COMPARATIVE STUDY OF FRACTURES OF PELVI-ACETABULUM INVOLVING ANTERIOR WALL AND ANTERIOR COLUMN BETWEEN CONSERVATIVE AND OPERATIVE PROCEDURE.
It is widely accepted that the most important principle of acetabular fracture treatment is anatomical restoration of the acetabular surface, particularly the weight bearing zone and stable internal fixation, resulting in a congruent hip [1,2], i.e. the head of the femur is well covered and protected by the acetabular wall, particularly the weight bearing portion of the head. Open reduction and internal fixation (ORIF) is still the best treatment for displaced acetabular fractures. However, it is a specialized surgery and requires technical expertise and practice in addition to knowledge. To the average orthopaedic surgeons, bilateral below knee (Spad) surface traction or skeletal traction applied in the lower end of femur or upper end of tibia, is an alternative for minimally displaced fractures. The stability of the hip, the concentricity of the femoral head below the acetabular roof, and the condition of the acetabulum are the major factors influencing the outcome of non-operative treatment of the acetabulum fractures . Fractures not involving the weight bearing dome have much better prognosis , and can be treated conservatively. However displaced fractures, and those involving the weight bearing dome are better managed surgically.
This prospective study was conducted at the Department of Orthopaedic Surgery, Calcutta National Medical College, between July 2015 and January 2017, to compare the outcomes of the treatment of Acetabulum fractures by operative and conservative methods. Of the patients attending the emergency room and OPD with pelvi-acetabular fractures, study population was drawn from consecutive 22 patients, who gave informed consent and who met the inclusion and exclusion criteria. After routine investigations, including antero-posterior, inlet, outlet and Judet view skiagrams and Computerised Axial Tomograms. Twelve patients were operated and remaining 10 patients were treated conservatively, by below knee skeletal traction. Ethical clearance was obtained from the Institute's ethics committee. Outcome was assessed by radiologic methods as described by Matta J.  (Box 1) and functional methods as described by Harris Hip Score,  and Merle d'Aubigne and Postel  (Box-2).
1. Patients presenting within one week of incidence.
2. Fractures involving the anterior column of acetabulum.
3. Fractures of the Pelvic brim including pubic rami and ischium.
4. Fractures involving the sacrum and sacroiliac joint.
5. Patients within 20-70 years of age.
1. Fractures involving only posterior column or wall of acetabulum.
2. Protrusio acetabuli or central fracture dislocation also involving posterior wall or column of the acetabulum.
3. Patients with serious co-morbid pathologies, or associated long bone fractures of the lower limbs.
Procedures Used in Conservative Treatment
Only in minimally displaced anterior wall or column fractures, i.e. < 3 mm stepping we have used bilateral below knee skeletal tractions for 6 weeks. Following this traction period patients were encouraged to do hip and knee movements in sitting posture and supine positions for another six weeks. Bilateral axillary crutch assisted partial weight bearing was the next step, in the rehabilitation period. Meticulous nursing care was imperative to prevent pressure sores. Patients would be made to sit up in the bed to prevent hypostatic pneumonia. Lung physiotherapy including deep breathing exercises were advised. Static and dynamic knee exercises were encouraged as the pain waned. Anticoagulants were not administered in this series. Only 10 patients had been treated conservatively, but unfortunately one patient was lost in follow-up.
Procedures Used in Operative Treatment In the other 12 patients, we used the ilio-inguinal approach using three separate windows. The medial most retracting the spermatic cord and lymphatic venous plexus, the lateral most retracting the femoral vessels and nerves and the intermediate, retracting the iliopsoas. Reconstruction plates were bent and aligned along the curvature of the bone, fracture fragments reduced gently with bone spikes and fractures fixed rigidly. Occasionally buttressing of quadrilateral surface of the acetabulum, was done using buttress plates, or reconstruction plates.
Data were analysed using SPSS (Statistical Package for Social Scientists) version 20.0, IBM, Armonk, New York, USA. Unpaired T-test and Chi-square test were applied at 5% significance level.
Results were assessed by radiologic methods as described by Matta. J. (Box 1) and functional methods as described by Harris Hip Score (Annexure-1), and Merle d'Aubigne and Postel (Box-2).
In this study we observed that the patients were from age 29 years to 60 years with maximum incidence between 31 to 40year age. The mean age for patients in conservatively treated group was 48.33 yrs. [+ or -] 10.74, and that for patients of ORIF group was 35.6 yrs. [+ or -] 4.14, with a significant p value of less than 0.001 (Table 2).We also observed that incidence amongst males was 3.2 times more than females, with a p value of 0.35(yates correction, Table 2), which is statistically insignificant.
Of the 9 patients treated by conservative methods, who followed up, radiological outcome was good in 5 and fair in the rest 4. Harris Hip Score was 79.67% [+ or -] 4.5% (fair to good). Five Patients in this group with congruous reductions had an average HHS of 82.4% [+ or -] 2.70%, and the rest 4 who had incongruous reductions had an average HHS of 79.67% [+ or -] 4.5%. The overall Merle d'Aubigne-Postel score in this group was 13.89 [+ or -] 1.54 (The 5 with congruous reductions having a score of 14.8 [+ or -] 1.30, and the rest 4 having an average of 12.75 [+ or -] 0.96).
The other group of twelve patients underwent ORIF. In this group, where 10 patients had congruous and 2 had incongruous reduction, radiological outcome was excellent in 8 of the 10 congruent reductions and was good in rest 2 (Table 1). The 2 other patients who had incongruous reduction, had good outcome (Table 1). Overall Harris Hip Score was 88.42% [+ or -] 3.87% in this group of which 10 patients with congruous reduction had a mean HHS of 89.5 % [+ or -] 3.24 % (Good to excellent) and rest 2 had a mean HHS of 83% (good). The overall mean MDBP score for the operated group of 12 patients was 17.08 [+ or -] 1.38 (Mean MDBP scores were 17.5 [+ or -] 1.08 and 15.0 respectively for congruous and incongruous reduction).
The results obtained by radiological outcomes were not compared to ascertain significance of variation as there were some zero results. In this study we observed that there was statistically significant difference, between the groups treated with operative and conservative methods, P < 0.001 in both HHS and MDBP scores (Table 3). Comparison of the HHS and MDBP scores in the operated patients with congruous and incongruous reduction, showed that the difference observed was significant, P = 0.02 for HHS and P = 0.03 for MDBP respectively (Table 4). Again, the same scores observed and compared between the congruous reduction patients and incongruous reduction patients among the conservatively treated patients, was of significant variance, P = 0.03 in both the instances (Table 4). We also found on comparing both the HHS and MDBP scores for congruous reduction patients treated by ORIF and those treated conservatively, had a significant variation with P = 0.001 (Table 5). The difference of HHS for patients with incongruous reduction treated by ORIF and those treated conservatively had a statistically not so significant value of P = 0.089 whereas the difference in MDBP scores in this group being significant, P = 0.023 (Table 5).
All minimally displaced (Lesser than 3 mm) fractures of anterior column treated conservatively showed signs of union. Functional outcome of the patients treated conservatively was good although there was initial stiffness which was overcome by continuous physiotherapy. Union time was approximately 8 weeks in the conservative group and 10 weeks in the operated patients. Infection, mostly superficial complicated the course of 10% of patients in the operated group, but was manageable by superficial debridement, lavage and antimicrobials. There was no avascular necrosis, or non-union in this study.
Surgeries for management of pelvi-acetabular fractures are gaining popularity with every passing day. Continuous research and studies in this field, has led to the adoption of various methods of approach and solution to the puzzles of the pelvi-acetabular fractures.
In our study we found that patients who underwent conservative methods of treatment with minimal displacement were of a higher age group as compared to the other group, may be due to the lesser activity level, and lower force of trauma.
Though ORIF is the best method of the treatment of pelvi-acetabular fractures, it is a fact that surgeries of acetabular fractures are technically challenging. The surgical approaches and reduction techniques must be thoroughly understood to properly manage this three-dimensional problem. The complicated anatomy of the acetabular region, frequent severe associated injuries, and long-term complications, all contribute to management difficulties. 
In a case report by Dhaniwala NS, Dhaniwala MN, they observed that conservative treatment in form of traction followed up with mobilization of hip can be tried with reasonable functional outcome in undisplaced/minimally displaced fracture acetabulum.  In a study by Magala M et.al, they observed that conservative management can also give good radiological and functional outcomes in congruent reductions.  Sen RK and Veerappa LA in a study observed that conservative treatment continues to be the mainstay of treatment in many centers in developing countries due to lack of infrastructure, and poor availability of skilled services, and also to some extent, due to delayed referrals, economic constraints of patients and patients not consenting to surgery.  Roetman B and others in a study found that conservative treatment is also associated with lesser complications, like iatrogenic nerve palsies, infections, pulmonary embolism, femoral head necrosis, and heterotrophic ossification. These complications, usually follows ORIF, which tend to decline the functional outcome of the fractures, following ORIF, in the long run, in spite of achieving good reduction during surgery. 
Minimally displaced fractures with lesser than 3 mm displacement or without stepping, may be treated by conservative methods, but fractures with larger displacements and non-congruent ones should be managed operatively. Expertise of the surgeon and approach to the fracture also influences the outcome. [12,13] A larger study, having larger number of patients in both the groups, or multicentric studies are required to have a better understanding of the comparison.
We hereby acknowledge Dr. Shuvankar Mukherjee, Assistant Professor of Community Medicine, Calcutta National Medical College, for guiding us through the statistical calculations and analyses.
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Rajiv Roy (1), Subhasis Ranjan Mitra (2)
(1) Associate Professor, Department of Orthopaedic Surgery, Calcutta National Medical College, Kolkata, West Bengal, India.
(2) Associate Professor, Department of Orthopaedic Surgery, Calcutta National Medical College, Kolkata, West Bengal, India.
'Financial or Other Competing Interest': None.
Submission 07-11-2018, Peer Review 26-05-2019,
Acceptance 01-06-2019, Published 17-06-2019.
Subhasis Ranjan Mitra, #16B, Dr. Sundari Mohan Avenue, Kolkata-700014, West Bengal, India.
Caption: Figure 1. Fixation of Anterior Column Fracture by Reconstruction Plates
Caption: Figure 2. Fixation of Anterior Column Fracture with Sacro-Iliac Joint by Reconstruction Plates
Caption: Figure 3. Fixation of the Anterior Column Fracture, Quadrilateral Plate and SI Joint
Caption: Figure 4. Fixation of Anterior Column Fracture by Reconstruction Plate
Caption: Figure 5. Conservative Management of an Acetabulum Fracture by Bilateral Upper Tibial Traction
Table 1. Radiological Outcome as per Mata's Criteria Operative Conservative Excellent 8 - Good 4 5 Fair - 4 No poor outcome in any group Table 2. Patient Demographics Demographics Patients Treated Patients Treated by P by ORIF (n = 12) Conservative Methods (n = 9) Age (mean 35.67 [+ or -] 4.14 48.33 [+ or -] 10.74 <0.0013 [+ or -] S.D.) yrs. Sex Male 10 (83.33) 6 (66.67) 0.35 No. Female 2 (16.67) 3 (33.33) (Yates (%) correc- tion) Table 3. Comparison of Results by Functional Outcomes Methods of Patients Treated by Patients Treated P Scoring ORIF (n = 12) Mean Conservatively (n [+ or -] S.D. = 9) Mean [+ or -] S.D. Harris' 88.42 [+ or -] 3.87 79.67 [+ or -] 4.5 <0.0001 Hip Score (%) Merle 17.08 [+ or -] 1.38 13.89 [+ or -] 1.54 <0.0001 d'Aubigne- Postel Score Table 4. Comparison of Results by Functional Outcomes Between Congruous Reduction and Incongruous Reduction within Patients Treated by ORIF and by Conservative Means Methods of Patients Treated by ORIF Scoring Mean [+ or -] S.D. Congruous Incongruous p Reduction (n = 10) Reduction (n = 2) Harris' 89.5 [+ or -] 3.24 83.0 [+ or -] 0 P = 0.02 Hip Score (%) Merle 17.5 [+ or -] 1.08 15.0 [+ or -] 0 P = 0.01 d'Aubigne- Postel Score Methods of Patients Treated Conservatively Scoring Mean [+ or -] S.D. Congruous Incongruous p Reduction (n = 5) Reduction (n = 4) Harris' 82.4 [+ or -] 2.70 76.25 [+ or -] 4. 03 P = 0.03 Hip Score (%) Merle 14.8 [+ or -] 1.30 12.75 [+ or -] 0. 96 P = 0.03 d'Aubigne- Postel Score Table 5. Comparison of Results by Functional Outcomes Between Patients Treated by ORIF and by Conservative Means Within Congruous Reduction and Incongruous Reduction Methods of Congruous Reduction from Both Groups Scoring Treated by ORIF Treated Conservatively P (n = 10) (n = 5) Harris' 89.5 [+ or -] 3. 24 82.4 [+ or -] 2.7 0 P = 0.001 Hip Score (%) Merle 17.5 [+ or -] 1. 08 14.8 [+ or -] 1.3 0 P = 0.001 d'Aubigne- Postel Score Methods of Incongruous Reduction from both Groups Scoring Treated by ORIF Treated Conservatively P (n = 2) (n = 4) Harris' 83.0 [+ or -] 0 76.25 [+ or -] 4.0 3 P = 0.089 Hip Score (%) Merle 15.0 [+ or -] 0 12.75 [+ or -] 0.9 6 P = 0.023 d'Aubigne- Postel Score Box 1. Mata's Criteria Grade Osteophyte Joint Space Narrowing Sclerosis Excellent None Normal None Good Small >2 mm Minimal Fair Moderate <50% Moderate Poor Large >50% Severe With Femoral Head Collapse Box 2. Merle d'Aubigne-Postel Scoring System Score Pain Hip Range Of Walking Ability Motion 0 Disabling pain at Ankylosis in poor No walking rest position possible 1 Pain interfering No movement, Only with 2 with sleep slight deformity crutches or frame 2 Pain that prevents Flexion > Minimal walking walking 40[degrees] with one cane 3 Pain tolerable Flexion Walking for < 1 with limited 40[degrees]- hour with one cane activity 60[degrees] 4 Pain that Flexion Short walk without disappears with 60[degrees]- cane but marked rest 80[degrees] limp 5 Mild pain with Flexion Walks without cane normal activity 80[degrees]- but noticeable 90[degrees] + limp 15[degrees] abduction
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|Title Annotation:||Original Research Article|
|Author:||Roy, Rajiv; Mitra, Subhasis Ranjan|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jun 17, 2019|
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