Joel M. Matta

Fractures of the Acetabulum: Accuracy of Reduction and Clinical Results in Patients Managed Operatively within Three Weeks after the Injury*

The results were reviewed for 259 patients who had open reduction and internal fixation of 262 displaced acetabular fractures within twenty-one days after the injury. Two hundred and fifty-five hips were followed for a mean of six years (range, two to fourteen years) after the injury; the remaining seven, which clearly had a poor result, were followed for less than two years. According to the classification of Letournel and Judet, associated fracture types accounted for 208 (79 per cent) of the fractures, with both-column fractures being the most common type (ninety-two hips; 35 per cent). Two hundred and fifty-eight hips were operated on with a single operative approach (Kocher-Langenbeck, ilioinguinal, or extended iliofemoral). The four remaining hips were operated on with a Kocher-Langenbeck as well as an ilioinguinal approach. The reduction was graded as anatomical in 185 hips (71 per cent). The rate of anatomical reduction decreased with increases in the complexity of the fracture, the age of the patient, and the interval between the injury and the reduction. The over-all clinical result was excellent for 104 hips (40 per cent), good for ninety-five (36 per cent), fair for twenty-one (8 per cent), and poor for forty-two (16 per cent). The clinical result was related closely to the radiographic result. The clinical result was adversely affected by associated injuries of the femoral head, an older age of the patient, and operative complications. It was positively affected by an anatomical reduction and postoperative congruity between the femoral head and the acetabular roof. Osteonecrosis of the femoral head was noted in eight hips (3 per cent), and progressive wear of the femoral head was seen in thirteen (5 per cent). Subsequent operations included a total replacement of seventeen hips (6 per cent), an arthrodesis in four (2 per cent), and excision of ectopic bone in twelve (5 per cent). These findings indicate that in many patients who have a complex acetabular fracture the hip joint can be preserved and post-traumatic osteoarthrosis can be avoided if an anatomical reduction is achieved. An increase in the rate of anatomical reduction and a decrease in the rate of operative complications should be the goals of surgeons who treat these fractures.

Fractures of the Acetabulum: A Retrospective Analysis

A roentgenographic analysis of 204 acetabular fractures is presented. In addition, 64 displaced fractures (43 treated surgically) are evaluated clinically and roentgenographically (average follow-up period, 3.7 years). Most fractures can be adequately evaluated from anteroposterior and oblique roentgenograms of the pelvis. The roentgenographic and clinical results correlate closely. Fractures must be reduced to a displacement of 3 mm or less, in addition to congruent reduction of the femoral head with the weight-bearing dome of the acetabulum, to achieve a satisfactory clinical result. Most displaced fractures involve the weight-bearing dome and require surgery. With an intact weight-bearing dome, nonoperative treatment is considered. Quantification of this dome with three measurements termed the medial, anterior, and posterior roof arc obtained from the standard roentgenograms is valuable in determination of appropriate treatment for displaced acetabular fractures.

Internal fixation of pelvic ring fractures.

The orthopedic care of unstable pelvic fractures requires reduction and stabilization in order to promote union in a satisfactory position and provide a satisfactory clinical result. The results of three treatment techniques, skeletal traction and/or pelvic sling, anterior frame external fixation, and internal fixation, were evaluated over a four-year period.

Internal fixation of unstable pelvic ring injuries.

One hundred and seven unstable pelvic fractures were treated operatively. Reductions were graded by the maximal displacement measured on the 3 standard views of the pelvis. Criteria were: excellent 4 mm or less, good 5 to 10 mm, fair 10 to 20 mm, and poor more than 20 mm. Overall there were 72 excellent, 30 good, 4 fair, and 1 poor reduction. Ninety-five percent of all reductions were excellent or good. Open reduction and internal fixation within 21 days were associated with a higher percentage of excellent reductions than in reductions performed after 21 days (70% versus 55%). These differences were not statistically significant, however. Complications were infrequent using the techniques described.

Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion.

Closed internal degloving is a significant soft-tissue injury associated with a pelvic trauma in which the subcutaneous tissue is torn away from the underlying fascia, creating a cavity filled with hematoma and liquefied fat. It commonly occurs over the greater trochanter but may also occur in the flank and lumbodorsal region. When this closed internal degloving occurs over the greater trochanter, it is known as a Morel-Lavallée lesion. We reviewed 24 patients who sustained a closed internal degloving injury. Cultures from the closed internal degloving injury were positive in 46% (11 of 24 cases). The incidence of positive cultures was not dependent on the time from injury to debridement. All wounds were treated by thorough debridement before or during pelvic or acetabular surgery. Three patients subsequently developed deep-bone infections, only one of whom had a positive culture at the initial debridement. One patient whose wound was primarily closed over suction drains developed a chronic deep soft-tissue infection requiring multiple debridements. The development of hematoma in the zone of operation reduces the safety of early operative intervention by increasing the risk of infection. An expanding hematoma in a closed internal degloving injury may further compromise the skin vascularity if not promptly drained. The injured soft tissues should be debrided early, either before or at the time of fracture fixation. The wound should be left open, and repeated surgical debridement of the injured tissue is recommended.

Displaced acetabular fractures.

Displaced acetabular fractures occur primarily in young adults involved in high energy trauma and can lead to disabling posttraumatic arthritis. An initial roentgenographic evaluation with accurate delineation of all fracture lines provides the key to decisions about whether to give closed or open treatment. When open treatment is indicated, a surgical approach can be chosen that will almost always lead to reduction without the necessity of a second approach. The authors have found that the Kocher-Langenbeck, ilioinguinal, and extended iliofemoral approaches are the most useful. A fracture table and specialized reduction instruments aid fracture reduction and fixation. Satisfactory operative reduction of the fracture is the factor that correlates best with a satisfactory clinical result. The rate of satisfactory operative reductions improved gradually over the first 50 operations of a prospective study of 121 displaced acetabular fractures. Overall, there were 80% satisfactory clinical results in this series. Complications included a 3% infection rate and a 5% incidence of nerve palsy. Open reduction and internal fixation are indicated for the majority of displaced fractures. However, closed treatment can produce satisfactory results in selected patients.

Fractures of the acetabulum. Early results of a prospective study.

One hundred two patients with 105 displaced fractures of the acetabulum were treated for fractures involving at least one column of the acetabulum and displaced at least 5 mm (rim fractures were excluded). The patients were primarily young adults with multiple injuries secondary to motor-vehicle-associated trauma. Fractures were classified according to the classification of Letournel. The most common fractures were the complex associated types with 44 complete both column, 19 T-shaped, and 18 associated transverse and posterior wall. Seventeen fractures were treated closed, and 88 were treated operatively. Closed treatment with skeletal traction was undertaken if roof arc measurements demonstrated a satisfactory remaining acetabular dome following fracture and in some cases of apparent congruence following complete both column fractures. Fractures not meeting these criteria were operated upon through the Kocher-Langenbeck, extended iliofemoral, or ilioinguinal approach. Ninety percent of the operations produced a satisfactory reduction of the fracture (3 mm or less displacement). A follow-up study longer than one year was obtained for 50 fractures. Clinical results were 80% satisfactory overall. Operative complications included 3% infection, 5% nerve palsy, and 7% significant ectopic bone. Operative treatment can produce satisfactory fracture reductions and clinical results with an acceptably low complication rate.

Outcome of operatively treated unstable posterior pelvic ring disruptions.

Forty-six patients with 48 operatively fixed unstable posterior pelvic ring disruptions were observed for an average of 44 months. Two thirds of the patients returned to their original jobs and 16% changed jobs because of an associated injury. Sixty-three percent of the patients had no pain or pain only on strenuous activity and ambulated without limitation. However, 35% of the patients had significant neurologic injuries that compromised their final result. Properly performed open reduction and internal fixation of unstable posterior pelvic ring injuries may he expected to yield good functional results in the majority of patients. Associated injuries continue to be a major source of disability.

Fractures of the acetabulum in patients aged 60 years and older: AN EPIDEMIOLOGICAL AND RADIOLOGICAL STUDY

Using a prospective database of 1309 displaced acetabular fractures gathered between 1980 and 2007, we calculated the annual mean age and annual incidence of elderly patients > 60 years of age presenting with these injuries. We compared the clinical details and patterns of fracture between patients > 60 years of age (study group) with those < 60 years (control group). We performed a detailed evaluation of the radiographs of the older group to determine the incidence of radiological characteristics which have been previously described as being associated with a poor patient outcome. In all, 235 patients were > 60 years of age and the remaining 1074 were < 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first half of the study period and the second half (10% (62) vs 24% (174), p < 0.001). Fractures characterised by displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% (150) vs 43% (462), respectively, p < 0.001). Common radiological features of the fractures in the study group included a separate quadrilateral-plate component (50.8% (58)) and roof impaction (40% (46)) in the anterior fractures, and comminution (44% (30)) and marginal impaction (38% (26)) in posterior-wall fractures. The proportion of elderly patients presenting with acetabular fractures increased during the 27-year period. The older patients had a different distribution of fracture pattern than the younger patients, and often had radiological features which have been shown in other studies to be predictive of a poor outcome.

Indications for anterior fixation of pelvic fractures.

From April 1982 to August 1995, the author treated 127 patients with pelvic ring injuries by open reduction and internal fixation within 3 weeks of injury. Fifty-five (43%) patients (none of whom had a symphysis dislocation) had posterior internal fixation without anterior pelvic internal or external fixation. In 37 patients (29%) anterior and posterior internal fixation was performed whereas 35 patients (28%) were treated by anterior internal fixation alone. Plates and screws were used for all anterior fixations. Bladder or urethral injury was not considered a contraindication to anterior internal fixation. Of 109 patients who were observed until union of their fractures, 3 required a repeat surgery because of loss of reduction or failure of fixation or both. All 3 patients maintained reduction and healed after the second intervention. Of 72 anterior internal fixations, 1 deep infection was the only surgical complication. A single plate is reliable for fixation of the symphysis pubis and when necessary, the superior pubic ramus. However, even in displaced and unstable pelvic ring injuries, most fractures of the pubic rami do not require stabilization by internal or external fixation. Eighty-eight of 105 fractures of the obturator ring were not internally fixed and none required subsequent treatment for nonunion or loss of reduction; nor did their initial instability cause failure of posterior fixation. Internal fixation of the anterior pelvic ring, though safe and reliable, should be reserved for symphysis pubis dislocations and only a minority of pubic ramus fractures.