Primary arthroplasty gave better early function and fewer reoperations than fixation alone in older adults with acetabular fractures

Design

Systematic review and meta-analysis of 20 studies, random-effects model

Population

2,703 patients aged 55 or over with acetabular fractures; 2,034 fixation, 417 arthroplasty

Primary outcome

Harris and Oxford Hip Scores, 90-day and 1-year mortality, reoperation

Effect

HHS 73.6 vs 66.3 at 3 months; reoperation pooled OR 2.34 (95% CI 1.31 to 5.67) favouring arthroplasty; 90-day mortality OR 1.08 (0.58 to 2.02)

Acetabular fractures in older adults are rising, bone is poor and many hips already have osteoarthritis, so fixation often fails and is converted to hip replacement. This systematic review and meta-analysis searched four databases for studies from 1997 to 2025 in patients aged 55 or over, and included 20 studies with 2,703 patients (mean age 74, mean ASA grade 2.8). It compared fixation (n = 2,034) with arthroplasty, either primary hip replacement or a combined fix-and-replace procedure (n = 417).

At three months the arthroplasty group scored higher on the Harris Hip Score (73.6 against 66.3). Reoperation was lower with primary arthroplasty (4.4% to 7.7%) than with fixation, which carried a 14% to 45% conversion rate to hip replacement; the pooled odds ratio was 2.34 (95% CI 1.31 to 5.67). Fix-and-replace operations ran longer (median 185 against 125 minutes) with more blood loss (1,000 against 500 ml). Ninety-day mortality was 11% with fixation and 15% with arthroplasty, not significantly different (OR 1.08, 0.58 to 2.02).

The included studies are mostly retrospective, and patients selected for arthroplasty differ from those chosen for fixation, so these data cannot be read as a randomised comparison. They support considering primary arthroplasty for selected patients with comminuted fractures or joint impaction, a choice for a specialist pelvic and acetabular team.

• Primary arthroplasty gave higher 3-month Harris Hip Score (73.6 vs 66.3) than fixation alone.
• Fixation was followed by conversion to hip replacement in 14% to 45%.
• Arthroplasty operations were longer (185 vs 125 minutes) with more blood loss.
• 90-day mortality did not differ significantly (OR 1.08, 95% CI 0.58 to 2.02).
• Consider arthroplasty for comminuted fractures or joint impaction, and discuss at a pelvic and acetabular meeting.

Why it matters

It strengthens the case that avoiding a failed fixation and a second, harder operation may matter more than a shorter first one.

Don't overread it

The evidence is mainly retrospective and does not cover all fracture patterns, so it does not support arthroplasty for every older patient.

The statistics, in plain English

A pooled odds ratio of 2.34 with an interval of 1.31 to 5.67 favours arthroplasty on reoperation, but the interval is wide and includes a more than fourfold difference. Most pooled studies were observational, so differences in who got which operation may explain part of the gap.

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