title: Does supplemental epidural anesthesia improve outcomes of acetabular fracture surgery?
abstract: OBJECTIVE
  Addition of epidural anesthesia to general anesthesia is theorized to reduce hospital length of stay, improve postoperative pain control, reduce time to mobilization, and reduce intraoperative blood loss for operative treatment of acetabular fractures. Our hypothesis was that epidural anesthesia would result in improvement in short-term outcomes and therefore justify any associated increases in anesthesia induction time, treatment costs, or risks.
  
  
  METHODS
  Retrospective case-control.
  
  
  METHODS
  Academic trauma center.
  
  
  METHODS
  We identified 163 patients who underwent open reduction and internal fixation of posterior wall acetabular fractures from 2002 through 2007. We excluded patients who were intubated before the procedure (n = 20) and patients with incomplete intraoperative anesthesia records (n = 5). Patients were divided into two groups: Group 1 received combined epidural plus general anesthesia (CEGA) (n = 64) and Group 2 received general anesthesia alone (GA) (n = 74). No differences were observed between the two groups in terms of age, gender, Injury Severity Score, head Abbreviated Injury Score, mechanism of injury, number of associated fractures, number of comorbidities, or delay between injury and day of surgery.
  
  
  METHODS
  General anesthesia with or without epidural anesthesia.
  
  
  METHODS
  Length of stay, postanesthesia care unit initial and discharge pain scores, time to mobilization with physical therapy, estimated blood loss, and anesthesia time.
  
  
  RESULTS
  : No significant differences were shown between the two groups for length of stay (CEGA, 6.2 days; GA, 5.9 days; P = 0.62; 80% power to detect a difference of 1.3 days), postanesthesia care unit initial pain scores (CEGA, 3.5; GA, 3.4; P = 0.92), postanesthesia care unit discharge pain scores (CEGA, 2.5; GA, 3.3; P = 0.13), or time to mobilization with physical therapy (CEGA, 1.5 days; GA, 1.7 days; P = 0.43). Intraoperative blood loss was less in the CEGA group (CEGA, 458 mL; GA, 543 mL; P = 0.05). Mean anesthesia time was longer for the CEGA group (CEGA, 85 minutes; GA, 66 minutes; P < 0.01).
  
  
  CONCLUSIONS
  Although addition of epidural anesthesia added an average of 19 minutes to the anesthesia time (P < 0.01), we found no advantage to CEGA regarding length of stay, pain scores, or time to rehabilitation. Mean decrease of blood loss of less than 100 mL in the CEGA group is unlikely to be of clinical significance. Our results contrast findings in support of CEGA in the hip arthroplasty literature and question the use of CEGA for posterior wall acetabular fractures.
authors.affiliation: R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Strauss
authors.forename: Robert V
authors.initials: RV
authors.lastname: O'Toole
authors.forename: Andrew N
authors.initials: AN
authors.lastname: Pollak
mesh_terms: D000077:Acetabulum / Q000293:injuries* / Q000601:surgery*; D000328:Adult; D000767:Anesthesia, Epidural / Q000706:statistics & numerical data*; D003131:Combined Modality Therapy / Q000706:statistics & numerical data; D015897:Comorbidity; D005260:Female; D005593:Fracture Fixation, Internal / Q000706:statistics & numerical data*; D050723:Fractures, Bone / Q000453:epidemiology* / Q000601:surgery*; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008396:Maryland / Q000453:epidemiology; D010149:Postoperative Pain / Q000453:epidemiology* / Q000517:prevention & control; D015995:Prevalence; D018570:Risk Assessment; D012307:Risk Factors; D016896:Treatment Outcome