Functional outcome of complex acetabular fractures by combined anterior and posterior approach in a single sitting: a case report

INTRODUCTION

While there is a consensus that complex acetabular fractures require anatomical reduction and stable fixation for their management, there is no agreement on the surgical approaches to be used for achieving that goal. Invariably two surgical approaches are needed for management of such fractures. Whether these approaches should be performed in different anesthetic sittings or in the same sitting, sequentially or simultaneously, is debatable. Anatomical reduction of articular surfaces combined with rigid internal fixation and early mobilisation is accepted gold standard treatment of displaced complex acetabular fractures.

These fractures require operative treatment which is very challenging.^1-3 Most acetabular fractures can be operated upon with a single surgical approach, but it is not always possible to do so in complex fractures. This specially holds true for fractures involving two columns.⁴ for complex acetabular fractures, combined anterior and posterior approaches in same anaesthetic sitting have been routinely used. Staged procedures are often associated with complications such as increased rates of infections, delayed rehabilitation, higher rates of ectopic ossification and prolonged abductor weakness.^5-7

CASE REPORT

A 23-year-old male patient came with chief complaints of pain and swelling in right hip since 3 days. Patient had history of fall from train 3 days back. Primary stabilization was done with pelvic bracing. Signs and symptoms were assessed to check for hip dislocation. Urinary catheterization was done look for any signs of hematuria. After primary stabilisation the patient was sent for the plain radiographs of pelvis with both hips with bilateral full length femur. Jude’s view was done to know the extent of the fracture line. On clinical examination pain, tenderness and global restriction of movement at hip joint were noted. On plain radiographs complex acetabulum fracture was identified and CT scan of pelvis was done to confirm the diagnosis. After clinical and haematological examination, patient was explained regarding surgical management required for the due fracture. Locking recon plating by combined anterior and posterior approach was planned. Under all aseptic precautions patient was kept in floppy position, and fracture site was exposed from both anterior and posterior approach. Fracture site was identified after soft tissue separation and reduction was obtained with the help of reduction forceps. Reduction was confirmed under c-arm fluoroscopy and fixation of fracture with recon locking plate with locking screw was done. Wound wash was given and Soft tissue was closed in layers. Procedure was uneventful. Local wound examination was done on post operative day 5 and patient was discharged on day 12 after complete suture removal. Patient was advised nil weight bearing for 6 weeks and was asked for follow up on 24 day, 36 days and 45 days respectively. Follow up X-rays were taken with subsequent visits. Partial weight bearing was started after 45 days followed by complete weight bearing. Patient being student by profession went back to his routine life without any complication.

DISCUSSION

Acetabular fractures result from either high-energy trauma such as motor vehicle accidents, or low-energy trauma such as falls, especially in the elderly. Data from meta-analysis had reported that 80.5% of acetabular fractures result from motor vehicle accidents and 10.7% result from falls.^8-12

The fracture classification system developed by Judet and Letournel was the most widely accepted system; it differentiated fractures into ten types, five elementary fractures and five associated fractures based on observations from plain radiographs.^12-14

Adequate treatment of acetabular fractures requires an accurate definition of the type of fracture, the degree of comminution, and the presence of intraarticular debris.¹⁵ Classifying acetabular fractures is challenging, yet vitally important to selecting the best surgical strategy and approach.^16,17 In spite of the large variety of different techniques available for their treatment. Acetabular fractures still posed a formidable challenge to the orthopaedic surgeon with a close relationship having been observed between degree of reduction, radiological findings and clinical results. The combined approaches were indicated in most of the both column fractures. Although KL approach affords good access to posterior column, the indirect access to anterior part depends on the type and site of fracture of anterior column, degree of communition, involvement of quadrilateral plate and surgeon’s comfort. Standard illioinguinal approach provided complete access to the anterior column and wall. In cases of non communited anterior column fracture illioinguinal approach provided easy sliding of a contoured reconstruction plate. This provided adequate access in most cases without exposure of femoral nerve, external iliac vessels and lymphatic channels of inguinal canal additionally. An intact recurs abdominis was postulated to offer additional benefits of early functional recovery. Decision making about the approach to be used first depended largely on the preoperative planning and clear understanding of the fracture pattern. The column which had a greater amount of communition should be addressed first in presence of dislocation; approach giving direct access to the dislocation must be used first. We didn’t try to reduce the fracture with single approach and opened the fracture with both the approaches simultaneously. Quality of the reduction had been reported as the most important predicting factor which affects the clinical and radiological outcome and predict occurrence of post traumatic arthritis. The reduction was evaluated post operatively which was congruent and anatomical. The use of two approaches had its own disadvantages the patient was not fully supine and prone and it took time for surgeon to adopt to this position of the patient, especially in heavily built individuals. Blood loss and longer duration of surgery were other complications associated.

CONCLUSION

Combined anterior and posterior approaches of acetabulum in a single sitting can be used as safe alternative to step wise extensible approaches used routinely. Outcomes associated with single sitting are good as it is associated with lesser morbidity of patient, early functional mobility and less hospital stays. Though it’s not devoid of complications decision must be taken depending upon the condition of the patient and surgeons’ choice.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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