Abstract
Aims
Acetabular fractures have major personal and societal impact. However, prospective longitudinal data about the patient’s recovery trajectory is scarce. Therefore, we aimed to assess the course of the patient’s functional recovery, up till five years post-injury. Additionally, predictors of no full recovery and patient’s perception of most experienced difficulties were assessed.
Methods
A prospective longitudinal cohort study was performed, including adult patients treated for an acetabular fracture at a level 1 trauma centre between January 2017 and August 2023. Patient-reported outcome measures (PROMs) were used to assess functional status with the Short Musculoskeletal Function Assessment (SMFA) at baseline (recalled pre-injury), six weeks, three and six months, and one, two, and five years post-injury. We assessed whether patients had returned to their baseline level health status. Predictors for incomplete recovery were identified using logistic regression analysis. The most frequently experienced difficulties were presented by analyzing the highest reported scores on individual items of the SMFA.
Results
A total of 202 patients with an acetabular fracture filled out the PROMs. After two and five years of follow-up,109 out of 148 (74%) and 65 out of 83 (78%) of the patients fully recovered in terms of physical functioning, respectively. Patients with a posterior wall fracture had worse outcome compared to other Letournel fracture types. Enduring high-energy trauma and not being fully recovered on the SMFA emotion subscale at three months were independent predictors for incomplete recovery after two years on the SMFA function index. At two years, the most frequently reported severe difficulties were walking with a limp and feeling disabled.
Conclusion
Acetabular fractures significantly affect patient-reported functional status, with an initial decline until three months, followed by rapid improvement between three to six months, and gradual recovery up until five years following the injury. Patients with posterior wall fractures showed worse outcomes. High-energy trauma was the strongest predictor for incomplete recovery. The most frequently reported difficulties were walking with a limp and feeling disabled.
Cite this article: Bone Jt Open 2025;6(10):1239–1247.
Keywords: Acetabular fracture, Physical fuctioning, SMFA, Mental health, acetabulum fractures, patient-reported outcome measures (PROMs), Musculoskeletal Function Assessment, trauma, high-energy trauma, logistic regression analysis, cohort study, lower limb trauma, displaced fractures
Introduction
The incidence of acetabular fractures is estimated at eight per 100,000 inhabitants per year.1 Fracture types vary from elementary type minimally displaced fractures to associate type, severely displaced fractures. These injuries are treated either conservatively or surgically depending on fracture type, degree of fracture displacement and patient characteristics like comorbidity and pre-existent mobility.2,3 Having knowledge on what patient-reported outcomes to expect would be helpful for patient counselling and shared decision-making about treatment of acetabular fractures. Although there has been a shift in terms of outcome assessment with increasing emphasis on patient-reported outcome, research concerning acetabular fractures is still focused on objective outcomes (i.e. fracture reduction or conversion to total hip arthroplasty (THA)).2,4,5 Unfortunately, literature on patient-reported outcomes after acetabular fractures is limited and studies often use non-validated patient-reported outcome measures (PROMs).6
Acetabular fractures can have major personal as well as societal impact.7 Some retrospective studies reported fair patient-reported physical functioning,8-10 where others reported substantial residual dysfunction even after a follow-up period of more than five years.11 The only prospective study available reported on surgically treated patients and found that approximately 60% of patients failed to regain their pre-injury physical function and approximately 40% reached their pre-injury mental baseline status.12 However, which factors contributed to patient’s inability to regain the pre-injury health status remains unclear.12 As a result, patients with an acetabular fracture cannot be informed properly about course of recovery, predictive factors for outcome, and what difficulties in functioning, both physical and psychological, could be expected.
This study will report on prospective collected data concerning the mid-term effects of acetabular fractures on patient-reported functional status, in terms of physical and psychological functioning. Based on this information, patients can be informed properly about what to expect from the rehabilitation period in terms of when or whether they will regain their normal life again. Hence, the research questions of this study were: 1) what is the course of recovery in terms of physical functioning within the first five years after an acetabular fracture?; 2) which patient and fracture characteristics are predictive of a decreased physical functioning two years after the injury?; and 3) from a patient perspective, what are the most experienced difficulties during the recovery process after an acetabular fracture?
Methods
A prospective longitudinal cohort study was performed, including adult patients who had been treated for an acute acetabular fracture at a level-1 trauma centre between January 2017 and August 2023. Patients who survived the initial injury, without cognitive disorders or severe psychiatric disorders and who were able to speak and understand the national language were informed about the study and asked to participate. Patients with peri-prosthetic fractures, pre-existent hip arthrodesis, leg amputations or spinal cord injury were not eligible for this study. Participants needed to have at least one year of follow-up at the participating level 1 trauma centre to be eligible. Patient characteristics, including injury and treatment, were prospectively collected and entered into a database at presentation. Complications, traumatic urological and neurological injuries and mortality were continuously monitored throughout the follow-up period. Two experienced trauma surgeons (KTD, FFAIJ) then reviewed CT scans and classified the acetabular fractures using the Letournel system.13 The local Medical Ethical Review Board of the University Medical Center Groningen, (UMCG), the Netherlands, reviewed the methods employed and waived further need for approval (METc 2017/543).
Study population
A total of 210 patients with an acetabular fracture were eligible during the study period. Seven patients were excluded due to the following reasons: refusal to participate (n = five); missed inclusion (n = one); and missing pre-injury questionnaire (n = one). Eventually, 202 patients were included and filled out one or more follow-up questionnaires.
Most of the included patients were male and underwent operative treatment (Table I). The standard rehabilitation protocol included six weeks of partial weightbearing. One patient sustained a bilateral acetabular fracture. In total, 25 patients (12%) converted to a THA after a median follow-up time of 11 months (IQR 7 to 27). In total, 20 out of 202 (10%) patients had a grade 3 complication according to the Clavien-Dindo classification,14 of whom 12 had a fracture-related infection (FRI) which required debridement in theatre and in two patients removal of osteosynthesis materials. Two patients had an intraoperative bleeding successfully treated with coiling and clipping respectively. There were no grade 4 or 5 complications. A full overview of grade 3 complications is provided in the Supplementary Material. A total of eight patients sustained traumatic neurological injuries (Table I). One patient had traumatic urological injury consisting of a bladder rupture. In total, 36 out of 121 patients (30%) treated with osteosynthesis of the acetabulum achieved an excellent reduction (residual fracture displacement of 0 to 1 mm on postoperative CT scan), 48 out of 121 (40%) patients a good reduction (2 to 3 mm), and 36 out of 121 patients (30%) a moderate reduction (> 3 mm).
Table I.
Patient and fracture characteristics.
| Variable | Data for all patients (n = 202) |
|---|---|
| Male, n (%) | 169 (84) |
| Median age at the time of injury, yrs (range) | 54 (36 to 67) |
| HET, n (%) | 117 (58) |
| Injury mechanism, n (%) | |
| Fall from standing height | 81 (40) |
| Fall from height | 39 (19) |
| One-sided car accident | 43 (21) |
| Pedestrian/bike vs car | 11 (5) |
| Two-sided accident | 20 (10) |
| Compression injury | 3 (2) |
| Crush injury | 5 (3) |
| Median Injury Severity Score, (IQR) | 9 (4 to 22) |
| Letournel classification, n (%) | 203 |
| Posterior wall | 41 (20) |
| Posterior column | 2 (1) |
| Anterior wall | 11 (5) |
| Anterior column | 32 (16) |
| Transverse | 7 (3) |
| Posterior column + posterior wall | 7 (3) |
| Transverse + posterior wall | 24 (12) |
| T-type | 21 (10) |
| Anterior column + posterior hemitransverse | 21 (10) |
| Both column | 37 (18) |
| Traumatic hip luxation, n (%) | 46 (23) |
| Nonoperative treatment, n (%) | 76 (38) |
| Operative treatment, n (%) | 126 (62) |
| Plate or screw fixation | 121 (96) |
| Primary THA | 3 (2) |
| Plate + primary THA | 2 (2) |
| Secondary THA, n (%) | 25 (12) |
| Combined pelvic ring injury, n (%) | 44 (22) |
| Associated Pipkin fracture, n (%) | 3 (2) |
| Associated lower limb injury, n (%) | 49 (24) |
| Traumatic nerve injury | 8 (4) |
| Axonotmesis of the sciatic nerve | 3 (1.5) |
| Axonotmesis of the peroneal nerve | 1 (0.5) |
| Axonotmesis of the lumbosacral plexus | 4 (2) |
| Traumatic urological injuries | 1 (0.5) |
| Postoperative reduction, residual fracture displacement as measured on a postoperative CT scan, n (%) | |
| Excellent (0 to 1 mm) | 36 out of 121 (30) |
| Good (2 to 3 mm) | 49 out of 121 (40) |
| Moderate (> 3 mm) | 36 out of 121 (30) |
| Not applicable (conservative or primary total hip arthroplasty) | 81 out of 202 (40) |
| Number of patients with complications, n (%) | 69 (34) |
| Clavien-Dindo Classification, n (%)14 | 69 (34) |
| Grade 1 | 13 (6) |
| Grade 2 | 36(18) |
| Grade 3 | 20 (10) |
| Deceased, n (%) | 8 (4) |
HET, high-energy trauma; THA, total hip arthroplasty.
Patient-reported functional status
Functional status was measured with the Short Musculoskeletal Function Assessment (SMFA).15 The SMFA questionnaire consists of 46 items which are scored on a five-item Likert scale. It was designed to assess the functional status of patients with various musculoskeletal disorders and injuries. Two indices (Function and Bother)15 and four subscales (upper limb dysfunction, lower limb dysfunction, problems with daily activities, and mental and emotional problems) can be calculated.16 Scores are calculated by summing up the scores on the individual items and transforming scores on a range from zero to 100, with higher scores indicating better function. The SMFA-NL has been shown to be a valid and reliable questionnaire for the assessment of physical functioning in injured patients.16,17
The SMFA-NL was administered at admission (for recalled pre-injury status), and at three months, six months, one year, two years, and five years post-injury. PROMs were securely distributed via RoQua (UMCG), linked to electronic patient files, allowing patients to complete them at home or during follow-up visits.
Imputation
To be eligible, patients had to complete at least the pre-injury and one follow-up questionnaire. Some patients had missing data, so multiple imputations were used, except for those who were deceased, hadn't reached follow-up, or missed more than 50% of follow-up moments. Patients who missed more than half of the follow-up were classified as missing data and were not included in the imputation process. Between 3% and 8% of data were imputed per timepoint, generating 24 imputed datasets.18 An output management system (OMS) procedure combined these into one dataset for the first two research questions, while the last question, focused on patient perspective, used the original dataset.
Statistical analysis
Descriptive statistics were performed to present patient and injury characteristics such as injury mechanism, fracture patterns, and treatment methods. Means and SDs were calculated from the normally distributed data and the median and IQR from not-normally distributed data.
To gain insight into the decrease in physical functioning (SMFA) at every timepoint of follow-up relative to their pre-injury status, the scores on the SMFA were expressed as a percentage of the pre-injury score. Additionally, each patient was classified as 'fully recovered' in terms of physical functioning when his/her score on the SMFA indices and subscales was 15 points or less below the recalled pre-injury SMFA scores. A chi-squared test was conducted to assess whether the recovery rated differed significantly among Letournel fracture types.
Independent predictors for patients that were classified as not being fully recovered as measured by the SMFA indices and subscales after two years of follow-up, were analyzed by using a binary logistic regression analysis (backward selection procedure, p-out = 0.157). Sex (female/male), age (< 65/≥ 65 years), injury mechanism (low-/high-energy trauma (LET/HET)), injury type (elementary vs associated according to Letournel),13 combined pelvic ring injury (yes/no), combined lower limb injury (yes/no), associated hip luxation (yes/no), complications according to Clavien-Dindo,19 and no full emotional recovery measured on the emotion subscale of the SMFA at three months post-injury (yes/no) were evaluated for being possible predictors. The results of the final model are presented as odds ratios (ORs) with their corresponding 95% CI and p-values.
The top five individual items of the SMFA at which most patients experienced severe problems at three months, six months, one year, two years, and five years of follow-up were reported to be able to identify in which domains or activities people felt most limited and whether the (level of) limitations on these domains/activities change over time. Data were analyzed using the SPSS software v. 23.0 for Windows (IBM, USA). Statistical significance was set at p ≤ 0.05.
Results
Patient-reported functional status
Figure 1 illustrates the regain of functional status over a five-year period after sustaining an acetabular fracture. SMFA results are presented in Table II together with the median percentage of recovery at every timepoint of follow-up. For the function index of the SMFA, 69% of patients regained a full recovery at one year, 74% at two years, and 78% at five years of follow-up (Table II, last column). For the Bother index of the SMFA, 62% (one year), 68% (two years), and 76% (five years) regained full recovery. For all SMFA subscales, 25% of patients did not regain full recovery after five years.
Fig. 1.
Short Musculoskeletal Function Assessment (SMFA) outcomes at different timepoints during the course of recovery after acetabular fractures. ADL, activities of daily living.
Table II.
PROM scores with level of recovery at every timepoint of follow-up compared to pre-injury scores.
| Score | Period | Median PROM scores (IQR) | Median % level of recovery (IQR)* | Patients fully recovered, n (%) |
|---|---|---|---|---|
| SMFA | ||||
| Function index | Pre-injury | 97.1 (93.4 to 99.4) | N/A | N/A |
| 3 months | 68.0 (57.4 to 79.4) | 72 (60 to 81) | 35/163 (22) | |
| 6 months | 79.4 (71.2 to 89.2) | 82 (76 to 95) | 78/162 (48) | |
| 1 year | 84.8 (75.0 to 94.3) | 90 (80 to 98) | 112/162 (69) | |
| 2 years | 88.1 (76.7 to 93.9) | 93 (83 to 98) | 109/148 (74) | |
| 5 years | 89.7 (83.8 to 97.1) | 96 (86 to 99) | 65/83 (78) | |
| Bother index | Pre-injury | 97.9 (93.8 to 100.0) | N/A | N/A |
| 3 months | 65.0 (52.1 to 77.1) | 69 (56 to 83) | 41/163 (25) | |
| 6 months | 79.0 (66.2 to 89.6) | 83 (71 to 94) | 78/162 (48) | |
| 1 year | 81.8 (70.8 to 95.8) | 89 (77 to 98) | 100/162 (62) | |
| 2 years | 85.4 (75.0 to 95.8) | 92 (80 to 99) | 100/148 (68) | |
| 5 years | 87.5 (81.3 to 97.9) | 96 (85 to 100) | 63/83 (76) | |
| Lower limb | Pre-injury | 100.0 (95.8 to 100.0) | 96 (85 to 100) | N/A |
| 3 months | 66.7 (56.3 to 77.1) | 69 (56 to 80) | 33/163 (20) | |
| 6 months | 79.4 (70.4 to 89.6) | 81 (73 to 92) | 72/162 (44) | |
| 1 year | 85.4 (75.0 to 95.8) | 88 (78 to 98) | 98/162 (61) | |
| 2 years | 89.3 (77.1 to 97.4) | 92 (80 to 98) | 101/148 (70) | |
| 5 years | 91.7 (83.3 to 97.9) | 96 (85 to 100) | 64/83 (77) | |
| ADL | Pre-injury | 98.8 (98.8 to 100.0) | N/A | N/A |
| 3 months | 55.3 (38.8 to 70.0) | 59 (44 to 72) | 27/163 (17) | |
| 6 months | 73.2 (60.0 to 86.3) | 76 (65 to 90) | 60/162 (37) | |
| 1 year | 80.0 (66.3 to 93.8) | 86 (71 to 99) | 91/162 (56) | |
| 2 years | 83.8 (71.3 to 93.8) | 90 (75 to 99) | 91/148 (62) | |
| 5 years | 87.5 (81.2 to 97.5) | 92 (83 to 100) | 59/83 (71) | |
| Emotion | Pre-injury | 93.8 (87.5 to 100.0) | N/A | N/A |
| 3 months | 80.5 (68.8 to 90.6) | 90 (79 to 97) | 102/163 (63) | |
| 6 months | 82.5 (73.4 to 91.4) | 91 (83 to 100) | 112/162 (69) | |
| 1 year | 84.4 (71.9 to 93.8) | 94 (81 to 100) | 116/162 (72) | |
| 2 years | 84.7 (75.7 to 93.8) | 94 (86 to 103) | 113/148 (76) | |
| 5 years | 87.5 (80.9 to 93.8) | 97 (87 to 103) | 56/83 (68) |
Individual patient-reported outcome measure scores at every timepoint of follow-up were expressed as percentage of the pre-injury score.
ADL, activities of daily living; N/A, not applicable; SMFA, Short Musculoskeletal Function Assessment.
Sub-analysis demonstrated that level of recovery varies in relation to Letournel classification (Figure 2 and Supplementary Material).
Fig. 2.
Percentage of patients fully recovered according to the Short Musculoskeletal Function Assessment Function index of the most common Letournel classifications. At two years of follow-up, the percentage of fully recovered patients with posterior wall fractures (19 of 33 patients recovered) and transverse + posterior wall fractures (11 of 19 patients recovered) was significantly lower than for those with anterior column fractures (18 of 20 patients recovered; p = 0.013 and 0 = 0.022, respectively) or T-type fractures (15 of 17 patients recovered; p = 0.028 and p = 0.042, respectively).
Factors associated with no full recovery two years after injury
Sustaining a HET was a predictor for not being fully recovered on the SMFA function and Bother indices after two years of follow-up. Patients who endured a HET had an almost six-times higher odds at not recovering for the function index (OR 5.99; 95% CI 2.12 to 16.88) and three times higher odds for the Bother index (OR 3.45; 95% CI 1.33 to 8.92) (Table III). Patients who had not fully recovered on the emotion subscale of the SMFA at three months were more likely to have incomplete recovery on the Function index (OR 2.95; 95% CI 1.16 to 7.53) and Bother index (OR 2.52; 95% CI 1.05 to 6.17) at two years (Table III). Patients with combined lower limb injury were at higher risk for not recovering on the Bother index (OR 2.90; 95% CI 1.02 to 8.21) (Table III).
Table III.
Independent predictors for no full recovery of the Short Musculoskeletal Function Assessment Function index and Bother index at two years.
| Variable | B | OR (95% CI) | p-value* |
|---|---|---|---|
| Function index | |||
| High-energy trauma | 1.79 | 5.99 (2.12 to 16.88) | < 0.001 |
| No full recovery on emotion subscale SMFA at 3 months post-injury | 1.08 | 2.95 (1.16 to 7.53) | 0.02 |
| Female gender | 1.00 | 2.71 (0.73 to 10.05) | 0.14 |
| Bother index | |||
| High-energy trauma | 1.24 | 3.45 (1.33 to 8.92) | 0.01 |
| No full recovery on emotion subscale SMFA at 3 months post-injury | 0.03 | 2.54 (1.05 to 6.17) | 0.04 |
| Combined lower limb injury | 1.06 | 2.90 (1.02 to 8.21) | 0.05 |
Binary multivariate logistic regression analysis was performed (backward selection procedure, p-out = 0.157).
B, regression coefficient; OR, odds ratio; SMFA, Short Musculoskeletal Function Assessment.
Patients’ perception of experienced difficulties
A significant number of patients continued to experience limitations in physical activities and effects on their mental wellbeing after three months, one year, two years, and five years of follow-up. At three months, half of the patients reported severe problems with daily function, heavy housework, and recreational activities. Nearly 50% of all patients felt disabled and walked with a limb. During follow-up, these complaints persisted in 15% to 20% of patients. After five years of follow-up, approximately 20% of patients still felt disabled/impaired (Table IV). Sexual function, as assessed by the relevant item of the SMFA, demonstrated notable changes over time. Prior to injury, 12 out of 202 patients (6%) reported moderate to very severe difficulties. At three months post-injury, 64 out of 147 (44%) reported moderate to very severe difficulties. By 12 months post-injury, sexual function had improved, with 23 out of 147 (16%) reporting moderate to very severe difficulties.
Table IV.
Patients’ perception of most experienced difficulties – retrieved from the individual questions of the Short Musculoskeletal Function Assessment – at three months, and one, two, and five years of follow-up after an acetabular fracture.
| 3 months | %* | 1 year | % | 2 years | % | 5 years | % |
|---|---|---|---|---|---|---|---|
| Physical recreational activities (walking, biking) | 56 | Walking with a limb | 25 | Walking with a limb | 20 | Feeling physically disabled | 23 |
| Walking with a limb | 53 | Feeling physically disabled | 22 | Feeling physically disabled | 20 | Heavy housework or yard work | 14 |
| Heavy housework or yard work | 51 | Problems with bending or kneeling down | 18 | The effect of doing too much on one day | 18 | Problems performing daily work | 13 |
| Problems performing daily work | 47 | The effect of doing too much on one day | 18 | Problems with bending or kneeling down | 17 | Problems with bending or kneeling down | 12 |
| Feeling physically disabled | 47 | Physical recreational activities Problems performing daily work Feeling tired |
15 | Bothered by stiffness and pain | 15 | Physical recreational activities (walking, biking) | 12 |
Percentage of patients that experience severe difficulties (SMFA score 4 or 5 for a particular item).
SMFA, Short Musculoskeletal Function Assessment.
Discussion
In this prospective longitudinal study, we assessed patient-reported functional status up to five years following an acetabular fracture. Immediately after the injury, patients experienced a significant decline in functional status, but it gradually improved over the next five years. Despite this improvement, functional status was still reduced after five years with recovery rates of around 75% compared to pre-injury levels. Especially patients with (transverse) posterior wall fractures had worse physical outcome after two years of follow-up. Enduring HET and not being fully recovered on the SMFA emotion subscale at three months were independent predictors for incomplete recovering after two years on the SMFA Function index. At two years, the most frequently reported severe difficulties were walking with a limp and feeling disabled.
Patients reported a noticeable decrease in functional status three months after the injury compared to their recalled pre-injury health status. From that timepoint, functional status continued to improve up to five years post-injury. The recovery curve was steepest between three and six months, then flattened but still showed improvement until five years after the injury. These findings align with those of Tucker et al,12 the only other prospective cohort study on acetabular fractures available in the literature. They observed the greatest improvement in SMFA Function and Bother index scores between six months and one year post-injury, consistent with our results. They found that a significant proportion of patients did not achieve the minimal clinically important difference (MCID) compared to their pre-injury baseline, with 50% for SMFA function index and 66% for SMFA Bother index, indicating both significant physical and persistent psychological effects. In contrast, our study found that 25% of patients did not reach pre-injury levels at the five-year follow-up. This discrepancy is not explained by differences in baseline or fracture characteristics, as mean age, sex, median Injury Severity Score, and the prevalence of HET were similar. The variation in results may be attributed to differences in the definition of 'fully recovered'. Our study defined full recovery as returning to pre-injury levels or within 15 points of pre-injury levels, while Tucker et al’s study12 used a stricter MCID range of 5 to 8 points. Regardless of where the cutoff for 'fully recovered' is set, the main takeaway from the results remains unchanged. Most patients will recover, with the most rapid improvements occurring within the first year. However, a substantial portion of patients will not return to their pre-injury levels, even at five years after the injury. Therefore, we aimed to identify the factors that contribute to a decreased recovery.
We found that patients with posterior wall fractures, as well as those with transverse + posterior wall fractures, tend to have poorer outcomes. This aligns with existing literature, where many studies showed that operatively treated fractures of the posterior acetabular wall often result in unsatisfactory outcome and a higher risk of conversion to THA.20-22 Factors such as associated marginal impaction, delayed reduction of hip dislocation, comminution, and residual displacement are frequently cited.4,20,22,23 Although our study does not specifically address these fracture characteristics, our study findings suggest a different perspective. Our study showed that a significant contributing factor to worse outcome is enduring a HET. Among patients with transverse+ posterior wall fractures, 22 of 24 (92%) patients experienced a HET, and 28 of 40 (70%) patients with posterior wall fractures had a HET. This could suggest that it may not be the fracture type itself that predicts worse outcome, but rather the fact that most of these patients suffered a HET. This observation aligns with our finding that HET was a predictor for no full recovery at two years post-injury.
Prospective longitudinal data are lacking with only one study reporting on PROMs during five years of follow-up time.12 A subgroup analysis of the 36-Item Short-Form Health Survey questionnaire Physical Component Summary (SF-36 PCS)24 revealed that HET (measured as a New Injury Severity Score25 > 18) and associated lower limb trauma contributed to worse SF-36 outcomes during follow-up.12 These findings align with our results, where HET was a significant predictor of incomplete recovery on the function and Bother indices and associated lower limb trauma was a predictor of incomplete recovery on the Bother index only. The complexity of factors influencing recovery makes it challenging to identify universal predictors of incomplete recovery. We attempted to consider psychological factors by measuring the emotion subscale of the SMFA. There is limited research on the impact of psychological factors on recovery in patients with an acetabular fracture. We found that not being recovered on the emotion subscale of the SMFA at three months after injury was a predictor for no recovery at two years. As psychological resilience is known to affect recovery in other fracture types,26 it may also play a role in acetabular fractures. A strong decline in emotion subscale could suggest a lower psychological resilience, which might explain why we found that not being fully recovered on the emotion subscale at three months was a predictor for not being physically recovered at two years. Our findings suggests that future care for patients with pelvic injuries could benefit from ongoing follow-up using PROMs. If emotional recovery is impaired in the early months after injury, it may be advisable to consider additional support. Integrating mental health interventions, such as counselling or cognitive behavioral therapy, may help improve overall recovery outcomes. We believe that a comprehensive approach that considers both physical and psychological wellbeing may lead to improved clinical outcomes. Further research is needed in this area.
We evaluated most severe challenges that patients faced during follow-up. At the three-month mark, half of patients reported severe problems with daily function, heavy housework, walking with a limb, and engaging in recreational activities. Nearly 50% of all patients felt disabled, underscoring the mental impact of the injury. Even after five years, more than 20% of patients continued to feel disabled. Monteleone et al7 found that one-third of patients reported changes in sexual habits. Giannoudis et al27 demonstrated a significant reduction in level of activity and frequency of participation in sport across all age groups compared to the English population. Overall, enduring an acetabular fracture had a significant impact on a patient’s life in terms of physical functioning in daily life.
Some strengths and limitations of this study need to be addressed. The prospective longitudinal design, including recalled pre-injury physical functioning is undoubtedly a strength of the present study. With comparable data collected at seven different timepoints, change over time in individual patients could be observed and recall bias avoided. To the best of our knowledge, this is one of the largest prospective longitudinal follow-up studies evaluating functional status after acetabular fractures by using valid PROMs. By comparing PROM scores at different timepoints to the pre-injury scores, insight was given into the course of recovery. As a result, both the clinician and the patient could be provided with valuable information about whether and when to expect complete recovery. A limitation of this study might be the heterogeneity of the group in terms of age, fracture types, injury severity, and presence of associated injuries. However, our study population is an actual reflection of patients with acetabular fractures presenting to a large level 1 trauma centre. Another limitation is the potential selection bias in the patient cohort, as this study included patients in a level 1 trauma centre, and patients with minor trauma unlikely to be referred to a level 1 trauma centre. However, regional agreements ensure that patients with acetabulum fractures are referred to our centre, and our data show that the distribution of fracture types aligns with what is reported in literature,28 making potential bias less likely. Lastly, the sample size at the five-year follow-up was limited, as a substantial proportion of the patient population had not yet reached this timepoint. Similarly, the sample sizes for the subgroup analyses of the different fracture types remained relatively small. Future research with an even larger sample size, enabling further subgroup analyses, would be preferable. Moreover, the missing data are a limitation. However, we addressed this by imputing data.
In conclusion, acetabular fractures significantly affect patient-perceived functional status, with an initial decline until three months, followed by rapid improvement between three to six months, and gradual recovery up till five years following the injury. The percentage of patients who fully regained their pre-injury level of functional status was 22% at three months, 48% at six months, 69% at one year, 74% at two years, and 78% at five years. Patients with (transverse) posterior wall fractures showed worse outcomes. HET was the strongest predictor for incomplete recovery. At two years, the most frequently reported severe difficulties were walking with a limp and feeling disabled, affecting still 15% to 20% of patients. Our findings provide clinicians and patients with valuable information about the course of recovery up till five years post-injury. A multidisciplinary approach covering both the physical and mental consequences of acetabular fractures seems appropriate and deserves further attention in future large prospective cohort studies.
Take home message
- Acetabular fractures significantly affect patient-perceived functional status, with an initial decline until three months, followed by rapid improvement between three to six months, and gradual recovery up till five years following the injury.
- The percentage of patients who fully regained their pre-injury level of functional status was 22% at three months, 48% at six months, 69% at one year, 74% at two years, and 78% at five years.
- Patients with (transverse) posterior wall fractures showed worse outcomes. High-energy trauma was the strongest predictor for incomplete recovery.
- At two years, the most frequently reported severe difficulties were walking with a limp and feeling disabled, still affecting 15% to 20% of patients.
Author contributions
N. M. Trouwborst: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Visualization, Writing – original draft
K. ten Duis: Conceptualization, Data curation, Supervision, Writing – review & editing
H. Banierink: Conceptualization, Data curation, Project administration, Writing – review & editing
A. M. L. Meesters: Conceptualization, Data curation, Writing – review & editing
J. J. W. Ploegmakers: Conceptualization, Data curation, Writing – review & editing
A. J. Andela: Conceptualization, Data curation, Writing – review & editing
M. M. Hamminga: Conceptualization, Data curation, Writing – review & editing
R. L. Jaarsma: Conceptualization, Supervision, Writing – review & editing
J. P. M. de Vries: Conceptualization, Supervision, Writing – review & editing
I. H. F. Reininga: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing
F. F. A. IJpma: Conceptualization, Data curation, Methodology, Supervision, Writing – review & editing
Funding statement
The author(s) received no financial or material support for the research, authorship, and/or publication of this article, other than the open access funding outlined below.
ICMJE COI statement
J. J. W. Ploegmakers reports consulting fees from OTOMA J&J DePuy, which is unrelated to this work. All other authors have no conflicts of interest to disclose.
Data sharing
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
Acknowledgements
The authors would like to acknowledge A. Hamminga, J. Renkema, C. Renkema, M. Rurenga, G. T. Laanstra, and C. H. M. Wiersema for their valuable contributions at the outpatient clinic. Their assistance in patient communication and questionnaire collection is sincerely appreciated.
Ethical review statement
The local Medical Ethical Review Board of the University Medical Center Groningen (UMCG), the Netherlands, reviewed the methods employed and waived further need for approval (METc 2017/543)
Open access funding
The open access publication costs were covered by the MD/PhD programme of the Graduate School of Medical Sciences from the University of Groningen, the Netherlands.
Supplementary material
Additional information on complications, the number of patients who recovered according to the function index and Bother index stratified by the Letournel classification, as well as supplementary univariate and multivariate regression analyses for the lower extremity, activities of daily living, and emotion subscales.
© 2025 Trouwborst et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
Data Availability
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and analyzed in the current study are not publicly available due to data protection regulations. Access to data is limited to the researchers who have obtained permission for data processing. Further inquiries can be made to the corresponding author.