Article

Analysis of Incidence and Outcome Predictors for Patients Admitted to US Hospitals with Acetabular Fractures from 1990 to 2010

Publish date: September 27, 2018

References

1. Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br. 2005;87(7):969-973. doi:10.1302/0301-620X.87B7.16017.

2. Geoghegan JM, Longdon EJ, Hassan K, Calthorpe D. Acetabular fractures in the UK. What are the numbers? Injury. 2007;38(3):329-333. doi:10.1016/j.injury.2006.09.015.

3. Tavakoli Darestani R, Kazemian G, Emami Moghaddam M, Manafi Rasi A, Alipour Y, Bagherian Lemraski MM. An unusual combination of acetabular and pelvic fracture: is this a new subtype of acetabular fracture? Trauma Mon. 2013;18(1):37-40. doi:10.5812/traumamon.9613.

4. McDonnell M, Schachter AK, Phillips DP, Liporace FA. Acetabular fracture through the triradiate cartilage after low-energy trauma. J Orthop Trauma. 2007;21(7):495-498. doi:10.1097/BOT.0b013e31812f67ff.

5. Giannoudis PV, Grotz MR, Tzioupis C, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma. 2007;63(4):875-883. doi:10.1097/01.ta.0000242259.67486.15.

6. Gänsslen A, Pohlemann T, Paul C, Lobenhoffer P, Tscherne H. Epidemiology of pelvic ring injuries. Injury. 1996;27 Suppl 1:S-A13-A20. doi:10.1016/S0020-1383(96)90106-0.

7. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632-1645. doi:10.2106/00004623-199611000-00002.

8. Wright R, Barrett K, Christie MJ, Johnson KD. Acetabular fractures: long-term follow-up of open reduction and internal fixation. J Orthop Trauma. 1994;8(5):397-403. doi:10.1097/00005131-199410000-00005.

9. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br. 2005;87(1):2-9.

10. Davarinos N, Ellanti P, Morris S, Mc Elwain JP. Epidemiology of pelvic and acetabular trauma in a Dublin tertiary hospital: a 10-year experience. Ir J Med Sci. 2012;181(2):243-246. doi:10.1007/s11845-011-0791-4.

11. Mauffrey C, Hao J, Cuellar DO 3rd, et al. The epidemiology and injury patterns of acetabular fractures: are the USA and China comparable? Clin Orthop Relat Res. 2014;472(11):3332-3337. doi:10.1007/s11999-014-3462-8.

12. Dente CJ, Feliciano DV, Rozycki GS, et al. The outcome of open pelvic fractures in the modern era. Am J Surg. 2005;190(6):830-835. doi:10.1016/j.amjsurg.2005.05.050.

13. Grotz MR, Allami MK, Harwood P, Pape HC, Krettek C, Giannoudis PV. Open pelvic fractures: epidemiology, current concepts of management and outcome. Injury. 2005;36(1):1-13. doi:10.1016/j.injury.2004.05.029.

14. Gabbe BJ, de Steiger R, Esser M, Bucknill A, Russ MK, Cameron PA. Predictors of mortality following severe pelvic ring fracture: results of a population-based study. Injury. 2011;42(10):985-991. doi:10.1016/j.injury.2011.06.003.

15. Arroyo W, Nelson KJ, Belmont PJ Jr, Bader JO, Schoenfeld AJ. Pelvic trauma: what are the predictors of mortality and cardiac, venous thrombo-embolic and infectious complications following injury? Injury. 2013;44(12):1745-1749. doi:10.1016/j.injury.2013.08.007.

16. Flint L, Cryer HG. Pelvic fracture: the last 50 years. J Trauma. 2010;69(3):483-488. doi:10.1097/TA.0b013e3181ef9ce1.

17. Plaisier BR, Meldon SW, Super DM, Malangoni MA. Improved outcome after early fixation of acetabular fractures. Injury. 2000;31(2):81-84. doi:10.1016/S0020-1383(99)00233-8.

18. Centers for Disease Control and Prevention: National Hospital. Discharge survey. http://www.cdc.gov/nchs/nhds.htm. Accessed August 22, 2013.

19. Dennison C, Pokras R. Design and operation of the National Hospital Discharge Survey: 1988 redesign. Vital Health Stat. 2000;(39):1-42.

20. Centers for Disease Control and Prevention, National Center for Health Statistics. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). http://www.cdc.gov/nchs/icd/icd9cm.htm. Accessed June 18, 2013.

21. Memtsoudis SG, González Della Valle A, Besculides MC, Gaber L, Sculco TP. In-hospital complications and mortality of unilateral, bilateral, and revision TKA: based on an estimate of 4,159,661 discharges. Clin Orthop Relat Res. 2008;466(11):2617-2627. doi:10.1007/s11999-008-0402-5.

22. Stundner O, Kirksey M, Chiu YL, et al. Demographics and perioperative outcome in patients with depression and anxiety undergoing total joint arthroplasty: a population-based study. Psychosomatics. 2013;54(2):149-157. doi:10.1016/j.psym.2012.08.009.

23. Iezzoni LI, Daley J, Heeren T, et al. Using administrative data to screen hospitals for high complication rates. Inquiry. 1994;31(1):40-55.

24. Lemeshow S, Teres D, Klar J, Avrunin JS, Gehlbach SH, Rapoport J. Mortality Probability Models (MPM II) based on an international cohort of intensive care unit patients. JAMA. 1993;270(20):2478-2486.

25. Bot AG, Menendez ME, Neuhaus V, Ring D. The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23(4):519-527. doi:10.1016/j.jse.2013.12.006.

26. United States Census Bureau. Population. https://www.census.gov/topics/population.html. Accessed December 4, 2012.

27. Porter SE, Schroeder AC, Dzugan SS, Graves ML, Zhang L, Russell GV. Acetabular fracture patterns and their associated injuries. J Orthop Trauma. 2008;22(3):165-170. doi:10.1097/BOT.0b013e318165918b.

28. Centers for Disease Control and Prevention. Motorcycle Crash-Related Data. https://www.cdc.gov/motorvehiclesafety/mc/index.html Accessed September 23, 2018

29. Ragnarsson B, Jacobsson B. Epidemiology of pelvic fractures in a Swedish county. Acta Orthop Scand. 1992;63(3):297-300. doi:10.3109/17453679209154786.

30. Melton LJ 3rd, Sampson JM, Morrey BF, Ilstrup DM. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res. 1981;155(155):43-47. doi:10.1097/00003086-198103000-00008.

31. al-Qahtani S, O'Connor G. Acetabular fractures before and after the introduction of seatbelt legislation. Can J Surg. 1996;39(4):317-320.

32. Ochs BG, Marintschev I, Hoyer H, et al. Changes in the treatment of acetabular fractures over 15 years: analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU). Injury. 2010;41(8):839-851. doi:10.1016/j.injury.2010.04.010.

33. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;151(151):81-106. doi:10.1055/s-2007-980136.

34. de Ridder VA, de Lange S, Kingma L, Hogervorst M. Results of 75 consecutive patients with an acetabular fracture. Clin Orthop Relat Res. 1994;305(305):53-57. doi:10.1097/00003086-199408000-00008.

35. Aho AJ, Isberg UK, Katevuo VK. Acetabular posterior wall fracture. 38 Cases followed for 5 years. Acta Orthop Scand. 1986;57(2):101-105. doi:10.3109/17453678609000878.

36. Stöckle U, Hoffmann R, Südkamp NP, Reindl R, Haas NP. Treatment of complex acetabular fractures through a modified extended iliofemoral approach. J Orthop Trauma. 2002;16(4):220-230. doi:10.1097/00005131-200204000-00002.

37. Tibbs BM, Kopar P, Dente CJ. Acetabular and isolated pelvic ring fractures: a comparison of initial assessment and outcome. Am Surg. 2008;74(6):538-541; discussion 541.

38. Holstein JH, Culemann U, Pohlemann T, Working Group Mortality in Pelvic Fracture Patients. What are predictors of mortality in patients with pelvic fractures? Clin Orthop Relat Res. 2012;470(8):2090-2097. doi:10.1007/s11999-012-2276-9.

39. Vallier HA, Cureton BA, Ekstein C, Oldenburg FP, Wilber JH. Early definitive stabilization of unstable pelvis and acetabulum fractures reduces morbidity. J Trauma. 2010;69(3):677-684. doi:10.1097/TA.0b013e3181e50914.

40. Enninghorst N, Toth L, King KL, McDougall D, Mackenzie S, Balogh ZJ. Acute definitive internal fixation of pelvic ring fractures in polytrauma patients: a feasible option. J Trauma. 2010;68(4):935-941. doi:10.1097/TA.0b013e3181d27b48.

41. Buller LT, Best MJ, Quinnan SM. A nationwide analysis of pelvic ring fractures: incidence and trends in treatment, length of stay, and mortality. Geriatr Orthop Surg Rehabil. 2016;7(1):9-17. doi:10.1177/2151458515616250.

42. Yoshihara H, Yoneoka D. Trends in the incidence and in-hospital outcomes of elective major orthopaedic surgery in patients eighty years of age and older in the United States from 2000 to 2009. J Bone Joint Surg Am. 2014;96(14):1185-1191. doi:10.2106/JBJS.M.01126.

43. Lo JC, Srinivasan S, Chandra M, et al. Trends in mortality following hip fracture in older women. Am J Manag Care. 2015;21(3):e206-e214.

44. Halvorson JJ, Lamothe J, Martin CR, et al. Combined acetabulum and pelvic ring injuries. J Am Acad Orthop Surg. 2014;22(5):304-314. doi:10.5435/JAAOS-22-05-304.

45. Osgood GM, Manson TT, O'Toole RV, Turen CH. Combined pelvic ring disruption and acetabular fracture: associated injury patterns in 40 patients. J Orthop Trauma. 2013;27(5):243-247. doi:10.1097/BOT.0b013e31826c2751.

46. Poole GV, Ward EF, Muakkassa FF. Pelvic fracture from major blunt trauma. Outcome is determined by associated injuries. Ann Surg. 1991;213(6):532-538; discussion 538.

47. Knöferl MW, Angele MK, Diodato MD, et al. Female sex hormones regulate macrophage function after trauma-hemorrhage and prevent increased death rate from subsequent sepsis. Ann Surg. 2002;235(1):105-112. doi:10.1097/00000658-200201000-00014.

48. Goldstein A, Phillips T, Sclafani SJ, et al. Early open reduction and internal fixation of the disrupted pelvic ring. J Trauma. 1986;26(4):325-333. doi:10.1097/00005373-198604000-00004.

49. Latenser BA, Gentilello LM, Tarver AA, Thalgott JS, Batdorf JW. Improved outcome with early fixation of skeletally unstable pelvic fractures. J Trauma. 1991;31(1):28-31. doi:10.1097/00005373-199101000-00006.

50. Riemer BL, Butterfield SL, Diamond DL, et al. Acute mortality associated with injuries to the pelvic ring: the role of early patient mobilization and external fixation. J Trauma. 1993;35(5):671-675; discussion 676.

51. Madhu R, Kotnis R, Al-Mousawi A, et al. Outcome of surgery for reconstruction of fractures of the acetabulum. The time dependent effect of delay. J Bone Joint Surg Br. 2006;88(9):1197-1203. doi:10.1302/0301-620X.88B9.17588.

52. Centers for Disease Control and Prevention. The State of Aging & Health in America 2013. https://www.cdc.gov/aging/pdf/state-aging-health-in-america-2013.pdf. Accessed December 5, 2013.

53. Bohl DD, Basques BA, Golinvaux NS, Baumgaertner MR, Grauer JN. Nationwide Inpatient Sample and National Surgical Quality Improvement Program give different results in hip fracture studies. Clin Orthop Relat Res. 2014;472(6):1672-1680. doi:10.1007/s11999-014-3559-0.

54. Memtsoudis SG. Limitations associated with the analysis of data from administrative databases. Anesthesiology. 2009;111(2):449. [author reply:450-451]. doi:10.1097/ALN.0b013e3181adf739.

55. Neuhaus V, Swellengrebel CH, Bossen JK, Ring D. What are the factors influencing outcome among patients admitted to a hospital with a proximal humeral fracture? Clin Orthop Relat Res. 2013;471(5):1698-1706. doi:10.1007/s11999-013-2876-z.

DISCUSSION

This study evaluates the incidence of acetabular fractures in the US between 1990 and 2010, and identifies prognostic factors associated with complications and death. The study demonstrates an increase in the population-adjusted incidence of acetabular fractures between 1990 and 2010 (7.84 cases per 100,000 capita to 9.5 cases per 100,000 capita), in contrast to the decreasing trend reported by Mauffrey and colleagues.¹¹ Some studies suggest that up to 80% of acetabular fractures are associated with motor vehicle collisions and motorcycle accidents.^9,27 While the rate of motor vehicle accidents has remained stable over the study period, motorcycle ownership and deaths more than doubled between 2001 and 2008,²⁸ primarily among individuals over 40 years of age. In this study, the mean age of patients with acetabular fractures ranged from 48 to 57 years. The dramatic increase in motorcycle ownership and deaths in these age groups may partially explain the rising incidence of acetabular fractures. The other possibility is that changes in automobile design and safety equipment may have altered the injury patterns observed in patients surviving motor vehicle crashes. Compared to the United Kingdom, in which studies report a fixed incidence of 3 per 100,000 capita¹ between 1988 and 2003, the incidence of acetabular fractures in the US is greater. In contrast, the incidence of acetabular fractures reported in this study is less than the 20 per 100,000 reported in Sweden between 1976 and 1985,²⁹ or the 37 per 100,000 reported in Rochester, Minnesota between 1968 and 1977,³⁰ which may be due to increased seatbelt usage.³¹

In addition to the national incidence, this study demonstrated that the proportion of patients with acetabular fractures treated with ORIF increased from 12.6% to 20.4% between 1990 and 2010. This is substantially lower than the 77% reported by Ochs and colleagues³² in a German population. Concurrent with the increase in ORIF, there was a decrease in in-hospital mortality from 5.9% in 1990 to 0.4% in 2010. The initial mortality rates in this study are comparable to much earlier reports and some small studies,^9,32-37 but the rates reported in the later years of this study show a substantial decrease that is likely a more accurate estimation of the current incidence. The improved survival rates may be due to advances in the operative treatment of acetabular fractures, in which mechanical stabilization allows for early patient mobilization and facilitation of optimal nursing care.³⁸ With ORIF becoming the standard of care for displaced acetabular fractures,⁹ numerous reports have demonstrated an association between early definitive fixation and improved survival.^17,39,40 This is similar to our study, which found ORIF to be associated with the lowest odds of mortality in multivariate logistic regression analysis. It is possible that advances in patient care by intensivists over this period have also contributed to the decrease in mortality, but the correlation with operative treatment in this study is very strong and agrees well with prior studies.¹⁶ Moreover, multiple studies have demonstrated decreased in-hospital mortality among patients undergoing various orthopedic surgical procedures during this period.^41-43 The correlation with operative treatment in this study agrees well with prior studies.¹⁶

In contrast, higher odds of mortality were seen in patients over the age of 85 years with pulmonary insufficiency, congestive heart failure, pneumonia, or an associated femur or pelvic fracture. This is similar to prior reports in which patients with combined acetabulum and pelvic ring injuries fared worse than those with isolated injures,^44,45 as did patients with associated non-musculoskeletal injuries.⁴⁶ The finding that age over 85 years was associated with higher odds of mortality likely reflects the increased number of comorbidities and decreased physiologic reserve seen in this patient population. Finally, male gender was associated with higher odds of in-hospital mortality. There are 2 possible explanations for this: Either there is gender dimorphism in sex hormones and cytokine activity in response to hemorrhage and sepsis,^38,47 or there is a greater tendency for males to be involved in higher energy accidents with more severe concomitant injuries.

The results of multivariable regression analysis demonstrated that patients were more likely to require blood transfusion if they were managed surgically or had atrial fibrillation, congestive heart failure, or associated femur fracture. Not surprisingly, concurrent pelvic fracture was also associated with higher odds of blood transfusion, as pelvic hemorrhage is reported to be the cause of death in up to half of patients who die following a pelvic fracture.⁴⁶

Between 1990 and 2010, in-hospital days of care decreased from 17.0 days to 10.3 days. While a decreased length of stay has been demonstrated in other orthopedic conditions over the study period,⁴¹ it is possible the decrease in length of stay demonstrated in this study is due to improved surgical technique and the implementation of early surgical intervention.^39,48-50 Plaisier and colleagues¹⁷ demonstrated superior functional outcomes, quicker return to baseline function, and decreased length of stay in patients treated with early ORIF of their acetabular fractures. Other studies have shown that the benefits of early surgery include improved reduction quality and ease of reduction,⁵¹ as well as control of bleeding, pain relief, and mobilization of the patient.³⁹ Another possible explanation for the decreased length of stay is the increased rate of discharge to other inpatient facilities, such as rehabilitation facilities, which was demonstrated in this study.

Continue to: Interestingly, male gender and younger age...