Analysis of Incidence and Outcome Predictors for Patients Admitted to US Hospitals with Acetabular Fractures from 1990 to 2010
TAKE-HOME POINTS
- The population-adjusted incidence of acetabular fractures increased between 1990 and 2010. Mortality associated with acetabular fractures decreased from 5.9% to 0.4% between 1990 and 2010.
- The proportion of patients treated with ORIF increased from 12.6% to 20.4% between 1990 and 2010.
- The average in-patient hospital length of stay following acetabular fracture decreased from 17.0 to 10.4 days between 1990 and 2010.
- ORIF is associated with the lowest odds of mortality following acetabular fracture.
MORTALITY
In-hospital mortality decreased from 5.9% in 1990 to 0.4% in 2010 (P < .001) (3.5% for the total cohort) (Tables 1 and 2). Multivariable logistic regression analysis demonstrated pulmonary insufficiency (odds ratio [OR], 9.07; 95% confidence interval [CI], 8.52-9.66; P < .01), pneumonia (OR, 3.22; 95% CI, 3.05-3.39; P < .01), and age >85 years (OR, 2.28; 95% CI, 2.16-2.40; P < .01) to be associated with the highest odds of inpatient mortality. CRIF (OR, 1.99; 95% CI, 1.78-2.23; P < .01), external fixator (OR, 1.82; 95% CI, 1.45-2.29; P < .01), and having received a blood transfusion (OR, 1.81; 95% CI, 1.71-1.91; P < .01) were also associated with increased odds of mortality. Treatment with ORIF (OR, 0.19; 95% CI, 0.17-0.20; P < .01) was independently associated with decreased odds of inpatient mortality, as was age <20 years (OR, 0.26; 95% CI, 0.23-0.30; P < .01) (model fit: for omnibus test of model coefficients, X = 25,966 P < .01; Nagelkerke, R2 = 0.20) (Table 3).
Table 3. Logistic Regression for Predictors of Mortality Among Patients with Acetabular Fractures (n = 403,927)
Variable | OR (95% CI) | P |
Pulmonary insufficiency | 9.07 (8.52–9.66) | < 0.01 |
Pneumonia | 3.22 (3.05–3.39) | < 0.01 |
Age >85 years | 2.28 (2.16–2.40) | < 0.01 |
Closed reduction internal fixation | 1.99 (1.78–2.23) | < 0.01 |
External Fixator | 1.82 (1.45–2.29) | < 0.01 |
Blood transfusion | 1.81 (1.71–1.91) | < 0.01 |
Gender (male) | 1.76 (1.70–1.83) | < 0.01 |
Associated femoral neck fracture | 1.23 (1.15–1.30) | < 0.01 |
Age 41-60 years | 1.19 (1.11–1.29) | < 0.01 |
Age 61-85 years | 1.17 (1.11–1.23) | < 0.01 |
Congestive heart failure | 1.14 (1.07–1.22) | < 0.01 |
Associated pelvic fracture | 1.13 (1.10–1.17) | < 0.01 |
Geographic region | 1.11 (1.09–1.12) | < 0.01 |
Source of payment | 1.02 (1.01–1.02) | < 0.01 |
Race | 0.99 (0.98–0.99) | < 0.01 |
DOC | 0.98 (0.98–0.98) | < 0.01 |
Hypertension | 0.67 (0.64–0.71) | < 0.01 |
Atrial fibrillation | 0.52 (0.48–0.57) | < 0.01 |
Diabetes mellitus | 0.35 (0.32–0.38) | < 0.01 |
Age 20-40 years | 0.32 (0.30–0.35) | < 0.01 |
Age <20 years | 0.26 (0.23–0.30) | < 0.01 |
Coronary artery disease | 0.21 (0.18–0.24) | < 0.01 |
Open reduction internal fixation | 0.19 (0.17–0.20) | < 0.01 |
Omnibus X 25,966, P < .01 | ||
Nagelkerke R2= 0.20 |
Abbreviations: CI, confidence interval; DOC, days of care; OR, odds ratio.
COMORBIDITIES AND ADVERSE EVENTS
The prevalence of comorbidities and adverse events is listed in Tables 4 and 5, respectively. Hypertensive disease was the most common comorbidity at 15.3%, followed by diabetes mellitus at 6.9%. Overall, 25.9% of patients experienced an in-hospital adverse event, with the most common being postoperative anemia (7.3%) and blood transfusion (8.1%) (Tables 1 and 5). The percentage of patients experiencing an adverse event increased from 10.9% in 1990 to 37.6% in 2010 (P < .01) (Table 2). Multivariable logistic regression analysis revealed CRIF (OR, 3.08; 95% CI, 2.91-3.26; P < .01), coronary artery disease (OR, 2.02; 95% CI, 1.91-2.15; P < .01), associated femoral neck fracture (OR, 1.53; 95% CI, 1.47-1.60; P < .01), and ORIF (OR, 1.22; 95% CI, 1.20-1.24; P < .01) to be associated with higher odds of inpatient adverse events (model fit: for omnibus test of model coefficients, X = 160,275, P < .01; Nagelkerke, R2 = 0.41) (Table 6).
Table 4. Prevalence of Comorbidities in Patients with Acetabular Fractures Between 1990 and 2007 (n = 403.927)
Parameter (ICD-9) | Percentage of Total |
Hypertensive disease (401–405) | 15.3% |
Diabetes mellitus (250) | 6.9% |
Atrial fibrillation (427.31) | 4.0% |
Congestive heart failure (428) | 3.9% |
Osteoporosis (733.0) | 2.1% |
Coronary artery disease (414.01) | 2.0% |
Obesity (278.00, 278.01) | 2.0% |
Abbreviation: ICD-9, International Classifications of Diseases, 9th Revision.
Table 5. Prevalence of In-Hospital Adverse Events Among Patients with Acetabular Fractures Between 1990 and 2007 (n = 403,927)
Parameter (ICD-9) | Percentage of Total |
Transfusion of blood (99.0) | 8.1% |
Acute postoperative anemia (285.1) | 7.3% |
Intubation (96.x) | 4.9% |
Acute renal failure (584) | 3.4% |
Pneumonia (480-486) | 3.2% |
Pulmonary insufficiency (518.5) | 2.3% |
Pulmonary embolism (415.1) | 1.6% |
Deep venous thrombosis (453.4) | 1.0% |
Acute myocardial infarction (410) | 0.9% |
Postoperative bleeding (998.1) | 0.7% |
Acute postoperative infection (998.5) | 0.5% |
Induced mental disorder (293) | 0.4% |
Abbreviation: ICD-9, International Classifications of Diseases, 9th Revision.
Table 6. Logistic Regression for Predictors of Adverse Events Among Patients Hospitalized for Acetabular Fracture (n = 403,927)
Variable | OR (95% CI) | P |
Closed reduction internal fixation | 3.08 (2.91-3.26) | < 0.01 |
Coronary artery disease | 2.02 (1.91-2.15) | < 0.01 |
Associated femoral neck fracture | 1.53 (1.47-1.60) | < 0.01 |
Open reduction internal fixation | 1.22 (1.20-1.24) | < 0.01 |
Gender (male) | 1.16 (1.14-1.18) | < 0.01 |
Associated fracture of any part of femur | 1.13 (1.10-1.17) | < 0.01 |
Age >85 years | 1.08 (1.05-1.12) | < 0.01 |
Geographic region | 1.07 (1.06-1.07) | < 0.01 |
DOC | 1.04 (1.04-1.04) | < 0.01 |
Race | 1.02 (1.02-1.03) | < 0.01 |
Source of payment | 1.01 (1.01-1.01) | < 0.01 |
Congestive heart failure | 1.01 (0.96-1.06) | 0.78 |
Atrial fibrillation | 0.88 (0.84-0.92) | < 0.01 |
Age 61-85 years | 0.68 (0.66-0.71) | < 0.01 |
Age <20 years | 0.67 (0.64-0.70) | < 0.01 |
Associated pelvis fracture | 0.64 (0.63-0.66) | < 0.01 |
Age 41-60 years | 0.58 (0.56-0.61) | < 0.01 |
Diabetes mellitus | 0.48 (0.46-0.50) | < 0.01 |
Age 20-40 years | 0.45 (0.43-0.47) | < 0.01 |
Hypertension | 0.44 (0.43-0.45) | < 0.01 |
External Fixator | 0.39 (0.35-0.44) | < 0.01 |
Omnibus X 160,275, P < .01 | ||
Nagelkerke R2 = 0.41 |
Abbreviations: CI, confidence interval; DOC, days of care; OR, odds ratio.
BLOOD TRANSFUSION
Overall, 7.3% of patients experienced acute postoperative anemia (Table 5). Between 1990 and 2010, the percentage of patients receiving blood transfusions increased from 0.3% to 9.5%, respectively (P < .01) (Table 2). In multivariable logistic regression analysis, patients treated with ORIF (OR, 8.13; 95% CI, 7.91-8.36; P < .01), those with congestive heart failure (OR, 4.23; 95% CI, 4.06-4.41; P < .01), those with an associated femur fracture (OR, 3.13; 95% CI, 2.99-3.27; P < .01), those with atrial fibrillation (OR, 1.96; 95% CI, 1.88-2.05; P < .01), and those treated with CRIF (OR, 1.42; 95% CI, 1.29-1.56; P < .01) were associated with significantly higher odds of blood transfusion (model fit: omnibus test of model coefficients, X = 42,653, P < .01; Nagelkerke, R2 = 0.19) (Table 7).
Table 7. Logistic Regression for Predictors of the Requirement for Blood Transfusion Among Patients with Acetabular Fractures (n = 403,927)
Variable | OR (95% CI) | P |
Open reduction internal fixation | 8.13 (7.91-8.36) | < 0.01 |
Congestive heart failure | 4.23 (4.06-4.41) | < 0.01 |
Associated fracture of any part of femur | 3.13 (2.99-3.27) | < 0.01 |
Atrial fibrillation | 1.96 (1.88-2.05) | < 0.01 |
Closed reduction internal fixation | 1.42 (1.29-1.56) | < 0.01 |
Geographic region | 1.38 (1.36-1.39) | < 0.01 |
Hypertension | 1.38 (1.34-1.42) | < 0.01 |
Associated pelvic fracture | 1.28 (1.25-1.31) | < 0.01 |
Age 61-85 years | 1.06 (1.02-1.11) | 0.01 |
Source of payment | 0.99 (0.98-0.99) | < 0.01 |
Race | 0.98 (0.97-0.98) | < 0.01 |
DOC | 0.96 (0.96-0.96) | < 0.01 |
Age >85 years | 0.74 (0.72-0.77) | < 0.01 |
External fixator | 0.69 (0.59-0.80) | < 0.01 |
Coronary artery disease | 0.62 (0.57-0.68) | < 0.01 |
Age 41-60 years | 0.57 (0.54-0.60) | < 0.01 |
Gender (male) | 0.54 (0.52-0.55) | < 0.01 |
Diabetes mellitus | 0.38 (0.36-0.41) | < 0.01 |
Age 20-40 years | 0.32 (0.30-0.34) | < 0.01 |
Associated femoral neck fracture | 0.29 (0.27-0.31) | < 0.01 |
Age <20 years | 0.24 (0.22-0.26) | < 0.01 |
Omnibus X = 42,653, P < .01 | ||
Nagelkerke R2 = 0.19 |
Abbreviations: CI, confidence interval; DOC, days of care; OR, odds ratio.
TREATMENT WITH ORIF
Over the 20-year study period, 23.2% of patients with acetabular fractures were treated with ORIF (Table 1). In 1990, 12.6% of patients underwent ORIF, while in 2010 this percentage increased to 20.4% (P < .001) (Table 2). Multivariable logistic regression analysis demonstrated that age between 41 and 60 years (OR, 1.88; 95% CI, 1.78-1.98; P < .01) was associated with the highest odds of undergoing ORIF. Age 20 to 40 years (OR, 1.86; 95% CI, 1.76-1.97; P < .01), age <20 years (OR, 1.82; 95% CI, 1.72-1.93; P < .01), and male gender (OR, 1.65; 95% CI, 1.63-1.68; P < .01) were also associated with being treated by ORIF. In contrast, coronary artery disease (OR, 0.27; 95% CI, 0.25-0.30; P < .01), age >85 years (OR, 0.46; 95% CI, 0.44-0.47; P < .01), and congestive heart failure (OR, 0.48; 95% CI, 0.46-0.51; P < .01) were associated with the lowest odds of undergoing ORIF (model fit: omnibus test of model coefficients, X = 71,118, P < .01; Nagelkerke, R2 = 0.20) (Table 8).
Table 8. Logistic Regression for Predictors of the Requirement for Discharge to Another Inpatient Facility Among Patients with Acetabular Fractures (n = 403,927)
Variable | OR (95% CI) | P |
Age 41-60 years | 1.88 (1.78-1.98) | < 0.01 |
Age 20-40 years | 1.86 (1.76-1.97) | < 0.01 |
Age <20 years | 1.82 (1.72-1.93) | < 0.01 |
Gender (male) | 1.65 (1.63-1.68) | < 0.01 |
Larger hospital bed size | 1.46 (1.45-1.47) | < 0.01 |
Hypertension | 1.35 (1.32-1.38) | < 0.01 |
Diabetes mellitus | 1.09 (1.05-1.13) | < 0.01 |
DOC | 1.02 (1.02-1.02) | < 0.01 |
Source of payment | 1.01 (1.01-1.02) | < 0.01 |
Race | 1.00 (0.99-1.00) | 0.17 |
Age 61-85 years | 0.94 (0.90-0.99) | 0.02 |
Region | 0.92 (0.91-0.93) | < 0.01 |
Atrial fibrillation | 0.83 (0.79-0.87) | < 0.01 |
Congestive heart failure | 0.48 (0.46-0.51) | < 0.01 |
Age >85 years | 0.46 (0.44-0.47) | < 0.01 |
Coronary artery disease | 0.27 (0.25-0.30) | < 0.01 |
Omnibus X 71,118, P < .01 | ||
Nagelkerke R2 = 0.20 |
Abbreviations: CI, confidence interval; DOC, days of care; OR, odds ratio.
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