates pain management and rehabilitation following surgery. A study by Markary et al. of approximately 600 older patients undergoing elective surgery found that intermediately frail patients were more likely to experience 30-day postoperative complications (odds ratio = 2.06; 95% CI 1.18–3.60), longer lengths of stay (by 44–53%), and were more likely to be discharged to a skilled nursing facility (odds ratio = 3.16; 95%CI: 1.9.99). Outcomes were worse in frail patients. This study showed that frailty independently predicted outcomes when compared with other commonly used risk measures including the American Society of Anesthesia (ASA) score [9]. The ASA score is a clinical assessment of an individual’s physical health with scores ranging from 1 (a normal healthy patient) to 5 (moribund patient not expected to survive without operation) [10]. While this is a quick and easy way to assess physical status prior to surgery,