Acetabular fractures: epidemiological, lesional, therapeutic and evolutionary aspects

<p class="abstract"><strong>Background:</strong> Fractures of the acetabulum are serious because they affect a deep, load-bearing joint that is difficult to repair surgically at first. They occur in a context of polytrauma. The aim of our work is to study the epidemiological, lesional, therapeutic and evolutionary aspects of acetabulum fractures.</p><p class="abstract"><strong>Methods: </strong>This is a 5-year retrospective study from January 2012 to December 2016 including 45 patients treated for acetabulum fracture.</p><p class="abstract"><strong>Results: </strong>45 patients including 38 men and 7 women with a mean age of 36 years (extremes 18 and 74). The circumstances of occurrence were dominated by road traffic accidents with 42 cases (93.3%).</p><p class="abstract">According to the Judet-Letournel classification, we observed 28 elementary fractures (16 posterior wall fractures, 11 posterior column fractures, 1 anterior column fracture) and 17 complex fractures (7 posterior column and posterior wall fractures, 6 transverse and posterior wall fractures, 3 posterior and anterior column fractures, 1 anterior column and posterior hemi-transverse fracture). The association of a dislocation with an acetabulum fracture was found in 32 cases. Associated lesions (fractures) were observed in 23 patients. One case of associated TCE was noted. Treatment was orthopedic in 18 patients, surgical in 18 patients and functional in 9 patients. According to the Matta criteria we obtained after treatment 46.7% good reduction, 51.1% satisfactory and 2.2% unsatisfactory reduction. According to the Postel-Merle D'Aubigné rating, 16 patients obtained excellent results with overall 93.3% satisfactory results. The complications found were coxarthrosis (15 cases), para-articular ossification (2 cases) and vicious callus (1 case).</p><p class="abstract"><strong>Conclusions:</strong> The treatment of acetabulum fractures depends on the type of fracture, the age and activities of the patients. Orthopedic, surgical as well as functional treatment can give good acetabular reconstructions and functional results.</p>

Morphological Characteristics of Posterior Wall Fragments Associated with Acetabular Both-column Fracture

Treatment of both-column fractures with posterior wall involvement is still a controversial topic. This type of posterior wall fracture is different from isolated acetabular posterior wall fracture (AO/OTA62-A1). The aim of this study is to compare the morphology of the posterior wall fragments of these two fracture patterns using computed tomography (CT) scans. All measured data were compared, and the differences between the groups (acetabular both-column fractures with posterior wall involvement were included in group A, and acetabular isolated posterior wall fractures were included in group B) were significant (P ≤ 0.05), including the direction angle, displacement, articular surface-posterior cortex ratio and articular surface area of the fracture fragment. The intraclass correlation coefficient of the measurements included inter-observer (ICC = 0.860) and intra-observer (ICC = 0.853). The morphology of the posterior wall fragments associated with both-column fractures is significantly different from that in isolated acetabular posterior wall fractures, and the treatment of the posterior wall fragment involved in both-column fractures of the acetabulum should be different from that of isolated acetabular posterior wall fractures.

Early Total Hip Arthroplasty for the Treatment of Acetabular Fractures

Early total hip arthroplasty in patients with acetabular fractures is considered in rare situations with specific indications. Generally, this treatment option is considered in patients older than 55 or 60 years, but the physiological age must also be considered. The patient should be functional and ambulatory before the injury and healthy enough to tolerate the insult of a surgical procedure of this magnitude. Preexisting conditions such as osteoporosis and osteoarthritis encourage consideration of total hip arthroplasty. Specific injury patterns are predictive of fixation failure in older patients with acetabular fractures. These findings represent worse articular injury and low bone density that would intuitively lead to failure. This “gull sign” or “seagull sign” describes either the central–superior dome impaction seen in high-transverse fractures or the impaction of the subchondral bone on the intact edge of a partial posterior column fracture. Other radiographic predictors of failure in posterior wall fractures include comminution of more than three fragments, involvement of the superior dome in high posterior wall fractures, and marginal impaction. Older patients have a high incidence of these radiographic findings, predictive of fixation failure without arthroplasty. Other injury characteristics including concomitant displaced femoral neck fracture and femoral head injury are also indications for total hip arthroplasty in older patients. Acute hip arthroplasty can be performed using the posterolateral, direct lateral, anterolateral, and anterior approaches to the hip. There are also reports of patients who underwent combined approaches to the hip for stabilization of the injury using the anterior intrapelvic approach and ilioinguinal approach. Combined approaches are generally not recommended. Extended approaches are not recommended or necessary for early arthroplasty in acetabular fractures. This review article highlights recent trends of early total hip arthroplasty in senior patients with acetabular fracture, and the indications for the procedure, complications, clinical outcomes, and technical considerations, with cases to highlight these concepts.