Surgical treatment of Acetabular Fractures at MJRC.

Acetabular fractures

Dr.A.K.Venkatachalam

MS(Orth),DNB(Orth),FRCS,MCh.Orth(Liverpool)

Senior Specialist Orthopaedics

Ibri regional hospital, Oman

My tenure at IBRI HOSPITAL is My tenure at IBRI HOSPITAL is from 01 July 2002from 01 July 2002

Demographic details

Period of this series-2002Number of patients-12(2 before June 2002)Number of fractures-13(One bilateral)Age group- Range 19-62 years.Mean age- 34.58 years.All were healthy except one female who had

Sickle cell disease. Bone quality was good in all.

Patient Characteristics

Males-9

Females-3

Side of injury-Right-6, left-5, Bilateral-1

9 patients sustained their injuries during the Ramadan season. Most were towards the evening

Mechanism of injury

• Road traffic accidents-11

• Fall of debris on the back-1

• Of patients involved in RTA’s 6 were drivers of the car and 5 were passengers

• All males in this series were drivers. The females were seated in the front passenger seat.

• One passenger was in harness.

Associated injuries• Posterior dislocation of hip-8

• Central dislocation of hip-1

• Pelvic injuries-2 – 1 APC III, 1 APC II

• Femoral head fracture-1

• Ipsilateral knee injuries-2(One combined ACL and PCL, another yet to be diagnosed)

Associated injuries• Intra-abdominal injury-1

• Chest injuries-2

• Other injuries-medial malleolar fracture-1, fracture femur-1 and fracture scapula-1

Period of follow up

>3 months-AllOne death

All operated cases were reviewed by calculation of hip scores and x rays(5 cases)

Three conservatively managed cases were also evaluated along the same lines.

Three patients are lost to follow upOne patient is dead

Management

• Early management

Immediate resuscitation for all patients. One patient was in severe hypovolemic shock.

• Reduction of dislocations-7 patients

• Subsequent management-

• Conservative treatment-5 patients( 2 before June 2002, 3 afterwards)

• Open reduction and internal fixation-5 patients, 6 fractures, (One bilateral)

• LAMA-1• Death-1(exsanguinating

hemorrhage)

Imaging protocol

• All patients had an X-ray Pelvis AP as part of the primary survey

• Seven patients had Judet internal and external views and CT scans.

• Image intensification used routinely per-operatively.

• Check X ray in the ward the same day or the next day.

• Further X rays at 6 weeks and three months• One patient had a post operative CT scan

Personality of the fracture

Illustration of fracture types(Letournel)

Classification of the fractures in this series ( Letournel)

• Type A-9• Type B-3• Type C-0Associated posterior dislocation of hip in 8

fractures (Seven patients)Central dislocation of the hip in 1 patientNo dislocation in 4 patientsTotal- 12 patients

Classification of Operated fractures in this series

• A1-5

• A1+A2=4

• B2+A1=3

Classification of Non operated fractures in this series

IMK B1 +A1 β3

KSK LAMA (X-rays not traceable)

NMG A1

SSA A1β3Not available for follow up<June 2002)

SK A1(No follow up, <June 2002)

KK B 1 +A1(undisplaced)

Dr.S A1β3

Interval between injury and surgery

• Range-4-10 days

• Mean-6.8 days

Indications for surgery

• Obvious instability

• Presence of intra-articular loose bony fragments( to be distinguished from avulsion of bony attachments of the ligamentum teres)

• Significant displacement of posterior wall as seen on CT and 3 D CT reconstruction

• Loss of congruity

Surgical technique

• All patients were positioned in the lateral decubitus position.

• Routine General anaesthesia in all patients except for the sickler where precautions were taken to prevent Vaso occlusive crisis(VOC)

• Kocher Langenbeck approach• Trochanteric osteotomy in two patients.• Debridement of the necrotic gluteus minimus in

one patient.

Surgical technique

• Anatomic reduction obtained in transverse fracture by manipulation of the anterior column first, then the posterior column was manipulated. In posterior wall fractures the reduction was obtained by reduction forceps or manipulation and fixed with screws.

Operative findings

• Intra-articular loose fragments-5

• Acetabular impaction-2

• Degloving of articular cartilage-1

• Femoral head and acetabular abrasions -3

Implants

• 3.5mm reconstruction plates were used in Four fractures.

• Screws alone used in one posterior wall fracture roof)

• Hooked buttress plate was used in two patients. Thus all posterior wall fractures had fixation with some kind of plate.

• Cancellous screw fixation of the anterior column in one.

Harris hip score

• Pain-maximum points- 44

• Function-47 points

• Deformity-4 points

• Motion-5 points

Harris hip score for operated patients

• Case 1- 96(Excellent)

• Case 2- 92( Excellent)

• Case 3-89 (Good)

• Case 4-38 (Poor) due to refracture more time to union and myositis

• Case 5- 92(Excellent)

Harris hip scores of non operated patients

NM (Operation refused by patient)

96

Dr.SM (undisplaced fracture)

100 Excellent (Pipkin type II femoral head fracture)

KK (Undisplaced fracture)

70.92 (Fair)

Post operative management

• Immobilization or traction was not used routinely.

• Non weight bearing crutch walking progressing to full weight bearing by six to eight weeks.

• In one patient with re-fracture and second operation skeletal traction was used for 3 weeks.

• Prophylaxis for DVT and myositis

Complications

• Myositis ossificans-3

• DVT-1

• Re-fracture in one patient in the post-op period due to a slip and sudden weight bearing on the affected leg.

• One screw loosening from the plate

Illustrative cases Case1

• FS.26/male, A1+A2, β3

• Dubai police

Case 1cont’d

Case 1 cont’d

Case 1 cont’d

Case 1cont’d

The Spring plate or hooked buttress plate (Jeff Mast)

Showing the curvature of the posterior wall and the necessity to

contour the plates

Columns of Acetabulum

Application of the hooked plate and contouring the recon plate

Case 1 cont’d

Case 1cont’d

Case 1 cont’d

Case 1 cont’d Harris hip score-96 at 4.5 months follow-up

Case 2

• AA,19/male B1(Transverse involving anterior column, posterior column +posterior wall) +β3

Case 2 cont’d

Case 2 cont’d 3 D C T reconstruction

Case 2 cont’d post reduction Ischial view

Post op X-ray case 2

Showing position of screws in the anterior column

Pathomechanics in transverse fractures

Manipulation of the posterior column

Union of the fracture at 4 months.

Case 2 cont’d Harris hip score at 4 months-92

Case 3

• HA, 39/M• Bilateral• Right-A1+A2• Left-A1+A2• Bilateral β3

Trick photo showing the bilateral fractures and the intra-articular

bone on the left

Case 3 cont’d

Case 3 cont’d at 4 months

Case 3 cont’d Harris hip score 89(Good)

Case 4 25 female A 1 β 3 Harris hip score at 3.5 months-92

Case 5

• 42 Male A1 + A 2 β3

He had a re-fracture in the second post op week Fracture reduced again.

Major posterior wall fragment was intact. Re-fracture through the roof. Difficult to fix using screws again. Another use of the hooked buttress plate ( Multiple prongs) to reduce and fix the fracture.

Case 5 Post-op x ray

Case 5 showing incongruent position, refracture through the

dome and posterior wall.

Case 5 cont’d union of refracture after revision hooked buttress

plating

Case 5 cont’d showing union of the fracture

Conclusions

• Posterior column and posterior wall fractures are the commonest in this series.

• Pre-op CT scan is essential to determine the presence of loose fragments and 3D CT is best to determine the fracture anatomy.

• Preoperative planning is absolutely essential.• Kocher Langenbeck approach is the easiest to

manage posterior and transverse fractures.• Dissection of the fragments should be

atraumatic to minimize the incidence of Myositis.

Conclusions cont’d

• Special instruments like modified Farabeuf forceps,sciatic nerve retractor, Matta’s clamps are useful.

• Hooked buttress plate has a role in comminuted posterior wall fragments, fixation of wall fragments in lieu of screws and in re-fractures without disturbing the original hardware. Advantage is that screw placement is distant from the acetabulum

Screw placement

• Screw placement should be away from the joint in the safe corridor which is 10mm away from the lip. Screws should be in bone and not protrude into the hip joint or pelvis.

• Avoid screw placement into the danger zone(10mm from the lip). Beyond the danger zone the screws should be angled posteriorly and never at right angles into the acetabulum.

Safe zone of the posterior wall for screw placement

• Red-danger zone

• Green- safe zone

Conclusions cont’d

• Long (100mm-120mm 3.5mm cortical screws or 6.5mm cancellous screws may be needed to fix the anterior column through the posterior approach

Conclusions cont’d

• Myositis remains the unconquered complication.incidence upto 100% ? role of debridement of the necrotic muscle.(Rath et al Injury Vol 33,number 9, November 2002)

• Good results are achieved by a focused surgeon doing more cases as there is a learning curve for achieving perfect reduction and mastering the approaches.

Current concepts

• Dis-impaction of acetabular depression and bone grafting from the femur.

• Fibrin glue to stick osteochondral loose fragments.

Fossils showing that life is not as we thought that it was

More fossils

Universal Comprehensive classification.

• The first comprehensive classification was proposed by Judet and Letournel in 1964 Judet, R., Judet, J., and Letournel, E.: Fractures of the Acetabulum: Classification and Surgical Approaches for Open Reduction. J. Bone Joint Surg., 46A:1615–1647, 1964.

• Salient points- elementary and associated types.

• The present Universal classification is based on the AO classification which divides all fractures into three types A,B and C with increasing severity towards C

Universal comprehensive classification

• Developed with the help of Letournel, Matta, Helfet and others. Has been recognised by SICOT, OTA (Orthopaedic trauma associatio) and the AO group

• Some deficiencies are that some B type fractures are high energy, shearing fractures with worse prognosis than C types. Muller, M.E., Allgower, M., Schneider, R., and Willeneger, H.: AO Manual on Internal Fixation, 3rd ed. New York, Springer-Verlag, 1990.