Open reduction and internal fixation vs acute total hip arthroplasty for geriatric acetabular fractures: A multicenter matched cohort study.

Abstract

Optimal management of acetabular fractures remains controversial. Open reduction and internal fixation (ORIF) may be followed by post-traumatic degeneration and late conversion arthroplasty, whereas acute total hip arthroplasty (THA) may introduce implant-related risks. We compared short- and long-term outcomes after ORIF versus acute THA in a large, multicenter electronic health record cohort. We performed a retrospective cohort study using the TriNetX Network. Adults with isolated, closed, acute acetabular fractures treated with either ORIF or acute primary THA were identified. Patients were propensity score-matched (PSM) 1:1 on demographics and comorbidities. Outcomes were assessed at 90 days and at 1, 2, 5, and 10 years, including mortality, complications, health care utilization, and procedure-specific failures (for ORIF: nonunion, post-traumatic osteoarthritis, and conversion to THA; for THA: periprosthetic fracture, prosthetic joint infection [PJI], instability/dislocation, and mechanical complications). After PSM, 3700 matched pairs comprised the early follow-up cohorts. At 90 days, ORIF was associated with higher mortality (5.2% vs 3.5%; OR 1.5; p < 0.0001) and higher rates of stroke, respiratory failure, venous thromboembolism, and ICU admission, whereas acute THA had higher emergency department visits (9.1% vs 5.3%; p < 0.0001) and hip pain (23.2% vs 13.2%; p < 0.0001). Over long-term follow-up, acute THA demonstrated higher implant-related complications at 2 years, including periprosthetic/implant fracture (3.0% vs 0.8%), PJI (6.8% vs 3.8%), instability (7.7% vs 3.0%), and mechanical complications (6.3% vs 3.5%) (all p < 0.0001), while overall reoperation rates were similar at 2 years (11.8% vs 11.2%; p = 0.53) and remained comparable through 10 years. In the ORIF cohort, nonunion reached 11.3%; conversion to THA increased from 4.3% at 2 years to 5.8% at 10 years; and post-traumatic osteoarthritis (PTOA) increased from 21.2% at 2 years to 27.2% at 10 years. Pre-index hip disease was markedly more common among acute THA patients (OA 51% vs 10%; AVN 14% vs 1%). In this study, ORIF was associated with higher early mortality and systemic complications, whereas acute THA was associated with higher implant-related complications. Despite these differing complication profiles, cumulative reoperation rates were similar through long-term follow-up. Progressive PTOA and conversion to THA remain important sequelae after ORIF.