Surgical Treatment of AssociatedPatterns of Fracture Acetabulum with New Trends Thesis submitted BySherif Mohammed Mostafa El-AidyAssistant Lecturer of Orthopedic SurgeryFaculty Of Medicine, Zagazig University2015

Under Supervision of

Prof. Dr.Abd El-Salam Mohammad HefneyProfessor of Orthopedic SurgeryFaculty of Medicine - Zagazig UniversityProf. Dr.Omar Mohammad Abd-elwahab KilanyProfessor of Orthopedic SurgeryFaculty of Medicine - Zagazig UniversityDr.Yousuf Mohammad kheraAssistant professor of Orthopedic SurgeryFaculty of Medicine - Zagazig University

Discussing Committee

Prof. Dr.Abd El-Salam Mohammad HefneyProfessor of Orthopedic SurgeryFaculty of Medicine - Zagazig UniversityProf. Dr.Osama Ahmed FaroukProfessor of Orthopedic SurgeryFaculty of Medicine - Assiut UniversityProf. Dr.Khalid Idris Abd El-RahmanProfessor of Orthopedic SurgeryFaculty of Medicine - Zagazig University

ACKNOWLEDGEMENT

INTRODUCTION

The associated patterns of fracture acetabulum according to Judet and Letournel classification 1961 include: Posterior column and posterior wall fracture, Transverse and posterior wall fracture , T-shaped fracture, Anterior column and posterior hemitransverse fracture and Associated both-column fracture. Surgical intervention with (ORIF) is the treatment of choice for indicated cases . These fractures tend to be more severe in nature and require very careful planning to ensure appropriate access and obtain an anatomic reduction with lowest incidence of complications .

AIM OF THE WORK

The aim of this work is to evaluate the results of surgical treatment of associated patterns of fracture acetabulum (Letournel and Judet classification) and new trends in surgical treatment.

REVIEW OF LITERATURE

ANATOMY The acetabulum is a complex geometric structure .The pubis forms the anterosuperior fifth of the articular surface, the ischium forms the floor of the fossa and the posteroinferior two-fifths of the articular surface, and the ilium forms the remainder

It has six principal components: Anterior column Posterior column Anterior wall Posterior wall Acetabular dome or tectum Medial wall

Anteriorly:

The femoral vessels are extremely close . The iliopectineal fascia separates the femoral vessels from the femoral nerve within the iliopsoas muscle.

The corona mortise connecting inferior epigastric vessels and obturator vessels may be present up to 30% in some studies.

Important anatomical realtionships

Posteriorly:

It is important to understand the relationship between the piriformis muscle ( which is oriented 45 into piriformis fossa) and the peroneal component of sciatic nerve.

The obturator internus and the 2 gemilli (oriented transversely) protect the sciatic nerve when retracted. The Superior gluteal bundle crosses the greater sciatic notch.

The medial femoral circumflex artery ascends close to lateral rotators insertion.

Mechanism of injury

Fractures of the acetabulum are caused by forces that drive the femoral head into the pelvis.

The type of acetabular fracture depends on the position of the femoral head at themoment of impact.

The injurious force may be applied to the flexed knee (as in the dashboard injury) to the greater trochanter, foot, or lumbosacral area .

Classification of Fracture Acetabulum

ANATOMIC CLASSIFICATION:The most widely used classification is that of Judet and Letournel 1961. This system divides fractures of the acetabulum intofive simple (elementary) patterns : - the anterior wall, - anterior column, - posterior wall, -posterior column, -transverse fractures2. five complex (associated) patterns: -Posterior column and posterior wall fracture, -Transverse and posterior wall fracture. , -T-shaped fracture, -Anterior column and posterior hemitransverse fracture, -Associated both-column fracture

Assessment of Acetabular Fractures

(A)Clinical assessment:History: the mechanism of injury , the patient's post trauma status ,general medical profile and age of the patient .

Physical Examination: 1. General examination: searching for bleeding source, associated pelvic disruption or associated fractures.

2. Local examination: pain in groin area.The injured hip may be dislocated (shortened and externally or internally rotated). Inspection of the skin for open wounds or (MorelLavalle lesion).

3. Careful neurologic examination for nerve palsy.

4. Genitourinary and rectal examination.

On the AP pelvis x-ray, six lines (Judet lines) are identified: 1-iliopectineal line.2-ilioischial line.3-teardrop.4- roof.5-anterior rim (acetabuloobturator line). 6- posterior rim (ischioacetabular line).

(B)Radiographic assessment:(1) plain radiography: The three standard pelvic views anteroposterior, inlet, and outlet.

The iliac oblique, and the obturator oblique (Judet views).

(2)Computed tomography:(plain , multiplaner and 3dimention)CT vital in assessment of :

- The fracture site and extent.

Degree of comminution .

- Marginal impaction.

- Intraarticular fragment.

- Femoral head injury.

- pelvic haematoma.

(3)Dynamic floroscopic stress examination:

Management of Associated Patterns of Fracture Acetabulum

Initial Management:Polytrama patient management follows the Advanced Trauma Life Support (ATLS) guidelines .

2. Any hemodynamically unstable patient must be investigated and treated aggressively .

3. Extraskeletal and Skeletal injuries are managed according to their priorities.

4. Reduction of a dislocated femoral head when patient is stabilized and application of traction if needed .

5. Subcutaneous degloving injury (MorelLavalle lesion) debridment.

Citeria for Conservative Management:

(1)Comorbities limiting physiological reserve.

(2)Insufficient bone stock to allow adequate fixation.

(3)Displacement of less than 2mm.

(4) Roof arcs of more than 45, a intact subchondral CT arc(superior 10 mm).

(5) Congruence on all veiws ,or 2ndry Congruent both column fractures.

(6) Displacement of less than 50% of the posterior wall.

Indications for Operative treatment:

(1)Displacement of fractures(5mm is absolute indication).

(2)Roof-arc angle less than 45 degrees on (AP) and oblique radiographs.

(3) Irreducible fracture-dislocation hip .

(4) loss of congruence on any of the three plain radiographic views.

(5)posterior wall fracture with associated hip instability(size of posterior wall fragment >50%).

(6)An incarcerated osteochondral fragment . (7) polytrauma patient with an acetabular fracture that needs to be mobilized.

SURGICAL APPROACHES

Choice depends on:

(1)The fracture pattern.

(2)The local soft tissue conditions.

(3)The presence of associated major systemic injuries.

(4) The interval from injury to surgery.

Type of FractureApproachPosterior column posterior wallPosterior approach Transverse plus posterior wallPosterior approachAnterior column posterior hemitransverseAnterior approachT-typeAll approaches applicable :anterior,posterior,or combined approaches ;depending on major displacementBoth-columnAnterior approachposterior approach, combined and Rarely extensile

POSTERIOR KOCHER-LANGENBECK APPROACH

Position:the lateral decubitus position or prone.

Access:direct access to the retroacetabular surface of the innominate bone Indirect access to the quadrilateral surface.Surgical Technique:-The skin incision from PSIS to the posterior one third proximal femur.-The gluteus maximus is divided .

-Identify the piriformis and short lateral rotators insertions which are divided 1.5 cm from their insertion on the femur (avoiding MFCA injury) .

Advantages:- Adequate for posterior pathology, well-known to most surgeons and Muscle dissection is minimal, as is blood loss.

Structures at Dangers and disadvantages:Superior Gluteal Neurovascular Bundle, Sciatic Nerve , pudendal nerve, medial femoral circumflex artery , Heterotopic Ossification and Hip Abductor Weakness.

Modification: Greater trochantric osteotomy either classic or flip .

Surgical Technique:-Dissection extends from the ischial tuberosity to the iliac wing.

THE ILIOINGUINAL APPROACH

Position :Supine on a fluoroscopic table.

Access: Direct visualization of iliac fossa ,sacroiliac joint, entire anterior column, and symphysis pubis.

Surgical Technique:-The skin incision extends from the lateral iliac crest down to two fingerbreadths above the syphysis.

-Division of aponeurosis of external oblique abdomenus muscle .

-Subperiosteal exposure of internal iliac fossa.

Surgical Technique: -Snaring of spermatic cord with Penrose drain, cutting the iliopectineal arch between vascular and muscular compartments.

-Snaring of femoral artery and vein. Snaring of iliopsoas muscle and femoral nerves over iliopubic eminence.

-Exposure of 3 windows of the approach.

Advantages:Excellent access to the anterior and internal aspects of the entire pelvis and acetabulum. heterotopic ossification is minimal.

Structures at Dangers and disadvantages: -The femoral vessels, the corona mortis , The femoral nerve and The lateral femoral cutaneous nerve .-It is extraarticular with the reduction by indirect means . -Postoperative hernia can occur.

THE ANTERIOR INTRA-PELVIC (AIP) (MODIFIED STOPPA) APPROACH

Positioning: The patient is placed supine on a radiolucent table. The surgeon stands opposite the fractured acetabulum. .

Access: Excellent visualization of the pelvic ring, including the medial wall, dome, and quadrilateral plate to ala of sacrum.

Surgical Technique :-Incision begins 2 cm superior to the symphysis pubis in a transverse fashion with the length extending approximately from the ipsilateral external inguinal ring to the contralateral external ring.

-The rectus abdominus muscle is split vertically.

-The corona mortise exposed to be ligated.

Surgical Technique :-The rectus and iliofemoral vessels next are retracted laterally and anteriorly.

The lateral window use is optional when necessary.

Advantages:-direct access to the pelvic brim, posterior column, and the quadrilateral surface. less invasive .

Disadvantages and Dangers:-Extraarticular , requires indirect reduction maneuvers.

-The same structures are at risk as during the ilioinguinal approach( except LFCN of Thigh) specially obturator vessels and lumbosacral trunk.

.-

EXTENSILE APPROACHES:-Useful in delayed cases and specific fractures e.g. T-type , AC+PHT and ABC with posterior wall.-These approaches have high complication rate e.g.infection, stiffness and flap necrosis.

(B)Triradiate approach:-composed of posterolateral incision with trochantric osteotomy and anterior incision to ASIS in triradiate fashion.

Extended Iliofemoral Approach:-It allows access to both columns by elevating gluteal muscle flap posteriorly.COMBINED APPROACHES:The combination of an anterior and posterior approach either simultaneous or staged .

Techniques of Reduction and Fixation

Required human and material resources:Assistants: two and occasionally three assistants are necessary.

Special instruments: like fracture pushers, Farabeuf clamps, The pelvic reduction clamp and other standard fracture clamps .

Traction:

-Traction table: is controversial.

-Manual Traction: manual pull , sharp hook, a corkscrew, Schantz pin and femoral distractor.

Implants:

Plates:-3.5-mm reconstruction plate.- 4.5-mm reconstruction plate -1/3 tubular plate as spring plate.

Screws: Varity of cancellous lag screws and 3.5 mm and 4.5 mm cortical screws or cannulated screws.

Marginal impaction:-Depressed rotated fragment of the posteromedial part of the acetabulum.

-marginal fragment is reduced into position and buttressed by bone graft from greater trochanter.

COLUMN SCREWS:

(A)Anterior Column Screw(ACS):1-Retrograde used in low anterior column fracture line. 2-Antegrade used in high anterior column fracture line.

(B)Posterior Column Screw(PCS)1-Retrograde .

2-Antegrade:

COMPLICATIONS:

Early complications:

1-Venous Thromboembolism. 2-Neurovascular injury: Sciatic nerve, the lateral femoral cutaneous nerve, Femoral nerve, Superior gluteal bundle and the iliofemoral vessels.3-Intraarticular hardware.4-Malreducton.5-Failure of fixation.6-Infection.

Late complications:

1-Avascular necrosis: femoral or acetabular.2-Posttraumatic Arthritis. 3-Heterotopic Ossification.4-Nonunion.

PATIENTS AND METHODS

During period between January 2011 and January 2014, this study was conducted prospectively .

Fifty patients of associated patterns fracture acetabulum ( according to Letournel and Judet classification) underwent surgery in Zagazig university hospitals.

Follow up was at least for 1 year . Evaluation of the patients was done clinically and radiologically.

We adopted in this study in addition to standard methods of surgical treatment of open reduction and internal fixation :

1-(modified Stoppa approach) as new trend in the surgical exposures in some patients

2-(antegrade posterior column screw) as new trend in the methods of fixation in other patients.

Inclusion Criteria:

1-Patients with associated patterns (Letournel & Judet classification) of fracture acetabulum.

2- Age group from 20 to 60 years old .

3-Surgical treatment within 3 weeks from time of fracture.

Exclusion Criteria:

1-Septic focus

2-Soft tissue loss at site of incision

Patients:

1-Age and Sex distribution:The age of the patients ranged from (21-58)

2-Mechanism of injury:

3-Associated injuries

3-Side of injury:The side of injury was left in (17) patient, right in (33) patientsrepresenting and no bilateral cases.

4-Associated injuries:

Isolated acetabular injury patients were 19 , and associated injuries were present in 31 patients.

5-Time of operation:

Ranged from 3 days to 20 days from time of injury.

6-Types of fractures:

Preoperative management:

Clinical assessment.

Radiological assessment.

Ten cases presented with posterior fracture dislocation (6 of them had preoperative sciatic nerve palsy) acetabulum were reduced under general anaethesia.

All patients received DVT prophylaxis by 40I.U. of Clexane to be stopped 12 hours before surgery, Prophylactic broad spectrum antibiotic and urethral catheter.

Anaesthesia: spinal anesthesia and epidural anesthesia were used for (34) patients and general anesthesia was used for (16) patients.

Methods of surgical treatment:

Approaches:Four types including KocherLangenbeck approach in 37 patients. The Ilio-inguinal approach in 7 patients. The (modified Stoppa) approach in 4 patients. Combined staged approaches ( Kocher langenbeck with ilioinguinal approach) in 2 patients.

Fixation:

The most commonly used implant was the 4.5 mm reconstruction plates (standard and low profile) and 4.5 mm cortical screws .

The 3.5 mm reconstruction plates with 3.5 screws

1/3 tubular plate was used as spring plate

Antegrade posterior column screw (>90mm long 4.5 cortical screw)

Interfragmentry screws mostly 3.5 mm screws

Reduction: By Specialized instruments using methods of manual traction on radiotranslucent table with the assistance of intraoperative flouroscopy.

Postoperative management:

Closed suction surgical drains were used routinely for 24-48 hours.

Prophylactic parentral broad spectrum antibiotics were used for 1 week , then oral antibiotics for 2 weeks.

Indomethacin (25 mg three times daily for six weeks postoperatively) .

Subcutaneous single daily injection of (Clexane 40 IU) .

Postoperative x-rays were done in addition to postoperative CT in some cases .

The patients were allowed to move in bed as soon as pain tolerated. They subsequently began physical therapy . Axillary crutches were allowed to move without weight bearing for 3 months.

Data Collection:The telephone numbers and addresses of the patients were recordedfollow up evaluation was scheduled at two weeks, six weeks, three months, six months, ninth months and one year At the last follow-up examination , radiographic , clinical grades and complications were assigned.

Radiological evaluation:

-The plain radiographs made after surgery were reviewed to assess fracturereduction(degrees of displacement), according to Matta et al. (1986) criteria

-The followup radiographs were examined for complications e.g. avascular necrosis of the femoral head and arthritic changes .

DisplacementGrade of reductionZero or 1mmAnatomical2-3mmSatisfactory>3mmUnsatisfactory

Clinical Evaluation:

The clinical grade was based on a modification of the system of Merle d'Aubign and Postel (Matta.1996).

Modified Merle d'Aubign and Postel Clinical Grading systemPointsPainNone6Slight or intermittent5After walking but resolves4Moderately severe but patient is able to walk3Severe, prevents walking2WalkingNormal 6No cane but slight limp 5Long distance with cane or crutch 4Limited even with support 3Very limited 2Unable to walk1Range of motion95100%68094%57079%46069%35059%2