SHORT TERM ANALYSIS OF FUNCTIONAL RESULTS OF
ACETABULAR FRACTURES TREATED BY INTERNAL
FIXATION WITH RECON PLATE USING
KOCHER-LANGENBECK APPROACH
Submitted To
THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI
In Partial Fulfilment Of The Regulations For The Award Of The Degree Of
M.S. DEGREE BRANCH-II ORTHOPAEDIC SURGERY
DEPARTMENT OF ORTHOPAEDIC SURGERY KILPAUK MEDICAL COLLEGE
CHENNAI-10
CERTIFICATE
This is to certify that “SHORT TERM ANALYSIS OF FUNCTIONAL
RESULTS OF ACETABULAR FRACTURES TREATED BY INTERNAL FIXATION WITH RECON PLATE USING KOCHER-LANGENBECK APPROACH”
Is a bonafide work done by Dr. S. Basheer Ahmed, Post Graduate student, Department Of Orthopaedic Surgery, Government Royapettah Hospital,
Kilpauk Medical College.
In Fulfillment Of Regulations Of The Tamilnadu Dr. M.G.R. Medical University For The Award Of M.S. Degree Branch II, (Orthopaedic Surgery) During The
Academic Period From May 2015 To May 2018.
THE DEAN Prof. Dr. S.SENTHIL KUMAR M.S. Ortho,
Kilpauk Medical College Professor & H.O.D. Chennai 600 010. Department Of Orthopaedics Govt. Royapettah Hospital
DECLARATION
I, Dr. S.Basheer Ahmed , declare that the dissertation entitled “SHORT TERM
ANALYSIS OF FUNCTIONAL RESULTS OF ACETABULAR
FRACTURES TREATED BY INTERNAL FIXATION WITH RECON
PLATE USING KOCHER-LANGENBECK APPROACH” submitted by me
for the degree of M.S. DEGREE BRANCH – II ORTHOPAEDIC SURGERY
is the record work carried out by me during the academic period of May 2015 to April 2018 under the guidance of my respected
Chief Prof. Dr. S.SENTHIL KUMAR. MS Ortho, Professor & H.O.D of Orthopaedics, Govt. Royapettah Hospital, Kilpauk Medical College, Chennai –
600 010.
This dissertation is submitted to the Tamil Nadu Dr.M.G.R. Medical
University, Chennai, in partial fulfilment of the University regulations for the
award of degree of M.S. DEGREE BRANCH – II ORTHOPAEDIC
SURGERY examination tobe held in May 2018.
Place: Chennai Signature of the Candidate
Date : (Dr.S.Basheer Ahmed )
Signature of Guide
ACKNOWLEDGEMENT
I wish to express my sincere thanks to our dean, Prof. Dr.P.VASANTHAMANI
Dean, Kilpauk Medical College, for having allowedme to conduct this study.
It is my proud privilege to express my sincere thanks to my beloved and kind-hearted Chief Prof. Dr. S..SENTHIL KUMAR. M.S. (Ortho), Professor & H.O.D Of Orthopaedics, Government Royapettah hospital, for his invaluable help, guidance and encouragement in preparing this study.
I wish to submit my sincere gratitude and thanks to Prof. Dr. N.NAZEER AHMED M.S. (Ortho), D.Ortho., Professor and retired H.O.D. Of Orthopaedics, Kilpauk Medical College and Hospital.
I wish to express my sincere heartfelt thanks to Prof.Dr.R. BALACHANDRAN M.S. (Ortho), D.Ortho. and Prof. Dr. K. RAJU.M.S.(Ortho), D.Ortho., for their encouragement.
I am also very thankful to, Dr. THIRUNARAYANAN, Dr. RAMPRASATH, Dr. THANIGAIARASU, Dr. AMARNATH, Dr. SIVABALAN, Dr. AGNIRAJ, In the department who have been a constant source of inspiration andencouragement.
CONTENTS
Chapter
No.
Title
Page No.
1.
Introduction
8
2.
Aim & Objective
11
3.
Review of Literature
13
4.
Applied Anatomy
19
5.
Mechanism of Injury
28
6.
Fracture Classification
32
7.
Clinical Assessment
37
8.
Radiological Assessment
39
9.
Kocher-Langenbeck Approach
46
10.
Materials and Methods
55
11.
Observations and Results
66
12.
Discussion
71
13.
Conclusion
77
14
Master Chart
79
15
Case Illustration
81
The rise in the high-speed motor vehicles accidents and high velocity
injuries like fall from heights had increased the incidence of polytrauma and pelvic
injuries over the past decade. Developments in the field of emergency trauma care
and healthcare infrastructure facilities helped in increased survival of these
polytrauma victims. About 10 % of pelvic injuries involves acetabulum of which
more than 80 % occurred in road traffic accidents and 10.7% in fall victim
injuries[1] .
Meta-analysis by P. V. Giannoudis et al. [1] using medline search data
including 3670 fractures over the period of 40 years found that acetabular fractures
occurred more commonly in young active male population (69%). Posterior wall
fractures are most frequent type accounting for 23.6% of the total acetabular
injuries based on Letournal classification[2].
Acetabulum being important weight-bearing surface of hip joint, fixation of
these fractures becomes extremely important to give congruous stable painless hip
joint to provide early mobilization and to avoid secondary osteoarthritis. However
acetabular fracture fixation are most challenging for the orthopaedic surgeons
because of steep learning curve, complex anatomy of acetabulum , complicated
fracture pattern and difficult access to the fracture site[3] and frequent association
with polytrauma which makes additional discomfort in positioning the patient intra
The functional outcome of these fractures involves various factors such as
age, associated injuries to vital structures, fracture pattern[4,5], superomedial dome
impaction, femoral head dislocation at the time of injury[6], femoral head damage,
delay to surgery, and quality of reduction[7]. As posterior wall and column are most
commonly involved and they are major weight bearing part, this study mainly
conducted to analyse the short term functional outcome after stable rigid internal
fixation of posterior column and posterior wall in acetabular fractures through
Aim & Objective
History of acetabular fractures can be broadly classified into operative and
non-operative era. During early period acetabular fractures are rare and are usually
identified during autopsy finding after significant trauma like war death. First
report on acetabular fracture was made by Henrick Callison in 1788. But it was
Sir. Astley Pasten Cooper in 1821, who first made a detailed description about
central acetabular fracture dislocation based on the autopsy findings of protrusion
of femoral head into the pelvis [8].
In 1909, W.E.Schroder MD published in the bulletin of North-western
University Medical school, collection of 49 cases of central fracture dislocation of
acetabulum which are mainly based on postmortem findings [9]. In 1911, Penn
Skillern and Henry Pancoast were first to give the illustrated copy of 4 cases of
central fracture dislocation based on the clinical findings and radiographs. They
also gave a brief note on the etiology, mechanism of injury, symptoms,
complications and prognosis of acetabular fractures[10].
In 1926, Macguire first reported on the treatment of acetabular fracture with
lateral traction using threaded pin through the proximal femur followed by
immobilization in a bed for a period of 3 months[11]. In 1934 Phemister added to
work by documenting the avascular necrosis in 4 of his patients after traumatic
of hip with acetabular fractures and throws light on early diagnosis and reduction
of hip dislocation to avoid irreparable damage of hip joint [13].
More aggressive open reduction and internal fixation was first reported by
Levine MA in 1943. His case reports include mainly both column fractures
operated through Smith-Peterson approach placing the plate over the iliac bone but
with only short follow up[14]. More number of research works on acetabular
fractures reported during and after the second world war, one of the notable works
was by Thompson and Epstein in 1951, who gave the early classification of
acetabular fractures [15] and insisted on the removal of loose bony fragments from
the hip joint after trauma to prevent the early secondary arthritis.
In 1958, Knight and Smith[16] described the operative treatment in acetabular
fractures with the help of specialized reduction clamps and radiographs for better
understanding the fracture pattern. They used iliofemoral approach and posterior
approach for horizontal and vertical fractures respectively.
In 1961, Rowe and Lowell, based on retrospective observations of 93
acetabular fractures in 90 patients, first published their work in which they
attempted to correlate they injury related factors to the long term functional
outcome [17]. The important factors that found to affect the long term function are
2. Maintaining congruent hip joint.
3. Intact femoral head.
4. Maintenance of stable hip joint.
They also described the oblique view for analyzing the fracture pattern of
acetabulum. In 1964, Judet et. al[18] published their landmark article in which they
signified the importance of oblique view( Iliac oblique views and Obturator
oblique views also known as Judet views) in understanding the three-dimensional
anatomy of the acetabulum. Six recommendations provided by them for best
functional outcome are
1. Careful study of radiographic lines in pelvis.
2. Concept of Anterior and Posterior columns.
3. Preoperative analysis of fracture pattern and planning the procedure accordingly.
4. Anatomical classification based on wall and column.
5. Anatomic restoration of articular surface.
6. Marginal impaction of fragments
Throughout 1970s many surgeons had skeptical ideas on the operative
treatment. In 1980 there was significant development in the field of acetabular
fractures after works of Emile Letournal got approved in North America. First
clinical course on treatment of acetabular fractures conducted by Letournal in
1984 in Paris. In 1988, Matta [19] published two articles in which he mentioned the
scientific evidence regarding the conservative management of acetabular fractures
not involving the weight bearing dome of acetabulum based on the concept of
―roof arc measurement‖. His concept of roof arc measurement in AP and Oblique
views greater than 45°, maintaining congruent surface between femoral head and
acetabulum without any traction with no posterior wall fragment ( if present may
lead to instability) were considered as important for conservative treatment.
The concept of roof arc measurment given by Matta was further refined by
the advent of computerized tomography subchondral arc. Based on study by
Steven A Olson et al. utilizing CT, superior 10mm of acetabular roof is equivalent
to that covered by 45° of roof arc and called as subchondral roof arc. Based on the
above observation by Steven A Olson et al.[20,21] the current recommendation of
non-operative treatment of acetabulum includes
1. Superior 10mm subchondral roof arc of the acetabulum is intact in CT.
2. Femoral head maintains congruent articular surface with acetabulum in
3. No posterior wall fracture of significant size (greater than 40% is
significant).
4. No evidence of subluxation in intraoperative stress views.
Letournel suggested the protocol for treatment as thorough knowledge in
understanding the fracture pattern from radiographs and proper pre-operative
planning based on fracture classification, appropriate operative positioning of
patient, whenever possible to operate though a single surgical approach, and to
achieve good articular reduction either by direct or indirect method for achieving
good functional outcome in acetabular fractures. Clinical results published by the
surgeons who follow Letournel‘s protocol are consistently successful.
The pelvic girdle forms the junction between the spine and the lower limbs.
Pelvic girdle is formed by three bones namely two innominate bones, one on either
side connected posteriorly by the sacrum forming two sacroiliac joints and
anteriorly they join to form pubic symphysis.
Each innominate bone is formed by three separate bones –Ilium, Ischium
and Pubis that are fused together by the triradiate cartilage to become single bone
at the age of 16 to 18 years.
Acetabulum is the hemispherical socket that is formed on the external
enlarging femoral head forming the hip joint. It contains inverted horse shaped
articular surface for articulating with the head of femur and non articulating
part-cotyloid fossa. Column concept as proposed by Letournal and Judet, the acetabular
socket is supported by two columns –anterior and posterior column that forms
inverted Y shaped structure.
.
Anterior column comprises anterior half of the ilium with iliac spines,
anterior half of the acetabulum containing anterior acetabular wall and the pubis.
Posterior column comprises posterior half of acetabulum, ischium, ischial spines,
of the acetabulum. Sciatic buttress is the thick bone that connects the acetabulum
to the sacrum and axial skeleton.
Anatomical relationship of acetabulum relevant to kocher-langenbeck approach:
Gluteus maximus muscle is large muscle forming the main bulk of gluteal
region originating from the posterior gluteal line of ilium, iliac crest, dorsal surface
of the lower sacrum and coccyx forming the bilaminar structure. Upper part runs
laterally and inserts into the iliotibial tract. Lower part inserts in the ischial
Next layer of muscle is gluteus medius originating from the gluteal surface
of ilium below the gluteus maximus between the anterior and posterior gluteal line.
It is fleshy thick muscle converges into thick tendon inserted over upper lateral
surface of greater trochanter forming powerful abductor of hip. Pyriformis and
short external rotators( superior and inferior gamelli, obturator internus, quadratus
femoris) lies in same plane of gluteus medius under the cover of gluteus maximus
and attached to the lateral surface of the greater trochanter.
Pyriformis originates from the anterior surface of sacrum exits the pelvis
inferior to the gluteus medius insertion. Obturator internus arise from the true
pelvis from the anterolateral surface of true lesser pelvic cavity receiving
additional contributions from inferior pubic ramus, ischial ramus exits the pelvis
through lesser sciatic notch turns 90° fuse with the gamelli tendons and gets
inserted into medial surface of greater trochanter inferior to the gluteus medius
insertion.
Quadratus femoris is the flat muscle present between the gamellus inferior
above and adductor magnus below. It originates from the posterior surface of the
ischial tuberosity runs transversely and inserted into posteromedial aspect of the
greater trochanter below the gamellus inferior insertion. Quadratus femoris should
not be divided in order to protect the ascending branch of medial circumflex
femoral artery that may disturb the vascularity of femoral head.
Vascular anatomy:
Thorough knowledge of anatomy of these three vessels is important as they are
closely related with the Kocher-Langenbeck approach.
1. Superior gluteal artery.
2. Inferior gluteal artery.
Superior gluteal artery, branch of posterior division of internal iliac artery
exits the greater sciatic notch and runs in laterally curved fashion over the gluteal
surface of ilium which is important in deciding the placement of plate. Superior
gluteal artery may retract into the pelvis if injured inadvertently near the greater
sciatic notch causing bleeding. Inferior gluteal artery, branch of anterior division of
internal iliac artery exits pelvis through the gap between the pyriformis and
superior gamellus. Ascending branch of medial circumflex femoral artery runs in
the quadratus femoris, care should be taken not to divide this muscle which may
lead to avascular necrosis of femoral head. Internal pudendal artery exiting below
Nerve relations:
1. Sciatic nerve.
2. Superior gluteal nerve.
3. Inferior gluteal nerve.
Sciatic nerve is commonly injured either during initial trauma or during
surgery in acetabular fractures. The nerve exits through the greater sciatic notch
under the pyriformis and lies on the bed of short external rotators and quadratus
femoris. Surgeon should be familiar with the anatomical variations in the sciatic
nerve to avoid iatrogenic injury. Throughout the surgery sciatic nerve should be
notch and follows similar course with the superior gluteal artery and supplies
gluteus medius, placing the spike retractor in greater sciatic notch should be
avoided as it may cause injury to the nerve causing abductor weakness. Inferior
gluteal nerve emerges in the interval between the pyriformis and superior gamellus
Acetabular fractures are caused by the force transmitted along the axis of
femur through the neck and head of femur to the acetabulum. So pattern of fracture
depends upon four factors mainly
1. Direction of force causing injury.
2. Position of hip joint during impact.
3. Magnitude of force.
4. Strength and quality of bone.
In case of lateral impact injuries over greater trochanter the force is directed
to the floor of acetabulum through neck of femur that causes central fracture
dislocation of acetabulum. Whereas in cases of fall from height with either hip
flexed or extended, axial loading force is transmitted vertically along the shaft of
femur and produces either anterior or posterior fracture of acetabulum based on
either head of femur in external rotation or internal rotation respectively.
Magnitude of force is another important factor that determines the degree of
comminution, amount of displacement, marginal impaction of articular fragment
and associated femoral head fracture. Strength and quality of bone is yet another
factor directly related to the degree of fracture comminution and planning the
Fracture pattern based on position of hip and direction of force.[22]
Direction of force
Position of hip (Rotation)
Position of hip (Adduction/
Abduction)
Fracture pattern
Along axis of femoral neck
Neutral Neutral Anterior column with posterior hemitransverse
25 degrees ER Neutral Anterior column
50 degrees ER Neutral Anterior wall
20 degrees IR Neutral Variable: transverse, T shaped, or both-column
50 degrees IR Neutral Posterior column plus complete or incomplete transverse component
20 degrees IR Adduction Transtectal transverse
20 degrees IR Abduction Juxta/infratectal transverse
Along axis of femoral shaft (hip flexed 90
degrees)
Any Neutral Posterior wall ± hip dislocation
Any Abduction 50
degrees
Transverse
Any Abduction 15
degrees
Posterior column
Any Adduction Posterior hip dislocation ± posterior wall fracture
Along axis of femoral shaft (hip extended)
Any
Neutral Posterior-superior fracture of the posterior wall
As the acetabular fractures almost always as a result of high velocity blunt
trauma , they are frequently associated with the other skeletal or visceral injuries.
Unusual hypotension in isolated acetabular fracture should raise suspicion to check
for associated skeletal or other system injuries. So all patients admitted with
acetabular fractures should be thoroughly screened for the presence of additional
injuries which may be life threatening.
Associated fractures of femoral head or neck have to be fixed along with
acetabulum and surgical approach is planned accordingly. Alternatively
intertrochanteric or subtrochanteric fracture need not be operated in urgent manner,
they can be managed by staged procedure depending upon the surgeon‘s
convenience and general condition of the patient.
Sciatic nerve injury is the most commonly associated nerve injury with this
fracture that may be either partial or complete [23]. The functional recovery depends
on the degree of involvement of peroneal nerve division at the time of injury.
Complete or near complete recovery occurs in case of tibial part injury of sciatic
nerve whereas prognosis is guarded with the peroneal nerve part[23].
Letournel and Judet classification of acetabular fractures[2]
Fracture classification mainly for understanding the fracture pattern, better
communication among the surgeons and also preoperative planning. There are
three main classification system that helps us to classify these acetabular fractures
namely
1. The Letournel and Judet acetabular fracture classification system.
2. AO classification system.
3. O.T.A classification system.
Letournel classification system, introduced in 1961 with subsequent fewer
modifications by same author was a landmark classification system in acetabular
fractures and still followed by most of the acetabular surgeons. Letournal classified
the acetabular fractures into 5 simple fracture (elementary) types and 5 more
complex associated fracture types.
Letournel classification of acetabular fractures:
Simple fracture types:
1. Posterior wall fracture.
2. Posterior column fracture.
4. Anterior column fracture.
5. Transverse fracture.
Associated fracture types:
1. Posterior column and posterior wall fracture.
2. Transverse and posterior wall fracture.
3. T-shaped fracture.
4. Anterior column and posterior hemitransverse fracture.
5. Complete both column fracture.
AO classification system:
A-partial articular involving only one column
62-A1 involving only posterior wall.
62-A2 involving only posterior column.
62-A3.1 involving anterior wall.
A3.2 involving anterior column.
B- partial articular involving transverse
B1.2 involving transverse component with posterior wall.
62-B2 involving t type fracture
62-B3 involving anterior column with posterior
hemitransverse
C-complete articular:
62-C1 fractures are high fractures extending to the iliac crest.
62-C2 fractures are low fractures, extending to the anterior border of the ilium.
Clinical assessment includes both history and physical examination. A clear
history about position of hip joint during the time of accident and direction of the
force gives roughly an idea about the probable type of fracture. Dash board injury
in front seat driver or passenger usually produces posterior dislocation with
posterior wall or posterior column fracture. In case of fall from height landing on
foot with extended hip produces central fracture dislocation.
On receiving patient in emergency room quick primary survey is done that
includes ABC-Airway, Breathing and Circulation. Once primary survey is
completed, secondary survey is done that includes inspecting for CNS, skeletal and
visceral injuries which may produce hypotension and need emergency intervention
even before the acetabulum.
Skeletal injuries such as spine fractures, fractures of long bones, head
injuries and visceral injuries like bowel ,bladder injuries, urethral injuries, rectal
injuries should be identified, documented and expert management should be sought
whenever necessary. Flexed, adducted and internally rotated attitude with limb
shortening gives clue on the associated posterior dislocation. Bruises, internal
degloving due to extensive fat necrosis (Morel-lavallee lesion) which may appear
later at the site of injury should not be missed. Per rectal examination to look for
central fracture dislocation and rectal injuries should be done . Sciatic nerve injury
After stabilizing the patient hemodynamically, diagnosis of fracture type and
subsequent treatment is based on radiographic evaluation. Plane of the ilium is
perpendicular to the plane of obturator foramen and the frontal plane lies in
midway between these two. So in AP radiograph, plane of Obturator foramen and
plane of Ilium are oriented 45° obliquely to the frontal plane in anterior and
posterior aspect respectively [18]. Based on the above anatomical relationship Judet
et al. [22] suggested three basic views for diagnosing fracture acetabulum -
1. Anteroposterior view,
2. Obturator oblique view(Judet view),
3. Iliac oblique view (Judet view).
which are very helpful before the advent of CT.
1- Iliopectineal line. It represents Anterior column.
2- Ilioischial line. It represents posterior column.
3- Tear drop. It is not true anatomical landmark. Radiographically it is formed by
medial and lateral limbs. Medial limb is formed by the obturator canal and lateral
limb s formed by inferior part of anterior wall of acetabulum.
4- Roof of acetabulum.
5- Anterior wall of acetabulum.
Obturator oblique view (Judet view or Internal oblique view) : taken by lifting the affected hip 45° off the ground , so that obturator foramen is parallel to the ground and perpendicular to the X-ray beam.
1. Iliopectineal line(Anterior column)
Iliac oblique view ( Judet view or External Oblique view): taken by lifting the unaffected hip 45° off the ground, so that Iliac bone is parallel to the ground and perpendicular to the X-ray beam.
1- Posterior border of ilium (i.e. Posterior column is visible)
CT scan:
CT scan cannot replace the standard radiograph, but it is an adjunct to the radiograph. To get a reliable information , it is taken with less than 3mm cuts .CT scan provides addition al information about
1. Intra-articular free fragments or fracture of the femoral head,
2. Extension of wall fractures,
3. Orientation of fracture lines,
4. Rotation of fragments,
5. Marginal impaction of articular fragments,
6. Associated posterior pelvic ring injuries.
Recent innovation of 3 dimensional CT gives exact picture of fracture and
Letournal and Judet[22] described four main approaches for acetabular fractures
1. Kocher-Langenbeck approach,
2. Ilioinguinal approach,
3. Iliofemoral approach,
4. Extended iliofemoral approach.
Each approach has its own indications and limitations. We used Kocher–
langenbeck approach in our study. Fractures that could not be addressed by
Kocher-Langenbeck approach are excluded from the study (Anterior column,
Anterior wall, Both column fracture, and Anterior column with posterior
hemitransverse are excluded)
Kocher-Langenbeck approach:
Langenbeck first described the curved proximal part of the incision in 1874 for
hip infections. In 1911, Kocher described the caudal extension of Langenbeck
approach. In1954, Judet et al. combined these two to create the so called
Kocher-Langenbeck approach, named so in 1980 for surgical procedures.
Indications:
Posterior wall,
Posterior column,
Transverse,
Posterior column & Posterior wall,
Transverse & Posterior wall,
T-shaped.
Regions accessible through Koche-Langenbeck approach:
Blue- Direct visualization Red- Indirect visualization.
Approach proper:
Patient in prone position after catheterizing the bladder with adequate
padding to relieve the abdominal pressure and adequate extension of the table to
allow for the C-arm. Knee kept in flexion throughout the procedure to relax the
sciatic nerve. Distal femoral pin traction can be used to provide traction. Skin incision- centered over greater trochanter with proximal limb in curved fashion towards PSIS stopping 6cm short of this bony point and distal limb of incision
continued 15cm along the lateral aspect of femur. Superficial dissection-Fascia lata incised using sharp scalpel and gluteus maximus by blunt dissection along the
direction of fibres. Deep dissection-After incising the trochanteric bursa , short external rotators identified and sciatic nerve identified over the quadratus femoris
and traced proximally. Bone- short external rotators are released 1.5 cm medial to their insertion in greater trochanter to avoid injury to the ascending branch of
medial circumflex femoral artery , gently lifted and retracted medially with sutures
tied to their tendons that allows the exposure of the posterior column. Dissection
distal to inferior gamelli is avoided order to prevent the injury of medial circumflex
femoral artery running in the quadratus femoris, if need for exposure quadratus
femoris can be elevated from its ischial attachment rather than its femoral
superolateral aspect of ilium. Care should be taken while placing the spike
retractor in the greater sciatic notch as it may injure the superior gluteal nerve or
vessels. Greater trochanter flip osteotomy can also be made to increase the
\
Reduction techniques and tools used:
After, adequate exposure reduction can be great challenge. It is not as easy as in
long bone fractures, in addition to usual instruments we need specialized reduction
tools to achieve anatomical reduction and to hold the reduction during fixation. We
used Farabeuf‘s clamps (A.1 & A.2), Matta‘s quadrangular clamps(B) , point
reduction clamp with stopper(C), the lengthiest small fragment screws(D) in our
This is a prospective study conducted in the Department of Orthopaedic
surgery, Government Royapettah hospital to analyse the short term functional and
radiological outcome of acetabular fractures treated by open reduction and internal
fixation through Kocher-Langenbeck approach.
Inclusion Criteria:
1. Age more than 18 years and less than 65 years.
2. Closed acetabular fractures displaced more than 2 mm including Posterior
wall , Posterior column, Transverse, Posterior column with posterior wall,
Transverse with posterior wall, T type fractures ( Judet classification).
3. Fracture less than 3 weeks.
4. Acetabular fracture with or without posterior hip dislocation.
Exclusion criteria:
1. Open fractures.
2. Local soft tissue problems.
3. Severe medical contraindications for surgery.
4. Fractures more than 3weeks old.
6. Patients with other disorders such as Ankylosing spondylitis, Rheumatoid
arthritis.
7. Pathological fracture.
8. Acetabular fractures of types Anterior wall, Anterior column, Anterior
column with posterior hemitransverse, Both column fractures (Judet classification).
Age Distribution:
Age
No of Patients
Percentage
< 20 Years
02
10 %
21 to 30 Years
06
30%
31 to 40 Years
08
40%
41 to 50 Years
03
15%
51to 60 years
01
05%
The Mean age of the patients was 34.3 year ranging from 18 to 60 years.
Sex Distribution:
Male: 17 Female: 03
Age distribution of patients
Sex distribution of patients
2
6
8
3
1
0 1 2 3 4 5 6 7 8 9
less than 20 years
21 to 30 years 31 to 40 years 41 to 50 years 51 to 60 years
Mode of Injury:
About 15 patients out of 20 admitted after Road traffic accident and remaining
5 patients admitted after fall from height.
Mode of Injury No. of patients Percentage
Fall from height 5 25%
Road traffic accident 15 75%
Associated Injuries:
Ten patients had associated injuries
Associated Injuries No.of patients
1.Fracture distal radius 4
2.Fracture Shaft of femur 1
3.Fracture both bone I/L leg
2
4.Fracture clavicle 1
5.Fracture I/L Superior pubic rami
2
Preoperative Radiological assessment:
For all patients three radiographs are taken preoperatively and roof arc measurements are done separately in all three views.
1.Anteroposterior view.
2.Obturator oblique view .
3.Iliac Oblique view.
Computerised Tomography is done preoperatively and fracture classification is done. Posterior dislocation in patients were reduced in emergency operation theatre. All the patients were put on upper tibial skeletal traction with Bohler Braun splint and operated on or after 5th post trauma day.
Fracture Distribution
Type of fracture No. of patients Percentage
Posterior Wall 4 20%
Posterior column 3 15%
Transverse 3 15%
Posterior column with posterior wall
5 25%
Transverse with posterior wall
3 15%
Initial Management:
After initial hemodynamic stabilization all patients thoroughly checked for
associated fractures and nerve injury. All patients were put on distal femur skeletal
traction and placed on Bohler Braun splint for a period of 5 days .
DVT prophylaxis:
DVT prophylaxis with 40mg of Low molecular weight heparin (LMWH)
given subcutaneously once daily started on the day of admission . DVT
prophylaxis stopped one day prior to surgery and restarted on 3rd post-operative
day and continued for next 5 days.
Surgical Approach:
All patients operated through Kocher-Langenbeck approach in Prone position after 5th day of trauma.
Post Operative Protocol :
All patients were given one dose of pre-operative antibiotics and continued
post operatively for 7 days.
T.Indomethecin 25mg TDS started on first post-operative day and continued
Drain removed on 2nd post- operative day .
Passive mobilization was started on 2nd post- operative day. Active
movements started gradually in accordance with pain tolerance.
Suture removed on 12th post-operative day.
Patient advised to come for radiological and functional examination on
monthly basis for initial six months and thereafter once in three months.
Weight bearing was allowed mostly on the 3rd or 4th month.
Post-operative radiological assessment:
Postoperatively quality of fracture reduction was assessed from CT and
classified as Anatomic, Imperfect and Poor reduction depending on the residual
displacement of fracture according to Matta‘s criteria[24].
Anatomic reduction <1mm
Imperfect 1–3mm
Poor >3mm
Postoperative functional assessment:
Functional outcome analysed using Modified Merle‗d Aubigné And Postel
Ambulation and Range of motion. Based on the above parameters patients are
classified as excellent, good, fair and poor.
Modified Merle„d Aubigné And Postel Grading System[25]
Pain
None 6
Slight or intermittent 5
After walking but resolves 4
Moderately severe but patient is able to walk 3
Severe, prevents walking 2
Walking
Normal 6
No cane but slight limp 5
Long distance with cane or crutch 4
Limited even with support 3
Very limited 2
Clinical score
Excellent 17 or 18
Good 15 or 16
Fair 13 or 14
Poor <13
Range of
motion
95% to 100% 6
80% to 94% 5
70% to 79% 4
60% to 69% 3
50% to 59% 2
Following observations were made from following up of twenty patients admitted
with acetabular fractures in our study.
1. 16 out of 20 patients (80%) belonged to age less than 40 years which is the
most active age group.
2. Male patients dominated in our study with ratio of 6.3:1.
3. Majority of fracture caused by road traffic accident (75%) followed by fall
injury victims(25%). Among road traffic accidents, most commonly injury was due
to direct impact of high speed vehicle on flexed knee of the driver of
two-wheeler (40%) with hip in flexed position at the time of injury.
4. Posterior column with posterior wall fracture is most common fracture type in
our study [5 patients (25%)] followed by Posterior wall fracture [4 patients(20%)].
5. Ten patients (50%) had associated skeletal injuries. One patient had sciatic nerve
injury in post op period that improved over the period of 3 months.
6. The average time interval between injury and surgery is 7.2 days with minimum
of 6 and maximum of 11 days.
8. The average blood loss is about 600 ml and eight patients required intraoperative
blood transfusion.
9. 3 patients had operative complications
(a) One patient expired intra-operatively. Patient had cardiac arrest at the end
of surgery. Resuscitative measures were started immediately but patient could not
be revived .
(b) One pateint had sciatic nerve injury, clinically presented with foot drop in
immediate in post-operative period, that improved over the period of 3 months
with physiotherapy.
(c) One patient had superficial infection which settled with antibiotics.
10.Two patient had hip pain with mild restriction of movements after 5 months
and diagnosed as post-traumatic secondary arthritis and they are planned for Total
Hip Replacement in the future.
11. No patient had pubic diastasis or sacroiliac disruption.
12. No patient had deep vein thrombosis.
13. Postoperatively quality of fracture reduction analyzed based on Matta‘s criteria
- 7 patients had anatomic reduction, 8 patients had satisfactory reduction and 4
reduction was poor. Also, with increasing degree of fracture comminution, there
was difficulty in achieving congruent articular surface.
14. The mean score in anatomically reduced fractures was 16.57, in imperfect
reduction is 14.4 and in poorly reduced fracture is 11.3.
Type of fracture
No. of patients
Average score
Functional outcome
Excellent Good Fair Poor
Posterior wall 4 17.25 4 - - -
Posterior column 3 14.3 - 2 - 1
Transverse 3 14.3 - 2 - 1
Posterior column with posterior wall
5 13.8 - 2 2 1
Transverse with posterior wall
3 13.6 - 2 1 -
15. Out of 19 patients, four patients(20%) had excellent , eight patient(40%) had
good , four patient(20%) had fair and three patient(15%) had poor results.
16. Average Functional outcome score was 14.73 for ranging from 11 to 18 (
Maximum Score- 18).
17. There were 4 patients with isolated posterior wall fracture and all of them had
excellent functional outcome.
18. No patient had heterotopic ossification.
19. No patient had Post-traumatic osteonecrosis.
20. In one patient there was intraoperative superior gluteal artery injury and but
was able to arrest bleeding with bipolar coagulation. No superior gluteal nerve
injury found postoperatively in this patient.
There is continuous evolution in the field of treatment of acetabular fractures.
Treating the fracture includes treating the patient as a whole, as acetabular
fractures are produced by high energy forces and almost always have an additional
visceral or skeletal injuries or both. Current concepts of damage control
orthopaedics suggests the primary survey and hemodynamic stabilization should be
done prior to definitive fracture fixation which can be delayed for more than a
week to minimize the postoperative ARDS [26,27].
Knowing and understanding the mechanism of injury is the key factor in
identifying the potential injuries and providing optimum care in trauma patients[28].
Pre-op evaluation including special views and CT helps in pre-op planning the
appropriate approach, minimizing the duration of surgery and reducing the
intraoperative and postoperative complications. Kocher-Langenbeck approach is
one of the preferred surgical approaches by many pelvi acetabular surgeons and
used in majority of fractures not involving anterior wall, anterior column. It is used
frequently in about 90% of cases in many studies [29, 30, ].
Zhu et al., in their study on retrospective evaluation of 80 cases(81 hips)
of associated acetabular fractures (including 5 T-shaped fractures, 53 transverse
and posterior wall fractures, 18 posterior column and posterior wall fractures, 4
both column fractures and 1 anterior column with posterior hemitransverse
satisfactory functional outcome can be achieved by single Kocher-Langenbeck
approach[31] .They also said that restoration of joint function is purely based on the
accuracy of articular reduction.
But, H.J.Kreder et al.[32] in their study involving 128 acetabular fractures,
suggested that anatomical reduction alone was not sufficient to restore the joint
function. In addition to articular reduction functional outcome was also determined
by fracture pattern, marginal impaction, age of the patient and associated
co-morbid conditions. They also suggest primary total hip replacement surgery in
patients with age more than 50 years for fractures involving marginal impaction
with posterior wall comminution.
Similar another study from Egypt by T.A. El-khadrawe et al.[33] involving
55 patients of which 54% of case operated by Kocher-Langenbeck approach
concluded that functional outcome was based on the personality of the fracture –
determined by the degree of damage to the articular cartilage and on the other
hand, to the ability of the surgeon to obtain an anatomical reduction. The other
factors resulting in poor functional outcome are advanced age, injury of the
femoral head and delaying in the treatment.
Regarding intra operative positioning of patient, the Kocher-Langenbeck
comparing between the prone and lateral position. In 2009, Negrin et al.[34]
published a study on 27 cases of transverse acetabular fractures in which all were
operated through Kocher-Langenbeck approach and followed for a period of 9
months. They found more number of unsatisfactory reductions and arthritis with
respect to lateral position.
Same author published another study involving 104 cases in 2010 with
equal number of cases operated in prone and lateral position and reported that
fracture reduction was better and incidence of arthritis was less in prone position
but incidence of post-op wound infection was less in lateral position[35]. So the
choice of positioning can be preference of surgeon in our study. We operated all
patients in prone position and there was 2 cases of arthritis and 1 case of superficial
infection.
Regarding the delay between the injury and surgery, Zhang et al. [36]
conducted study on 17 cases with delay of 6 hours to 9 days using Matta‘s
radiological criteria , he concluded that it is important to minimize the delay in
case of transverse with posterior wall fractures to achieve anatomical reduction and
to reduce the incidence of arthritis.
Regarding post op complications, based on the observations made by
ilioinguinal approach accounting for about 16% when compared to Kocher-
Langenbeck approach where there is about 10% and in our study it is about 5% (1
patient developed post op sciatic nerve injury recovered in a period of 3 months) In
the same study incidence of deep space infection was found to be 1.5% and
bleeding from superior gluteal artery was about 5% which needs identifying and
ligating the superior gluteal artery unfortunately may result in superior gluteal
nerve injury and abduction weakness. In our study there was one case of superior
gluteal injury that was controlled with ligation without superior gluteal nerve
injury.
The risk of avascular necrosis of femur head in KL approach varies between
2-10 % among various studies[37,38,39]. The incidence of AVN could not be solely
attributed to the approach, as it may be also due to various other factors such as
initial violence of injury, prolonged duration of unreduced femoral head
dislocation and finally it may also iatrogenic. The injury to the ascending branch of
medial circumflex vessels while accidental extension of dissection over quadratus
femoris causes AVN, that can be prevented avoiding the dissection below the level
of inferior gamellus. However if exposure is needed the quadrats femoris can be
elevated from ischial attachment but not from the femoral attachment. There was
Heterotopic ossification was another important complication associated with
surgical treatment of acetabular fractures .The incidence of myositis varies in
different studies, it was reported as low as 10 % in Deo et al.[40] study but it was
about 53% in Borreli et al.[41] study. In our study we used Indomethacin 25mg tds
for all patients from first postoperative day & continued upto 6 weeks. No patients
in our study had Heterotopic ossification.
Eventhough our study comprises of only 20 patients, with good preoperative
planning and with early rehabilitation we could able to achieve 85 % of excellent
to fair outcome in our patients according to Modified Merle de Aubigne Postel
scoring system However to comment on long term outcome further follow up is
needed.
From our study we conclude that,
Patients age and co-morbid illness should be considered before deciding the
choice of treatment. Undisplaced fractures or fractures with roof arc angles more
than 45° in elderly patients with co-morbid illness can be managed by
conservatively.
In young active age group with displaced fractures, surgical treatment is
preferred and the aim of surgical treatment is to achieve anatomical reduction,
stable fixation and early mobilization which are the important determinants of
functional outcome of patient.
Kocher-Langenbeck approach can be used address almost all the fractures
except fractures involving Anterior wall ,Anterior column and Bicolumn fracture.
Providing prophylaxis against DVT and heterotopic ossification reduces the
complications of surgical treatment.
The learning curve being relatively slow, proper understanding the fracture
pattern and good preop planning will help to minimize the duration of surgery and
complications. Finally, skill and experience of surgical team is another crucial
Mas ter C h ar t S. No Na me Age Se x S ide
Mode of Injur
y T y pe o f fr ac tur e Assoc iate d inj ur ies S ur g er y time F oll ow up mont hs Matta ’s Qua li ty of re duc ti on F unc ti on al Outc ome M erle A
ubig scor
CASE 1
38 years male patient admitted with history of road traffic accident with Posterior
dislocation., After reduction diagnosed as Transverse fracture with posterior wall of Right acetabulum..He was operated on 6th day after trauma. Open reduction and internal fixation with recon plates through Kocher Langenbeck approach. With one
Preop Radiology
Before reduction of dislocation.
After reduction of dislocation.
Post op radiology showing JUDET VIEWS and functional outcome of patient.
CASE 2
45 years male patient admitted with history of fall from height diagnosed as
Posterior column fracture of Left acetabulum .He was operated on 7th day after injury. Open reduction and internal fixation with recon plate through Kocher
Preop radiology:
Pre operative X ray showing fracture in Left Posterior column( break in Ilioischial line)
Post op radiology showing JUDET VIEWS and functional outcome of patient.
CASE 3
21 years male patient admitted with history of road traffic accident (dash
board injury) diagnosed as Posterior dislocation with Posterior wall fracture of Right acetabulum .Following emergent reduction of hip joint,he was operated on 7th day after injury. Open reduction and internal fixation with recon plate through
Kocher Langenbeck approach. With 14 months follow up patient showed
Pre op radiology:
X ray showing posterior . disocation.
After reduction of dislocation
Post op radiology showing JUDET VIEWS and functional outcome of patient :
CASE 4
45 years male patient admitted with history of fall from height , diagnosed as
transverse fracture with Posterior wall fracture of Right acetabulum .Following greater trochanter skeletal traction for a period of 20 days, he was operated on 21th
day after injury. Open reduction and internal fixation with recon plate through
Kocher Langenbeck approach. With 9 months follow up patient showed poor
Preop radiology.
Preop X ray showing transverse fracture with Greater Trochanter traction
PreOp CT showing transverse fracture with Posterior wall
Post op radiology showing JUDET VIEWS and functional outcome of patient :
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PATIENT CONSENT FORM
Study detail:
“Short Term Analysis of functional results of Acetabular fractures treated by Internal fixation with Recon plate using Kocher-Langenbeck approach”
Study centre : GOVT ROYAPETTAH HOSPITAL, CHENNAI Patients Name :
Patients Age : Identification Number :
Patient may check ( ) these boxes
I confirm that I have understood the purpose of procedure for the above study. I had the opportunity to ask question and all my questions and doubts have been answered to my complete satisfaction.
I understand that my participation in the study is voluntary and that I am free to withdraw at any time without giving reason, without my legal rights being affected.
I understand that sponsor of the clinical study, others working on the sponsor‘s behalf, the ethical committee and the regulatory authorities will not need my permission to look at my health records, both in respect of current study and any further research that may be conducted in relation to it, even if I withdraw from the study I agree to this access. However, I understand that my identity will not be revealed in any information released to third parties or published, unless as required under the law. I agree not to restrict the use of any data or results that arise from this study. I hereby make known that I have fully understood the use of above surgical procedure, the possible complications arising out of its use and the same was clearly explained to me and also understand that this technique is a new method of treatment of patella fractures and this study is done to know the usefulness of the same in management of patella fractures
I agree to take part in the above study and to comply with the instructions given during the study and faithfully cooperate with the study team and to immediately inform the study staff if I suffer from any deterioration in my health or well-being or any unexpected or unusual symptoms.
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