The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures.

OBJECTIVES: To identify factors affecting the outcomes of surgery for acetabular fracture in patients over the age of 60 years.
DESIGN: Retrospective review of records and radiographs; current examination, radiographs and outcome surveys when possible.
SETTING: Academic, Level 1 trauma center. PATIENTS/PARTICIPANTS: Forty-eight patients over age 60 with displaced acetabulum fractures. INTERVENTION: Surgical reduction and fixation. MAIN OUTCOME MEASUREMENTS: Clinical ratings and radiographic evaluations, Short Musculoskeletal Functional Assessment survey (SMFA), SF-36, and hip-specific questions. Radiographs were evaluated using the criteria of Matta.
RESULTS: Ten patients died since surgery. Four were lost to follow-up. Seven had >12 months of follow-up information in the chart. Twenty-seven had current evaluations for the study. Average follow-up was 37 months, range 1-114 months. The average age at surgery was 71.6 years (range 61-88). No perioperative deaths occurred. Initial reductions achieved: 61% anatomic, 34% imperfect, and 5% poor. A specific radiographic finding (superomedial dome impaction) predictive of failure was identified. This was designated the "Gull Sign." These patients had inadequate reduction, early fixation failure, or medial/superior joint narrowing and subluxation. Functional outcomes in patients with current examination were similar to age-matched controls. Radiographic outcomes: 30% excellent, 30% good, 9% fair, 23% poor, and 7% arthroplasty. Anatomic reduction was closely related to good or excellent radiographic result.
CONCLUSIONS: While some patients over sixty years of age can have satisfactory functional outcomes after acetabular fracture fixation, a significant number will have failure of the procedure. Osteopenic patients with superomedial dome impaction (the Gull Sign) did not benefit from attempted open reduction and internal fixation in this series.