Acetabular fracture usually occurs as a result of high velocity injury and often affects the young and economically productive population. Previously, treatment of acetabular fracture was grossly inadequate and many patients were left with incapacitating pain, limitation of movement. Proper management should be given in our set-up to save lives and to minimize long term complications and related disabilities [1].

Acetabular fractures were often feared because of the poor out come as many patients are treated non operatively. However many others continued to report good results with conservative treatment and problem of operative treatment such as heterotrophic ossification and inadequate reduction were feared. Recently it has become obvious that accurate reduction of the fracture is an important factor in achieving satisfactory outcome and open reduction is better than closed reduction which resulted in incongruence of articular surface of hip joint and patients were left with enormous pain and end result stiff and painful suboptimal functioning hip joint [2,3].

The treatment of simple fractures of acetabulum is well known and studied. Treatment of complex Acetabular fracture is difficult as it involves both the column of the acetabulum, for reduction and fixation, both columns have to manipulated and fixed [4].

The purpose of this study is to evaluate the functional outcome and complications after open reduction and internal fixation of acetabulum fractures done in our department.

Aims and Objectives

To study the to evaluate the functional outcome and complications after open reduction and internal fixation of acetabulum fractures.               

Study Background: This prospective and retrospective study was conducted in the Department of Orthopaedic Surgery, Indira Gandhi Medical College, Shimla. Informed consent was obtained from every patient prior to commencement of the study after ethical committee approval.

Table 1: Elementary Fracture

Table 2: Associated Fractures

Study Period

The prospective study was done from July 2019 to December 2020 and a total of 16 cases were included in the study. In retrospective study all 28 patients operated in this institution in last 7 years from 2012 to June 2019, whose records could be retrieved from the Medical Record Department and came for final follow as called by telephonic calls were included in the study after fulfilling the inclusion criteria. 

Study Subjects

All the subjects who fulfilled inclusion criteria were included in the study. Patients were assessed in detail regarding the mode of injury, any associated injuries or neurovascular deficit after the injuries. 

Inclusion Criteria:

• Age group more than18 years

Exclusion Criteria:

• Revision surgery

• Any active infection

Data Collection

An exhaustive general physical and hip examination was done to know the patient’s fitness for surgery, its expected outcome and postoperative rehabilitation plan to be carried out after surgery. After Clinical and radiological assessment, Pre anaesthetic assessment was done on all patients to obtain fitness for surgery from anaesthesiologist.

Surgical Technique

The below mentioned Table 1 and 2 acts a guide for choosing the correct surgical approach in different types of acetabular fractures.

Results were assessed for pain relief, range of motion of hip joint and improvement of mobility and Postoperative scoring and functional outcome in relation to Modified Merle d’ Augbigneand Postel score, Modified Harris hip score and radiological scoring by Matta et al. was done.

Every patient was advised to come for follow up clinical and radiological assessment on outdoor basis at 6 weeks interval for first 6 months till fracture union and further at 9 months and 12 months. 

Statistical Analysis

Data was entered into Microsoft excel spreadsheet, cleaned for errors and was analysed using the latest version of Statistical Package for Social Sciences Software. Qualitative variables were presented as frequencies and their percentages. Quantitative variables were described as means and their standard deviations. Chi-square/Fischer exact test was used for analysis of associations between different variables. Odds ratio for associations were also be calculated along with their 95% confidence interval. A p value of less than 0.05 was considered as statistically significant.

The present study was done to evaluate the functional outcome and complications after open reduction and internal fixation of acetabulum fractures. A total of 44 patients were included in the study. Prospective series included 16 patients (36.4%) from July 2019 to December 2020. Retrospective study included 28 patients (63.6%) operated between 2012 to June 2019 whose records could be retrieved from Medical Record Department and came for final follow-up in Outdoor Patient Department (OPD) of Orthopaedics IGMC Shimla as called telephonically.

Most of the patients 28 (63.6%) were Retrospective. 39(88.5%) were in the age group of 21 to 60 years. 77% patients were male and 23% female. Male to female ratio was 3.4:1 (Table 3).

There were 18 patients with posterior wall fracture that comprised about 41% of the cases; 12 patients (27%)had posterior wall and posterior column, bicolumnar fracture was seen in 4 patients, anterior column in 4 patients, anterior wall in 3 patients, anterior column with posterior hemi-transverse in 2 patients and T-type fracture was seen in one patient only  (Table 4)

Modified Merle d’Aubigne and postel (MDA) score was excellent in 77%patients, good in 13%, fair in 10% (Table 5).

Matta’s radiological score at final follow up was excellent in 54.55%, good in 36.36%, fair in 4.55% and poor in 4.54% patients (Table 6).

The average Modified Harris Hip score was 94 at final follow up in 44 patients. Patients with anterior column fracture had HHS of 96 at final follow up; posterior wall fracture patients had average HHS of 92 at final follow up. The fair result in one patient as assessed by Modified Harris Hip was due to avascular necrosis of femoral head. This patient had fracture femoral head with posterior wall fracture and was operated by Ganz surgical dislocation of hip with trochanteric flip osteotomy. Total hip replacement was planned for this patient at 10 months after surgery (Table 7).

Two patients had complications. One patient had femoral head fracture along with fracture of posterior wall developed AVN and also hadsubsequently Secondary OA     with    post-operative    subluxation   of  femoral   head.

Table 3: Distribution of Age and Gender

Table 4: Fracture Type based on Judet Oblique Views and CT Scan

Table 5: Final Outcome According to Modified Merle D’Aubigne Postel Scoring

Table 6: Final Outcome According to Matta’s Radiological Criteria

Table 7: Final Outcome According to Modified Harris Hip Score

Table 8: Complications among Study Participants

Thus three complications were seen in this patient. Another patient with fracture dislocation with fracture of posterior wall developed AVN and subsequently secondary OA 5 year after surgery. No patient developed sciatic nerve injury post operatively (Table 8)

Modified Merle d’Aubigné Postel (MDA) score was initially developed by d’Aubigne and Postel in the 1950s to determine the functional results after THA, but gained popularity as a score for surgically treated acetabular fractures after Letournel published the results of their series in 1980. The main problems with this score was that it has never been validated for use on patients with acetabular fractures and it is prone to a substantial ceiling effect [5,6]. Kim et al. [7] found that the modified Merle D’Aubigne and Postel score at final follow-up was excellent in 55.7%, good in 15.3% and poor in 30.3% patients. Suresh et al. [8] reported good to satisfactory result in 94% of their patients according to this score. Dana et al. [9] observed 86% good results according to this score at final follow up. In present study the mean Modified Merle D’Aubigne postel (MDA) score was excellent in 77% of patients, good in 13%, fair in 10% and none of patient had a poor result. The results seem to be comparable oreven better than the past studies, however a large sample size can be of more value in arriving at a better conclusion. 

According to Matta’s radiological score the accuracy of the fracture reduction strongly correlated with the clinical outcome. Kim et al. [7] reported that according to the radiologic criteria of Matta et al. 30.3% patients had excellent results, 42.4% good, 4 (12.1%) fair and in 5 (15.2%) results were poor. Sagar et al. [10] observed that the 49.1% of patients had excellent results, 27.3% good, 16.4% fair and 7.3% patients had poor results at final follow up. In present study Matta’s radiological score at final follow up was excellent in 54.55%, good in 36.36%, fair in 4.45% and poor in 4.54% patients. The scores are better than other studies because of anatomical reduction which was achieved post-operatively was the most important factor in the prognosis in acetabular fractures.

Modified Harris Hip Score is the most commonly used hip specific score for assessing the clinical result after operative treatment of acetabular fractures. Harris developed this score in the 1960s to assess the results for THA after debilitating osteoarthritis due to acetabular fractures [11]. Letournel and Judet [12] reported 350 fractures of the acetabulum with excellent results in 75%, good results in 8% and poor results in 17% at final follow up based on HHS. Dana et al. [9] assessed 57 patientsand concluded that the 45(79%) patients had excellent or good results on HHS. Clarke-Jhenson et al. [13] found that the average HHS was 88 with 81% having good or excellent results. The presence of femoral head injury caused a significantly reduced HHS to 84, anterior column fractures had a significantly better HHS of 94 and they found no differences for other fracture types. Hassain et al. [14] analysed the final outcome based on modified Harris hip score after surgery and found to be excellent in 25%, good in 45.5%, fair in15.1% and poor in 11.4% of patients. The results of study in view of Harris hip score are comparable to others studies done in the past.

In present study, 2 (4.54%) patients had complications. A total of 2(4.54%) patients had avacular necrosis of femoral head. One patient with fracture dislocation with fracture of posterior wall developed AVN and subsequently secondary OA 5 year after surgery. Another patient had femoral head fracture along with fracture of posterior wall developed AVN and also had subsequently secondary OA with post-operative subluxation of femoral head. Thus three complications were seen in this patient. Giannoudis et al. [15] in his meta-analysis reported AVN in 20 (5.6%) patients operated by posterior approach. While in present study it was 4.54% which is less as compared with others studies.

Dunet et al. [16] analysed 72 patients and found that 29(40%) patients had secondary OA at the end of 7 years. In present study 2(4.54%) patients developed secondary osteoarthritisafter having AVN of femoral head as mentioned above. One had femoralhead fracture along with fracture of posterior wall; another patient with fracture dislocation of right hip with fracture posterior wall developed secondary osteoarthritis after 5 years post-surgery.

In present study only 1(2.2%) patient developed post-operative subluxation of femoral head. He was operated through the Ganz safe surgical dislocation of hip as there was Pipkin type I fracture of femoral head along with fracture acetabulum. Clarke-Jenssen et al. [13] demonstrated that injury to the femoral head and acetabular impaction as the strongest predictors of failure after acetabular fracture fixation as cartilage damage to the femoral head/acetabulum and marginal impaction are predictors of poor clinical outcome and with both of them the combined survival of native hip was up to 0% at 3 years. 

The study data supports open reduction and internal fixation as a gold standard for acetabulum fractures in which it is indicated with excellent to good results in majority of the patients as assessed by Modified Merle d’Aubigne score, Modified Harris hip score and Matta Radiological score with minimal complications at final follow up.

Limitations

The limitation of the study is small sample size and short follow up especially in prospective patients. A large sample size with longer follow up would be helpful for future studies.

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