Evaluation of outcome of Open Reduction Internal Fixation of Acetabular fractures: A prospective clinical study. Charansingh Chaudahry, Amrut Borade Rajendra Verma. S.M.S. Medical College, Jaipur

Introduction The difficulties in approaching and fixing the acetabular fractures lead many surgeons either to accept inferior surgical results or to insist on conservative treatment.

To explore the guidelines already laid for operative treatment of these fractures we undertook study evaluating the functional outcomes of displaced acetabular fracture patients treated by open reduction and internal fixation.

Materials & Methods Prospective study was undertaken in the department of orthopaedics, SMS Medical College, Jaipur from Dec 2009 to 2011. INCLUSION CRITERIA Fractures of acetabulum in skeletally mature. >2mm displaced fractures of weight bearing region. <45% roof arc measurement >50% involvement of posterior wall by fracture. EXCLUSION CRITERIA Fractures associated with perineal, urethral and gut injuries Associated with vertically unstable pelvic ring injuries Pre-existing old hip fractures Acetabular fractures that were more than 3 weeks old.

PREOPERATIVE EVALUATION All the cases were initially investigated with anteroposterior, oblique Judet x ray views of the pelvis, Computed tomograms of pelvis with 3D reconstruction. Analysis of the fracture pattern fitting into one of the types of Classification system of Letournel and Judet. Amount of initial fracture displacement noted. Medial, Anterior and Posterior roof-arc angles were measured.

Surgical Approaches as per fracture anatomy Primary aim of the surgery was anatomical reduction and rigid fixation asssessed by reduction of fracture lines in the cortical surface of the pelvic bone or in cases of arthrotomy intraarticular reduction was visualised per se. Surgical Approaches as per fracture anatomy KOCHER-LANGENBECK APPROACH. ILIOINGUINAL APPROACH ILIOFEMORAL AND EXTENDED ILIOFEMORAL APPROACH TRIRADIATE EXTENSILE

EVALUATION SCORE FUNCTIONAL OUTSCORING SYSTEM BY MATTA: Degree of pain Degree of ambulation Range of motion (ROM): Right Left Percent of injured hip = (total injured ROM/ total normal ROM) Clinical grade: total points (pain + ambulation + ROM) 18 = excellent 15-17 = good 13-14 = fair <13 = poor  

Observations & Results Pre-operative Patient demographics: 26 cases 22 males and 4 females. Mean age of the patients approximately 38 years. Mode of injury in 77 % of the patient was RTA. 46.15 % of the total patients had associated fractures. 61.5% of the patients had posterior wall &/or column fracture. The mean time between injury and surgery was 9 days. Kocher Langenbeck approach in 77% (greater trochaenter osteotomy in 65%.), Triradiate extensile in 11.5% and Extended iliofemoral & combined approach in 12.5% patient.

Post-operative observation: Bone union was achieved at an average of 14 weeks(12 – 20weeks) No case of implant failure. Mean ROM at final follow up were flexion 122 deg, extension 10 deg, external rotation 31 deg, internal rotation 24 deg, abduction 36 deg & adduction 27 deg. Maximum follow up in our study was 18 months. The average MATTA score, at final follow up was 17 (range: 12- 18). 61.5% patients achieved excellent results. 19.5% attained good; 11.5% achieved fair & 7.5% had poor results. 80 % of the patients were rehabilitated to their previous occupation.

Complications observed were: Avascular necrosis of femoral head occurred in 5 patients all of which presented with posterior dislocation of hip. Heterotrophic ossification occurred in 3 cases. One case of deep infection occurred which resolved after serial debridement & secondary closure. Pre-operative Sciatic nerve palsy noted in 3 patients.

Case 1 Harshwardhan

Case 2 Ghanshyam

Case 3 Anwar

Case 4 : Vivek

Conclusion Open reduction & internal fixation of the displaced acetabular fractures is effective method of treatment despite complexities & difficulties in approach & reduction. In the Indian population with high occupational & social demands like squatting & sitting cross-legged it is important to have a functional & stable hip joint with good range of motion which can achieved with ORIF in cases of displaced acetabular fractures. Restoring normal anatomy will enable the patient to have better quality of life in near future & to have successful reconstructive procedures in distant future. During this study process of development of the infrastructure at our institution started in view of acetabular fracture surgery & learning curve improved.

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