Early Results Of Operative Management of Acetabular Fracture At Khartoum North

Teaching Hospital

Mubarak M F A KerimMBBS MS MCh Orth FRCSI FRCSEd

FRSMOrthopaedic Surgeon

Introduction

• Acetabular fractures occur primarily in young adult patients as a result of high-energy trauma.

• Displaced fractures are best treated with anatomical reduction and internal rigid fixation .

• Residual displacement of more than one or two millimeters may lead to progressive post-traumatic OA and a poor functional result.

• The goals of surgical treatment of acetabular fractures is to restore the normal shape of the acetabulum, the contact area and the normal pressure distribution within the joint

History

• Campbell in 1936 :divided posterior dislocations of the hip with posterior rim fractures into three types based on the extent of displacement of the head.

• Armstrong in 1948 classified fracture dislocations into 4 types:

• -i.dislocation alone• -ii.dislocation with fracture of the rim

History

• -iii.dislocation with fracture of the floor of the acetabulum

• -iii.dislocation with fracture of the femoral head.• In 1951 Thompson Epstein expanded the

classification into 5 types by adding comminution to type ii.

• In 1954 Stewart and Milford divided fracture dislocations into 4 grade- system and applied a similar four grade-system to central dislocations

History

• This classification discussed:

• 1- the patterns of acetabular Fractures that lead to central dislocations

• 2-it addressed the importance of comminution of the superior portion of the acetabulum

• In 1958 Knight and Smith tried to assess the frequency of different patterns of fractures.

History

• In 1961 Crsyssel and Schnep and Rowe and Lowell described fractures of the acetabulum based on the direction of the force and its intensity.

• In 1961 Judet and Letournel divided acetabular fractures into elemental and associated fractures.

Letournel and Judet classificationElementary fractures Associated fractures

Posterior wall Posterior column and wall

Posterior column Anterior column or wall or hemitransverse

Anterior wall Transverse and posterior wall

Anterior column T -shaped

Transverse Both columns

Incidence Of Different Types Of Fractures

• Acetabular Fracture is usually a result of significant trauma.

• 50% will have multiple trauma.• Posterior 24%• Posterior column 4%• Anterior wall 23%• Anterior column 4%• Other fractures 25%

• The study was conducted at KNTH in the period July 2005 to December 2006.

• Total number of patients was 17 cases.

• All patients were assessed by an AP pelvis and a 45 degrees oblique views.

• CT scan was used routinely and 3D reconstruct was requested in almost all cases.

• All patients received prophylactic antibiotics and heparin as prophylaxis against deep vein thrombosis.

• The modified d'Aubigné and Postel grading system was used to assess the clinical outcome

• The study was conducted at KNTH in the period July 2005 to December 2006.

• Total number of patients was 17 cases.

• All patients were assessed by an AP pelvis and a 45 degrees oblique views.

• CT scan was used routinely and 3D reconstruct was requested in almost all cases.

• All patients received prophylactic antibiotics and heparin as prophylaxis against deep vein thrombosis.

• The modified d'Aubigné and Postel grading system was used to assess the clinical outcome

Literature review• Letournel and Judet in 1986 reported 569 acetabular fractures that were treated within

twenty-one days of injury .Articular reductions were perfect implying the articular surface and radiological landmarks of the acetabulum retuned to normal alignment on an AP pelvis and 45 degrees oblique views in 73%• 26.5 % WERE IMPERFECT.

• Matta reported on 262 displaced acetabular fractures treated surgically within 21 days with 2 to 13 years follow-up.

• Over all there were 72% anatomic reductions ,20% imperfect reductions and 8% • Matta reported 68% excellent to good functional outcome in those who had anatomical

reduction.

• The results of Letournel and Matta emphasize the correlation of accuracy of articular reduction with improved clinical outcome.

Incidence Of Different Types

• Acetabular fractures are usually the result of significant trauma.

• 50% will have multiple trauma.

• Posterior 24%

• Posterior column 4%

• Anterior wall 23%

• Anterior column 4%

• Other fractures 25%

Results Operated within 21 days 12 70.5%

Operated within 30 days 2 11.7%

Operated more than 30 days 3 17.6%

Heparin 17 100%

Antibiotic prophylaxis 17 100%

Results Males 16 94%

females 1 5.8%

Associated pelvic injuries 11 67.7%

Other extra skeletal injuries 5 29%

Road traffic accident 15 88%

Falls 2 12%

Posterior column fractures 15 88.2%

Anterior column fractures 2 11.8%

Surgical Approaches Kocher -Langenbeck 15 (88.2%)

Ilioinguinal 2(11.8%)

iliofemoral 0

combination 0

Postoperative reductionAnatomical 12 hips 70.5%

Imperfect 3 hips 17.6%

Poor 3 hips 17.6%

Fracture type association Chi square =44.895 p<0.001

Clinical grading

Pain

None 6

Slight or intermittent 5

After walking but resolves 4

Moderately severe but patient is able to walk 3

Severe, prevents walking 2

Walking

Normal 6

No cane but slight limp 5

Clinical grading

Long distance with cane or crutch 4

Limited even with support 3

Very limited 2

Unable to walk 1

Range of motion

95–100% 6

80–94% 5

70–79% 4

60–69% 3

50–59% 2

<50% 1

Clinical grading

Clinical grade Score

Excellent

18

Good

15, 16, or 17

Fair

13 to 14

Poor

<13

Results-quality of reductionAnatomical 12 his (70.5%)

Imperfect 3 hips (17.6%)

Poor 3 hips (17.6%)

Results –clinical outcomeClinical grade Score Number of patients

Excellent 18 9

Good 15, 16, or 17 3

Fair 13 to 14 2

Poor <13 3

Discussion

• This study is an early result of a smaller number of hips and a shorter duration of follow- up, but still anatomical and imperfect reductions were similar to large studies .

• Hips that operated earlier had a higher rate of anatomical reduction and those operated later had a poor rate of reduction

• The patient age was a significant variable with regard to accuracy of reduction (Sci square=37.650 ;p<0.006).

• The initial displacement was not a predictive of the accuracy of anatomical reduction

Discussion• The fracture type was an important factor in getting anatomical reduction and an

excellent clinical outcome.

• Associated injuries were not a significant factor in obtaining anatomical reduction.• Posterior hip dislocation was found in only one patient and the reduction was not

affected by dislocation.

• Wound infection was a complication in five cases ,all were superficial and were treated promptly.

• We didn’t observe osteoarthritis in our series because of the shorter duration of follow-up.

Outcome

• After 3/52 outcome is poor because reduction is difficult

• Letournel reported that 73% out of 569 acetabular fractures surgically treated within 3/52 returned to normal alignment on pain AP X-ray and 45 degrees oblique views.

• In 151 (26% )reduction was imperfect • OA developed in 97 cases (10%) ,1 to 13 years follow-

up.

Outcome

• 2 year follow-up:77% had an excellent clinical outcome.

• Applying d'Aubigné and Postel clinical outcome grading system

• -Pain• -Ambulation• -Rom

Complications

• Wound infection

• Iatrogenic nerve injury

• Heterotopic bone formation

• Post-traumatic OA.

• DVT

Realistic objectives

• Surgeon’s experience• Set-up• Limited number of cases• The difficult anatomy• Complexity of reduction strategies• The diversity of the injury patterns

The future

• ORIF is the choice now.This is made difficult by infrequencies of operations, the difficult anatomy and the potential for both intra and postoperative complications.

• Special imaging techniques• Specialized surgical tools and implants• Operating tables(considering our hospital)• Hip Arthroplasty • Diversity of assessment protocols

Thank you