Abstract
Introduction
Acetabular fractures, resulting from high-energy trauma, present significant orthopaedic challenges. Despite their rarity, the incidence of these fractures is rising, necessitating a comprehensive understanding of their epidemiological characteristics, especially in diverse populations like India.
Methods
This retrospective study analyzed data from 3643 patients across four level-1 trauma centers in India (North 1, North 2, West, and South) from January 2001 to December 2019. Prior ethical approval was obtained from the respective institutions. Data were collected using the computerized patient record system (CPRS) and included patients with complete clinical and radiological records. Only patients with full radiological data were included, comprising standard anteroposterior radiograph, Judet views on radiographs, and computed tomography scan of the pelvis. The study evaluated the demographic characteristics, fracture patterns and surgical approaches.
Results
The majority of patients were males (84.05 %) and the fractures were mostly seen in young individuals between 19 and 40 years’ age group (44.9 %), followed by 41–60 years (42.3 %). Associated bony or other system injuries were seen in 53.42 % of patients, with pelvic injuries being the most common (9.8 %). Posterior wall fractures were the most frequent (20.7 %), while anterior wall fractures were the least common (0.8 %). Operative management was employed in 82 % of cases, with the Kocher-Langenbeck approach being the most commonly employed (42.5 %).
Conclusion
High-velocity trauma remains the commonest cause of acetabular trauma in India, primarily affecting young male individuals. Pelvic fractures are the most commonly associated injuries. Posterior wall fractures are the commonest type of acetabular fracture, and the Kocher-Langenbeck approach is the commonly adopted surgical approach.
Keywords: Acetabulum, India, Epidemiology, Registry, Pelvis-acetabulum, Fracture
1. Introduction
Acetabular fractures are relatively rare, accounting for 1.5 % of all adult fractures.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 These injuries typically result from high velocity trauma, such as motor vehicle accidents and falls from heights, especially in developing and underdeveloped countries. In the recent years, the incidence of pelvi-acetabular trauma among elderly individuals in many developed nations has been increasing. The most common causes of this type of trauma are osteoporosis leading to insufficiency fractures.2,4,11 Management of pelvi-acetabular fractures is challenging due to the complex anatomy, proximity to major neurovascular structures and associated injuries. Displaced fractures are managed operatively while those fractures in the non-weight bearing region can be managed conservatively.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22 Despite optimal care, many patients experience severe complications, leading to increased morbidity, prolonged work absences, and a significant burden on the healthcare system and society.5,6,23, 24, 25, 26, 27, 28
Understanding the demographics of these fractures is crucial for grasping the magnitude of the problem within the community, identifying affected age groups and genders, and analyzing associated injury patterns. This also helps us in formulating policies and decision making in future. For instance, the incidence of acetabular fractures is common in young and middle age in developing nations while the incidence is higher in the elderly in the European nations.22 In comparing the demographics of pelvi-acetabular trauma between China and the USA, Mauffrey et al. found that more patients in China underwent surgical treatment than in the USA. They reported that high-velocity injuries, such as motor vehicle accidents and falls from heights greater than 10 feet, remained consistent in both countries. However, Chinese patients tended to have longer hospital stays compared to those in the USA.14
The available evidence on the epidemiology and demographics of acetabular trauma is limited and primarily based on data from surgically treated patients, with much of our understanding derived from Western studies. Over the past two decades, there have been notable changes in the presentation and demographic variations of these fractures.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28 However, data from diverse countries like India is lacking. Therefore, a large multicentric study with a significant sample size is essential to better understand the epidemiological characteristics of acetabular fractures in the Indian population. Our study was conducted in four level-1 trauma centers across various parts of India, encompassing both operatively and non-operatively managed acetabular fractures.
2. Methodology
2.1. Study design
This retrospective study was conducted in four level-1 trauma centers in different regions of India: North 1 (N1), North 2 (N2), West (W), and South (S). The institutional ethics committee of each institute approved the study. The study included patients who sustained acetabular fractures, with or without pelvic injury, between January 2001 and December 2019. Data were collected using the hospitals' computerized patient record system (CPRS). A total of 3643 patients were identified, consisting of 3062 males and 581 females, all of whom had complete clinical and radiological records.
2.2. Inclusion and exclusion criteria
Only patients with full radiological data were included, comprising standard anteroposterior and Judet views radiographs, and computed tomography scans of the pelvis. Patients with incomplete data were excluded from the study.
2.3. Surgical Indications and Procedures
Surgery was performed in cases with: fracture displacement greater than 2 mm, Matta's roof arc angle greater than 45°, absence of concentric joint space reduction, unstable posterior wall fractures and presence of marginal impaction. The approach and the sequence of fracture fixation were determined based on the type of fracture, degree of displacement, degree of comminution, vector of the primary force from the displaced femoral head, involvement of the quadrilateral plate, and the surgeons' discretion.
2.4. Classification and demographic data evaluation
The anteroposterior and oblique views radiographs were used to classify acetabular fractures as per the Judet and Letournel classification, which was further confirmed by Non Contrast Computed Tomograpy (NCCT) scans.12 The demographic characteristics of the study included region-wise distribution of acetabular fractures by age, sex, associated injuries, fracture pattern and surgical approach. The patients were divided into four groups: the pediatric age (less than 18 years), young age (19–40 years), the middle age (41–60 years), and elderly (above 60 years).
2.5. Statistical analysis
Data were stored in Microsoft Excel and processed in SPSS version 21. The incidences were calculated. All statistical testing was two-sided at a significance level of 0.05.
3. Results
3.1. Gender distribution
Out of the total 3643 patients, 3062 (84.05 %) were males and 581 (15.95 %) were females. The region-wise distribution is given below (Table 1). Acetabular fractures were more common among males across India compared to females, with a statistically significant difference (p < 0.0001).
Table 1.
Age, sex and associated injuries in different centers across India.
| South | West | North 1 | North 2 | Total (%) | ||
|---|---|---|---|---|---|---|
| Gender | Male | 611 | 510 | 705 | 1236 | 3062(84.05 %) |
| Female | 78 | 113 | 159 | 231 | 581(15.95 %) | |
| Total | 689 | 623 | 864 | 1467 | 3643 | |
| Age group | Above 60 years | 101 | 31 | 86 | 198 | 416(11.4 %) |
| 41–60 years | 462 | 221 | 273 | 585 | 1541(42.3 %) | |
| 19–40 years | 126 | 348 | 497 | 664 | 1635(44.9 %) | |
| Pediatric age | 0 | 23 | 8 | 20 | 51(1.4 %) | |
| Total | 689 | 623 | 864 | 1467 | 3643 | |
| Associated injuries | Pelvis | 121 | 93 | No data | 144 | 358(9.8 %) |
| Head injury | 176 | 48 | No data | 9 | 233(6.4 %) | |
| Femur fracture | 79 | 64 | No data | 113 | 256(7 %) | |
| Forearm | 66 | 26 | No data | 24 | 116(3.2 %) | |
| Abdomen | 14 | 65 | No data | 7 | 86(2.4 %) | |
| Other injury | 335 | 323 | No data | 254 | 912(25 %) | |
| Total | 791 | 619 | No data | 551 | 1961 (53.8 %) | |
3.2. Age distribution
The age-wise distribution is given below (Table 1). Overall, acetabular fractures were more common in the young age group (19–40 years, 44.9 %), followed by the middle age group (41–60 years, 42.3 %), with the least number of cases seen among the elderly and pediatric patients. The age-wise distribution of fractures was consistent in northern India, and Western India, whereas in Southern India, the highest number of fractures were noted among the 41–60 years age group.
3.3. Associated injuries
Associated injuries were seen in 1961 patients (53.82 %), with the most common being pelvis injury (9.8 %). Other injuries like head injuries (6.4 %) and ipsilateral femur fractures (7 %) were also noted in patients with acetabular fractures. Similar trends were seen in all regions, except in South India where head injury (25.54 %) was more common than pelvic injury. Other less common injuries included fractures of both bones of leg, injuries involving the knee joint, blunt trauma to the chest, humerus fractures, vascular injury, and facial injuries. This information is summarized in Table 1. Data on associated injuries from the Northern 1 region were not available.
3.4. Fracture patterns
The acetabular fracture patterns were classified according to the Judet-Letournel classification (Fig. 1). The distribution of various acetabular fractures is shown in Table 2. Out of 3561 classified fractures, isolated posterior wall fractures were the most common with an incidence of 20.7 %, followed by associated both column (ABC) type (18.4 %). Similar incidences were noted across centers in Southern and Western India, whereas ABC fractures were the most common type in Northern (N1 & N2) India. Isolated anterior wall fractures were the least common type seen across all regions, with an overall incidence of 0.8 %. The number of isolated anterior column fractures was substantially higher in the Northern 1 region compared to other regions.
Fig. 1.
Bar diagram showing region-wise distribution of Acetabular Fractures According to the Letournel and Judet Classification.
Table 2.
Acetabular fracture pattern across different centers in India.
| Type | South | West | North 1 | North 2 | Total |
|---|---|---|---|---|---|
| Posterior Wall | 211 | 88 | 133 | 321 | 753 (20.7 %) |
| Posterior Column | 20 | 32 | 27 | 33 | 112 (3.0 %) |
| Anterior Wall | 19 | 0 | 6 | 4 | 29 (0.8 %) |
| Anterior Column | 38 | 33 | 163 | 96 | 330 (9.0 %) |
| Transverse | 50 | 56 | 62 | 164 | 332 (9.1 %) |
| T-Type | 90 | 67 | 90 | 170 | 417 (11.5 %) |
| Posterior Column with Posterior Wall | 88 | 36 | 42 | 88 | 254 (6.9 %) |
| Transverse with Posterior Wall | 84 | 81 | 85 | 149 | 399 (10.9 %) |
| Anterior Column Posterior Hemitransverse | 26 | 84 | 60 | 98 | 268 (7.4 %) |
| Associated Both Column | 63 | 64 | 196 | 344 | 667 (18.4 %) |
| Total classified fractures | 689 | 541 | 864 | 1467 | 3561 (97.8 %) |
| Unclassified fractures | 0 | 82 | 0 | 0 | 82 (2.2 %) |
| Total cases | 689 | 623 | 864 | 1467 | 3643 |
3.5. Surgical approaches
Out of 3643 patients, 2986 (82 %) were operated on, and the rest were managed non-operatively (Table 3). The Kocher-Langenbeck (KL) approach was the most commonly used (42.5 %), followed by the anterior intra-pelvic (AIP) approach (16.1 %), iliofemoral (15.2 %), and ilioinguinal (5.8 %) approaches (Fig. 2). Combined approaches were used in about 14.2 % of cases.
Table 3.
Surgical approaches used in different centers across India.
| Approach | South | West | North 1 | North 2 | Total |
|---|---|---|---|---|---|
| Kocher-Langenbeck | 392 | 172 | 277 | 428 | 1269 (42.5 %) |
| Anterior Intrapelvic | 18 | 92 | 329 | 44 | 483 (16.1 %) |
| Iliofemoral | 52 | 123 | 47 | 232 | 454 (15.2 %) |
| Ilioinguinal | 3 | 96 | 49 | 21 | 169 (5.8 %) |
| Trochanteric osteotomy, Ganz's safe surgical dislocation | 24 | 47 | 13 | 1 | 85 (2.8 %) |
| Combined Approach | 125 | 88 | 47 | 165 | 425 (14.2 %) |
| Percutaneous fixation | 0 | 5 | 0 | 96 | 101 (3.4 %) |
| Total operated | 614 | 623 | 762 | 987 | 2986 (82 %) |
| Nonoperative | 75 | 0 | 102 | 480 | 657 (18 %) |
| Total cases | 689 | 623 | 864 | 1467 | 3643 |
Fig. 2.
Bar diagram showing region-wise distribution of different surgical approaches adopted for treating acetabular fractures.
4. Discussion
This demographic study on acetabular fractures in India revealed that young male patients (19–40 years) are the commonest victims. Pelvic fractures were frequent associated injuries (10.52 %). Posterior wall fractures were the commonest (20.7 %), while anterior wall fractures were the least common (0.8 %). Operative management was used in 82 % of cases, with the Kocher-Langenbeck approach being the most common (42.5 %).
In India, acetabular fractures are commonly seen in young trauma victims, indicating that most result from high-velocity trauma rather than osteoporotic fractures. These findings contrast with studies by the Finnish group and Mauffrey et al., which indicated a bimodal age distribution of acetabular fractures.14,15 The study by Alvarez-Nebreda et al. showed higher fracture rates among older osteoporotic females in the USA between 2007 and 2014.16 The Swedish registry indicated that older males over 70 years sustained more acetabular fractures.17 The reason for the late peak could be the aging population in these countries, unlike India, where the majority of the population is still young. Increased life expectancy, better medical care, osteoporosis, and lack of family support are the main reasons behind increased geriatric insufficiency fractures in Western countries. In fact, China also reported an increasing trend of elderly fractures, from 5.7 % to 24.0 % from 2010 to 2019, although high-velocity trauma is still common.29 Brazil, Qatar, and other developing nations report that high-velocity trauma remains the most common cause of acetabular fractures, typically affecting young patients in their reproductive age group.19,22
Regarding gender distribution, acetabular fractures are five times more common in males than in females, which aligns with the higher involvement of males in motor vehicle accidents. Trikha et al., Meena et al., and Jindal et al. had similar observations in their studies.5,17,18 Data from Qatar and Singapore also showed a male predominance.19,20 However, females patients were twice the number of males affected in developed countries, owing to cultural differences where females participate in more outdoor activities, driving and also because of increased incidence of post-menopausal osteoporotic fractures.14,15
The most commonly associated injuries in our study are pelvic ring injuries, followed by head injuries. There is demographic variation in this value, as the proportion of head injury cases is higher in the South Indian center compared to other centers. It is likely that many of the victims are pedestrians struck by vehicles, or that there is a lower rate of helmet usage in the vicinity of the southern center. The associated injuries were 1.5–2 times more common in our study compared to other studies.6,21,22 Trikha et al. reported associated multisystem involvement in 26 % of cases.
Overall, fractures of posterior wall are the commonest type of acetabular fracture, while isolated fractures of anterior wall are the least common. Our results align with the study by Trikha et al.18 Similar findings were elucidated by Singh et al., who reported that posterior wall fractures occurred in 23 % of cases.20 Most cases were managed operatively rather than conservatively, indicating that displaced acetabular fractures are quite common and surgeons have developed the necessary skills to manage such injuries operatively. These findings contrast with those of Boudissa et al., who managed over half of their injuries conservatively.23 This could be because the majority of patients in their study had sustained anterior wall fractures, which can often be managed without surgery. However, management trends globally have been increasingly favouring surgical intervention in recent years.6,14,16,24
The most commonly used approach is the Kocher-Langenbeck approach, likely because most fractures reported had a posterior wall fracture, which is easily visualized and fixed by this approach. Among other approaches, the anterior intra-pelvic approach is the second most preferred among surgeons. Combined approaches were used in about 14.2 % of cases, encouraged for fixing complex fracture patterns encountered in daily practice.
Previous demographic studies on acetabular trauma have been performed on smaller populations involving only single centers.5,17,19,21, 22, 23,26, 27, 28 Due to the scarcity of data, various studies with limited sample sizes often included demographic characteristics of patients as their secondary objective.5,17,21,26 To the best of our knowledge, our study has the largest sample size from India and one of the largest epidemiological series of surgically treated acetabular fractures from various institutions over a period of 18 years.
However, this study has a few limitations. The population catered to each center is referred from other institutions, and therefore, our findings may not be representative of the entire population. Secondly, owing to the retrospective nature of this study, the possibility of biases cannot be ruled out. Future studies must focus on establishing a country-based registry for acetabular and pelvic injuries. Long-term follow-ups are needed, and patients must be followed up until mortality. Finally, functional data beyond mortality, such as cognition, functional dependence, and quality of life, are necessary. It is necessary to establish an integrated national trauma registry to document the details of trauma patients and their management in order to ascertain the evolving trends of acetabular fracture patterns in the country over time.
To conclude, high-velocity trauma is the leading cause of acetabular fractures in India, predominantly affecting young males. Pelvic fractures are the most commonly associated injuries. Posterior wall fractures are the most frequent type of acetabular fracture, with the Kocher-Langenbeck approach being the commonly adopted surgical method.
Credit author statement
RKS, VT, RP, and UM provided data. The data were compiled and analyzed by SV, MM and SK. MM and SV prepared the initial draft. SKT provided intellectual content and finalised the draft. All authors read the manuscript and approved for publication.
Conflict of interest statement
The authors declare that some of the authors (Ramesh Kumar Sen, Vivek Trikha, and Sujit Kumar Tripathy) serve on the editorial board of the Journal of Clinical Orthopaedics and Trauma (JCOT) and one author (Ramesh Kumar Sen) is the editor of VSI Acetabulum.
Funding
None.
Author statement
All authors agree in unison to publish this registry of acetabular fracture. The contributions of each author has been mentioned in the author credit statement.
Declaration of competing interest
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:
The authors declare that some of the authors (RKS, VT, and SKT) serve on the editorial board of the Journal of Clinical Orthopaedics and Trauma (JCOT), and one author is the editor of VSI Acetabulum.
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