Operative Fixation Of Acetabular Fractures Research Articles

Delayed Fixation of Acetabular Fractures Affects Functional Outcomes and Health-Related Quality of Life, Not Just Quality of Reduction.

Delayed operative fixation of acetabular fractures remains a major problem in many parts of the world. No previous studies have reported the effect of fixation delay on health-related quality of life (HRQOL). We aimed to investigate the effect of delayed operative fixation of acetabular fractures on health-related quality of life, EuroQol-5 Dimension questionnaire (EQ-5D), and other related outcomes. We retrospectively analysed 117 patients who underwent open reduction internal fixation for displaced acetabular fractures between 2014 and 2021. Patients were divided into groups based on the admission-to-surgery time (interval between injury and definitive surgery): 1-14, 15-21, and >21days. Patients were analysed for associations between admission-to-surgery time and postoperative outcomes, including operative time, estimated blood loss, blood transfusion, postoperative complication, and quality of reduction. Eighty-five patients with a mean follow-up time of 3.94 ± 1.84years were analysed for the association between admission-to-surgery time and conversion to total hip arthroplasty, the Modified Merle d'Aubigné and Postel score, EQ-5D score, ability to sit cross-legged, and ability to sit squat. Multivariable linear regression was used for continuous outcomes and logistic regression for categorical outcomes associated with delayed operative fixation. An admission-to-surgery time > 14days was associated with significantly higher blood loss [785mL (236-1335), p = 0.006]. For associated fractures, an admission-to-surgery time > 21days increased the risk of poor reduction [odds ratio (OR), 5.21 (1.42-19.11), p = 0.013]. Further, admission-to-surgery time > 21days was associated with poor Modified Merle d'Aubigné and Postel scores [OR, 8.46 (1.48-48.29), p = 0.016], EQ-5D pain domain [OR, 3.55 (1.15-11), p = 0.028], and EQ-5D usual activity domain [OR, 4.24 (1.28-14), p = 0.018]. Delayed operative fixation of acetabular fractures after 21days affected the functional outcomes and HRQOL, independent of the reduction status. Surgical interventions and patient referrals should occur at the earliest and within 21days from the time of injury. The online version contains supplementary material available at 10.1007/s43465-024-01163-x.

The Effect of Surgeon Experience on Short- to Medium-Term Complication Rate Following Operative Fixation of Acetabular Fractures

Operative management of acetabular fractures is technically challenging, but there is little data regarding how surgeon experience affects outcomes. Previous efforts have focused only on reduction quality in a single surgeon series. We hypothesized that increasing surgeon experience would be associated with improved acetabular surgical outcomes in general. Retrospective cohort study. Urban academic level-I trauma center. Seven hundred ninety-five patients who underwent an open reduction internal fixation for an acetabular fracture. There was a significant association between surgeon experience and certain outcomes, specifically reoperation rate (16.9% overall), readmission rate (13.9% overall), and reduction quality. Deep infection rate (9.7% overall) and secondary displacement rate (3.7% overall) were not found to have a significant association with surgeon experience. For reoperation rate, the time until 50% peak performance was 2.4 years in practice. Surgeon experience had a significant association with reoperation rate, quality of reduction, and readmission rate after open reduction internal fixation of acetabular fractures. Other patient outcomes were not found to be associated with surgeon experience. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for the Development of Heterotopic Ossification Following Acetabular Fractures: A Systematic Review.

Heterotopic ossification (HO) following acetabular fractures is a common complication that may affect clinical outcomes. However, the effects of prophylactic treatment with nonsteroidal anti-inflammatory drugs or radiation therapy remain controversial. While several factors have been related to the development of HO, there is considerable uncertainty regarding their importance or effect size in the setting of acetabular surgery. Therefore, this systematic review aims to summarize the risk factors for HO following the operative fixation of acetabular fractures and clarify their interrelationships. In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, PubMed, MEDLINE, Embase, and CINAHL databases were searched from inception to February 2021. Studies that assessed factors related to HO development among patients with operatively repaired acetabular fractures were included. Outcomes were risk factors and their effect size (p values, odds ratios, and 95% confidence intervals). Twenty-five studies and 1 conference abstract with a total of 3,940 patients were included. The following risk factors for HO were identified. Patient factors were increased body mass index, male sex, and increased age. Injury factors were intensive care unit (ICU) admission and length of stay, non-ICU hospitalization for >10 days, the need for mechanical ventilation for ≥2 days, abdominal and/or chest injuries, the number and type of associated fractures, traumatic brain injuries, T-type acetabular fractures, pelvic ring injuries, and hip dislocation. Care factors were a delay to surgery, extensile and posterior surgical approaches to the hip, trochanteric osteotomy, postoperative step-off of >3 mm, and a delay to prophylaxis following injury or surgery. Ethnicity, Injury Severity Score, cause of the fracture, femoral head injuries, degloving injuries, comminution, intra-articular debris, the type of bone void filler, gluteus minimus muscle preservation, prolonged operative time, and intraoperative patient position were not risk factors for developing HO. HO following operative fixation of acetabular fractures is not uncommon, with severe-grade HO associated with substantial disability. Careful consideration of the risk factor effect sizes and interdependencies could aid physicians in identifying patients at risk for developing HO and guide their prophylactic management. The results of this study could establish a framework for future studies. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Development of Cam Impingement following Operative Fixation of Acetabular Fractures

AbstractThe development of femoroacetabular impingement following acetabular fracture fixation is under-recognized. This study assessed radiographic changes of the hip joint after acetabular fracture fixation, and the clinical implications of associated radiographic changes. Institutional review of patients under age 40 who underwent acetabular fracture fixation from 2010 to 2016 with minimum 1-year radiographic follow-up was performed. Two independent evaluators compared immediate postoperative radiographs and those at final follow-up for basic radiographic parameters. Chi-squared test, Fisher's exact test, and two-tailed t-tests were used to compare those with and without cam lesion development. Two-hundred twenty-four hips were reviewed, with 55 hips (53 patients) meeting inclusion criteria (age = 29.2 years, 60% male, average follow-up = 2.1 years). Average α angle increased from 53.8 to 75.5 degrees postfixation (p < 0.001). Average immediate postoperative joint space was unchanged from that at follow-up (3.6 versus 3.6 mm, p = 0.90), and there was no association between joint space narrowing and cam lesion development. Forty-four hips had postoperative α angles of less than 65 degrees. At final follow-up, 26/44 hips (59.1%) had α angles of greater than 65 degrees. Lower body mass index was an independent risk factor for increase in α-angle (p < 0.05). Hip dislocation, acetabular fracture pattern, age, and joint space narrowing were not risk factors for the development of cam deformity. Two patients had undergone hip preservation procedures at the last follow-up. Our findings identify the development of primarily femoral-sided femoroacetabular impingement following acetabular fracture fixation and highlight the importance of prolonged postoperative follow-up for these patients. Providers should scrutinize radiographs in those with new-onset pain or poor satisfaction following acetabular fixation.

Heterotopic Ossification Prophylaxis Following Operative Fixation of Acetabular Fractures: A Systematic Review.

Heterotopic ossification (HO) is a well-recognized complication following operative fixation of acetabular fractures with a range of severity and clinical consequences. The purpose of this review was to: (1) report the incidence of heterotopic ossification (HO) formation following operative fixation of acetabular fractures; (2) determine the effectiveness of prophylactic treatments for HO; and (3) assess the radiographic severity of HO with and without prophylactic treatment. A literature search for peer-reviewed articles was conducted utilizing a variety of research databases. PRISMA guidelines were followed and included in this review were full-length, English language manuscripts published before September 2019, using the following search criteria: "heterotopic ossification AND acetabulum OR acetabular." Studies that reported HO as one of the reported outcomes were included. Articles were excluded if radiographic HO was not reported and if it was evaluated in surgeries other than those involved in acetabular fractures. Extracted data included, but was not limited to: type of prophylaxis; incidence of HO; severity of HO based on the Brooker classification; and statistical significance. A methodologic quality appraisal of the included studies was also conducted. A total of 54 full-text studies with 5,890 patients with operatively fixed acetabular fractures met inclusion criteria. There were four level I studies, four level II study, 26 level III studies, and 20 level IV studies. The overall incidence of HO after acetabular fracture surgery was 28.4%. The rate of HO formation was: 34.9% without prophylaxis, 28.3% with non-steroidal anti-inflammatory drugs (NSAID) prophylaxis, and 21.2% with radiation therapy (RT). Patients receiving a combination of both RT and NSAIDs developed HO 21.8% of the time. The rate of radiographic severe HO was 13.9% (range, 0-75%) in patients without prophylaxis, 9.4% (range, 0-50%) with NSAID prophylaxis, 5.7% (range, 0-12.8%) with RT prophylaxis, and 11.7% (range, 0-18.5%) with the combination of RT and NSAIDs. With the current literature collected in this systematic review, there was a lower incidence and severity of heterotopic bone formation following acetabular fracture fixation using radiation prophylaxis compared to NSAIDs or no treatment. The available literature is heterogeneous in fracture characteristics, surgical approaches, and prophylactic regimens with a general lack of randomized control trials. Further prospective studies are required to make definitive claims on the optimal prophylactic strategy to prevent heterotopic ossification.

Do Indomethacin or Radiation for Heterotopic Ossification Prophylaxis Increase the Rates of Infection or Wound Complications After Acetabular Fracture Surgery?

To compare the rates of infection and wound complications in patients undergoing operative fixation (ORIF) of acetabular fractures receiving heterotopic ossification (HO) prophylaxis using indomethacin or external beam radiation therapy (XRT) versus no prophylaxis. Retrospective cohort. Level I trauma center. We reviewed 473 patients undergoing ORIF of acetabular fractures through posterior, combined, or extensile surgical approaches from 2012 to 2017, with a median follow-up of 13 months (0.5-77 months). Rates of infection and wound complications were stratified according to their HO prophylaxis method into three groups as indomethacin, XRT, and no prophylaxis. Overall, 167 patients (35.3%) received indomethacin, 104 patients (22.0%) received postoperative XRT, and 202 patients (42.7%) received no prophylactic treatment. There was no difference between the 3 groups for the risk of surgical site infection (P = 0.280). The XRT group had a significantly increased risk of noninfectious wound complications (20.2%) compared with the indomethacin group (6.6%, P = 0.002) and the no prophylaxis group (5.0%, P < 0.0001). Multivariate analysis revealed XRT remained a significant risk factor for noninfectious wound complications compared with no prophylaxis (odds ratio 5.39; 95% confidence interval 2.37-12.22; P < 0.0001). Although there is no difference between XRT, indomethacin, and no HO prophylaxis for the risk of surgical site infection, the use of XRT results in more than 5 times increased risk of noninfectious wound complications compared with no prophylaxis. This increased risk should be considered when contemplating XRT for HO prophylaxis in acetabular fracture patients. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

CORR Insights®: Risk Factors for Surgical Site Infection after Operative Fixation of Acetabular Fractures: Is Psoas Density a Useful Metric?

CORR Insights®: Risk Factors for Surgical Site Infection after Operative Fixation of Acetabular Fractures: Is Psoas Density a Useful Metric?

Risk Factors for Surgical Site Infection after Operative Fixation of Acetabular Fractures: Is Psoas Density a Useful Metric?

Surgical site infection (SSI) occurs in 5% to 7% of patients undergoing operative fixation of acetabular fractures, with reported risk factors including longer operative duration, increased blood loss, pelvic artery embolization, and concurrent abdominal organ injury, among others. Psoas muscle density is a measure of muscle quality and, as a metric for sarcopenia and/or nutrition status, has been associated with poor outcomes such as mortality across multiple surgical specialties. To date, psoas muscle density has not been explored for its associations with SSI in acetabular fracture patients.Questions/purposes (1) Is decreased psoas muscle density, as measured by Hounsfield units, associated with an increased SSI risk after acetabular fracture fixation? (2) What patient, operative, and hospital variables are associated with an increased SSI risk after acetabular fracture fixation? Between 2012 to 2017, surgeons performed 684 acetabular ORIF procedures at one level I trauma center. Of those, 8% (56 of 684) did not meet inclusion criteria, leaving 92% (n = 628) for analysis in this study. The median (range) follow-up duration was 12 months (0.5-77). Patient demographics, comorbidities, operative and in-hospital variables, and psoas muscle density measured using preoperative pelvic CT images-acquired for all operative acetabular fracture patients-were analyzed. SSI was defined by positive culture results obtained during irrigation and débridement. Overall, 7% (42 of 628) of patients had an SSI. A multivariable regression analysis was performed to identify independent risk factors. Sensitivity analysis was performed with minimum follow-up set at 3 months and 6 months. There was no difference in the mean psoas muscle density between patients with SSI (50.9 ± 10.2 Hounsfield units [HUs]) and those who did not have an SSI within 1 year of open reduction and internal fixation (51.4 ± 8.1 HUs) (mean difference: 0.5 [95% confidence interval -2.34 to 3.32]; p = 0.69). Four variables were independently associated with an increased risk of SSI: increased operative time (1.04 [95% CI 1.00 to 1.07]; p = 0.03), estimated blood loss (1.08 [95% CI 1.02 to 1.14]; p = 0.01), female sex (2.34 [95% CI 1.19 to 4.60]; p = 0.01), and intravenous drug use (3.95 [95% CI 1.51 to 10.33]; p = 0.01). Sensitivity analysis showed no change in results using either 3-month or 6-month minimum follow-up. Risk factors for SSI after acetabular fixation include female sex, intravenous drug use, prolonged operative times, and increased intraoperative blood loss. Although the density of the psoas muscle may be a surrogate for nutritional markers, it was not associated with SSI in our patients with acetabular fractures. Thus, it is not useful for risk assessment of SSI in the general population with acetabular fracture; however, future studies with larger sample sizes of patients older than 60 years may re-investigate this marker for SSI risk. Contrary to the results of previous studies, pelvic artery embolization, intraoperative blood transfusion, and intensive care unit stay did not increase the risk of SSI; however, we may have been underpowered to detect differences in these secondary endpoints. Future large, multisite studies may be needed to address these conflicting results more definitively. Level III, therapeutic study.

Risk Factors for Early Reoperation After Operative Treatment of Acetabular Fractures.

To identify the risk factors for early reoperation after operative fixation of acetabular fractures. Retrospective evaluation. Level I Trauma Center. Seven hundred ninety-one patients with displaced acetabular fractures treated with open reduction and internal fixation (ORIF) from 2006 to 2015. Average follow-up was 52 weeks. Early reoperation after acetabular ORIF, defined as secondary procedure for infection or revision within 3 years of initial operation. Fifty-six (7%) patients underwent irrigation and debridement for infection and wound complications. Four associated risk factors identified were length of stay in the intensive care unit, pelvic embolization, operative time, and time delay between injury and surgical fixation. Sixty-two (8%) patients underwent early revision, including 45 conversions to total hip arthroplasty, 10 revision ORIF, 6 fixation device removals because of concern for joint penetration (2 acutely and 4 > 6 months after surgery), and 1 stabilization procedure. Three risk factors associated with early revision were hip dislocation, articular comminution, and concomitant femoral head or neck injury. Combined injuries to the pelvic ring and acetabulum, fracture pattern, marginal impaction, and body mass index had no significant effect on early revision surgery. Risk factors for early reoperation after operative fixation of acetabular fractures differed based on the reason for return to the operating room. Infection was more likely to occur in patients who had prolonged stays in the intensive care unit, had prolonged operative times, were embolized, or experienced delay in time to fixation. Revision was more likely with hip dislocation, articular comminution, femoral head or neck fracture, and advancing age. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Achieving Anatomic Acetabular Fracture Reduction-When is the Best Time to Operate?

We hypothesize that earlier operative intervention for acetabular fractures improves the probability of achieving an anatomic reduction. Retrospective review. Academic level I trauma center. Six hundred fifty acetabular fractures treated through open reduction and internal fixation (ORIF) between September 2001 and February 2014. Acetabular fracture ORIF. Reduction quality was assessed through postoperative radiographs. Displacement of ≤1 mm was considered an anatomic reduction, 2-3 mm imperfect, and >3 mm poor. Anatomic reductions were observed in 85% (n = 553) of cases, imperfect reductions in 11% (n = 74) of cases, and poor reductions in 4% (n = 23) of cases. Patients with anatomic reductions had significantly shorter times from injury to ORIF [odds ratio (OR) interval] (median, 3 d) when compared with either imperfect (median, 4.5 days, P = 0.02) or poor reductions (median, 7 days, P < 0.001) reductions. The OR interval of imperfect reductions was also significantly shorter than that of poor reductions (P = 0.02). Logistic regression analysis demonstrated that OR interval had an effect of -0.12, meaning that the log odds of anatomic reduction decreases by 0.12 with each day from injury to ORIF. The interval from injury to operative fixation of acetabular fractures affects reduction quality. Earlier intervention improves the probability of achieving an anatomic reduction; therefore, ORIF should be performed as early as possible, provided the patient is optimized for surgery. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Use of the Obturator-Outlet Oblique View to Guide Percutaneous Retrograde Posterior Column Screw Placement

In contrast to open reduction internal fixation, percutaneous fixation is a relatively new option for operative fixation of acetabular fractures. The techniques for percutaneous insertion of anterior and posterior column screws have been previously described. For technical aspects of retrograde percutaneous posterior column screws, much attention has been paid to the proper start point. However, descriptions of proper trajectory and end point have not been as clearly delineated. Understanding of posterior column anatomy and its radiographic correlates are fundamental in the safe placement of this screw. Herein, we present technical advice for acquisition and interpretation of fluoroscopic images needed to ensure a safe trajectory and end point in retrograde percutaneous posterior column screw placement. We highlight our steps to ensure correct placement in a small series.

Operative Fixation of Acetabular Fractures in the Pregnant Patient

To describe in utero radiation exposures in pregnant patients undergoing acetabular fracture repair. Retrospective case series. University-affiliated regional trauma center. Eight pregnant patients with acetabular fractures treated over a 6-year period. There were an additional 518 acetabular fractures in nonpregnant patients treated during the same time period. Open reduction and internal fixation of the acetabulum fracture. None. This is a descriptive series reporting fetal radiation doses, fetal fluoroscopy exposure times, and fetal viability after treatment. The gestational age of the fetuses at presentation ranged from 5 to 26 weeks. Infant delivery averaged 27 weeks from the time of surgery and all pregnancies reached 36 weeks. Apgar scores were normal each child including 1 twin delivery. There were 4 posterior wall fractures, 3 transverse or posterior wall fractures, and 1 posterior column fracture. Intraoperative pelvic fluoroscopy averaged 39 seconds. There were no operative complications and fracture reductions were anatomic in 7 patients. Computed tomography scan of the pelvis conferred the greatest exposure risk to the fetus and fluoroscopy conferred the least. In each case that required a computed tomography scan of the pelvis, the calculated radiation exposure dose to the fetus was greater than 5 cGy. The results of this study demonstrate that with a team approach and the judicious use of radiographic imaging during the surgical care of a displaced acetabular fracture in the pregnant patient, minimal risk to the baby can be achieved in pursuit of acceptable articular reductions.