Controversies in Treatment of Acetabular Fracture

Abstract

Introduction:Acetabular fractures treatment represents a great controversy, challenge and dilemma for an orthopedic surgeon.Aim:The aim of the paper was to present the results of treatment of 96 acetabular fractures in the Clinic of Traumatology Banja Luka, in the period from 2003 to 2013, as well as to raise awareness regarding the controversy in the methods of choice in treating acetabulum fractures.Material and methods:The series consists of 96 patients, 82 males and 14 females, average age 40.5 years. Traffic trauma was the cause of fractures in 79 patients (85%), and in 17 patients (15%) fractures occurred due to falls from height. Polytrauma was present in 31 patients (32%). According to the classification of Judet and Letournel, representation of acetabular fractures was as follows: posterior wall in 32 patients, posterior column in 28, anterior wall in 4, anterior column in 2, transverse fractures in 8, posterior wall and posterior column in 10, anterior and posterior wall in 6, both- column in 4 and transversal fracture and posterior wall in 2 patients. 14 patients were treated with traction, that is, 6 patients with femoral traction and 8 patients with both lateral and femoral traction. 82 patients (86.4%) were surgically treated. Kocher-Langenbeck approach was applied in the treatment of 78 patients. In two patients from the Kocher-Langenbeck’s approach, the Ollier’s approach had to be applied as well. Two acetabular were primarily treated with Ollier’s approach. Extended Smith- Peterson’s approach was applied 4 times, and Emile Letournel’s (ilioinguinal) approach 14 times.Results:Functional outcome (after follow-up of 18 months), according to the Harris hip score of surgical treatment in 82 patients, was as follows: good 46 (56%), satisfactory 32 (39%) and poor 4 (5%). Results of acetabulum fractures treated with traction were: good 8 (57%), satisfactory 4 (28%) and poor 2 (15%). According to the Brook’s classification of heterotopic ossification, periarticular hetero-tropic calcifications after surgical treatment were: 0° in 65 patients (79%), I-II° in 9 patients (11%) and III-IV ° in 8 patients (10%). Calcifications in 14 patients treated with traction of heterotopic ossification by Brook-s classification were as follows: 0° in 10 patients (72%), I-II ° in 3 patients (22%) and III-IV° in 1 patient (6%).Conclusion:At the occurrence of acetabular fracture, it is necessary to start the treatment immediately, with an obligatory application of thromboembolic and antibiotic prophylaxis. Conservative treatment is acceptable if the dislocation of fracture is less than 5 mm. Indications for surgical treatment are incongruent or unstable fractures with verified dislocation greater than 5 mm, as well as when the radiography measured by JM Matta shows incongruence of acetabular roof less than 40° in all planes. Kocher-Langenbeck approach is the choice of surgical approach for the management of posterior column / wall, and Letournel’s (ilioinguinal) approach is the choice for the management of anterior wall/column.

Results of 167 consecutive cases of acetabular fractures using the Kocher-Langenbeck approach: a case series

“…Because of the extensive blood supply of the pelvic bone, acetabular fractures may be associated with bleeding from the bone itself and/or a retroperitoneal hematoma that may cause severe hemorrhagic shock several hours after the injury [21, 22]. …”

Minimally invasive surgical treatment of minimally displaced acetabular fractures does not improve pain, mobility or quality of life compared to conservative treatment: a matched-pair analysis of 50 patients

“…There is no standard definition as to when a fracture may be considered "displaced". Grubor et al describe a degree of dislocation of more than 5 mm as the threshold for opting for surgical treatment [15]. They considered this threshold when indicating operative treatment in 85% of patients (n = 96).…”

“…The percutaneous approach has already been studied with respect to reduction outcome and clinical outcome after 30 months, and the results were good to very good [14]. Conservative treatment appears to be at least a therapeutic option with satisfactory clinical results in particular in the area of minimally displaced acetabular fractures [15,16].…”

Complications After Posterior Acetabular Wall Internal Fixation – Avascular Necrosis and Nonunion.

“…The most common cause of such trauma is a road traffic accident, dashboard injury or a fall from height. Fall is the second commonest cause of acetabulum injury occurring in about 10% (Grubor P, 2015).…”