The “Gull Sign”

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Abstract
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.

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