Is the ‘Fix-and-Replace’ Method Associated with Higher Early Perioperative Risk than Isolated Internal Fixation for Acetabular Fractures in Frail Patients?

Objectives: To examine the impact of frailty on 30-day outcomes of ORIF alone or ORIF+THA (fix-and-replace) for the treatment of acetabular fractures. Methods: Design: Retrospective Cohort Setting: 700 hospitals in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database Patient Selection Criteria: Included were patients aged 60 years or older undergoing ORIF+/-THA for OTA/AO type 62 A-C fractures from 2015-2020 Outcome Measures and Comparisons: Preoperative frailty was assessed by the revised Risk Analysis Index (Not frail: <21, pre-frail: 21-30, frail: 31-40, severely frail: >40) and the 5-Item Modified Frailty Index (mFI-5) factor. All outcome measures were in-hospital or within 30 days postoperatively, including the ‘favorable outcome’, defined as: no readmission, length of stay<cohort median, and no major complication or death. Results: There were 585 patients included [ORIF (88%): mean age - 70.5 ± 14.2, sex – 41.4% female; ORIF+THA (12%): mean age - 77.0 ± 13.4; sex – 65.7% female]. Frail patients (n=353, 65.5%) were more likely to experience a complication (OR: 3.31, CI: [1.83-5.96]) and mortality (3.7% vs. 0.0%). ORIF+THA had higher association with postoperative transfusion (OR: 2.70, CI: [1.63-4.48]) but lower association with length of stay >3 days (OR: 0.41, CI: [0.24-0.72]) and non-home discharge (OR: 0.52, CI: [0.27-0.98]) than ORIF. Pre-Frail and Frail patients undergoing ORIF+THA were more likely to achieve favorable outcomes than those non-frail or severely frail (OR: 9.69, [3.40-27.57]). Conclusions: Surgical intervention for acetabular fractures carried a 30-day complication risk of 12-19% for frail patients. Frailty had similar predictability to age for early morbidity following surgery to treat acetabular fractures. Open reduction and internal fixation with the addition of an acute total hip arthroplasty was associated with a higher rate of blood transfusion and shorter hospital length of stay in frail patients with acetabular fractures.