Operative Treatment Of Acetabular Fractures Research Articles

Long-term follow-up and survival of delayed total hip arthroplasty following acetabular fracture: a matched cohort study of 552 cases from the Norwegian Arthroplasty Register.

Operative treatment of acetabular fractures generally yields good results, but several authors report up to 15-20% of patients developing post-traumatic osteoarthritis (OA). Previous studies have shown that total hip arthroplasty (THA) following post-traumatic OA have inferior results compared to THA for primary OA. The aim of this study was to report on long-term outcome of THA following acetabular fracture, compared to primary OA. We performed a matched cohort study with data from the Norwegian Arthroplasty Register (NAR). All patients receiving THA following an acetabular fracture between 1987 and 2018 were identified. A 3:1 matched cohort consisting of patients treated for primary OA with THA was selected using propensity scores and matched for age, gender and year of surgery. Survival analysis was performed with revision of any cause as endpoint. Cox regression was used to identify factors associated with risk of revision surgery. 552 cases were identified, 397 men and 155 women. Mean age was 58.8 (11-91) years. 224 had previously been operated for the acetabular fracture, 328 had been treated non-operatively. Mean follow up time was 8.7 (1-29) years. Implant survival at 10 years was 79.7% (75.6-83.3) and at 20 years 62.4% (55.5-69.3). The hazard ratio for revision was 1.38 (1.07-1.77, p < 0.001) compared to the OA cohort, regardless of operative or non-operative treatment of the index acetabular fracture. Uncemented acetabular components had an increased risk of revision with hazard ratio for revision 1.61 (p = 0.012). THA following an acetabular fracture can be performed with acceptable results regarding implant survival, however, we report an increased risk for revision when compared to primary OA. Our results indicate that previous operative fracture treatment does not increase the risk for THA revision compared to cases treated non-operatively.

Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures

IntroductionPatients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures. MethodsAdults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality. ResultsAfter propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality. ConclusionCirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture. Level of EvidencePrognostic Level III.

Complications of Morbid Obesity in the Treatment of Acetabular Fractures: Re-evaluating Outcomes a Decade Later.

To determine the rate of perioperative complications between morbidly obese (body mass index greater than 40 kg/m2) and nonmorbidly obese patients undergoing operative treatment of acetabular fractures across 2 periods (2000-2005 and 2012-2019). Retrospective, case-control study. Level I academic trauma center. Four hundred thirty-five consecutive patients from 2000 to 2005 and 216 consecutive patients from 2012 to 2019 with acetabular fractures treated by a single surgeon. Operative fixation of acetabular fracture. Outcome variables include positioning time, operative time, estimated blood loss, hospital stay, wound complications, and perioperative complications. Twenty-eight morbidly obese and 188 nonmorbidly obese patients from 2012 to 2019, as well as 41 morbidly obese patients and 394 nonmorbidly obese patients from 2000 to 2005 were included in the study. The relative risk (RR) of wound complications between 2012 and 2019 groups was significantly higher for morbidly obese patients (RR = 5.31, P = 0.009) but has decreased significantly for morbidly obese patients between 2000-2005 and 2012-2019 (RR = 0.31, P = 0.017). The rate of total perioperative complications was similar between morbidly obese and nonmorbidly obese groups from 2012 to 2019 (21% vs. 8%, P = 0.230). For morbidly obese patients, the rate of total perioperative complications decreased significantly between 2000-2005 and 2012-2019 (63% vs. 21% P = 0.010). Acetabular fracture surgery can be safely performed in morbidly obese patients. Although obesity remains a significant risk factor for wound complications, the risk for morbidly obese patients has decreased significantly since our initial investigation because of adaptations to surgical techniques and surgeon's experience. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fracture and Patient Characteristics Associated With Early Conversion Total Hip Arthroplasty After Acetabular Fracture Fixation.

To determine risk factors for early conversion total hip arthroplasty (THA) after operative treatment of acetabular fractures. Retrospective cohort. Level I trauma center. We reviewed 685 operative acetabular fractures at our institution from 2011 to 2017, with a median follow-up of 12 months (range, 4-105 months). Multivariable regression analysis was performed after univariate analysis to identify independent risk factors for conversion THA. Sensitivity analysis was performed with minimum follow-up set at 6 and 12 months. One hundred eight patients (16%) underwent conversion THA, with 52% of conversions occurring within 1 year, an additional 27% within 2 years, and the remaining 21% within 6 years of the index acetabular open reduction internal fixation. The median time to conversion THA was 11.5 months (range, 0.5-72 months). The risk of conversion THA by fracture pattern was 53 of 196 (27%) for transverse posterior wall (TPW), 12 of 52 (23%) for T shaped, 10 of 68 (15%) for posterior column with posterior wall, and 25 of 207 (12%) for posterior wall. Independent risk factors for early conversion included the following: TPW fracture, protrusio, hip dislocation, increased body mass index, increased age, infection, and dislocation after open reduction internal fixation. Independent risk factors for early conversion THA specific to patients with TPW fractures include only increased age and body mass index. Sensitivity analysis showed no change in results using either 6 or 12-month minimum follow-up. Transverse posterior wall fractures have a high risk of early conversion THA compared with other acetabular fracture patterns, especially when in combination with other significant risk factors. Consideration for different and novel management options warrants further study in this subset of acetabular fracture patients. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Early Operative Treatment of Acetabular Fractures Does Not Increase Blood Loss: A Retrospective Review.

To compare cell salvage (CS) volume, intraoperative blood loss, intraoperative blood transfusions, and operative time for acetabular fractures undergoing early (≤48 hours from admission) versus delayed fixation (>48 hours from admission). Retrospective. Level one trauma center. One hundred thirty-one patients with unilateral acetabular fractures involving at least one column. Open reduction and internal fixation performed through the anterior intrapelvic approach or posterior approach. CS volume, estimated blood loss (EBL), intravenous fluids (IVFs), intraoperative packed red blood cells (PRBCs), and operative time. Early versus delayed fixation through the posterior approach was associated with shorter operative times and less intraoperative PRBCs (140 vs. 301 mL, MD -161 mL, 95% confidence interval -25 to -296 mL) with no differences in CS, EBL, or IVF. Early versus delayed fixation through an anterior intrapelvic approach was more common in less severe fracture patterns with no differences in PRBCs, CS, EBL, or IVF. CS, through either approach, was successful in returning blood to 77% of patients for an average of 267 ± 168 mL (range, 105-900 mL). Fixation of acetabular fractures within 48 hours of admission did not increase blood loss or intraoperative transfusions. CS was successful in returning an average of one unit of blood to a majority of patients. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An analysis of surgical management of acetabular fractures

With increase in number of high-speed road traffic accidents the incidence of acetabular fracture is increasing. Historically satisfactory results after non operative treatment of acetabular fractures were obtained only in a minority of cases (13-30%). Non operative treatment options include traction and early mobilization with progressive weight bearing. Unsuccessful outcomes after non operative treatment were mostly related to early posttraumatic arthritis likely due to articular incongruity, hip joint instability, and muscle dysfunction. In our study, all the acetabular fractures are classified using standard investigations, operatively managed in indicated cases and followed up post-operatively with regards to improvement in clinical and radiological outcome. Out of 50 patients, 12 patients had excellent result, 24 patients had good result, 9 patients had fair result, and 5 patients had a poor result. Aims and Objectives 1. To study and analyze the outcomes of open reduction and internal fixation in patients with acetabular fractures in terms of radiology, clinical and functional outcomes. 2. To study the role of early range of motion exercises in the functional outcome.3. To study the complications associated with the surgical approaches. Materials and Methods 1. Type of study: Descriptive, case series, comparison study, partly retrospective and prospective. 2. The study was done to assess the clinical, radiological and functional outcome of patients with acetabular fractures treated with open reduction and internal fixation at Goa Medical College. 3. Study setting: Inpatient ward no 103,104,105, under Department of Orthopaedics, Goa Medical College. 4. Methods: All fractures have been classified using the Letournel and Judet classification. All the cases were followed up post operatively and were analyzed for radiological, functional and clinical outcome. The radiological outcome was evaluated with radiograph pelvis AP view, Obturator oblique view and Iliac oblique views. The functional outcome was evaluated with Merle d’Aubigne and Postel modified clinical grading system and Harris hip score.

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.

Modified Stoppa approach for operative treatment of acetabular fractures: 10-year experience and mid-term follow-up

IntroductionThe (modified) Stoppa approach for acetabular fracture surgery has gained significant popularity and early results have been encouraging but clinical outcome at extensive follow-up is scarce. The purpose of this study is to provide an update on our experience with this approach for operative treatment of acetabular fractures and to assess clinical outcome at mid-term follow-up. MethodsIn this retrospective study, all patients treated operatively for an acetabular fracture using the Stoppa approach over a 10-year period were included. Surgery details were reviewed and patients were contacted and requested to return for follow-up. Primary outcome was native hip survivorship, secondary outcome measures included; functional outcome (Merle d’Aubiginé, Harris hip) scores, health-related quality of life (short-form 36) and radiographic outcome (heterotopic ossification, hip osteoarthritis). ResultsForty-five patients received operative fixation for 47 acetabular fractures using the Stoppa approach. Complications requiring surgical intervention were found in one patient (with a vascular lesion) intra-operatively and 3 patients (with wound infections (2) and diffuse bleeding (1)) post-operatively. Follow-up was 83% and 29/39 (74%) native hips survived at mean 59 months (SD 49) postoperatively. Excellent-good functional scores were found in 88% (Merle d’Aubiginé) and 76% (Harris hip) of patients who had retained their native hip. Most (6/8) short-form 36 indices in these patients were comparable to population norms. Of 29 native hips with radiographic follow-up (mean 59 months (SD 49), 4 (86%) had no-minimal radiographic abnormalities. ConclusionThis study confirms that the Stoppa approach is a safe and effective technique for acetabular fracture fixation. Moreover, at mid-term follow-up, this approach is associated with satisfactory results in terms of hip survivorship as well as functional and radiographic outcome. As such, our findings reinforce the notion that this less invasive technique presents a valuable alternative to the ilioinguinal approach for the surgical treatment of acetabular fractures.

Cementless Acetabular Reconstruction for Arthropathy in Old Acetabular Fractures.

This study was conducted to identify the factors influencing mechanical failure of cementless acetabular reconstruction for arthropathy after operative treatment of acetabular fractures. Fifty-six patients (56 hips) undergoing cementless total hip arthroplasty were enrolled and followed for a mean of 120 months (range, 60-180 months). The 10-year survival rate, with mechanical failure (radiographic loosening or revision due to aseptic loosening) as the endpoint, was analyzed with respect to sex, age, body mass index (BMI), acetabular bone deficiency, sclerotic changes to the acetabulum, and use of the Trabecular Metal (TM) cup (Zimmer, Inc, Warsaw, Indiana). Mean 10-year survival rates of the acetabular component were as follows: 80% (range, 65%-96%) in males and 100% in females (P=.032); 77% (range, 60%-95%) in patients younger than 50 years and 91% (range, 82%-100%) in older patients (P=.027); 88% (range, 78%-98%) in patients with a BMI less than 30 kg/m(2) and 81% (range, 74%-89%) in patients with a BMI of 30 kg/m(2) or higher (P=.068); 54% (range, 32%-76%) in patients manifesting large acetabular deficiency and 90% (range, 78%-100%) in the remaining patients (P<.001); 78% (range, 65%-91%) in patients with the presence of sclerotic acetabulum and 92% (range, 86%-100%) in patients with the absence of sclerotic acetabulum (P=.022); and 82% (range, 73%-100%) in patients who received a conventional shell and 100% in patients who received the TM cup (P=.039). Male sex, age younger than 50 years, large acetabular deficiency, and sclerotic changes of the acetabulum were significant factors contributing to the mechanical failure of cementless acetabular reconstruction performed for old acetabular fractures treated with open reduction and internal fixation. Use of the TM cup seemed able to prolong the endurance of the acetabular component in the subsequent reconstruction.

Effect of surgical treatment on mortality after acetabular fracture in the elderly: a multicenter study of 454 patients.

Controversy exists regarding the effect of operative treatment on mortality after acetabular fracture in elderly patients. Our hypothesis was that operative treatment would confer a mortality benefit compared with nonoperative treatment even after adjusting for comorbidities associated with death. Retrospective study. Three University Level I Trauma Centers. All patients aged 60 years and older with acetabular fractures treated from 2002 to 2009 were included in the study. Four hundred fifty-four patients were identified with an average age of 74 years. Sixty-seven percent of the study group was male and 33% female. One of 4 treatments: nonoperative management with early mobilization, percutaneous reduction and fixation, open reduction and internal fixation, acute total hip arthroplasty. Kaplan-Meier survival curves were created, and Cox proportional hazards models were used to calculate unadjusted and adjusted hazard ratios (HRs) for covariates of interest. In contrast to previous smaller studies, the overall mortality was relatively low at 16% at 1 year [95% confidence interval (CI), 13-19]. Unadjusted survivorship curves suggested higher 1-year mortality rates for nonoperatively treated patients (21% vs. 13%, P < 0.001); however, nonoperative treatment was associated with other risk factors for higher mortality. By accounting for these patient risk factors, our final multivariate model of survival demonstrated no significant difference in hazard of death for nonoperative treatment (0.92, P = 0.6) nor for any of the 3 operative treatment subgroups (P range, 0.4-0.8). As expected, we did find a significantly increased hazard for factors such as the Charlson comorbidity index [HR, 1.25 per point (95% CI, 1.16-1.34)] and age [HR, 1.08 per year of age more than 70 years (95% CI, 1.05-1.11)]. In addition, associated fracture patterns (compared with elementary patterns) significantly increased the hazard of death with a ratio of 1.51 (95% CI, 1.10-2.06). The operative treatment of acetabular fractures does not increase or decrease mortality, once comorbidities are taken into account. The reasons for this are unknown. Regardless of the causes, the decision for operative versus nonoperative treatment of geriatric acetabular fractures should not be justified based on the concern for increased or decreased mortality alone. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A feasibility study into the use of three-dimensional printer modelling in acetabular fracture surgery.

There are a number of challenges associated with the operative treatment of acetabular fractures. The approach used is often extensive, while operative time and perioperative blood loss can also be significant. With the proliferation of 3D printer technology, we present a fast and economical way to aid the operative planning of complex fractures. We used augmented stereoscopic 3D CT reconstructions to allow for an appreciation of the normal 3D anatomy of the pelvis on the fractured side and to use the models for subsequent intraoperative contouring of pelvic reconstruction plates. This leads to a reduction in the associated soft tissue trauma, reduced intraoperative time and blood loss, minimal handling of the plate, and reduced fluoroscopic screening times. We feel that the use of this technology to customize implants, plates, and the operative procedure to a patient's unique anatomy can only lead to improved outcomes.

Risk factors for the development of heterotopic ossification after acetabular fracture fixation.

Heterotopic ossification (HO) is a common complication of the operative treatment of acetabular fractures. Although the surgical approach has been shown to correlate with the development of ectopic bone, specific risk factors have not been elucidated. The purposes of this study were to determine specific risk factors associated with the development of severe HO and the frequency with which patients develop severe HO after acetabular fracture fixation through an isolated Kocher-Langenbeck approach. Using an institutional orthopaedic trauma database at a regional Level I trauma center, patients undergoing open treatment of acetabular fractures during the study period (January 2000 to January 2010) were identified. A review of medical records and imaging studies was performed on 508 patients who were treated by the senior author (MR) through an isolated Kocher-Langenbeck approach. During the study period, the senior author used indomethacin for HO prophylaxis in patients who had ipsilateral femur fracture treated with antegrade reamed medullary nailing or severe local soft tissue injury; 49 (10%) of the patients he treated with the Kocher-Langenbeck approach received prophylaxis, and they were excluded from this study, leaving a total of 459 patients who met inclusion criteria. Of those, 147 (29%) were lost to followup or did not have radiographs both before and at a minimum of 6 weeks (median, 1 week; range, 0-3 weeks), leaving 312 (61% of the patients treated with the Kocher-Langenbeck approach during this time) available for this analysis. Demographic data as well as information related to cause of injury, associated periacetabular findings, other system injuries, and treatment were gathered. Final followup radiographs were assessed for the presence of ectopic bone by two of the authors (TJO, AS) using the modified Brooker classification. Logistic regression was performed to identify possible predictors of development of severe ectopic bone. The only predictor we identified for the development of severe HO was the need for prolonged mechanical ventilation (odds ratio, 7.1; 95% confidence interval, 2.9-17.3; p=0.001). Injury Severity Score, sex, presence of comminution, femoral head impaction, dislocation, degloving injury, debris in the joint, number of other fractures, and head and chest Abbreviated Injury Score>2 did not correlate with severe HO. Severe HO (Brooker Class III or IV) developed in 38 of 312 patients (12%). Patients with prolonged mechanical ventilation might benefit from HO prophylaxis given the increased risk of developing severe HO in this patient population. However, future prospective studies need to be performed to verify this finding given the fact that a considerable number of patients were prophylactically treated in this study. Level IV, prognosticstudy. See Guidelines for Authors for a complete description of levels of evidence.

Heterotopic Ossification Excision Improves Kinetic and Kinematic Gait Parameters as Demonstrated by Computerized Motion Analysis

Heterotopic ossification (HO) is defined as formation of bone in abnormal locations. HO has been extensively reported in the orthopaedic literature, particularly following total hip arthroplasty, the operative treatment of acetabular fractures, and after spinal cord, traumatic brain, and burn injuries1-24. The hip is the most common site of HO. While many patients with HO are asymptomatic, more severe cases can result in pain and substantial limitations in joint range of motion. The Brooker classification, which is based on the appearance of HO on a single anteroposterior radiograph, remains the most commonly used classification system for HO, although other modified rating systems have been suggested3,7,25. In patients who undergo procedures that result in substantial risk of HO, prophylaxis can be considered; numerous studies have reported successful prophylaxis against HO formation in patients following total hip arthroplasty and open reduction and internal fixation for acetabular fractures2,9,15,16,20,21,24,26-30. The key to preventing HO is early prophylaxis in the inflammatory stage. In patients with symptomatic HO, surgical excision may be considered. Previous studies report improved range of motion following HO excision31-35. Because the incidence of HO recurrence after surgical excision is extremely high, postoperative prophylaxis with radiation or anti-inflammatory medications is recommended. To the best of our knowledge, this is the first case report of HO excision with documentation of both static and dynamic changes of hip range of motion with use of preoperative and postoperative three-dimensional (3D) computerized motion analysis. The patient and her parents were informed that data concerning the case would be submitted for publication, and they provided consent. An eight-year-old girl with duodenal atresia had developed duodenal perforation …

Operative Treatment of Acetabular Fractures in the Medicare Population

The purpose of this study was to determine the incidence of and evaluate the risk for complications and mortality following open treatment of acetabular fractures in the Medicare population. Patients treated with open reduction and internal fixation (ORIF) for acetabular fractures were identified using current procedural terminology codes in a 5% national sample of Medicare records. Complications within 90 days and within 1 year were evaluated based on the presence of ICD-9-CM diagnosis codes and Current Procedural Terminology reoperation codes. A total of 1286 fractures were treated closed and 359 were treated with ORIF. Multivariate Cox regression was performed to compare complication rates and risk factors. The incidence of acetabular fractures in the Medicare population has increased by 29% since 1998. Complications in the ORIF group included cardiac complications, deep venous thrombosis, infection, pulmonary embolism, refixation, and conversion to total hip arthroplasty. Risk factors for complications with ORIF included advanced age and comorbidities. Mortality in the ORIF group was 14.4% at 1 year. The incidence of reoperation with conversion to total hip arthroplasty or revision fixation following ORIF is 10% and 15%, respectively. Further investigation is required to improve outcomes and decrease complications in this group of patients, especially cardiac, deep vein thrombosis, and infection.

Screw- versus plate-fixation strength of acetabular anterior column fractures

The standard for operative treatment of acetabular fractures is open reduction and plate fixation. Recently, screw fixation-only methods through less invasive approaches are reported, but biomechanical data are missing. Questions posed in this study are (1) is the static fixation strength of different screw types equivalent to the standard plate fixation for anterior column fractures of the acetabulum? and (2) does the placement of an additional screw in the infra-acetabular corridor increase the fixation strength independent of the used implant? Three groups of different screws (group II, titanium; group III, stainless steel; and group IV, biodegradable Poly-L-Lactid) were compared with the standard plate fixation (group I) in Synbone pelves with custom-made anterior column fractures. Six pelvises per group were axial loaded with six cycles of 800 N, twice with and without an additional placed infra-acetabular screw. The fixation strength of titanium screws was equivalent to the standard plate fixation. The stainless steel and Poly-L-Lactid screw fixation strengths were equivalent to each other but inferior to the aforementioned. The additional placement of an infra-acetabular screw significantly increased the fracture fixation strength, independent of the used implant. Screw fixation is a promising alternative approach for the stabilization of noncomminuted acetabular fractures of the anterior column with equivalent fixation strength to the standard plate fixation. The additional placement of an infra-acetabular screw significantly increases the fracture fixation independent of the used implant and should be considered for acetabular fractures with separation of both columns. Therapeutic study, level IV.

Operative Treatment of Acetabular Fractures in an Older Population Through a Limited Ilioinguinal Approach

To compare treatment of acetabular fractures in elderly patients through a limited approach versus a standard ilioinguinal approach and assess changes in outcome and morbidity. Retrospective cohort comparison analysis. Tertiary referral center. Between January 1992 and January 2006, 143 patients 55 years of age or older were treated for acetabular fractures. Of these, 41 were treated through either a traditional or limited ilioinguinal approach. Patients with unilateral surgeries and a minimum follow-up of 2 years were included. Open reduction and internal fixation of acetabular fractures through a limited (lateral two windows) approach versus traditional three window ilioinguinal approach. Radiographic assessment of healing, reduction quality, progression to arthritis and total hip arthroplasty, operative time, length of stay, complications, SF-36, Musculoskeletal Functional Assessment, and the Short Musculoskeletal Functional Assessment. The two groups were equivalent in terms of preinjury comorbidities, mechanism of injury, type and severity of fracture pattern, time to surgery, length of hospitalization, and incidence of postoperative complications. The overall rate of secondary total hip arthroplasty was 26.8% and was equivalent between the two groups. Functional outcome scores were comparable. The use of the lateral two windows was associated with a significant reduction in both blood loss and operative time. The limited ilioinguinal approach to certain fracture patterns commonly seen in the elderly was associated with a decreased blood loss and surgical time. Moreover, there was no negative impact on outcomes in our cohort. The benefits of decreased blood loss and shorter operative time have a potential positive impact on management of these injuries. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does Supplemental Epidural Anesthesia Improve Outcomes of Acetabular Fracture Surgery?

Addition of epidural anesthesia to general anesthesia is theorized to reduce hospital length of stay, improve postoperative pain control, reduce time to mobilization, and reduce intraoperative blood loss for operative treatment of acetabular fractures. Our hypothesis was that epidural anesthesia would result in improvement in short-term outcomes and therefore justify any associated increases in anesthesia induction time, treatment costs, or risks. Retrospective case-control. Academic trauma center. We identified 163 patients who underwent open reduction and internal fixation of posterior wall acetabular fractures from 2002 through 2007. We excluded patients who were intubated before the procedure (n = 20) and patients with incomplete intraoperative anesthesia records (n = 5). Patients were divided into two groups: Group 1 received combined epidural plus general anesthesia (CEGA) (n = 64) and Group 2 received general anesthesia alone (GA) (n = 74). No differences were observed between the two groups in terms of age, gender, Injury Severity Score, head Abbreviated Injury Score, mechanism of injury, number of associated fractures, number of comorbidities, or delay between injury and day of surgery. General anesthesia with or without epidural anesthesia. Length of stay, postanesthesia care unit initial and discharge pain scores, time to mobilization with physical therapy, estimated blood loss, and anesthesia time. : No significant differences were shown between the two groups for length of stay (CEGA, 6.2 days; GA, 5.9 days; P = 0.62; 80% power to detect a difference of 1.3 days), postanesthesia care unit initial pain scores (CEGA, 3.5; GA, 3.4; P = 0.92), postanesthesia care unit discharge pain scores (CEGA, 2.5; GA, 3.3; P = 0.13), or time to mobilization with physical therapy (CEGA, 1.5 days; GA, 1.7 days; P = 0.43). Intraoperative blood loss was less in the CEGA group (CEGA, 458 mL; GA, 543 mL; P = 0.05). Mean anesthesia time was longer for the CEGA group (CEGA, 85 minutes; GA, 66 minutes; P < 0.01). Although addition of epidural anesthesia added an average of 19 minutes to the anesthesia time (P < 0.01), we found no advantage to CEGA regarding length of stay, pain scores, or time to rehabilitation. Mean decrease of blood loss of less than 100 mL in the CEGA group is unlikely to be of clinical significance. Our results contrast findings in support of CEGA in the hip arthroplasty literature and question the use of CEGA for posterior wall acetabular fractures.

Changes in the treatment of acetabular fractures over 15 years: Analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU)

Epidemiological, clinical and radiological data of 1266 patients with a unilateral acetabular fracture of up to 29 hospitals was reviewed. Three time periods, 1991–1993 (Registry I; n = 359), 1998–2000 (Registry II; n = 503), and 2005–2006 (Registry III; n = 404) were compared with regard to injury pattern and severity, fracture type, and chosen nonoperative vs. operative treatment to elucidate changes over time in the treatment of acetabular fractures. In the operatively treated group, time to operation, surgical approach, fracture fixation implants and fracture reduction quality were examined. 641 (50.6%) patients with isolated acetabular fractures, 410 (32.4%) multiple injured and 215 (17.0%) polytrauma patients with 642 (50.7%) simple and 624 (49.3%) associated acetabular fractures were evaluated. In the time period from 1991 to 2006, the rate of operative treatments increased nationwide to 77% ( ρ < 0.001). The distribution of fracture types involving the anterior and posterior wall changed with age ( ρ < 0.001). Across all registries, 583 (68.0%) operations were performed within 7 days, 212 (24.7%) operations between 7 and 14 days and 54 (6.3%) operations were performed later than 14 days after injury. An anatomical reduction (0–1 mm displacement) was achieved in 551 (64%) acetabular fractures. The obtained reduction quality did not correlate with time to operation, was lower in associated than in simple fracture types, and also lower in patients with isolated acetabular fractures than in polytrauma patients. Most importantly, the fracture reduction quality did not improve over time despite a higher frequency of surgical interventions. The Kocher–Langenbeck approach was preferred in the nineties in nearly three quarters of all operative procedures. Currently, the Kocher–Langenbeck and the ilioinguinal approaches are used equally often. The fracture fixation did not change over time and is achieved in 51% with plates in combination with single screws. This multisurgeon series illustrates a nationwide performance in acetabular fracture management. Despite changes in the chosen approaches and an increased surgical frequency, the operative treatment of acetabular fractures of the last 15 years did not lead to an increased reduction quality. Therefore, the rarity and complexity of acetabular fractures demands further specific teaching by experienced acetabular surgeons, scientific research and clinical outcome evaluation.

Complications of Acetabular Fracture Surgery in Morbidly Obese Patients

To compare the early complications with operative treatment of acetabular fractures in morbidly obese (body mass index >or=40) patients when compared with all other patients. Retrospective review. University medical center. Four hundred thirty-five consecutive patients with acetabular fractures operatively treated by a single surgeon. Forty-one of these patients were morbidly obese (group 1) and were compared with the remaining patients (group 2). Group 2, therefore, included patients who were clinically overweight and obese. Operative repair of acetabular fracture. Outcome variables included patient positioning time, total operative time, estimated intraoperative blood loss, length of hospital stay, perioperative complications, and late complications. The average total operative time was 293 minutes for group 1 and 250 minutes (P = 0.008) for group 2. The hospital stay for group 1 averaged 26 days versus 15 days in group 2 (P < 0.01). There were 19 (46%) wound complications in group 1 compared with 49 (12%) in group 2 (P < 0.0001). Overall, there were complications in 26 of the 41 patients (63%) in group 1 and in 96 of the 394 patients (24%) in group 2. Group 1's relative risk of having a complication was 2.6 (95% confidence interval = 2.4-2.8) when compared with group 2. Our morbidly obese population had a statistically higher complication rate, longer operative times, and greater estimated intraoperative blood loss. The majority of complications were related primarily to wound healing problems and successfully controlled with aggressive approach to surgical debridement.

Results of operative treatment of acetabular fractures from the Third World—how local factors affect the outcome

The objective of this study was to assess the outcome of operations on acetabular fractures from a developing country in the presence of locally available facilities. Sixty-three acetabular fractures were assessed at an average follow up of 52.94 months after operation. Twenty-six patients operated upon in the first three years and 37 operated thereafter were separately studied to discover the effect of the learning curve. Regarding the fractures, 47 of 63 (74.6%) had excellent/good results (Harris Hip Score>80). The complications included broken drill bit in eight patients (12.69%), deep infection and heterotopic ossification in five patients (7.93%), avascular necrosis and sciatic nerve palsy in two patients (3.17%) and implant failure in one patient (1.58%). The results collected during the learning curve were inferior in the complex fractures (p value<0.001). Complications were common in patients opting for local implants and in those operated after over 2 weeks delay.