Comparing outcomes of acetabular fracture fixation in early career versus experienced orthopaedic trauma surgeons

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Abstract

Background:

The goal of this study was to compare clinical and functional outcomes of acetabular fractures treated with open reduction internal fixation (ORIF) by orthopaedic trauma fellowship-trained surgeons in their first 5 years of practice with their more experienced counterparts.

Materials and Methods:

We retrospectively reviewed patients with acetabular fractures treated with ORIF at our level I trauma center from 2018 to 2021. Inclusion criteria included patients 18 years or older with an acetabular fracture treated with ORIF by an early career orthopaedic trauma surgeon in their first 5 years of practice or by a more experienced partner at least 10 years into practice. The primary outcome was fracture reduction quality. Secondary outcomes were operative time, estimated blood loss, reoperations, perioperative 30-day mortality, native hip survivorship, and HOOS JR scores at 1 year.

Results:

Ninety-nine patients with 100 acetabular fractures were included. The average age was 51.3 ± 19.5 years. Seventy-six percent were male. Sixty-six fractures were treated by early career surgeons, 33 were treated by later career surgeons. The 2 groups were similar in patient demographics, fracture characteristics, operative time, estimated blood loss, reoperation, 30-day mortality, native hip survivorship, and HOOS JR scores. There were no differences in reduction grade between groups (82% vs 90% grade A/B in the early career and later career groups, respectively, P = 0.38). Early career surgeons used postoperative computed tomography significantly more than experienced surgeons.

Conclusions:

Reassuringly, patients with acetabular fractures treated with ORIF by early career surgeons demonstrate comparable outcomes with those treated by more experienced surgeons.

1. Introduction

The treatment of acetabular fractures represents one of the most complex topics in orthopaedic trauma. As recently as the 1940s, these fractures were almost universally managed without surgery. It was not until the 1950s that Robert Judet, disappointed by the outcomes of closed treatment, began exploring operative fixation of acetabulum fractures. In 1961, Judet and his then resident Emile Letournel published an initial series of patients with acetabular fractures treated operatively. They followed this up in 1964 with their landmark paper that both established their eponymous classification system and described different surgical approaches to the acetabulum. This would ultimately change the way these fractures are managed.^1–3

In 1980 in his follow-up study, Letournel² demonstrated 80% good-to-excellent results in nearly 500 hips following surgical intervention, cementing the role of open reduction internal fixation (ORIF) in treatment of acetabular fractures. In 2012, another master surgeon, Joel Matta, found 79% native hip survivorship in over 800 patients with acetabular fractures treated with ORIF at 20 years follow-up.⁴ This confirmed the efficacy of anatomic reduction and internal fixation in treating these complicated injuries.

The literature until now can largely be summarized by Emile Letournel when he wrote “22 years of experience in this field allow us to say that a perfect open reduction is the method of choice to treat displaced acetabular fractures.” However, he went on to explain that “difficult cases require experience.”² Most literature to date has largely focused outcomes only for these very experienced, “master” surgeons, while the results of acetabular fracture fixation performed by early career surgeons remain poorly described. In our study, we sought to describe the clinical and functional outcomes of acetabular fractures treated by orthopaedic traumatologists in their first 5 years of practice and see how these compared with the outcomes of more experienced orthopaedic traumatologists.

2. Materials and methods

After approval from our Institutional Review Board, a retrospective review was performed of patients with acetabular fractures treated with open reduction internal fixation by orthopaedic trauma surgeons at a single level I trauma center from 2018 to 2021. Inclusion criteria include patients 18 years or older with an acetabular fracture treated with open reduction internal fixation treated by an early career orthopaedic trauma fellowship-trained surgeon during the first 5 years of practice following their fellowship completion or by a more experienced orthopaedic trauma fellowship-trained surgeon a minimum of 10 years into their orthopaedic trauma practice. Patients were excluded if their acetabular fracture was periprosthetic, was treated nonoperatively or with percutaneous fixation, or they underwent planned acute total hip arthroplasty.

Chart review was used to record patient demographics, acetabular fracture patterns (using the Letournel and Judet classification system), operating room time, and estimated blood loss (EBL). Return to operating room within 180 days postoperative and conversion to total hip arthroplasty at any time point postoperative was also collected. To facilitate statistical analysis, fracture patterns were labeled as either simple (including the elementary fracture patterns such as anterior wall, posterior wall, anterior column, posterior column, and transverse) or complex (including the associated fracture patterns such as associated both column, anterior column posterior hemitransverse, T-type, transverse posterior wall, and posterior column posterior wall). Reduction quality was evaluated by 2 independent reviewers who were not a part of the initial surgery using standard postoperative pelvic radiographs or computed tomographies (CTs) when postoperative radiographs were not available. The senior author served as a third reviewer to determine the final grading when there was a discordance between the 2 reviewers. The reduction received a grade A if there was 0 to 2 mm of articular step-off postoperatively, a grade B for 2 to 4 mm step off, and a grade C when there was greater than 4 mm of step-off after surgical intervention. Patients who had a completed 1-year postoperative Hip Disability and Osteoarthritis Outcome Score, Joint Replacement (HOOS JR) patient-reported outcome (PRO) score were reported to quantify functional outcomes.⁵ If a patient was converted to a total hip arthroplasty, we did not include their PRO data.

The collected data were summarized as means and standard deviations for continuous variables and counts and percentages for categorical variables within the overall sample. Patients treated by early career surgeons were compared with those treated by later career surgeons using univariate testing (Mann-Whitney or Fisher exact test) to compare patient demographics as well as surgical outcomes. Multivariate analyses were performed to determine what independent factors (presence of a hip dislocation at time of injury, patient age, fracture pattern (simple or complex), surgeon experience (early career vs late career), EBL, and operative time) affected reduction grade, and native hip survivorship (dependent factors).

3. Results

There were 99 patients (75 male, 24 female) with 100 acetabular fractures in the final analysis. The early career surgeons managed 67 fractures, while the later career surgeon group managed the remaining 33 fractures. There were no differences between the 2 groups in terms of patient and fracture characteristics. The 3 most common fracture patterns were posterior wall (22 fractures; 33%), associated both column (17 fractures; 26%), and transverse posterior wall (12 fractures; 18%). There were no significant differences in fracture complexity between surgeon groups (Table 1).

Table 1.

Patient and fracture characteristics.

	Early career surgeons (N = 66 patients)	Experienced surgeons (N = 33 patients)	P
Age (years)	51.1 ± 20.5	51.5 ± 17.4	0.94
Sex	52 male (79%)	23 male (70%)	0.33
BMI	28.1 ± 5.9	29.2 ± 6.4	0.51
Fracture types	67 fractures	33 fractures	0.67
Simple	22 (33%)	10 (30%)
PW	12 (18%)	2 (6%)
TPW	6 (9%)	0 (0%)
Transverse
Complex	17 (26%)	6 (18)
ABC	4 (6%)	3 (9%)
ACPH	2 (3%)	0 (0%)
T-type	3 (5%)	5 (15%)
PCPW	1 (2%)	6 (18%)
AC	0 (0%)	1 (3%)
AW
Dislocations	16 (24%)	13 (39%)	0.16

AC, anterior column; AW, anterior wall; ABC, associated both column; ACPH, associated both column plus posterior hemitransverse; BMI, body mass index; PW, posterior wall; PCPW, posterior wall and posterior column; TPW, transverse plus posterior wall.

Regarding surgical outcomes, there were no differences between the 2 surgeon groups in fracture reduction grades, operative time, estimated blood loss, reoperations, 30-day perioperative mortality, native hip survivorship, and HOOS JR scores at 1 year (Table 2).

Table 2.

Outcome comparisons.

	Early career surgeons	Experienced surgeons	P
Operative time (minutes)	231 ± 93	201 ± 75	0.13
Estimated blood loss (mL)	760 ± 568	732 ± 544	0.55
Reduction grading			0.08
A 0–2 mm	41 (61%)	16 (48%)
B 2–4 mm	14 (21%)	14 (42%)
C > 4 mm	12 (18%)	3 (9%)
Return to operating room (RTOR)	28.8% (19 RTOR in 16 patients)	15.2% (5 RTOR in 5 patients)	0.07
Lifetime THA conversion	11 (16.4%)	4 (12%)
Irrigation and debridement	3 (4.5%)	0 (0%)
Implant removal	1 (1.5%)	0 (0%)
Revision ORIF	2 (3%)	1 (3%)
HO excision	1 (1.5%)	0 (0%)
Reinjury	1 (1.5%)	0 (0%)
30-day perioperative mortality	3 (4.5%)	2 (6%)	1.0
1-year native hip survivorship	57 (85.1%)	31 (93.9%)	0.33
HOOS JR at 1 year	73.8 ± 20.2	85.3 ± 10.9	0.07

Most fractures were graded A or B with 82% of fractures in the early career group versus 90% in the early career group (P = 0.38).

Of note, postoperative imaging use between the 2 groups was different. Postoperative CT was used significantly more often in 32 fractures (48%) by the early career surgeons, while postoperative CT was only obtained for 3 fractures (9%) in the experienced surgeons group (odds ratio: 8.9; 95% confidence interval [CI]: 2.4–50.3; P < 0.001). Among the 35 CT scans obtained, there were 2 that resulted in a decision to return to the operating room, 1 in the early career surgeon group and 1 in the experienced surgeon group. Zero of the 2 patients had a total hip arthroplasty conversion by last follow-up.

Multivariate analysis demonstrated that both higher EBL (P < 0.001; 95% CI 0.00018–0.00063) and complex fracture patterns (P = 0.009; 95% CI 0.085–0.604) were independently associated with worse fracture reductions, while surgeon experience was not associated with fracture grading. Age, fracture patterns, fracture grading, EBL, and surgeon experience were not associated with native hip survivorship.

4. Discussion

Acetabular fractures are complex, and the operative management of these injuries is technically challenging. Acquiring the surgical skill necessary to navigate the intricate periacetabular anatomy requires experience. Butler et al⁶ found that 2.4 years or 19 cases appeared to be the learning curve for acetabulum fractures. Recent publications have shown that in recent years, as the number of fellowship trained orthopaedic trauma surgeons has increased, there has been an simultaneous decrease in the number of acetabulum fracture surgeries performed per surgeon, suggesting dilution of the surgical experience of early career surgeons. The number of acetabular surgeries performed per candidate per year decreased significantly over time from a mean of 10.1 cases in 2003 to 5.2 cases in 2015.⁷ In our series, we observed an average of 5.6 fractures/surgeon/year in line with these national case volume trends. To address these decreased case volumes, the Orthopaedic Trauma Association (OTA) has recently recommended a minimum of 25 acetabulum fracture operations for an orthopaedic trauma fellowship to ensure trainees have completed most of the curve before independent practice.

In our single-center study, there were comparable outcomes after operative fixation of acetabulum fractures in the hands of early career surgeons compared with their more experienced counterparts. There were no differences noted in reduction quality, operative time, EBL, reoperations, native hip survivorship, or HOOS JR scores at 1 year based on surgeon experience. Interestingly, complex fracture patterns were independently associated with worse reduction grading but not surgeon experience. It is worth noting that the early career surgeon groups managed two-thirds of the acetabular fractures encountered during this period with no difference in fracture complexity based on experience. Our study offers reassurance that current orthopaedic trauma fellowship training adequately prepares its trainees to safely manage even the most complex orthopaedic injuries.

One notable difference between early career and later career surgeons was regarding their preferred postoperative imaging protocol. In the early career surgeon group, postoperative CTs were ordered in for 48% of the time, while they were obtained just 9% of the time in the experienced surgeon group. Although there remains controversy regarding the use of postoperative computed tomography scans after acetabular ORIF, recent studies have demonstrated postoperative CT are superior to plain radiographs for assessing reduction quality and identifying inadequately positioned implants and articular malreductions that could benefit from early revision surgery especially for certain fracture patterns such as posterior wall.^8,9 Others advocate for more judicious postoperative CT scan use depending on fracture complexity and initial postoperative radiographs.⁹ Although there are no clear guidelines regarding the use of postoperative CT, it is interesting to note how postoperative CT rates vary based on surgeon experience. In our study, 2 postoperative CT scans led to the decision of revision, supporting their clinical importance in some cases.

This study does have several limitations. We only included results from 9 surgeons at a single level I trauma center, so the results may not be broadly generalizable. Another major limitation is regarding our relatively short follow-up of just one to 3 years. It can take years to develop significant enough post-traumatic arthritis to necessitate conversion total hip arthroplasty, so the rate of native hip survivorship is likely an overestimation and would likely decrease as we proceed further out from the index operation. In addition, HOOS JR data are most studied in the measurement in the context of total hip arthroplasty outcomes, not outcomes related to acetabulum fracture open reduction internal fixation.⁵ Finally, the response rate for the patient reported outcomes was just 24% response rate. Such a low rate may limit the broader applicability to all patients. PROs are increasingly being collected routinely in clinical practice. The American Board of Orthopaedic Surgery currently require Part II candidates to collect patient PROs.¹⁰ The Part II examination period aligns well with the timeline of early career surgeons. Future studies that include multiple institutions will be valuable to increase the number of patients and participating surgeons, as patient accrual in this study was inherently limited once our early career surgeons completed their initial five-years of practice.

In summary, appropriate treatment of acetabular fractures necessitates anatomic reduction and internal fixation for the possible best outcomes. Given the inherent complexity of these procedures, a learning curve is to be expected. In fact, Matta himself found “the overall rate of anatomical reduction increased consistently over time from 40% in 1980 to 92% in 2006.”⁴ Despite this learning curve, we found that patients with acetabular fractures treated with open reduction internal fixation by newly graduated orthopaedic trauma surgeons demonstrated similar outcomes to those treated by their more experience colleagues. Our study conveys a reassuring message to the public that acetabular fractures can be safely and effectively managed by early career orthopaedic trauma surgeons.

Data availability statement

The data sets generated during and/or analyzed during the current study are not available.