Acetabular Fractures: Does Delay to Surgery Infl uence Outcome?

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Chapter 56 Acetabular Fractures: Does Delay to Surgery Infl uence Outcome?

RICHARD J. JENKINSON, MD, FRCSC, MARCELLA. MAATHUIS, HANS J. KREDER, MD, MPH, FRCSC, DAVID J.G. STEPHEN, MD, FRCS(C)

Fractures of the acetabulum can be devastating injuries often associated with high-energy trauma. Patient outcome is adversely affected by many factors, some of which cannot be influenced by the treating surgeon. These include age, osteoporosis, obesity, and associated injuries. The fracture pattern and severity, as well as specific prognostic features such as marginal impaction and femoral head damage are also outside of the surgeon’s control. However, the surgeon is able to influence factors such as the timing of surgery, choice of approach, accuracy of reduction, and the maintenance of that reduction.^1,²

Historically, acetabular fractures were treated with traction and other nonoperative techniques. However, modern treatment now involves operative reduction and fixation of the acetabulum in most cases.³ Acetabular fractures are classified as either elementary fractures involving one fracture line or associated fractures involving multiple fracture elements.^4,⁵ Anatomic reduction has been consistently identified as an important prognostic indicator of a good clinical outcome in acetabular fractures.⁵^–¹¹

Acetabular fracture surgery is demanding and requires a specialized surgeon and team (Level V). Surgical treatment strategies often involve partial fracture exposure and reduction via indirect means because of anatomic constraints of the pelvis. These indirect reduction strategies rely on mobility between the fracture fragments especially when treating associated fracture types. As the fracture begins to heal, organized hematoma and callus can interfere with fracture mobility. This decreased mobility makes anatomic reduction difficult, allowing imperfect reductions to become more prevalent.^9,^{10, 12} A strategy to deal with decreased fracture mobility involves the use of more direct fracture reduction techniques; however, this often requires multiple or extensile exposures with their associated morbidity.¹³^–¹⁵

The reasons for delay to treatment can vary from patient to patient. In some cases, the patient’s traumatic or medical comorbidities may necessitate a delay until the patient is suitable for prolonged surgery. Availability of specialized surgeons and surgical resources can also be a cause for delay. In some medical systems, shortage of hospital bed resources can significantly delay transfer to specialized centers.¹⁶ Few surgeons will argue that treatment of these injuries should be excessively delayed. The purpose of this chapter is to guide clinicians using the best available evidence as to the optimal timing for surgery and to evaluate the evidence regarding a potential threshold beyond which further delay to surgery adversely affects outcome.

EVIDENCE

Delay to surgery is mentioned as a contributing factor influencing outcome in several studies summarized in Table 56-1.^9,^10,^12,^13,¹⁷^–²⁰ These studies are retrospective in design and usually originate from a single center. Most of these studies are small and do not achieve statistical significance.^9,^13,¹⁷^–²⁰ However, they consistently note a trend of delay to surgery being associated with less favorable radiographic or functional outcome.

TABLE 56-1 Summary of Literature Examining Delay to Fixation of Acetabular Fractures

A retrospective review from Mears and researchers ¹⁰

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