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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 1-6

Acetabulum reconstruction: A demanding surgery


1 Department of Orthopaedics, Renuka Orthopaedic Centre and Tara Hospital and Research Centre, Patna, Bihar, India
2 Department of Orthopaedics, Nalanda Medical College and Hospital, Patna, Bihar, India

Date of Web Publication16-Aug-2019

Correspondence Address:
Dr. Rajat Charan
Assistant Professor, Department of Orthopaedics, NMCH, Patna, Renuka Orthopaedic Centre, 275 Nehru Nagar, Patna 13, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jodp.JODP_2_18

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  Abstract 


Introduction: Incidence of fracture in acetabulum is rising and requires anatomical reduction and fixation for proper functioning hip joint. Earlier majority of such fractures were treated conservatively with occasional satisfactory results. Its surgical management is technically demanding but is evolving fast. Material and Methods: Eighteen surgically managed patients in last 2 years were included in the study. On admission, patients were stabilized first the associated dislocation was reduced and maintained on traction. Surgery was planned as soon as general condition permitted after radiological evaluation. Surgical approach depends upon site and pattern of fracture. Postoperative radiological results were assigned according to the criteria described by Matta (Matta JM. Fractures of the acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78:1632-45) and functional results were evaluated using Merle d'Aubigne and Postel's system modified by Matta et al. (Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of the acetabulum: A retrospective analysis. Clin Orthop Relat Res 1986;230-40) after a minimum 6-month follow-up. Results: According to the Merle d'Aubigne and Postel scoring system modified by Matta, the clinical outcome was excellent in 9 cases (50%), good in 5 cases (27.7%), fair in 3 cases (16.6%), and poor in 1 case (5.5%). In our series, the overall incidence of sciatic nerve palsy was seen in 2 cases (11%), and other nerve damage was not seen. In our study, all patients received mechanical prophylaxis, and just one patient developed pulmonary embolism. This is in concordance with result of an Indian study. (Shrestha D, Dhoju D, Shrestha R, Sharma V. Acetabular fracture: Retrospective analysis of thirty three consecutive cases with operative management. Kathmandu Univ Med J (KUMJ) 2014;12:279-87.) In our study, deep infection was seen in one case, i.e., 5.5%, and two cases (i.e., 11%) had superficial infection. Conclusion: Nowadays open reduction internal fixation is the gold standard for the displaced acetabulum fractures. A good-to-excellent functional outcome was seen in more than 60% of the patients and a good-to-excellent radiological outcome was seen in more than 50% of the patients treated surgically.

Keywords: Acetabulum reconstruction, anatomical reduction and fixation, demanding surgery


How to cite this article:
Charan R, Verma PK, Chaurasia T. Acetabulum reconstruction: A demanding surgery. J Orthop Dis Traumatol 2019;2:1-6

How to cite this URL:
Charan R, Verma PK, Chaurasia T. Acetabulum reconstruction: A demanding surgery. J Orthop Dis Traumatol [serial online] 2019 [cited 2019 Nov 13];2:1-6. Available from: http://www.jodt.org/text.asp?2019/2/1/1/264617




  Introduction Top


Acetabulum fractures are growing in developing countries with increasing incidence of high-energy trauma such as road traffic accidents or falls from a significant height.[1],[2] According to epidemiology data, the incidence of acetabulum fractures is approximately 3 per 100,000 population per year.[3] They usually result from intense injuries and often occur in multiple trauma patients.[4] However, fragility acetabular fractures in osteoporotic patients can occur as a result of simple low-energy fall from standing height or minor trauma.[5] Judet et al.[6] have classified acetabulum fractures as follows.

Management of acetabulum fracture is difficult regarding the complicated anatomy of the acetabulum. These fractures are always a challenge for the trauma surgeons. Before 1964, most acetabulum fractures were treated with closed reduction.[6] Nowadays, open reduction and internal fixation are the standard treatment for displaced acetabulum fracture [Figure 1],[Figure 2],[Figure 3],[Figure 4]. Generally, surgical approaches to the acetabulum can be anterior [Figure 3]j, posterior [Figure 4]e, extensile, or combined such as the ilioinguinal, iliofemoral, extended iliofemoral, Kocher-Langenbeck, triradiate, and combined anterior and posterior approaches.[7],[8] The ilioinguinal approach remains to be the most common approach for anterior acetabulum fixation as described by Letournel[9] in 1961, and the Kocher-Langenbeck approach is considered as the gold standard for posterior access.[6] However, the decision for an appropriate approach substantially depends on the type and nature of each fracture. The approach to be selected should provide a sufficient angle of visualization, allow anatomic reduction, and permit control of the fracture area. For example, an extended or combined approach can be used in the patients with wide displacement in both the anterior and posterior columns of the acetabulum.[10],[11]
Figure 1: (a) Simple fracture type. (b) Associated fracture types

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Figure 3: Patient 2 (a) pre-OP X-ray Judet view. (b) Per OP Judet View. (c) Pre-OP Judet View showing Ant. Column # dislocation. (d) Pre-OP x ray pelvis AP view after closed reduction and traction. (e) Pre-OP 3D CT. (f) Pre-OP 3D CT. (g) Pre-OP 3D CT head substraction view showing ant. Column# (h) Pre-OP CT coronal section showing displacement and instability. (i) Pre-OP axial CT showing displacement and instability. (j) Ant. ilioinguinal approach surface marking. (k) Intra-OP ilioinguinal approach showing windows. (l) Post-OP X-ray after fixation with matta plate. (m) 6 months post op x ray showing union. (n) 6 month post op x ray showing union. (o) 1 year post op functional result. OP = opertation

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Figure 4: Patient 3 (A) pre-Op X-ray pelvis AP view. (B) Pre-OP 3D CT head substraction view showing T shaped fracture involving both column. (C) Pre-OP CT coronal section. (D) Pre Op CT axial view. (E) Intra-Op fixation with matta plate. (F) Intra-Op X-ray showing fixation of Ant. column with lag screw and matta plate. (G) 6 months functional out come. (H) 6 months functional outcome. OP = operative

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The most studies reported good-to-excellent functional outcomes in 71-88% patients after surgical treatment of acetabular fractures.[12],[13],[14],[15] The important prognostic factors to influence clinical outcome include associated fracture type, damage to the femoral head, associated injuries, dislocation at the time of injury, inadequate fracture reduction, age, development of heterotopic ossification, and a delay in surgical treatment.[16],[17],[18],[19],[20],[21] In addition, the surgeon's training and expertise is a crucial factor.[22] The practical skills of the surgeon help him to choose the most appropriate approach for achieving anatomical reduction for a favorable outcome.


  Materials And Methods Top


Between 2015 and 2017, 18 patients of acetabulum fractures were treated operatively. Informed consent of each patient was obtained. The study was approved by the local ethics committee of Nalanda Medical College and Hospital, Bihar, India. Exclusion criteria included minimally displaced fracture and fractures sparing weight-bearing dome of the acetabulum who were managed conservatively, gross osteoporosis, patients aged less than 16 years at the time of their injury, and patients lost to follow-up.


  Study Protocol Top


Patients initially were stabilized if required; then the patients were preoperatively evaluated with physical examination, AP pelvis radiograph [Figure 2]a, [Figure 3]d, [Figure 4]a, Judet pelvis radiographs [Figure 3]a, [Figure 3]b, [Figure 3]c, and [Figure 3]a CT scan [Figures 2]f, [Figures 3]h, and [Figures 3]i, [Figures 4]c and [Figures 4]d with thin cuts and 3D reconstructions [Figures 2]b, [Figures 3]e, [Figures 3]f and [Figures 3]g,[Figures 4]b as part of the standard protocol for these injuries.

Indications for surgical intervention unless contraindicated by underlying medical conditions were unstable fracture dislocation of hip and fracture involving weight-bearing area, displaced fracture>2 mm within superior articular surface, fracture involving >25% surface of posterior wall, retained intra-articular fragments, and lack of secondary congruence or loss of congruence of joint on any view.

The fractures were classified into posterior wall, posterior column, anterior wall, anterior column, transverse, or five associated patterns (T-shaped, posterior column with posterior wall, transverse with posterior wall, anterior with posterior hemi transverse, associated both column) as described by Judet et al[6] [Figure 1]. In our centers, open reduction and internal fixation were carried out using the ilioinguinal approach [Figure 3]J for anterior fractures, the Kocher-Langenbeck approach [Figure 4]e,[Figure 4]f for the posterior fractures, and combined or extensile approach for bicolumnar fractures.

Baseline characteristics of them include age, gender, mechanism of injury, fracture pattern, site of fracture, associated injuries, surgical approach, delay from admission to time of surgery, operation time, and blood loss during operation.

Standard radiographs including AP pelvis [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 3]l and [Figure 3]m and Judet pelvis were taken in postoperative out-clinic consultations. We considered 6 months as the minimum time of follow-up to be included in the study [Figure 3]n. At the time of the most recent follow-up, each patient was clinically and radiographically evaluated. Radiological results were assigned according to the criteria described by Matta.[23] Excellent indicates a normal-appearing hip joint, good indicates mild changes with minimal sclerosis and joint narrowing, fair denotes intermediate changes with moderate sclerosis and joint narrowing (<50%), and poor denotes advanced changes. The functional outcomes [Figure 2]g and [Figure 2]h, [Figure 3]o, [Figure 4]g, and [Figure 4]h were assessed using Merle d'Aubigne and Postel's system modified by Matta et al.[24] [Table 1]. In addition, postoperative complications such as heterotopic ossification, osteoarthritis of hip, and avascular necrosis of head of femur were evaluated.
Figure 2: Patient 1 (a) pre-OP x ray pelvis showing posterior column fracture dislocation. (b) Pre-OP 3D CT after closed reduction. (c) Post-OP X-ray after fixation with matta plate. (d) Post-OP X-ray. (e) 9 months post-OP x ray showing union. (f) Pre-OP CT coronal view showing displacement and instability. (g) 9 months post-OP functional result. (h) 9 months post-OP functional result. OP = operative

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Table 1: Grading system of Merle d'Aubigné and Postel as modified by Matta et al.[24] for postoperative functiona evaluation

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  Results Top


Baseline characteristics

There were 18 patients with acetabular injury managed operatively in Renuka Orthopaedic Centre, Nalanda Medical College and Hospital, and Tara hospital, Bihar, India.

The mean age of the patients was 35.44±11.92 years old, ranging from 16 to 50 years.

There were 12 (66.66%) men and 6 (33.33%) women among the patients.

Eleven patients (61.11%) had acetabular injury related with road traffic accidents and seven (38.88%) of them had falls from a significant height.

The side of fracture was left in 10 (55.55%) patients and right in 8 (44.44%) patients.

Associated injuries were seen in six of the patients (33.33%). Lower extremities injury (16.6%) was the most common associated injuries, followed by upper extremities injury (11.11%), head injury (5.55%), and thoracic injury (5.55%), whereas both abdominal injury (5.5%) and vertebral injury (5.5%) were the least common.

The frequency of fracture patterns included posterior wall in 7/18 patients (38.8%), both columns in 3/18 patients (16.6%), posterior column/posterior wall in 2/18 patients (11.11%), posterior column in 2/18 patients (11.11%), T-type in 1/18 patients (5.55%), anterior column in 1/18 patients (5.55%), transverse/posterior wall in 1/18 patients (5.55%), anterior wall in 1/18 patients (5.5%).


  Clinical Outcomes Top


The mean follow-up of patients was 18.6 months (range 6-24 months). According to the Merle d'Aubigne and Postel scoring system modified by Matta, the clinical outcome was excellent in nine cases (50%), good in five cases (27.7%), fair in three cases (16.6%), and poor in one case (5.5%).

Patient 1: Post.column fracture dislocation

Patient 2: Ant.column fracture dislocation

Patient 3: T shaped Fracture involving both column


  Discussion Top


Acetabular fracture is intra-articular fracture, and it was historically an enigma for the orthopedic surgeons.[23] However, the trend changed with development of imaging modalities, fracture classification as described by Judet,[6] and introducing surgical management by Letournel.[9]

Nowadays open reduction internal fixation is gold standard for the displaced acetabulum fractures.

Our results showed about 68% excellent-to-good clinical outcomes at minimally 6 months postoperatively. The quality of reduction and clinical outcome are strongly correlated with the fracture type, and posttraumatic arthritis. Therefore, a comparison with other studies should be treated with caution. Whereas, the results from most of them are in line with our 68%. For example, Gupta et al.[1] reported 74%, Mayo[25] reported 75%, and Briffa et al.[26] reported 72% excellent to good clinical outcomes.

As mentioned by Matta et al.[24] the main complication following a fracture of the acetabulum is post-traumatic osteoarthritis. The incidence of osteoarthritis in our series could not be calculated because of short study duration, but its incidence in other studies is 52% as reported by Isaacson et al.[27] and 21.6% as reported by Negrin et al.[28]

Iatrogenic nerve injuries including sciatic nerve, femoral nerve, and lateral cutaneous nerve of thigh are possible complications during acetabular surgery. In our series, the overall incidence of sciatic nerve palsy was seen in two cases (11%), and other nerve damage was not seen. Nerve damage was 6% in a study by Shrestha et al.,[29] and reported 12% in another study.[26] It mentions that there was not any nerve damage in ilioinguinal approach, and it was seen in posterior approach. This is similar to what was reported by previous studies who treated the patients through anterior approach.[30],[31]

The incidence of deep vein thrombosis and pulmonary embolism are conflicting in Asian population. Sen et al.[32] reported 28.5% venous thromboembolism and 17.8% pulmonary embolism among the patients who had undergone acetabular surgery without chemical prophylaxis. In our study, all patients received mechanical prophylaxis, and just one patient developed pulmonary embolism. This is in concordance with result of an Indian study.[29]

In our study, deep infection was seen in one case, i.e., 5.5%, and two cases (i.e., 11%) had superficial infection. This rate is acceptable in comparing other studies that reported infection rate of 3-11%.[1],[26],[29]

Heterotopic ossification following acetabular fracture surgery may be related with increased postoperative pain and affected functional outcomes.[33] Moreover, it seems that race is an important factor. According to previous study, African American patients are considerably more likely to develop severe heterotopic ossification when compared to Caucasian patients.[34] In our study, 11% of our patients developed heterotopic ossification. Whereas 37.9% of the patients were affected by heterotopic ossification in an Austrian study, it was 25.6% in a study reported by Shrestha et al.[29]

In conclusion, a good-to-excellent functional outcome was seen in more than 60% of the patients and a good to excellent radiological outcome was seen in more than 50% of the patients treated surgically. Moreover, the rate of complication was acceptable in our study. In summary, the operative treatment for acetabular fractures gives universally satisfactory results. Thereafter, this study provides evidence that ilioinguinal approach is a good choice for anterior fractures, Kocher-Langenbeck is a good choice for posteriors fractures, and combined approach may be a good choice in the management of acetabular fractures involving two columns.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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