Session I - Pelvis

Accuracy of Articular Reduction following ORIF of Acetabular Fractures: An Analysis of a Single Surgeon's Initial Practice Experience

Steven A. Olson, MD; James Fait, MD; Peter Verhey, MD; Christopher G. Finkemeier, MD; University of California, Davis Medical Center, Sacramento, CA

Introduction: Open reduction and rigid internal fixation is recommended treatment for the majority of displaced acetabular fractures. Residual displacement of more than one mm may lead to an increased incidence of post-traumatic arthritis and a poor clinical outcome. Past studies have suggested that complex articular fractures should be treated by a limited number of surgeons to concentrate the surgical experience. To evaluate the hypothesis that as a surgeon gains experience with these complex fractures, the quality of the reduction improves, we evaluated the initial practice experience of a single surgeon treating these injuries.

Methods: From July 1993 to June 1998, 122 patients with 126 displaced acetabular fractures were treated consecutively by a single trauma-fellowship-trained surgeon entering practice in 1993, at a referral level 1 trauma center. Data for inclusion in this investigation was obtained from records of 103 patients with 105 fractures. Pre- and postoperative radiographs were retrospectively reviewed for maximal articular displacement on each view. Fractures were classified according to the system proposed by Letournel. Medical records were reviewed for demographic data and peri-operative complications. Average patient age was 39 (range 11-90); 84 (80%) were male, and 60 (57%) had associated injuries. Seventy-one fractures (67%) resulted from a motor vehicle collision, and 27(26%) resulted from a fall. Fractures were operated following the protocol outlined by Letournel.

Results: The most common fracture types were transverse+PW [OTA 62-B1.3] 30 (29%), posterior wall [62-A1] 18 (17%), both column [OTA 62-C] 14 (13%), and anterior column [OTA 62-A3] 14 (13%). One hundred one (97%) of the fractures were operated through a single surgical approach; 48 (46%) were operated via Kocher-Langenbeck, 39 (37%) via ilioinguinal, 12 (11%) via extended iliofemoral, and 4 (3%) via Kocher and ilioinguinal approaches. Preoperative displacement on the preoperative anterior posterior, iliac oblique, and obturator oblique radiographs averaged 12.7+/-9.0 mm, 11.0+/-9.2mm, and 12.7+/-9.1mm, respectively. Postoperative displacement on the anterior posterior, iliac oblique, and obturator oblique radiographs measured 1.1+/-1.9mm, 0.8+/-1.5mm, and 1.0+/-1.8 mm, respectively. The postoperative quality of reduction was graded as anatomic for 57 hips (55.2%), imperfect for 34 hips (32.4%), and poor for 13 hips (12.4%). Linear regression analysis indicated that quality of reduction decreased with increasing patient age (age > 40, P=.04). Patients age £ 40 years old (n = 54) were divided into 3 groups of 18 chronologically. The number (%) of anatomic reductions for the 3 groups were 8 (44%), 13 (72.2%), and 12 (66.7%), respectively. There was one poor reduction (5.5%) in each group. There was a significant improvement (P<.05) in quality of reductions for groups 2 and 3 of the age £ 40 patients. No significant improvement in reductions was seen for patients age > 40. There was a nearly significant decrease in operative time and surgical blood loss with increased experience as well. Peri-operative complications included a 3% incidence of infection and 6% incidence of partial sciatic nerve palsy.

Conclusions: The quality of articular reductions and complications in this series are comparable to those of reports in the recent literature. The relatively low incidence of complications and the improvement in reduction of these complex fractures when treated with open reduction and internal fixation support the efficacy of operative treatment via a single surgical appraoch. The quality of reduction improved as the surgeon's experience increased in treating these fractures. This work supports the practice of concentrating the operative experience of complex articular injuries to a limited number of surgeons in order to improve surgical outcomes.