The incidence and trauma mechanisms of acetabular fractures: A nationwide study in Finland between 1997 and 2014

Acetabular fracture in India: An epidemiological study

Introduction

Acetabular fractures, resulting from high-energy trauma, present significant orthopaedic challenges. Despite their rarity, the incidence of these fractures is rising, necessitating a comprehensive understanding of their epidemiological characteristics, especially in diverse populations like India.

Methods

This retrospective study analyzed data from 3643 patients across four level-1 trauma centers in India (North 1, North 2, West, and South) from January 2001 to December 2019. Prior ethical approval was obtained from the respective institutions. Data were collected using the computerized patient record system (CPRS) and included patients with complete clinical and radiological records. Only patients with full radiological data were included, comprising standard anteroposterior radiograph, Judet views on radiographs, and computed tomography scan of the pelvis. The study evaluated the demographic characteristics, fracture patterns and surgical approaches.

Results

The majority of patients were males (84.05 %) and the fractures were mostly seen in young individuals between 19 and 40 years' age group (44.9 %), followed by 41-60 years (42.3 %). Associated bony or other system injuries were seen in 53.42 % of patients, with pelvic injuries being the most common (9.8 %). Posterior wall fractures were the most frequent (20.7 %), while anterior wall fractures were the least common (0.8 %). Operative management was employed in 82 % of cases, with the Kocher-Langenbeck approach being the most commonly employed (42.5 %).

Conclusion

High-velocity trauma remains the commonest cause of acetabular trauma in India, primarily affecting young male individuals. Pelvic fractures are the most commonly associated injuries. Posterior wall fractures are the commonest type of acetabular fracture, and the Kocher-Langenbeck approach is the commonly adopted surgical approach.

The Current Incidence and Future Projection of Acetabular Fractures in Korea

BACKGROUND

As one of the most challenging fractures to orthopedic surgeons, acetabular fractures show a wide range of incidence among countries and regions with even more variance in the treatment modalities. In this study, we aimed to investigate the epidemiology of acetabular fractures, and to compare the rate of subsequent total hip arthroplasty (THA) between nonoperative and operative treatments in South Korea using a medical claims database.

METHODS

This was a retrospective study using the Korean Health Insurance Review and Assessment database. Patients admitted for acetabular fractures from January 2007 to December 2018 were identified using International Classification of Diseases-10 codes. Kaplan-Meier survival analysis was used to compare the cumulative incidence of THA between two groups. We also evaluated the survivorship of operative group according to the type of institutions.

RESULTS

The incidence rate of acetabular fractures increased by 28% between 2007 and 2018. Acetabular fractures were more common in men (62%) than women (38%), and most common in the patients older than 80 years. The number of acetabular fractures was estimated to increase 1.7-fold in 2030 compared to 2018. Operative treatment accounted for 16% of cases, and nonoperative treatment for 84%. The incidence of subsequent THA was higher in the operative treatment group than in the nonoperative group (P < 0.001). The higher rate in the operative treatment group is probably related with the severity of the fracture type. The rate of subsequent THA was higher in patients who initially treated in general hospitals compared with those who were initially treated in tertiary hospitals.

CONCLUSION

The incidence of acetabular fractures is increasing in South Korea, in line with global trends. Most acetabular fractures are treated conservatively, and those who receive surgery are more likely to require a subsequent THA. Patients who were operated in general hospitals had highest possibility of subsequent THA after acetabular fractures.

Developing a core outcome set for acetabular fractures: a systematic review protocol

BACKGROUND

Clinical trials investigating acetabular fractures are heterogeneous in their investigated outcomes and their corresponding measurements. Standardization may facilitate comparability and pooling of research results, which would lead to an increase in knowledge about the optimal treatment of acetabular fractures, resulting in long-term evidence-based treatment decisions and improvements in patient care. The aim of this systematic review is to identify the reported outcomes and their measurements from studies on treatments for acetabular fractures to develop a core outcome set which contains the most relevant outcome measures to be included in future studies.

METHODS

Studies published in English and German including patients aged 16 years and older, with a surgically treated acetabular fracture, will be included. Studies with nonsurgical treatment, pathologic fractures, polytraumatized patients, and patients younger than 16 years of age will be excluded because other outcomes may be of interest in these cases. Any prospective and retrospective study will be included. Systematic reviews will be excluded, but their included studies will be screened for eligibility. The literature will be searched on MEDLINE, CENTRAL, Web of Science, ClinicalTrials.gov, and WHO ICTRP. Risk of selective reporting of outcomes will be assessed using the Outcome Reporting Bias in Trials classification system. Heterogeneously defined outcomes that measure the same outcome will be grouped and subsequently categorized into outcome domains using the taxonomy of the Core Outcome Measures in Effectiveness Trials Initiative.

DISCUSSION

It is expected that a high number of studies will be included, and many outcomes will be identified using different definitions and measurement instruments. A limitation of this systematic review is that only previously investigated outcomes will be detected, thus disregarding potentially relevant outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022357644.

Revision Surgery Risk After Open Reduction and Internal Fixation Versus Acute Total Hip Arthroplasty in Geriatric Acetabular Fractures: A Nationwide Study

BACKGROUND

The aging population has contributed to a rising incidence of acetabular fractures in older patients, yet current evidence guiding surgical treatment is limited by small sample sizes. This study used a nationwide database to investigate outcomes in older patients undergoing open reduction and internal fixation (ORIF) versus acute total hip arthroplasty (THA).

METHODS

The PearlDiver database was queried for patients aged 60 years and older with an acute acetabular fracture who underwent ORIF or acute THA (2010 to 2021). ORIF patients were matched 1:1 to THA patients based on age, sex, US region, insurance plan, and Charlson Comorbidity Index score. Patients with less than 2 years of follow-up were excluded. The primary outcome was revision surgery.

RESULTS

Of 120,032 patients with an acetabular fracture, 3,768 (3.1%) underwent surgical treatment: 1,482 (39.3%) THA and 2,286 (60.7%) ORIF. Mean age was 71.0 ± 6.51 years. Mean follow-up duration was 5.2 ± 2.1 years. THA patients were slightly older (72.4 versus 70.2 years), had higher Charlson Comorbidity Index scores (3.3 versus 2.7), and had a higher percentage of female patients (62.5% versus 32.2%). After matching, 962 ORIF and 962 THA patients were included. ORIF patients had longer LOS (10.7 versus 8.1 days). ORIF patients were less likely to experience joint infections and periprosthetic fractures, but more likely to experience transfusions. The overall revision surgery rate within 10 years was 14.8% in the ORIF cohort and 6.2% in the THA cohort. In the ORIF cohort, 13.5% of patients had a delayed conversion to THA.

CONCLUSIONS

In this large national database, acute with or without internal fixation for geriatric acetabular fractures was associated with lower rates of revision surgery within 10 years when compared with a matched cohort undergoing ORIF. ORIF was associated with increased LOS, increased transfusion risk, and lower risk of joint infection and periprosthetic fracture.

LEVEL OF EVIDENCE

III.

The infraacetabular screw versus the antegrade posterior column screw in acetabulum fractures with posterior column involvement: a biomechanical comparison

INTRODUCTION

Traditionally, plate osteosynthesis of the anterior column combined with an antegrade posterior column screw is used for fixation of anterior column plus posterior hemitransverse (ACPHT) acetabulum fractures. Replacing the posterior column screw with an infraacetabular screw could improve the straightforwardness of acetabulum surgery, as it can be inserted using less invasive approaches, such as the AIP/Stoppa approach, which is a well-established standard approach. However, the biomechanical stability of a plate osteosynthesis combined with an infraacetabular screw instead of an antegrade posterior column screw is unknown.

MATERIAL AND METHODS

Two osteosynthesis constructs were compared in a synthetic hemipelvis model with an ACPHT fracture: Suprapectineal plate + antegrade posterior column screw (APCS group) vs. suprapectineal plate + infraacetabular screw (IAS group). A single-leg stance test protocol with an additional passive muscle force and a cyclic loading of 32,000 cycles with a maximum effective load of 2400 N was applied. Interfragmentary motion and rotation of the three main fracture lines were measured.

RESULTS

At the posterior hemitransverse fracture line, interfragmentary motion perpendicular to the fracture line (p < 0.001) and shear motion (p < 0.001) and at the high anterior column fracture line, interfragmentary motion longitudinal to the fracture line (p = 0.017) were significantly higher in the IAS group than in the APCS group. On the other hand, interfragmentary motion perpendicular (p = 0.004), longitudinal (p < 0.001) and horizontal to the fracture line (p = 0.004) and shear motion (p < 0.001) were significantly increased at the low anterior column fracture line in the APCS group compared to the IAS group.

CONCLUSIONS

Replacing the antegrade posterior column screw with an infraacetabular screw is not recommendable as it results in an increased interfragmentary motion, especially at the posterior hemitransverse component of an ACPHT fracture.

Acetabular fractures in elderly patients are associated with high rates of complications during the initial admission

Background

Acetabular fractures among the elderly are common. Identification of risk factors predisposing elderly patients to in-hospital complications is critical to mitigating morbidity and mortality.

Methods

A retrospective cohort study was performed including 195 patients ≥60 years old who sustained acetabulum fractures treated at a single level 1 trauma center. Operative (n=110, 56.4%) or non-operative management was undertaken, and complications during the index hospitalization were defined.

Results

Seventy-three patients (37%) developed a complication during their hospitalization. Most common complications were acute respiratory failure: 13.3%, pneumonia: 10.3%, urinary tract infection: 10.3%, cardiac dysrhythmia: 9.7%, and acute kidney injury: 6.2%. On multivariable analysis, factors associated with in-hospital complications were increased age (adjusted OR (AOR): 1.06, 95% CI: 1.01 to 1.11, p=0.013), more comorbidities (AOR: 1.69, 95% CI: 1.07 to 2.65, p=0.024), operative management (AOR: 0.3, 95% CI: 0.12 to 0.76, p=0.011), and increased length of stay (AOR: 1.34, 95% CI: 1.2 to 1.51, p<0.001).

Conclusions

Acetabular fractures in the elderly are associated with high rates of in-hospital complications. Advanced age, more medical comorbidities and longer lengths of stay predicted higher risk of developing complications. Whereas operative management was associated with lower risk of developing complications during the initial admission, it is important to note the selection bias in which healthier patients with improved baseline functionality may be more likely to undergo operative management.

Level of evidence

Level III therapeutic.

Surgical outcomes of acetabular fracture of elderly patients with superomedial dome impaction

This study aimed to investigate the outcomes of elderly acetabular fractures according to the reduction of impacted dome fragments. A retrospective cohort study was performed in two institutions. Fifty-four patients aged ≥ 60 years with acetabular fractures were enrolled. Data for dome impaction and postoperative reduction was collected. Patients were divided into the good reduction group (displacement ≤ 3 mm) and poor reduction group (displacement > 3 mm). Postoperative osteoarthritis (OA), Harris hip score (HHS), total hip arthroplasty conversion, good/poor outcomes were compared between the two groups. The good reduction group (N = 45) demonstrated a lower proportion of radiographic OA (18 vs. 77%, P = 0.001), higher HHS (82.1 vs. 68.6, P = 0.022), and higher proportion of good outcomes than the poor reduction group (N = 9) (89 vs. 22%, P < 0.001). In a subgroup analysis of the patients with dome impaction, the good reduction group had a higher proportion of good outcomes (80 vs. 20%, P = 0.031). On comparing within the good reduction group, dome impaction did not influence clinical outcomes. Elderly acetabular fractures demonstrated favorable outcomes when adequate reduction was achieved even with dome impaction. Well-reduced dome impaction could achieve satisfactory outcomes in elderly acetabular fractures.

Mid-term results of the treatment of complex acetabular fractures with combined acute fixation and total hip replacement in the older patient

INTRODUCTION

The incidence of acetabular fractures in older patients is increasing. The management of these patients is evolving due to the recognition of risks associated with prolonged immobility with conservative treatment.

MATERIALS AND METHODS

Consecutive patients undergoing fixation and total hip replacement (THR) for displaced acetabular fractures undergoing single operation with acetabular fixation and THR were identified. Outcomes were assessed using radiographs, clinical notes, Oxford Hip Score and EuroQol-5L.

RESULTS

77 patients were identified with 51 completing outcome scores. Mean age 68 years at time of injury. Mean follow-up 5 (2-12) years, OHS 40, EQ-5D 0.78. Revision surgery performed in 7 patients (9%).

DISCUSSION

Acute fixation combined with THR for acetabular fractures in the elderly patient, offers good functional outcomes and a low complication rate in the mid-term.

Dome impaction classification in acetabular fractures: Identifying atypical dome impactions with absence of the gull sign: A retrospective descriptive study

We aimed to describe variations of dome impaction fractures and their characteristics using a new classification system, to explore the relationship between dome impaction and the gull sign. The present study was a retrospective descriptive study. All 104 cases of acetabular fracture that were treated in our institution from 2013 to 2022 were enrolled. Of these, 22 had dome impaction fractures. The primary outcome variable was to describe the variations and characteristics of dome impaction fractures. They were classified into 3 major subgroups based on reconstructed axial, coronal, and sagittal computed tomography findings: anteromedial, superomedial (SM), and posteromedial. The secondary outcome variable was to explore the relationship between dome impaction on computed tomography findings and the gull sign on plain radiographs. There were 4 cases of anteromedial (18.2%), 13 of SM (59.1%), and 5 of posteromedial (22.7%). There were 15 cases (68.2%) with the gull sign and 7 cases (31.8%) without the gull sign on plain radiographs. Twelve of fifteen cases (80.0%) with the gull sign had dome impaction fractures of the SM type. We found a variety of patterns of dome impaction fracture. Surgeons should be aware of atypical dome impactions not showing the gull sign.

Predictors for post-traumatic hip osteoarthritis in patients with transverse acetabular fractures following open reduction internal fixation: a minimum of 2 years' follow-up multicenter study

BACKGROUND

The predictors of post-traumatic osteoarthritis (PTOA) in patients with transverse acetabular fractures (TAFs) following open reduction internal fixation (ORIF) remain unclear. This study aimed to investigate the risk factors for PTOA in TAFs after ORIF.

METHODS

Data of TAF patients receiving ORIF were collected from January 2012 and February 2021. Patients suffered PTOA were classified as the osteoarthritis group (OG), while those without PTOA were classified as the non- osteoarthritis group (NG) with a minimum follow-up of 2 years. PTOA was diagnosed according to Tönnis OA classification during the period of follow-up. Univariate analysis, logistic regression analysis, and receiver operating characteristic (ROC) curve analyses were used to evaluate demographics, injury-related characteristics, perioperative and post-discharge information.

RESULTS

Three hundred and eleven TAF patients were analyzed in this study, including 261 males and 50 females, with a mean age of 40.4 years (range 18 to 64 years). The incidence of PTOA was 29.6% (92 of 311) during the mean follow-up of 36.8 months (range 24 to 70 months). Several factors of PTOA were found using univariate analysis, including transverse fracture associated with posterior wall acetabular fracture (TPW-AF, p = 0.002), acetabular roof fracture (ARF, p = 0.001), femoral head lesion (FHL, p = 0.016), longer time from injury to surgery (TIS, p＜0.001) and physical work after surgery (PWAS, p＜0.001). Logistic regression analysis showed that TPW-AF (p = 0.007, OR = 2.610, 95%CI: 1.302-5.232), ARF (p = 0.001, OR = 2.887, 95%CI: 1.512-5.512), FHL (p = 0.005, OR = 2.302, 95%CI: 1.283-4.131), TIS (p<0.0001, OR = 1.294, 95%CI: 1.192-1.405) and PWAS (p<0.0001, 3.198, 95%CI: 1.765-5.797) were independent risk factors of PTOA. Furthermore, ROC curve analysis indicated 11.5 days as the cut-off values to predict PTOA.

CONCLUSIONS

Our findings identified that TPW-AF, ARF, FHL, TIS and PWAS were independent risk factors for PTOA in patients with TAFs following ORIF. It can help orthopedic surgeons to take early individualized interventions to reduce its incidence.

Acetabular fractures: Epidemiology and mortality based on 2,132 fractures from the Swedish Fracture Register

Aims

To describe the epidemiology of acetabular fractures including patient characteristics, injury mechanisms, fracture patterns, treatment, and mortality.

Methods

We retrieved information from the Swedish Fracture Register (SFR) on all patients with acetabular fractures, of the native hip joint in the adult skeleton, sustained between 2014 and 2020. Study variables included patient age, sex, injury date, injury mechanism, fracture classification, treatment, and mortality.

Results

In total, 2,132 patients with acetabular fractures from the SFR were included in the study. The majority of the patients were male (62%) and aged over 70 years old (62%). For patients aged > 70 years, the 30-day mortality was 8% and one-year mortality 24%. For patients aged ≤ 70 years, the 30-day mortality was 0.2% and one-year mortality 2%. Low-energy injuries (63%) and anterior wall fractures (20%) were most common. Treatment was most often non-surgical (75%).

Conclusion

The majority of patients who sustain an acetabular fracture are elderly (> 70 years), of male sex, and the fracture most commonly occurs after a simple, low-energy fall. Non-surgical treatment is chosen in the majority of acetabular fracture patients. The one-year mortality for elderly patients with acetabular fracture is similar to the mortality after hip fracture, and a similar multidisciplinary approach to care for these patients should be considered.

Can CT-based gap and step-off displacement predict outcome after nonoperative treatment of acetabular fractures?

Aims

The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

Methods

A multicentre cross-sectional study was performed in 170 patients who were treated nonoperatively for an acetabular fracture in three level 1 trauma centres. Using the post-injury diagnostic CT scan, the maximum gap and step-off values in the weightbearing dome were digitally measured by two trauma surgeons. Native hip survival was reported using Kaplan-Meier curves. Predictors for conversion to THA were determined using Cox regression analysis.

Results

Of 170 patients, 22 (13%) subsequently received a THA. Native hip survival in patients with a step-off ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 94% vs 70% vs 74%). Native hip survival in patients with a gap ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 100% vs 84% vs 78%). Step-off displacement > 2 mm (> 2 to 4 mm hazard ratio (HR) 4.9, > 4 mm HR 5.6) and age > 60 years (HR 2.9) were independent predictors for conversion to THA at follow-up.

Conclusion

Patients with minimally displaced acetabular fractures who opt for nonoperative fracture treatment may be informed that fracture displacement (e.g. gap and step-off) up to 2 mm, as measured on CT images, results in limited risk on conversion to THA. Step-off ≥ 2 mm and age > 60 years are predictors for conversion to THA and can be helpful in the shared decision-making process.

Evaluation of the effect of pelvis type in percutaneous acetabular column fixation: a computed tomography study

This study aimed to evaluate the effect of pelvis type in percutaneous acetabular column fixation. What is the effect of pelvis type in percutaneous acetabular colon fixation? The available pelvic computed tomography (CT) scans which were obtained in the diagnostic imaging center with a 1 mm slice width were evaluated. The pelvic type was classified with the help of MPR (Multiplanar Reformat) and 3D (Three Dimensional) imaging modes. All evaluated bony pelvic structures were anatomically intact. 40 types of android, gynecoid, anthropoid, and platypelloid pelvis were determined. CT sections were created in MPR imaging mode. Anterior obturator oblique (AOO) and inlet images were created for anterior column evaluation, while iliac oblique (IO) and outlet images were created for posterior column evaluation. The possibility of obtaining a linear corridor for acetabular columns was investigated by measuring corridor width and lengthon images of pelvic CTs. A linear corridor could not be obtained between the pubic tubercle and the supraacetabular region of 12 (30%) CTs in the anterior column of gynecoid pelvis group. The diameter of the anterior column corridor was below 5.5 mm in 10 (25%) of Gynecoid pelvis group, 5 (12.5%) of Anthropoid pelvis group, and 10 of Platypelloid pelvis group, , and all those scans belonged to the female gender. There was a statistically significant difference between pelvis types in terms of anterior and posterior column diameters (p <0.001). While the android pelvis type had the highest diameter and corridor length in both anterior column and posterior column measurements, the gynecoid pelvic type had the lowest diameter and corridor length. In the evaluations made according to gender, both anterior and posterior column diameters were larger and longer in males than in females (p <0.001). Pelvis type is an important factor which can affect anterior and posterior column diameter and length of acetabulum. Pelvic typing before acetabular surgery can help the surgeon determining the most appropriate patient position, surgical approach, and implant selection. Level of Evidence: Level 2.

Acetabular fractures in elderly

BACKGROUND

This study aimed to determine characteristics of acetabular fractures in the elderly by evaluating clinical course and computed tomography-based radiological features between low- and high-energy acetabular fractures.

METHODS

We reviewed 178 consecutive patients with acetabular fractures aged ≥60 years from six centers. Low-energy fractures (group 1) were identified in 23 (12.9%) patients and high-energy fractures (group 2) in 155 (87.1%) patients. We compared demographics, radiological findings, and clinical course between the groups.

RESULTS

Average age (70.6 vs. 67.8 years, p = 0.046) and ratio of females (47.8% vs. 23.2%, p = 0.021) were significantly higher in group 1 than in group 2. The Charlson comorbidity index was also higher in group 1, but no other demographics showed difference. More patients in group 2 than in group 1 underwent surgery (91.6% vs. 73.9%); however, more in group 1 underwent minimally invasive surgery (17.4% vs 4.5%). Anterior column-associated fracture patterns occurred in 91.4% and 38.7% of cases in groups 1 and 2, respectively. Most fractures were displaced (>2 mm); 68% of which were comminuted. Furthermore, 24.2% of the fractures had superior dome impaction, whereas 23.0% were associated with posterior wall impaction.

CONCLUSIONS

Patients who sustained low-energy acetabular fractures were mostly women, were older, and had more comorbidities. Radiological findings of low-energy acetabular fractures showed anterior column involvement associated with injury to the quadrilateral surface. Additionally, it was observed to be commonly combined with comminution and impacted fragments.

Epidemiology of pelvic and acetabular fractures in the USA from 2007 to 2014

Incidence of pelvic and acetabular fracture is increasing in Europe. From 2007 to 2014 in the USA, this study found an age-adjusted incidence of 198 and 40 fractures/100,000/year, respectively, much higher than what has been described before. Incidence remained steady over that period and only a small increase in incidence of pelvic fracture in men was identified.

PURPOSE

To determine the incidence of pelvic ring and acetabular fractures in the USA over the period 2007-2014 and to examine trends over time.

METHODS

Retrospective population-based observational study using data from the Nationwide Emergency Department Sample (NEDS), a 20% stratified all-payer sample of US hospital-based emergency departments (EDs). All patients seen in the ED and diagnosed with pelvic/acetabular fracture from 2007 to 2014 were included. The primary outcome was age-adjusted incidence of pelvic and acetabular fractures per 100,000 persons/years. Secondary outcomes included incidence stratified by age and sex, patient- and hospital-related characteristics, and ED procedures. Tests for linear trends were used to determine if there were statistically significant differences by sex and age groups over time.

RESULTS

The age-adjusted incidence of pelvic fracture was 198 fractures/100,000/year, 323 in women and 114 in men. The age-adjusted incidence of acetabular fracture was 40 fractures/100,000/year, 36 in women and 51 in men. A small increase in the age-adjusted incidence of pelvic fracture in men was the only significant trend observed during the study time (p = 0.03). Over that period, the mean age of patients at presentation increased, as well as their number of comorbidities and associated fragility fractures, and they were more often sent home or to nursing facilities.

CONCLUSIONS

When considering all patients coming to the ED, not only those admitted to the hospital, adjusted incidence of pelvic and acetabular fracture is much higher than what has been described before. Contrarily to the global increase seen in other countries, incidence of pelvic and acetabular fractures dropped in the USA from 2007 to 2014 and only a small increase in age-adjusted incidence of pelvic fracture in men was identified.

Incidence of traumatic sciatic nerve injury in patients with acetabular fractures and factors affecting recovery: a retrospective study

BACKGROUND

Reports on traumatic sciatic nerve injury associated with acetabular fracture are rare. In this study, we investigated the demographics of these injuries, their clinical characteristics, management, and factors potentially influencing neurological recovery.

METHODS

We retrospectively reviewed all patients diagnosed to have acetabular fracture at our trauma center between January 2014 and June 2021. Data on patient demographics, characteristics of sciatic nerve injury, neurological recovery, factors potentially influencing neurological recovery were analyzed.

RESULTS

Eighteen patients (bilateral in one case) met the diagnostic criteria. All these injuries involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Four of the 19 sides with traumatic sciatic nerve injury involved the common peroneal nerve division and 15 involved both the common peroneal and tibial nerve divisions. Seventeen patients (18 sides) underwent intraoperative nerve exploration, which revealed abnormalities in 7 sides and no obvious abnormality in 11 sides. At the last follow-up, 10 sides (52.6%) had complete recovery and 9 (47.4%) had partial recovery; the difference was statistically significant between those with or without abnormal nerve damage during exploration (P = 0.046). Linear regression analysis showed that a nerve abnormality detected intraoperatively was a predictor of nerve recovery (P = 0.009). The mean recovery time was significantly longer for partial recovery than for complete recovery (13.78 months vs. 6.70 months; P = 0.001).

CONCLUSIONS

All the injuries in this series involved the posterior wall or posterior column, and most patients had posterior dislocation of the hip joint. Damage to the common peroneal nerve division was more severe than that to the tibial nerve division preoperatively. However, the degree of recovery of the common peroneal division was not worse than that of the tibial division. There was a relationship between the degree of neurological recovery and whether there was an abnormality at the time of intraoperative nerve exploration. Patients with partial recovery took longer to recover.

Management of Complex Acetabular Fractures by Using 3D Printed Models

Background and Objectives: Using 3D printed models in orthopaedics and traumatology contributes to a better understanding of injury patterns regarding surgical approaches, reduction techniques, and fracture fixation methods. The aim of this study is to evaluate the effectiveness of a novel technique implementing 3D printed models to facilitate the optimal preoperative planning of the surgical treatment of complex acetabular fractures. Materials and Methods: Patients with complex acetabular fractures were assigned to two groups: (1) conventional group (n = 12) and (2) 3D printed group (n = 10). Both groups included participants with either a posterior column plus posterior wall fracture, a transverse plus posterior wall fracture, or a both-column acetabular fracture. Datasets from CT scanning were segmented and converted to STL format, with separated bones and fragments for 3D printing in different colors. Comparison between the two groups was performed in terms of quality of fracture reduction (good: equal to, or less than 2 mm displacement, and fair: larger than 2 mm displacement), functional assessment, operative time, blood loss, and number of intraoperative x-rays. Results: A significant decrease in operative time, blood loss, and number of intraoperative x-rays was registered in the 3D printed group versus the conventional one (p < 0.01), with 80% of the patients in the former having good fracture reduction and 20% having fair reduction. In contrast, 50% of the patients in the conventional group had good reduction and 50% had fair reduction. The functional score at 18-month follow-up was better for patients in the 3D printed group. Conclusions: The 3D printing technique can be considered a highly efficient and patient-specific approach for management of complex acetabular fractures, helping to restore patient′s individual anatomy after surgery.

A review of Risk Factors for Post-traumatic hip and knee osteoarthritis following musculoskeletal injuries other than anterior cruciate ligament rupture

Post-traumatic osteoarthritis (PTOA) is a common form of osteoarthritis that might occur after any joint trauma. Most PTOA publications mainly focus on anterior cruciate ligament (ACL) injuries. However, many other traumatic injuries are associated with PTOA, not only for the knee but also for the hip joint. We aim to identify and summarize the existing literature on the musculoskeletal injuries associated with knee and hip PTOA and their risk factors in determining those with a worse prognosis, excluding ACL injuries. Despite the narrative nature of this review, a systematic search for published studies in the last twenty years regarding the most relevant injuries associated with a higher risk of PTOA and associated risk factors for OA was conducted. This review identified the six more relevant injuries associated with knee or hip PTOA. We describe the incidence, risk factors for the injury and risk factors for PTOA of each. Meniscal injury, proximal tibial fracture, patellar dislocation, acetabular, femoral fractures and hip dislocations are all discussed in this review.

The incidence of musculoskeletal injuries: a systematic review and meta-analysis

Aims

The aim of this systematic review and meta-analysis was to gather epidemiological information on selected musculoskeletal injuries and to provide pooled injury-specific incidence rates.

Methods

PubMed (National Library of Medicine) and Scopus (Elsevier) databases were searched. Articles were eligible for inclusion if they reported incidence rate (or count with population at risk), contained data on adult population, and were written in English language. The number of cases and population at risk were collected, and the pooled incidence rates (per 100,000 person-years) with 95% confidence intervals (CIs) were calculated by using either a fixed or random effects model.

Results

The screening of titles yielded 206 articles eligible for inclusion in the study. Of these, 173 (84%) articles provided sufficient information to be included in the pooled incidence rates. Incidences of fractures were investigated in 154 studies, and the most common fractures in the whole adult population based on the pooled incidence rates were distal radius fractures (212.0, 95% CI 178.1 to 252.4 per 100,000 person-years), finger fractures (117.1, 95% CI 105.3 to 130.2 per 100,000 person-years), and hip fractures (112.9, 95% CI 82.2 to 154.9 per 100,000 person-years). The most common sprains and dislocations were ankle sprains (429.4, 95% CI 243.0 to 759.0 per 100,000 person-years) and first-time patellar dislocations (32.8, 95% CI 21.6 to 49.7 per 100,000 person-years). The most common injuries were anterior cruciate ligament (17.5, 95% CI 6.0 to 50.2 per 100,000 person-years) and Achilles (13.7, 95% CI 9.6 to 19.5 per 100,000 person-years) ruptures.

Conclusion

The presented pooled incidence estimates serve as important references in assessing the global economic and social burden of musculoskeletal injuries. Cite this article: Bone Joint Res 2022;11(11):814–825.

Quantitative Three-Dimensional Measurements of Acetabular Fracture Displacement Could Be Predictive for Native Hip Survivorship

This study aims to develop a three-dimensional (3D) measurement for acetabular fracture displacement, determine the inter- and intra-observer variability, and correlate the measurement with clinical outcome. Three-dimensional models were created for 100 patients surgically treated for acetabular fractures. The ‘3D gap area’, the 3D surface between all the fracture fragments, was developed. The association between the 3D gap area and the risk of conversion to a total hip arthroplasty (THA) was determined by an ROC curve and a Cox regression analysis. The 3D gap area had an excellent inter-observer and intra-observer reliability. The preoperative median 3D gap area for patients without and with a THA was 1731 mm2 versus 2237 mm2. The median postoperative 3D gap area was 640 mm2 versus 845 mm2. The area under the curve was 0.63. The Cox regression analysis showed that a preoperative 3D gap area > 2103 mm2 and a postoperative 3D gap area > 1058 mm2 were independently associated with a 3.0 versus 2.4 times higher risk of conversion to a THA. A 3D assessment of acetabular fractures is feasible, reproducible, and correlates with clinical outcome. Three-dimensional measurements could be added to the current classification systems to quantify the level of fracture displacement and to assess operative results.

Incidence of Traumatic Sciatic Nerve Injury in Association with Acetabular Fracture: A Retrospective Observational Single-Center Study

Purpose

Patients and Methods

Results

Conclusion

Outcomes of acetabular fractures treated with acute fix and replace versus open reduction and internal fixation in elderly population: a multicentric retrospective study

Purpose

The optimal operative treatment for displaced acetabular fractures in elderly population is still object of debate. Acute fix and replace procedure, the so called “combined hip procedure” (CHP), was introduced because of the poor results of the open reduction and internal fixation (ORIF) alone. The aim of the study is to compare clinical outcomes of CHP and ORIF alone for the treatment of acetabular fractures in elderly patients.

Methods

This is the largest multicentric retrospective analytical study, with a case–control design on the issue. Hospital records and clinical notes were reviewed to collect demographic, peri-operative, and clinical data.

Results

A total of 45 patients met the inclusion criteria: 24 patients entered the CHP group whereas 21 entered the ORIF control group. The mean age was 69.5 +  − 1.12 years in the ORIF group and 73.4 +  − 1.84 in the control group. The most frequent traumatic mechanism was the fall from same level in both groups (37.5% CHP; 42.9% ORIF). Operating time was significantly lower in the CHP group compared to the ORIF group (207 +  − 11.0 ORIF; 175 +  − 9.16 CHP; p < 0.05). Moreover, full weight-bearing was allowed significantly earlier in the CHP group compared to ORIF alone (37.3 +  − 1.59 ORIF; 32.5 +  − 1.69 CHP; p < 0.05). Among the clinician-completed scores, the HHS at three months was higher in the CHP group (66.3 +  − 1.83 ORIF;73.6 +  − 2.09 CHP; p < 0.05). All the other clinical outcomes were similar in both study groups.

Conclusion

CHP is desirable treatment option in elderly patients with acetabular fracture when there are poor expected outcomes in terms of joint survival with ORIF alone.

How to improve the performance of acetabulum fracture diagnoses: investigating the use of three-dimensional CT-scan reconstructions

PURPOSE

The classification of acetabular fractures remains a challenge for the junior radiologist, although he is the first line of diagnosis in Emergency Department. The advantages of three-dimensional reconstructions have yet to be evaluated on a large scale.

METHOD

A total of 212 fractures were classified according to Letournel and Judet by a senior orthopaedic surgeon, a senior radiologist, and a resident radiologist. The CT scans were first analysed in 2D and then a second time using 2D + 3D reconstructions of the acetabulum excluding the femoral head.

RESULTS

3D reconstructions improved correct classification not only for the radiologist resident (+ 5%) but also for senior radiologist and orthopaedist (+ 2 and + 3%). 3D reconstructions also more significantly improved the diagnoses of complex fractures (+ 8.3%) compared to simple fractures (+ 0.4%).

CONCLUSIONS

3D reconstructions have improved the routine diagnosis of acetabular fractures, especially for junior radiologist or in cases of complex fractures.

Validation of the classification of surgically treated acetabular fractures in the Swedish Fracture Register

OBJECTIVES

To validate the classification of surgically treated acetabular fractures in the Swedish Fracture Register (SFR) and to investigate the intra- and interrater reliability of the Judet-Letournel / AO/OTA classification systems.

METHODS

Surgically treated acetabular fractures were randomly selected from the SFR (n = 132) and 124 fractures were classified independently by three experienced orthopedic pelvic surgeons at two different occasions. A gold standard classification was established for each case after these two sessions or, if necessary, after a discussion session. The gold standard classification was compared to the registered SFR classification to assess the validity of SFR data. Accuracy and intra- and interrater agreement were evaluated using Cohen´s kappa with interpretation according to Landis and Koch.

RESULTS

There was moderate agreement between the established gold standard classification and the SFR (kappa 0.43). The level of agreement differed between classification groups. The intrarater agreement was substantial to almost perfect and interrater agreement was moderate to substantial.

CONCLUSIONS

The accuracy of acetabular fracture classifications in the SFR was moderate and comparable to previous validation studies from the SFR on other fracture types. As the accuracy differed between fracture groups, care should be taken when analyzing data from the SFR on specific acetabular fracture groups.

Complications after surgical treatment of acetabular fractures: a 5-year follow-up of 229 patients

PURPOSE

Acetabular fractures are injuries often surgically treated, but the surgical intervention is associated with a high risk of subsequent complications. The primary aim of this study was to explore the rate of reoperations and to identify potential risk factors for reoperation. Secondary aims were other adverse events and mortality.

METHODS

Patients ≥ 18 years with a surgically treated acetabular fracture at a single trauma center in Sweden between 2010 and 2019 were retrospectively included. Data were collected through review of medical records and radiographs. Logistic regression analysis was performed to investigate factors associated with reoperations and other adverse events.

RESULTS

A total of 229 patients with a surgically treated acetabular fracture were included, mean age (± SD, range) 60 (19, 19-94) years. The majority of the patients were males (n = 180, 79%), and the median (IQR) follow-up time was 1779 (1906) days (4.9 years). 47 patients (21%) underwent a reoperation. THA as surgical method was associated with a lower reoperation rate compared to ORIF (OR 0.3, 95% CI 0.1-0.8, p < 0.01). 72 patients (31%) sustained an adverse event not requiring reoperation, and admittance to ICU was associated with an increased risk (OR 2.6, 95% CI 1.2-5.7, p = 0.02). 30-day mortality was 3.1% and 1-year mortality 5.7%.

CONCLUSION

The complication rate after acetabular fracture surgery was high, and surgical treatment with primary THA was associated with a reduced risk for reoperation.

Comparison between ilioinguinal approach and modified Stoppa approach for the treatment of acetabular fractures: An updated systematic review and meta-analysis

BACKGROUND

The modified Stoppa (MS) approach is an alternative to the ilioinguinal (IL) approach and three meta-analyses comparing these two approaches for the treatment of acetabular fractures were published previously. The aim of this study was to provide an updated systematic review and meta-analysis comparing the MS approach with the IL approach for the treatment of acetabular fractures and to answer the following question: are the results of the MS approach superior to those of the IL approach in terms of reduction quality, operative time, operative blood loss, complications, and clinical outcomes for treatment of acetabular fractures?

PATIENTS AND METHODS

An updated systematic literature review was conducted using relevant original studies from various databases (PubMed, Web of Science and the Cochrane Library). Pooling of data was performed using RevMan software (version 5.3, Cochrane Collaboration, Oxford, UK). A p-value of<0.05 was considered to be significant. We calculated the mean differences (MDs) for continuous data and odds ratio (OR) for dichotomous data with 95% confidence intervals (CIs) for each outcome. Statistical heterogeneity was assessed based on I² using the standard Chi² test. When I²>50%, significant heterogeneity was assumed and a random-effects model was applied for the meta-analysis. A fixed-effects model was applied in the absence of significant heterogeneity.

RESULTS

Six studies were included in this meta-analysis. The findings demonstrated that the rate of anatomical reduction was significantly higher in the MS approach than in the IL approach (I²=0%, OR=1.75, 95% CI: 1.13-2.69, p=0.01), the operative time was significantly shorter in the MS approach than in the IL approach (I²=88%, MD=-63.60, 95% CI: -93.01 - (-34.20), p<0.0001) and operative blood loss was significantly lower in the MS approach than in the IL approach (I²=75%, MD=-350.51, 95% CI: -523.45 - (-177.58), p<0.0001). There was no significant difference in the rate of nerve injury (I²=0%, OR=0.47, 95% CI: 0.16-1.39, p=0.17), the rate of vascular injury (I²=0%, OR=0.51, 95% CI: 0.17-1.49, p=0.22), the rate of infection (I²=0%, OR=0.53, 95% CI: 0.25-1.12, p=0.10), the rate of heterotopic ossification (I²=45%, OR=0.63, 95% CI: 0.22-1.85, p=0.40), and the rate of excellent or good clinical score (I²=21%, OR=1.15, 95% CI: 0.56-2.38, p=0.70) between the two approaches.

DISCUSSION

The MS approach provided better reduction quality, shorter operative time, lower operative blood loss, although there were no significant differences in the rate of complications, and excellent or good clinical score between the two approaches.

LEVEL OF EVIDENCE

III.

Biomechanical analysis of fixation methods in acetabular fractures: a systematic review of test setups

Purpose

Optimal anatomical reduction and stable fixation of acetabular fractures are important in avoiding secondary dislocation and osteoarthritis. Biomechanical studies of treatment options of acetabular fractures aim to evaluate the biomechanical properties of different fixation methods. As the setup of the biomechanical test can influence the experimental results, this review aimed to analyze the characteristics, comparability and clinical implications of studies on biomechanical test setups and finite element analyses in the fixation of acetabular fractures.

Methods

A systematic literature research was conducted according to the PRISMA guidelines, using the PubMed/MEDLINE and Web of Science databases. 44 studies conducting biomechanical analyses of fixation of acetabular fractures were identified, which met the predefined inclusion and exclusion criteria and which were published in English between 2000 and April 16, 2021. The studies were analyzed with respect to distinct parameters, including fracture type, material of pelvis model, investigated fixation construct, loading direction, loading protocol, maximum loading force, outcome parameter and measurement method.

Results

In summary, there was no standardized test setup within the studies on fixation constructs for acetabular fractures. It is therefore difficult to compare the studies directly, as they employ a variety of different test parameters. Furthermore, the clinical implications of the biomechanical studies should be scrutinized, since several test parameters were not based on observations of the human physiology.

Conclusion

The limited comparability and restricted clinical implications should be kept in mind when interpreting the results of biomechanical studies and when designing test setups to evaluate fixation methods for acetabular fractures.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01936-9.

Effect of osteoporosis-related reduction in the mechanical properties of bone on the acetabular fracture during a sideways fall: A parametric finite element approach

Purpose

The incidence of acetabular fractures due to low-energy falls is increasing among the geriatric population. Studies have shown that several biomechanical factors such as body configuration, impact velocity, and trochanteric soft-tissue thickness contribute to the severity and type of acetabular fracture. The effect of reduction in apparent density and elastic modulus of bone as well as other bone mechanical properties due to osteoporosis on low-energy acetabular fractures has not been investigated.

Methods

The current comprehensive finite element study aimed to study the effect of reduction in bone mechanical properties (trabecular, cortical, and trabecular + cortical) on the risk and type of acetabular fracture. Also, the effect of reduction in the mechanical properties of bone on the load-transferring mechanism within the pelvic girdle was examined.

Results

We observed that while the reduction in the mechanical properties of trabecular bone considerably affects the severity and area of trabecular bone failure, reduction in mechanical properties of cortical bone moderately influences both cortical and trabecular bone failure. The results also indicated that by reducing bone mechanical properties, the type of acetabular fracture turns from elementary to associated, which requires a more extensive intervention and rehabilitation period. Finally, we observed that the cortical bone plays a substantial role in load transfer, and by increasing reduction in the mechanical properties of cortical bone, a greater share of load is transmitted toward the pubic symphysis.

Conclusion

This study increases our understanding of the effect of osteoporosis progression on the incidence of low-energy acetabular fractures. The osteoporosis-related reduction in the mechanical properties of cortical bone appears to affect both the cortical and trabecular bones. Also, during the extreme reduction in the mechanical properties of bone, the acetabular fracture type will be more complicated. Finally, during the final stages of osteoporosis (high reduction in mechanical properties of bone) a smaller share of impact load is transferred by impact-side hemipelvis to the sacrum, therefore, an osteoporotic pelvis might mitigate the risk of sacral fracture.

Outcome After Open Reduction Internal Fixation of Acetabular Fractures in the Elderly

OBJECTIVES

(1) Assess outcomes of acetabular open reduction and internal fixation (ORIF) in the elderly, (2) investigate factors influencing outcome, and (3) compare outcomes after low-energy and high-energy mechanisms of injury.

DESIGN

Retrospective case series.

SETTING

Level 1 trauma center.

PATIENTS

Seventy-eight patients older than 60 years (age: 70.1 ± 7.4; 73.1% males).

INTERVENTION

ORIF for acetabular fractures.

MAIN OUTCOME MEASUREMENTS

Complications, reoperation rates, Oxford Hip Score (OHS), and joint preservation and development of symptomatic osteoarthritis. Cases with osteoarthritis, OHS < 34, and those who required subsequent total hip arthroplasty were considered as poor outcome.

RESULTS

At a mean follow-up of 4.3 ± 3.7 years, 11 cases post-ORIF required a total hip arthroplasty. The 7-year joint survival post-ORIF was 80.7 ± 5.7%. Considering poor outcome as failure, the 7-year joint survival was 67.0 ± 8.9%. The grade of reduction was the most significant factor associated with outcome post-ORIF. Female sex (P = 0.03), pre-existing osteoporosis (P = 0.03), low-energy trauma (P = 0.04), and Matta grade (P = 0.002) were associated with poor outcome. Patients with associated both-column fractures were more likely to have nonanatomic reduction (P = 0.008). After low-energy trauma, joint survivorship was 36.6 ± 13.5% at 7 years compared with 75.4 ± 7.4% in the high-energy group when considering poor outcome as an end point (log rank P = 0.006). The cohort's mean OHS was 37.9 ± 9.3 (17-48).

CONCLUSIONS

We recommend ORIF whenever an anatomic reduction is feasible. However, achievement and maintenance of anatomic reduction are a challenge in the elderly, specifically in those with low-energy fractures involving both columns, prompting consideration for alternative management strategies.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Functional outcomes more than 5 years following acetabulum fracture

Objectives:

The purposes of this project were to evaluate functional outcomes more than 5 years after acetabulum fracture and to determine factors related to function.

Methods:

This retrospective study consisted of 205 adult patients treated for acetabulum fracture who completed the Musculoskeletal Function Assessment (MFA) a minimum of 5 years following injury. The MFA includes survey of daily activities, gross and fine mobility, social and work function, sleeping, and mood. Higher scores indicate worse function.

Results:

Two hundred five patients with 210 fractures, 69.3% of whom were male, with mean age of 45.7 and mean body mass index 30.1 were included after mean 128 months follow-up. Fracture patterns included OTA/AO 62A (37.1%), 62B (40.5%), or 62C (22.4%), and 80.0% were treated surgically. Late complications were noted in 35.2%, including posttraumatic arthrosis (PTA: 19.5%), osteonecrosis and/or heterotopic ossification. Mean MFA of all patients was 31.4, indicating substantial residual dysfunction. Worse MFA scores were associated with morbid obesity (body mass index >40: 42.3, P>.09), and current tobacco smoking history vs former smoker vs nonsmoker (45.2 vs 36.1 vs 23.0, P < .002). Patients with late complications had worse mean MFA scores (38.7 vs 27.7, P = .001); PTA was the most common late complication, occurring in 19.5%.

Conclusions:

More than 5 years following acetabulum fracture, substantial residual dysfunction was noted, as demonstrated by mean MFA. Worse outcomes were associated with late complications and tobacco smoking. While fracture pattern was not associated with outcome, those patients who had late complications, mostly PTA, had worse outcomes.

The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients

INTRODUCTION

Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA.

MATERIALS AND METHODS

Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures.

RESULTS

The mean age was 80.5 years (range 65-98 years). The average time from injury to surgery was 8.5 days (range 1-28). Mean time of surgery was 167 min (range 100-303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification.

CONCLUSIONS

The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group.

Minimizing misclassification bias with a model to identify acetabular fractures using health administrative data: A cohort study

Acetabular fractures (AFs) are relatively uncommon thereby limiting their study. Analyses using population-based health administrative data can return erroneous results if case identification is inaccurate ('misclassification bias'). This study measured the impact of an AF prediction model based exclusively on administrative data upon misclassification bias.We applied text analytical methods to all radiology reports over 11 years at a large, tertiary care teaching hospital to identify all AFs. Using clinically-based variable selection techniques, a logistic regression model was created.We identified 728 AFs in 438,098 hospitalizations (15.1 cases/10,000 admissions). The International Classification of Disease, 10th revision (ICD-10) code for AF (S32.4) missed almost half of cases and misclassified more than a quarter (sensitivity 51.2%, positive predictive value 73.0%). The AF model was very accurate (optimism adjusted R2 0.618, c-statistic 0.988, calibration slope 1.06). When model-based expected probabilities were used to determine AF status using bootstrap imputation methods, misclassification bias for AF prevalence and its association with other variables was much lower than with International Classification of Disease, 10th revision S32.4 (median [range] relative difference 1.0% [0%-9.0%] vs 18.0% [5.4%-75.0%]).Lone administrative database diagnostic codes are inadequate to create AF cohorts. The probability of AF can be accurately determined using health administrative data. This probability can be used in bootstrap imputation methods to importantly reduce misclassification bias.

Femoral Neck Osteotomy: A Salvage Procedure for Unstable and Locked Acetabulum Fractures in Selected Frail Patients

INTRODUCTION

Purpose of the study is to present and discuss the femoral neck osteotomy as a salvage procedure for unstable, locked geriatric acetabular fractures in selected frail patients. When disadvantages and possible risks of other treatments exceed the benefits, this method may relieve pain and allow for early wheelchair mobilization in frail patients with limited mobility.

MATERIALS AND METHODS

We report nine patients from 2008 to 2020, which were treated with an osteotomy of the femoral neck for an unstable acetabular fracture. Indications, ASA-Score, Frailty Index, operative procedure, length of hospital stay, complications and outcomes will be discussed.

RESULTS

Patient's age averaged 86 years (range 81-92). Acetabular fractures were classified as six both column fractures, two anterior column posterior hemitransversal fractures and one destruction of the acetabulum by multiple metastases. Fracture dislocation with medialization plus locking of the femoral head and a superomedial dome impaction were present in all patients. All patients were classified as ASA III/ IV and the average value on the CSHA Frailty index was 7 (range 6-7). The operation time averaged 52 min (range 34-62). Immediate wheelchair mobilization in seven out of nine patients was started postoperatively.

CONCLUSION

The osteotomy of the femoral neck may be discussed as a salvage procedure in low functional demanding, multimorbid, frail geriatric patients with unstable acetabular fractures and impairment of mobilisation due to a locked femoral head. The procedure has the advantages of a short operation time and immediate mobilization of the patients. However, this procedure only applies as a salvage solution in selected individual cases.

Does 3D-Assisted Acetabular Fracture Surgery Improve Surgical Outcome and Physical Functioning?-A Systematic Review

Three-dimensional technology is increasingly being used in acetabular fracture treatment. No systematic reviews are available about the added clinical value of 3D-assisted acetabular fracture surgery compared to conventional surgery. Therefore, this study aimed to investigate whether 3D-assisted acetabular fracture surgery compared to conventional surgery improves surgical outcomes in terms of operation time, intraoperative blood loss, intraoperative fluoroscopy usage, complications, and postoperative fracture reduction, and whether it improves physical functioning. Pubmed and Embase databases were searched for articles on 3D technologies in acetabular fracture surgery, published between 2010 and February 2021. The McMaster critical review form was used to assess the methodological quality. Differences between 3D-assisted and conventional surgery were evaluated using the weighted mean and odds ratios. Nineteen studies were included. Three-dimensional-assisted surgery resulted in significantly shorter operation times (162.5 ± 79.0 versus 296.4 ± 56.0 min), less blood loss (697.9 ± 235.7 mL versus 1097.2 ± 415.5 mL), and less fluoroscopy usage (9.3 ± 5.9 versus 22.5 ± 20.4 times). The odds ratios of complications and fracture reduction were 0.5 and 0.4 for functional outcome in favour of 3D-assisted surgery, respectively. Three-dimensional-assisted surgery reduces operation time, intraoperative blood loss, fluoroscopy usage, and complications. Evidence for the improvement of fracture reduction and functional outcomes is limited.

Rapid Destruction of the Hip Joint After Acetabular Fracture in an Elderly Patient

Cases of rapidly progressive destruction of the hip joint after acetabular fractures are rarely reported. A 78-year-old woman fell from a chair. There was no fracture diagnosis; however, retrospective evaluation of the plain radiograph showed a slightly displaced fracture of the acetabulum. Her pain worsened after experiencing additional minor falls. The left hip joint had severe bone defects at 3 months after the initial injury. She underwent total hip arthroplasty using a KT-plate with an autogenous bone graft for acetabular bone defects. This case indicates that rapid destruction of the hip joint may occur after acetabular fracture from minor falls and bone fragility in elderly patients. In such cases, closer follow-up with advanced imaging can lead to early surgical intervention before severe destruction develops.

Regional anesthesia does not decrease opioid demand in pelvis and acetabulum fracture surgery

INTRODUCTION

Patients with pelvic and acetabular fractures often have considerable pain in the perioperative period. Regional anesthesia (RA) including peripheral nerve blocks and spinal analgesia may reduce pain. However, the real-world impact of these modalities on inpatient opioid consumption and outpatient opioid demand is largely unknown. The purpose of this study was to evaluate the impact of perioperative RA on inpatient opioid consumption and outpatient opioid demand.

METHODS

This is a retrospective, observational review of inpatient opioid consumption and outpatient opioid demand in all patients ages 18 and older undergoing operative fixation of pelvic and acetabular fractures at a single Level, I trauma center from 7/1/2013-7/1/2018 (n = 205). Unadjusted and adjusted analyses were constructed to evaluate the impact of RA on inpatient opioid consumption and outpatient opioid demand while controlling for age, sex, race, body mass index (BMI), smoking, chronic opioid use, ASA score, injury mechanism, additional injuries, open injury, and additional inpatient surgery.

RESULTS

Adjusted models demonstrated increases in inpatient opioid consumption in patients with RA (12.6 estimated OE's without RA vs 16.1 OE's with RA from 48 to 72 h post-op, p < 0.05) but no significant differences at other timepoints (17.5 estimated OE's without RA vs 16.8 OE's with RA from 0 to 24 h post-op, 15.3 vs 17.1 from 24 to 48 h post-op, p > 0.05). Estimated cumulative outpatient opioid demand was significantly higher in patients with RA at discharge to 90 days post-op (and 156.8 vs 207.9 OE's to 90 days, p < 0.05) but did not differ significantly before that time (121.5 OE's without RA vs 123.9 with RA from discharge to two weeks, 145.2 vs 177.2 OE's to 6 weeks, p > 0.05).

DISCUSSION

In pelvis and acetabulum fracture surgery, RA was associated with increased inpatient and outpatient opioid demand after adjusting for baseline patient and treatment characteristics. Regional anesthesia may not be beneficial for these patients.

The Anatomic Relevance of the Iliopectineal Fascia for Acetabular Surgery

OBJECTIVE

To describe in detail the variability of the attachments of the iliopectineal fascia (IPF) and its relation to the external iliac vessels to inform surgical approaches and help prevent injury to the adjacent vascular structures.

METHODS

A cadaveric study was performed on 16 specimens. The IPF was identified from the lateral and medial perspectives of the II and anterior intrapelvic approaches, respectively, and its anatomic characteristics were described.

RESULTS

The IPF originates in the fascia of the psoas muscle, it has variable attachments in the pelvic brim, and it inserts in the medial surface of the iliac bone where it is continuous with the obturator internus fascia. Two variants were found in relation to the external iliac vessels. In one variant found in 4 cadavers, the IPF formed a sail-like structure that surrounds the external iliac vessels. In the other variant observed in 4 cadavers, the IPF overlaid the iliac fossa, under the external iliac vessels which laid free in the iliac fossa.

CONCLUSIONS

The anatomic variants of the attachment of the IPF to the pelvic brim and its variants in relation to the external iliac vessels must be accounted for when performing acetabular surgery to prevent vascular injury and attain adequate exposure.

A Systematic Review and Meta-Analysis of 3D Printing Technology for the Treatment of Acetabular Fractures

Purpose

Three-dimensional (3D) printing technology has been widely used in orthopedics surgery. However, its efficacy in acetabular fractures remains unclear. The aim of this systematic review and meta-analysis was to examine the effect of using 3D printing technology in the surgery for acetabular fractures.

Methods

The systematic review was performed following the PRISMA guidelines. Four major electronic databases were searched (inception to February 2021). Studies were screened using a priori criteria. Data from each study were extracted by two independent reviewers and organized using a standardized table. Data were pooled and presented in forest plots.

Results

Thirteen studies were included in the final analysis. Four were prospective randomized trials, and nine used a retrospective comparative design. The patients aged between 32.1 (SD 14.6) years and 51.9 (SD 18.9) years. Based on the pooled analyses, overall, 3D printing-assisted surgery decreased operation time by 38.8 minutes (95% CI: -54.9, -22.8), intraoperative blood loss by 259.7 ml (95% CI: -394.6, -124.9), instrumentation time by 34.1 minutes (95% CI: -49.0, -19.1). Traditional surgery was less likely to achieve good/excellent function of hip (RR, 0.53; 95% CI: 0.34, 0.82) and more likely to have complications than 3D printing-assisted surgery (RR, 1.19; 95% CI: 1.07, 1.33).

Conclusions

3D printing technology demonstrated efficacy in the treatment of acetabular fractures. It may improve surgery-related and clinical outcomes. More prospective studies using a rigorous design (e.g., randomized trial with blinding) are warranted to confirm the long-term effects of 3D printing technology in orthopedics surgeries.

The horizontal shear fracture of the pelvis

PURPOSE

Various classification systems describe fractures of the acetabulum and pelvis separately. Horizontal shear fractures involve the pelvic ring and both acetabula and have not been previously described. The aim of this study is to describe the horizontal shear fracture of the pelvis.

METHODS

At a level 1 trauma centre over 10 years from December 2008 to December 2018, 1242 patients had pelvic and acetabular fractures. Six patients had horizontal shear fractures, comprising 0.5% of all pelvic and acetabular fractures. Demographic, clinical and radiological data was collected. Clinical outcomes were pain and mobility level, sciatic nerve symptoms, further acetabular or pelvic surgery, or total hip arthroplasty. Radiological outcomes included fracture displacement, implant migration, femoral head osteonecrosis, and post-traumatic arthritis. Outcomes were assessed at a minimum 12 month follow-up.

RESULTS

The median patient age was 35 years. Five of six shear fractures were due to motorcycle crashes. No mortalities occurred. At follow-up, three patients reported pain, two patients had difficulty mobilising associated with traumatic sciatic nerve injury, and one patient underwent total hip arthroplasty for femoral head osteonecrosis. No fracture displacement or implant migration occurred. The Matta arthritis grade was excellent or good in all except one hip. Median follow-up time was 1.8 (range 1.1-7.8) years.

CONCLUSION

The horizontal shear fracture of the pelvis is a high-energy injury characterised by separation of the anterior and posterior pelvic ring through the acetabula. Good outcomes can be achieved with open reduction and internal fixation of displaced fractures.

Increasing incidence of pelvic and acetabular fractures. A nationwide study of 87,308 fractures over a 16-year period in Sweden

BACKGROUND

Fractures of the pelvis and acetabulum are major injuries, often associated with hospitalization, reduced function and sometimes life-threatening conditions. Current data on nationwide incidence and treatment is sparse. Existing epidemiological studies are either single-centered or investigating only in-patients. The aim of this study was to investigate the epidemiology and treatment of pelvic and acetabular fractures in a nationwide register study including all adult patients in Sweden during 2001-2016.

METHODS

We used the Swedish National Patient Register to collect data on the entire Swedish population aged ≥18 years from 2001 to 2016. Variables included age, gender, fracture type and treatment.

RESULTS

We found a total of 87,308 pelvic and acetabular fractures (71% females) in Sweden during the 16-year study period and the incidence increased from 64 to 80 per 100,000 person-years from 2001 to 2016. The incidence of pelvic fractures increased from 58 to 73 per 100,000 person-years and the majority of the patients (74%) were female. The incidence of acetabular fracture increased from 8.7 to 11 per 100,000 person years and the majority of the patients (58%) were male. Only 2.0% of all patients with a pelvic fracture were treated surgically, as compared to 15% for acetabular fractures. The rate of surgical treatment was higher for males compared to females for both pelvic (4.4 and 1.2% respectively) and acetabular (19 and 10% respectively) fractures.

CONCLUSION

The incidence of pelvic and acetabular fractures increased markedly in Sweden from 2001-2016. Pelvic fractures were more common among females and acetabular among males. The surgical rate was higher for acetabular compared to pelvic fractures. Major gender differences in treatment choices were found with higherproportion of men treated surgically for both fracture types, and in all age groups.

Current concepts: managing acetabular fractures in the elderly population

The aim of this review is to summarise the current concepts in the management of acetabular fractures in the elderly population. A literature review of the evidence regarding the management of elderly acetabular fractures was performed utilising PubMed and Ovid. The predominant causes and fracture patterns of acetabular fractures are changing as populations age. Consequently, the operative management has had to change also. Judet and LeTournel did not offer operative treatment to any patients older than sixty. However, in the present time, according to the German Pelvic Registry, over half the patients aged sixty or over, sustaining acetabular fractures underwent operative fixation. We find that the increasing age of the population raises particular challenges for the operating surgeon. Postoperative rehabilitation should be focused on early mobilisation. More research needs to be focussed on standardised treatment protocols and long-term outcomes for this cohort of patients.

Feasibility of Imaging-Based 3-Dimensional Models to Design Patient-Specific Osteosynthesis Plates and Drilling Guides

IMPORTANCE

In acetabular fracture surgery, achieving an optimal reconstruction of the articular surface decreases the risk of osteoarthritis and the subsequent need for total hip arthroplasty. However, no one-size-fits-all osteosynthesis plate is available owing to differences in fracture patterns and variations in pelvic anatomy. Currently, osteosynthesis plates need to be manually contoured intraoperatively, often resulting in inadequate reduction and fixation of the fractured segments.

OBJECTIVE

To determine the feasibility and accuracy of a novel concept of fast-track 3-dimensional (3-D) virtual surgical planning and patient-specific osteosynthesis for complex acetabular fracture surgery.

DESIGN, SETTING, AND PARTICIPANTS

This case series study examines the use of patient-specific osteosynthesis plates for patients needing operative treatment for displaced associated-type acetabular fractures at a tertiary university-affiliated referral center and level 1 trauma center between January 1, 2017, and December 31, 2018. Models were created in 3-D based on computed tomography (CT) data, fractures were virtually reduced, and implant positions were discussed in a multidisciplinary team of clinicians and engineers. Patient-specific osteosynthesis plates with drilling guides were designed, produced, sterilized and clinically applied within 4 days. Data were analyzed at the 1-year follow-up.

EXPOSURES

Development and clinical implementation of personalized fracture surgery.

MAIN OUTCOMES AND MEASURES

The primary outcome was the quality of the reduction as determined by the postoperative CT scan. The secondary outcomes were accuracy of the screw placement and clinical outcome using patient-reported outcome measures.

RESULTS

Ten patients with a median (range) age of 63 (46-79) years with an acetabular fracture were included. The median (interquartile range [IQR]) preoperative gap was 20 (15-22) mm, and the median (IQR) step-off was 5 (3-11) mm. Postoperatively, the median (IQR) gap was reduced to 3 (2-5) mm (P = .005), and the median (IQR) step-off was reduced to 0 (0-2) mm (P = .01), indicating good fracture reduction, indicating good fracture reduction. The mean difference between the preoperative and postoperative gap was 14.6 (95% CI, 10-19) mm, and the mean difference in step-off was 5.7 (95% CI, 2-9) mm. The median (IQR) difference in screw direction between the planning and actual surgery was only 7.1° (7°-8°). All patients retained their native hip and reported good physical functioning at follow-up.

CONCLUSIONS AND RELEVANCE

These findings suggest that 3-D virtual surgical planning, manufacturing, and clinical application of patient-specific osteosynthesis plates and drilling guides was feasible and yielded good clinical outcomes. Fast-track personalized surgical treatment could open a new era for the treatment of complex injuries.

Outcomes of Total Hip Arthroplasty After Acetabular Open Reduction and Internal Fixation in the Elderly-Acute vs Delayed Total Hip Arthroplasty

BACKGROUND

Optimum management for the elderly acetabular fracture remains undefined. Open reduction and internal fixation (ORIF) in this population does not allow early weight-bearing and has an increased risk of failure. This study aimed to define outcomes of total hip arthroplasty (THA) in the setting of an acetabular fracture and compared delayed THA after acetabular ORIF (ORIF delayed THA) and acute fixation and THA (ORIF acute THA).

METHODS

All acetabular fractures in patients older than 60 years who underwent ORIF between 2007 and 2018 were reviewed (n = 85). Of those, 14 underwent ORIF only initially and required subsequent THA (ORIF delayed THA). Twelve underwent an acute THA at the time of the ORIF (ORIF acute THA). The ORIF acute THA group was older (81 ± 7 vs 76 ± 8; P < .01) but had no other demographic- or injury-related differences compared with the ORIF delayed THA group. Outcome measures included operative time, length of stay, complications, radiographic assessments (component orientation, leg-length discrepancy, heterotopic ossification), and functional outcomes using the Oxford Hip Score (OHS).

RESULTS

Operative time (P = .1) and length of stay (P = .5) for the initial surgical procedure (ORIF only or ORIF THA) were not different between groups. Four patients had a complication and required further surgeries; no difference was seen between groups. Radiographic assessments were similar between groups. The ORIF acute THA group had a significantly better OHS (40.1 ± 3.9) than the ORIF delayed THA group (33.6 ± 8.5) (P = .03).

CONCLUSION

In elderly acetabulum fractures, ORIF acute THA compared favorably (a better OHS, single operation/hospital visit, equivalent complications) with ORIF delayed THA. We would thus recommend that in patients with risk factors for failure requiring delayed THA (eg, dome or roof impaction) that ORIF acute THA be strongly considered.

The Burden of High-Energy Musculoskeletal Trauma in High-Income Countries

INTRODUCTION TO THE PROBLEM

Though declining in the recent decades, high-energy musculoskeletal trauma remains a major contributor to the burden of disease in high-income countries (HICs). However, due to limitations in the available body of the literature, evaluation of this burden is challenging. The purpose of this review is to assess: (1) the current epidemiologic data on the surgical burden of high-energy musculoskeletal trauma in HICs; (2) the current data on the economic impact of high-energy musculoskeletal trauma; and (3) potential strategies for addressing gaps in musculoskeletal trauma care for the future.

REVIEW OF LITERATURE

In 2016, mortality from road traffic injuries (RTIs) between the ages of 15-49 was reported to be 9.5% (9.0-9.9) in high-income countries, accounting for approximately 255 million DALYs. While RTIs do not fully capture the extent of high-energy musculoskeletal trauma, as the most common mechanism, they serve as a useful indicator of the impact on the surgical and economic burden. In 2009, the global losses related to RTIs were estimated to be 518 billion USD, costing governments between 1 and 3% of their gross domestic product (GDP). In the last decade, both the total direct per-person healthcare cost and the incremental direct per-person costs for those with a musculoskeletal injury in the USA rose 75 and 58%, respectively.

FUTURE DIRECTIONS

ADDRESSING THE GAPS: While its impact is large, research on musculoskeletal conditions, including high-energy trauma, is underfunded compared to other fields of medicine. An increased awareness among policy makers and healthcare professionals of the importance of care for the high-energy musculoskeletal trauma patient is critical. Full implementation of trauma systems is imperative, and metrics such as the ICD-DALY have the potential to allow for real-time evaluation of prevention and treatment programs aimed to reduce injury-related morbidity and mortality. The dearth in knowledge in optimal and cost-effective post-acute care for high-energy musculoskeletal trauma is a reason for concern, especially since almost half of the costs are attributed to this phase of care. Multidisciplinary rehabilitation teams as part of a musculoskeletal trauma system may be of interest to decrease further the long-term negative effects and the economic burden of high-energy musculoskeletal trauma.

Return to work after surgically treated acetabular fractures in an Asian population

BACKGROUND

Acetabular fractures are rare but are severe injuries that occur in younger patients with a significant economic impact. There is limited evidence describing the return to work rates in this group of patients. The aim of our study was to examine the rate and time to return to work (RTW) after surgical fixation of acetabular fractures.

METHODS

We performed a retrospective study on all patients with surgically treated acetabular fractures at a single institution between 1 July 2010 and 31 December 2018. Medical records were reviewed to analyze demographics such as age, gender, occupation and RTW characteristics.

RESULTS

There were 30 patients, with a mean age of 43.3 ± 12.7 years. There were 26 patients who were employed prior to injury. The most common mechanism of injury was from a road traffic accident (73.3%). The average ISS was 8.9 ± 5.2. The mean follow-up duration was 21.5 months ± 15.7. The rate of RTW was 80.8%. Eighteen patients (85.7%) returned to the same job and duties, while two (9.5%) returned with same job but lighter duties and one (4.8%) had to change job. Three patients (11.5%) retired. The average time to return to work was 8.3 months (range 2-57.5). RTW rates were 15.4%, 61.5%, 69.2% at 3, 6 and 12 months, respectively.

CONCLUSION

Acetabular fractures can lead to loss of economic productivity, with 80.8% of patients returning to work. Work reintegration programs after acetabular fractures are important.

Medial buttressing of the quadrilateral surface in acetabular and periprosthetic acetabular fractures

Background

In geriatric acetabular fractures, the quadrilateral plate is often involved in the fracture pattern and medially displaced. Open reduction and internal fixation (ORIF) includes reduction of the quadrilateral plate and securing its position. In this study, the concept of medial buttressing in acute and periprosthetic acetabular fractures is evaluated.

Materials and methods

Patients, who sustained an acetabular fracture between 2012 and 2018, in whom ORIF with a specific implant for medial buttressing was performed, were included in the study. Patients were divided in two groups; acute acetabular fractures (group 1) and periprosthetic acetabular fractures (group 2). Demographics, type of fracture, surgical approach, type of implant for medial buttressing, comorbidities, general and surgical in-hospital complications and length of hospital stay were recorded retrospectively. The following data were collected from the surviving patients by telephone interview: EQ-5D-5L, SF-8 physical and SF-8 mental before trauma and at follow-up, UCLA activity scale, Parker Mobility Score and Numeric Rating Scale.

Results

Forty-six patients were included in this study, 30 males (65.2%) and 16 females (34.8%). Forty patients were included group 1 and six patients in group 2. The median age of patients of group 1 was 78 years. Among them, 82.5% presented with comorbidities. Their median length of in-hospital stay was 20.5 days. 57.5% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all but one patient. ORIF together with primary total hip arthroplasty (THA) was carried out as a single stage procedure in 3 patients. Secondary THA was performed in 5 additional patients (5/37 = 13.5%) within the observation period. Among surviving patients, 79.2% were evaluated after 3 years of follow-up. Quality of life, activity level and mobility dropped importantly and were lower than the values of a German reference population. SF-8 mental did not change. The median age of patients of group 2 was 79.5 years, all of them presented with one or several comorbidities. The median length of in-hospital stay was 18.5 days. 50% of patients suffered from in-hospital complications. The concept of medial buttressing was successful in all patients. 5 of 6 patients (83.3%) could be evaluated after a median of 136 weeks. In none of these patients, secondary surgery was necessary. Quality of life, activity level and mobility importantly dropped as well in this group. SF-8 mental remained unchanged.

Conclusion

In geriatric acetabular fractures with involvement and medial displacement of the quadrilateral plate, medial buttressing as part of ORIF proved to be reliable. Only 13.5% of patients of group 1 needed a secondary THA within 3 years of follow-up, which is lower than in comparable studies. Despite successful surgery, quality of life, activity level and mobility dropped importantly in all patients. The loss of independence did however not influence SF-8 mental values.

Does use of a quadrilateral surface plate improve outcome in elderly acetabular fractures?

BACKGROUND

Acetabular fractures in the elderly frequently involve segmental quadrilateral plate injury, yet no consensus exists on how to best control the femoral head medial displacement. Quadrilateral surface plates (QSP) were developed to help buttress these challenging fractures. The study aims to 1) Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2) Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome.

METHODS

This was a retrospective study conducted at a level-1 trauma centre. . All patients over 60-years that sustained an acetabular fracture between 2007 and 2019 were reviewed. Pre-operative pelvic radiographs and CT imaging were reviewed for 96 patients, to assess for SQPF. From the 96 patients reviewed, over one third of patients (n = 40, 41.6%) sustained a SQPF. Patients that had an acute-THA (n = 7) were excluded as were patients that underwent an ORIF but did not have a QSP or an anterior column buttress plate (n = 3). The remaining 30 formed the study's cohort. We assessed the ability to achieve and maintain reduction in this elderly population, and compared outcomes using traditional anterior column buttress plates (ilioingual or intra-pelvic approach) versus an intra-pelvic pre-contoured buttress suprapectineal plate (QSP). Outcome measures included: fracture reduction using the Matta classification (desirable: anatomical/imperfect and poor), re-operations, conversion to THA and Oxford Hip Score (OHS) (for the preserved hips).

RESULTS

Ten patients had an ORIF with utilization of a QSP (QSP-group), and 20 had an ORIF but did not have the QSP (non-QSP-group). There was no difference in patient demographics between groups. Fracture patterns were also similar (p = 0.6). Postoperative fracture reduction was desirable (anatomical/imperfect) in 17 patients and poor in 13. Improved ability to achieve a desirable reduction was seen in the QSP-group (p = 0.02). Conversion to THA was significantly lower in patients that had a desirable fracture reduction (appropriate: 3/17; poor: 7/13). No patients in the QSP-group have required a THA to-date, compared to 10/20 patients in the non-QSP-group (p = 0.01). The mean time to THA was 1.6 ± 2.1 year. There was no difference in OHS between the two groups (34.4 ± 10.3).

CONCLUSION

Elderly acetabulum fractures have a high incidence (approaching 40%) of segmental QPF. Desirable (anatomical/imperfect) fracture reduction was associated with improved outcome. The use of a QSP was associated with improved ability to achieve an appropriate reduction. A QSP should be considered as they are both reliable and reproducible with a significantly improved fracture reduction and lower conversion to THA.

The incidence of pelvic fractures and related surgery in the Finnish adult population: a nationwide study of 33,469 patients between 1997 and 2014

Background and purpose - Information on the epidemiological trends of pelvic fractures and fracture surgery in the general population is limited. We therefore determined the incidence of pelvic fractures in the Finnish adult population between 1997 and 2014 and assessed the incidence and trends of fracture surgery.Patients and methods - We used data from the Finnish National Discharge Register (NHDR) to calculate the incidence of pelvic fractures and fracture surgery. All patients 18 years of age or older were included in the study. The NHDR covers the whole Finnish population and gives information on health care services and the surgical procedures performed.Results and interpretation - We found that in Finnish adults the overall incidence of hospitalization for a pelvic fracture increased from 34 to 56/100,000 person-years between 1997 and 2014. This increase was most apparent for the low-energy fragility fractures of the elderly female population. The ageing of the population is likely therefore to partly explain this increase. The annual number and incidence of pelvic fracture surgery also rose between 1997 and 2014, from 118 (number) and 3.0 (incidence) in 1997 to 187 and 4.3 in 2014, respectively. The increasing number and incidence of pelvic fractures in the elderly population will increase the need for social and healthcare services. The main focus should be on fracture prevention.

Epidemiology of pelvic and acetabular fractures in France

INTRODUCTION

Acetabular and pelvic fracture accounts for 1.5% of fractures in adults and 2-5% of fractures requiring hospital admission. Several national-level epidemiological studies have been conducted outside France, but French national data are not known. We therefore assessed all patients admitted for acetabular or pelvic fracture in France between 2006 and 2016. The study objectives were: 1) to determine incidence of acetabular and pelvic fracture, 2) to determine progression in incidence between 2006 and 2016, and 3) to determine progression in treatment.

HYPOTHESIS

Incidence of acetabular and pelvic fracture in France is increasing.

METHODS

The following data for the period 2006-2016 were collated from the French national health insurance (CPAM: Caisse Primaire d'Assurance Maladie) database: gender, age, type of treatment, and geographical distribution by administrative area (Département). Two-tailed Student tests were used for comparison of means for numerical variables between independent samples; linear regression was used to analyze correlations; and the Chi² test was used to compare percentages of categoric variables.

RESULTS

There were 32,614 acetabular and 164,694 pelvic fractures, with male predominance for the acetabulum and female predominance for the pelvis. Mean age at acetabular fracture was 66±22 years (range, 1-108 years), and 74±20 years (range, 1-112 years) for pelvic fracture. The rate of acetabular fracture increased to 3,301 in 2016 from 2,316 in 2006, with a strong increase in the rate of pelvic fracture, to 18,902 in 2016 from 10,806 in 2006. Incidence of acetabular fracture per 100,000 increased from 3.67 in 2006 to 4.95 in 2016, and from 17.06 to 23.18 in over-75 year-olds. Incidence of pelvic fracture per 100,000 increased from 17.1 to 28.33, and from 129.30 to 210.69 in over-75 year-olds. Linear regression predicts incidence per 100,000 of 5.9 for acetabular fracture and of 41 for pelvic fracture by 2030 in young subjects and 32 and 309 respectively in over-75 year-olds. Management was surgical for acetabular fracture in 12.31% of cases in 2006 and in 14.33% in 2016, and in 1.43% and 2.16% respectively for pelvic fracture.

DISCUSSION

The present data agree with previous reports, with strong increase in incidence of fracture in young and especially in elderly subjects. In elderly subjects, such fractures may require surgery.

LEVEL OF EVIDENCE

IV, retrospective study without control group.

Open reduction and internal fixation of acetabular fractures in patients of old age

MATERIAL AND METHODS

There is an ongoing debate on which treatment for acetabular fractures in elderly patients is the most appropriate. This study was set up to identify the role of open reduction and internal fixation of acetabular fractures in persons of old age. We retrospectively reviewed the medical charts and radiological data of all patients older than 65 years, who suffered an isolated acetabular fracture and were admitted in our Department between 2010 and 2014 (5-year period). Complications, outcome and mortality were recorded. Of all surviving patients, quality of life (QoL), mobility and independence were graded with European Quality of Life 5 Dimensions 3 Level (EQ-5D-3L), European Quality of Life 5 Dimensions Visual Analogue Scale (EQ-5D-VAS), Numeric Rating Scale (NRS), Elderly Mobility Scale (EMS) and Tinetti Mobility Test (TMT).

RESULTS

Seventy patients could be identified. There were 52 men (74%) and 18 women (26%) with a median age of 79.0 years (range: 65-104 years). Forty-six patients (66%) had been treated with open reduction and internal fixation (ORIF), 24 (34%) conservatively. There were negative predictive factors-subchondral impaction, damage to the femoral head and multiple fragments-in 54% of the operative group. With ORIF, an anatomical reduction could be achieved in 27 patients (59%), an acceptable in 18 (39%) and a poor in one (2%). At follow-up, 18 patients (26%) had died and 23 (33%) were not able to participate. The follow-up rate of the surviving operatively treated patients was 77%. Eleven of 46 operated patients (24%) needed a conversion to a total hip arthroplasty (THA). All patients undergoing conversion had imperfect reduction after surgery. No patient in the non-operative group underwent conversion to THA during follow-up. The median follow-up time of operatively treated patients without conversion (n = 17) was 30 months (range, 16-73 months), of patients with THA (n = 9) 30 months after conversion (range, 17-55 months). Quality of reduction correlated to QoL, mobility and independence in all recorded parameters. Patients with secondary THA had similar good outcomes as patients after ORIF without later conversion. Men had better outcome than women.

CONCLUSION

ORIF of acetabular fractures in patients of old age results in excellent outcomes at short-term follow-up when anatomical reduction can be achieved. In case of negative predictive factors, ORIF cannot be regarded as a definitive solution, rather as the construction of a stable socket for secondary THA. The decision of therapy should be made dependent on pre-operative radiographic parameters.