Injury - 2026-03-25 - Journal Article
ORIF is associated with lower early morbidity but greater long-term revision risk compared with acute THA for acetabular fractures in the elderly.
Elnaggar A, Almaat A, Jawich B, Harhash T, Hilo AK, Alqasmi H, Andreou S, Suhrawardy A, Vaidya R
Topics
Key Takeaway
In propensity-matched elderly patients with acetabular fractures, ORIF carries a 69% higher relative risk of revision arthroplasty at 2 years compared to acute THA (10.4% vs 6.1%), but acute THA has significantly higher early infection (7.1% vs 4.5%) and dislocation (5.7% vs 4.3%) rates.
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Summary
This study used the TriNetX database (2005–2025) to compare ORIF versus acute THA in patients ≥65 years with acetabular fractures via 1:1 propensity matching on demographics and comorbidities. ORIF was associated with higher 2-year revision risk (10.4% vs 6.1%; RR 1.69) but lower early infection and dislocation rates; mortality favored ORIF at 5 and 10 years. Conversion THA after failed ORIF achieved revision and mortality rates comparable to acute THA, with lower dislocation at 5 years.
Key Limitation
Absence of fracture classification data (Letournel pattern, roof arc, Crowe grade for any dysplastic anatomy) means the most critical determinant of surgical strategy is uncontrolled, introducing substantial selection bias that propensity matching on demographics alone cannot resolve.
Original Abstract
INTRODUCTION
The optimal surgical strategy for geriatric acetabular fractures remains controversial. While open reduction and internal fixation (ORIF) preserves native anatomy, fixation failure may necessitate conversion to total hip arthroplasty (THA). Conversely, acute THA enables immediate stability but carries higher perioperative risk. This study compared outcomes of ORIF and acute THA and evaluated whether conversion THA achieves comparable results to acute THA.
METHODS
A retrospective cohort analysis using the TriNetX Research Network (2005-2025) identified patients ≥ 65 years with acetabular fractures. ORIF and acute THA cohorts were 1:1 propensity-matched for demographics and comorbidities. The primary outcome was revision arthroplasty within 2 years. Secondary outcomes included infection, dislocation, venous thromboembolism, mortality, ED visits, and readmission. Subgroup analyses compared conversion THA (after ORIF) with acute THA. Statistical significance was set at p < 0.05 with Benjamini-Hochberg correction.
RESULTS
After matching, 2026 patients per group were analyzed. Revision was more frequent after ORIF than acute THA at 2 years (10.4% vs 6.1%; RR 1.69, p < 0.001) and across 15 years. Infection (4.5% vs 7.1%) and dislocation (4.3% vs 5.7%) were lower after ORIF (p < 0.05). Mortality favored ORIF at 5 and 10 years. Conversion and acute THA showed similar long-term revision and mortality rates, with dislocation lower after conversion at 5 years (p = 0.002).
CONCLUSION
In elderly acetabular fractures, ORIF offers lower early morbidity but higher long-term revision risk, whereas acute THA yields greater perioperative complications yet fewer reoperations. Conversion THA achieves outcomes comparable to acute THA, supporting it as an effective salvage strategy.
LEVEL OF EVIDENCE
III (Retrospective cohort study).