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13 Fractures of the Acetabulum 291 13 Fractures of the Acetabulum 13 Fractures of the Acetabulum 291 13 Fractures of the Acetabulum M. Tile reading the literature to separate the apples from 13.1 the oranges, that is, to compare only similar fracture Introduction types (Fig. 13.1c). For example, in the article by Rowe and Lowell (1961), Fractures of the acetabulum are relatively uncom- closed methods using traction were recommended as mon, but because they involve a major weight-bear- the treatment of choice for acetabular fractures. How- ing joint in the lower extremity, they assume great ever, close scrutiny of this paper describing 93 fractures clinical importance. The principle of management in 90 patients revealed a large number of inconsequen- for this fracture is as for any other displaced lower tial fractures in older individuals with expected good extremity intra-articular fracture, namely, that ana- results, and, in examining the high-energy injuries, 26 tomical reduction is essential for good long-term involved the superior weight-bearing dome of the ace- function of the hip joint. In some cases, anatomi- tabulum. When anatomical reduction was obtained, 13 cal reduction may be obtained by closed means, but of 16 had a good result, but when anatomical reduction more often, open reduction followed by stable inter- of the dome fragment was not obtained, ten out of ten nal fixation allowing early active or passive motion had a poor result. Of the posterior wall fractures, of will be required. In the past, the achievement of this which there were 17, closed management led to poor ideal, that is, anatomical reduction, has been difficult results in six out of nine cases, whereas open manage- because of technical problems such as those caused ment led to good results in eight out of eight cases. The by complicated anatomy, difficulty with surgical undisplaced fractures and the medial wall fractures in exposure, severe comminution in many cases, and elderly individuals without protrusio gave satisfactory major associated injuries. Permanent disability was results with closed means. Thus, the conclusion from reported to be high whether open or closed methods this early series should have been that high-energy were used. displaced fractures involving the posterior wall or the superior weight-bearing dome were best treated by open reduction and internal fixation if the anatomy 13.1.1 could not be restored by closed means. Conversely, Natural History the study also shows that both-column fractures (in this study called medial wall fractures) as well as some A search of the early literature on this subject may anterior types in elderly patients can be managed non- seem confusing because it is based on broad gener- operatively with the expectation of a good result. alizations made by lumping all acetabular fractures Judet et al. (1964) recommended open reduction together. It is important when reading this literature and internal fixation for all displaced acetabular frac- to remember that it is not the overall results that are tures and proposed a classification of these fractures important, since they may reflect a high proportion based on the pattern of injury. of inconsequential fractures. If one is making broad Pennal et al. (1980), reporting on 103 fractures of generalizations based on a number of acetabular the acetabulum, indicated that of those with a poor fractures, a knowledge of the case mix of the series reduction, 72% had clinical and radiographic osteo- becomes essential. If a large percentage of the cases arthritis at 5-year follow-up, whereas of those with a are of the type shown in Fig. 13.1a, then one would good reduction, only 30% had such changes. Although expect good results from simple closed treatment. the incidence of osteoarthritis in those with a good On the other hand, if the majority of cases are like reduction in this series may seem high, the severity the one in Fig. 13.1b, poor results may be expected of the arthritis was much less and the incidence less from closed treatment. Therefore, it is essential when than half of those with a poor result. 13.1 Introduction SCHA_13-Tile.indd 291 17.04.2005 15:00:04 Uhr 292 M. Tile a b Fig. 13.1. a–c Comparing the undisplaced acetabular fracture (a) to the grossly displaced com- minuted acetabular fracture asso- ciated with a pelvic ring disruption (b) is like comparing an orange to c an apple (c). (From Tile 1984) Letournel (1980) reported on 350 fractures of ally examined by one of the authors, and standard the acetabulum with very good results in 75%, good radiographs taken. Our findings mirrored those in results in 8%, and poor results in 17%. Of the 74% the literature. Excellent results could be attained if of the patients with an anatomically reduced hip anatomical reduction was achieved and complica- joint, 90% had a good result. Of the 26% imperfectly tions avoided. reduced, only 55% had a good result if some incon- Matta et al. (1986) stressed that anatomical reduc- gruity remained, only 11% if a degree of protrusio tion can rarely be achieved by closed means, there- remained, and only 9% if there were major technical fore decision-making must be based on the spe- failures. cialized radiographic views of Letournel and Judet In a review of our own case material (Tile et al. (1981). Displacement of greater than 3 mm, especially 1984), 227 charts were examined. Ninety-five cases through the roof of the acetabulum, was considered of minor trauma were excluded because displace- an indication for open reduction and internal fixa- ment was less than 5 mm at the joint. Thus, all incon- tion. sequential fractures were removed from this series. Similar conclusions have been reported in the Only two of those 95 had any difficulty with their more recent literature (Goulet and Bray 1989; hip at review. There were 13 deaths, eight in the post- Pantazopoulos and Mousafiris 1989; Powell et al. trauma period, all in older individuals between 59 1988). Letournel and Judet (1993), in the largest series and 88 years of age, and five with subsequent trauma, of operatively treated acetabular fractures, followed a frequent finding in such a series. Fifteen cases were this same principle. His results, considered the gold lost to follow-up; two were treated at 9 and 12 months standard in 1995, showed variations in the ability to and thereby excluded from the series, leaving 102 achieve anatomical reduction (Table 13.1), depend- cases. At review, all patients were recalled, person- ing on the type and severity of the fracture; even in 13.1 Introduction SCHA_13-Tile.indd 292 17.04.2005 15:00:06 Uhr 13 Fractures of the Acetabulum 293 Table 13.1. Clinical results of acetabular fractures (from Letournel and Judet 1993) Type of fracture Clinical results Percentage of excellent Excellent Very good Good Fair Poor Total results Posterior wall 87 6 3 4 17 117 74 Posterior column 9 – 1 1 – 11 81.82 Anterior wall 6 – 1 1 1 9 66.67 Anterior column 12 1 1 – 2 16 75.00 Transverse 17 1 – – 1 19 89.47 T-shaped 20 3 – – 3 26 76.92 Transverse and posterior wall 49 16 10 9 17 101 48.51 Posterior column and posterior wall 5 1 2 1 8 17 29.41 Anterior column and posterior 26 5 4 3 3 41 63.41 hemitransverse Both-column 76 21 14 11 13 135 56.30 Total 307 54 36 30 65 492 62.40 (62.40%) (10.98%) (7.32%) (6.10%) (13.21%) (100%) the most expert hands, anatomical reduction was means, including computed tomography (CT), and achieved in only 70% of fixations. must cover all the essential parts of the acetabulum, Thus, the literature need not be considered con- including the anterior column, the superior weight- fusing and, if fractures of a similar type and severity bearing portion, and the posterior column. Failure to are compared, the relevant studies make the follow- recognize incongruity caused by displacement of the ing statement with surprising unanimity: joint con- columns, comminution, or articular impaction will gruity is essential for good long-term function; how- result in early destruction of the hip joint (Fig. 13.2). ever, joint congruity may be difficult to achieve. Joint If closed reduction fails to achieve congruity, then congruity must be assessed by strict radiographic open reduction is essential, but open reduction and a b c Fig. 13.2a–c. Anteroposterior radiograph (a) of the left hip of a 17-year-old girl demonstrating a transverse fracture of the left acetabulum through the dome with a central dislocation of the hip. The two arrows in a point to loose bony fragments. Follow- ing closed reduction (b), the two bony fragments have been retained within the joint (arrow). Despite the traction, reduction is inadequate, with bony fragments in the joint and incongruity between the femoral head and acetabulum. Defi nitive treat- ment consisted of traction until the fracture healed. c Her result at 18 months. Note the severe narrowing and erosions on the superior weight-bearing margin of the femoral head. The patient’s clinical result was poor. She had a 60° fl exion deformity with continuous pain, and required an arthrodesis. (From Tile 1984) 13.1 Introduction SCHA_13-Tile.indd 293 17.04.2005 15:00:07 Uhr 294 M. Tile internal fixation will only improve the results if ana- The major factors affecting the prognosis are as tomical reduction is achieved and operative compli- follows: cations are avoided. Failure to obtain an anatomical 1. The degree of initial displacement reduction in the patient shown in Fig. 13.3 resulted 2.
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