ORIGINAL ARTICLE
Combined Hip Procedure Versus Open Reduction and
Internal Fixation for Displaced Acetabular Fractures in
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Patients Older than 75 years: A Matched Cohort Study
Edward Kahhaleh, MD,a b Etienne L. Belzile, MD,a Thomas Reed-Métayer,a Julien Dartus, MD, MSc,a c
, ,
Dominic Plante, MD,a Martin Lesieur, MD,a Jean Lamontagne, MD,a Luc Bédard, MD,a
and Stéphane Pelet, MD, PhDa d
,
Objective: To compare surgical outcomes between combined hip
procedure (CHP: open reduction and internal fixation [ORIF] with
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total hip replacement) and ORIF alone for the treatment of displaced
acetabular fractures in a geriatric population.
Design: Retrospective case–control study.
Setting: Academic Level 1 trauma center.
Patients: Consecutive patients from 2012 till 2020 with acetabular
fractures fitting inclusion criteria were enrolled.
Intervention: Combined hip procedure or ORIF alone for
displaced acetabular fractures.
Main Outcome Measurement: Revision surgery at the latest
follow-up, defined as the need for implant revision in the CHP group
and conversion to total hip replacement in the ORIF group.
Results: The need for revision surgery was lower in the CHP group
(12.5%) compared with the ORIF alone group (25%). The median
time for conversion to total hip replacement in the ORIF alone group
was 2.6 years. Ten-year survivorship was significantly higher in the
CHP group (85.7% vs. 45.8%, P , 0.01). Patients in the CHP group
presented with higher American Society of Anesthesiologists and
Accepted for publication September 8, 2023.
From the aDivision of Orthopedic Surgery, Department of Surgery, CHU de
Québec-Université Laval, Quebec City, QC, Canada; bUniversité Libre de
Bruxelles, Brussels, Belgium; cUniversité de Lille, Lille, France; and
d
Centre de Recherche FRQS du CHU de Québec, Axe Médecine
Régénératrice, Quebec City, QC, Canada.
Dr Stéphane Pelet is an associate editor for the Orthopaedics and
Traumatology: Surgery and Research (OTSR). He receives financial
research support all outside this work from the Canadian Institutes of
Health Research, the Social Sciences and Humanities Research Council,
the Natural Sciences and Engineering Research Council of Canada, the
Fonds de Recherche du Québec-Health and Society and Culture, and the
Ministère de la Santé et des Services sociaux du Québec. The remaining
authors report no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.jorthotrauma.
com).
Reprints: Stéphane Pelet, MD, PhD, Laval University CHU de Québec –
Hôpital Enfant-Jésus - 1401, 18ème Rue, Québec, QC G1J 1Z4,
Canada (e-mail: stephane.pelet.ortho@gmail.com).
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/BOT.0000000000002699
J Orthop Trauma  Volume 37, Number 12, December 2023
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Charlson index scores and had more marginal impaction and con-
comitant femoral head fractures.
Conclusions: In patients older than 75 years presenting with
a displaced acetabular fracture with marginal impaction or femoral
head fracture, survivorship of CHP is higher than ORIF alone. A
combined hip procedure should be considered in such patients.
Key Words: acetabular fracture, combined hip procedure, open
reduction internal fixation, revision
Level of Evidence: Therapeutic Level III. See Instructions for
Authors for a complete description of levels of evidence.
(J Orthop Trauma 2023;37:601–606)
INTRODUCTION
Geriatric acetabular fractures were historically managed
nonoperatively in most patients due to physiologic frailty and
poor bone quality. Previous outcome studies reported high
mortality rates in this patient group, as well as a high rate of
conversion to total hip replacement (THR) due to post-
traumatic osteoarthritis (PTOA)1 and frequent failure to return
to baseline ambulation status.2,3 More recent nonoperative
protocols emphasizing early mobilization and weightbearing
have demonstrated similar complication rates in well-selected
patients.3,4 Not only early attempts at primary open reduction
and internal fixation (ORIF) of displaced acetabular fractures
lead to high mortality and conversion rates due to PTOA5,6
but they also came with a substantial risk of nonfatal compli-
cations.7 In the hope to optimize ambulation status and reduce
the risk of secondary procedures, combined hip procedures
(CHP) in a primary setting, consisting of consecutive acetab-
ular ORIF and THR during the same surgical session, have
been recommended with promising results.8,9 Such procedure
was advocated at the index hospital admission for fracture
patterns including posterior wall comminution, marginal ace-
tabular impaction, femoral head fracture with severe cartilage
damage, or inability to achieve anatomic reduction.10–14
Despite the growing trend toward early surgical care,
the optimal operative treatment for displaced geriatric ace-
tabular fractures is still debated and studies tend to focus on
center-specific cohorts. This was specifically demonstrated in
a recent study by Manson et al15 revealing the large variation
in treatment strategies for geriatric acetabular fractures. With
the aging population, we have seen an increasing incidence of
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 Kahhaleh et al
these fractures, having more than doubled in recent years.16,17
Displaced acetabular fractures will continue to present
a unique challenge regarding patient and procedure selection
considering the elevated mortality risks in the geriatric pop-
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ulation18 and a high risk of related complications.
The aim of the study was to evaluate and compare
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surgical outcomes between CHP and acetabular ORIF alone
for the treatment of displaced acetabular fractures in a geriatric
population.
MATERIALS AND METHODS
We conducted a retrospective cohort study at a level 1
trauma center (CHU de Québec-Hôpital Enfant-Jésus) includ-
ing all patients older than 75 years admitted with an acetab-
ular fracture between 2012 and 2020. Patients with
concomitant pelvic fractures, pathologic fractures, and con-
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comitant femoral neck fractures were excluded. This study
received full Ethic Review Board approval and was per-
formed in accordance with the Declaration of Helsinki and
STROBE statements.
The electronic medical charts of all patients were
reviewed by 3 independent observers (E.K., J.D., and T.R.-
M.) not involved in the patient’s treatment. Data were col-
lected and sorted based on demographics, trauma, surgery,
follow-up, and complications. The center treats acetabular
fractures from a large area, and all complications and read-
missions related to the acetabular fracture are sent to the
center, reducing the risk for missing data.
Fractures were sorted according to Judet and Letournel
classification19 and corresponds to Orthopaedic Trauma
Association 62A, -B, and -C fracture types.20 Pelvic radio-
graphs at admission included antero-posterior and Judet
views. All patients had a CT-scan with 3D reconstruction
views before the surgery. A systematic follow-up with radio-
logical pelvic views was performed for all patients at 3 and
12 months and yearly if a complication required treatment.
All x-rays were reviewed by a fellow in orthopedic trauma
surgery (E.K.). In case of discordance with the surgeon’s
report, an additional review was performed by a specialized
hip preservation surgeon trained in hip arthroplasty and pelvis
osteotomy (E.L.B.). The main observed criteria were acetab-
ular fracture type, marginal impaction, femoral head fracture,
loss of reduction, osteoarthrosis, heterotopic ossifications
(HO), and THR-related complications. Acetabular marginal
impaction was defined as an impacted and rotated osteochon-
dral fragment or a multifragmented fracture with depression
into the underlying cancellous bone. Quality of reduction was
expressed in millimeters (mm) according to Matta criteria:21
a gap between fracture fragments of #2 mm was considered
as anatomic, between 2 and 3 mm as imperfect and .3 mm
as poor.
All surgeries were performed by 4 fellowship-trained
orthopedic trauma surgeons with expert skills in pelvic
trauma and hip reconstruction. The type of surgery (CHP or
ORIF) was in all cases discussed during a team meeting, and
no intraoperative conversion was performed. After surgery,
patients who underwent CHP were allowed full weightbear-
ing, whereas patients in the acetabular ORIF alone group
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J Orthop Trauma  Volume 37, Number 12, December 2023
were allowed 50% weightbearing with a walker for 6 weeks
to protect reduction, then progressed to full weightbearing.
All patients received standard antibiotics at induction and
postoperative thromboprophylaxis.
All patients with a CHP (n = 16) were matched for age
and sex to patients with ORIF alone at a 1:2 ratio. CHP were
evenly distributed during the study period. The main compar-
ative outcome was procedure survivorship at the latest follow-
up, defined as the need for revision surgery in the CHP group
and conversion to THR in the ORIF alone group.
Demographic, surgical data, and complications were com-
pared between groups. Figure 1 illustrates the selection
process.
Descriptive analyses were performed using SAS On
demand for Academics (2021, SAS Institute, Cary, NC).
Values were expressed as means (95% CI, range) or
percentages. Univariate analyses were performed with an
unpaired Student t test for continuous variables and Fisher
exact test for qualitative data. Signification was arbitrarily set
at alpha = 0.05. Survival curves were obtained.
RESULTS
The first cohort included 16 patients with a CHP. The
mean age was 83 6 6 years (77–92) and 56% were males.
Forty five patients older than 75 years underwent ORIF alone
during the same study period (mean age 82 6 5 years [76–
90], 58% males). Thirty two patients were matched for a 2:1
ratio to best fit age and sex. The mean age in the second
cohort was 80 6 4 years (75–88) and 56% were males. The
2 groups did not differ for body mass index, lifestyle habits,
and trauma-related variables. However, patients in the CHP
group were significantly less healthy and frailer with a higher
American Society of Anesthesiologists (ASA) score (75%
ASA III vs. 40.6%; P = 0.02) and a higher Charlson index
(5.4 6 1.5 vs. 4.4 6 1.2; P = 0.04). Table 1 summarizes the
medical history and patient’s conditions.
Fractures with an anterior pattern were the most
frequent in both groups (CHP 81.3% vs. ORIF 75%; P =
0.26). The 2 main radiologic differences between study
groups were the presence of acetabular marginal impaction
(100% in the CHP group vs. 38% in the ORIF group; P ,
0.01) and the presence of a femoral head fracture (19% vs.
0%; P = 0.03). Pre-existing osteoarthritis was slightly higher
in the CHP group (50% vs. 28%; P = 0.09). Surgical data
such as blood loss and duration of procedure did not signif-
icantly differ between groups (Table 2). The quality of reduc-
tion in the ORIF group was anatomic in 27 patients (84.3%),
imperfect in 3 (9.4%), and poor in 2 (6.3%).
The mean follow-up period was similar in both groups
(CHP 3.1 years vs. ORIF 3.3 years; P = 0.8). Six patients in
the CHP group (37.5%) and 8 in the ORIF group (25%) were
deceased with implants in place at the time of this review (P =
0.17). The follow-up ranged from 0 to 10 years in both
groups.
Three patients (6.3%) died during the hospital stay from
medical complications, 1 in the CHP group and 2 in the ORIF
group. Thromboembolic complications were reported in 4
patients (8.3%) despite rigorous prophylaxis with low
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 J Orthop Trauma  Volume 37, Number 12, December 2023 CHP Versus ORIF for Geriatric Acetabular Fractures
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FIGURE 1. Selection process of the study.

molecular weight heparin: 3 deep vein thrombosis (2 in the
ORIF group) and 1 nonfatal pulmonary embolism (ORIF
group).
During the study period, 19 orthopedic complications in
18 patients were recorded: 3 HO (18.8%), 2 THR dislocations
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combined with THR has been advocated by various authors
in the presence of predictive factors for posttraumatic osteo-
arthritis, such as acetabular marginal impaction and posterior
wall fractures.5,20,23,24 The results of this study suggest that
patients older than 75 years who undergo a combined hip

(12.5%), and 1 femoral periprosthetic fracture (6.3%) in the procedure for a displaced acetabular fracture are less likely
CHP group; 11 post-traumatic osteoarthrosis (34.4%), 1 iat- to undergo a revision surgery compared with patients treated
rogenic nerve injury (3.1%) (lateral femoral cutaneous nerve), with primary ORIF. Our series showed a 25% conversion rate
and 1 traumatic early implant failure (3.1%) in the ORIF to total hip arthroplasty in the ORIF group at a median
group. No infection was censed. Ten patients required a revi- 2.6 years postoperatively. In half of cases, conversion was
sion surgery: 8 conversions to THR in the ORIF group and 2 associated with marginal impaction which prevented achiev-
THR revisions in the CHP group (25% vs. 12.5%; P = 0.1). ing or maintaining an anatomic reduction. We could not iden-
Only the complications related to revision surgeries and THR tify a specific fracture pattern associated with a revision
reduction required readmission during the study period. surgery or early PTOA in this series, although most fractures
Conversion to THR in the ORIF group was required requiring revision had severe involvement of the weightbear-
because of PTOA in 7 cases and for 1 early traumatic implant ing zone of the acetabulum.
failure (the patient sustained a fall 26 days after surgery). The Our results are in concordance with other articles
median time to conversion to THR was 2.6 years (range 26 reporting revision surgery rates after primary ORIF alone
days–5.4 years). Four of the 7 THR (57.1%) for PTOA had between 20% and 64%.6,14,21,25–27 To date, only one
marginal impaction and a nonanatomic reduction (2 medium
and 2 poor according to Matta criteria). A variety of fracture
patterns among these patients were observed: 3 anterior col-
TABLE 1. Demographic and Trauma Mechanism of Displaced
umn and posterior hemitransverse, 2 transverse, 1 associated
Acetabular Fractures
both columns, and 1 transverse with posterior wall. No frac-
ture pattern could be statistically directly associated with ORIF (n = 32) CHP (n = 16) P
a higher risk of failure with ORIF alone beside marginal Male* 18 (56) 9 (56) 0.2
impaction. Age† 80 6 4 (75–88) 83 6 6 (77–92) 0.09
Revision THR in the CHP group was performed for 1 BMI† 24 6 3 27 6 7 0.5
patient with recurrent dislocations 4 months after the surgery. Active tobacco users* 2 (6) 2 (13) 0.3
A constrained acetabular implant was used. Another patient Daily alcohol consumption* 3 (10) 5 (31) 0.06
sustained a femoral periprosthetic fracture 11 months after the Diabetes* 11 (34) 4 (25) 0.2
index surgery and required a femoral stem revision. One Charlson comorbidity index 4.4 6 1.2 5.4 6 1.5 0.04
patient with a single dislocation episode had no further ASA score* 0.02
recurrence and did not require an additional surgery. I 1 0
Figure 2 illustrates the cumulative survivorship for revi- II 18 4
sion in both groups. Ten-year survivorship should be inter- III 13 (40.6) 12 (75)
preted with caution as most patients did not reach this period High-energy trauma* 10 (31) 5 (31) 0.2
(mean follow-up time 3.2 years). Figure 3 and Supplemental Motor vehicle accident 5 2
Digital Content 1 (see Figure, http://links.lww.com/JOT/ Fall from high 5 3
C92) show the radiological results for both procedures. Fall from same level* 22 (69) 11 (69)
Concomitant fractures* 11 (34) 4 (25)
Head injury* 2 (62) 1 (6)
DISCUSSION Abdominal or thoracic injury* 2 (6) 0 (0)

Treatment of displaced acetabular fractures in the *Values expressed as n (%).

†Values expressed as means 6 SD (range).
elderly population is challenging due to osteoporosis and Values expressed in bold indicates significance.
difficulty in achieving an anatomical reduction.22 Early ORIF

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 Kahhaleh et al J Orthop Trauma  Volume 37, Number 12, December 2023

TABLE 2. Radiological and Surgical Data of Displaced Acetabular Fractures

ORIF (n = 32) CHP (n = 16) P
Fracture type (Judet-Letournel) 0.4
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Anterior column + posterior hemitransverse 14 5

Associated both columns 6 3
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Anterior column + anterior wall 4 4

Transverse + posterior wall 3 0
Posterior wall 2 1
Transverse 2 1
T-type 1 0
Anterior wall 0 1
Posterior column + posterior wall 0 1
Marginal impaction* 12 (38) 16 (100) ,0.001
Posterior dislocation* 2 (6) 1 (6) 0.5
Femoral head fracture* 0 (0) 3 (19) 0.03
Pre-existing osteoarthritis* 9 (28) 8 (50) 0.09
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Surgical approach ,0.001

Kocher-Langenbeck 7 12
Modified Stoppa 4 0
Modified Stoppa + lateral window 18 0
Ilio-inguinal 3 0
Combined approach 0 4
Time to surgery (d)† 3.7 6 2.3 4.9 6 5 0.4
Surgery duration (min)† 202 6 74 234 6 58 0.1
PRBCu transfusion (n patients)* 24 (75) 12 (75) 0.3
Blood loss (mL)† 1095 6 675 963 6 398 0.4
Length of stay (d)† 17 6 10 22 6 13 0.2
*Values expressed as n (%).
†Values expressed as means 6 SD
PRBCu, packed red blood cell units.
Values expressed in bold indicates significance.

prospective clinical trial confirmed that ORIF + THR marginal impaction or femoral head fracture is a sound deci-
decreased the absolute risk of reoperation by 28% in a geriat- sion. Clinically important osteoarthritis and comminuted pos-
ric population compared to patients treated with ORIF terior wall fractures are other factors that should be
alone.25 However, the statistically higher prevalence of mar- considered in the surgical decision-making. Thus, in a popu-
ginal impaction and femoral head fracture in the CHP group lation that include frail individuals, if operative treatment is
induces a selection bias and prevents us from concluding chosen, CHP allows early mobilization and full weightbear-
whether all acetabular fractures in this age group would ben- ing and will minimize the risk for reintervention, long
efit from a CHP. Pre-existing degenerative joint disease was
present in both groups but was more prevalent in the CHP
cohort (although not statistically significant). It is likely that
the clinical and radiographic severity of such osteoarthrosis,
rather than its mere presence should influence a surgeon into
favoring a specific treatment. The same rationale can be
applied for posterior fracture dislocations where posterior
wall involvement alone is likely a weak selection criterion
while the fracture severity and related predictability of
ORIF quality might be a more relevant surgical criterion.
Although secondary THR provides good overall functional
outcomes and improved pain scores,28–30 late conversion to
THR is technically difficult and associated with high compli-
cation rates, lower implant survivorship, and less satisfactory
patient-reported outcome measures compared with patients
undergoing THR for primary osteoarthritis.31,32 Considering
these figures and in agreement with published reports,9,27,33 FIGURE 2. Survivorship curves estimated by the Kaplan–Meier
we believe that selecting a CHP for patients presenting with method.

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 J Orthop Trauma  Volume 37, Number 12, December 2023
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FIGURE 3. 83-year-old women with a displaced anterior column and posterior hemitransverse fracture with marginal impaction
treated with CHP (A, Preop antero-posterior pelvis view. B1, B2, CT views. C1, C2, One-year radiologic views).
rehabilitation, and geriatric complications related to delayed
full weightbearing required after ORIF.
Overall nonfatal complication rate was comparable
between groups. Among these, dislocation is a major com-
plication after THR for acetabular fractures. In our series, 2 of
the 16 patients (12.5%) presented with instability. One was
successfully treated by closed reduction and the other
required cup revision. Our dislocation rate is in line with
other reports in the literature,9,22,26,27 in part due to compa-
rable surgical teams with hybrid traumatology and reconstruc-
tive practices. We believe that these complex surgical
procedures should be performed by experienced surgeons or
teams to minimize variability and increase efficiency. If
a combined hip replacement is performed, special attention
should be directed at hip arthroplasty stability. Similarly, HO
was significantly higher in the CHP group. It could be ex-
plained by the predominant use of the Kocher-Langenbeck
approach in these patients with damage to the gluteus
muscles. In discordance with other articles, none of the
patient in the ORIF group developed HO, whereas rates in
the literature have reached up to 100%.34 This can be ex-
plained by the common use of the Stoppa approach for
ORIF alone. No HO prophylaxis was administered in any
of our patients. At 3 years, only half of the CHP group were
still alive compared with 63% of the ORIF group. This could
be explained by frailer patients in the CHP group, as demon-
strated by higher ASA scores and Charlson index scores.
Although this study compares 2 groups with operative
management, recent studies focus on the nonoperative
management of acetabular fractures in frail patients with
early mobilization and weightbearing. For selected patients,
this option should be considered and present interesting short-
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CHP Versus ORIF for Geriatric Acetabular Fractures
term clinical results with similar intrahospital complication
rates than with surgical treatment.1,4,7
Our study presents the strength of a moderate median
follow-up time comparable in both groups. This enabled us to
retrace all potential complications that occurred acutely and
chronically. As a reference center, no data were lost as all
follow-up medical records were shared with the treating sur-
geons and any surgical complication was sent back to our
team for treatment. Finally, the matched case–control design
reduced the risk of confounding biases from age or sex. The
thirteen excluded patients were younger and healthier, did not
present significant complications, or needed revision surger-
ies; they do not represent the geriatric patient included in this
study.
This study has several limitations. The main limitation
is a retrospective design with a long observation period and
a small number of patients in the CHP group. Some living
patients have not had enough follow-up time to develop
PTOA, and the need for revision after 10 years is probably
underestimated. On the other hand, patients with CHP did not
have time to develop symptomatic implant loosening. The
ten-year survivorship is then very low and should be inter-
preted with caution. Quality of reduction was only assessed
on standard plain radiographs, which is less accurate than
computed tomography. The hospital ethics committee has
approved a new prospective research protocol that will enable
our department to perform postoperative CT scans on all
ORIF patients to better judge reduction and eventually better
study risk factors for developing PTOA. There was also
a selection bias because surgeons were more prone to suggest
CHP in the setting of marginal impaction and femoral head
fracture. Even if our center is a reference center for all
www.jorthotrauma.com | 605
 Kahhaleh et al
acetabular fractures in a large area, some complications could
have not been reported. Finally, no clinical outcomes scores
were collected during the survey.
In conclusion, in a population older than 75 years
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presenting with a displaced acetabular fracture, conversion
rate to THR for patients treated with internal fixation alone
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was higher than implant revision rate for patients managed
with CHP. CHP should be considered in patients with
marginal impaction when anatomic reduction is not likely
to be achieved or maintained. In our understanding, ORIF
remains the most common treatment used for geriatric
acetabular fractures, but for patients presenting with risk
factors for difficult reduction (or hard to maintain) such as
marginal impaction and femoral head fracture, a combined
procedure is likely a sound option, especially for patients
expected to live longer. New studies with a higher number of
patients and longer follow-up are required to best identify
8RUrJKAsXnivNajc on 02/02/2024
patients who will benefit from a CHP rather than ORIF after
an acetabular fracture in a geriatric population.
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