Integrative surgical approach for complex transverse-posterior wall fractures of the acetabulum: A case series of 21 patients evaluating mid-term outcomes

1. Introduction

Complex acetabulum-fractures represent a significant challenge due to their complicated nature and their crucial role in the function and stability of hip joint. The AO/ATO classifies associated transverse-posterior-wall (TPW) fractures-of-acetabulum as partial articular fractures¹; and they account for 24–32 % of all acetabulum-fractures,^{2, 3, 4} making them one of the most prevalent patterns in the Letournel-classification.^{5, 6, 7, 8, 9} High velocity trauma are the most common cause of complex fractures of acetabulum, with automobile accidents being the most common mode of injury.^{2,4,7, 8, 9}

The complexity of acetabulum-fractures arises from the anatomical intricacies of the region.¹⁰ The major fracture line traverses the weight-bearing area, and passes over the acetabular dome, and the fracture pattern of transverse component can be categorized into a transtectal, infratectal, or juxtatectal.^6,11 Meanwhile, the posterior-wall fragment can be categorized as posterior, posteroinferior, or posterosuperior.¹¹ Due to the unstable nature of the posterior-wall fragment, the majority of such fractures are displaced and need stable fixation.⁸ The treatment of TPW-fractures has shown significant advancements. Despite the advancements in treatment modalities and their strategies, optimal treatment remains a subject of ongoing research, and debate regarding the best surgical approach is inconclusive, especially in complex fracture patterns with a significant displacement.^{12, 13, 14, 15, 16}

In this case series, we have focused on outcome analysis of patients with TPW-fracture of acetabulum who were treated by a dual/combined approach using Kocher-Langenbeck's (KL) approach and ilio-femoral (IF) approach. With this study, we aim to analyze the radiological, and functional outcomes and determine the rate of complications among these patients. And, to report the epidemiological pattern of combined TPW fractures.

2. Methods and materials

After ethical committee clearance a retrospective observational study was conducted in a level 1 tertiary care center on patients with TPW-fracture. During the period of January 2015 to January 2023, 512 acetabulum-fractures were managed surgically in our hospital. 87 Out of them had TPW-type of fractures (incidence; 17 %). Among these 87, two died preoperatively due to multiple systemic injuries (mortality rate: 2.3 %) and six were lost for follow-up.

For this study, we included patients of all age groups, who had complex TPW-fracture treated by a combined surgical approach (KL and IF-approach) with a minimum of 1-year follow-up. We excluded those with TPW-fractures treated by a single approach, and we also excluded patients with isolated transverse fractures, isolated posterior-wall fractures, undisplaced fractures that were treated conservatively, and individuals who were unfit for surgery. Twenty-one patients met criteria and were included. Previous records, which include admission notes, surgical notes, and progress notes, were reviewed, and details of demographic data, mode-of-injury, time-of-injury, time-of-admission, type-of-fracture, and associated injuries (skeletal and non-skeletal injuries) were collected. Fig. 1 demonstrates the PICO flow diagram.

Fig. 1.

Summarizes the PICO flow diagram of the study population.

2.1. Assessment and evaluation

Emergency treatment was given under advanced-trauma-life-support (ATLS) guidelines. All patients underwent clinical and radiological evaluation. All radiographs were obtained at standard magnification, the pelvis with both hips anteroposterior (AP) view and oblique views (Iliac and obturator view) were taken pre-operatively, and all the patients underwent CT scans pre-operatively. Post-operative radiographs were taken on the first day of surgery and during subsequent follow-ups at the 6 weeks, 3rd month, 6th month, 1-year, and last follow-up.

Radiological findings like fracture pattern, type of hip dislocation, marginal impaction, roof arc angle, femoral head fracture, comminution in the acetabulum, and number of articular fragments were analyzed. Post-operative radiological results were graded based on Matta score.¹⁷ Functional-outcome analysis was done based on the EuroQOL-5D.¹⁸ The occurrence of complications like conversion to total-hip-replacement (THR), heterotrophic ossification (HO), osteoarthritis (OA), and avascular necrosis (AVN) was evaluated.

2.2. Post-operative protocol

For patients with isolated pelvic trauma: On postoperative day one, chest physiotherapy was started, and the patient was made to sit in bed. From post-operative day two, they were allowed to walk non-weight bearing (NWB) with 4-point crutch support for 6 weeks. From week 6 onwards, the patient was mobilized with partial weight bearing (PWB) walking with a crutches for another six weeks. Full-weight-bearing (FWB) walking with walker support began in the third month, followed by FWB walking with elbow crutches six weeks later. For these patients, anticoagulant therapy consisted of oral aspirin 150 mg once a day for six weeks.

For patients with multiple fractures/Limb fractures/Polytrauma: These patients were not mobilized for six weeks and were put on anticoagulant medication with Tablet Apixaban-5 mg twice a day. From the sixth week onward, the same protocol was used for individuals with isolated pelvic injuries.

2.3. Statistical analysis

Data entered in Excel sheet. For categorical data – the percentage & frequency distribution were employed. Moreover, for metric data – arithmetic mean and standard deviation (SD) were used. Analysis of categorical data was done using chi-square test.

A one-tail analysis with an available sample size of 21 patients was performed by taking an effect-size of 0.5 and an alpha-error-probability as 0.05 into consideration. The power of study (1-beta error prob) was found to be 81 %. A radiological assessment was done by two independent observers, and the intraclass correlation coefficient (ICC) agreement was achieved. For statistical analysis, IBM-SPSS Version-26 software was utilized for analysis.

3. Results

All the demographic-details of study population have been provided in Table-1. Associated-TPW fracture accounts for 17 % among all the acetabulum-fractures. Males outnumbered females in the study population (M: F = 19: 2), with an overall mean-age of 39 years (range: 22–70 years). Diabetes-mellitus(DM), hypertension(HTN), chronic-kidney-disease(CKD), ischemic-heart-disease (IHD), or a combination of these co-morbidities affected 38 % (8 of 21). All the patients in the study group sustained injuries because of a high-velocity road traffic collision/accident (RTA). 47.6 % (10/21) of the patients had multiple injuries, 38.1 % (8/21) were polytraumatized, and 14.3 % of patients (3/21) had isolated pelvic trauma. On arrival, a sciatic nerve injury was seen in 19 % (4 of 21) patients. The mean-follow-up period was 30.5months (range: 12–74months).

Table-1.

Demographic details and associated injury details of the patients included in the study.

Demographic details of the patients included in the study.
Characteristics		No of patients
Sex	Males	19
	Females	2
Mean age	39 years (range 22–70 years)
Side of injury	Right	13
	Left	8
Mode of injury	Road traffic accident (RTA)	21 (100 %)
	Fall from height (FFH)	0
Associated Comorbidities	DM	3
	HTN	1
	CKD	0
	HTN + IHD	1
	DM + HTN	3
Associated injuries	Isolated pelvic trauma	3(14.3 %)
	Limb injuries	10 (47.6 %)
	Other systemic injuries (Polytrauma)	8 (38.1 %)
Sciatic nerve injury		4 (19 %)

3.1. Radiological findings

On arrival, hip dislocation was seen in 71.5 % of the patients (15/21), of which 86.7 % (12/15) had posterior dislocation, while central dislocation was seen in 13.3 % (2/15). 6.7 % (1/21) of patients had an associated femoral head fracture. According to the transverse fracture pattern, 66.7 % (14/21) were transtectal, 33.3 % (7/21) were juxtatectal, and none of them had infratectal. Moreover, according to the number of fragments, 28.6 % (6/21) had a single fragment, 14.3 % (3/21) had two fragments, and 57.1 % (12/21) of them had comminution. Marginal impaction and contusion were seen in 24 % (5/21). The mean roof arc angle was found to be 29 ± 10°.

3.2. Operative data

Average days between admission to surgical intervention were 6 days (range: 2–20 days). A trochanteric flip osteotomy was performed in 1 case. The mean surgical time was 165 min (range: 120–270 min), and the average intraoperative blood-loss was 600 ml (range: 350–1000 ml).

Sequence of surgical fixation and method of fixation: In patients with posterior comminution, the anterior-column was addressed first, and fixation was done using a plate and screw construct, followed by posterior-wall and posterior-column fixation using plate osteosynthesis. However, in patients with a single large fragment or 2 fragments without comminution, the first posterior-wall and column fixation was done using plate osteosynthesis, followed by the anterior-column, which was addressed either using an anterior-column screw with or without additional plate fixation. All the patients underwent plate osteosynthesis for posterior-column and posterior-wall stabilization. For stabilization of anterior-column, a combination of anterior-column screws and additional plate osteosynthesis was performed in 81 % (17/21) of the patients. Whereas, in the rest of the 19 % (4/21) reduction and stabilization were found to be stable with the anterior-column screw alone.

3.3. Radiological outcome

For the evaluation of the quality of reduction, the Matta scoring system was used¹⁷; excellent reduction was found in 47.6 % (10/21), good in 38.1 % (8/21), fair in 14.3 % (3/21), and none of the cases demonstrated poor reduction.

3.4. Functional outcome

The EuroQoL-5D scoring was used to do functional outcome evaluation. 1 patient who underwent THR was not included in the final functional outcome analysis. The rest of the 20 patients completed functional outcome analysis. Details of 20 patients’ available are described in Table 2 and Fig. 2.

Table 2.

Functional outcome analysis of 20 patients using EuroQoL-5D scoring.

Functional outcome analysis based on EuroQoL-5D scoring.
	Mobility		Self-care		Usual activities		Pain/Discomfort		Anxiety/Depression
	Number	%	Number	%	Number	%	Number	%	Number	%
Level-1	15	75.0	13	65.0	14	70.0	14	70.0	16	80.0
Level-2	4	20.0	5	25.0	3	15.0	4	20.0	3	15.0
Level-3	1	5.0	1	5.0	3	15.0	1	5.0	1	5.0
Level-4	0	0.0	1	5.0	0	0.0	1	5.0	0	0.0
Level-5	0	0.0	0	0.0	0	0.0	0	0.0	0	0.0

Fig. 2.

Chart demonstrating functional outcome based on EuroQoL-5D scoring.

Fig. 3 demonstrates the images of 41-years male who had a road-traffic-collision and sustained a TPW-fracture on the left side. He underwent fixation using a combined approach and had an excellent outcome at a 3-year follow-up.

Fig. 3.

A-M: Demonstrates the images of a 41-year-old male who had a road-traffic-collision and sustained a TPW fracture on the left side. He underwent fixation using a combined approach and had an excellent outcome. 3A: radiographs of the pelvis with both hips in AP view; 3B–F: CT scan image; 3G–I: immediate postoperative x-rays showing AP. iliac and obturator views, 3J–L: radiological outcome at 3 years follow-up; 3M: functional outcome with the patient able to comfortably sit in a crossed-leg sitting position.

3.5. Complications

Immediate and early complications: None of the patients had major (>1500 mL) intraoperative blood-loss. Iatrogenic sciatic-nerve injury was noted in two patients, who were provided with foot drop splints and were started on oral methylcobalamine 1500 mg daily. Nerve function recovered eventually in patients with iatrogenic nerve injury. Three patients had surgical site infections; two of them had superficial surgical site infections and were started on systemic antibiotics for 1 week, followed by oral antibiotics for another 2 weeks. The infection settled well, and the surgical wound went on to heal well. Another patient developed a deep infection that needed debridement of the wound and eventually went on to heal well.

Late complications: On arrival, 4 patients had presented with post-traumatic sciatic nerve injury; three of them recovered from nerve injury; however, one patient had persistent foot drop. On examination and analysis of final follow-up radiographs, we found that 3 patients (14.3 %) had femoral head avascular necrosis (AVN). Heterotrophic ossification (HO) was seen in 7 patients (33.3 %), and post-traumatic osteoarthritis (OA) was seen in 2 patients (9.5 %). Among these patients, the one who underwent conversion to THR had grade 4 AVN (Fig. 4). Table 3 provides the details of nerve injury and other complications.

Fig. 4.

A –M: Demonstrates the images of a 30-year-old female who sustained a TPW fracture of the right side following a road traffic collision and had sustained polytrauma with multiple fractures, including ipsilateral femur shaft fracture. He underwent fixation by dual approach but developed avascular necrosis (AVN) of the femoral head and underwent secondary total-hip-replacement (THR). 4A–F: preoperative radiographs and CT scan images; 4G: immediate post-operative x-rays showing AP. 4H–J: 3 months follow-up radiographs of AP, iliac, and obturator views showing early arthritic changes and heterotrophic ossification.; 4K: X-ray images showing AVN of the femoral head and proximal migration of femur at 8th month follow-up, 4L: X-ray of immediate post-THR done; 4M: radiographs at 18 months follow-up post-THR.

Table 3.

Details of complications: Immediate complications either occurring intra-operatively or during the immediate post-operative period. Early complications occur within 3 months of surgery, and late complications are those occurring after 3 months of surgery.

Details of the complications in study population (Pre-operative, immediate post-operative, early, and lateral complications)
Complication	No of patients (frequency in %)
Sciatic nerve injury	6 (28.6 %)
•Pre-operative (Traumatic)	4 (19 %)
•Post-operative (Iatrogenic)	2 (9.5 %)
Early complications:
•Deep vein thrombosis	0(0 %)
•Surgical site infection	3 (14.3 %)
Late complications:
•Avascular necrosis (AVN)	3 patients (14.3 %)
•Heterotrophic ossification (HO)	7 patients (33.3 %)
•Post-traumatic osteoarthritis (OA)	2 patients (9.5 %)
Rate of conversion to THR	1 Patient (4.7 %)

4. Discussion

We report an incidence of TPW-fracture to be 17 %, the existing literature reports its incidence to range between 4 and 22 %.^2,7,11 Changes in the acetabular shape, result in cartilage degeneration and post-traumatic arthritis due to altered forces acting across the hip joint,^7,9 hence the most crucial aspects in management of TPW-fracture are anatomical reduction, stable fixation, and early hip motion.^7,8,15,19 A TPW-fracture can be surgically managed using either a single or a dual approach. During the surgical-fixation, restoring the posterior-wall and roof and additionally correcting the rotation of the free-floating segment is a challenge.^15,16,20

The level of transverse-fracture component and the amount of displacement at the fracture site determines the initial surgical approach.¹⁵ The KL-approach is commonly used for T-shaped fractures due to posterior displacement.^{12,13,20, 21, 22} Hip dislocation after greater trochanteric flip osteotomy can aid in reducing the posterior-column and visualizing the articular-surface in cases with high transverse fractures with posterior-column displacement.²⁰ Additionally, if the vertical line of fracture intersects the ischium, in such cases the posterior approach is required; and if it crosses the obturator-foramen, the anterior approach may be used.^13,20,22

Based on the morphological parameters of the fracture we choose the approach and sequence of fixation. In cases with significant anterior-column displacement, anterior-column reduction & fixation were performed using a dual approach. In patients with a single large or two posterior-wall fragments and patients without comminution, the posterior-wall and column were addressed first. Then, based on the displacement and roof arch angle, the anterior-column was addressed. If the displacement at the anterior-column is more than 2 mm and the roof-arc-angle is less than 45°, the anterior-column was addressed using the iliofemoral approach. Moreover, in patients with comminution at posterior-wall or column with simple anterior-column fracture, first anterior -column stabilization can be achieved, followed by the stabilization of posterior-wall and column.^7,11,15

The combined approach has to be performed when the morphological parameters of the fracture demand it.^11,15,16,20 Even though the dual approach has its disadvantages, like more exposure, more blood loss, prolonged operating time, and a higher risk of neurovascular injury, it provides controlled and adequate exposure to reduce and fix both columns and walls, which helps a surgeon to achieve excellent reduction and stable fixation.^11,15,20,21 Although various biochemical-studies support a two-column fixation module, Baoqing et al.²³ in their biomechanical study found that posterior plate additional to anterior-column lag screw was better than plating of both columns.²³

Quality-of-reduction in literature has been studied either in transverse fractures or posterior-wall fractures; Bogden et al.²⁰ reported 100 % anatomic reduction and suggested an algorithm for the management of TPW-fractures. Letournel and Judet,¹⁰ Matta,²⁴ Gansslen et al.⁷ reported 68 %, 80 %, and 76 % excellent reductions, respectively. Similarly, Fahmy et al.¹⁵ reported 80 % anatomic reduction, and Yang et al.¹¹ reported 70 % anatomic reduction. Meanwhile, we utilized Matta score to evaluate the quality-of-reduction, and our results were similar to the documented studies in the literature; excellent to good reduction was found in 86 % (18/21), fair reduction in 14 % (3/21), and none of the cases had poor reduction.

Only a few studies have looked at the outcome of TPW fracture fixation, and they all used the Merle D-Aubigne scoring methods for functional outcome analysis.^{11,13,15,16,25,26} We used EuroQoL-5D to determine the functional result.¹⁸ Based on the EuroQoL-5D scoring system, our study population reported levels 1 (no problem) to 2 (slight problem) in mobility by 95 %, self-care by 90 %, usual activities by 85 %, no or slight pain or discomfort by 90 %, and no or slight anxiety or depression by 95 % (Table-2, Fig. 2).

Our study has some limitations: first, a mean-follow-up of 30.5months is considered mid-term, and post-traumatic arthritis develops over a long-term period, hence long-term studies are required. Second, it is a retrospective study. Despite these limitations, our study adds valuable data to the existing literature, and as far as we looked into literature we realised that our study is 1st study to evaluate functional-outcomes using the EuroQoL-5D system in patients with complex TPW-fractures managed using a combined approach.

5. Conclusion

In cases of complex TPW-fractures with complete displacement and/or comminution, the integrative use of the KL and IF-approach provides comprehensive and controlled exposure for the reduction & fixation of posterior wall and both columns, thereby facilitating excellent-reduction and stable-fixation.

For those presenting with comminution at posterior-wall or column and simple anterior-column fracture, the IF-approach should be employed first to stabilize anterior-column, followed by posterior-wall and column using KL-approach. Contrarily, in cases without posterior-wall or column-comminution, initial fixation and stabilization of posterior aspect can be performed by KL-approach. Subsequently, if intra-operative assessment reveals an anterior-column displacement greater than 2 mm and intra-operative roof-arc-angle less than 45°, IF-approach should be utilized to address anterior-column if indirect reduction from the posterior-approach proves insufficient.

CRediT authorship contribution statement

Ramesh Perumal: Conceptualization, Methodology, Writing – review & editing, Project administration, Supervision, Validation. Owais Ahmed: Writing – original draft, Data curation, Formal analysis, Investigation, Validation, Visualization. Asif Imran: Formal analysis, Validation, Visualization. Mohamed Zackariya: Supervision, Validation, Writing – review & editing. Dheenadhayalan Jayaramaraju: Writing – review & editing, Project administration, Supervision. Rajasekaran Shanmuganathan: Methodology, Writing – review & editing, Project administration, Supervision, Resources.

Statements and declaration

No conflict of interest.

No acknowledgments.

No Disclosures.

No Source of funding.

Declaration of interest statement

We authors have no conflict of interest.