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A Prospective Study on Functional Outcome of Open Reduction and Internal Fixation of Acetabular Fractures

The current study is a prospective study on the functional outcome of open reduction and internal fixation of acetabular fractures. About 30 patients were analyzed for the functional outcome of acetabular fractures treated by open reduction and internal fixation over a period of one year and eight months from March 2017 to October 2018 with a minimum follow up period of 9 months at Sree Balaji Medical College & Hospital, Chromepet, Chennai. The mean age of the patient was 37.96 year ranging from 20 60 years. The Joel Matta score was used for calculation of radiological outcome of 30 patients. The results were excellent in 19 (66.3%), good in 8 (26.6%), fair in 3 (10%), and poor in 0 (0%) patients. Functional outcome of displaced acetabular fractures more than 2 mm displacement was found to have excellent results on open reduction and internal fixation.


INTRODUCTION
Acetabular fractures are the injuries which are quite challenging for the orthopaedic surgeon because of their low incidence and their deep & complex anatomy [1]. They are growing in developing countries with the increasing incidence of high energy trauma [2,3].
Fractures of the acetabulum are as a result from high-impact falls or motor vehicle accidents that transmit force most commonly from an impact to the greater trochanter or the flexed knee [4,5]. In younger individuals, High energy trauma is the primary cause of acetabular fractures. Most common type of fractures are posterior wall fractures accounting for approximately 25% of all acetabular fractures [4,5,6] & fractures of anterior wall are rare which constitute only 1% to 2% of all acetabular fractures [4,5]. Fractures of the acetabulum which occur in association with other fractures will influence management options, surgical approach and clinical outcomes [7].
Management of the acetabular fractures is a complex entity in orthopaedics that is being continually refined. It involves a definite learning curve [8]. The surgical management of acetabular fractures has been rapidly evolved over the past three decades, leading to decreased morbidity and improved outcome [9][10][11][12][13]. To a greater extent, this can be attributed to the revolutionary techniques introduced by Judet and Letournel [4,9,14].
Previously most acetabular fractures were treated by closed reduction [14]. Currently, open reduction and internal fixation is considered to be the gold standard treatment for displaced acetabular fractures, as restoration of joint congruity is of supreme importance to reduce the incidence of early hip osteoarthritis [15]. Factors including patient age, general medical condition and associated injuries must be considered before making definitive management decision [16]. The goals of treatment should be anatomic restoration of the articular congruity and early mobilization [8].
In view of increase in road traffic accidents in our country, multiple complex injuries of the acetabulum are noted, hence the need for detailed evaluation and the study for a better functional outcome for acetabular fractures remains a growing challenge for the surgeons. In this study of acetabular fractures we decided to enrich the knowledge of open reduction and internal fixation for these types of acetabular fractures.

METHODS
The present study is a prospective study done in 30 patients to analyze the functional outcome of acetabular fractures treated by open reduction and internal fixation over a period of one year and eight months from March 2017 to October 2018 with a minimum follow up period of 9 months at Sree Balaji Medical College & Hospital, Chromepet, Chennai. The recruitment of patients was from March 2017 to February 2018 (12 months).

Inclusion Criteria
 Age group greater than 20 yrs and less than 60 yrs of age.  Closed fractures.  Patients with fractures less than 3 wks duration.  All clinically and radiologically proven acetabular fractures having indication of operative treatment.  Acetabular fractures with displacement > 2 mm. Open reduction and internal fixation was done within 5-7 days of injury. After completing clinical and radiological examination preoperative planning regarding approach and implant to be used was made on basis of fracture type, displacement and associated injuries.

Exclusion Criteria
Medicine and cardiology opinion was obtained, prior to getting anaesthesia fitness. All patients were started on broad spectrum 3 rd generation cephalosporins half an hour before the surgery.
All acetabular fractures except both column fractures, the standard fracture reduction sequence is to first to reduce and stabilize the displaced column, if present and then reduce any wall fracture then may be present. After definitive fixation of the reduced fragments, the entire construct is stabilized with locking reconstruction plates.
For the both column fractures the sequence is to first reduce and stabilize one of the columns to the axial skeleton, then the other column, if present, the wall component. After definitive fixation of the reduced fragments the entire construct is stabilized with locking reconstruction plates.
In posterior approach, Schanz pins are placed in greater trochanter, ischial tuberosity and iliac crest for simultaneous manipulation. Various reduction clamps are available to facilitate reduction and holding.
In anterior approach, a Fara beuf clamps or a Schanz pin is placed into iliac crest to manipulate and facilitate reduction.
Mattas quadrangular clamps of various sizes and with offsets and Picador ball spike pusher are used. Reduction fixed with lag screws whenever possible. Lagging is done with 4mm cancellous screws or 3.5mm cortical screw with washer. 3.5mm reconstruction plates are used as neutralization plates.
Spinal or General anaesthesia is usually employed. The position of the patient can be either prone or in the lateral decubitus position on a fracture table or with the leg free according to the procedure planned.
The surgical exposure that affords the best opportunity to restore the joint congruency by anatomic reconstruction and stabilization of the articular surface was selected [17].
The main stay surgical approaches to the acetabulum are those described by Leutournel and Judet: a) The Kocher-Langenbeck Approach, b) The Ilioinguinal Approach, c) The Iliofemoral Approach, and d) The Extended Iliofemoral Approach.
The first three approaches provide direct access to only one column of the acetabulum (Posterior for the Kocher-Langenbeck; Anterior for the Ilioinguinal and Iliofemoral) and rely on indirect manipulation for reduction of any fracture lines that traverse the opposite column. The Extended ilio-femoral approach affords complete direct access to all aspects of the acetabulum. It is most often used for delayed treatment of an associated fracture type in which healing precludes indirect manipulation.

Postoperative Protocol
 All patients were given pre-operative antibiotics and post-operatively for 5 days of intravenous antibiotics and then 10 days of oral antibiotics.  First dressing with drain removal done after 48 hrs, second on 5 th Post-op day, third on 8 th Post-op day.  Low molecular weight heparin was given 7 days for DVT prophylaxis.  Indomethacin is given in a dose of 25mg TDS daily beginning within 24 hours of surgery and continued for 4 to 6 weeks.  Passive mobilization was started on postoperative day2. Active movements started gradually in accordance with pain.  Suture removal done on 12 th to 14 th postoperative day.  Radiological and Functional examination was done on monthly review for first 6 months and third monthly thereafter.  Gentle hip ROM and non-weight bearing walking was started after 6 weeks. Weight bearing was gradually started after 12 weeks. Partial weight bearing was allowed initially and full weight bearing was not allowed until evidence of complete radiological union.
The patients in the study were analysed by the Matta's radiographic assessment postoperatively        Frequency distribution of subjects according to the clinical outcome was done and Chi square was done to assess the significance. There is statistically significant difference in the outcomes with better outcomes in all the fracture patterns, (Chi sq value -11.9, p = 0.049). Frequency distribution of subjects according to the radiological outcome was done and Chi square was done to assess the significance. There is  Frequency distribution of subjects according to the clinical outcome was done and Chi square was done to assess the significance. There is statistically significant difference in the outcomes better outcomes in all the fracture patterns, 11.9, p = 0.049). Frequency distribution of subjects according to the radiological outcome was done and Chi square was done to assess the significance. There is statistically significant difference in the outcomes with better outcomes in all the fracture patterns, (Chi sq value -13.4,p = 0.037). Based upon the values obtained both clinically and radiologically, there was a significant p value of 0.049 clinically and 0.037 radiologically.

Fig. 4. Comparison of clinical outcome with Fracture type
In the present study, congruency of the fracture site post-operatively has directly impact on the functional outcome. Those patients with fair results radiologically, had proportionately impacted the clinical outcome. However delay in rehabilitation, has also impacted the clinical outcome, because of the complex fracture pattern. Limitations in our study was small patient group, because of rarity of the cases and long term follow-up will be a good predictor for the functional outcome.

CONCLUSION
Functional outcome of displaced acetabular fractures more than 2 mm displacement was found to have excellent results on open reduction and internal fixation. In our study, the excellent results for 30 patients were found to be clinically and radiologically significant. For a better outcome and better study, anatomical reduction and stable fixation presents a good outcome. Wherein, for a good study the number of patients needs to be in large number with a long follow-up to assess the functional outcome CONSENT Formal consent was taken from each patient pre operatively and at each follow-up visit.

ETHICAL APPROVAL
As per international standard or university standard written ethical permission has been collected and preserved by the author(s).
; Article no.JPRI.54216 ence in the outcomes with better outcomes in all the fracture patterns, 13.4,p = 0.037). Based upon the values obtained both clinically and radiologically, there was a significant p value of 0.049 clinically he present study, congruency of the fracture operatively has directly impact on the functional outcome. Those patients with fair results radiologically, had proportionately impacted the clinical outcome. However delay in impacted the clinical outcome, because of the complex fracture pattern. Limitations in our study was small patient group, because of rarity of the cases and longup will be a good predictor for the Functional outcome of displaced acetabular fractures more than 2 mm displacement was found to have excellent results on open reduction and internal fixation. In our study, the excellent results for 30 patients were found to be clinically significant. For a better outcome and better study, anatomical reduction and stable fixation presents a good outcome. Wherein, for a good study the number of patients needs to be in large number with a long-term up to assess the functional outcome aptly.
Formal consent was taken from each patient preup visit.
As per international standard or university standard written ethical permission has been author(s).