Surgical treatment of acetabular fractures: review of 48 cases

Abstracts

Realizou-se um estudo retrospectivo clínico e radiológico de 48 pacientes submetidos a tratamento cirúrgico de fraturas deslocadas do acetábulo, efetuadas no período entre setembro de 1995 a setembro de 1998, no Departamento de Ortopedia e Traumatologia do Hospital Cristo Redentor em Porto Alegre. A idade dos pacientes variou entre 20 a 53 anos, sendo a maioria na faixa entre 20 a 30 anos (61,5%). 72,95% dos pacientes avaliados eram masculinos. Os acidentes de automóveis foram as causas mais freqüentes (41,66%). Realizou-se avaliação clínica pelos critérios de Merle D´Aubigné e Postell e a avaliação radiológica e classificação pelos critérios propostos por Tile. Obtiveram-se 62,5% de bons resultados contra 4,16% de maus resultados. Observaram-se como complicações a lesão do nervo ciático (12,74%) como a mais freqüente. Os autores concluem que o tratamento cirúrgico é preferível ao tratamento conservador nas fraturas deslocadas de acetábulo, sendo a congruência articular e a mobilidade precoce, fatores essenciais para o bom resultado do procedimento. Também ressaltam a importância do conhecimento anatômico e da experiência cirúrgica para melhores resultados na obtenção da redução e prevenção de complicações.

Fraturas articulares deslocadas; acetábulo; pelve

ARTIGO DE REVISÃO

Surgical treatment of acetabular fractures: review of 48 cases^*

André Luiz Horta Barbosa^I; Paulo Cezar Schütz^II; Lisandro Pavan^III

^IMédico Ortopedista e Traumatologista.Preceptor Chefe do Serviço de Residência Médica.

^IIMédico Ortopedista e Traumatologista. Preceptor do Serviço de Residência Médica.

^IIIResidente do 2º ano do Serviço de Residência Médica.

SUMMARY

The authors performed a clinical retrospective study and 48 patients' radiologic submitted to surgical treatment of moved fractures of the acetabulum, made in the period among September from 1995 to September of 1998, in the Department of Orthopedics and Traumatologia of the Hospital Cristo Redentor in Porto Alegre. The patients' age varied among 20 to 53 years, being most in the strip among 20 to 30 years (61,5%). 72,95% of the appraised patients were masculine. The accidents of automobiles were the most frequent causes (41,66%). The authors performed clinical evaluation for Merle D´Aubigné's criteria and Postell and the evaluation radiologic and classification for the criteria proposed by Tile. 62,5% of good results were obtained against 4,16% of resulted bad. They were observed as complications the lesion of the sciatic nerve (12,74%) as the most frequent. The authors conclude that the surgical treatment is preferable to the conservative treatment in the moved fractures of acetábulo, being the consistency to articulate and the precocious mobility, essential factors for the good result of the procedure. They also point out the importance of the anatomical knowledge and of the surgical experience for better results in the obtaining of the reduction and prevention of complications.

Key Words: Fractures articulate moved; acetabulum; pelve

INTRODUCTION

Morbidity and the need for anatomical and stable reductions raise questions when establishing the treatment for dislocated fractures of the acetabulum because of the anatomical and technical difficulties of approach of these complex fractures ⁴. The initial treatments proposed were incongruent methods that presented difficulties in the restoration of the articular surface and consequently, a delay in returning to normal function and especially, functional incapacity. In 1964, Judet and Letournel published a classic paper in which they affirm that surgical treatment is preferable to conservative treatment because it presents better long-term results due to the anatomical reduction that is possible with this kind of treatment ¹. Other authors also showed the need for surgery in order to achieve anatomical reduction of fractures and assure such results ².

One major contribution to the resolution of these problems was the perfection of the radiological assessments of these patients. The establishment of specialized radiological views by Judet and Letournel⁵, associated with advancements in diagnosis by image, allowed for better evaluations and helped in indicating the method of treatment. The development of rational classifications has also been a great help in the precise determination of the type of fracture and consequently, of the type of treatment to be instituted, based on evidence of the results published in literature. With the evolution of these factors, associated with the development of instruments and materials for synthesis, the open reduction and internal fixation of these fractures has become trustworthy and safe when done by experienced hands.

MATERIAL AND METHODS

A retrospective clinical and radiological study was done with 48 patients who underwent surgical reduction and internal fixation of dislocated fractures of the acetabulum, during the period of September 1995 to September 1998, at the Department of Orthopedics and Traumatology of the Hospital Cristo Redentor in Porto Alegre. The average length of patient follow-up time was 19,7 months (minimum of 6 and maximum of 28 months).

The patients' ages varied from 20 to 53 years, with the majority between 20 and 30 years of age (61,5%). There was a predominance of males (72,95%). The most frequent cause was automobile accidents (41,66%), followed by motorcycle accidents (35,41%), falling from [great] heights (6,25%) and being hit by vehicles (6,66%). A large percentage of patients had associated lesions that were concurrently treated.

All of the patients were submitted to radiological investigation with anteroposterior, foraminal and alar oblique views of the pelvis, according to the criteria of Judet e Letournel. A C.T. scan was performed on all patients. None of the patients was submitted to any emergency procedure. All of the patients underwent surgery within seven days.

Antibiotic prophylaxis was used with cephalothin, 1g IV every 6 hours, until 48 hours post-operative, beginning 1 hour before the procedure. An aspiration drain was used in all patients for 48 hours. After the procedure, the patients were followed with radiographic controls until the fracture consolidated.

The clinical evaluation was made in accordance with the criteria of Merle D´Aubigné and Postell³. The Tile classification was used to identify the types of fractures. The incidence of the different types of fractures is shown in Table 1.

RESULTS

The patients submitted to evaluation according to the criteria of Merle D´Aubigné & Postell were accompanied until consolidation and presented the results shown in Graph 1.

Bone consolidation occurred in all of the cases, and was confirmed radiologically by the imbrication of fracture lines. The consolidation period varied from 3 to 6 months. During the evaluation period, no loss of reduction or failure of synthesis material was observed.

Nine cases (18,75%) of sciatic nerve lesion were observed as associated complications, 2 of which iatrogenic that showed spontaneous regression in 6 months. The other cases evolved with permanent lesions. Other complications seen were: lesion of the inferior gluteal artery (2,08%) which evolved to massive necrosis of the gluteus medius; heterotrophic ossification (2,08%); avascular necrosis (2,08%); chondrolysis (2,08%); lesion of the lateral femoral cutaneous nerve (6,25%); infection (2,08%). In 5 cases (10,41%) secondary osteoarthrosis was observed within the period of 2 years.

DISCUSSION

We point out the need for tomographic evaluation of cases as well as the classic (X-ray) views to guide the treatment decision, since the identification of diminute intra-articular fragments, which are not identified by X-Ray views, modifies the therapeutic conduct.

Surgical treatment is preferable to conservative treatment in the dislocated fractures of the acetabulum, and it is indicated in cases of dislocations greater than 3 mm or with a Matta angle of more than 45 degrees .^2,4

The surgical intervention is more successful if the patient is first stabilized and a good pre-operative evaluation is performed, with surgery being done, when necessary, within 3 to 7 days.

The choice of surgical approach is vital for the success of the procedure. There is no single defined approach for all cases. The surgeon should be familiar with the different types of approaches, as well as their anatomical characteristics and possible variations.

Cases in which the acetabular roof was involved showed poorer results when compared to the rest.

The complications observed are compatible with those mentioned in literature, except for heterotrophic ossification, which showed significantly lower rates. We infer that this result is due to the short time of follow-up. We point out that the learning curve is imperious in order to diminish the number of complications observed and increase the expectation of better results. A trained multidisciplinary team and adequate materials are of fundamental importance.

REFERÊNCIAS

• 1. Judet, R., Judet, J. & Letournel, E.: Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg [AM] 46:1615-1646, 1964.
• 2. Matta, J.: Operative Incidactions and Choice of Surgical Approach for Fractures of the Acetabulum. Techniques Ortopaed, 1:13-22. 1976.
• 3. Merle D´Aubigné, R.: Functional results of hip arthroplasty with acrylic prothesis, J Bone Joint Surg [AM] 36: 451-475, 1954.
• 4. Tile, M.: "Fractures of the acetabulum", in Rockwood Jr., Green, D.P. & Bucholz, R.W.: Fractures in adults, Philadelphia, J.B. Lipincott, 1984. Cap17, p 1442-1479.
• 5. Tile, M.: Fractures of the Pelvis and Acetabulum, p. 178, Baltimore, Williams & Wilkins, 1984.

*

Trabalho realizado no Serviço de Residência Médica em Ortopedia e Traumatologia do Hospital Cristo Redentor - Porto Alegre - RS.

Publication Dates

• Publication in this collection
  07 May 2007
• Date of issue
  Sept 2000