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ORIGINAL ARTICLE

Open reduction and internal fixation of posterior wall acetabular fractures: a study of 45 cases 

Bassi JL*, Chandarjeet Dattal**, Pankaj Mahindra***, Navdeep Singh***

*Dept of Orthopaedics, Dayanand Medical College, Ludhiana, India
**Consultant Orthopaedics, Panchsheel Hospital, Palampur, India
***Senior Registrar, Dayanand Medical College, Ludhiana, India
 
 
Address for Correspondence
 
J.L. Bassi
914/5, Tagore Nagar,Civil Lines, Ludhiana (Pb) 141001
INDIA  
 
Phone:  +91-9814438434
Tele Fax:  91-161-2304242
E-mail jlbassi@rediffmail.com

Abstract

Background: This study was done to evaluate the operative results of posterior wall fractures of the acetabulum.
Methods: This retrospective study included 45 patients who had undergone open reduction and internal fixation for posterior wall fractures of the acetabulum .Their functional outcome, at minimum of five years follow-up was evaluated.
Results: The post-operative reduction was graded as excellent in 35%, good in 40%, fair in16% and poor in 9% cases. 87.9% of patients operated within first five days had good or excellent reduction which was significantly more than those operated beyond this percentage.
Conclusion:
There is a positive relationship between quality of reduction and functional outcome. The quality of reduction is significantly affected by surgical lag. Though certain amount of degenerative changes is inbuilt in the mechanism of injury the main aim   should be to avoid unnecessary delay and always strive to achieve anatomical reduction for the best possible functional outcomes for the patient.

J.Orthopaedics 2007;4(1)e17

Introduction:

Acetabular fractures are one of those injuries in which even the best efforts of the treating surgeon may not bring back the patient to his pre injury level [11]. The main complication that may arise following a fracture acetabulum is post-traumatic osteoarthrosis [5]. This leads to significant discomfort, pain and loss of mobility. According to Judet and Letournel   operative treatment offers the best chance of reducing post traumatic osteoarthritis for all displaced acetabular fractures [5]. A study by Olson et al, has revealed that there occurs marked alteration in the mechanics of load transmission across the hip after fracture of the posterior wall of the acetabulum [14]. These findings are consistent with the clinical observations of Rowe and Lowell that conservative management of large fractures of the posterior wall of the acetabulum predisposes to hip osteoarthrosis [5]. This retrospective study was done to assess the results of the operative management of fractures of the posterior wall of the acetabulum.

Materials and methods:

Between July 1995 and April 2000, 53 patients with posterior wall fractures of the acetabulum were treated by open reduction and internal fixation at the department of Orthopedics, Dayanand Medical College and Hospital, Ludhiana.

Patientís whose five year follow-up was available were taken into the study group. Out of the 53 patients treated, follow-up of 45 patients was available. The study group consisted of 38 male and seven female patients. Right hip was involved in 26 cases and 19 cases had left sided involvement. The most common mechanism of injury was motor vehicle accident (40 patients). Three patients had motor vehicle pedestrian accident and two had fractured acetabulum after fall from height. Associated injuries were present in 30 patients. Twenty three of these had fractures other than fracture acetabulum, six had abdominal injuries, four had associated head injury and an equal number of patients had chest injury. There were two patients with sciatic nerve palsy.

All patients were evaluated pre- operatively with three standard plain radiographs (one AP and two oblique Judet views) and a two dimensional computed tomography scan. Kocher and Langenbeckís approach was used in 31 patients and an extensile triradiate approach was used in the remaining 14. A triradiate approach was preferred when visualization of the fracture was impaired because of obesity or musculature of the patient. When the triradiate approach was used, a desired anterior limb dissection was done along with greater trochanter osteotomy.

Prophylactic antibiotic (cephalosporin and aminoglycoside) treatment was used in the peri-operative period and were stopped on the 3rd post operative day. Ankle pump, static quadriceps and static glutei exercises were started on day one. Touch-down ambulation with support was started on 3rd to 4th day after surgery and full weight bearing was individualized.  Before the patient was discharged from the hospital, three standard radiographs of the pelvis were obtained. For each of these radiographs the maximum displacement seen, at any of the radiographic lines of the acetabulum or the innominate bone, was recorded in millimeters. The highest of the three values were used to grade reduction, according to the categories given in table 1.  

At each follow up three standard radiographs of the pelvis were taken. These radiographs were graded for changes according to the criteria described by Matta as shown in table II.

At five years, the patientís functional outcome was evaluated using the clinical grading system developed by Merle-d-Aubigne and Postel and subsequently modified by Matta [6]. This system has been generally accepted as the clinical grading system to evaluate results of acetabular fractures [11].  At follow up the AP radiographs were assessed for heterotrophic ossification and graded as per the Brooker et al classification [1].

Observation and results:

The post operative radiographs were assessed for adequacy of reduction. It was graded as excellent in 16 hips (35%), good in 18 hips (40%), fair in seven hips (16%) and poor in four (9%) hips. Twenty-nine out of thirty-three (87.9%) patients operated within five days had good or excellent reduction, whereas only 41.7% operated beyond five days had the same result. From table III it can be seen that there are significantly more chances of obtaining good or excellent reduction if patient is operated upon in first five days after injury.The final functional outcome as assessed by Merle-de-Aubigne and Postelís modified criteria, was excellent in 13 (29%), good in 17(38%), fair in seven (16%) and poor in eight (18%). As evident in table IV, 80% of the patients who had achieved good or excellent reduction post-operatively, had good or excellent functional outcome at five years follow-up. On the other hand only 13.3% of patients with fair or poor post-operative reduction could achieve a good functional outcome. This difference is statistically significant. Thus, the final functional outcome is strongly affected by post operative reduction achieved.

There were seven cases of osteoarthrosis. Two of these patients had severe joint space narrowing, osteophyte formation and required total hip replacement.  The other five had minimal joint space narrowing and sclerosis, out of which three had good and two had fair functional outcome. There were four cases of osteonecrosis out of which two were grade IV and required total hip replacement. In the other two patients, we did core decompression and their overall result was good. There were five cases of heterotrophic ossification, one grade I, one grade II and three grade III. We observed no correlation of development of heterotrophic ossification with regards to surgical approach and timing of operation.

There were no cases of iatrogenic nerve palsy. Two patients had post traumatic sciatic nerve palsy, both involving the peroneal component. One recovered partially with slight hypoesthesia in the peroneal distribution of nerve. The course of the other nerve palsy was static and later required foot drop splint during mobilization. There were three cases of wound infection, two acute and one late. Acute infection was treated by wound wash, debridement and closure over a suction drain. Antibiotics were given for a period of six weeks. These patients responded to treatment and the infection healed completely. One of the patients followed up late, at nine months with a discharging sinus. Radiograph of this patient showed chondrolysis and required excision arthroplasty. There were four cases of proved deep venous thrombosis and were treated by standard anticoagulant protocol.

Table I

Grading of reduction:-
Grade                          Displacement
Excellent                            0 - 1 mm
Good                                   < 2 mm
Fair                                    3 - 5 mm
Poor                                    > 5 mm

Table II

Relation between Surgical lag and the reduction

Surgical Lag

                         Reduction

Days

Excellent

Good

Fair

Poor

0-3

8

8

1

0

4-5

6

7

2

1

6-7

2

2

3

0

8-10

0

1

1

0

> 10 day

0

0

0

3

For statistical purpose, good or excellent reduction and fair or poor reduction were clubbed together and, number of days taken were 0-5 and > 6 days. The value of p is <0.01 and thus statistically significant.

 Table III

Relation of functional outcome to the quality of reduction

Reduction

Functional outcome

 

Excellent

Good

Fair

Poor

Excellent

6

7

1

2

Good

7

8

2

1

Fair

0

2

2

3

Poor

0

0

2

2

For statistical purpose good or excellent clinical results and fair or poor clinical results are clubbed together. Similarly good or excellent reduction and fair or poor reduction are clubbed together. P value is<0.01 and thus statistically significant.

Discussion :

The most important factor responsible for successful long term clinical outcome after surgical fixation of acetabular fracture is the quality of reduction [2, 5, 16]. In our study, the quality of reduction is significantly affected by surgical lag beyond five days.  Matta in his study of 262 acetabular fractures concluded that a surgical lag beyond fourteen days significantly affected the quality of reduction [6].

There are changes in the mechanisms of the hip joint after a fracture and a failure of anatomical operative repair to restore normal loading [14]. With the circumferential congruity of the acetabulum disrupted, the femoral head makes superior contact without the development of normal peripheral contact force. Decreased peripheral contact also explains the increase in contact force within the superior aspect of the acetabulum of the fractured joint. Hadley et al observed that increased pressure in the hip, when maintained for a period of years, was prognostic for degenerative changes [3]. The occurrence of post traumatic osteoarthritis is the greatest in patients with articular surgical incongruity or residual subluxation of hip joint. After a perfect reduction within 3 weeks of injury Letournel noted osteoarthritis in only 10.2% of cases as compared with 37.5% with imperfect reduction [5]. In our series, four out of eleven (36.7%) patients with fair or poor reduction developed osteoarthrosis, out of which two required total hip replacement. There were three out of 34(8.9%) patients with excellent or good reduction that developed osteoarthritis. In none was osteoarthrosis severe enough to warrant second surgery. The osteoarthrosis could be attributed to imperfect reduction and damage to femoral head or joint cartilage at the time of injury.

AVN can significantly affect post operative outcome [18].  The incidence of AVN after operative treatment of acetabular fracture has generally ranged from 3-9 % [5, 6, 7] with majority identified between three and eighteen months after surgery [5]. In our series there were four(9%) cases of AVN out of which two had grade IV AVN. Matta reported AVN in 8(3%) of 262 fractures [6], whereas Letournel and Judetreported AVN in19 of 492(4%) fractures [5]. Letournel has noted an increased incidence of AVN of the femoral head in cases presenting after 3 weeks and those associated with posterior fracture dislocation [5] .Higher rates of osteonecrosis (23%) have been reported by Wright [17].

Out of the five patients with heterotrophic ossification three patients were operated by triradiate approach. Out of these two had grade III and one had grade II heterotrophic ossification. In all three patients the final result was compromised because of heterotrophic ossification. In other two patients operated by Kocher and Langenbeck approach, one patient had grade I and other grade III heterotrophic ossification. In patient with grade III heterotrophic ossification, the result had deteriorated from initial good result at six months to fair result at final follow-up. Heterotrophic ossification results in significant loss of hip motion in fewer than 5% of patients [4, 12, 13]. Our results are in concurrence with the same.

There is a strong relationship between quality of reduction and clinical results [10]. Yet, certain amount of degenerative changes is inbuilt in the mechanism of injury. In all probability, the fate of femoral head is determined at the time of injury [2, 8]. The overall results from this series validate the efficacy of open reduction internal fixation as the treatment of choice for displaced posterior wall fractures of the acetabulum.

Reference :

  1. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement: incidence and a method of classification. J. Bone and Joint Surg Am. 1973 Dec; 55(8):1629-1632.

  2. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br. 2005 Jan;87(1):2-9

  3. Hadley NA., Brown TD, and Weinstein SL. The effects of contact pressure elevation and aseptic necrosis on the long term outcome of congenital hip dislocation. J. Orthop Res 1990 Jul; 8(4): 504-513.

  4. Kumar A, Shah NA, Kershaw SA, Clayson AD. Operative management of acetabular fractures. A review of 73 fractures. Injury. 2005 May;36(5):605-612

  5. Letournel E and Judet R.  Fractures of acetabulum, edited by R.A. Elson. New York, Springer, 1993.

  6. Matta JM. Fractures of acetabulum: Accuracy of reduction and clinical results in patients managed operatively within three weeks after injury. J. Bone and Joint Surg. Am. 1996 Nov; 78(1): 1632-1645.

  7. Matta JM, Anderson LM, Epstein HC, Hendricks P.  Fracture of the acetabulum: a retrospective analysis. Clin. Orthop. Rela. Res. 1986 Apr ;( 205): 230-240.

  8. Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res. 2003 Feb;(407):173-186

  9. Moed BR, Carr SE, Gruson KI, Watson JT, Craig JG. Computed tomographic assessment of fractures of the posterior wall of the acetabulum after operative treatment. J. Bone Joint Surg Am. 2003 Mar;85-A(3):512-522

  10. Moed Br, Willson Carr SE, Watson JT. Results of operative treatment of fractures of posterior wall of the acetabulum. J. Bone Joint Surg Am 2002 May;84-A(5):752-758

  11. Moed BR, YU PH, Gruson KI. Functional outcomes of acetabular fractures. J Bone Joint Surg Am. 2003 Oct;85-A(10):1879-1883

  12. Moed BR, Letournel E. Low dose irradiation and indomethacin prevent heterotrophic ossification after acetabular fracture surgery. J. Bone and Joint Surg.Br. 1994 Nov; 76(6): 895-900.

  13. Murphy D, Kaliszer M, Rice J, McElwain JP. Outcome after acetabular fracture. Prognostic factors and their inter-relationships. Injury. 2003 Jul;34(7):512-517.

  14. Olson SA, Bay BK et al. Biomechanical consequences of fracture and repair of the posterior wall of the acetabulum. J. Bone and Joint Surg. Am. 1995 Aug; 77(8): 1184-1192.

  15. Rowe CR, Lowell J.D. Prognosis of fractures of acetabulum. J. Bone and Joint Surg. Am. 1961 Jan; 43-A (1): 30-59.

  16. Tan KY, Lee HC, Chua D. Open reduction and internal fixation of the fractures of the acetabulum- local experience. Singapore Med J. 2003 Aug;44(8); 404-409.

  17. Wright R, Barret K, Christie MJ, Johnson KD. Acetabular fractures: Long term follow up of open reduction and internal fixation. J. Orthop. Trauma. 1994 Oct; 8(5): 397-403.

  18. Yu JK, Chiu FY, Feng CK, Chung TY, Chen TH. Surgical treatment of displaced fractures of posterior column and posterior wall of the acetabulum. Injury. 2004 Aug;35(8):766-770

 

This is a peer reviewed paper 

Please cite as : Bassi JL:Open reduction and internal fixation of posterior wall acetabular fractures: a study of 45 cases 

J.Orthopaedics 2007;4(1)e17

URL: http://www.jortho.org/2007/4/1/e17

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