Surgical treatment of displaced acetabular fractures - 72 cases followed for 10 (6-14) years

Predictor variables in acetabular fractures surgically treated

INTRODUCTION

Up to 25% of acetabular fractures have poor functional outcomes in short-term follow-up. The aim of our study is to analyze predictors related to poor outcome in surgically treated acetabular fractures. Damage to the femoral head cartilage and poor fracture reduction has been reported as predictors to total hip arthroplasty (THA).

MATERIAL AND METHODS

retrospective study of 207 consecutive patients with acetabular fractures, over a fourteen-year period. Demographic data, fracture pattern according to AO/OTA, complications related to surgery and predictor variables were analyzed.

RESULTS

Analyzing predictor variables, we observed seagull sign, femoral head dislocation, femoral osteochondral damage, acetabular marginal impaction, poor acetabular roof congruency after surgery (p < 0.001) and postoperative fracture congruence (>3mm) (p < 0.023) statistically related to the need of a THA during follow-up. Age (p = 0,98), Sex(p = 0,27), AO-OTA classification (p = 0,10), type of dislocation (p = 0,25), surgical approach (p = 0,57), time to surgery (p = 0,66) and posterior wall involvement (p = 0,06) were not related to THA. Most frequent complication was nerve injury, affecting 22 patients (20.18%). Only seventeen patients (15.6%) needed a THA at an average time of 6 years after initial open reduction and internal fixation.

CONCLUSION

Femoral head damage and dislocation, fracture reduction, and seagull sign were the strongest predictors related to THA after surgical treatment of acetabular fractures.

Factors influencing functional outcomes following open reduction internal fixation of acetabular fractures

INTRODUCTION

Recent large series of patient-reported outcomes after acetabulum fracture are limited, and potentially modifiable risk factors may be unidentified. The goal of this study was to describe patient and injury factors which negatively influence functional outcomes following operative management of acetabular fractures.

METHODS

699 patients with acetabular fractures were treated with open reduction and internal fixation (ORIF). Musculoskeletal Function Assessment (MFA) questionnaire was completed after a minimum 12 months post-injury by 283 adults. MFA scores range from 1 to 100 and higher scores represent greater dysfunction. Factors were assessed for potential association with MFA scores, and univariate and multiple linear regression analyses were performed.

RESULTS

Survey respondents were more severely injured than non-respondents, with more chest injury (38% vs 22%, p<0.001) and higher Injury Severity Score (19.3 vs 16.8, p=0.003). Patients were 69% male with mean age 44.0 years. Approximately one-third were smokers (31%), while 14% had comorbid diabetes mellitus type II. The majority of injuries occurred during a motor vehicle collision (65%); low-energy mechanisms were rare (4.2%). The most common fracture pattern was isolated posterior wall (23%), followed by transverse/posterior wall (21%). Heterotopic ossification (HO) was noted in 22%: Brooker 1: 29.5%, 2: 23.0%, 3: 32.8%, and 4: 14.8%. Tobacco use (β = 18.4, p<0.001), obesity (β = 0.39, p=0.009), diabetes (β = 8.2, p=0.029), post-traumatic arthrosis (PTA) (β = 5.94 p=0.035), and increasing HO severity (β = 8.93, p<0.001) were independently associated with worse MFA scores. Tobacco use had the strongest association, followed by the severity of HO.

CONCLUSION

In a large series of patient-reported functional outcomes following fixation of acetabular fractures, tobacco use, obesity, comorbid diabetes, PTA, and HO were associated with worse MFA scores. Further study to mitigate HO should be considered.

LEVEL OF EVIDENCE

III.

Fixation of Displaced Acetabular Fractures With an Anatomic Quadrilateral Surface Plate Through the Stoppa Approach

Satisfactory fixation for displaced acetabular fractures involving the quadrilateral surface remains difficult to obtain with conventional reconstruction plates. To achieve minimally invasive management of fractures of the quadrilateral surface, the authors designed a type of anatomic quadrilateral surface plate (AQSP). A retrospective study to assess the therapeutic results of the AQSP was performed at their institution. A total of 26 patients with quadrilateral surface fractures fixed with an AQSP through the Stoppa approach from February 2014 to February 2015 were included in this study. There were 16 men and 10 women with a mean age of 37.5 years. The patients were followed for a mean of 28.81 months (range, 24-36 months). The mean operative time was 98.85±16.08 minutes, and the mean intraoperative blood loss was 353.85±124.84 mL. Postoperative radiographs and computed tomography scans showed that anatomic and good reductions were obtained in 88.46% (23 patients) and 11.54% (3 patients) of the patients, respectively. Screw loosening was not observed. All of the fractures healed well at a mean of 3.54 months. Two cases of obturator nerve injury and 1 case of corona mortis rupture were observed. However, permanent complications were not observed. The mean Merle d'Aubigné score at final follow-up was 16.38±1.33 points. The authors conclude that satisfactory fixation with the AQSP system can be achieved through the Stoppa approach. [Orthopedics. 2019; 42(2):e180-e186.].

Heterotopic Ossification following acetabular fixation: Incidence and risk factors: 10-year experience of a tertiary centre

BACKGROUND

Heterotopic Ossification (HO) is a well-recognized complication following acetabular fracture fixation and its presence is prognostic for suboptimal clinical outcome. There are many controversies pertaining to its aetiology, including surgical approach, associated injuries and the use of HO prophylaxis. Long term data from high volume centres is necessary to address these issues.

AIM

To determine the incidence of HO post open reduction and internal fixation (ORIF) of acetabular fractures and to examine the associated risk and prognostic factors.

METHOD

We studied a cohort of 369 consecutive acetabular fractures that underwent ORIF at our institution over a 10 year period. Data was analyzed using univariate and multivariate logistic regression.

RESULTS

The existence of HO was evident in 65 patients (17.62%), of these 39 (60.0%) were Class I, 16 (24.6%) were Class II, 8 (12.3%) were Class III, and 2 (3.1%) were Class IV according to Brooker Classification. We found a significant association between admission to an Intensive Care Unit (ICU) (P-value=0.039), chest injury (P-value=0.013), multiple fractures (P-value=0.005), and the time lapse between injury and operation (P-value=0.025), and some statistical significance with surgical approach, ipsilateral fractures, open fractures, tibial and patellar fractures. Age over 30 years as the only prognostic factor for severe HO. Prophylaxis with Indomethacin did not appear to confer any benefit in our patient group.

CONCLUSION

The risk factors for developing HO following acetabular fracture fixation are multifactorial and include admission to ICU, associated chest injuries, multiple fractures and delay between injury and surgery. Surgical approach, ipsilateral fractures and tibia and patellar fractures may also play a role. Age over thirty years was the only prognostic factor for developing severe HO.

Radiographic Measurement of Displacement in Acetabular Fractures: A Systematic Review of the Literature

OBJECTIVES

To report methods of measurement of radiographic displacement and radiographic outcomes in acetabular fractures described in the literature.

METHODS

A systematic review of the English literature was performed using EMBASE and Medline in August 2014. Inclusion criteria were studies of operatively treated acetabular fractures in adults with acute (<6 weeks) open reduction and internal fixation that reported radiographic outcomes. Exclusion criteria included case series with <10 patients, fractures managed >6 weeks from injury, acute total hip arthroplasty, periprosthetic fractures, time frame of radiographic outcomes not stated, missing radiographic outcome data, and non-English language articles. Basic information collected included journal, author, year published, number of fractures, and fracture types. Specific data collected included radiographic outcome data, method of measuring radiographic displacement, and methods of interpreting or categorizing radiographic outcomes.

DATA SYNTHESIS

The number of reproducible radiographic measurement techniques (2/64) and previously described radiographic interpretation methods (4) were recorded. One radiographic reduction grading criterion (Matta) was used nearly universally in articles that used previously described criteria. Overall, 70% of articles using this criteria documented anatomic reductions.

CONCLUSIONS

The current standard of measuring radiographic displacement in publications dealing with acetabulum fractures almost universally lacks basic description, making further scientific rigor, such as testing reproducibility, impossible. Further work is necessary to standardize radiographic measurement techniques, test their reproducibility, and qualify their validity or determine which measurements are important to clinical outcomes.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Assessment of functional outcomes of surgically managed acetabular fractures

We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling.

Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results.

Cite this article: Bone Joint J 2016;98-B:690–5.

EPIDEMIOLOGY OF ACETABULUM FRACTURES TREATED AT THE INSTITUTO NACIONAL DE TRAUMATOLOGIA E ORTOPEDIA (INTO)

Objectives: The purpose of this study was to review the epidemiological aspects of displacement fractures of the acetabulum that had been treated surgically at the National Institute of Traumatology and Orthopedics (INTO). Methods: We retrospectively analyzed 126 acetabulum fractures that had been treated surgically at INTO between March 2006 and November 2008. The following factors were taken into account: age, sex, trauma mechanism, injury classification, time elapsed between trauma and surgery, affected side and associated bone injuries. Results: 76.8% were male; the mean age was 39.6 years. The trauma mechanism was traffic accidents in 59%; the time that elapsed between injury and surgery was on average 16.4 days; 55% of the cases were on the right side; 30% of the patients presented associated fractures. Conclusion: Most of the patients were male, in an economically active age group, and were victims of traffic accidents. Edge and/or posterior column fractures were the most frequent types. Associated injuries were common and most of the fractures operated in our service came to us late.

Analysis of Predictors of Results after Surgical Treatment of Acetabular Fractures

Purpose

The aim of this study was to analyze the factors affecting the outcomes after surgical treatment of acetabular fractures.

Materials and Methods

Between January 2000 and December 2012, 106 patients with acetabular fractures were treated with open reduction and internal fixation. We performed a retrospective cohort study to analyze the factors which may influence a patient's prognosis after surgical treatment of an acetabular fracture. The factors examined included age, femoral head injury, fracture type, dislocation, initial displacement, delay to injury-related surgery (in days), and quality of reduction. Additionally, we investigated clinical and radiological outcomes, as well as the development of osteoarthritis.

Results

Patients included 85 males (80.2%) and 21 females (18.8%) with a mean age of 50.4 (17-78) years. The mean follow-up period was 2.6 (1-10) years. In a univariable regression analysis, quality of reduction, age, and initial displacement were significantly associated with radiological and clinical outcomes. In a multivariable regression analysis, quality of reduction (P<0.001) and initial displacement (P=0.001) were found to be factors predictive of clinical and radiological outcomes. Additionally, the quality of reduction (P=0.005) was found to be predictive of osteoarthritis development.

Conclusion

Study results indicated that the quality of reduction was the most important factor influencing the prognosis of patients with acetabular fractures.

Acetabular fractures labelled poor surgical choices: Analysis of operative outcome

PURPOSE

We report the surgical outcome in 52 patients with acetabular otherwise considered as poor surgical choices.

METHODS

43 male and 9 female patients were operated at a mean age of 43 years and followed up for a mean duration of 60.3 months. There were 22 elementary fractures and 31 associated ones according to Letournal and Judet classification. Osteosynthesis was attempted in 48 patients whereas a primary total hip arthroplasty was performed in 4 patients. Outcome was assessed radiologically and functionally employing Harris Hip Score (HHS).

RESULTS

Average HHS in osteosynthesis group was 82.56 ± 12.4 with excellent to good results in 59.6% of the cases. Symptomatic osteoarthritis occurred in 13.5% of cases, avascular necrosis and severe heterotopic ossification in 7.7% each, infection and nerve palsy in 11.5% each.

CONCLUSION

Although the complication rates in this series is marginally more than that reported in literature, we recommend that the indications of surgical fixation in acetabular fractures need to be extended to those which were considered poor surgical choices.

Long term results after surgical management of posterior wall acetabular fractures

BACKGROUND

Posterior wall fractures are the most common of all acetabular fractures, and there is universal consensus that displaced fractures are best treated with anatomical reduction and stable internal fixation. Though early and mid term results for such studies are available, few shed light on long term results. This study was performed to evaluate long term functional and radiological outcomes in patients with posterior wall acetabular fractures and to determine factors that may contribute adversely to a satisfactory final outcome.

MATERIALS AND METHODS

We retrospectively analysed the hospital records for patients who underwent open reduction and internal fixation (ORIF) for posterior wall acetabular fractures. Twenty-five patients (20 men, five women), including one with bilateral posterior wall fracture, with a mean age of 41.28 ± 7.16 years (range 25-60 years) and a mean follow-up of 12.92 ± 6.36 years (range 5-22 years) who met the inclusion criteria formed the study cohort. Matta's criteria were used to grade postoperative reduction and final radiological outcome. Functional outcome at final follow-up was assessed according to d'Aubigné and Postel score.

RESULTS

Anatomic reduction was achieved in 22 hips, imperfect in four and poor in none. Radiological outcome at final follow-up revealed excellent results in ten hips, good in eight, fair in five and poor in three. The final d'Aubigné and Postel scores were excellent in 14 hips, good in six and fair and poor in three each. Patients with anatomical reduction had a favourable functional and radiological long term outcome. However, the presence of associated injuries in lower limbs and a body mass index (BMI) >25 adversely affected the final functional outcome. Osteonecrosis was seen in three patients, heterotopic ossification in two and Morel Lavallee lesion in one. One patient had postoperative sciatic nerve palsy, which recovered 6 weeks after surgery.

CONCLUSION

Anatomic postoperative reduction leads to optimal functional and radiological outcome on long term follow-up; however, the presence of associated lower-limb injuries and BMI >25 adversely affects a satisfactory final outcome in patients with posterior wall acetabular fractures.

LEVEL OF EVIDENCE

(Level 4) Retrospective case series.

Surgical dislocation technique for the treatment of acetabular fractures

BACKGROUND

Surgical hip dislocation allows for a 360° view of the acetabulum and may facilitate a reduction in selected acetabular fractures. To our knowledge there is no description in the literature of the different techniques used to reduce acetabular fractures through this approach. The aims of this study are to describe a technique of hip surgical dislocation to treat a variety of acetabular fracture patterns and to ascertain the early results with this technique, including the quality of fracture reductions achieved, clinical results, operative time, and complications such as avascular necrosis and heterotopic ossification.

DESCRIPTION OF TECHNIQUE

The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. T-type, transverse fractures alone or associated with posterior wall could be reduced with specific clamps and reduction adequacy can be judged by direct view. Anterior column fixation could be performed with one or two screws; the posterior column could be fixed with a single posterior plate or with two plates if a transverse fracture is associated with a posterior wall fracture.

METHODS

Between 2005 and 2011, we used this approach selectively to manage those types of fractures; during the period in question, we treated 312 acetabular fractures surgically, of which 31 (10%) were treated using this approach. Patient demographic, injury, and surgical variables as well as complications were recorded. Outcomes were evaluated with the Merle d'Aubigné and Postel system. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs (AP and Judet views). Minimum followup was 24 months (mean, 43 months; range, 24-87 months).

RESULTS

Fracture reduction was defined as anatomic in 65% cases, imperfect in 16%, and poor in 19%. Mean Merle d'Aubigné score was 15 points (out of 18, with higher scores being better). Two patients developed symptomatic femoral head avascular necrosis.

CONCLUSIONS

In complex cases, surgical dislocation presents several advantages; a single approach may reduce surgical time, permit direct intraarticular assessment, and facilitate screw placement closer to the articular surface. It also presents several limitations; some difficulties with bone-reduction clamp positioning, limited fixation of the anterior column, and a small risk of greater trochanter malunion.

Surgical management of acetabular fractures: a case series

INTRODUCTION

For decades, acetabular fractures were treated conservatively. Judet et al. in 1960s established the operative treatment of these fractures by continuous improvement of pre-operative evaluation and classification of fractures. Several studies demonstrated that accurate fracture reduction decreases the incidence of post-traumatic arthritis and improves functional outcome.

CASE SERIES

We report 67 consecutive patients who underwent surgical treatment for acetabular fracture; 44 patients were available for follow-up. In 35 (79.5%) cases, congruent reductions were achieved. The final mean Harris hip score was 81.8 (53-95). Functional outcomes according to Harris score were excellent and good in 31 patients (70.5%).

CONCLUSIONS

The results of internal fixation of displaced acetabular fractures in our series were satisfactory.

Acetabular fracture: long-term follow-up and factors associated with secondary implantation of total hip arthroplasty

HYPOTHESIS

The present study sought to determine long-term outcome in acetabular fracture and the factors associated with secondary implantation of a total hip arthroplasty and/or with poor functional results.

MATERIAL AND METHODS

Seventy-two patients admitted between 2000 and 2005 were followed up for a maximum 11 years (mean, 6.8 years): 16 females, 56 males; mean age at injury, 41.6 years (median, 40 years). There were 45 simple acetabular fractures, 27 complex fractures and 27 dislocations. Late complications were: osteoarthritis (n=29), osteonecrosis of the femoral head (ONFH: n=8) and heterotopic ossification (n=2).

RESULTS AND DISCUSSION

Twenty-five total hip arthroplasties (THA) were performed, with a mean time to surgery of 3.7 years. Associated factors for THA were: VAS (P<0.0001), PMA (P<0.0001), osteoarthritis (P<0.0001), ONFH (P<0.0002), initial dislocation (P=0.0002), no functional treatment (P=0.0014), surgical treatment (P=0.0065), initial traction (P=0.0068), anterior and posterior congruency defect (P=0.0072 and P<0.0001), and initial intra-articular foreign body (P=0.045). Factors associated with poor or bad functional results were the same, plus: etiology (P=0.0021), BMI (P=0.03) and posterior wall fracture (P=0.0325).

LEVEL OF EVIDENCE

4; retrospective study.

Quadrilateral plate fractures of the acetabulum: an update

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures, which are not specifically defined by any current classification system. Their incidence is increasing due to the rising number of elderly osteoporotic fractures. They have always been notoriously difficult fractures to treat. We present a systematic review of conservative and operative management and their respective outcomes over the last century.

Quality of life after operative fixation of displaced acetabular fractures

OBJECTIVE

The aim of this study was to determine quality of life (QoL) changes over time after internal fixation of acetabular fractures.

DESIGN

This pertains to a prospective cohort study, which was single centered.

SETTING

The study was conducted at the University Hospital.

PATIENTS

One hundred thirty-six patients (108 men, 28 women), age 17-83 years operated for an acetabular fracture during 2004-2008 were prospectively included and followed up for 2 years.

MAIN OUTCOME MEASURES

QoL was evaluated via Short Form-36 (SF-36) and Life Satisfaction-11 at 6, 12, and 24 months. Radiographs were evaluated according to Matta at 2 years.

RESULTS

The most frequent fracture types were posterior wall (n31), associated anterior-posterior hemitransverse (n34), and associated both column (n29). One hundred twenty-nine patients could be assessed at 2 years, 4 did not respond, and 3 had died. The patients scored lower than norms in all 8 SF-36 domains with improvement over time for Physical Function (P < 0.0001) and Role Physical (P < 0.0001). The patients with postop reduction 0-1 mm scored better (P < 0.001-0.039) in 7 domains, all except vitality (P = 0.07), when compared with patients with residual displacement of ≥2 mm. Life satisfaction did not change with time and showed lower scores than normative in 9 of 11 items. Nineteen patients had undergone total hip replacement, and the strongest predictor was acetabular or femoral head impaction.

CONCLUSIONS

QoL in surgically treated patients with displaced acetabular fracture keeps improving in physical SF-36 domains over a 2-year period although still lower than norms, and anatomical reduction results in better QoL outcome in most dimensions.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Acetabular fractures]

Treatment of acetabular fractures requires extensive knowledge of the bony anatomy, the amount of possible exposure of the bone with the selected approaches and fracture type-dependent indications of operative treatment. Classification of the fracture with detailed analysis of the fracture morphology is the basis for decision making and planning. The primary treatment aim is the anatomic reconstruction of the acetabulum which results in optimal long-term results.The basis of this overview is the presentation of standard treatment concepts in acetabular fracture surgery. Beside characteristics of the acetabular bony anatomy, biomechanical and pathomechanical principles and the relevant radiological anatomy, the treatment options, both conservative and operative and basic principles of the indications for standard surgical approaches will be discussed.The special fracture type is discussed in detail regarding incidence, injury mechanism, concomitant injuries, options for conservative and operative treatment, quality of operative reduction and long-term results.Furthermore, epidemiological data on typical postoperative complications are evaluated.

Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate

BACKGROUND

Older patients tend to have acetabular fractures with medial displacement patterns and associated comminution, particularly of the quadrilateral surface. Our goal was to investigate the appropriateness of open reduction and internal fixation using an infra-pectineal buttress plate for osteopenic acetabular fractures.

MATERIALS AND METHOD

We conducted a retrospective review involving twenty one consecutive patients over the course of 4 years with an acetabular fracture in an academic level 1 trauma centre. We performed the modified Stoppa approach with buttress plating of the quadrilateral surface. Clinical examination radiographs was done using criteria described by Matta. Functional outcome was evaluated using surveys including SF-12, WOMAC, Harris Hip score and modified Postel Merle D'Aubigne.

RESULTS

Average follow-up was 4.2 years with a minimum of 2 years. Mean age for patients was 64.3 years. We obtained anatomic reduction in 52.4% (11/21) of cases, imperfect reduction in 38.1% (8/21) of cases and poor reduction in 9.5% (2/21) of cases. Significant loss of reduction was seen in 2 patients. A superior dome impaction (a Gull sign) was correlated to arthroplasty (p=0.02) and reduced quality of initial reduction (p=0.02). Two patients required re-intervention with a total hip arthroplasty. There was one traumatic injury to the obturator nerve and 2 patients were noted to have temporary weakness of the hip adductors postoperatively.

CONCLUSION

Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures in the elderly.

The surgical treatment of anterior column and anterior wall acetabular fractures

Isolated fractures of the anterior column and anterior wall are a relatively rare subgroup of acetabular fractures. We report our experience of 30 consecutive cases treated over ten years. Open reduction and internal fixation through an ilioinguinal approach was performed for most of these cases (76.7%) and percutaneous techniques were used for the remainder. At a mean follow-up of four years (2 to 6), 26 were available for review. The radiological and functional outcomes were good or excellent in 23 of 30 patients (76.7%) and 22 of 26 patients (84.6%) according to Matta’s radiological criteria and the modified Merlé d’Aubigné score, respectively.

Complications of minor to moderate severity were seen in six of the 30 cases (20%) and none of the patients underwent secondary surgery or replacement of the hip.

Reconstruction of acetabular posterior wall fractures

Background

The results after acetabular fracture are primarily related to the quality of the articular reduction. We evaluated the results of internal fixation of posterior wall fractures with using three-step reconstruction.

Methods

Thirty-three patients (mean age at the time of injury, 47.9 years; 28 males and 5 females) were followed for a minimum of 2 years after surgery. The three-step reconstruction included 1) preservation of soft tissues and reduction of the marginally impacted osteochondral (articular) fragments using screws, 2) filling the impacted cancellous void with a bone graft, and 3) reinforcement with buttress-plating. Clinical evaluation was done according to the criteria of D'aubigne and Postel, while the radiological criteria were those of Matta. The associated injuries and complications were evaluated.

Results

The clinical results were excellent in 15 (45.5%) patients and they were good in 5 (15.2%), (i.e., satisfactory in 60.7%), while the radiologic results were excellent in 10 (30.3%) and good in 14 (42.4%) (satisfactory in 72.7%). Heterotopic ossification was common, but this did not require excision, even without prophylactic treatment with indomethacin. Deep infection was the worst complication and this was accompanied by a poor outcome.

Conclusions

This study confirms that three-step reconstruction facilitates accurate and firm reduction of displaced posterior wall fractures of the acetabulum. Therefore, we anticipate less long-term arthrosis in the patients treated this way.

[Reconstruction of fractures of the anterior wall and the anterior column of the acetabulum using an ilioinguinal approach]

OBJECTIVE

Restoration of the congruence of the hip joint. Correction of gaps or steps in the articular surface, especially in the main weight-bearing area of the acetabular dome. Correction of femoral head subluxation. Restoration of joint stability in order to enable early postoperative mobilization.

INDICATIONS

Fractures of the anterior wall and/or column that are characterized by intraarticular gaps or steps of > 1 mm in the area of the main weight-bearing dome of the acetabulum. Fractures complicated by subluxation or dislocation of the femoral head.

CONTRAINDICATIONS

Poor general physical condition and/or dementia. Critical soft-tissue conditions in the area near the surgical approach. Local soft-tissue infection. Preexisiting severe osteoarthritis of the hip joint.

SURGICAL TECHNIQUE

Exposure of the fracture through an ilioinguinal approach. Reduction of a subluxated femoral head. Reduction of the anterior column and/or wall. Correction of articular gaps, steps and areas of joint impression. Internal fixation using small-fragment reconstruction plates, if required in combination with additional screws.

POSTOPERATIVE MANAGEMENT

Postoperative radiographs for the documentation of the surgical result and implant position (exclusion of intraarticular implants). Postoperative computed tomography, if indicated. Active and passive exercises of the hip joint starting on day 1. Hip joint flexion limited to 90 degrees . Prophylaxis of thrombosis until full weight bearing, starting preoperatively. Mobilization without weight bearing or 15 kg partial weight bearing for 8-12 weeks. Progressive weight bearing over a time period of 4-6 weeks. Radiologic evaluation after 2, 6, and 12 weeks as well as after 6, 12, and 24 months.

RESULTS

Excellent and good functional results are observed in 73-85% of the isolated anterior column fractures. The anterior wall fracture is a seldom injury. Functional results are worse in comparison to the other simple fracture types. Good or excellent results can only be observed in two thirds of cases. This observation is related to the fact that anterior wall fractures often occur in elderly patients with osteoporotic bone.

Is radiation superior to indomethacin to prevent heterotopic ossification in acetabular fractures?: a systematic review

Heterotopic ossification is a well-known complication after fixation of an acetabular fracture. Indomethacin and radiation therapy are used as prophylaxis to prevent heterotopic ossification. It is unclear, however, whether either is superior, although this may relate to lack of power in individual studies. To compare the effectiveness of indomethacin with the effectiveness of radiation therapy, we conducted a systematic review in which all published prospective studies were evaluated. We performed a literature search in PubMed, MEDLINE, EMBASE, and the Cochrane Controlled Trial Register. The retrieved studies were analyzed and categorized according to the quality and validity score of Jadad et al. We found five appropriate prospective studies, describing 384 patients. Although the quality of the available studies made a proper meta-analysis inappropriate, the incidence of heterotopic ossification was significantly lower in patients treated with radiation than in patients receiving indomethacin (five of 160 versus 20 of 224, respectively). Until further information is available, we believe the evidence supports radiation therapy as the preferred method for preventing heterotopic ossification after operative treatment of acetabular fractures.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Acetabular fractures in the 21st century

Acetabular fractures are uncommon other than in the polytrauma setting, and most orthopaedic surgeons will never develop a wide exposure to them. The early management of these injuries can have profound effects on the long term outcomes from what is often a significant injury in a young patient. We present a current review of the anatomy, classification and management guidelines for acetabular fractures, including a comprehensive review of the major decision making processes, as well as describing the most common complications and the expected outcomes.

External iliac artery thrombosis associated with the ilio-inguinal approach in the management of acetabular fractures: a case report

Introduction

The ilio-inguinal approach has come to be used routinely in the management of acetabular fractures involving the anterior wall. Thrombotic complications following surgery via this route are a serious, but rare, complication.

Case presentation

We report the case of a 66-year-old male patient who slipped on an icy pavement and fell on his left hip. He sustained a comminuted acetabular fracture (a transtectal T-fracture with an incomplete posterior stem through the ischial tuberosity), and was operated on five days later, via an ilio-inguinal approach. In the recovery room, his left lower limb was found to be cool and pale. Immediate re-exploration showed a left external iliac artery thrombosis, and thrombectomy was performed. In the surgical management of acetabular fractures, thrombosis of a major pelvic artery is a rare but potentially devastating complication. We discuss the possible aetiology (initial vessel trauma versus iatrogenic, intraoperative arterial injury) and pathomechanism, and wish to draw attention to this complication and to recommend ways in which it can be prevented.

Conclusion

We recommend circulation monitoring in patients with acetabular fractures, especially where nerve blocks and/or deep sedation/analgesia have been used. High-risk patients should be identified and subjected to intensive preoperative screening, including ultrasonography and if necessary angiography.

Surgically treated acetabular fractures via a single posterior approach with a follow-up of 2-10 years

The results of operative treatment of acetabular fractures as well as its role in the occurrence of post-traumatic osteoarthritis (OA) are presented. From 1990 to 2000, 50 patients (32 male and 18 female), aging from 18 to 71 years (mean: 37.8 years) underwent an open reduction and internal fixation of their displaced acetabular fracture. They were reviewed at a mean of 5.8 years (2-10 years). A typical Kocher-Langebeck approach was selected in all the patients and in 14 cases a trochanteric osteotomy was added to enhance exposure. The fractures were classified according to the Letournel-Judet classification. The aim of the operation was the anatomic reduction and stable fixation of the fracture with less than 2mm residual displacement, which was achieved in 39 of 50 cases. Post-operative protocol included low-molecular-weight heparin (LWMH) as antithrombotic prophylaxis and 75 mg of indomethacin against heterotopic ossification (HO). At the final follow-up, the patients were evaluated clinically according to D'Aubigne-Postel scoring system and radiologically based on the criteria described by Matta. The clinical results were excellent in 20 patients, good in 18, fair in 5 and poor in 7. The radiological results were excellent in 20 patients, good in 16, fair in 5 and poor in 9. Early post-operative complications included 2 peroneal nerve palsies and 3 wound infections and late complications included 1 patient with avascular necrosis of the femoral head (ANFH), 5 patients with grade III and IV heterotopic ossification according to Brooker classification and 12 patients with post-traumatic osteoarthritis of the hip joint. Although the rates of early and late complications were relatively common, the functional outcome was satisfactory in most of the cases and comparable with other larger series. We concluded that operative treatment of most of the displaced acetabular fractures--except of isolated anterior column or/and anterior wall - could be attempted via a single posterior approach, leading to good to excellent results in the majority of the cases.

Impact of timing of pelvic fixation on functional outcome

Pelvic fractures are the third most common cause of death in motor vehicle accidents. Recent improvements in mortality can be attributed to the progress made in modern critical care medicine, multidetector CT, ATLS principles, multidisciplinary protocols and early fracture stabilisation. Currently, the timing of pelvic fixation is often based on the haemodynamic status and response of the patient to resuscitation, the fracture pattern, the presence of associated injuries and the immuno-inflammatory status of the patient. The purpose of this review is to focus on the impact of timing of reconstruction of pelvic fractures on the functional outcome of the patients. Thirty seven scientific studies on the outcome of pelvic and acetabular injuries were reviewed. Four on pelvic ring fractures, and one study on pelvic and acetabular fractures met our second inclusion criterion of prospective or retrospective studies investigating the outcome after early or late pelvic and acetabular fixation. These five studies suggested early pelvic and acetabular fixation for optimal outcome but their main difference was the definition of the length in time of that early period. In polytrauma patients, the "damage control orthopaedics" principle should be applied for haemodynamic and skeletal stabilisation (and faecal diversion, if indicated in cases of open fractures of the pelvis). The definitive fixation should be performed after the fourth post-injury day, when the physiological state of the patient is conducive to surgery.

Operative management of acetabular fractures. A review of 73 fractures

Between June 1994 and December 2000, 80 displaced acetabular fractures were treated by open reduction and internal fixation, where possible by a single surgical approach. We report our results in 72 patients (73 fractures) who completed a minimum follow-up of 2 years. The average age of patients was 39.5 years (range 15-76 years). Thirty-four fractures were classified as simple and the remaining 39 were complex fractures. Twenty-four patients were recorded to have posterior dislocation of the hip joint at the time of initial presentation and at surgery eight patients were noted to have varying degrees of damage to the head of the femur. The average time to surgery was 11.7 days (range 1-35 days); 80% of cases were operated within 2 weeks period. The average follow-up was 45.5 months (range 24-96 months). In 67 fractures (92%), only a single approach was used (Anterior Ilioinguinal 26 cases; Posterior Kocker-Lagenbach 41 cases). Five fractures needed an extensile triradiate approach and only one case required a combined anterior and posterior approach. Congruent reduction was achieved in 89% of cases. Main complications included deep infection in two patients (2.7%) and severe degenerative changes in three patients (4.2%). A total of four patients (5.5%) required a total hip replacement. There were no cases of deep vein thrombosis or pulmonary embolism. Heterotopic ossification grade III was seen in three (4.1%) cases and none were grade IV. At the latest follow-up the average Harris hip score was 85 (range 20-100). We conclude that in the majority of cases internal fixation is possible through a single approach provided patients are referred early to a specialist unit. This results in satisfactory outcome with reduced morbidity and complication rate.

Operative treatment of displaced fractures of the acetabulum. A meta-analysis

Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate the classification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries. We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present in less than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity which can be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the most accurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome.

Entrapment of the external iliac vein in a both-column acetabular fracture

We present a patient with an associated both-column acetabular fracture with entrapment of the external iliac vein in the fracture. This complication was not recognized until fracture manipulation during open reduction and fixation. This case report demonstrates that an acetabular fracture can have an associated vascular injury without any obvious clinical signs. This can be especially dangerous during percutaneous manipulation and fixation of these fractures as an obstruction or injury to the external iliac vein may occur and remain unrecognized. We feel that any surgeon involved in treating patients with acetabular or pelvic fractures should be aware of this potentially serious complication.

The "Gull Sign": a harbinger of failure for internal fixation of geriatric acetabular fractures

OBJECTIVES

To identify factors affecting the outcomes of surgery for acetabular fracture in patients over the age of 60 years.

DESIGN

Retrospective review of records and radiographs; current examination, radiographs and outcome surveys when possible.

SETTING

Academic, Level 1 trauma center.

PATIENTS/PARTICIPANTS

Forty-eight patients over age 60 with displaced acetabulum fractures.

INTERVENTION

Surgical reduction and fixation.

MAIN OUTCOME MEASUREMENTS

Clinical ratings and radiographic evaluations, Short Musculoskeletal Functional Assessment survey (SMFA), SF-36, and hip-specific questions. Radiographs were evaluated using the criteria of Matta.

RESULTS

Ten patients died since surgery. Four were lost to follow-up. Seven had >12 months of follow-up information in the chart. Twenty-seven had current evaluations for the study. Average follow-up was 37 months, range 1-114 months. The average age at surgery was 71.6 years (range 61-88). No perioperative deaths occurred. Initial reductions achieved: 61% anatomic, 34% imperfect, and 5% poor. A specific radiographic finding (superomedial dome impaction) predictive of failure was identified. This was designated the "Gull Sign." These patients had inadequate reduction, early fixation failure, or medial/superior joint narrowing and subluxation. Functional outcomes in patients with current examination were similar to age-matched controls. Radiographic outcomes: 30% excellent, 30% good, 9% fair, 23% poor, and 7% arthroplasty. Anatomic reduction was closely related to good or excellent radiographic result.

CONCLUSIONS

While some patients over sixty years of age can have satisfactory functional outcomes after acetabular fracture fixation, a significant number will have failure of the procedure. Osteopenic patients with superomedial dome impaction (the Gull Sign) did not benefit from attempted open reduction and internal fixation in this series.