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

Abstract

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