outcome of operative treatment of acetabular fractures

J Ayub Med Coll Abbottabad 2015;27(2)

ORIGINAL ARTICLE

OUTCOME OF OPERATIVE TREATMENT OF ACETABULAR FRACTURES: SHORT TERM FOLLOW-UP Raja Irfan Qadir, Syed Imran Bukhari Department of Orthopaedics, Northwest General Hospital and Research Centre, Hayatabad, Peshawar-Pakistan

Background: Fractures of the acetabulum result from high energy accidents. The anatomic location of the acetabulum, as well as the three-dimensional structure of the bone, makes the treatment of these injuries extremely challenging. The objective of this study was to determine the outcome of operative treatment of acetabulum fractures with one year follow-up. Methods: In this descriptive case series, 31 patients with acetabular fracture were admitted in North West General Hospital, Peshawar, from July 2010 to Sept 2013. Patients were followed-up till one year. In follow-up, patients were assessed clinically with Merle d’ Aubigne and Postel grading method. Radiological assessment was done using Matta criteria. Results: All patients were male. Twelve (38.7 %) were managed non-operatively, as they fulfilled criteria for non-operative treatment and 19 (61.3%) patients were operated after fulfilling the criteria for internal fixation; they were included for analysis. Ages ranged from 20–60 years with mean age of 37.21±10.07 years. Fourteen (73.7%) patients had anatomic reduction and 5 (26.3 %) patients had imperfect reduction based on Matta radiographic criteria. At 1 year follow-up, we had 16 (84.2 %) excellent hips, 2 (10.5%) good hips and 1 (5.3%) poor hip , based on radiographs; and clinically we had 9 (47.4 %) hips with excellent function, 7 (36.8 %) hips with good outcome, 2 (10.5 %) had fair function and 1 (5.3 %) patient had poor function. Conclusion: Our results show that internal fixation of acetabular fractures lead to good outcome in majority of patients. Keywords: Acetabular fractures, anatomic reduction, imperfect reduction J Ayub Med Coll Abbottabad 2015;27(2):287–91

INTRODUCTION Fractures of the acetabulum result from high energy accidents. The anatomic location of the acetabulum, as well as the three-dimensional structure of the bone, makes the treatment of these injuries extremely challenging. The severity of these injuries is demonstrated by the fact that early descriptions of acetabular fractures are the result of autopsy findings of patients who had sustained significant trauma. 1 Callisen in 1788 is said to have reported the case of an acetabular fracture, but without significant detail in his description.1 In 1821, Cooper reported the first detailed description of an acetabular fracture.2 This case described autopsy findings in a patient with an associated central dislocation of the femoral head into the pelvis. In 1909, Schroeder reported a detailed compendium of the first 49 cases reported in the literature. 1,3 There was a brief trial of femoral head mold arthroplasty as a treatment for displaced acetabular fractures. The theory behind this treatment was that the vitalian coating on the femoral head would effectively “mold” the acetabulum into an appropriately shaped socket on healing in this displaced position.2,4 In 1961, Rowe and Lowell published their landmark article entitled “Prognosis of Fractures of the Acetabulum” 5. This was a retrospective study of 93

acetabular fractures in 90 patients, all with a minimum of one-year follow-up. In 1964, Judet et al. published their classic article entitled “Fractures of the Acetabulum, Classification and Surgical Approaches for Open Reduction”.6 This manuscript described AP and 45º oblique views of the pelvis to evaluate the acetabular fractures. This article represented a substantial step forward in the understanding of acetabular anatomy and fracture classifications. In 1986, Matta published two articles that helped establish the guidelines for those acetabular fractures, which could be managed non-operatively. Using the AP and the 450 oblique views of the pelvis, Matta developed the concept of a “roof arc measurement”. 7 Acetabular surgery is one of the more intensive and complex surgeries performed in orthopaedics. This includes the complexity of the surgical dissection, the significant risk of neurovascular and/or visceral injury, and the threedimensional challenge of reducing and fixing the fracture itself. It is important to try to understand the essential features and behaviour of each pattern, the so called “personality” of the fracture, so that an appropriate tactic can be performed 2. We want to share our experience of treatment of these complex fractures with our colleagues who are dealing with these fractures and add to the meagre literature on this topic in our part of the world.

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MATERIAL AND METHODS This descriptive case-series consisted of patients admitted via outpatient as well as emergency department of North West Hospital Peshawar. Nineteen patients fulfilling the selection criteria, as suggested by Letournel and Judet6 , were identified. They were explained about the procedure and informed consent was taken. Complications were discussed with patients. The demographic profiles were recorded. Radiographs (pelvis AP and Judet views) and CT scan with 3D reconstruction were carried out according to clinical findings. Clinical examination and X-rays were done and data recorded at: Admission, 1st post-op day, 2 weeks, 6 weeks, 3 months, 6 months, and 12 months. Reduction and fixation were assessed using AP and 45 degree oblique views using Matta criteria8,9. At 1 year follow-up, radiographic grading using Matta method11 was done, and at the same follow-up, modified Merle d’Aubigne & Postel 10 system as used for clinical grading. Patients were mobilized on 1st postoperative day. Thrombo-prophylaxis was started after 6 hours of surgery. Non-weight bearing status was continued for at least 6 weeks; partial weight bearing was encouraged thereafter, with full weight bearing by 3 months. Sutures were routinely removed after 14 days. No prophylaxis was advised for heterotopic ossification.

In this study, 19 patients were included. Age ranged from 20–60 years. Mean age was 37.21±10.07 years. All the patients were male. Twelve patients (63.2%) had right sided acetabulum fracture and the other 7 (36.8%) had left sided acetabulum fracture. In 16 (84.2%) patients, mode of injury was road traffic accident and 3 (15.8%) patients had fall from height. Seven patients had one additional injury. Four patients had dislocation along with posterior wall fracture. The average time to surgery was 4.15 days. The average postoperative stay was 3.52 days. Table-1 shows the types of acetabular fractures which were dealt with in this study. On the basis of fracture configuration and according to recommendations of Letournel & Judet, different approaches were used: Kocher 15(78.9%), Extended ilio-femoral 1 (5,3%), and Kocher+Ilio-inguinal 3 (15.8%). Fourteen (73.7%) of our patients achieved anatomic reduction and 5 (26.3%) ended up with imperfect reduction. Imperfect reduction at surgery was observed in 1 posterior column fracture, 1 posterior wall fracture and 3 both column fractures. Matta radiographic criteria was used at 1 year follow-up for outcome assessment (Table-2). Merle d’Aubigne & Postel system was used at 1 year follow-up for clinical grading (Table-2).

RESULTS Case-1

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Table-1: Acetabular Fracture distribution Simple fractures Posterior column fracture Posterior wall fracture Transverse fracture Associated fracture types Transverse + posterior wall fracture Both column fractures

14 (73.7%) 2 11 1 5 (26.3 %) 1 4

Table-2: Radiological and Clinical Outcome Outcome Excellent Good Fair Poor

Radiological 16 ( 84.2%) 2 (10.5%) 0 (0%) 1(5.3%)

Clinical 9 (47.4 %) 7 (36.8%) 2 (10.5 %) 1 (5.3 %)

Table-3: Comparison of Results Author(s) 16

Cases

Bircher Madhu et al17 Deo et al18 Fica et al19 Rommens et al20 Matta et al21 Mayo22 Ruesch et al23 Brueton24 Present study

161 237 74 84 175 255 163 53 26 19

Mean Follow-up 11.3 2.9 2.6 5.5 2 6 3.7 1 2 1

Excellent / Good% 73 76 74 68 76 76 75 83 61 84

Matta reduction criteria Anatomical Imperfect Poor Surgical secondary congruence

zero to one millimetre of displacement two to three millimetres more than three millimetres

Matta radiographic criteria at follow-up Excellent Good Fair Poor

Normal appearance of the hip; Mild changes, small osteophytes, moderate (1 mm) narrowing of joint & minimum sclerosis; Intermediate changes, moderate osteophytes, moderate (50 %) narrowing of the joint, collapse or wear of the femoral head, and acetabular wear.

Merle d’ Aubigne and Postel criteria Pain None Slight or intermittent After walking but resolves Moderately severe but patient is able to walk Severe, prevents walking Walking Normal No cane but slight limp Long distance with cane or crutch Limited even with support Very limited Unable to walk Range of motion 95–100% 80–94% 70–79% 60–69% 50–59% 85% of patients had satisfactory reduction (40% in fractures involving posterior dislocation of hip. It is pertinent to mention that sciatic nerve, especially the peroneal component, is in close proximity to posterior wall in greater sciatic notch. Iatrogenic nerve injuries were found in 8% in the meta-analysis, mainly to the sciatic nerve. The high number of injuries to the lateral cutaneous nerve is only described in the study of Mayo et al.30 Helfet and Schmeling 31 in their study described the incidence of nerve injury following acetabular fractures to be around 29%; 5% had iatrogenic nerve injury. The quality of reduction is a critical factor which is dependent on the surgeon’s expertise. Other factors which influence functional outcome include advanced age9,10, delay in operative treatment18,24, presence of damage to the femoral head9,29, additional injuries and local soft tissue complications. Mears et al 25 pointed out that poor outcome is related to the use of extensile approaches and co-morbidity, such as obesity, osteopenia and a history of medical disorders. We had 1 patient with advanced age with osteopenia, both column fractures with multiple additional fractures, which had a poor outcome with loss of fixation. The incidence of heterotopic ossification (HO) following acetabular surgery in the metaanalysis12 was 25.6%. Only 5.7% of patients went on to develop Brooker grade III or IV heterotopic ossification34. Many studies have documented the correlation of HO with severity of fractures and the extensile approaches used at surgery. 22,33 Other risk factors include high injury severity score, delay in fixation of the fracture and an associated head injury. Prophylactic treatment of HO compared to no treatment showed no difference in the meta-analysis. In our study, we had a single case (5.3%) of heterotopic ossification, associated with both column fracture and head injury with good functional outcome. Limitations of our study are: that we had a small number of patients, and besides the follow-up duration is short.

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CONCLUSION Acetabular fractures are not meant to be treated by the inexperienced surgeons. They should be referred to a tertiary care setting as soon as the conditions allow as the timing of surgery is very important. It is imperative to achieve accurate reduction at the time of surgery and the surgeon should be well familiar with different surgical approaches.

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Address for correspondence Dr Raja Irfan Qadir, Department of Orthopedics, Northwest General Hospital & Research Centre, Hayatabad, Peshawar-Pakistan Cell: +92 333 963 0619 Email: [email protected]


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