1: J Orthop Trauma. 2003 Oct;17(9):625-34.  

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

Anglen JO, Burd TA, Hendricks KJ, Harrison P.

Department of Orthopaedic Surgery, University of Missouri Hospital and Clinics,
Boone Orthopaedic Associates, 1601 East Broadway, Suite 300, Columbia, MO 65201,
USA. anglenj@health.missouri.edu

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.

PMID: 14574190 [PubMed - in process]