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Acetabular fracture

AO COMPREHENSIVE CLASSIFCATION
Type A. Partial articular one column
A1.

Posterior wall

A2.

Posterior column

A3.

Anterior wall and/or column

Type B.

Partial articular oriented fracture;


transverse type with portion of the roof attached to intact ilium

B1.

transverse and posterior wall

B2.

T type

B3.

anterior and posterior hemitransverse

Complete artricular, both column fracture;


Both columns are fractured and articular segments, including the
Type C. root,
are detached from the remaining segment of the intact ilium,
" the floating acetabulum "
C1.

both column - anterior column fracture extending to the iliac creast ( high variety )

C2.

both column - anterior column fracture extending to the anterior border ( low variety )

C3.

both column - anterior fractrure enters the sacroiliac joints

Dislocation of Hip : Levin Classification


No significant associated fracture.
Type I.
No clinical instability after concentric reduction
Type II irreducible dislocation without femoral head or accetabular fracture
Type III unstable hip after reduction or incarcerated fragments of cartilage, labrum or bone
Type IV

associated acetabular fracture requiring recontruction to restore hip stability or joint


congruity

Type V associated femoral head or neck injury ( fracture or impaction

Dislocation of Hip : Sahin Classification


Grade 1
simple dislocation without fracture
Grade 2

dislocation with fragment, stability after reduction

Grade 3

explosive or burst fracture, gross stability

Grade 4

with femoral head and neck fracture

RADIOGRAPHIC EVALUATION

An anteroposterior (AP) radiograph of the pelvis is essential, as


well as a cross-table lateral view of the affected hip.

On the AP view of the pelvis


o
The femoral heads should appear similar in size, and the joint
spaces should be symmetric throughout. In posterior dislocations, the
affected femoral head will appear smaller than the normal femoral
head. In anterior dislocation, the femoral head will appear slightly
larger than the normal hip because of magnification of the femoral
head to the x-ray cassette.
o
The Shenton line should be smooth and continuous.
o
The relative appearance of the greater and lesser trochanters
may indicate pathologic internal or external rotation of the hip. The
adducted or abducted position of the femoral shaft should also be
noted.
o
One must evaluate the femoral neck to rule out the presence
of a femoral neck fracture before any manipulative reduction.

A cross-table lateral view of the affected hip may help distinguish a


posterior from an anterior dislocation.

Use of 45-degree oblique (Judet) views of the hip may be helpful to


ascertain the presence of osteochondral fragments, the integrity of the
acetabulum, and the congruence of the joint spaces. Femoral head
depressions and fractures may also be seen.

Computed tomography (CT) scans may be obtained following


closed reduction of a dislocated hip. If closed reduction is not possible
and an open reduction is planned, a CT scan should be obtained to
detect the presence of intra-articular fragments and to rule out
associated femoral head and acetabular fractures.

The role of magnetic resonance imaging in the evaluation of hip


dislocations has not been established; it may prove useful in the
evaluation of the integrity of the labrum and the vascularity of the
femoral head.

The AO/OTA classification for hip dislocations (JOT supplement, November/December 2007) is presented
below. Associated fractures are coded separately.
30A - dislocation of the hip
1 - Anterior
2 - Posterior
3 - Medial or central (fracture through acetabulum)
4 - Obturator
5 - Other

Epidemiology of acetabular fractures


Only 10% of the pelvic disruptions involve the acetabulum.

Posterior wall fractures are most common, comprising 24% of acetabular

fractures.
The primary cause in younger individuals is high-energy trauma. Fractures
secondary to moderate or minimal trauma are increasingly of concern in those

over 35 years.
Acetabular fractures generally occur in conjunction with other fractures.

Treatment of acetabular fractures


Heterotopic ossification (HO) may be more common in surgical versus non

surgical treatment.
No studies comparing different operative treatments were found.

Satisfactory reduction is reported in 94% of patients and excellent/good functional


scores are reported in 77%-85% of patients treated surgically, based on pooled

information from case series.


Common complications of surgical treatment include HO (30%), osteoarthritis
(90%), and traumatic nerve palsy (16%) based on pooled data from case series.

Heterotopic Ossification Prophylaxis


HO incidence was not different between patients receiving indomethacin versus those
receiving no prophylaxis.

HO incidence (Grade III or IV) was twice as high for patients receiving indomethacin than
patients receiving radiation therapy.

Prognostic studies of acetabular fractures


Significant associations with poor reduction include fracture pattern, age, delayed

surgery, complete loss of joint space and fair/poor functional scores.


Complete loss of joint space was significantly associated with fair/poor functional

scores.
Surgical delays were associated with fair/poor functional scores.

Recommendations for future research


For the most common types of treatment well-designed cohort studies, with

adequate samples sizes and sound methods should be conducted.


Well designed cohort studies are needed to clarify the extent to which surgical

approach is associated with HO.


Randomized trials with sufficient sample size are needed to clarify the best

treatment and benefits of prophylaxis for HO.


Prognostic studies designed to reduce bias and measurement error are needed.

Epidemiology of acetabular fractures


Acetabular fractures are rare: Of approximately 37 per 100,000 pelvic fractures in the USA
annually, only 10% involve the acetabulum with an estimated 4000 per year among the
elderly (23). High-energy trauma is the primary cause in younger individuals and commonly
associated with other fractures and pelvic ring disruptions. Fractures secondary to moderate
or minimal trauma are increasingly of concern in those over 35 years because of
osteoporotic changes (23). Acetabular fractures are most often associated with lower limb
fractures resulting from falls, particularly in older individuals (23, 36). Posterior wall
fractures are the most common and account for approximately 24% of acetabular fractures
(11).
A. Acetabular fractures (Letournel Classification)
Acetabular fractures are classified based on the concept that two columns or pillars, one
anterior and one posterior, comprise the acetabulum. This is currently the most commonly
used classification system.
Elementary fractures include:

Anterior wall, anterior column, posterior wall, posterior column or transverse


fractures

Associated fractures include:

T-Shaped, Anterior wall/column plus posterior hemitransverse, transverse plus


posterior wall, posterior column plus posterior wall, both columns

B. Acetabular fractures (AO classification)


The AO system incorporates the concepts of the Letournel classification:
Type A

Partial articular, involving only one of the two columns


A1: Posterior wall fracture
A2: Posterior column fracture
A3: Anterior wall or column fracture

Type B

Partial articular, involving a transverse component


B1: Pure transverse fractures
B2: T-Shaped fractures
B3: Anterior column and posterior hemitransverse

Type C

Complete articular fractures, both columns


C1: High variety, extending to the iliac crest
C2: Low variety, extending to the anterior border of the ilium
C3: Extension into the sacroiliac joint

Management of acetabular fractures: introduction


Acetabular fractures are generally associated with other injuries of the pelvis and/or lower
limbs which may influence treatment options, surgical approach and clinical outcomes (16).
Patient age, fracture stability, the presence of comorbidities and osteoporosis, combined
with surgeon experience, also influence treatment options. Treatment options include
conservative methods (e.g. traction, progressive weight bearing), percutaneous fixation in
situ, open reduction and acute total hip arthroplasty (23, 36). Open reduction and internal
fixation appears to be the standard treatement (23, 36). Surgical approaches routinely used
for operative management are Kocher-Langenbeck, ilioinguinal and extended iliofemoral or
triradiate approaches or combinations of them (23, 16).
Between 18 and 90% of patients may have heterotopic ossification (HO) following internal
fixation (5, 20, 27) and HO incidence may be related to surgical approach (5, 11). HO,
which may influence functional outcome, may be seen radiographically by three weeks,
reaching a maximum extent by six to twelve weeks (27). Risk factors historically cited

include male gender, thoracic and abdominal trauma, closed head injury, T-Type fracture and
delayed fixation (5).
Complications of concern perioperatively include neurovascular injury, embolic events and
infection. Chondrolysis and post-traumatic arthritis may occur later (11, 36).
We summarize the following aspects of acetabular fracture treatment:
1. Comparison of operative and nonoperative treatment
2. Pooled outcome and complication rates in surgically treated patients
3. HO prophylaxis:
1. Indomethacin (IM) versus no prophylaxis
2. Indomethacin (IM) versus radiation therapy (RAD)
4. Prognostic (risk) factors

Comparison of operative versus nonoperative treatment


Case series (CoE IV) currently provide the primary information on treatment methods for
reduction of acetabular fractures. Insufficient information for evidence-based
recommendations regarding treatment is currently available.

One comparative study (CoE III) of operative versus nonoperative treatment


(traction) was found (15).
HO was three time more common in the operative group, RR = 3.0

(1.1-8.1).
Average length of hospital stay was longer for nonoperative patients.

The authors cite lower anatomic reduction rates (and use of surgical
techniques) for less-experienced trauma surgeons (46%) compared
with experienced trauma surgeons (77%), but do not report rates based
on operative versus nonoperative treatment.

Pooled outcome and complication rates in surgically treated patients:


Operative treatment: No comparative studies were found. Based on pooled information from
case series it appears that satisfactory reduction is achieved in 94% of patients and 77-85%
of patients have excellent or good results based on the Harris Hip Score (HHS) and the
Merle D'Aubigne-Postel Score (MDP), respectively (11, 17).
The systematic review (SR) of primarily CoE IV studies and one additional case-series
published subsequently to the SR provide the basis for this summary. (11, 17)

Heterotopic Ossification (Brooker Classification) prevalence was 30%, with the


Class I/II being most common at 26.5%. The iliofemoral approach appears to

have the highest rate of HO (23.6%).


Severe osteoarthritis (Matta Classification III/IV) occurs in 19.1% of patients

following acetabular fracture.


The rate of iatrogenic nerve palsy was 7.8% while traumatic palsy was reported at

16%.
Arthroplasty appears to have the most frequent revision rate (8.4%).

Rates of local infection and DVT/PE are approximately 4%.

Heterotopic ossification (HO) prophylaxis


One quasi randomized trial, (CoE II) and reports that include subsets of this population are
summarized (4, 5, 20, 27). Plain radiograph data are used as CT results were available only
for patient subsets.

Two of the studies(4, 27) are subsets of the third study (5), so results of these

three studies are not completely independent.


No difference in the frequency of HO was found between groups receiving 100 mg
indomethacin three times a day for six weeks and those not receiving prophylaxis

(20).
The overall incidence of Grade III or IV HO was 10%, with an incidence of 14%

and 7% in the indomethacin and radiation therapy groups respectively (5).


Patients receiving indomethacin had approximately a two-fold increased risk of
developing Grade III or IV HO compared with radiation therapy: RR=1.97 (95%
CI 0.8, 5.1). The risk difference is 7% between the two treatments but this
difference was not statistically significant, raising the question of whether the

study was adequately powered to detect differences between treatments.


Overall, HO incidence is noted to decrease from 14% in 1993-96 to approximately

7% in 1996-99. Declines in incidence may reflect changes in medical practice.


The risk of long bone nonunion was over three times greater among indomethacin
recipients compared with those receiving radiation, unadjusted RR= 3.7 (95% CI
1.1-12.1). This group effect persisted after adjustment for Injury Severity Score
(p=0.042) and no significant differences between groups with regard to the
number or distribution of long bone fractures (4). The absolute risk increase is
0.21, thus 4-5 patients (95% CI 2-23) would need to be treated before one case

of nonunion would occur.


No differences in HO frequency based on surgical approach were reported for two
studies (20, 27).

Prognosis of acetabular fractures


Four prognostic studies (CoE III) are summarized (23, 26, 29, 38), two of which focus on
posterior wall factures (26, 38). Significant associations are reported below:

Older age at injury was associated with fair/poor Merle dAubign-Postel (MDP),
Harris Hip (HHS) and Matta Hip (MHS) Scores and reduction quality, presumably

due to osteoporotic changes with age.


Facture patterns and comminution were associated with fair/poor outcome scores,

complete loss of joint space and suboptimal reduction.


Quality of reduction was associated with fair/poor MDP and HHS

Surgery delays were associated with suboptimal reduction and fair/poor HHS and

MHS.
Complete loss of joint space was associated with fair/poor Musculoskeletal
Assessment Scores (MFA), including sub-scores related to activities of daily living

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