Operative time in acetabular fracture fixation: predictors and impact on postoperative outcomes

Surgical fixation of acetabular fractures is technically demanding, and operative time is often treated as a surrogate for surgical complexity and a presumed driver of complications. Whether prolonged operative time reflects identifiable preoperative factors, and whether it independently worsens outcomes, remains unclear. We aimed to identify factors associated with prolonged operative time in acetabular fracture fixation and to determine whether longer operative time is associated with worse postoperative outcomes.

We retrospectively reviewed patients undergoing surgical fixation for acetabular fracture at a single center with a minimum follow-up of 3 months. Operative time was dichotomized at the median (127 min) into short (≤ 127 min) and long (> 127 min) operative time groups.

A total of 441 patients were included (222 short, 219 long). On univariate analysis, long operative time was associated with lower preoperative hemoglobin (11.8 ± 1.7 vs. 12.3 ± 1.7 g/dL, p = 0.001), high-energy trauma (83.7% vs. 72.3%, p = 0.004), the presence of associated lesions (48.4% vs. 31.5%, p < 0.001), an anterior-predominant fracture pattern and use of a combined surgical approach (both p < 0.001), and a longer time to surgery (8.9 ± 5.4 vs. 7.6 ± 5.3 days, p = 0.011). Conversely, dislocation (22.2% vs. 40.6%, p < 0.001), posterior wall involvement (p = 0.001), and femoral head lesions (p = 0.020) were more frequent in the short operative time group at presentation. On multivariable regression, the presence of associated lesions (OR 1.8, p = 0.02) and high-energy trauma (OR 1.9, p = 0.02) independently predicted long operative time, whereas dislocation was independently associated with shorter operative time (OR 0.5, p = 0.007). Notably, long operative time was not associated with higher rates of infection, heterotopic ossification, femoral head necrosis, post-traumatic osteoarthritis, or conversion to total hip arthroplasty.

In acetabular fracture fixation, prolonged operative time was driven primarily by case complexity particularly associated lesions, and trauma type whereas dislocation, typically addressed through a single posterior approach, was associated with shorter operations. Longer operative time did not translate into worse postoperative outcomes.

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