The incidence of acetabulum fractures has been increasing rapidly worldwide in last few decadesdue to increase in rail, road traffic accidents and high velocity motor vehicle collisions. Other type of injuries like fall from height, mine accidents also contribute to increase in these injuries. These fractures are often associated with other life threatening injuries [1].

The treatment of acetabular fractures is a complex area of orthopaedics that is being continuously refined. There have been many changes in the treatment modalities over time as the understanding of acetabular anatomy and fracture pattern has developed which acts as a first step in decision making for mode of treatment [1,2]. In elderly patients (defined as more than 60 years of age),the most common cause of injury is a fall, as opposed to the situation of a younger patient, in whom a motor vehicle accident is the most common cause. In the past, the literature from the 1950s and 1960s came with conflicting recommendation regarding the optimal care for fracture acetabulum. Both non operative and operative treatment regimens were purported to be the best [3]. 

The outcome from fracture of acetabulum can be influenced by many factors. The surgeon is unable to control the age, fracture pattern, presence of critical chondral damage to femoral head, dislocation of hip at time of injury, damage to sciatic nerve and patient co-morbidities. However the timing of surgery, the surgical approach, the quality of reduction and avoidance of loss of reduction are within the influence of surgeon [4]. We have been doing open reduction internal fixation of all types of acetabulum fractures in our institution for the last 7-8 years. Hence it was considered worthwhile to assess the socio-demographic and clinical parameters after open reduction and internal fixation of acetabulum fractures done in our department.

Aims and Objectives

To study the socio-demographic and clinical parameters 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.

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 Tables 1 and 2 mentioned table 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’ Augbigne and Postel score, Modified Harris hip score and radiological scoring by Matta et al. was done. 

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.

Table 1: Elementary Fracture

Table 2: Associated Fractures

The present study was done to evaluate the socio-demographic and clinical parameters 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. In our study, 98% patients belonged to rural background and remaining 2% belong to urban area. The most common mode of trauma was road side accident in 63.6% patients followed by fall in 36.4% (Table 3).

Table 3: Distribution of Age, Gender and other Socio-Demographic Variables

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).

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

The average time interval between injury and surgery was 15 days (range 3-55 days). About 34% patients were operated within 7 days of injury and 36% patients between 8-14 days. Thirty patients were operated with Kocher-Langenbeck approach in lateral position, 7 patients by Ilioinguinal approach in supine position, 2 patients with Iliofemoral, 2 with Modified Stoppas intrapelvic approach, 2 with combined (Kocher-Langenbeck and Ilioinguinal) approach and one patient underwent Ganz surgical dislocation of hip with trochanteric flip osteotomy (Table 5).

Table 5: Duration between Injury and Surgery and Surgical Approach

Intravenous Tranexamic acid was used in 24 patients and both topical and intravenous Tranexamic acid was used in 15 patients. Autogenous bone graftingwas done in 31.7% patients. It was harvested from Iliac crest in 12 patients and from greater trochanter in two. Tricortical iliac crest grafting to support the posterior wall had to be done in two (4.5%) patients as the posterior wall had excessive comminution. Articular surface of the dome was disimpacted and filled with cortico-cancellous graft in 2 (4.5%) patients (Table 6).

Table 6: Use of Tranexamic Acid and Bone Grafting

In accordance with Matta’s radiological scoring which is based upon residual post-operative displacement, in 94% patients the reduction was anatomical, 6% had imperfect (Table 7).

Table 7: Matta’s Radiological Scoring on Immediate Postoperative x-Rays (Prospective Group)

The mean hospital stay was 24 days. Majority 19 (43%) of the patients stayed in hospital between 1-2 weeks, 13 (29%) patients had hospital stay of more than 2 weeks, 12 (27%) patients had hospital stay of less than 1 week. The mean duration of follow up was 18 months, minimum being 6 months and maximum 96 months. Duration of follow up was more in retrospective group (Table 8).
 

Table 8: Hospital Stay and Follow up among Study Participants

This study was conducted in the Department of Orthopaedics Indira Gandhi Medical College Shimla to study the functional outcome after open reduction and internal fixation of fracture acetabulum using Modified Harris Hip score, Modified Merle d’Aubigne Postal scoring and Matta’s radiological score. 

In a total of 44 patients, the mean age was 45.07 years (Range 22 to 74 years) with maximum number of 39 (88%) patients falling under 60 years. Laird et al. [5] analysed 153 patients and the mean age was 46.8 years in their series. Gunaseelan et al. [6] studied 47 patients with average age as 35.6 years ranging from 19 to 53 years. Kumar et al. [7] found that the mean age of 39.5 years in 73 patients (Range 15-76 years). Thus the mean age of 45.07 years in present study is comparable to the others studies done in the past.

In the present study 34(77.3%) were males with 10 females (22.7%). Male to female ratio was 3.4:1 with male preponderance. Marcelo et al. [8] in 87 patients analysed 75 (77.3%) male and 10 females’ cases with fracture acetabulum. Boudissa et al. [9] assessed 156 cases and had a majority of 126 (81%) male patients. Mauffrey et al. [10] studied 212 patients and found 163 men (76.88%) and 49 females (23.22%) with male to female ratio of 3:1. In present study males outnumbered female patients because males are more involved in outdoor activities and hence more susceptible to sustain injury.

The most common mode of trauma was road side accident in 63.6% patients followed by fall in remaining 36.4%. Fall from height was the second major cause of trauma because of the mountain hilly terrains and people have to go for their earnings to far flung area. Sudhir et al. [11] found road traffic accident as the most common cause of these fractures in 66.67% and fall from height as the second most common cause in 27.78% patients. Gupta et al. [12] concluded that road side accident was the most common cause of acetabular fracture in 69.2% of patients and fall from height in 30.8%. Thus the results of present study are comparable to others studies done in the past.

There were 18 patients with posterior wall fractures that constituted about 41% of the cases while 12 patients had posterior wall with posterior column fracture forming 27% of cases. Navid et al. [13] analysed that posterior wall acetabular fractures werethe most common acetabular fracture patterns treated, followed by fracture of posterior wall and posterior column. Seyed et al. [14] observed that 43% patients had posterior wall fracture. Hussain et al. [15] assessed a total of 30 patients and found 7 patients with posterior wall plus posterior column, 5 patients had isolated Posterior wall, 8 cases had Transverse plus posterior wall, Bicolumnar fracture was seen in 5, Transverse in 4, Posterior column was seen in 2 patients. 

The average time interval between injury and surgery was 15 days (range 3-55 days). Sixteen (36%) patients were operated between 8-14 days and fifteen (34%) patients were operated between 0-7 days. It was found that patients operated between first 2 weeks had significantly better functional outcomes according to Modified Merle d’ Aubigne and HHS.

In present study about 66% patients were operated one week after injury. This is due to the fact that some patients present late because of mountain hilly terrain, lack of knowledge, ignorance, some prefer to go private practioners and also some time is lapsed in arranging the finances. Letournel [16] demonstrated that 80.69% had excellent results in 492 hips treated surgically within 3 weeks of injury as assessed by the method of Merle d’Aubigne and Postel Matta et al. [17] studied 262 fractures treated within 21 days and found that most (80%) of them had good functional outcome at final follow up. 

In present study, 30(68%) patients were operated with Kocher-Langenbeck approach in lateral position followed by 7(15.9%) patients with ilioinguinal approach in supine position, 2(4.5%) with iliofemoral, 2(4.5%) by Modified Stoppas intrapelvic approach, 2(4.5%) with combined (Kocher-Langenbeck and Ilioinguinal) approach and one with Ganz surgical dislocation of hip with trochanteric flip osteotomy. Kocher-Langenbeck approach has been one of the preferred surgicalapproach used in majority of acetabular fractures not involving anterior wall, anterior column. It has been used frequently in about 90% of cases in previous studies [18]. Chiu et al. [19] on retrospective evaluation of 80 patients found that excellent reduction and satisfactory functional outcome were achieved by single Kocher-Langenbech approach. They also said that restoration of joint function is purely based on the accuracy of articular reduction. Khadrawe et al. [20] studied 55 patients of which 54% of cases were operated by Kocher-Langenbeck approach. They concluded that functional outcome was based on the personality of the fracture, degree of damage to the articular cartilage and on the other hand to the ability of the surgeon to obtain an anatomical reduction. 

In present study the mean duration of hospital stay was 24 days (range 7-35 days). Gunaseelan et al. [6] analysed 47 patients and found that the post-operative hospital stay was 14 days. The post-operative stay was significantly shorter for patients with simple fracture, the maximum stay was 14 days with a median of 7 days. Kim et al. [21] observed that the duration of hospital stay was 5 days. Shaukat et al. [22] found the average hospital stay as 7 days. Ghosh et al. [23] reported that the maximum hospital stay was 45 days and the mean hospital stay was 14.4 days.

The mean duration of follow up was 18 months (range 6-96 months) in present study. The functional and radiological outcome was assessed by Modified Merle d’Augbigne Postel score, Modified Harris Hip score and radiological scoring by Matta et al. [17] at every follow up in prospective patients and at last follow up in retrospective patients The mean duration of follow up albeit on lower side in present study is similar to previous study by Matta et al. [17].

Study concluded that most of the patients were in the age group of 21-60 years, males, belonged to rural area, injured due to Road traffic accidents, had posterior wall, operated within 15 days and were operated by Kocher-Langenbeck approach in lateral position.

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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