„ TRAUMA
The surgical treatment of anterior column
and anterior wall acetabular fractures
SHORT- TO MEDIUM-TERM OUTCOME
P. V. Giannoudis,
N. K. Kanakaris,
R. Dimitriou,
R. Mallina,
R. M. Smith
From Leeds Teaching
Hospitals NHS Trust,
Leeds, United
Kingdom
„ P. V. Giannoudis, BSc, MD,
FRCS, Professor and Chairman
Academic Department of
Trauma and Orthopaedics,
School of Medicine
University of Leeds, Clarendon
Wing, Leeds General Infirmary,
Great George Street, Leeds LS1
3EX, UK.
„ N. K. Kanakaris, MD,
Consultant
„ R. Dimitriou, MD, Clinical
Fellow
„ R. Mallina, MB ChB, MRCS,
Core Surgical Trainee
Department of Trauma and
Orthopaedics
Leeds Teaching Hospitals NHS
Trust, Beckett Street, Leeds LS9
7TF, UK.
„ R. M. Smith, MD, FRCS,
Professor of Trauma &
Orthopaedic Surgery
Massachusetts General
Hospital, 55 Fruit Street,
Boston, Massachusetts 02114,
USA.
Correspondence should be sent
to Professor P. V. Giannoudis;
e-mail: [email protected]
©2011 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.93B7.
26105 $2.00
J Bone Joint Surg [Br]
2011;93-B:970-4.
Received 15 November 2010;
Accepted after revision 14
March 2011
970
Isolated fractures of the anterior column and anterior wall are a relatively rare subgroup of
acetabular fractures. We report our experience of 30 consecutive cases treated over ten
years. Open reduction and internal fixation through an ilioinguinal approach was performed
for most of these cases (76.7%) and percutaneous techniques were used for the remainder.
At a mean follow-up of four years (2 to 6), 26 were available for review. The radiological and
functional outcomes were good or excellent in 23 of 30 patients (76.7%) and 22 of
26 patients (84.6%) according to Matta's radiological criteria and the modified Merlé
d'Aubigné score, respectively.
Complications of minor to moderate severity were seen in six of the 30 cases (20%) and
none of the patients underwent secondary surgery or replacement of the hip.
Isolated anterior column and anterior wall
fractures account for only 6.3% of acetabular
fractures.1 Their outcome is often analysed
with other associated fracture patterns, particularly hemi-transverse or bicolumnar fractures,2-4 thereby masking their true prognosis.
In spite of extensive literature on the management of acetabular fractures in general, information on outcome following open reduction
and internal fixation (ORIF) of anterior
column and anterior wall fractures is scarce.5-9
In the majority of institutions, ORIF has
become the standard treatment for any acetabular fracture which is displaced by > 5 mm,
thereby allowing early mobilisation and minimising long-term complications.1 Promising
results are also seen with closed reduction and
percutaneous fixation for minimally displaced
acetabular fractures.10-13
We report the medium- to long-term functional and radiological outcomes of surgically
treated anterior column and anterior wall fractures from a tertiary referral centre.
Patients and Methods
Between July 1999 and December 2007, 400
acetabular fractures were managed operatively in
our institution. From a prospective database,
patients whose fractures involved only the anterior column and or anterior wall were included in
this case series. Data on the mechanism of injury,
demographic characteristics, associated injuries,
severity of overall injury (ISS),14 in patient records
and post-discharge information were collected.
Pre-operative assessment and classification
were based on plain radiographs (anteroposterior and Judet views1) and CT scans. In
general, displacement of > 5 mm was considered an indication for surgical fixation. When
possible, the patients were operated on within
seven days from injury, and in cases of polytrauma once their physiological status was
optimal. However, many patients underwent
surgery after these times, mostly due to delays
with inter-hospital transfer.
At induction, prophylactic antibiotics
(cefuroxime 1.5 mg IV) were administered
and a urinary catheter was inserted, if not
already present. The patient was placed
supine on a radiolucent fracture table which
allowed assisted reduction by controlled
traction using a distal femoral pin with the
knee flexed to approximately 30°. Depending on the displacement and stability of the
fracture fragments, either closed reduction
and percutaneous fixation, or ORIF through
an ilioinguinal approach was performed.
A daily subcutaneous injection of lowmolecular-weight heparin (LMWH) was
used as thromboprophylaxis for a minimum
of six weeks post-operatively. This was
extended to 12 weeks in high-risk cases, such
as polytrauma or obesity.
All patients were assessed clinically and
radiologically at six, 12, 24, 36 and 52 weeks
post-operatively in a specialist clinic. Thereafter, they were reviewed annually depending
on their clinical progress.
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THE SURGICAL TREATMENT OF ANTERIOR COLUMN AND ANTERIOR WALL ACETABULAR FRACTURES
Fig. 1a
Fig. 1c
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Fig. 1b
Fig. 1d
Figures 1a and 1b – pre-operative CT scans showing axial cuts (a and b) of an anterior column right acetabular fracture. Figures 1c and 1d – postoperative radiographs of c) closed reduction and percutaneous antegrade anterior column 3.5 mm screw fixation showing complete radiological healing at 12 months post-operatively and d) iliac oblique right acetabular view taken 12 months post-operatively.
The functional outcome was recorded at the last attendance according to the modified Merle d'Aubigné hip
score,15 and the radiological outcome was assessed using
plain radiographs (anteroposterior pelvic and Judet views)
according to Matta's criteria for accuracy of reduction and
late outcome.9
Statistical analysis. We used Microsoft Access for Windows
(Microsoft Corporation, Redmond, Washington) to track all
data. Descriptive statistics were used where needed for explanatory purposes. Statistical significance was set at p < 0.05.
Results
During the study period, a total of 30 of 400 acetabular
fractures (7.5%) were isolated anterior fractures of the
acetabulum. These 30 patients (20 men) had a mean age of
46.8 years (20 to 86). A total of 26 (86.6%) anterior acetabular fractures involved the anterior column (Figs 1a and 1b),
two the anterior wall (Figs 2a and 2b) and two involved
both. Road traffic accidents and falls from a height were the
cause of the injury in 21 (70%) and nine (30%) patients,
respectively. All were closed fractures, and one was associated with an anterior dislocation of the hip. Serious head,
chest and abdominal injuries (an Abbreviated Injury Score
VOL. 93-B, No. 7, JULY 2011
(AIS)16 > 2) were recorded in six, seven and four cases,
respectively. Two patients had a concomitant lumbar spine
fracture, one a tear of the bladder, and two had ipsilateral
tibial fractures. The mean ISS was 11 (4 to 45).
The mean time to surgery was 10.6 days after injury (3 to
44). Seven cases (23.3%) were treated by closed reduction
and percutaneous fixation (Figs 1c and 1d) and 23 (76.7%)
by ORIF through an ilioinguinal approach (Figs 2c and 2d).
The mean operative time was 190 minutes (40 to 315). There
were several complications: five patients had symptoms of
neuropraxia of the lateral cutaneous femoral nerve, which
were permanent in two, one developed a direct inguinal hernia, one a subclinical heterotopic ossification (Brooker class
217), one a MRSA wound infection, and one was diagnosed
with pulmonary embolism. Two patients developed pneumonia during their early post-operative course. All the complications were confined to the ORIF group except for one
case of transient neuropraxia associated with closed reduction and percutaneous fixation. The mean in-patient stay
after operation was 16 days (3 to 44). This mean stay after
operation was longer for the ORIF group than the closed
reduction and percutaneous fixation group (19.1 days (10 to
44) versus 5.1 days (3 to 7), respectively, p = 0.02). Partial
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P. V. GIANNOUDIS, N. K. KANAKARIS, R. DIMITRIOU, R. MALLINA, R. M. SMITH
Fig. 2a
Fig. 2c
Fig. 2b
Fig. 2d
Figure 2a – anteroposterior radiograph of a fracture-dislocation of the right acetabulum (anterior column and wall). Figure 2b – pre-operative axial
CT scan showing the comminution of the anterior wall/column fracture and the dislocation of the femoral head. Figure 2c – anteroposterior pelvic
radiograph four years post-operatively. Fracture was stabilised with plates and screws. Figure 2d – iliac oblique right acetabular radiograph four years
post-operatively.
weight-bearing was allowed at a mean of 6.2 weeks (2 to 11)
post-operatively. The mean time to full weight-bearing was
10.8 weeks (6 to 16).
The mean follow-up was four years (2 to 6) and
14 (46.7%) patients were followed for five years or more,
thereby offering evidence of their mid-term outcome. At the
final review 26 patients (90%) were available for a complete assessment of functional outcome. The other four
were not contactable.
The assessment of radiological outcome was available in
all 30 cases. The quality of reduction, as assessed on the
early post-operative radiographs, was rated as anatomical
in 15 patients (50.0%), satisfactory in 13 (43.3%) and
unsatisfactory in two (6.7%). The late radiological outcome according Matta's criteria9 was graded as excellent in
12 patients (40.0%), good in 11 (36.7%), fair in four
(13.3%), and poor in three (10.0%). The clinical outcome
according to the modified Merle d'Aubigné score15 was
excellent in eight patients of the 26 assessed (30.8%), very
good in eight (30.8%), good in six (23.1%) and fair in four
(15.4%). None of the patients needed total hip replacement
during follow-up.
Discussion
The outcome for patients with a fracture of the acetabulum
is continually evolving through improved surgical
approaches9,13,18,19 and new methods of fixation.1,12,20,21
There is ample evidence that surgery for displaced acetabular fractures results in a favourable outcome.21-24 To our
knowledge, only the Letournel series1 has so far provided
substantial evidence on the outcome of individual simple
acetabular fracture patterns such as anterior column and or
anterior wall fractures. This can be attributed to their rarity
and the fragmentation of experience between different
trauma centres.25,26
There are weaknesses in this study. The number of
patients did not allow for subgroup analysis. However,
for the first time, they provide a separate analysis of the
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THE SURGICAL TREATMENT OF ANTERIOR COLUMN AND ANTERIOR WALL ACETABULAR FRACTURES
mid-term outcome of these rare fractures. The method of
treatment was not randomised but was mainly the surgeon's preference based on the characteristics of the patient
and the fracture. The comparative results between ORIF
and closed reduction and percutaneous fixation should be
interpreted with caution owing to the small numbers and
lack of randomisation.
The follow-up assessment included radiological and
functional criteria, which are considered as the benchmark
for these types of injury. Only 10% of the overall number of
patients were lost to follow up and 14 (47%) were followed
for five years or longer. A ten-year review of all available
cases is planned.
In a search of the English literature we compared our
experience of the surgical management of isolated anterior
column and anterior wall fractures with other series.2-8,27-31
Two of the authors (RM, NKK) independently assessed the
suitability of the manuscripts, which were retrieved from
PubMed using the keywords ‘anterior column’, ‘anterior
wall’ and ‘acetabular fracture’. Wherever there was discrepancy in the reviewers' opinion after reviewing the abstracts,
the whole manuscript was screened and a consensus reached.
The combined incidence of anterior column and anterior
wall fractures in our series (7.5%) was higher than in other
series (6%),1 which could be attributed to the referral
patterns in our region. The only other series reporting a
similar incidence (6.6%) is from Oxford, United Kingdom.31 As with several other reports, our incidence of isolated anterior wall fractures is low (1.3%) and almost equal
to that of the landmark series of Letournel in 1993.1
Isolated anterior column fractures were also generally more
common in our study (6.5%) than in others (2.5% to 6.6%).
The timing of operation, although a key factor in optimising the outcome of acetabular surgery,6,31 was not optimal in
our series as 30% of the cases were operated on more than
ten days after injury. As already mentioned in an earlier
study,32 delays with inter-hospital transfer and weaknesses of
the tertiary referral system were the main reasons.
Although several approaches to the anterior acetabulum
have been described including a modified Smith-Peterson,18
a modified triradiate3 the ilioinguinal approach continues
to be the benchmark procedure and gives adequate access
to most types of anterior acetabular fracture. However,
because of the small numbers in our study any particular
difficulties or advantages of this approach for the different
types of anterior column and anterior wall fracture, could
not be evaluated individually. Closed reduction and percutaneous screw fixation, complemented in some cases by a
neutralising external fixator, provided a reasonable alternative for our minimally displaced fractures (23.3%). The
previously reported advantages of this option8,10-12,33-35
were also evident in this small group, but further comparative analysis was not feasible.
Our overall rate of definite complications (six of 30,
20%) is in accordance with that of other comparable series.
The complications are either minor and associated mostly
VOL. 93-B, No. 7, JULY 2011
973
with the surgical approach, or related to the trauma. In our
series all but the incisional hernia and heterotopic ossification, developed in patients who were operated on more
than ten days after injury.
The functional outcome following acetabular surgery
can be assessed using various hip scores, thereby making
comparison between studies difficult.1,31 Many report the
overall functional scores of their cases, making it difficult to
draw conclusions on subtypes. There are only two series
reporting the functional outcome of anterior acetabular
fractures. Mears et al2 used the Harris hip score36 and
reported 72% good to excellent results. In Letournel's
series,1 the modified Merle d'Aubigné and Postel hip
score37 recorded 86% of the fractures having very good to
excellent function, which is similar to our figure of 84.6%.
Most of the available series report only the early radiological outcomes following fixation, with little or no
emphasis on the final radiological outcome.3,4,6,7,30,31,38 It
has been shown that the quality of reduction assessed in the
immediate post-operative period determines the development of osteoarthritis requiring total hip replacement.1,2,24
In this case series, the post-operative residual displacement
was < 3 mm in 28 of the 30 cases (93.3%), and at the time
of final radiological assessment9 20 of 26 (76.9%) maintained their good to excellent outcome. Two cases had an
unsatisfactory reduction and a poor final radiological
score, but reported good to fair function. Five of the radiologically reviewed cases with a satisfactory reduction initially deteriorated and scored only fair at final follow-up,
with good or fair function. All patients with an anatomical
reduction had optimal clinical and radiological outcomes,
in accordance with other series.24
We found that the outcome following fixation of an anterior acetabular fracture was satisfactory and similar to that
in other large series.
Supplementary material
Two tables showing a) the patients with anterior
column and/or anterior wall fractures and their clinical characteristics and b) the existing English literature on
isolated anterior column and anterior wall fractures and
reported data, are available with the electronic version of
this article at www.jbjs.org.uk
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