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SYMPOSIUM Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 1  |  Page : 31-32
Acetabular fractures: Late presentation


Laud Clinic, Mumbai, India

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How to cite this article:
Laud N S. Acetabular fractures: Late presentation. Indian J Orthop 2002;36:31-2

How to cite this URL:
Laud N S. Acetabular fractures: Late presentation. Indian J Orthop [serial online] 2002 [cited 2019 Dec 9];36:31-2. Available from: http://www.ijoonline.com/text.asp?2002/36/1/31/35923
Acetabular fractures are difficult injuries to treat. When such patients present late for treatment the problems are compounded. Upto two weeks following the injury the fracture fixation can be done in the standard way. From two to four weeks following the injury the fracture fixation becomes more difficult, but is still possible. Four to six weeks is the time when some of the fractures can be fixed with expectation of getting good outcome. Any acetabular fracture, which is more than six weeks old, should not be attempted for primary fixation, as the surgery is formidable and the outcome is not very good. In such fractures salvage procedures like total hip arthroplasty or excision hip arthroplasty if patient has severe pain should be considered.

Factors determining the outcome of the late acetabular fixations

Apart from the time of presentation, various other factors decide whether a particular case will have a good outcome following surgical intervention. Here "good outcome" denotes a well­-constructed and stable acetabulum with an intact weight-bearing dome. It also means having a centrally located, well-contained femoral head without development of avascular necrosis.

Direction of dislocation: Posterior or anterior dislocation have a better outcome than central dislocation. In central dislocation the femoral head gets obstructed at the neck and is difficult to extract out unless proper reduction is done. The central wall is deficient because of which concentric reduction is difficult to maintain.

Presence of dome comminution: The comminuted dome fracture is difficult to reconstruct and can lead to delayed arthritis and postoperative pain.

Impacted articular fragments: Unless these are disimpacted and aligned well by open reduction, they can lead to traumatic arthritis.

Femoral head fractures: Femoral head fractures if in the upper quadrant, can lead to rapid traumatic arthritis. When these fractures are present, one must consider joint replacement surgery as an option for the treatment.

Prior treatment: Improper treatment given to the patient of acetabular fracture is more harmful in many cases than no treatment at all! It is necessary to reduce the acetabular fracture and maintain a proper traction if immediate surgery is not possible. This simplifies the late reconstruction greatly. Any previous attempts at internal fixation or giving trochanteric traction will increase the risk of infection and compromise the outcome.

Problems of late presentation

When we contemplate the surgical reconstruction of acetabular fractures, it deviates from the early cases in the following aspects:There is shortening of soft tissues and contractures of muscles. This leads to difficulty in exposing the fracture fragments. Intra-operative distraction techniques are required for realignment of the fragments. There is formation of callus with a consequent increase in the vascularity in the region of the fracture. This leads to significantly increased blood loss during the surgery. Prolonged duration of dislocated position of femoral head will cause increased chances of future head avascular necrosis. Incarceration of sciatic nerve in the fracture fragment and fracture callus will cause increased risk of intra-operative damage to this nerve compared to the primary surgery of acetabulum. It is recommended that the sciatic nerve should be dissected and isolated safely before approaching the fracture. Scarring from the previous surgery makes the approach difficult. The increased risk of infection from previous surgery is a serious consideration.

Approach to the late presentation of acetabular fracture

In preparing for the surgery of late presentation one must have good quality radiograms (Pelvis AP and Judet views), CT scan with 3-D reconstruction if possible. This enables the surgeon to plan the approach to the fracture and select the implants, which would be required for the fracture fixation. A complete medical evaluation of the patient prior to a major surgical reconstruction is necessary. Arrangement for 4 to 6 units of blood to replenish the intraoperative blood loss is a must! Use of epidural anaesthesia may be better option as it can be used for postoperative pain relief with infusion pumps. Invasive intra-operative monitoring is required. The patient may need post operative stay in an intensive care or a high dependency unit.

Approach to the Acetabulum: Depending upon the direction of dislocation the anterior ilio­inguinal approach (for anterior column fractures) or posterior Kocher-Langenbach approach (for pure posterior column) is necessary. In difficult cases it may become necessary to use an extensile approach for fixation in these difficult situations.

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Correspondence Address:
N S Laud
Laud Clinic, Hindu Colony, Dadar, Mumbai
India
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Source of Support: None, Conflict of Interest: None


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