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TRAUMATOLOGY Table of Contents   
Year : 2005  |  Volume : 39  |  Issue : 1  |  Page : 26-29
Treatment of acetabular fractures


Department of Orthopaedics, St John's Medical College & Hospital, Bangalore, India

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   Abstract 

Background: Acetabular fractures are difficult to manage. There are advocates of closed methods as well as surgical methods of treating acetabular fractures. But controversy still exist as to which is the best way of treatment.
Methods: We have evaluated from 1995 to 2000, 68 cases of acetabular fractures. Twenty two cases were managed surgically and 46 cases were managed non-operatively. The cases were followed up for a period ranging from 12 to 78 months (Avg. 36 months).
Results: The results of the treatment were assessed using the scoring system of Matta. In the non-surgically managed group congruent reduction was achieved in 36 cases and good to excellent functional results were achieved in 30 cases. In the surgically managed group congruent reduction was achieved in 18 cases and good to excellent functional results were achieved in 12 cases. In 32 cases early or late complications were seen.
Conclusion: Even if the prognosis for the restoration of normal joint function is not good, the restoration of normal anatomy will improve the results of future reconstructive procedures.

Keywords: Acetabulum; Fractures; Treatment

How to cite this article:
Amaravati RS, Phaneesha M S, Rajagopal H P, Reddy R. Treatment of acetabular fractures. Indian J Orthop 2005;39:26-9

How to cite this URL:
Amaravati RS, Phaneesha M S, Rajagopal H P, Reddy R. Treatment of acetabular fractures. Indian J Orthop [serial online] 2005 [cited 2019 Nov 22];39:26-9. Available from: http://www.ijoonline.com/text.asp?2005/39/1/26/36891

   Introduction Top


Letournel and Judet have provided with the classification, investigations and management strategies for acetabular fractures [1],[2] . The incidence of acetabular fractures has increased over the years [3]. High energy trauma and failure to use seat belts are main cause for these injuries [4]. Approximately two third of all injuries occur in young adults and associated injuries are common in 40% to 75% of patients [5] . There are mixed opinion about how to manage acetabular fractures [6],[7] . However the outcome is dependent on many variables and degenerative changes which usually occur in the long term [8] .

This study was undertaken to evaluate the results of treatment of acetabular fractures in our institution.


   Material and methods Top


Between the years 1995 and 2000, 68 patients of acetabular fractures were treated in our institution. Follow up was for a minimum period of 12 months with an average of 36 months (12 - 78 months).

There were 59 male and 9 female patients. The average age of the patients treated non-operatively was 38 years (range 17 - 68 years) and in the operative group it was 34 years (25 - 55 years). Fractures were classified and treated based on diagnostic and therapeutic criteria of Judet & Letournel [1] . In 45 cases the mechanism of injuries was motor vehicle accident, out of which 17 were two wheeler and 28 four wheeler injuries and 23 cases fell from a height of over 5 feet. In all patients antero-posterior, Judet views of the pelvis were available and in complex cases CT scan were taken. The acetabular weightbearing dome was assessed using roof arc measurements [9]. Forty six patients were treated non­operatively by upper tibial or lower femoral skeletal traction for 6 to 8 weeks. All surgically treated patients were operated within 3 weeks after trauma of which majority were posterior wall fractures. The Kocher-Langenbeck approach was used most of the time. Cefaperazone with amikacin or gentamycin was used as prophylactic antibiotics. All the patients received 75 mg of indomethacin daily in the peri and post operative period for three weeks.


   Results Top


The incidence of fracture type among the 68 patients is shown in [Table - 1]. There is an increased incidence of posterior wall fractures. About 57% of the patients in our series were in the 3rd or 4th decade of life. The right hip was involved 47 times and left hip 21 times. Clinically and radiologically the patients were assessed using the scoring system of Matta et al [9] [Table - 2]. In the non surgically managed group, congruent reduction was achieved in 36 cases and good to excellent functional results were achieved in 30 cases [Figure - 1]. In the surgically treated patients 18 had congruent reduction [Figure - 2], but good to excellent functional results were achieved in 12 patients. In addition to the acetabular fractures, 32 patients had associated injuries [Table - 2]. Complications [Table - 4] seen were avascular necrosis of femoral head (3), nerve palsy (6) and DVT (6) [Figure - 3].


   Discussion Top


The anatomic configuration of the hip provides extra ordinary stability to the joint [10] . Anterior dislocation accounts for 5% to 20% of traumatic hip dislocation where as posterior dislocation are more common [3]. Posterior wall fracture is the commonest type of fracture acetabulum [11] . The incidence of acetabular fractures in our series is comparable to the findings of Letournel [12]. Upadhya et al showed that reduced femoral antiversion or retroversion makes patients susceptible for posterior fracture dislocation [13] .

A standard antero-posterior and Judet view of the pelvis are the basic investigations to quantify acetabular fractures and CT scan obtained before reduction of the joint are helpful in evaluation and decision making of the injured hip [14]. MRI is of limited value in the diagnosis of acetabular fractures except in identifying undisplaced fracture [15] . Recently the use of dynamic digital rotational imaging in displaced and complex acetabular fractures has been proposed [16].

Factors influencing the outcome are [17] degree of initial displacement, damage to the superior weight bearing dome or femoral head, degree of hip joint instability caused by posterior wall fracture, adequacy of open or closed reduction and late complications like AVN, hetero-trophic ossification, chondrolysis or nerve injuries

The experience in this series confirms the learning curve of Matta, where accuracy of fracture reduction is dependent on the experience of the treating surgeon [18] . Others have reported that the clinical results are much better than what the roentgenograms indicate [7] . Closed treatment yields best result if displacement is less than 2 mm, congruence in Antero­posterior and Judet views of the pelvis, minimum of 50% posterior wall is intact and the roof arc measurement of equal to or more than 45 o [19],20],[21]. If the acetabular fracture configuration shows on the X-ray 30 o anterior, 40 o of medial and 50 o of posterior roof arc measurements and intact weight bearing dome, such cases can also be treated conservatively [9] .

Non-operative treatment for displaced fractures of the acetabulum are done when, large portion of the acetabulum remain intact and femoral head remains congruence within this portion of acetabulum and secondary congruence exists after only moderate displacement of both column fractures [22] . In 57 conservatively treated of the fractures acetabulum Hegg et al concluded that the results can be very successful even if fractures are crossing the weight bearing dome provided, congruence is preserved during the period of traction [23] .

Operative indications for acetabular fractures are unstable or incongruence of the hip, posterior wall or anterior wall fractures with column displacement [17] . Open reduction and internal fixation is best done within first 10 days to within 3 weeks of injury for better outcome and delayed treatment of acetabular fractures will lead to more complications [25] . In 1980, Pennal et al treated 103 fractures of the acetabulum and at 5 year follow up 72% of the cases of poor reduction develop osteoarthritis and 30% of the cases with good reduction also developed osteoarthritis [17] . Even in expert hands depending on the type of fracture and severity of the fracture, anatomical reduction was achieved only in 70% cases and the surgical outcome may be disappointing [17] . The results of our treatment could be improved by more experience in the surgical group.

Complications can occur from the injury per se or can be the result of surgical treatment. Early complications include thrombo embolism (30% to 50%), neurologic injury (16 % to 30%), infection (3% to 9%), mal reduction, loss of reduction, intra-articular hardware and vascular injury [26]. Late complications include avascular necrosis (2% to 25%) heterotrophic ossification (1% to 60%), post traumatic arthritis (12% to 57%) [26] . The rate of complications [47%] in our series do not exceed of what has been mentioned in the literature [9] . Despite perfect reduction, osteoarthritic changes are expected to develop in the long term for which most common procedures done are hip arthrodesis or total hip replacement [27],[28].

Incidence of acetabular fracture is on the rise in the third world countries too. Road traffic accidents is the main cause of these injuries in young adult males between 20 to 40 years of age group. The outcome of open methods can be improved with more surgical experience in treating acetabular fractures which will enable us to minimise the complications with appropriate and innovative treatment methods. Finally even if the prognosis for the restoration of normal joint function is not good, restoring normal anatomy will enable the patient to have a better quality of life and makes it easy for future reconstructive procedures.

 
   References Top

1.Letournel E, Judet R. Fractures of the acetabulum, 1st Ed. In Elson RA (ed). New York; Spinger-Verlag. 1981.  Back to cited text no. 1    
2. Letournel E, Judet R. Fractures of the acetabulum, 2nd Ed. In Elson RA (ed). New York; Springer-Verlag. 1993.  Back to cited text no. 2    
3. Yang RS, Tsuang YH, Hang YS, Liu TK. Traumatic dislocation of the Hip. Clin Orthop. 1991; 265: 218-227.  Back to cited text no. 3    
4. Dakin GJ, Eberhardt AW, Alonso JE, Stannard JP, Mann KA. Acetabular fracture patterns : association with motor vehicle crash information. J Trauma. 1999; 47: 1063-1071.  Back to cited text no. 4    
5. Suraci AJ. Distribution and severity of injuries associated with hip dislocations secondary to motor vehicle accidents. J Trauma. 1986; 26 : 458 - 460.  Back to cited text no. 5    
6. Rowe CR, Lowell JD. Prognosis of fractures of acetabulum. J Bone Joint Surg (Am). 1961;43: 30-59.  Back to cited text no. 6    
7. Tipton WW, D'Ambrosia RD, Garrett PR. Non-operative manage­ment of central fracture dislocations of the hip. J Bone Joint Surg (Am).1975;57: 888.  Back to cited text no. 7    
8. Tornetta P III, Mostafavi HR. Hip dislocation : current treatment regi­mens. J Am Acad Orthop Surg. 1997; 5: 27-36.  Back to cited text no. 8    
9. Matta JM, Anderson LM, Epstein HC, Hendrick P. Fractures of the acetabulum, A retrospective analysis. Clin Orthop, 1986; 205: 230 -240.  Back to cited text no. 9    
10. Reigstad A. Traumatic dislocation of the Hip. J Trauma. 1980;20 : 603-606.  Back to cited text no. 10    
11. Letournel E. Diagnosis & treatment of non-union & malunion of ac­etabular fractures. Orthop Clin North Am. 1990;21 : 769-788.  Back to cited text no. 11    
12. Letournel E. Acetabulum fractures: Classification & management. Clin Orthop. 1980;151 : 81-106.  Back to cited text no. 12    
13. Upadhyay SS, Moulton A, Burwell RG. Biological factors predispos­ing to traumatic posterior dislocation of the Hip. A selection process in the mechanism of injury. J Bone Joint Surg (Br).1985; 67: 232-236.  Back to cited text no. 13    
14. Brandser E, Marsh JL. Acetabular fractures : Easier classification with a systemic approach. Am J Roentgenol. 1998; 171(5): 1217-1228.  Back to cited text no. 14    
15. Laorr A, Greenspan A, Anderson MV, Moehring HD, McKinley T. Traumatic hip dislocation : Early MRI findings. Skeletal Radiol. 1995;24 : 239-245,.  Back to cited text no. 15    
16.Patel NH, Hunter J, Weber TG, Routt Jr ML. Rotational imaging of complex acetabular fractures. J Orthop Trauma. 1998;12 : 59 - 63.  Back to cited text no. 16    
17.Tile M. Fractures of the acetabulum. Schatzker J, Tile M :In the Ratio­ nale of operative fracture care. 2nd ed. New York, Springer - Verlag,1996; 271-324  Back to cited text no. 17    
18. Matta JM, Meritt PO. Displaced acetabular fractures. Clin Orthop. 1988;230:83-97.  Back to cited text no. 18    
19.Weise K, Maurer F, Schrade J. Hip dislocation & Hip fracture - acetabular fractures. Indication, technique & results of conservative treatment. Orthopade. 1997;26 (4) : 336-347.  Back to cited text no. 19    
20. Tornetta P III. Nonoperative management of acetabular fracture. The use of dynamic stress view. J Bone Joint Surg (Br). 1999;81: 67 - 70.  Back to cited text no. 20    
21. Mayo KA. Open reduction & Internal fixation of fractures of acetabulum. Clin Orthop. 1994;305 : 31-37.  Back to cited text no. 21    
22. Matta JM. Surgical treatment of acetabular fractures. Browner BD, Jupiter JB, Levine AM, Trafton PG: In Skeletal trauma. Basic Science Management, Reconstruction. Vol. 1, 3rd Ed. WB Saunders; Philadel­phia. 2003: 1109 - 1149.  Back to cited text no. 22    
23. Hegg M, Oostvogel MJ, Klasen HJ. Conservative treatment of ac­etabular fractures. The role of weight bearing dome and anatomic reduc­tion in the ultimate results. J Trauma. 1987;27(5):555 - 559.  Back to cited text no. 23    
24. Brueton RW. A review of 40 acetabular fractures: The importance of early surgery. Injury. 1993; 24 : 171 - 174.  Back to cited text no. 24    
25. Johnson EE, Matta JM, Mast WJ, et al. Delayed reconstruction of Acetabular fractures 21-20 days following surgery. Clin Orthop. 1994; 355 : 20-30.  Back to cited text no. 25    
26. Perry DC, Delong W. Acetubular fracture. Orthop Clin North Am. 1997; 28 (3) 405-417.  Back to cited text no. 26    
27. Alonso JE, Volgas DA, Giordano V, Stannard JP. A review of treatment of Hip dislocation associated with acetabular fractures. Clin Orthop. 2000; 377 : 32-43.  Back to cited text no. 27    
28. Romness DW, Lewallen DG. Total hip arthroplasty after fracture ac­etabulum. Long term results. J Bone Joint Surg (Br). 1990; 72; 761-764  Back to cited text no. 28    

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Correspondence Address:
Rajkumar S Amaravati
Department of Orthopaedics, St Johns Medical College Hospital, Bangalore- 560 034
India
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Source of Support: None, Conflict of Interest: None


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    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1], [Table - 2], [Table - 3], [Table - 4]



 

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    Abstract
    Introduction
    Material and methods
    Results
    Discussion
    References
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