Abstract
Background
Complex anatomy of acetabular fracture is quite challenging for the orthopedic surgeons. Many Acetabular fracture fixation approaches have been used for a long time to treat different fracture patterns of acetabulum. Kocher-Langenbeck Approach (K-L approach) of acetabulum fracture is usually used by most of orthopedic surgeons. In this retrospective study, we evaluated the clinical and functional outcome of subtypes of acetabulum fractures treated with K-L approach. Assessment of Intra and postoperative complications of subtypes of acetabulum fractures was also done.
Method
Eighty patients (48 men and 32 women) were included in this retrospective study with a mean follow-up period of 2.6 years. Fractures were classified according to Letournal and Judet classification. K-L approach was performed in all these patients. Post operative reduction, Radiological outcome was quantified using Matta's criteria while the functional outcome was assessed according to Merle d’Aubigné and Postel scoring system. Postoperative complications were evaluated.
Results
The mean age of a total of 80 cases was 43.64 ± 13.24 year. The type of fracture was found to be significantly associated with concentric/non-concentric reduction (p = 0.003) and with post op reduction (p = 0.005). The post operative reduction was found to be significantly associated with radiological (p < 0.001) and functional outcome (p < 0.001) at one year post op. The type of fracture was found to be significantly associated with radiological outcome (p < 0.001) while non-significantly found to be associated with functional outcome at 1 year (p = 0.050). The type of fracture was found to be significantly associated with post op complications (p = 0.003) and with arthritis (p = 0.001).
Conclusion
K-L approach is a multifaceted and convenient approach for treating acetabulum fractures. Type of fracture and post-operative reduction are key factors for a satisfactory outcome. Transverse with posterior wall fracture has the worst prognosis.
Keywords: Acetabulum fracture, Type of fracture, Kocher-langenback (K-L) approach, Radiological and functional outcome, Postoperative complications
1. Introduction
Acetabular fractures are a rare injury accounting for 3 patients/100,000/year globally.1,2 Approximately, 37 pelvic fractures per 100,000 annually have been reported in Western Europe and the United States out of which only 10% cases involve acetabulum while 17.7% cases of acetabular fractures have been reported in Indian population.3,4 Most of the acetabular fractures occur due to high-energy trauma like road accidents (80.5%) and fall from height (10.7%).5 Apart from this, fragility acetabular fractures are caused by low-energy fall from standing height in osteoporotic patients.6 Posterior wall fracture is the most common fracture accounting for 24.2% of all acetabular fractures.1,7, 8, 9 Incidence of posterior column, posterior wall with column, transverse, T-shaped, transverse with posterior wall and anterior column with posterior hemi-transverse is 4.1%, 2.7%, 8.6%, 6.6%, 20.7% and 5.7% respectively.10 Acetabular fracture is difficult to approach and treat due to its anatomical location and three dimensional (3D) structure of the bone. Numerous approaches are available to treat the various subtypes of acetabular fracture amongst which the K-L approach is familiar among the orthopaedic surgeons and considered as a gold standard approach due to direct visualization of the whole posterior wall and column.11,12 In addition to this, it also allows indirect access to the true pelvis and can also be used for fixation and reduction of hip fractures.13,14 A number of clinical studies have reported the surgical outcomes, as well as prognostic factors associated with all acetabular fracture.15,16 Only a few studies have documented the functional outcome of different types of acetabular fractures using the K-L approach. Most of the studies include only one or two fractures treated with K-L approach.15,17 The objective of this study is to investigate the clinico-radiological and functional outcomes of subtypes of acetabulum fracture treated with K-L approach in our institution. In addition to this, we also focused on the complications associated with acetabulum fractures.
2. Materials and methods
This study is a retrospective analysis of the subtypes of acetabular fracture treated with open reduction and internal fixation using Kocher-Langenbeck approach, and was carried out from 2015 to 2020. Patients were admitted to trauma center, and after initial stabilization, they were subjected to preoperative investigations including X-ray of pelvis with both hips -AP, lateral and Judet views. CT-scan with 3D reconstruction was done in all patients pre-operatively. On the basis of X-ray and CT-scan, fractures were categorized as described by Letournal and Judet.18 The inclusion criteria were-fracture within 2 weeks of injury in adult patients with posterior wall, posterior column, posterior column with wall, transverse, T-shaped, transverse with posterior wall and anterior column with posterior hemi-transverse and patients who were followed up for at least 1 year. Exclusion criteria were-patients having other types of acetabular fracture such as anterior wall, anterior column and both column fractures, patients who require anterior fixation, undisplaced fractures, and compound fractures, follow-up of less than 1 year and patients unfit for surgery. All patients with subtypes of acetabulum fractures were operated by using the standard K-L approach under spinal anaesthesia in lateral position by a single surgical team. Open reduction and internal fixation of fracture acetabulum was done using reconstruction plates and screws as per fracture pattern following AO fracture fixation protocol. Intra-operative assessment for the surgical time, blood loss, neurovascular injury (superior gluteal artery and sciatic nerve) was done. Patients were followed up at 3 weeks, 6 weeks, 12 weeks, 24 weeks, and then yearly. Postoperative radiographs were evaluated to assess the congruency and the fracture reduction according to Matta's criteria19 - the quality of reduction was based on maximal residual displacement (MRD) which may be anatomical (MRD<2 mm), imperfect (MRD between 2 and 3 mm) and poor (MRD >3 mm). Radiological evaluation was done at 1 year by Matta's criteria19 and categorized as excellent (normal appearance of hip joints on X-ray), good (minimal sub-chondral sclerosis and joint space narrowing), fair (50% joints space narrowing) and poor (>50% joint space narrowing). Functional outcome was evaluated by using Merle d'Aubigné-Postel at 1 year6 that includes pain, gait and mobility for outcome assessment.20 Documented complications such as sciatic nerve injury, avascular necrosis (AVN) of femoral head according to Ficat and Arlet classification,21 myositis ossificans according to Brooker classification,22 arthritis of hip joint were evaluated postoperatively.
3. Statistical analysis
The results were analyzed using descriptive statistics and making comparisons among various groups. Categorical data were summarized as proportions and percentages (%) while discrete (quantitative) as mean (SD). All the associations were tested by using chi square test. One way analysis of variance (ANOVA) was performed for comparing means of continuous variables among various fracture types. Statistical analyses were performed using SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). A value of p < 0.05 was considered statistically significant.
4. Results
4.1. Baseline manifestation
A total of 92 patients were operated out of which 80 patients (32 women and 48 men) met with inclusion criteria and had subtypes of acetabular fractures with mean age of 43.64 ± 13.24 year and mean follow up period 2.6 years (Table 1). Out of 80 cases, 62 (77.5%)patients had road traffic accidents and 18 (22.5%) cases fell from height. Of all patients, posterior wall fracture (33.8%), posterior column fracture (20.2%), anterior column with posterior hemi-transverse (6.3%), posterior column with posterior wall (11.3%), T-type (11.3%), transverse (8.8%) and transverse fracture with posterior wall (8.8%) were identified (Table 1). Posterior wall fracture was the most common fracture in patients with acetabular fracture. Non-significant association was found between mean ages and various types of fracture (p = 0.377).
Table 1.
Statistics of variables.
| Variables |
Frequency (%) |
|---|---|
| A) Qualitative | |
| 1.Gender | |
| Male | 48 (60%) |
| Female | 32 (40%) |
| 2.Mode of injury | |
| Road traffic accidents | |
| Fall from height | |
| 3.Type Of Fracture | |
| Posterior wall fracture | 27 (33.8%) |
| Posterior column fracture | 16 (20.0%) |
| Posterior column with posterior wall fracture | 9 (11.3%) |
| T-type fracture | 9 (11.3%) |
| Transverse fracture | 7 (8.80%) |
| Transverse fracture with posterior wall | 7 (8.80%) |
| Anterior column with posterior hemi transverse fracture | 5 (6.30%) |
| 4. Type of Reduction | |
| Concentric | 74 (92.5%) |
| Non-concentric | 6 (7.50%) |
| 5. Post Op Complications | |
| Arthritis | 11 (13.8%) |
| Myositis ossificancs | 6 (7.50%) |
| Avascular necrosis | 5 (6.30%) |
| Sciatic nerve palsy | 2 (2.50%) |
| Infection |
1 (1.30%) |
|
B) Quantitative | |
| 1.Mean average age | 43.64 ± 13.24 years |
| 2.Time between injury and surgery | 7.8 ± 2.8 days |
| 3.Mean operation time | 116.38 ± 22.46 min |
| 4.Mean blood loss | 50313 ± 162.91 ml |
4.2. Operational manifestation
All patients of this study were operated through K-L approach. The mean operation time was 116.38 ± 22.46 min on average, and the mean estimated intra-operative blood loss was 503.13 ± 162.91 ml (Table 1). No significant difference was found in mean operative time (p = 0.128) and blood loss (p = 0.397) with various types of fracture.
4.3. Radiological outcomes
Out of 80 cases, most of the fractures were concentric (92.5%) while only 7.5% were non-concentric. The type of fracture was found to be significantly associated with concentric/non-concentric outcome (p = 0.003). Most of the non-concentric outcomes were observed in cases of anterior column with posterior hemi-transverse (40%), T-type (22.2%) and transverse fracture with posterior wall (28.6%). The degree of post-operative reduction, as measured on radiograph, was graded as anatomic in 48 patients (60%), good in 22 patients (27.5%), and poor in 10 patients (12.5%) according to Matta's criteria. The type of fracture was found to be significantly associated with post op reduction (p = 0.005) (Table 2). Maximum anatomical reduction was found in cases of posterior column fracture (87.5%) (Case 1) followed by transverse fracture (71.4%).
Table 2.
Association of type of fracture with type of reduction.
| Type of Fracture | Concentric/Non concentric reduction |
chi sq | p-value | |||
|---|---|---|---|---|---|---|
| Concentric |
Non concentric |
|||||
| N | % | N | % | |||
| Anterior column with posterior hemitransverse fracture | 3 | 60.0% | 2 | 40.0% | 19.69 | 0.003 |
| Posterior column fracture | 16 | 100.0% | 0 | 0.0% | ||
| Posterior column with posterior wall fracture | 9 | 100.0% | 0 | 0.0% | ||
| Posterior wall fracture | 27 | 100.0% | 0 | 0.0% | ||
| T-type fracture | 7 | 77.8% | 2 | 22.2% | ||
| Transverse fracture | 7 | 100.0% | 0 | 0.0% | ||
| Transverse fracture with posterior wall | 5 | 71.4% | 2 | 28.6% | ||
Case 1.
a: Pre-Operative x-rays - AP and Lateral view showing fracture posterior column with hip dislocation.
b: Pre-Operative 3D CT-scan showing fracture posterior column with hip subluxation.
c: Post operative x-ray - AP view at 36 months.
d: Post-Operative x-ray at 60 months.
e: Final functional outcome.
According to Matta's grading system, radiological outcomes were graded as excellent in 37 patients (46.3%), good in 18 (22.5%), fair in 16 patients (20%), and poor in 9 patients (11.3%) at 1 year (Table 3). The postoperative reduction was found to be significantly associated with radiological outcome at one year post op (p < 0.001) (Table 3). The type of fracture were found to be significantly associated with radiological outcome (p = 0.020) (Fig. 1).
Table 3.
Association of post op reduction with radiological and functional outcome at one year.
| Excellent |
Fair |
Good |
Poor |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| No. | % | No. | % | No. | % | No. | % | ||||
| Post-Op Reduction With Radiological Outcome at One Year | Anatomical (48) | 27 | 56.3% | 6 | 12.5% | 13 | 27.1% | 2 | 4.2% | 22.25 | <0.001 |
| Good (22) | 9 | 40.9% | 5 | 22.7% | 5 | 22.7% | 3 | 13.6% | |||
| Poor (10) | 1 | 10.0% | 5 | 50.0% | 0 | 0.0% | 4 | 40.0% | |||
| Post-Op Reduction With Functional Outcome at One Year | Anatomical (48) | 34 | 70.8% | 5 | 10.4% | 9 | 18.8% | 0 | 0.0% | 32.43 | <0.001 |
| Good (22) | 8 | 36.4% | 5 | 22.7% | 4 | 18.2% | 5 | 22.7% | |||
| Poor (10) | 0 | 0.0% | 6 | 60.0% | 1 | 10.0% | 3 | 30.0% | |||
Fig. 1.
Association of type of fracture with radiological and functional outcome at one year.
4.4. Functional outcomes
According to Merle d’Aubigné and Postel grading system, functional outcomes were graded as excellent in 42 patients (52.5%), good in 14 (17.5%), fair in 16 patients (20%), and poor in 8 patients (10%) at 1 year (Table 3). There was a significant correlation between postoperative reduction and functional outcome (P < 0.001) (Table 3). The type of fracture was not found to be significantly associated with functional outcome at a 1 year (p = 0.050) (Fig. 1). However, maximum excellent outcome is found in cases of posterior column with posterior wall fracture (77.8%) followed by posterior column fracture (68.8%) (Case 1). Excellent functional outcome was found in around 30% cases with T-Type fractures (Case 2).
Case 2.
a: Pre-Operative x-ray showing T-Type acetabular fracture.
b: Pre-Operative 2-D CT scan showing T-Type acetabular fracture.
c: Pre-Operative 2-D CT scan showing T-Type acetabular fracture.
d: Post-Operative x-ray at 36 months follow-up.
e: Post-Operative x-ray at 60 months follow-up.
f: Final functional outcome.
4.5. Postoperative complications
The postoperative complications were found to be arthritis (13.8%), myositis ossificans (7.5%), AVN (6.3%), sciatic nerve palsy (2.5%) and infection (1.3%) (Table 1). The type of fracture was found to be significantly associated with post op complications (p = 0.003). The type of fracture was found to be significantly associated with arthritis (p = 0.001) (Fig. 2) and the proportion was larger among transverse fracture with posterior wall (Case 3). No deaths were reported after the surgery. No patients were admitted in ICU prior to or after surgery or had ARDS, chest or abdominal injuries.
Fig. 2.
Association of type of fracture with arthritis.
Case 3.
a: Pre-Operative x-ray showing T-Type acetabular fracture with posterior wall.
b: Pre-Operative 3D CT scan showing T type acetabular fracture with fracture posterior wall.
c: Post-Operative x-ray.
d: Post-Operative x-ray at 24 months follow-up shows arthritis and myositis.
5. Discussion
Acetabular fracture is a relatively uncommon fracture which is a challenge for surgeons as it is a more complex injury with respect to other injuries.23 An important goal of surgery is to restore a smooth gliding hip surface as this fracture damages the integrity of the cartilage surface of the bone. The result of open reduction and internal fixation depends upon various factors like energy level of the injury, knowledge of pelvic anatomy, radiographic fracture pattern, and timing of open reduction and internal fixation and choice of surgical approach.24,25 Due to anatomical complexity of acetabulum, various classifications have been proposed of which Judet-Letournel classification is most widely accepted.26 A meta-analysis study has reported that the average age of the patients was 38.6 ± 4.6 years.5 In this study, the average age of patients was 43.64 ± 13.24 years. Patients with young age were found to be associated with acetabulum fracture in this study which might be due to the huge young population in India. Previous studies have reported that males were more likely to be affected with acetabular fractures.5,16,27,28 In this study, mostly males (60%) were found to be affected with acetabular fracture which may be attributed to outdoor activity. A number of studies have shown that road traffic accident is a major mechanism of acetabular fracture.5,29 In the present study, 77.5% of patients were found to be associated with road traffic accidents in contrast to fall from height (22.5%). Timing of surgery is an important factor that may influence the outcome. Quality of reduction was also found to be associated with timing of surgery. Open reduction and internal fixation should be performed within 10 days of injury and within 3 weeks if the patient is unfit for surgery at presentation.10 An earlier study also showed that time between injury and surgery affects the outcomes.30 Giannoudis et al.,5 led a meta-analysis study and recorded the average time between injury and surgery that was 8.9 ± 2.9 days. In this study, the average time between injury and surgery was 7.8 ± 2.8 days. Previous studies have demonstrated that the posterior wall fractures are the most common fractures.5,16,31 We also reported the most frequent fracture was posterior wall fracture (33.8%) among the subtypes of fracture taken in this study. Several lines of evidence also suggest that types of fracture also affect the outcome and complications.5,32 A significant association was found between types of fracture with radiological outcome while non-significant association was observed with functional outcome. The type of fracture was found to be significantly associated with concentric/non-concentric outcome. In the present study, we have shown that most of the fractures were concentric (92.5%) reduction. Most of the non-concentric outcomes were observed in cases of anterior column with posterior hemi-transverse (40%). Due to poor outcomes of Anterior column with posterior hemi transverse fractures by K-L approach, with increasing experience authors subsequently switched to anterior approach to treat these fractures. K-L approach is the gold standard for the open reduction and internal fixation of acetabular fracture due to direct visualization of the complete lateral side of the posterior column of acetabulum.11 Numerous studies have utilized the K-L approach for surgery of acetabular fracture.2,5 In this study, we also used the K-L approach for surgery of subtypes of acetabulum fracture involving posterior column. The duration of surgery depends upon the complexity of fracture.5 Numerous studies have suggested its effect on complications and outcomes.5,10,33 A previous study has shown the mean operation time of 162.4 ± 78.5 min.34 In the present study, the mean operation time was 116.38 ± 22.46 min. Timing of surgery has been found to affect blood loss. One of the studies revealed that it is directly related with timing of surgery.35 The current study reported the mean estimated intra-operative blood loss that was 503.13 ± 162.91 ml. Numerous previous studies have reported the association of injury of superior gluteal artery with acetabulum fracture.36,37 In this present study, we observed superior gluteal artery injury in 3 cases and bleeding was controlled by direct pressure, gentle cauterization and gel-foam application. Quality of the postoperative reduction is a key factor that also affects the outcomes and complications.5,10,33 Earlier studies reported a satisfactory reduction rate from 57% to 100%.15,38 Several lines of evidence have reported the association of postoperative anatomical reduction with fracture type.5,19,38 In our study, the radiological outcome which was anatomical and good was 87.5% according to Matta's criteria. In previous studies, estimated radiological outcome (excellent or good) was found in 61% of patients.39,43,44 According to Matta's grading system, radiological outcomes were graded as excellent in 37 patients (46.3%), good in 18 (22.5%), fair in 16 patients (20%), and poor in 9 patients (11.3%) at 1 year in present study. The postoperative reduction was found to be significantly associated with radiological outcome at one year. Estimated functional outcome (excellent or good) was found in more than 83–89% of patients in a prior study.5 The functional outcome for this study was evaluated according to D'Aubigne-Postel scoring system, functional outcome were graded as excellent in 42 patients (52.5%), good in 14 (17.5%), fair in 16 patients (20%), and poor in 8 patients (10%) at 1 year. Several previous studies showed a significant correlation between postoperative reduction and functional outcome.40, 41, 42 A significant correlation between postoperative reduction and functional outcome was observed in this study. Numerous studies have reported the postoperative complications in acetabulum fracture.5,16 Most common long-term postoperative complication is osteoarthritis and usually leads to total hip replacement.5,43 The risk factor for this is age (>40 years) and associated fracture pattern.44 Approximately 80% survival has been reported in patients at 20 years treated with open reduction and internal fixation.16 Numerous studies have reported the incidence of osteoarthritis ranging from 20% to 50%.5,37,43 We have reported a very low incidence (13.8%) of osteoarthritis cases which might be due to mid-term follow up, as well as due to good postoperative reduction in the present study. The reported incidence of AVN in literature is around 10–15%.45 In most of the patients, AVN was caused by dislocation of the hip and was associated with posterior fracture patterns.16 Only 5 patients (6.3%) were found to be affected with AVN in this study. Lesser number of patients developing AVN might be due to surgical intervention performed within 2 weeks of injury and early reduction of hip joint. Usually, highest incidence of myositis ossificans occurs with extensile approach while lowest with anterior ilioinguinal approach. Numerous studies reported the overall incidence of myositis ossificancs was 25.6% according to Brooker classification.5,33,41,46 We reported a very low incidence of myositis ossificancs (7.5%) which might be due to prophylactic treatment of myositis ossificancs in selected patients with tablet Indomethacin 75 mg (TDS) six weeks postoperatively. A number of studies reported that the overall incidence of postoperative local infections is 4.4%.5,37 In this study, only one patient (1.3%) developed infection. Post-traumatic sciatic nerve palsy was caused by fracture dislocation of hip joints. An earlier study reported an association of sciatic nerve injury with acetabulum fracture with an incidence of 0%–2.8%.47 J Kelly et al. reported that the most significant change in complications of acetabular fractures was a substantial drop in iatrogenic nerve damage, particularly to the sciatic nerve.48 We had kept knee flexion and hip extension to prevent intra-operative sciatic injury.
In this present study, we observed 2 cases of sciatic injury preoperatively while 2 cases of sciatic injury postoperatively. Interestingly, sciatic injury occurred in one of the patients while managing intra-operative superior gluteal artery injury by compression at the sciatic foramen. Hence caution should be performed while managing superior gluteal artery injury by compression near the sciatic foramen. This patient recovered completely in due course of time. Out of 4 patients, two patients recovered completely while two patients recovered partially. The patients were operated by a single surgical approach and adequately followed up. We could not quantify the osteochondral and impaction injuries and association between co-morbidities and final outcomes. Out of the 80 cases of fracture acetabulum managed with open reduction internal fixation, 10 cases required conversion into total hip replacement. These patients reported good functional outcome49 in subsequent follow up.
6. Conclusion
The K-L approach is a very versatile and useful approach for treatment of subtypes of acetabulum fracture. It is less favorable for anterior column/posterior hemi-transverse fractures. Types of fracture and post-operative reduction were found to be significantly correlated with outcome. Transverse with posterior wall fracture has a poor outcome and patients should be explained about the prognosis. Multicentric studies with longer periods of follow up could be done for a better understanding of final outcome of acetabular fractures. Osteochondral and impaction injuries could be quantified along with co-morbidities to see their impact on final outcome in future.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
The authors declare that they possess no commercial or financial relationships that could be interpreted as a potential conflict of interest.
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