ORIF is associated with lower early morbidity but greater long-term revision risk compared with acute THA for acetabular fractures in the elderly.

Abstract

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. 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. 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). 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. III (Retrospective cohort study).