Fix-and-replace for comminuted acetabular fractures in older adults

Design

Systematic review and meta-analysis of 20 observational studies

Population

2,703 patients aged 55 or over with acetabular fractures

Primary outcome

Function, 90-day and 1-year mortality, reoperation

Effect

Reoperation OR 2.34 (1.31-5.67) favouring arthroplasty; mortality OR 1.08 (0.58-2.02)

This systematic review and meta-analysis pooled 20 studies, published 1997 to 2025, of 2,703 patients aged 55 or over with acetabular fractures (mean age 74, mean ASA 2.8). It compared open reduction and internal fixation alone with primary total hip arthroplasty, alone or combined with fixation.

Primary arthroplasty gave better Harris Hip Scores at three months (73.6 vs 66.3). After fixation alone, 14% to 45% of patients went on to conversion to hip replacement for post-traumatic arthritis or fixation failure; reoperation after primary arthroplasty was 4.4% to 7.7%, and the pooled odds ratio favoured arthroplasty (OR 2.34, 95% CI 1.31 to 5.67). Ninety-day mortality was 11% after fixation and 15% after arthroplasty, not a significant difference (OR 1.08, 0.58 to 2.02). Operations were longer (median 185 vs 125 minutes) and blood loss higher (1,000 vs 500 ml) with fix-and-replace.

The studies are observational and patients were selected for each approach, so those given arthroplasty probably had the worse fractures. The finding supports considering primary arthroplasty for older patients with comminution, marginal impaction or pre-existing arthritis, in centres able to manage the extra blood loss and operative time. It is not a case for replacing every geriatric acetabular fracture.

• Look for comminution, dome impaction and pre-existing arthritis on CT when planning geriatric acetabular fixation.
• Consider primary arthroplasty with fixation when these features make fixation alone likely to fail.
• Plan for about double the blood loss: cross-match and use tranexamic acid as your protocol allows.
• Involve an orthogeriatrician early; 90-day mortality was over 10% with either approach.

Why it matters

Fixation in osteoporotic, arthritic hips often fails, and a second operation in this age group is costly.

Don't overread it

These are non-randomised comparisons; selection of patients for each approach may explain part of the difference.

The statistics, in plain English

The mortality odds ratio of 1.08 with an interval from 0.58 to 2.02 means the data cannot exclude a meaningful difference in either direction. The reoperation result has a wide interval but stays above 1, so the direction is clear even if the size is uncertain.

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