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ORIGINAL ARTICLE

Outcome of Operatively Treated Anterior Column Fracture of the Acetabulum- A Short term Prospective Cohort Study

P. K. Sancheti, Atul Patil, A.K. Shyam, Kailash Patil,Milind Merchant.

Sancheti Institute of Orthopaedics and Rehabilitation, 16 Shivaji Nagar, Pune 411 005 Maharashtra, India.

Address for Correspondence:

A.K. Shyam.
Sancheti Institute of Orthopaedics and Rehabilitation,
16 Shivaji Nagar,
Pune 411 005,

Maharashtra, India.

Phone:  020 25536666, 91 9833110366
Fax    :  020 25533233
E-mail:
drashokshyam@yahoo.co.uk

Abstract:

Background: Treatment of the anterior acetabular fractures is known to have worse results than other fracture types. The operative results of the anterior acetabular fracture, however, have not been well documented and the literature concerning them is sparse. To determine the results of operative treatment for anterior column acetabular fractures, we did a prospective cohort study of 17 cases of anterior column fractures. Methods: A total of 17 patients had anterior column fractures, with an average follow-up period of 24 months; 1 anterior wall, 3 anterior column, 8 anterior fracture with posterior hemitransverse and 5 anterior wall with anterior column fractures. There were 15 men and 2 women, with a mean age of 36.6 years. The surgical approaches used were ilioinguinal approach used in 14 cases and extended iliofemoral approach used in 3 patients with delayed presentation. Postoperative radiographic results were evaluated by Matta’s criteria. Final clinical results were evaluated by a Harris Hip scoring system Results: All of the fractures healed. Postoperative radiology revealed 8 cases of anatomical reduction, 8 cases of imperfect reduction, and 1 cases of poor reduction. According to the clinical results, 16 patients had satisfactory results (11 excellent, 5 good), and 1 had poor result. Regarding complications, there were 1 case of traumatic osteoarthrosis and 1 of heterotopic ossification. The patients with an anatomical reduction had a higher satisfactory result rate. Poor reduction intra operatively seemed to have an adverse influence on the postoperative radiologic result as well as a correlation with the development of traumatic arthritis.

Conclusion: Anterior acetabular fractures have comparatively higher rates of imperfect reduction and may have a tendency toward traumatic osteoarthritis; however a longer follow up study is essential.

J.Orthopaedics 2009;6(4)e7

Keywords:

anterior acetabulum fractures; surgical management

 

Introduction:

Acetabular fractures are still and enigma and pose a major challenge to treating orthopaedic surgeon1. There is increase in the incidence of high velocity trauma resulting in complicated acetabulum fractures due to modernization2. The surgical treatment of acetabular fractures is a complex area that is being continually refined. Presently open anatomical reduction of the articular surface combined with rigid internal fixation and early mobilization is the standard treatment for these injuries3,4,5,6,7,8. The surgical management of these fractures involves a definite learning curve, probably best documented in a report by Matta and Merritt3 of the first 100 acetabular fractures treated operatively by Matta. Grouping the surgical reductions chronologically in groups of 20 clearly demonstrated that experience improved the ability to avoid unsatisfactory reductions and to perform anatomical reductions.

Problems like complex anatomy, difficult surgical approaches, perfect anatomic reduction necessary as major weight bearing joint, less space for operative maneuverability, comminution, and delayed presentation pose a challenge for the operating surgeon. Long term results, no matter which operative approach is used or fracture type is involved, are directly related to the quality of fracture reduction achieved6,9 . This point was first underlined by the long term follow up studies of Letournel and Matta in which they demonstrated that the fractures reduced to within 1mm of residual articular displacement have less incidence of posttraumatic arthritis and have a more durable and long-lasting functional hip joint than those fractures with 1 to 3 mm of residual displacement5,10. These series of operative management are considered as the gold standard in operative management of acetabulum fractures.

Pioneering work was done by Letournal and Judet in 1964 to systematically classify the acetabular fractures and to develop a logical line of thinking regarding management of these fractures11. Letournal and Judet conceived acetabulum to be made of two columns. Anterior column from below the sacroiliac joint to the ischial tuberosity and posterior column from superior iliac crest to pubic symphysis with both columns attached to the sacrum by thick strut of bone lying above greater sciatic notch and called sciatic buttress. Patients with associated fracture types according to the Letournel classification and those with injuries to the anterior wall and posterior column are most likely to have a poor functional outcome12,5. The anterior fractures are rare and literature about the operative results of anterior acetabular fracture is sparse. Here, we analysed our results regarding the surgical treatment of displaced anterior acetabular fractures with or without a minimal posterior involvement.

Materials and Methods:

This is a prospective cohort study of 17 cases of anterior acetabular fractures treated operatively between 2004 and 2006. The patients with anterior wall, anterior column, anterior fracture with posterior hemitransverse and anterior wall with anterior column fractures were included in the study taking into account Letournel’s classification5,13. The follow-up was for a minimum of 2 years. 6 patients had isolated acetabular fracture, and 11 had other associated fractures. All patients gave an informed consent to participate in the study and were prospectively followed up.

The patients with anterior wall, anterior column, anterior fracture with posterior hemitransverse and anterior wall with anterior column fractures were included in the study taking into account Letournel’s classification13. The indications for surgery were fractures of the anterior wall and/or column that are characterized by intraarticular gaps or steps of > 3 mm in the area of the main weight-bearing dome of the acetabulum, fractures complicated by subluxation or dislocation of the femoral head, an intraarticular fragment making the joint incongruous and interfering with joint movement and roof arc angle < 45deg. The patients with revision surgeries were excluded.     All patients were initially stabilized hemodynamically and then anteroposterior (AP) and Judet views were taken. A CT scan with a 3D reconstruction was obtained preoperatively in all patients. Patients were immobilized in a skeletal traction after the radiographs were taken. The fractures were classified according to the Letournel and Judet classification.

All the patients were operated within 4 weeks of trauma. The ilioinguinal approach was used in most patients while extended iliofemoral approach was used in cases with delayed presentation > 3 weeks. The ilioinguinal approach was performed with the patient in a supine position with a slightly elevated ipsilateral half of pelvis and the hip and knee flexed to 30 to 40 degrees to relax the neurovascular structures under the inguinal ligament. Intraoperative fluoroscopy was used to assess reductions.

Immediate postoperatively AP views and Judet views were taken. Post operatively all patients were immediately mobilized non weight bearing with the help of crutches or walker except who had polytrauma. All patients were reviewed clinically and radiologically at 3, 6, 12 and 18 months. After that they were reviewed every 12 months.

All operations were performed jointly by the 2 senior authors. Cefuroxime was used as prophylactic antibiotic. Postoperatively, 75mg of Indomethacin in 3 divided doses daily was given for 6 weeks for prophylaxis against heterotopic ossification14.

Follow-up included ongoing evaluation with radiographic films and assessment of range of motion of hip joints, degree of pain using the Visual Analogue Scale (VAS), and the degree of ambulation. The outcome of patients was evaluated by the Harris Hip Scores (HHS) and Visual Analogue pain Scale. Postoperative radiographic results were evaluated by Matta’s10 criteria (anatomic reduction <1mm; imperfect 1–3mm; poor >3mm). The patients were at the latest follow-up graded as per ambulation status and shortening.

 The presence of ectopic bone, sclerosis, spur formation of femoral head, congruence of the femoral head with acetabulum, signs of degeneration of the femoral head and acetabulum were assessed from the radiographs. Heterotopic ossification was evaluated and graded according to the classification of Brooker et al 15          

Results :

There were 15 males and 2 female patients with average age of 36.6 years (range, 17-66 years). The mechanisms of injury were fall from a two-wheeler in 8 patients, road accidents in 6, and 3 patients had a fall from height. 6 were left sided fractures while 11 were right sided. We did not have any patients with bilateral acetabular fractures.

The fractures were classified according to Judet and Letournel with 1 anterior wall, 3 anterior column, 8 anterior fracture with posterior hemitransverse and 5 anterior wall with anterior column fractures. None of the cases had any compound fractures.

One patient had sciatic nerve palsy preoperatively. All patients had a displaced fracture of acetabulum with intraarticular step more than 2 mm in all. The average roof arc angle as measured on AP view, obturator oblique view and iliac oblique view are 17.29 degrees, 20.24 degrees and 19.77 degrees respectively.

Out of the 17, six were polytrauma cases with 1 patient with a head injury and 1 with chest injury. There were no associated spinal injuries. 6 cases had associated ipsilateral lower extremity fractures and 4 had associated upper extremity fracture. 3 patients also had concomitant pelvic ring injuries and 1 had a femoral neck fracture. 2 patients had Moralle- Lavalle lesions, both of which resolved spontaneously. None of the patient had any associated bladder or urethral injuries. 4 cases presented with central hip dislocations along with anterior columnar fractures which were reduced with lateral skeletal traction. We had no incidence of anterior or posterior dislocations.

The average injury- operative interval was 8 days (range 1-28 days). The ilioinguinal approach was used in 14 cases and extended iliofemoral approach was used in 3 patients with delayed presentation. 5 patients had comminution of which 3 were anterior fracture with posterior hemitransverse and 2 were anterior column with a quadrilateral plate fracture.

The average operating time including the positioning of patient was 158 min (range 90- 320). The average blood loss was 515 ml (range 350-850 ml) and blood transfusions were required in 8 patients.

The quality of reduction was measured postoperatively on radiographs and was anatomic in 8, imperfect in 8 and poor in 1 case as per grading by Matta et al.

The average Visual Analogue Pain Score at the end of 3 months was 6.13 (range 5-8), at the end of 6 months was 3.94 (range 3-5), at the end of 1 year was 3.19(range 2-5) and at the end of 2 years was 2(range 1-5).The average HHS at 3 months was 69, at 6 months was 77, 1 yrs was 83.7, and at 2 yrs was 90.05. According to the clinical results, 16 patients had satisfactory results (11 excellent, 5 good), and 1 had poor result.

Heterotopic ossification developed in 1 patient who had Grade II according to Booker’s classification. He had no functional impairment due to heterotopic ossification.

Osteonecrosis was seen in none of the cases. 1 patient had post-traumatic osteoarthrosis of the hip. As expected, he had non anatomic reduction of intraarticular fragments with a poor reduction as per Matta’s grading . He developed a shortening of 1.5 cms. Another patient of associated polytrauma had 1 cm of post-operative shortening.

Additional complications included a superficial wound infection and a hematoma which healed with oral antibiotics without further problems. None of the cases had any intraoperative or postoperative neurovascular complication although one case had preoperative partial sciatic nerve palsy which did not recover fully at the final follow-up.

At the final follow-up 14 patients were walking independently of any walking aid, 2 were walking full weight bearing with help of a walking stick and 1 patient who had had an above knee amputation walking with an artificial prosthesis. Figure 1 to 4 shows two cases of our series with pre operative and final radiographs.

Figure 1:  Twenty three year old male having right anterior column fracture as seen on Judet view and 3-D CT scan

Figure 2:  same patient as in fig 1 treated by ilioinguinal approach using reconstruction plate[A]. B and C show 30 months follow up with good union

Figure 3: thirty four year male with anterior column and posterior hemitransverse fracture as seen on antero-posterior and Judet view radiographs.

Figure 4: Same patient as shown in Figure 3 treated with anterior plating with good union at 36 months follow up.

Discussion :

To our knowledge this is the first prospective series studying the anterior acetabular fractures in English literature. 16 of 17 patients operated upon in our series had excellent or good result at a early follow up of 2 years and these results were comparable to other authors.

According to a recent metaanalysis13 the anterior fractures constitute about 10.2% of the total acetabular fractures (this included the anterior wall, anterior column and anterior with posterior hemi-transverse). A road traffic accident was the causative mechanism in 80.5% of patients, 10.7% had falls and in 8.8% other causes were stated. In our series there were 14 cases of road traffic accident (82.3%) and three cases of fall from height which is almost similar to the meta-analysis data. Pre operative sciatic nerve injury was noted in 16.4% in the above article while we had only one case (5.8%) of sciatic nerve injury. This may be because most of the sciatic nerve injuries were noted in posterior fractures especially those with posterior dislocation and our series had no cases of posterior dislocation.

The goal of acetabular fracture treatment is to have a hip with good long-term function and the avoidance of posttraumatic osteoarthritis7,10,16. Letournel and Judet17 introduced the operative concepts of open reduction and internal fixation for acetabular fractures. The extent of influence the initial fracture pattern has on clinical outcome of acetabular fractures has been studied18,19,20. The radiographic roof arc angle is originally used to determine whether a fracture line crosses the weight-bearing dome21. It is also important to know the extent of the fracture when trying to predict clinical outcome. In our series all cases were selected according to the indications for operative treatment as stated by Matta et al thus this bias was eliminated. There were however 3 cases with comminution but there effect on final outcome cannot be pointed out as none of the cases with fair or poor results were having pre operative comminution.

Over the years the use of ilioinguinal approach was emphasized because of the good results it usually provided including non development of heterotopic ossification and quick rehabilitation. Giannoudis et al13 stated that incidence of HO is overall 25.6% and differs with surgical approach with highest incidence of 23.6% for iliofemoral approach and incidence of 1.6% for ilioinguinal approach. Chiu et al22 reported incidence of 5.6% with ilioinguinal approach and 66.7% in cases operated by iliofemoral approach. In our series we had only one case of booker grade II HO in a case operated by the iliofemoral approach. However since we used this approach in cases with delayed presentation only, this may also be a confounding factor in development of HO. This case in our series had good result and no functional limitation that can be attributed to the HO. We had no case of HO in cases operated with ilioinguinal approach thus agreeing with the literature about the low incidence of Ho, however, reduction of the posterior column can be a problem with this approach, especially of there is also a rotation of the posterior column.

A minimum follow up of 2 years was chosen as an acetabular fracture is intraarticular and osteoarthrosis will usually develop within the first 2 years. No major changes were found in clinical, functional and radiographic results between 1 to 2 years postoperatively. It appears that if the result is clinically and radiologically good or excellent and stable from the time of operation, without any signs of degenerative disease after 1 year, the long term outcome will not usually change however a long term study will be essential to study the validity of this statement. Traumatic osteoarthrosis is one of the worst complications of acetabular fractures, and many clinical studies have found that incongruent reduction of an acetabular fracture can lead to poor functional outcome because of posttraumatic arthrosis5,16. Analysis of literature states that the postoperative reduction was recorded as being satisfactory, with less than 2 mm of displacement, in 85.6% of fractures13. In our study however there were 8 cases with imperfect reduction and one case with poor reduction i.e. a total of 9 out of 17 (53%) with non anatomical reduction. This percentage for anterior acetabular fractures is significantly more than what is stated in literature for all acetabular fractures. Giannoudis et al13 also noted that if the reduction was satisfactory (≤ 2 mm), the incidence of osteoarthrosis was 13.2% and if the reduction was not satisfactory (> 2 mm), it increased to 43.5%. In this study with a relatively short follow-up, 1 of 17 patients (5.8%) developed osteoarthritis. As anticipated, this patient had not achieved anatomical reduction. However a longer follow-up will be required to study the correlation between imperfect reduction and development of osteoarthrosis in our series although we believe that anatomical reduction of the weight-bearing dome of the acetabulum should be achieved to minimize the incidence of posttraumatic arthritis.

There are several limitations to the present study. The incidence of anterior acetabular fractures is relatively lower than that of posterior fractures, so the study is underpowered and the number of patients may be insufficient to draw concrete conclusions. However since the study is still ongoing we will be enrolling more patients and follow-up time targeted as minimal 5 years so as to present a comprehensive study of these anterior acetabular fractures. 

Conclusion:

The surgical outcome depends on many factors; the ability of the surgeon to classify the fracture; choose the appropriate approach; to have adequate and proper instruments, theatre facilities and to employ a proper surgical technique so as to get a near anatomic reduction. Inspite of clearing these hurdles there are other factors that are not in surgeons control and can give a poor outcome like late presentation, gross comminution, and osteoporosis. Present study indicates that anterior acetabular fractures have comparatively higher rates of imperfect reduction and may have a tendency toward traumatic osteoarthritis, however a longer follow up and an appropriately powered study is essential to make other conclusions regarding these fractures.

Reference :

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  2. Gupta RK, Singh H, Dev B, Kansay R, Gupta P, Garg S. Results of operative treatment of acetabular fractures from the Third World--how local factors affect the outcome. Int Orthop. 2009 Apr;33(2):347-52.

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  6. Matta JM, Mehne DK, Roffi R (1986) Fractures of the acetabulum: early results of a prospective study. Clin Orthop Relat Res 205:241–250.

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  10. 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.

  11. Judet R, Judet J, Letournel E. Fractures of the acetabulum: Classification and surgical approaches for open reduction. J Bone Joint Surg Am. 1964;46A:1615-38.

  12. 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.

  13. E Letournel, Acetabular fractures, Current  Orthopaedics Volume 3, Issue 4, October 1989, Pages 233-243.

  14. Burd TA, Lowry KJ, Anglen JO. Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures. J Bone Joint Surg [Am] 2001;83-A:1783-8.

  15. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement: incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629–32.

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  17. Saterbak AM, Marsh JL, Nepola JV, Brandser EA, Turbett T. Clinical failure after posterior wall acetabular fractures: the influence of initial fracture patterns. J Orthop Trauma 2000; 14: 230–7.

  18. Moed BR, Carr SE, Gruson KI, Watson JT, Craig JG. Computed tomography assessment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am 2003;85:512–22.

  19. Vrahas MS, Widding KK, Thomas KA. The effects of simulated transverse, anterior column and posterior column fractures of the acetabulum on the stability of the hip joint. J Bone Joint Surg Am 1999; 81:966–74.

  20. Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop 2003;407:173-86.

  21. Heeg M, Oostvogel HJ, Klasen HJ. Conservative treatment of acetabulum fractures: the role of the weight- bearing dome and anatomic reduction in the ultimate results. J Trauma 1987; 27:555– 9.

  22. Chiu FY, Chen CM, Lo WH. Surgical treatment of displaced acetabular fractures: 72 cases followed for 10 (6-14) years. Injury 2000;31:181-5.

This is a peer reviewed paper 

Please cite as: A.K. Shyam: Outcome of Operatively Treated Anterior Column Fracture of the Acetabulum- A Short term Prospective Cohort Study.

J.Orthopaedics 2009;6(4)e7

URL: http://www.jortho.org/2009/6/4/e7

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