Acetabular fractures are usually caused by high-energy trauma, and in recent years, with the development of modern transportation and construction industries, the incidence of acetabular fractures has increased significantly, and if not treated properly, the disability rate is higher and the complications are more frequent. From September 2005 to December 2007, we treated 42 cases of acetabular fractures with satisfactory clinical results. The clinical results are reported as follows.
1.Clinical data
1.1 General data
There were 29 male cases and 13 female cases in this group. Age: 5-56 years old, average 37 years old. Cause of injury: 29 cases of car accident injury, 8 cases of smash and fall injury, 5 cases of fall injury. The main symptoms were severe hip pain and hip joint dysfunction. According to Letournel classification [1]: 7 cases of posterior wall fracture, 5 cases of posterior wall and posterior column fracture, 4 cases each of anterior wall fracture, anterior wall and anterior column fracture, and 5 cases of double column fracture.
There were 3 cases of double column with transverse fracture, 3 cases of hip dislocation with acetabular fracture, 3 cases of femoral neck fracture with comminuted fracture of the medial wall and 3 cases of posterior wall fracture of the acetabulum, 3 cases of femoral head fracture with posterior column fracture and 2 cases of anterior wall fracture. There were 4 cases of combined sciatic nerve injury, 7 cases of craniocerebral injury, 9 cases of lumbar compression fracture, and 12 cases of rib fracture. The diagnosis was confirmed by routine anterior-posterior pelvic, oblique closed-hole and oblique iliac radiographs, CT scans and CT 3D reconstruction imaging.
1.2 Preoperative preparation
After admission, the patients were given anti-shock, maintained stable vital signs, actively treated other organ injuries, and were treated with bone traction on the greater trochanter of the femur and tibial tuberosity or supracondylar bone traction on the femur. Maintain traction, clean enema 48h before surgery, use antibiotics 30 minutes before surgery, and determine the surgical plan according to X-ray and CT examination.
1.3 Treatment method
After the vital signs stabilize and the local swelling subsides, surgery is usually performed within 1 to 2 weeks. Epidural anesthesia or tracheal intubation was used, and the Kocher-Langenbech approach was selected according to the preoperative CT 3D reconstruction in 15 cases, the iliac inguinal approach in 11 cases, the iliofemoral approach in 2 cases, the combined anterior-posterior approach in 5 cases, and conservative treatment in 9 cases. In this group, 6 cases were fixed with tension screws and 27 cases were fixed with reconstructive plates. 1 case was treated with total hip arthroplasty after reconstruction of the posterior wall fracture and most of the defect of the posterior acetabular wall, and the combined femoral neck and femoral head fracture was fixed with hollow screws first.
1.4 Postoperative treatment
Postoperative anti-infection, oral anti-inflammatory pain and other symptomatic treatments were routinely administered. The drainage tube was left in place and removed within 24-48 hours according to the drainage flow. After 3 days, instruct the injured limb to take active contraction exercise and passive movement of the joint, which can be trained on the CPM machine. 2 weeks later, take active hip extension and flexion exercise, and gradually walk without weight-bearing with the help of crutches. The weight-bearing of the affected limb should be decided according to the review of X-ray film and the healing of the fracture.
2.Results
The fracture healed in 12-16 weeks on X-ray, with heterotopic ossification in 3 cases and traumatic arthritis in 2 cases. 4 cases recovered from sciatic nerve injury at 9 months after surgery. According to the criteria of Matta [2], the fracture displacement less than 1 mm on X-ray was considered as anatomic reduction, less than 3 mm as satisfactory reduction, and more than 3 mm as unsatisfactory reduction. Among the 42 cases in this group, 25 cases were anatomically repositioned, 13 cases were satisfactorily repositioned, and 4 cases were unsatisfactorily repositioned. The efficacy evaluation was based on the criteria of the American Academy of Orthopaedic Surgery [3], and was classified as follows: excellent, no pain, normal gait, at least 75% of the normal range of joint movement, no obvious osteoarthritic changes or mild joint space narrowing and sclerosis on X-ray; good, mild pain, normal gait, more than 50% of the normal range of joint movement, sclerosis of the joint surface, narrowing of the space, and bone formation on X-ray; poor In the case of the poor, there was significant pain, obvious limp, stiffness and deformity of the joint, and obvious arthritic changes on X-ray. The follow-up results of 42 cases in this group: 24 cases were excellent, 10 cases were good, 6 cases were acceptable, and 2 cases were poor, with an excellent rate of 80.95%.
3. Discussion
3.1 Acetabular fracture is an intra-articular fracture caused by high-energy injury. In recent years, with the increasing understanding of acetabular fracture treatment, it is a clinical consensus that the treatment of acetabular fracture emphasizes the ideal repositioning of acetabular fracture and restoring the flatness of the joint surface, especially the weight-bearing surface of the top of the socket. Surgical reduction and fixation has become the most ideal treatment for displaced acetabular fractures [4]. CT scan should be routinely performed before surgery, which is better than X-ray for showing the fracture, observing the fragmentation and the anatomical relationship of the fracture, and has certain guiding significance for fracture classification, treatment plan, operation selection and prognosis assessment [5-6].
3.2 Strict control of indications
For stable fractures with intact upper acetabular dome and posterior acetabular wall, no large displacement, good continuity, severe acetabular fractures where reconstruction is not possible, and acetabular fractures with contraindications to surgery can be considered for non-operative treatment. Patients with open fractures, severe adjacent skin injury, bladder rupture, high fever and osteoporosis should be treated surgically with caution.
The indications for surgery for acetabular fractures are [7].
(i) fracture displacement >3 mm;
(ii) Combined dislocation or subluxation of the femoral head;
(iii) Combination of intra-articular free bone mass;
④CT showed >40% posterior wall fracture defect;
⑤ Displaced fracture involving the socket (Matta parietal arc angle criteria);
⑥No osteoporosis.
3.3 Timing of surgery
In the early stage of acetabular fracture, due to many complications and poor general condition of the patient, except for open acetabular fracture or dislocation of the femoral head which is difficult to be repositioned surgically, emergency surgery should not be performed, so as not to increase unnecessary surgical bleeding, early treatment should include resetting the dislocated femoral head by manipulation or bone traction, which is the key to reduce the rate of ischemic necrosis of the femoral head. Continuous bone traction also helps to prevent the bone fragments or fracture ends from pressing on the femoral head and causing re-injury to the femoral cartilage. Because the surgical efficacy of acetabular fracture is closely related to the time of treatment, acetabular fracture should be operated as early as possible, usually no more than 3 weeks, preferably 4-7 d after the injury [8].
This is because the deep traumatic bleeding has stopped at this time, and the scar tissue affecting the repositioning has not yet formed, which is conducive to accurate fracture repositioning and reduction of bleeding. After 10 d after injury, fracture block repositioning is not easy to operate, and the bone scab hinders fracture repositioning 3 weeks after injury, which has poor efficacy, and the injured tissues begin to appear fibrosis, so delayed surgery can easily form heterotopic ossification and fixed deformity, and repositioning and fixation are very difficult. mears et al [9] reported that the anatomical repositioning rates of surgery 2 d, 3-10 d and 11-21 d after injury were 76%, 68% and 54%, respectively. The rate of anatomical repositioning after 11 d post-injury was significantly lower than that of surgery within 10 d.