Introduction
Background
-
Anterior roof arc > 30
-
Medial roof arc > 40
-
Posterior roof-arc > 50
Preexisting conditions
Age
Obesity
Time of injury
Fracture pattern
Both-column acetabular fractures
Posterior wall acetabular fractures
Anterior column/anterior wall fractures
Anterior column posterior hemitransverse acetabular fractures
Transverse acetabular fractures
Transverse plus posterior wall acetabular fractures
T-shaped acetabular fractures
Posterior column +/− posterior wall acetabular fractures
Posterior hip dislocation
Cartilage damage to the femoral head and/or acetabulum
Surgical treatment
Author
|
Year
|
Country
|
Cases (F/U yrs)
|
G-E Result/Survivorship
|
Negative prognostic factors
|
---|---|---|---|---|---|
Tannast/Matta et al [3] |
2012
|
USA
|
816 (2–20)
|
85% (10YR)
79% (20 YRS)
|
FHI, PW, AGE, DISP, MI
|
Letournel/Judet [4] |
1993
|
FRANCE
|
492 (1–33)
|
80%
|
PC/PW, AW, PR
|
Mears et al [48] |
2003
|
USA
|
424 (9.3)
|
89%
|
PR, FN, DEL > 11, AF, SI, FHI, OB, AW, AGE
|
Matta [20] |
1996
|
USA
|
255 (6)
|
76%
|
AGE, FHI, SI, TT/PW
|
Clarke-Jenssen et al [49] |
2017
|
NORWAY
|
253 (12)
|
86% (10YRS)
|
FHI, SI
|
Madhu et al [53] |
2006
|
UK
|
237 (2.9)
|
76%
|
DEL > 15 (EF), DEL > 10(AF)
|
2003
|
IRELAND
|
180 (6.3)
|
78%
|
AF, AGE, PR > 3, HO, LC
| |
Rommens et al [66] |
1997
|
BELGIUM
|
175 (2)
|
76%
|
TT/PW
|
Mayo [67] |
1994
|
USA
|
163 (3.7)
|
75%
|
–
|
Briffa et al [26] |
2011
|
UK
|
161 (11.3)
|
72%
|
AGE, DEL > 15, PR, PC/TT, FHI
|
1980
|
CANADA
|
103 (7.25)
|
–
|
FX, WB, PR, AGE, PELVIS
| |
Wright et al [56] |
1994
|
USA
|
87 (3.6)
|
45%
|
DL, HO, AVN, AGE, PR, EXP
|
2013
|
CHINA
|
86 (3.2)
|
84%
|
CPWF, FHI, PR
| |
Fica et al [68] |
1998
|
CHILE
|
84 (5.5)
|
67%
|
TT, PR, AGE, AVN
|
Zhi et al [69] |
2011
|
CHINA
|
82 (2.8)
|
71%
|
FX, AGE, LE FX, PR, DEL, DL
|
Rommens et al [50] |
2011
|
GERMANY
|
77 (3.7)
|
70%
|
CPWF, SI, IAF
|
Almedia et al [70] |
2011
|
BRAZIL
|
76 (4.9)
|
81%
|
PR, LOR, DI
|
Deo et al [71] |
2001
|
UK
|
74 (2.6)
|
74%
|
FH, PR, NERVE/DL
|
Chen et al [72] |
2000
|
TAIWAN
|
73 (7.5)
|
74%
|
PR
|
Uchida et al [73] |
2013
|
JAPAN
|
71 (8.6)
|
90%
|
PR, AVN, SI
|
Ragnarsson et al [74] |
1992
|
SWEDEN
|
55 (15)
|
60%
|
PR
|
Heeg et al [75] |
1990
|
HOLLAND
|
54 (9.6)
|
61%
|
PR, HO
|
Kebaish et al [54] |
1991
|
CANADA
|
54 (4.7)
|
86%
|
EXP, PR
|
Ruesch/Mast et al [76] |
1994
|
USA
|
53 (1+)
|
81%
|
N/A
|
De Ridder et al [55] |
1994
|
HOLLAND
|
51 (3)
|
76%
|
–
|
Oranksy et al [77] |
1993
|
ITALY
|
50 (3.5)
|
76%
|
DEL > 21, PR, EXP
|
1996
|
CHINA
|
27 (7)
|
81%
|
–
| |
Brueton [78] |
1993
|
UK
|
26 (2.2)
|
61%
|
PR, DEL > 17
|
-
Despite 94% perfect reductions of posterior wall fractures, 79.5% achieved at least a very good result. He felt this discrepancy was due to 1) osteonecrosis and 2) posterior wall comminution.
-
Among the associated fracture patterns, the worst outcome group was the posterior column/posterior wall group (29.41% excellent results) – followed by transverse/posterior wall (48.51% excellent results).
-
Among the simple fracture patterns, the least satisfactory results occurred among anterior wall fractures (67%) – which he accounted for because these fractures often occurred in elderly individuals with osteopenic bone.
-
Out of 302 cases with perfect radiographic results, 283 (93.2%) had perfect intra-operative reductions and 293 had excellent clinical results; a very good clinical result corresponds to a perfect radiographic appearance in 98.6% of cases
-
Imperfect reductions treated conservative/operative treatment may still lead to good/very good functional results if the femoral head remains congruent to a segment of the articular surface large enough to withstand the increased intra-articular pressure. Patients with surgical secondary congruence achieved 56% very good and 24% good results.
-
Complications in his series were: mortality 2.3%, post-operative infection 4.2%, post-operative sciatic palsy 6.3%, avascular necrosis 4.5%, post-traumatic arthritis 19.7%, ectopic bone formation 28.2%
-
Of those 816 surgeries, the reduction was categorized as 0–1 mm in 616 (75%), 2–3 mm in 148 (18%), and > 3 mm in 36 (4%).
-
In this study, 20-year survivorship was poorest for anterior wall fractures (34%) and highest for transverse (89%) and both-column (87%) acetabular fractures.
-
Overall rate of anatomical reduction increased from 40% in 1980 to 92% in 2006.
-
Non-controllable independent predictors of negative outcome include: 1) Age > 40, 2) anterior dislocation, 3) femoral head cartilage lesion, 4) involvement of the posterior wall, 5) marginal impaction, and 6) initial displacement > 20 mm.
-
Controllable independent predictors of negative outcome include: 1) nonanatomic reduction, 2) post-operative incongruence of the acetabular roof, and 3) utilization of the extended iliofemoral approach.
-
A higher rate of anatomic reduction was noted in elementary fracture patterns, patients treated early (< 21 days) and patients younger than 40.
-
Similar to other studies mentioned in this chapter (56) the first 50% of hip that failed did so by 1.5 years post-operatively. From 1.5 years to 20 years post-operatively, there is a linear decrease in survivorship
-
Anterior wall acetabular fractures had a higher prevalence in in the elderly, were associated with marginal impaction, and more difficult to reduce.
-
Both-column fractures had a significantly better outcome at twenty years, despite nonanatomic reduction – possibly due to secondary surgical congruence as the innominate bone potentially serves as a “crumple zone” and absorbs much of the energy rather than the cartilage of the femoral head. Figure 5 demonstrates pre-operative, immediate post-operative, and 21-year post-operative radiographs of a patient after reduction and fixation of a both-column acetabular fracture.
Survivorship (95% Confidence Interval) (%)
| |||||
---|---|---|---|---|---|
Two Years
|
Five Years
|
Ten Years
|
Twenty Years
|
Median Time to Failure
| |
Entire series (n = 816) |
91 (90–92)
|
88 (87–90)
|
85 (84–87)
|
79 (76–81)
|
1.5
|
Elementary fracture type (n = 241) |
91 (89–93)
|
86 (84–89)
|
84 (81–87)
|
73 (68–79)
|
1.3
|
Anterior wall (n = 12) |
91 (82–100)
|
68 (53–84)
|
68 (53–84)
|
34 (9–59)
|
2.3
|
Anterior column (n = 80) |
95 (92–97)
|
92 (88–95)
|
87 (83–91)
|
77 (70–85)
|
3.0
|
Posterior wall (n = 107) |
88 (84–91)
|
82 (78–86)
|
81 (77–85)
|
76 (71–82)
|
1.2
|
Posterior column (n = 14) |
100
|
100
|
100
|
100
|
–
|
Transverse (n = 28) |
89 (83–95)
|
89 (83–95)
|
89 (83–95)
|
89 (83–95)
|
0.3
|
Associated fracture type (n = 575) |
92 (91–93)
|
89 (88–91)
|
86 (84–87)
|
80 (78–83)
|
1.6
|
Posterior column, posterior wall (n = 26) |
85 (78–92)
|
85 (78–92)
|
85 (78–92)
|
85 (78–92)
|
0.5
|
Transverse, posterior wall (n = 143) |
89 (86–91)
|
85 (82–88)
|
81 (78–85)
|
74 (68–80)
|
1.5
|
T-shaped (n = 96) |
89 (85–92)
|
85 (81–89)
|
77 (72–81)
|
74 (65–84)
|
1.6
|
Ant. column, post. Hemitrans. (n = 76) |
92 (89–95)
|
92 (89–95)
|
88 (84–92)
|
75 (65–84)
|
1.3
|
Both columns (n = 234) |
96 (94–97)
|
83 (91–95)
|
91 (89–93)
|
87 (83–90)
|
2.2
|
Initial displacement
| |||||
≥ 20 mm (n = 226) |
86 (84–89)
|
84 (81–86)
|
78 (75–81)
|
68 (63–73)
|
1.3
|
≤ 20 mm (n = 590) |
93 (92–95)
|
90 (89–91)
|
88 (86–89)
|
83 (81–85)
|
1.9
|
Treatment delay
| |||||
< 21 days (n = 730) |
93 (92–94)
|
89 (88–91)
|
86 (85–88)
|
79 (77–82)
|
2.0
|
> 21 days (n = 86) |
82 (78–86)
|
80 (75–84)
|
74 (69–79)
|
74 (69–79)
|
0.9
|
Previous surgery
| |||||
Yes (n = 5) |
60 (38–82)
|
30 (6–54)
|
–
|
–
|
0.8
|
No (n = 811) |
92 (91–93)
|
89 (87–90)
|
85 (84–87)
|
79 (77–81)
|
1.6
|
Age
| |||||
< 40 yr. (n = 386) |
96 (95–97)
|
95 (94–96)
|
92 (91–94)
|
87 (84–89)
|
2.3
|
40–65 yr. (n = 318) |
88 (86–90)
|
83 (81–86)
|
81 (79–83)
|
74 (71–77)
|
1.3
|
> 65 yr. (n = 112) |
83 (79–87)
|
79 (75–83)
|
70 (65–76)
|
51 (38–64)
|
0.8
|
> 75 (n = 42) |
80 (73–87)
|
74 (66–83)
|
65 (54–76)
|
–
|
0.6
|
“One single factor appears paramount: the relocation of the head under a sector of roof of sufficient extent must be adequate. This is the practical prerequisite for all good results. However, it must not be taken that obtaining this result obviates the need for good reduction of the columns supporting the acetabulum.”