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Epidemiology of pelvic and acetabular fractures in France
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Original article
Epidemiology of pelvic and acetabular fractures in France Elias Melhem a , Guillaume Riouallon a,∗ , Khalil Habboubi a , Mehdi Gabbas b , Pomme Jouffroy a a b
Service de Chirurgie Orthopédique, Groupe Hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France Caisse Primaire d’Assurance Maladie, 50, avenue du Professeur André-Lemierre, 75020 Paris, France
a r t i c l e
i n f o
Article history: Received 22 January 2019 Accepted 27 November 2019 Available online xxx Keywords: Acetabular fracture Pelvic fracture Epidemiology Elderly
a b s t r a c t Introduction: Acetabular and pelvic fracture accounts for 1.5% of fractures in adults and 2-5% of fractures requiring hospital admission. Several national-level epidemiological studies have been conducted outside France, but French national data are not known. We therefore assessed all patients admitted for acetabular or pelvic fracture in France between 2006 and 2016. The study objectives were: 1) to determine incidence of acetabular and pelvic fracture, 2) to determine progression in incidence between 2006 and 2016, and 3) to determine progression in treatment. Hypothesis: Incidence of acetabular and pelvic fracture in France is increasing. Methods: The following data for the period 2006-2016 were collated from the French national health insurance (CPAM: Caisse Primaire d’Assurance Maladie) database: gender, age, type of treatment, and geographical distribution by administrative area (Département). Two-tailed Student tests were used for comparison of means for numerical variables between independent samples; linear regression was used to analyze correlations; and the Chi2 test was used to compare percentages of categoric variables. Results: There were 32,614 acetabular and 164,694 pelvic fractures, with male predominance for the acetabulum and female predominance for the pelvis. Mean age at acetabular fracture was 66 ± 22 years (range, 1-108 years), and 74 ± 20 years (range, 1-112 years) for pelvic fracture. The rate of acetabular fracture increased to 3,301 in 2016 from 2,316 in 2006, with a strong increase in the rate of pelvic fracture, to 18,902 in 2016 from 10,806 in 2006. Incidence of acetabular fracture per 100,000 increased from 3.67 in 2006 to 4.95 in 2016, and from 17.06 to 23.18 in over-75 year-olds. Incidence of pelvic fracture per 100,000 increased from 17.1 to 28.33, and from 129.30 to 210.69 in over-75 year-olds. Linear regression predicts incidence per 100,000 of 5.9 for acetabular fracture and of 41 for pelvic fracture by 2030 in young subjects and 32 and 309 respectively in over-75 year-olds. Management was surgical for acetabular fracture in 12.31% of cases in 2006 and in 14.33% in 2016, and in 1.43% and 2.16% respectively for pelvic fracture. Discussion: The present data agree with previous reports, with strong increase in incidence of fracture in young and especially in elderly subjects. In elderly subjects, such fractures may require surgery. Level of evidence: IV, retrospective study without control group. © 2020 Elsevier Masson SAS. All rights reserved.
1. Introduction Acetabular and pelvic fracture accounts for 1.5% of fractures in adults [1] and 2-5% of fractures requiring hospital admission [2]. Mechanisms are high-energy trauma in young subjects or body-height falls in osteoporotic elderly subjects [3]. Low energy
∗ Corresponding author at: Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier Paris Saint Joseph, 185, rue Raymond-Losserand, 75014 Paris, France. E-mail address: [email protected] (G. Riouallon).
acetabular or pelvic fracture is increasing in osteoporotic elderly subjects [4–6]. Most of the epidemiological data in the literature come from Finnish registries and cohorts [3,6,7]. Incidence of acetabular fracture ranged between 3 and 9.5 per 100,000 [3,8,9], and between 20 and 71 for pelvic (including acetabular) fracture [7,10,11]. Incidence was highest in over-80 year-olds, with age-adjusted incidence of 364/100,000 in 2013, compared to 73/100,000 in 1970 [5]. To our knowledge, apart from single-center data [12,13], there have been no epidemiological studies in France for these fractures and their treatment. We hypothesize that incidence in
https://doi.org/10.1016/j.otsr.2019.11.019 1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Melhem E, et al. Epidemiology of pelvic and acetabular fractures in France. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.019
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France is rising. We therefore conducted a study using the French national health insurance (CPAM: Caisse Primaire d’Assurance Maladie) database:
Statistics for other European countries were obtained from the European Union Statistics Bureau EUROSTAT site [16]. 3.2. Statistics
• to determine incidence of acetabular and pelvic fracture requiring hospital admission between 2006 and 2016; • to determine progression in incidence between 2006 and 2016; • to determine progression in treatment (surgical versus nonoperative). 2. Material and methods 2.1. Patients
Data were analyzed on Excel software (Microsoft Corporation, Redmond, Washington). Two-tailed Student tests were used to compare means of numerical variables for independent samples, linear regression for correlations, and Chi2 test for percentages of categoric variables. Prediction of incidence used a linear regression model under SPSS software, version 16.0 (SPSS Inc., Chicago, IL). The significance threshold was set at p < 0.05. 4. Results
The study used the systematically collected data of the CPAM. 3. Methods
4.1. Population
Combined data for all patients with acetabular or pelvic fracture between 2006 and 2016 were rendered anonymous: gender, age, type of treatment and geographical distribution by administrative area (Département). Pelvic fracture corresponded to non-articular fracture of the pelvis.
Between 2006 and 2016, there were 32,614 acetabular and 164,694 pelvic fractures. There was male predominance in acetabular fracture (20,055 – 61%; M/F ratio 1.6) and female predominance in pelvic fracture (118,723 – 72%; F/M ratio 2.58). Annual distribution according to gender is shown in Figs. 1 and 2, and geographic distribution in Fig. 3. Most fractures occurred in the vicinity of large cities.
3.1. Assessment
4.2. Mean age and age distribution
The demographic data for the French population were from the National Institute for Statistics and Economic Studies (INSEE) website [14], and road-accident data from the Road Safety Delegation (DSR) site [15]. The age limits of 20, 60 and 75 years were those of the INSEE data, enabling calculation of incidence per 100,000.
4.2.1. Acetabulum Mean age in acetabular fracture increased from 61.02 ± 23.18 years (range, 4–100 years) in 2006 to 66.45 ± 22.14 years (range, 2–106 years) in 2016. Table 1 shows progression in mean age and significance. Numbers increased from 2,316 to 3301. In under-60
Fig. 1. Yearly distribution of acetabular fractures according to gender.
Fig. 2. Yearly distribution of pelvic fractures according to gender.
Please cite this article in press as: Melhem E, et al. Epidemiology of pelvic and acetabular fractures in France. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.019
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Fig. 3. Geographical distribution of acetabular and pelvic fractures in 2015.
Table 1 Acetabular fracture. Mean age, standard error, standard deviation, maximum, minimum and Student test p-value comparing mean to previous year.
Mean Standard error Standard deviation Maximum Minimum p-value a
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
61.02 0.48 23.18 100 4
62.66 0.45 22.86 105 2 0.01a
63.72 0.43 22.50 101 2 0.08
63.99 0.43 22.52 105 1 0.6
65.80 0.41 21.97 103 3 0.002a
64.85 0.41 22.16 105 1 0.1
66.72 0.42 22.32 103 4 0.001a
67.63 0.41 21.74 104 3 0.12
66.54 0.40 21.82 103 3 0.06
68.08 0.39 21.71 108 1 0.006a
66.45 0.39 22.14 106 2 0.003a
Significant difference.
Fig. 4. Yearly incidence of acetabular fractures.
year-olds, incidence changed little, from 1026 cases in 2006 to 917 in 2015 and 1100 in 2016. Progression in fracture rate was not significantly associated with that of road accidents (R = 0.57; p = 0.06). In over-60 year-olds, on the other hand, numbers increased from 1290 in 2006 to 2201 in 2016 (Fig. 4).
4.2.2. Pelvis Mean age in pelvic fracture increased from 70.71 ± 22.25 years (range, 1–103 years) in 2006 to 74.62 ± 20.75 years (range, 1–106 years) in 2016, ranging over the whole period from 1 to 112 years. Table 2 shows progression in mean age and significance. Numbers increased from 10,806 to 18,902. In under-60 year-olds, incidence increased from 2703 cases in 2006 to 3544 in 2016. In over-60 yearolds, numbers increased from 8102 to 15,358 (Fig. 5). 65% of pelvic fractures were in over-75 year-olds.
4.3. Incidence 4.3.1. Acetabulum Incidence of acetabular fracture per 100,000 increased from 3.67 in 2006 to 4.95 in 2016 (Fig. 6). It fell from 0.7 to 0.58 in under-20 year-olds, and increased from 17.06 to 23.18 in over-75 year-olds (Table 3, Fig. 7).
4.3.2. Pelvis Incidence of pelvic fracture per 100,000 increased from 17.1 to 28.33 (Fig. 6), increasing in all age-groups, and especially in over-75 year-olds (Table 4, Fig. 8).
Please cite this article in press as: Melhem E, et al. Epidemiology of pelvic and acetabular fractures in France. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.019
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Table 2 Pelvic fracture. Mean age, standard error, standard deviation, maximum, minimum and Student test p-value comparing mean to previous year.
Mean Standard error Standard deviation Maximum Minimum p-value a
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
70.71 0.21 22.25 103 1
70.46 0.21 22.47 107 1 0.39a
71.09 0.20 21.91 106 1 0.03a
71.56 0.19 21.56 106 1 0.09a
72.15 0.18 21.43 105 1 0.04a
72.66 0.18 21.14 106 1 0.04a
73.32 0.18 21.11 112 1 0.009a
74.02 0.17 20.71 106 1 0.004a
74.27 0.16 20.67 105 1 0.27
75.07 0.16 20.41 108 1 < 0.001a
74.62 0.15 20.75 106 1 0.025a
Significant difference.
Fig. 5. Yearly incidence of pelvic fractures.
Fig. 6. Progression in incidence of acetabular and pelvic fracture.
Table 3 Acetabular fracture. Incidence per 100,000, according to age-group. Year
< 20 years
20-59 years
> 60 years
> 75 years
Total
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
0.70 0.65 0.61 0.73 0.59 0.58 0.59 0.40 0.48 0.49 0.58
2.68 2.91 2.71 2.70 2.71 2.82 2.45 2.49 2.68 2.48 2.98
9.80 11.28 11.98 11.93 13.17 12.24 12.45 12.46 12.15 13.03 13.25
17.06 20.62 21.51 21.21 24.08 21.71 23.29 23.79 22.29 25.16 23.18
3.67 4.12 4.20 4.26 4.55 4.44 4.34 4.35 4.42 4.58 4.95
4.4. Prediction of future incidence 4.4.1. Acetabulum We extrapolated these finding on linear regression to 2030 to predict future incidence. Incidence correlated with time for
acetabular fracture in the overall population and in over-75 year-olds (r = 0.77, p = 0.006; and r = 0.84, p = 0.001, respectively). The model predicted annual incidence of 5.9/100,000 for acetabular fracture in the general population and of 32 in over-75 year-olds (Fig. 9).
Please cite this article in press as: Melhem E, et al. Epidemiology of pelvic and acetabular fractures in France. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.019
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Fig. 7. Progression in incidence (per 100,000) of acetabular fractures over the 11 years in different age groups. Table 4 Pelvic fracture. Incidence per 100,000, according to age-group. Year
< 20 years
20–59 years
> 60 years
> 75 years
Total
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
2.91 3.32 3.04 3.03 3.19 2.97 3.00 3.00 2.95 3.81 3.59
6.56 7.18 7.11 7.23 7.56 7.88 7.47 7.38 7.99 7.68 8.77
61.56 66.25 66.82 68.61 73.56 75.54 75.23 79.09 82.37 84.68 92.47
129.30 138.25 139.33 145.27 157.45 163.28 165.49 175.32 185.50 194.62 210.69
17.10 18.75 19.05 19.79 21.40 22.27 22.27 23.41 24.71 25.63 28.33
Fig. 8. Progression in incidence (per 100,000) of pelvic fractures over the 11 years in different age groups.
Fig. 9. Predicted Incidence per 100,000, of acetabular fracture in people aged 75 years and over (left) and in the general population (right). Linear regression extrapolating incidence up to 2030 if acceleration is constant.
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Fig. 10. Predicted incidence (per 100,000) of pelvic fractures in people aged 75 years and above (left) and in the general population (right). Linear regression extrapolating incidence up to 2030 if acceleration is constant.
4.4.2. Pelvis Incidence likewise correlated with time for pelvic fracture in the overall population and in over-75 year-olds (r = 0.986, p < 0.001; and r = 0.983, p < 0.001, respectively). The model predicted annual incidence of 41/100,000 in the general population 309 in over-75 year-olds (Fig. 10).
2006 to 473 (14.33%) in 2016 (Table 5). Likewise, the increase in under-60 year-olds was from 247 (24.07%) to 366 (33.27%) and in over-60 year-olds from 38 (2.95%) to 107 (4.86%). Definitive closed reduction and traction was less frequent (Table 5).
4.5. Treatment
4.5.2. Pelvis The number and percentage of pelvic fractures managed by reduction and internal fixation increased from 154 (1.43%) to 409 (2.19%). The increase in under-60 year-olds was from 138 (5.1%) to 326 (9.2%) and in over-60 year-olds from 16 (0.20%) to 83 (0.54%).
4.5.1. Acetabulum The number and percentage of acetabular fractures managed by reduction and internal fixation increased from 285 (12.31%) in Table 5 Treatment of acetabular fracture. Open reduction and internal fixation Total
Closed reduction and traction
Age < 60
Age > 60
Total
Age < 60
Age > 60
Year
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
285 309 363 381 378 403 334 368 407 388 473
12.31% 11.78% 13.52% 13.92% 12.86% 13.99% 11.79% 12.89% 13.91% 12.75% 14.33%
247 265 302 306 317 334 273 297 330 333 366
24.07% 24.11% 29.52% 29.51% 31.20% 31.87% 29.45% 32.78% 33.50% 36.31% 33.27%
38 44 61 75 61 69 61 71 77 55 107
2.95% 2.89% 3.67% 4.41% 3.17% 3.76% 3.20% 3.64% 3.97% 2.59% 4.86%
78 63 57 62 70 55 48 36 36 26 22
3.37% 2.40% 2.12% 2.27% 2.38% 1.91% 1.69% 1.26% 1.23% 0.85% 0.67%
43 31 35 32 28 25 24 16 16 15 14
4.19% 2.82% 3.42% 3.09% 2.76% 2.39% 2.59% 1.77% 1.62% 1.64% 1.27%
35 32 22 30 42 30 24 20 20 11 8
2.71% 2.10% 1.32% 1.76% 2.18% 1.64% 1.26% 1.03% 1.03% 0.52% 0.36%
Table 6 Treatment of pelvic fracture. Open reduction and internal fixation Total
Closed reduction and traction
Age < 60
Age > 60
Total
Age < 60
Age > 60
Year
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
154 205 283 293 295 325 301 299 341 387 409
1.43% 1.72% 2.32% 2.30% 2.13% 2.25% 2.07% 1.95% 2.09% 2.27% 2.16%
138 181 247 256 259 274 256 242 290 318 326
5.10% 6.07% 8.48% 8.68% 8.41% 8.70% 8.49% 8.12% 9.11% 9.88% 9.20%
16 24 36 37 36 51 45 57 51 69 83
0.20% 0.27% 0.39% 0.38% 0.34% 0.45% 0.39% 0.46% 0.39% 0.50% 0.54%
136 127 142 107 139 82 69 52 42 28 33
1.26% 1.06% 1.17% 0.84% 1.01% 0.57% 0.47% 0.34% 0.26% 0.16% 0.17%
53 50 52 51 48 28 30 25 21 14 18
1.96% 1.68% 1.79% 1.73% 1.56% 0.89% 1.00% 0.84% 0.66% 0.43% 0.51%
83 77 90 56 91 54 39 27 21 14 15
1.02% 0.86% 0.97% 0.57% 0.85% 0.48% 0.34% 0.22% 0.16% 0.10% 0.10%
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Fig. 11. Population pyramids for European economic area (EEA), United Kingdom (UK), France and Germany.
The rate of closed reduction and traction fell from 136 cases 2006 to 33 in 2016 (Table 6). 5. Discussion This was the first nationwide epidemiological study to review all cases of acetabular and pelvic fracture with hospital admission
in France for the period 2006–2016. It confirmed that incidence is rising, especially in the elderly, and that treatment is increasingly surgical. The findings agree with those of Rinne et al. [3] and Laird et al. [8], who reported male predominance in acetabular fracture, and those of Lüthje et al. [2], Ragnarsson et al. [7] and Andrich et al. [17], reporting female predominance in pelvic fracture.
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The increase in acetabular and pelvic fracture rates in the elderly and increasing mean age in acetabular and pelvic fracture is a public health issue raised in several articles [4–6,8,10,17–21]. It is partly accounted for by population aging. Calculating incidence per 100,000 according to age-group eliminates much of the impact of population aging, but even so incidence is rising. Moreover, as demonstrated by Kannus et al. [4–6], even age-adjusted incidence is increasing. The reason for this is unknown, but may involve the increase in age-adjusted incidence of osteoporosis [6], or increased physical activity in the elderly [18]. Emergency physicians and community doctors are probably better trained in screening for these fractures. Also, CT has become increasingly available and implemented in hip and pelvic trauma in the elderly, improving diagnosis. Likewise, some extra diagnoses may be made thanks to better coding. The most alarming finding is the estimated incidence for 2030 of pelvic (309/100,000) and acetabular fracture (31.75/100,000) in over-75 year-olds. Obviously, progression may turn out not to be linear, and the predictions of the linear regression model are to be taken with caution. The population pyramids for the European Economic Area (EEA), UK and Germany are identical to that for France, or show a higher proportion of elderly subjects (Fig. 11). Extrapolating our findings to other European countries suggests that pelvic and acetabular fracture is a public health issue, and resources need mobilizing to deal with it by strategies of prevention (treatment of osteoporosis, prevention of falls, etc.), diagnosis and treatment (raising physician awareness, clear treatment decision-trees, etc.). The rate of treatment by reduction and external fixation has fluctuated, with no clear trend toward an increase. This is probably due to the increasing number of over-60 year-olds, who are less often managed surgically (2.95-4.86%) than younger patients (24.07–33.27%). The rate of surgical treatment of pelvic fracture, on the other hand, has clearly increased, from 154 (1.43%) in 2006 to 409 (2.16%) in 2016. This is probably due to improved understanding of pelvic instability and the consequences of non-operative treatment in such a case, and to the development of minimally invasive and navigation-guided techniques. Closed reduction with in-bed traction has become rare in pelvic and acetabular fracture, although coding of non-operative treatment by traction is not always clearly reported, and figures may be underestimated. Geographically, the higher incidence of these fractures in and around big cities is probably due to greater population density. While it seems logical that there should be a causal relation between incidence of acetabular fracture in young people and the rate of road accidents, the correlation between the two was not in fact significant (p = 0;06). The present study had several limitations. Firstly, the data were obtained from the CPAM national health insurance organization, based on coding performed by physicians. Coding errors may have led to underestimation; however, coding is also the basis of insurance cover and reimbursement, inciting physicians to be diligent. Some patients not admitted to hospital may not have been coded at all, but this was probably rare. There may also have been coding errors related to misdiagnosis or the coding of these fractures being overlooked in cases of multiple trauma. Secondly, data were lacking to calculate incidence per patient-year. Thirdly, data were lacking for fracture mechanism and associated lesions, which would have been interesting to analyze to shed light on the results. The incidence of these fractures in France was long underestimated, and management protocols were poorly defined. Many recent studies have focused on improving diagnosis [22,23], perioperative management [24] and surgical technique [25–27] to reduce the morbidity and mortality associated with these increasingly frequent fractures. However, well-defined protocols, recognized international guidelines and consensus on treatment are still far from being established.
6. Conclusions Incidence of acetabular and pelvic fracture is increasing rapidly, especially in the elderly, and a major increase can be expected by 2030. Treatment is increasingly surgical. Public health strategies need to be developed to reduce incidence and improve treatment. Further studies are needed to determine optimal strategy, as there is at present no consensus on treatment, notably in the elderly. Disclosure of interest The authors declare that they have no competing interest. Funding The study received no public, commercial or non-profit funding. Authors’ contributions Elias Melhem was involved in study design, data interpretation, article writing and revision and checking the final version. Guillaume Riouallon was involved in study design, statistical analysis, data interpretation, article writing and revision and checking the final version. Khalil Habboubi was involved in study design, statistical analysis, data interpretation, article writing and revision and checking the final version. Mehdi Gabbas was involved in study design, data collection, statistical analysis, data interpretation, article revision and checking the final version. Pomme Jouffroy was involved in study design, data interpretation, article writing and revision and checking the final version. References [1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37:691–7. [2] Ragnarsson B, Jacobsson B. Epidemiology of pelvic fractures in a Swedish county. Acta Orthop 1992;63:297–300. [3] Rinne PP, Laitinen MK, Huttunen T, Kannus P, Mattila VM. The incidence and trauma mechanisms of acetabular fractures: a nationwide study in Finland between 1997 and 2014. Injury 2017;48:2157–61. [4] Kannus P, Palvanen M, Parkkari J, Niemi S, Järvinen M. Osteoporotic pelvic fractures in elderly women. Osteoporos Int 2005;16:1304–5. [5] Kannus P, Parkkari J, Niemi S, Sievänen H. Low-trauma pelvic fractures in elderly Finns in 1970-2013. Calcif Tissue Int 2015;97:577–80. [6] Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Epidemiology of osteoporotic pelvic fractures in elderly people in Finland: sharp increase in 1970-1997 and alarming projections for the new millennium. Osteoporos Int 2000;11:443–8. [7] Lüthje P, Nurmi N, Kataja M, Heliövaara M, Santavirta S. Incidence of pelvic fractures in Finland in 1988. Acta Orthop 1995;66:245–8. [8] Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br 2005;87:969–73. [9] Best MJ, Buller LT, Quinnan SM. Analysis of incidence and outcome predictors for patients admitted to US hospitals with acetabular fractures from 1990 to 2010. Am J Orthop 2018:47. [10] Nanninga GL, de Leur K, Panneman MJM, van der Elst M, Hartholt KA. Increasing rates of pelvic fractures among older adults: The Netherlands, 1986-2011. Age Ageing 2014;43:648–53. [11] Melton LJ, Sampson JM, Morrey BF, Ilstrup DM. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res 1981:43–7. [12] Letournel E, Judet R. Fractures of the Acetabulum. Berlin, Heidelberg: Springer Berlin Heidelberg; 1993. [13] Boudissa M, Francony F, Kerschbaumer G, Ruatti S, Milaire M, Merloz P, et al. Epidemiology and treatment of acetabular fractures in a level-1 trauma centre: retrospective study of 414 patients over 10 years. Orthop Traumatol Surg Res 2017;103:335–9. [14] INSEE. Evolution et Structure de la Population. Institut National de la Statistique et des Études Économiques n.d. https://www.insee.fr/fr/statistiques. (accessed January 5, 2018). [15] Délégation à la sécurité routière (DSR). Séries longues n.d. http://www.securite-routiere.gouv.fr/la-securite-routiere/l-observatoirenational-interministeriel-de-la-securite-routiere/series-statistiques/serieslongues (accessed January 5, 2018). [16] Eurostat. Population and Social Conditions n.d. http://ec.europa.eu/eurostat/statistics-explained/index.php/Main Page (accessed April 3, 2018).
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[17] Andrich S, Haastert B, Neuhaus E, Neidert K, Arend W, Ohmann C, et al. Epidemiology of pelvic fractures in Germany: considerably high incidence rates among older people. PLoS One 2015;10:e0139078. [18] Ferguson TA, Patel R, Bhandari M, Matta JM. Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study. J Bone Joint Surg Br 2010;92:250–7. [19] Balogh Z, King KL, Mackay P, McDougall D, Mackenzie S, Evans JA, et al. The epidemiology of pelvic ring fractures: a population-based study. J Trauma - Inj Infect Crit Care 2007;63:1066–72. [20] Buller LT, Lawrie CM, Vilella FE. A Growing problem. Acetabular fractures in the elderly and the combined hip procedure. Orthop Clin North Am 2015;46:215–25. [21] Verbeek DO, Ponsen KJ, Fiocco M, Amodio S, Leenen LPH, Goslings JC. Pelvic fractures in the Netherlands: epidemiology, characteristics and risk factors for in-hospital mortality in the older and younger population. Eur J Orthop Surg Traumatol 2018;28:197–205. [22] Jouffroy P, Sebaaly A, Aubert T, Riouallon G. Improved acetabular fracture diagnosis after training in a CT-based method. Orthop Traumatol Surg Res 2017;103:325–9.
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[23] Tonetti J, Jouffroy P, Pelvis-Acetabulum Club. Recent progress in the diagnosis and treatment of pelvic ring and acetabular fracture. Orthop Traumatol Surg Res 2017;103:631–2. [24] Ostrowka C, Bonhomme S, Jouffroy P, Riouallon G. Evaluation of venous thromboembolic complications in patients operated on for pelvic fracture. Orthop Traumatol Surg Res 2018;104:917–21. [25] Boudissa M, Oliveri H, Chabanas M, Tonetti J. Computer-assisted surgery in acetabular fractures: virtual reduction of acetabular fracture using the first patient-specific biomechanical model simulator. Orthop Traumatol Surg Res 2018;104:359–62. [26] Elmada˘g M, Güzel Y, Acar MA, Uzer G, Arazi M. The Stoppa approach versus the ilioinguinal approach for anterior acetabular fractures: a case control study assessing blood loss complications and function outcomes. Orthop Traumatol Surg Res 2014;100:675–80. [27] Bone JP, (GETRAUM) Joint Trauma Study Group. Indications and technical challenges of total hip arthroplasty in the elderly after acetabular fracture. Orthop Traumatol Surg Res 2014;100:197–201.
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Original article
Epidemiology of pelvic and acetabular fractures in France Elias Melhem a , Guillaume Riouallon a,∗ , Khalil Habboubi a , Mehdi Gabbas b , Pomme Jouffroy a a b
Service de Chirurgie Orthopédique, Groupe Hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France Caisse Primaire d’Assurance Maladie, 50, avenue du Professeur André-Lemierre, 75020 Paris, France
a r t i c l e
i n f o
Article history: Received 22 January 2019 Accepted 27 November 2019 Available online xxx Keywords: Acetabular fracture Pelvic fracture Epidemiology Elderly
a b s t r a c t Introduction: Acetabular and pelvic fracture accounts for 1.5% of fractures in adults and 2-5% of fractures requiring hospital admission. Several national-level epidemiological studies have been conducted outside France, but French national data are not known. We therefore assessed all patients admitted for acetabular or pelvic fracture in France between 2006 and 2016. The study objectives were: 1) to determine incidence of acetabular and pelvic fracture, 2) to determine progression in incidence between 2006 and 2016, and 3) to determine progression in treatment. Hypothesis: Incidence of acetabular and pelvic fracture in France is increasing. Methods: The following data for the period 2006-2016 were collated from the French national health insurance (CPAM: Caisse Primaire d’Assurance Maladie) database: gender, age, type of treatment, and geographical distribution by administrative area (Département). Two-tailed Student tests were used for comparison of means for numerical variables between independent samples; linear regression was used to analyze correlations; and the Chi2 test was used to compare percentages of categoric variables. Results: There were 32,614 acetabular and 164,694 pelvic fractures, with male predominance for the acetabulum and female predominance for the pelvis. Mean age at acetabular fracture was 66 ± 22 years (range, 1-108 years), and 74 ± 20 years (range, 1-112 years) for pelvic fracture. The rate of acetabular fracture increased to 3,301 in 2016 from 2,316 in 2006, with a strong increase in the rate of pelvic fracture, to 18,902 in 2016 from 10,806 in 2006. Incidence of acetabular fracture per 100,000 increased from 3.67 in 2006 to 4.95 in 2016, and from 17.06 to 23.18 in over-75 year-olds. Incidence of pelvic fracture per 100,000 increased from 17.1 to 28.33, and from 129.30 to 210.69 in over-75 year-olds. Linear regression predicts incidence per 100,000 of 5.9 for acetabular fracture and of 41 for pelvic fracture by 2030 in young subjects and 32 and 309 respectively in over-75 year-olds. Management was surgical for acetabular fracture in 12.31% of cases in 2006 and in 14.33% in 2016, and in 1.43% and 2.16% respectively for pelvic fracture. Discussion: The present data agree with previous reports, with strong increase in incidence of fracture in young and especially in elderly subjects. In elderly subjects, such fractures may require surgery. Level of evidence: IV, retrospective study without control group. © 2020 Elsevier Masson SAS. All rights reserved.
1. Introduction Acetabular and pelvic fracture accounts for 1.5% of fractures in adults [1] and 2-5% of fractures requiring hospital admission [2]. Mechanisms are high-energy trauma in young subjects or body-height falls in osteoporotic elderly subjects [3]. Low energy
∗ Corresponding author at: Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier Paris Saint Joseph, 185, rue Raymond-Losserand, 75014 Paris, France. E-mail address: [email protected] (G. Riouallon).
acetabular or pelvic fracture is increasing in osteoporotic elderly subjects [4–6]. Most of the epidemiological data in the literature come from Finnish registries and cohorts [3,6,7]. Incidence of acetabular fracture ranged between 3 and 9.5 per 100,000 [3,8,9], and between 20 and 71 for pelvic (including acetabular) fracture [7,10,11]. Incidence was highest in over-80 year-olds, with age-adjusted incidence of 364/100,000 in 2013, compared to 73/100,000 in 1970 [5]. To our knowledge, apart from single-center data [12,13], there have been no epidemiological studies in France for these fractures and their treatment. We hypothesize that incidence in
https://doi.org/10.1016/j.otsr.2019.11.019 1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Melhem E, et al. Epidemiology of pelvic and acetabular fractures in France. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.019
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France is rising. We therefore conducted a study using the French national health insurance (CPAM: Caisse Primaire d’Assurance Maladie) database:
Statistics for other European countries were obtained from the European Union Statistics Bureau EUROSTAT site [16]. 3.2. Statistics
• to determine incidence of acetabular and pelvic fracture requiring hospital admission between 2006 and 2016; • to determine progression in incidence between 2006 and 2016; • to determine progression in treatment (surgical versus nonoperative). 2. Material and methods 2.1. Patients
Data were analyzed on Excel software (Microsoft Corporation, Redmond, Washington). Two-tailed Student tests were used to compare means of numerical variables for independent samples, linear regression for correlations, and Chi2 test for percentages of categoric variables. Prediction of incidence used a linear regression model under SPSS software, version 16.0 (SPSS Inc., Chicago, IL). The significance threshold was set at p < 0.05. 4. Results
The study used the systematically collected data of the CPAM. 3. Methods
4.1. Population
Combined data for all patients with acetabular or pelvic fracture between 2006 and 2016 were rendered anonymous: gender, age, type of treatment and geographical distribution by administrative area (Département). Pelvic fracture corresponded to non-articular fracture of the pelvis.
Between 2006 and 2016, there were 32,614 acetabular and 164,694 pelvic fractures. There was male predominance in acetabular fracture (20,055 – 61%; M/F ratio 1.6) and female predominance in pelvic fracture (118,723 – 72%; F/M ratio 2.58). Annual distribution according to gender is shown in Figs. 1 and 2, and geographic distribution in Fig. 3. Most fractures occurred in the vicinity of large cities.
3.1. Assessment
4.2. Mean age and age distribution
The demographic data for the French population were from the National Institute for Statistics and Economic Studies (INSEE) website [14], and road-accident data from the Road Safety Delegation (DSR) site [15]. The age limits of 20, 60 and 75 years were those of the INSEE data, enabling calculation of incidence per 100,000.
4.2.1. Acetabulum Mean age in acetabular fracture increased from 61.02 ± 23.18 years (range, 4–100 years) in 2006 to 66.45 ± 22.14 years (range, 2–106 years) in 2016. Table 1 shows progression in mean age and significance. Numbers increased from 2,316 to 3301. In under-60
Fig. 1. Yearly distribution of acetabular fractures according to gender.
Fig. 2. Yearly distribution of pelvic fractures according to gender.
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Fig. 3. Geographical distribution of acetabular and pelvic fractures in 2015.
Table 1 Acetabular fracture. Mean age, standard error, standard deviation, maximum, minimum and Student test p-value comparing mean to previous year.
Mean Standard error Standard deviation Maximum Minimum p-value a
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
61.02 0.48 23.18 100 4
62.66 0.45 22.86 105 2 0.01a
63.72 0.43 22.50 101 2 0.08
63.99 0.43 22.52 105 1 0.6
65.80 0.41 21.97 103 3 0.002a
64.85 0.41 22.16 105 1 0.1
66.72 0.42 22.32 103 4 0.001a
67.63 0.41 21.74 104 3 0.12
66.54 0.40 21.82 103 3 0.06
68.08 0.39 21.71 108 1 0.006a
66.45 0.39 22.14 106 2 0.003a
Significant difference.
Fig. 4. Yearly incidence of acetabular fractures.
year-olds, incidence changed little, from 1026 cases in 2006 to 917 in 2015 and 1100 in 2016. Progression in fracture rate was not significantly associated with that of road accidents (R = 0.57; p = 0.06). In over-60 year-olds, on the other hand, numbers increased from 1290 in 2006 to 2201 in 2016 (Fig. 4).
4.2.2. Pelvis Mean age in pelvic fracture increased from 70.71 ± 22.25 years (range, 1–103 years) in 2006 to 74.62 ± 20.75 years (range, 1–106 years) in 2016, ranging over the whole period from 1 to 112 years. Table 2 shows progression in mean age and significance. Numbers increased from 10,806 to 18,902. In under-60 year-olds, incidence increased from 2703 cases in 2006 to 3544 in 2016. In over-60 yearolds, numbers increased from 8102 to 15,358 (Fig. 5). 65% of pelvic fractures were in over-75 year-olds.
4.3. Incidence 4.3.1. Acetabulum Incidence of acetabular fracture per 100,000 increased from 3.67 in 2006 to 4.95 in 2016 (Fig. 6). It fell from 0.7 to 0.58 in under-20 year-olds, and increased from 17.06 to 23.18 in over-75 year-olds (Table 3, Fig. 7).
4.3.2. Pelvis Incidence of pelvic fracture per 100,000 increased from 17.1 to 28.33 (Fig. 6), increasing in all age-groups, and especially in over-75 year-olds (Table 4, Fig. 8).
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Table 2 Pelvic fracture. Mean age, standard error, standard deviation, maximum, minimum and Student test p-value comparing mean to previous year.
Mean Standard error Standard deviation Maximum Minimum p-value a
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
70.71 0.21 22.25 103 1
70.46 0.21 22.47 107 1 0.39a
71.09 0.20 21.91 106 1 0.03a
71.56 0.19 21.56 106 1 0.09a
72.15 0.18 21.43 105 1 0.04a
72.66 0.18 21.14 106 1 0.04a
73.32 0.18 21.11 112 1 0.009a
74.02 0.17 20.71 106 1 0.004a
74.27 0.16 20.67 105 1 0.27
75.07 0.16 20.41 108 1 < 0.001a
74.62 0.15 20.75 106 1 0.025a
Significant difference.
Fig. 5. Yearly incidence of pelvic fractures.
Fig. 6. Progression in incidence of acetabular and pelvic fracture.
Table 3 Acetabular fracture. Incidence per 100,000, according to age-group. Year
< 20 years
20-59 years
> 60 years
> 75 years
Total
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
0.70 0.65 0.61 0.73 0.59 0.58 0.59 0.40 0.48 0.49 0.58
2.68 2.91 2.71 2.70 2.71 2.82 2.45 2.49 2.68 2.48 2.98
9.80 11.28 11.98 11.93 13.17 12.24 12.45 12.46 12.15 13.03 13.25
17.06 20.62 21.51 21.21 24.08 21.71 23.29 23.79 22.29 25.16 23.18
3.67 4.12 4.20 4.26 4.55 4.44 4.34 4.35 4.42 4.58 4.95
4.4. Prediction of future incidence 4.4.1. Acetabulum We extrapolated these finding on linear regression to 2030 to predict future incidence. Incidence correlated with time for
acetabular fracture in the overall population and in over-75 year-olds (r = 0.77, p = 0.006; and r = 0.84, p = 0.001, respectively). The model predicted annual incidence of 5.9/100,000 for acetabular fracture in the general population and of 32 in over-75 year-olds (Fig. 9).
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Fig. 7. Progression in incidence (per 100,000) of acetabular fractures over the 11 years in different age groups. Table 4 Pelvic fracture. Incidence per 100,000, according to age-group. Year
< 20 years
20–59 years
> 60 years
> 75 years
Total
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
2.91 3.32 3.04 3.03 3.19 2.97 3.00 3.00 2.95 3.81 3.59
6.56 7.18 7.11 7.23 7.56 7.88 7.47 7.38 7.99 7.68 8.77
61.56 66.25 66.82 68.61 73.56 75.54 75.23 79.09 82.37 84.68 92.47
129.30 138.25 139.33 145.27 157.45 163.28 165.49 175.32 185.50 194.62 210.69
17.10 18.75 19.05 19.79 21.40 22.27 22.27 23.41 24.71 25.63 28.33
Fig. 8. Progression in incidence (per 100,000) of pelvic fractures over the 11 years in different age groups.
Fig. 9. Predicted Incidence per 100,000, of acetabular fracture in people aged 75 years and over (left) and in the general population (right). Linear regression extrapolating incidence up to 2030 if acceleration is constant.
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Fig. 10. Predicted incidence (per 100,000) of pelvic fractures in people aged 75 years and above (left) and in the general population (right). Linear regression extrapolating incidence up to 2030 if acceleration is constant.
4.4.2. Pelvis Incidence likewise correlated with time for pelvic fracture in the overall population and in over-75 year-olds (r = 0.986, p < 0.001; and r = 0.983, p < 0.001, respectively). The model predicted annual incidence of 41/100,000 in the general population 309 in over-75 year-olds (Fig. 10).
2006 to 473 (14.33%) in 2016 (Table 5). Likewise, the increase in under-60 year-olds was from 247 (24.07%) to 366 (33.27%) and in over-60 year-olds from 38 (2.95%) to 107 (4.86%). Definitive closed reduction and traction was less frequent (Table 5).
4.5. Treatment
4.5.2. Pelvis The number and percentage of pelvic fractures managed by reduction and internal fixation increased from 154 (1.43%) to 409 (2.19%). The increase in under-60 year-olds was from 138 (5.1%) to 326 (9.2%) and in over-60 year-olds from 16 (0.20%) to 83 (0.54%).
4.5.1. Acetabulum The number and percentage of acetabular fractures managed by reduction and internal fixation increased from 285 (12.31%) in Table 5 Treatment of acetabular fracture. Open reduction and internal fixation Total
Closed reduction and traction
Age < 60
Age > 60
Total
Age < 60
Age > 60
Year
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
285 309 363 381 378 403 334 368 407 388 473
12.31% 11.78% 13.52% 13.92% 12.86% 13.99% 11.79% 12.89% 13.91% 12.75% 14.33%
247 265 302 306 317 334 273 297 330 333 366
24.07% 24.11% 29.52% 29.51% 31.20% 31.87% 29.45% 32.78% 33.50% 36.31% 33.27%
38 44 61 75 61 69 61 71 77 55 107
2.95% 2.89% 3.67% 4.41% 3.17% 3.76% 3.20% 3.64% 3.97% 2.59% 4.86%
78 63 57 62 70 55 48 36 36 26 22
3.37% 2.40% 2.12% 2.27% 2.38% 1.91% 1.69% 1.26% 1.23% 0.85% 0.67%
43 31 35 32 28 25 24 16 16 15 14
4.19% 2.82% 3.42% 3.09% 2.76% 2.39% 2.59% 1.77% 1.62% 1.64% 1.27%
35 32 22 30 42 30 24 20 20 11 8
2.71% 2.10% 1.32% 1.76% 2.18% 1.64% 1.26% 1.03% 1.03% 0.52% 0.36%
Table 6 Treatment of pelvic fracture. Open reduction and internal fixation Total
Closed reduction and traction
Age < 60
Age > 60
Total
Age < 60
Age > 60
Year
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
n
Percent
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
154 205 283 293 295 325 301 299 341 387 409
1.43% 1.72% 2.32% 2.30% 2.13% 2.25% 2.07% 1.95% 2.09% 2.27% 2.16%
138 181 247 256 259 274 256 242 290 318 326
5.10% 6.07% 8.48% 8.68% 8.41% 8.70% 8.49% 8.12% 9.11% 9.88% 9.20%
16 24 36 37 36 51 45 57 51 69 83
0.20% 0.27% 0.39% 0.38% 0.34% 0.45% 0.39% 0.46% 0.39% 0.50% 0.54%
136 127 142 107 139 82 69 52 42 28 33
1.26% 1.06% 1.17% 0.84% 1.01% 0.57% 0.47% 0.34% 0.26% 0.16% 0.17%
53 50 52 51 48 28 30 25 21 14 18
1.96% 1.68% 1.79% 1.73% 1.56% 0.89% 1.00% 0.84% 0.66% 0.43% 0.51%
83 77 90 56 91 54 39 27 21 14 15
1.02% 0.86% 0.97% 0.57% 0.85% 0.48% 0.34% 0.22% 0.16% 0.10% 0.10%
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Fig. 11. Population pyramids for European economic area (EEA), United Kingdom (UK), France and Germany.
The rate of closed reduction and traction fell from 136 cases 2006 to 33 in 2016 (Table 6). 5. Discussion This was the first nationwide epidemiological study to review all cases of acetabular and pelvic fracture with hospital admission
in France for the period 2006–2016. It confirmed that incidence is rising, especially in the elderly, and that treatment is increasingly surgical. The findings agree with those of Rinne et al. [3] and Laird et al. [8], who reported male predominance in acetabular fracture, and those of Lüthje et al. [2], Ragnarsson et al. [7] and Andrich et al. [17], reporting female predominance in pelvic fracture.
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The increase in acetabular and pelvic fracture rates in the elderly and increasing mean age in acetabular and pelvic fracture is a public health issue raised in several articles [4–6,8,10,17–21]. It is partly accounted for by population aging. Calculating incidence per 100,000 according to age-group eliminates much of the impact of population aging, but even so incidence is rising. Moreover, as demonstrated by Kannus et al. [4–6], even age-adjusted incidence is increasing. The reason for this is unknown, but may involve the increase in age-adjusted incidence of osteoporosis [6], or increased physical activity in the elderly [18]. Emergency physicians and community doctors are probably better trained in screening for these fractures. Also, CT has become increasingly available and implemented in hip and pelvic trauma in the elderly, improving diagnosis. Likewise, some extra diagnoses may be made thanks to better coding. The most alarming finding is the estimated incidence for 2030 of pelvic (309/100,000) and acetabular fracture (31.75/100,000) in over-75 year-olds. Obviously, progression may turn out not to be linear, and the predictions of the linear regression model are to be taken with caution. The population pyramids for the European Economic Area (EEA), UK and Germany are identical to that for France, or show a higher proportion of elderly subjects (Fig. 11). Extrapolating our findings to other European countries suggests that pelvic and acetabular fracture is a public health issue, and resources need mobilizing to deal with it by strategies of prevention (treatment of osteoporosis, prevention of falls, etc.), diagnosis and treatment (raising physician awareness, clear treatment decision-trees, etc.). The rate of treatment by reduction and external fixation has fluctuated, with no clear trend toward an increase. This is probably due to the increasing number of over-60 year-olds, who are less often managed surgically (2.95-4.86%) than younger patients (24.07–33.27%). The rate of surgical treatment of pelvic fracture, on the other hand, has clearly increased, from 154 (1.43%) in 2006 to 409 (2.16%) in 2016. This is probably due to improved understanding of pelvic instability and the consequences of non-operative treatment in such a case, and to the development of minimally invasive and navigation-guided techniques. Closed reduction with in-bed traction has become rare in pelvic and acetabular fracture, although coding of non-operative treatment by traction is not always clearly reported, and figures may be underestimated. Geographically, the higher incidence of these fractures in and around big cities is probably due to greater population density. While it seems logical that there should be a causal relation between incidence of acetabular fracture in young people and the rate of road accidents, the correlation between the two was not in fact significant (p = 0;06). The present study had several limitations. Firstly, the data were obtained from the CPAM national health insurance organization, based on coding performed by physicians. Coding errors may have led to underestimation; however, coding is also the basis of insurance cover and reimbursement, inciting physicians to be diligent. Some patients not admitted to hospital may not have been coded at all, but this was probably rare. There may also have been coding errors related to misdiagnosis or the coding of these fractures being overlooked in cases of multiple trauma. Secondly, data were lacking to calculate incidence per patient-year. Thirdly, data were lacking for fracture mechanism and associated lesions, which would have been interesting to analyze to shed light on the results. The incidence of these fractures in France was long underestimated, and management protocols were poorly defined. Many recent studies have focused on improving diagnosis [22,23], perioperative management [24] and surgical technique [25–27] to reduce the morbidity and mortality associated with these increasingly frequent fractures. However, well-defined protocols, recognized international guidelines and consensus on treatment are still far from being established.
6. Conclusions Incidence of acetabular and pelvic fracture is increasing rapidly, especially in the elderly, and a major increase can be expected by 2030. Treatment is increasingly surgical. Public health strategies need to be developed to reduce incidence and improve treatment. Further studies are needed to determine optimal strategy, as there is at present no consensus on treatment, notably in the elderly. Disclosure of interest The authors declare that they have no competing interest. Funding The study received no public, commercial or non-profit funding. Authors’ contributions Elias Melhem was involved in study design, data interpretation, article writing and revision and checking the final version. Guillaume Riouallon was involved in study design, statistical analysis, data interpretation, article writing and revision and checking the final version. Khalil Habboubi was involved in study design, statistical analysis, data interpretation, article writing and revision and checking the final version. Mehdi Gabbas was involved in study design, data collection, statistical analysis, data interpretation, article revision and checking the final version. Pomme Jouffroy was involved in study design, data interpretation, article writing and revision and checking the final version. References [1] Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury 2006;37:691–7. [2] Ragnarsson B, Jacobsson B. Epidemiology of pelvic fractures in a Swedish county. Acta Orthop 1992;63:297–300. [3] Rinne PP, Laitinen MK, Huttunen T, Kannus P, Mattila VM. The incidence and trauma mechanisms of acetabular fractures: a nationwide study in Finland between 1997 and 2014. Injury 2017;48:2157–61. [4] Kannus P, Palvanen M, Parkkari J, Niemi S, Järvinen M. Osteoporotic pelvic fractures in elderly women. Osteoporos Int 2005;16:1304–5. [5] Kannus P, Parkkari J, Niemi S, Sievänen H. Low-trauma pelvic fractures in elderly Finns in 1970-2013. Calcif Tissue Int 2015;97:577–80. [6] Kannus P, Palvanen M, Niemi S, Parkkari J, Järvinen M. Epidemiology of osteoporotic pelvic fractures in elderly people in Finland: sharp increase in 1970-1997 and alarming projections for the new millennium. Osteoporos Int 2000;11:443–8. [7] Lüthje P, Nurmi N, Kataja M, Heliövaara M, Santavirta S. Incidence of pelvic fractures in Finland in 1988. Acta Orthop 1995;66:245–8. [8] Laird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br 2005;87:969–73. [9] Best MJ, Buller LT, Quinnan SM. Analysis of incidence and outcome predictors for patients admitted to US hospitals with acetabular fractures from 1990 to 2010. Am J Orthop 2018:47. [10] Nanninga GL, de Leur K, Panneman MJM, van der Elst M, Hartholt KA. Increasing rates of pelvic fractures among older adults: The Netherlands, 1986-2011. Age Ageing 2014;43:648–53. [11] Melton LJ, Sampson JM, Morrey BF, Ilstrup DM. Epidemiologic features of pelvic fractures. Clin Orthop Relat Res 1981:43–7. [12] Letournel E, Judet R. Fractures of the Acetabulum. Berlin, Heidelberg: Springer Berlin Heidelberg; 1993. [13] Boudissa M, Francony F, Kerschbaumer G, Ruatti S, Milaire M, Merloz P, et al. Epidemiology and treatment of acetabular fractures in a level-1 trauma centre: retrospective study of 414 patients over 10 years. Orthop Traumatol Surg Res 2017;103:335–9. [14] INSEE. Evolution et Structure de la Population. Institut National de la Statistique et des Études Économiques n.d. https://www.insee.fr/fr/statistiques. (accessed January 5, 2018). [15] Délégation à la sécurité routière (DSR). Séries longues n.d. http://www.securite-routiere.gouv.fr/la-securite-routiere/l-observatoirenational-interministeriel-de-la-securite-routiere/series-statistiques/serieslongues (accessed January 5, 2018). [16] Eurostat. Population and Social Conditions n.d. http://ec.europa.eu/eurostat/statistics-explained/index.php/Main Page (accessed April 3, 2018).
Please cite this article in press as: Melhem E, et al. Epidemiology of pelvic and acetabular fractures in France. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.019
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[17] Andrich S, Haastert B, Neuhaus E, Neidert K, Arend W, Ohmann C, et al. Epidemiology of pelvic fractures in Germany: considerably high incidence rates among older people. PLoS One 2015;10:e0139078. [18] Ferguson TA, Patel R, Bhandari M, Matta JM. Fractures of the acetabulum in patients aged 60 years and older: an epidemiological and radiological study. J Bone Joint Surg Br 2010;92:250–7. [19] Balogh Z, King KL, Mackay P, McDougall D, Mackenzie S, Evans JA, et al. The epidemiology of pelvic ring fractures: a population-based study. J Trauma - Inj Infect Crit Care 2007;63:1066–72. [20] Buller LT, Lawrie CM, Vilella FE. A Growing problem. Acetabular fractures in the elderly and the combined hip procedure. Orthop Clin North Am 2015;46:215–25. [21] Verbeek DO, Ponsen KJ, Fiocco M, Amodio S, Leenen LPH, Goslings JC. Pelvic fractures in the Netherlands: epidemiology, characteristics and risk factors for in-hospital mortality in the older and younger population. Eur J Orthop Surg Traumatol 2018;28:197–205. [22] Jouffroy P, Sebaaly A, Aubert T, Riouallon G. Improved acetabular fracture diagnosis after training in a CT-based method. Orthop Traumatol Surg Res 2017;103:325–9.
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[23] Tonetti J, Jouffroy P, Pelvis-Acetabulum Club. Recent progress in the diagnosis and treatment of pelvic ring and acetabular fracture. Orthop Traumatol Surg Res 2017;103:631–2. [24] Ostrowka C, Bonhomme S, Jouffroy P, Riouallon G. Evaluation of venous thromboembolic complications in patients operated on for pelvic fracture. Orthop Traumatol Surg Res 2018;104:917–21. [25] Boudissa M, Oliveri H, Chabanas M, Tonetti J. Computer-assisted surgery in acetabular fractures: virtual reduction of acetabular fracture using the first patient-specific biomechanical model simulator. Orthop Traumatol Surg Res 2018;104:359–62. [26] Elmada˘g M, Güzel Y, Acar MA, Uzer G, Arazi M. The Stoppa approach versus the ilioinguinal approach for anterior acetabular fractures: a case control study assessing blood loss complications and function outcomes. Orthop Traumatol Surg Res 2014;100:675–80. [27] Bone JP, (GETRAUM) Joint Trauma Study Group. Indications and technical challenges of total hip arthroplasty in the elderly after acetabular fracture. Orthop Traumatol Surg Res 2014;100:197–201.
Please cite this article in press as: Melhem E, et al. Epidemiology of pelvic and acetabular fractures in France. Orthop Traumatol Surg Res (2020), https://doi.org/10.1016/j.otsr.2019.11.019