Delayed presentation of complex acetabular fractures: Review of literature on outcome of internal fixations with reference to extended ilio-femoral approach

Abstract

Objective: Delayed presentation of complex acetabular fractures isn't uncommon. Surgical treatment of such fractures demand special consideration with respect to surgical approach, reduction techniques, fixation and avoidance of complications. This paper intends to review the literature with regard to the suggested treatment modalities and the reported outcome in late presentations and conclude any recommendations appropriate to the practice in current times.

Background: Displaced fractures of acetabulum, when remained untreated for more than three weeks, pose significant challenge to fracture reduction due to rapid callus formation. In 1976, Letournel described the "Extended Ilio-Femoral Approach"(EIFA) to provide adequate exposure for effective reduction of such fractures. It offered greater exposure of both anterior and posterior columns through a single window, which allowed more precise and controlled reduction of the complex fractures under vision. But despite early enthusiasm in its practice, there has been a steep decline in its application due to reported higher risk of complications. Despite the challenges, the accuracy of fracture reduction in complex acetabular fractures with late presentation was found to be superior in EIFA than the reduction that were achieved by other approaches. Hence a debate to find out the utility of this approach for late reconstruction of complex acetabular fractures (in the face of reported risks of complications) is worthwhile especially in younger patients, who are not suitable candidates for an acute hip replacement surgery and who need their native hip to function well at least for a few years, for their professional and personal high demand activities in their active youthful period.

Methods: The articles for review were retrived using Google Scholar for data retrieval as Pubmed didn't yield any meaningful results due to paucity of publication in this subject. There were only very few papers in the English literature since 1979, which focused on this condition and were considered for this review. We have included our experience on using EIFA in late presentations of complex acetabular fractures spanning from 1999 to 2019, an experience over two decades to this report.

Results: It was observed that despite delayed presentation, good articular reduction was possible by using EIFA even in complex acetabular fractures. Ultimate functional outcomes were directly related to the accuracy of fracture reduction thus achieved. The risk of heterotrophic ossification in EIFA, though emphasized as significant in the published literature, was found to be least of a problem in our experience.

Discussion: Surgical fixation in delayed cases of complex acetabular fractures was found to be challenging. The choice of surgical approach was found to have a great bearing on the accuracy of fracture reduction and long term functional outcome. In complex acetabular fractures, despite delay in presentation, precise reduction of such fractures was found to be possible when operated using EIFA. CONCLUSION: It was concluded that Every effort must be made to reconstruct the displaced fractures of acetabulum, even in the complex types,despite when they present late, provided the fracture fits into the selection criteria described by Letournel and operated using EIFA. This is very much appropriate to younger patients, who are not great candidate for total hip replacement surgery.

Keywords: Acetabulum fracture; Extended ilio-femoral approach; Internal fixation; Late presentation or delayed presentation; Outcome.

Fig. 1

A: Displaced ABC Fracture remains "Reduced in Traction"B: It gets displaced proximally and remains unstable when the traction is taken off,(even after being in traction for six weeks) indicating failure to unite and unstable architecture of this fracture, an indication for ORIF as per Letournel’s criterion., C: 45 days old displaced Trans-tectal TV-fracture, The head is not damaged despite a small Hill-Sach like lesion. It is Not a contraindication to ORIF .

Fig. 2

A: X ray pictures of a 47 days old displaced trans-tectal transverse fracture of acetabulum with Central dislocation of head of femur. B: Coronal CT shows Hill-Sach like lesion in the head of femur with some damage to the weight bearing part of the head. C: “Capsulotomy” as the “final part of the EIF approach” (and only possible in this approach): allowing intra articular exposure of reduction, so essential in assisting controlled anatomical reduction, especially in this trans-tectal transverse types of fractures. D: 9 years follow up x ray shows Matta's radiological scoring as “good” with minimal sclerosis in the hip:(the hip has been saved from replacement). E: Post internal fixation (intra-op picture) reduction verification through arthrotomy; the arrow head shows the accuracy of acetabular reduction.

Fig. 3

A: 28 days old Transtectal-TV fracture with posterior dislocation operated through EIFA B: Chondrolysis evident at 1 year post-op.

Fig. 4

A: The two screws on either side of the fracture are evidence for failure of the attempted reduction by application of bone spreader. The technique of Reduction of Periarticular Step off by "Locking Plate Interference technique" is demonstrated-The over contoured plate is being brought on to the bone surface by gradual tightening of the cortical screw in picture-Fracture is over-riding B: Apex Of Fracture reduced by gradual tightening of screw C: Another Plate used in same manner anteriorly.

Fig. 5

A: 23 Days old ABC fracture B: Saw-bones demonstrating small comminuted fragments, which are inadvertently removed during debridement C: Intra-articular malreduction due to apparent peripheral anatomical reduction ignoring the space occupied by the loss of smaller bony fragments, which were removed with callous during debridement D: Keeping hip congruous created gaps in the innominate bone peripherally in the iliac wing before fixation started E: Fixation done with congruous hip, no regards for attempting anatomical reduction on peripheral iliac wing F: c arm picture of revision fixation showing Congruous Hip with gaps in iliac wing G: Post Op X-ray H: 7 Years follow-up X-Ray showing Congruous Hip with Gap In Ilium at periphery.