Functional outcome following conservative management of acetabular fractures

INTRODUCTION

Acetabular fractures are result of high velocity injury involving 18% of all pelvic fractures.^1,2 Anatomical and congruent reduction of the acetabular fracture is the gold standard in the management of the acetabular fractures. In the published literature both conservative and operative management have been studied having advantages and disadvantages of both the modalities of treatment.^2-4

Quality of reduction and type of fracture determines the functional outcome in the acetabular fractures. Displaced fractures are best treated surgically by open reduction and internal fixation. Conservative method of treatment by closed reduction and maintaining the concentric reduction with the skeletal traction is still the main stay of treatment in developing countries.³

Acetabular fractures cause degenerative changes in the acetabulum and femoral head causing dysfunction of the hip due to alteration in the biomechanics leading to secondary arthrosis.⁵

Our aim in this study was to evaluate the functional and clinical outcome following conservative management of the acetabular fractures with long term follow up study.

METHODS

A retrospective study with prospective analysis done between 2011 and 2020 involved 39 patients with acetabular fractures who were treated conservatively at St John’s Medical College, Bangalore, India. Based on Judet et al classification the X-rays and CT scans were classified.⁶ The patients with associated pelvic ring fractures were excluded from the study. The inclusion criteria were patients having more than 3mm intra-articular displacement on the x rays and with a minimum follow-up of 5 years.

Patients were managed conservatively after closed reduction under sedation if associated with dislocation and followed by distal femur or proximal tibial longitudinal skeletal traction. Associated central dislocation was treated with standard lateral traction. The duration of traction was 6-8 weeks with 10-20% of the body weight. X-ray of pelvis with both hip joint AP view with traction was done every week. Gradually range of movement with the traction was started from 4th week onwards along with stepwise reduction of the traction weight. During the management patients were treated with in-bed exercise therapy and used water mattress to prevent bedsores, DVT prophylaxis started, chest physiotherapy, incentive spirometry and periodic psychological assessment and counselling was done to motivate the patients to maintain positive outlook.

Once the traction was off patient were subjected to post-operative rehabilitation involving tilt-table proprioceptive exercise, muscle strengthening exercise and non-weight bearing walking for 4-6 weeks. This was followed by progressive weight bearing from toe-touch to full weight bearing by the end of 8-12 weeks. Patients were followed up at 6 months, 1 year, 2 years and at the end of 5 years for functional evaluation and assessment with the clinical outcome scores Merle d’Aubigne and Postel score and Harris Hip Score.^8,9 The research analysis of the data was done using IBM SPSS Statistics data management tool version 25.0 (64-bit).

RESULTS

Study included 39 patients with the average age of 41.3 years with 31 (79.48) male and 8 (20.51) female patients with the average BMI 24.39 kg/m². The mechanism of injury was commonly RTA in 29 (74.35%) of patients and in 10 (25.64%) was fall from height. Based on the X-rays and CT scan patients had fractures involving 13 (33%) posterior wall 3 (7.5%) posterior column, 3 (7.5%) anterior column, 4 (10 %) transverse,1 (0.4%) posterior column with posterior wall, 4 (10%) transverse with posterior wall, 3 (7.7 %) T-shaped, 1 (0.4%) anterior column with posterior hemi-transverse, and 9 (23.5%) involved bi-columnar fractures (Figure 1). Average duration of skeletal traction was 6 weeks and the average follow up was 6.5 years with the minimum follow up of 4 years and maximum of 10 years (Table 1).

Complications during the management had 7 (17.94%) patients with grade 1 and 2 bed sores who were treated with application of moisture-barrier lotion and sore gradually reduced over a week’s time. There were 3 (7.69%) patients had restricted range of movement and was treated with physiotherapy. Following which patient attained functional range of movement. There were 3 (7.69%) patients developed pin tract infection in whom 2 (5.12%) recovered with oral antibiotics with daily dressing.

And in one patient the skeletal traction was removed and treated with intravenous antibiotics, adequate wash and buck’s traction was applied. 2 (5.12%) patients had developed avascular necrosis of the head of femur at the end of 2 years. There were no deep vein thrombosis and other systemic complications seen (Table 2).

Functional outcome score showed good to excellent results in 80%, fair to satisfactory results in 18 %, 0.5 to 2% had poor result in the patient analyzed with both Harris Hip Score, Merle d’Aubigne and Postel score. 31 (80%) patients were able to sit cross legged, 35 (90%) had returned to regular work and 4 (10%) patients changed their occupation to desk jobs (Figure 2, 3) (Figure 4) (Table 3).

DISCUSSION

Acetabular fractures are complex injuries to treat and require great skills in managing the fracture as it involves major weight bearing joint of the body. With advances in the management of the acetabular fracture, the complications involved with the treatment has reduced significantly.⁵ Controversy still exists as to which is the best treatment modality of choice.⁷

Sen et al conducted a long-term study on 32 patients with displaced acetabular fractures with more than 3 mm displacement involving the weight bearing dome without unstable pelvic fracture with 56.3% reducibility were treated conservatively had good to excellent functional results in 83.3% with good to excellent radiological grade in 50% of cases.²

Magala et al analyzed 140 patients and concluded that for un-displaced acetabular fractures and minimally displaced fractures conservative treatment is the method of choice with good to excellent results and satisfactory results were seen in displaced fractures with high risk for surgery who were managed conservative treatment.^3,10

Magu et al conducted a retrospective study with 69 patients who had 71 displaced acetabular fractures managed conservatively with the average follow-up of 4.34 years had good or excellent results in 45 patients with good congruent reduction and concluded the role of non-operative management of acetabular fracture with congruent reduction.⁴

Lovrić et al conducted retrospective study of 103 patients and compared functional status of hip joint following surgical and conservative treatment of acetabular fractures and concluded that the results obtained both the methods were equally effective and had similar functional status.⁵

Amaravati et al evaluated 68 cases of acetabular fractures with the average follow up 36 months showed that 30 cases out of 46 cases treated conservatively and 12 out of 22 cases treated surgically had achieved good to excellent results respectively.⁷

A retrospective study of 57 patients treated conservatively by Heeg et al with a n average follow up of 7.9 years demonstrated overall satisfactory functional results in 75% of cases in patients in whom the joint congruency was maintained.¹¹

In our study functional outcome score showed good to excellent results in 76%, fair to satisfactory results in 17%, 7% had poor result in the patient analyzed with both Harris Hip Score, Merle d’Aubigne and Postel score. 80% of the patients were able to sit cross legged, 90% had returned to regular work and 10% of the patients changed their occupation to desk jobs.

CONCLUSION

Acetabular fractures can be treated conservatively with good to excellent results. Joint congruency must be maintained especially in weight-bearing dome and monitored with serial x rays during the treatment with traction and early range of movement of the hip joint, proprioceptive exercise, muscle strengthening with progressive gait training will provide good to excellent Functional and clinical outcome.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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