- Email: [email protected]
Bilateral acetabular fractures: Mechanism, fracture patterns and associated injuries
Journal Pre-proof Bilateral Acetabular Fractures: Mechanism, Fracture Patterns and Associated Injuries. Jarrad M. Stevens, Sarah Shiels, Michael R. Whitehouse, Anthony J. Ward, Tim J. Chesser, Mehool Acharya PII:
S0972-978X(19)30548-3
DOI:
https://doi.org/10.1016/j.jor.2019.10.012
Reference:
JOR 847
To appear in:
Journal of Orthopaedics
Received Date: 26 August 2019 Accepted Date: 30 October 2019
Please cite this article as: Stevens JM, Shiels S, Whitehouse MR, Ward AJ, Chesser TJ, Acharya M, Bilateral Acetabular Fractures: Mechanism, Fracture Patterns and Associated Injuries., Journal of Orthopaedics, https://doi.org/10.1016/j.jor.2019.10.012. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.
1
Bilateral Acetabular Fractures: Mechanism, Fracture
2
Patterns and Associated Injuries.
3 4
Abstract:
5
Introduction: Acetabular fractures are uncommon and their management is often
6
reserved for specialist pelvic and acetabular surgeons. Bilateral acetabular fractures
7
are a particularly rare subgroup. We report the incidence, fracture pattern, mechanism
8
of injury and outcome of patients presenting to a tertiary trauma centre with traumatic
9
bilateral acetabular fractures.
10 11
Method: Bilateral acetabular fractures were identified from a prospective database of
12
acetabular fractures presenting to one institution over a six-year period. Patient notes
13
and imaging studies were reviewed to identify demographics, mechanism of injury,
14
Injury Severity Score, fracture pattern and management. Timing of operative
15
management was explored. Patient outcomes were collected in the form of
16
radiographs and Oxford Hip Scores at a minimum of one-year post injury.
17 18
Results: Eight patients with bilateral acetabular fracture were identified from a
19
database which contained records of 519 patients with acetabular fractures (incidence
20
of 1.5% amongst patients with acetabular fractures). Motor vehicle accidents were the
21
most common mechanism. Four acetabular fracture patterns were observed within the
22
cohort. Radiographic union occurred in all cases and Oxford Hip Scores are
23
suggestive of moderate to well functioning hip joints. Fractures were treated as single
24
or staged procedures.
25
26
Conclusion: Bilateral acetabular fractures are very rare due to the unique degree and
27
pattern of force required to fracture both acetabula. They are associated with 4 main
28
fracture patterns and present with Injury Severity Scores that averaged 25 (severe).
29
They are typically observed in young males with road traffic collision being the most
30
common mechanism of injury.
31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Key Words: acetabular; fracture; bilateral; trauma
51
Introduction:
52 53
Acetabular fractures are uncommon and their management is often reserved for
54
specialist fellowship trained orthopaedic pelvic and acetabular surgeons. The
55
documented incidence of acetabular fractures in the United Kingdom is 3/100 000
56
population/year [1]. High-energy trauma is typically required to fracture the
57
acetabulum and can result in complex injury patterns with significant morbidity and
58
risk of mortality. Road traffic accidents are the commonest cause, followed by falls
59
from height <10 feet, fall from height >10 feet and pedestrians hit by a vehicle [1].
60 61
There is no literature to date which explores the mechanism, demographics or
62
outcome of bilateral acetabular fractures. We hypothesis that a high energy force is
63
required to simultaneously fracture both acetabula and this may result in recurring
64
fracture patterns, associated injuries and high Injury Severity Scores.
65 66
In a study of 351 acetabular fractures, Laird and Keating report a single case of
67
bilateral acetabular fracture, the mechanism of which is not documented [1]. Gary et
68
al. reported on 80 acetabular fractures including one case of bilateral fracture, again
69
the mechanism and fracture pattern is not recorded [2]. To the authors knowledge,
70
the largest number of documented bilateral acetabular fractures in a database is fifteen
71
[3]. While the precise mechanism of injury was not documented in this study, 14 were
72
recorded as being due to high-energy trauma.
73
74
The aim of this study was to document the incidence of bilateral acetabular fractures
75
and explore the mechanism of injury, fracture patterns, associated injuries,
76
management and outcome of this rare trauma presentation.
77 78
Method and Materials:
79 80
Over a six-year period from January 2012 to July 2018, all patients with acetabular
81
fractures who presented to a single major trauma unit and tertiary referral centre were
82
prospectively identified and data collected on an institutional database. Details
83
including age, gender, the mechanism of injury, the site of injury, fracture
84
classification, Injury Severity Score (ISS) and the nature of treatment were recorded.
85
The database was reviewed to document patients sustaining bilateral acetabular
86
fractures. Patient medical records and digital radiographs (Kodak© Picture Archiving
87
and Communication System) were reviewed. Acetabular fractures were classified [4]
88
at the time of presentation based upon an analysis of the radiographs and CT scans by
89
the specialist consultants (Figures 1, 2 and 3). Associated injuries, management and
90
complications were recorded on a computer database for subsequent analysis.
91 92
Figure 1: Initial AP pelvis radiographs in the emergency department
93 94
Figure 2: Axial CT of left posterior wall fracture dislocation and right transverse
95
posterior wall fracture
96 97
Figure 3: PA 3D reconstruction of fracture pattern.
98
Operative intervention and time between staged surgeries on each site of fracture was
99
recorded. The approach to the fracture was identified and postoperative radiographs
100
and CT scans were reviewed (figure 4). Oxford Hip Scores were recorded at a
101
minimum one-year post injury[5].
102 103
Figure 4: Postoperative radiographs demonstrating bilateral internal fixation.
104 105
Results:
106 107
During the study period, a total of 527 acetabular fractures in 519 patients. Of the 527
108
acetabular fractures, 284 underwent operative intervention of which 245 were isolated
109
acetabular fractures and 39 were associated with sacral or pelvic fractures. Eight
110
bilateral acetabular fractures were recorded, which represents an incidence of 1.5% of
111
all patients presenting with acetabular fracture.
112 113
The mechanism of injury in five cases was road traffic collision. Forklift crush injury,
114
motorbike accident and mountain bike accident account for the remanding three
115
cases. The patient demographic, mechanism of injury, fracture pattern, treatment and
116
associated injuries are detailed in table 1:
117 118
Table 1: Open reduction Internal Fixation (ORIF), Kocherlagenbeck (KL),
119
Trochanteric Flip (TF) osteotomy, Days Between Operation (DBO).
120 121
The mean age of patients sustaining bilateral acetabular fractures was 32 compared to
122
a mean age of 39 in patients with isolated acetabular fracture requiring operation.
123
Seven patients were male and one was female. Six patients incurred associated injury
124
with three patients sustaining concurrent pelvic fractures. Complex open and closed
125
limb fractures, sciatic nerve palsy and lung injuries were also documented.
126 127
Four fractures patterns were identified; Anterior wall (n=4), posterior wall (n=4),
128
transverse posterior wall (n=6) and anterior column posterior hemi-transverse (n=2).
129
The mean Injury Severity Score at presentation was 25 (10-38). All patients were
130
followed up both clinically and radiographically until union. At one year, 6 patients
131
were able to be reviewed clinically and Oxford Hip Scores were recorded [2]. One
132
patient had a low score indicating moderate to severe joint disease (20-29), two
133
patients had scores that may indicate mild to moderate hip pathology (30-39), and
134
three patients had high scores indicating satisfactory joint function (40-48). There
135
were no superficial or deep infections and no patient required revision surgery. No
136
neurological or vascular complications as a result of surgery were recorded although
137
one patient did have a documented sciatic nerve palsy pre-operatively with partial
138
resolution at one-year follow-up.
139 140
Four patients underwent sequential fixation of fractures on the same day with the
141
remanding patients undergoing staged fixation between one and three days apart. The
142
decision to perform staged surgery on a different day and the number of days between
143
surgeries was dictated by operative room availability rather than patient factors.
144 145 146
Discussion:
147
Bilateral acetabular fractures are very rare and detailed documentation is currently
148
limited to a small number of case reports [6-10]. In our series, bilateral acetabular
149
fractures occurred in 1.5% of all acetabular fracture presentations. All patients were
150
young, predominantly male and their injuries were associated with high-energy
151
mechanisms with road traffic collision being the most common mechanism.
152 153
Four fractures patterns were identified; Anterior wall, posterior wall, transverse
154
posterior wall and anterior column posterior hemi-transverse. Anterior wall fractures
155
represent 1.8 to 3.7% of all acetabular fractures, yet appear more common in the case
156
of bilateral acetabular fractures (n=3; 19%) [1,11,12]. Letournel et al. postulated that
157
fractures involving the anterior acetabulum resulted from a force applied to the
158
greater trochanter in the axis of the femoral neck. To sustain a force that can drive one
159
femoral head posteriorly and the other anteriorly is difficult to account for. In two
160
cases of road traffic collision this pattern was identified. Further review of patient
161
notes revealed both patients were front seat occupants of vehicles travelling at high
162
speed involved in head on collisions. We postulate that as the occupant enters the
163
impact zone one femur will be driven posteriorly fracturing the acetabulum and
164
dislocating the hip whilst simultaneously turning the patient such that the contralateral
165
side is exposed to the same force but now at the greater trochanter driving the femur
166
and femoral head anteriorly fracturing and dislocating the hip.
167 168
Patients who sustained bilateral acetabular fractures also had high Injury Severity
169
Scores that correspond to the significant mechanism of injury required to generate this
170
rare fracture pattern. Mauffrey et al. recorded Injury Severity Scores for 883 patients
171
with acetabular fractures and reported a mean score of 12. Our patient cohort
172
demonstrated a significantly higher mean score with various associated injuries
173
including associated pelvic fractures, complex and open limb fractures, lung trauma
174
and neurological injury. These injuries were treated as both sequential and staged
175
procedures and are generally managed on a case-by-case basis.
176 177
Bilateral acetabular fractures after epileptic seizure have previously been documented
178
with hip dislocation being a differential diagnosis of hip pain following seizure [6-8].
179
Bilateral insufficiency fractures have also been reported on two occasions both of
180
which essentially represent progression of acetabular protrusio [9,10].
181
To date, this is the first report in the literature which studies in detail the
182
demographics, mechanism of injury, fracture pattern, associated injuries, management
183
and outcome of this rare sub-group of acetabular fractures.
184 185
Conclusion: In this series, bilateral acetabular fractures represent 1.5% of all
186
acetabular fracture presentations and are associated with four main fracture patterns.
187
They were most often seen in younger male patients as a result of road traffic
188
accidents. They typically present with high injury severity scores with a mean score
189
of 25.
190 191 192
Figure 1: Initial AP pelvis radiographs in the emergency department
193 194
Figure 2: Axial CT of left posterior wall fracture dislocation and right transverse
195
posterior wall fracture
196
197
Figure 3: PA 3D reconstruction of fracture pattern.
198
Operative intervention and time between staged surgeries on each site of fracture was
199
recorded. The approach to the fracture was identified and postoperative radiographs
200
and CT scans were reviewed (figure 4). Oxford Hip Scores were recorded at a
201
minimum one-year post injury[5].
202 203
Figure 4: Postoperative radiographs demonstrating bilateral internal fixation.
204 205
Table 1: Open reduction Internal Fixation (ORIF), Kocherlagenbeck (KL),
206
Trochanteric Flip (TF) osteotomy, Days Between Operation (DBO).
207 208
CONFLICT OF INTEREST and DISCLAIMER:
209
This study was supported by the NIHR Biomedical Research Centre at University
210
Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views
211
expressed in this publication are those of the author(s) and not necessarily those of the
212
NHS, the National Institute for Health Research or the Department of Health and
213
Social Care.
214 215 216 217 218 219 220 221
There is no grant money or financial support for this research or publication.
222
References:
223 224
1: Laird A, Keating JF. Acetabular fractures A 16-prospective epidemiology study.
225
JBJS(Br) 2005;87-B(7):969-973
226 227
2: Gary JL, Lefaivre KA, Gerold F, et al. Survivorship of the native hip joint after
228
percutaneous repair of acetabular fractures in the elderly Injury, Int. J. Care Injured
229
2001; 42:1144–1151
230 231
3: Papadakos N, Pearce R, Bircher MD. Low energy fractures of the acetabulum. Ann
232
R Coll Surg Engl 2014;96(4):297-301.
233 234
4: Letournel E. Acetabulum fractures: classification and management. Clin Orthop
235
Relat Res 1980;(151):81-106.
236 237
5: Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of
238
patients about total hip replacement. J Bone Joint Surg Br 1996;78(2):185-90
239 240
6: Granhed HP, Karladani A. Bilateral acetabular fracture as a result of epileptic
241
seizure: a report of two cases. Injury 1997; 28(2):65-68
242 243
7: Friedberg r, Buras D. Bilateral Acetabular Fractures Associated With a Seizure: A
244
Case Report. Annals of Emergency Medicine 2005; 46(3):260-262
245
246
8: Takahashi, Y., Ohnishi, H., Oda, K. et al. Bilateral acetabular fractures secondary
247
to a seizure attack caused by antibiotic medicine. J Orthop Sci 2007 12;308-310
248 249
9: Aynaci O, Kerimoglu S, Ozturk, C. et al. Bilateral non-traumatic acetabular and
250
femoral neck fractures due to pregnancy-associated osteoporosis
251
Trauma Surg 2008;128:313
Arch Orthop
252 253
10: Rosa M, Maccauro G & D’Arienzo M. Bilateral acetabular fracture without
254
trauma International Orthopaedics SICOT 1999;23:120
255 256
11: Mauffrey C, Hao J, Cuellar D.O, et al. The Epidemiology and Injury Patterns of
257
Acetabular Fractures Are the USA and China Comparable? Clin Orth and Rel
258
Research. 2014;472(11):3332-3337
259 260
12: Harvie P, Chesser TJS, Ward A. The Bristol regional pelvic and acetabular
261
fracture service: Workload implications of managing the polytraumatised patient
262
2008 Injury 39(8):839-43
263
24 Aug 2019 Journal of Orthopaedics Corresponding Author: Dr Jarrad M Stevens
Dear Editor and Team,
RE: Manuscript entitled - Bilateral Acetabular Fractures: Mechanism, Fracture Patterns and Associated Injuries.
CONFLICT OF INTEREST and DISCLAIMER: This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.
There is no grant money or financial support for this research or publication.
Dr Jarrad Stevens MBBS, ChM, FRACS, FAOrthA [email protected]
Age
Mechanism
Fracture Pattern according to Letournel
Treatment
Left
Right
Left
Right
DBO
Associated Injuries
Case 1
47
Mountain Bike
Transverse posterior wall
Posterior wall
ORIF, (KL)
ORIF (KL and TF)
2
Case 2
22
Road traffic collision
Transverse posterior wall
Transverse posterior wall
ORIF (KL)
ORIF (KL)
3
Stable thoracic vertebral fracture
Case 3
29
Fork lift crush injury
Anterior wall
Anterior Column posterior hemitransverse
ORIF (Stoppa)
ORIF Stoppa
Same
Open pelvis injury, Superficial femoral artery tear, complex mid-foot fracture
Case 4
16
Motor bike collision
Transverse posterior wall
Anterior Column posterior hemitransverse
ORIF (KL)
ORiF Stoppa
Same
Case 5
38
Road traffic collision
Posterior Wall
Anterior wall
Closed reduction, stable
ORIF KL
Same
Pelvic anterior-posterior compression 2 fracture, open femur fracture
Case 6
35
Road traffic collision
Transverse posterior wall
Transverse posterior wall
ORIF (KL TF)
ORIF (KL TF)
2
Pre-op sciatic nerve palsy, pneumothorax
Case 7
22
Road traffic collision
Posterior wall
Anterior wall
Closed reduction, stable
ORIF KL
Same
Case 8
45
Road traffic collision
Posterior wall
Posterior Wall
ORIF (KL)
ORIF (KL and TF)
1
Pipkin 4, scapula, bilateral lung contusions, Pelvic fracture lateral compression 1
Table 1: Open reduction Internal Fixation (ORIF), Kocherlagenbeck (KL), Trochanteric Flip (TF) osteotomy, Days Between Operation (DBO).
Bilateral Acetabular Fractures: Mechanism, Fracture Patterns and Associated Injuries.
AUTHORS: Jarrad M Stevens [1,2] , Sarah Shiels [1], Michael R Whitehouse[1,3,4], Anthony J Ward, [1], Tim J Chesser [1], Mehool Acharya [1]
Jarrad M Stevens, MBBS, ChM, FRACS, FAOrthA Sarah Shiels, MBChB, MRCS Michael R Whitehouse, BSc, MBChB, MSc, PhD, FRCS, PGCert, FHEA Anthony J Ward, FRCS Tim J Chesser, FRCS (Tr and Orth) Mehool Acharya, Bsc Hons, MBChB, FRCS(Tr and Orth)
INSTITUTION: 1: Department of Trauma and Orthopaedics , Southmead Hospital Bristol, BS10 5NB 2: St Vincent’s Hospital Melbourne, Australia 3: Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB 4: National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol
CORRESPONDING AUTHOR: JM Stevens Orthopaedic Surgeon Consultant Department of Trauma & Orthopaedics North Bristol Trust Southmead Hospital Bristol, BS10 5NB e-mail: [email protected]
S0972-978X(19)30548-3
DOI:
https://doi.org/10.1016/j.jor.2019.10.012
Reference:
JOR 847
To appear in:
Journal of Orthopaedics
Received Date: 26 August 2019 Accepted Date: 30 October 2019
Please cite this article as: Stevens JM, Shiels S, Whitehouse MR, Ward AJ, Chesser TJ, Acharya M, Bilateral Acetabular Fractures: Mechanism, Fracture Patterns and Associated Injuries., Journal of Orthopaedics, https://doi.org/10.1016/j.jor.2019.10.012. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2019 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.
1
Bilateral Acetabular Fractures: Mechanism, Fracture
2
Patterns and Associated Injuries.
3 4
Abstract:
5
Introduction: Acetabular fractures are uncommon and their management is often
6
reserved for specialist pelvic and acetabular surgeons. Bilateral acetabular fractures
7
are a particularly rare subgroup. We report the incidence, fracture pattern, mechanism
8
of injury and outcome of patients presenting to a tertiary trauma centre with traumatic
9
bilateral acetabular fractures.
10 11
Method: Bilateral acetabular fractures were identified from a prospective database of
12
acetabular fractures presenting to one institution over a six-year period. Patient notes
13
and imaging studies were reviewed to identify demographics, mechanism of injury,
14
Injury Severity Score, fracture pattern and management. Timing of operative
15
management was explored. Patient outcomes were collected in the form of
16
radiographs and Oxford Hip Scores at a minimum of one-year post injury.
17 18
Results: Eight patients with bilateral acetabular fracture were identified from a
19
database which contained records of 519 patients with acetabular fractures (incidence
20
of 1.5% amongst patients with acetabular fractures). Motor vehicle accidents were the
21
most common mechanism. Four acetabular fracture patterns were observed within the
22
cohort. Radiographic union occurred in all cases and Oxford Hip Scores are
23
suggestive of moderate to well functioning hip joints. Fractures were treated as single
24
or staged procedures.
25
26
Conclusion: Bilateral acetabular fractures are very rare due to the unique degree and
27
pattern of force required to fracture both acetabula. They are associated with 4 main
28
fracture patterns and present with Injury Severity Scores that averaged 25 (severe).
29
They are typically observed in young males with road traffic collision being the most
30
common mechanism of injury.
31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Key Words: acetabular; fracture; bilateral; trauma
51
Introduction:
52 53
Acetabular fractures are uncommon and their management is often reserved for
54
specialist fellowship trained orthopaedic pelvic and acetabular surgeons. The
55
documented incidence of acetabular fractures in the United Kingdom is 3/100 000
56
population/year [1]. High-energy trauma is typically required to fracture the
57
acetabulum and can result in complex injury patterns with significant morbidity and
58
risk of mortality. Road traffic accidents are the commonest cause, followed by falls
59
from height <10 feet, fall from height >10 feet and pedestrians hit by a vehicle [1].
60 61
There is no literature to date which explores the mechanism, demographics or
62
outcome of bilateral acetabular fractures. We hypothesis that a high energy force is
63
required to simultaneously fracture both acetabula and this may result in recurring
64
fracture patterns, associated injuries and high Injury Severity Scores.
65 66
In a study of 351 acetabular fractures, Laird and Keating report a single case of
67
bilateral acetabular fracture, the mechanism of which is not documented [1]. Gary et
68
al. reported on 80 acetabular fractures including one case of bilateral fracture, again
69
the mechanism and fracture pattern is not recorded [2]. To the authors knowledge,
70
the largest number of documented bilateral acetabular fractures in a database is fifteen
71
[3]. While the precise mechanism of injury was not documented in this study, 14 were
72
recorded as being due to high-energy trauma.
73
74
The aim of this study was to document the incidence of bilateral acetabular fractures
75
and explore the mechanism of injury, fracture patterns, associated injuries,
76
management and outcome of this rare trauma presentation.
77 78
Method and Materials:
79 80
Over a six-year period from January 2012 to July 2018, all patients with acetabular
81
fractures who presented to a single major trauma unit and tertiary referral centre were
82
prospectively identified and data collected on an institutional database. Details
83
including age, gender, the mechanism of injury, the site of injury, fracture
84
classification, Injury Severity Score (ISS) and the nature of treatment were recorded.
85
The database was reviewed to document patients sustaining bilateral acetabular
86
fractures. Patient medical records and digital radiographs (Kodak© Picture Archiving
87
and Communication System) were reviewed. Acetabular fractures were classified [4]
88
at the time of presentation based upon an analysis of the radiographs and CT scans by
89
the specialist consultants (Figures 1, 2 and 3). Associated injuries, management and
90
complications were recorded on a computer database for subsequent analysis.
91 92
Figure 1: Initial AP pelvis radiographs in the emergency department
93 94
Figure 2: Axial CT of left posterior wall fracture dislocation and right transverse
95
posterior wall fracture
96 97
Figure 3: PA 3D reconstruction of fracture pattern.
98
Operative intervention and time between staged surgeries on each site of fracture was
99
recorded. The approach to the fracture was identified and postoperative radiographs
100
and CT scans were reviewed (figure 4). Oxford Hip Scores were recorded at a
101
minimum one-year post injury[5].
102 103
Figure 4: Postoperative radiographs demonstrating bilateral internal fixation.
104 105
Results:
106 107
During the study period, a total of 527 acetabular fractures in 519 patients. Of the 527
108
acetabular fractures, 284 underwent operative intervention of which 245 were isolated
109
acetabular fractures and 39 were associated with sacral or pelvic fractures. Eight
110
bilateral acetabular fractures were recorded, which represents an incidence of 1.5% of
111
all patients presenting with acetabular fracture.
112 113
The mechanism of injury in five cases was road traffic collision. Forklift crush injury,
114
motorbike accident and mountain bike accident account for the remanding three
115
cases. The patient demographic, mechanism of injury, fracture pattern, treatment and
116
associated injuries are detailed in table 1:
117 118
Table 1: Open reduction Internal Fixation (ORIF), Kocherlagenbeck (KL),
119
Trochanteric Flip (TF) osteotomy, Days Between Operation (DBO).
120 121
The mean age of patients sustaining bilateral acetabular fractures was 32 compared to
122
a mean age of 39 in patients with isolated acetabular fracture requiring operation.
123
Seven patients were male and one was female. Six patients incurred associated injury
124
with three patients sustaining concurrent pelvic fractures. Complex open and closed
125
limb fractures, sciatic nerve palsy and lung injuries were also documented.
126 127
Four fractures patterns were identified; Anterior wall (n=4), posterior wall (n=4),
128
transverse posterior wall (n=6) and anterior column posterior hemi-transverse (n=2).
129
The mean Injury Severity Score at presentation was 25 (10-38). All patients were
130
followed up both clinically and radiographically until union. At one year, 6 patients
131
were able to be reviewed clinically and Oxford Hip Scores were recorded [2]. One
132
patient had a low score indicating moderate to severe joint disease (20-29), two
133
patients had scores that may indicate mild to moderate hip pathology (30-39), and
134
three patients had high scores indicating satisfactory joint function (40-48). There
135
were no superficial or deep infections and no patient required revision surgery. No
136
neurological or vascular complications as a result of surgery were recorded although
137
one patient did have a documented sciatic nerve palsy pre-operatively with partial
138
resolution at one-year follow-up.
139 140
Four patients underwent sequential fixation of fractures on the same day with the
141
remanding patients undergoing staged fixation between one and three days apart. The
142
decision to perform staged surgery on a different day and the number of days between
143
surgeries was dictated by operative room availability rather than patient factors.
144 145 146
Discussion:
147
Bilateral acetabular fractures are very rare and detailed documentation is currently
148
limited to a small number of case reports [6-10]. In our series, bilateral acetabular
149
fractures occurred in 1.5% of all acetabular fracture presentations. All patients were
150
young, predominantly male and their injuries were associated with high-energy
151
mechanisms with road traffic collision being the most common mechanism.
152 153
Four fractures patterns were identified; Anterior wall, posterior wall, transverse
154
posterior wall and anterior column posterior hemi-transverse. Anterior wall fractures
155
represent 1.8 to 3.7% of all acetabular fractures, yet appear more common in the case
156
of bilateral acetabular fractures (n=3; 19%) [1,11,12]. Letournel et al. postulated that
157
fractures involving the anterior acetabulum resulted from a force applied to the
158
greater trochanter in the axis of the femoral neck. To sustain a force that can drive one
159
femoral head posteriorly and the other anteriorly is difficult to account for. In two
160
cases of road traffic collision this pattern was identified. Further review of patient
161
notes revealed both patients were front seat occupants of vehicles travelling at high
162
speed involved in head on collisions. We postulate that as the occupant enters the
163
impact zone one femur will be driven posteriorly fracturing the acetabulum and
164
dislocating the hip whilst simultaneously turning the patient such that the contralateral
165
side is exposed to the same force but now at the greater trochanter driving the femur
166
and femoral head anteriorly fracturing and dislocating the hip.
167 168
Patients who sustained bilateral acetabular fractures also had high Injury Severity
169
Scores that correspond to the significant mechanism of injury required to generate this
170
rare fracture pattern. Mauffrey et al. recorded Injury Severity Scores for 883 patients
171
with acetabular fractures and reported a mean score of 12. Our patient cohort
172
demonstrated a significantly higher mean score with various associated injuries
173
including associated pelvic fractures, complex and open limb fractures, lung trauma
174
and neurological injury. These injuries were treated as both sequential and staged
175
procedures and are generally managed on a case-by-case basis.
176 177
Bilateral acetabular fractures after epileptic seizure have previously been documented
178
with hip dislocation being a differential diagnosis of hip pain following seizure [6-8].
179
Bilateral insufficiency fractures have also been reported on two occasions both of
180
which essentially represent progression of acetabular protrusio [9,10].
181
To date, this is the first report in the literature which studies in detail the
182
demographics, mechanism of injury, fracture pattern, associated injuries, management
183
and outcome of this rare sub-group of acetabular fractures.
184 185
Conclusion: In this series, bilateral acetabular fractures represent 1.5% of all
186
acetabular fracture presentations and are associated with four main fracture patterns.
187
They were most often seen in younger male patients as a result of road traffic
188
accidents. They typically present with high injury severity scores with a mean score
189
of 25.
190 191 192
Figure 1: Initial AP pelvis radiographs in the emergency department
193 194
Figure 2: Axial CT of left posterior wall fracture dislocation and right transverse
195
posterior wall fracture
196
197
Figure 3: PA 3D reconstruction of fracture pattern.
198
Operative intervention and time between staged surgeries on each site of fracture was
199
recorded. The approach to the fracture was identified and postoperative radiographs
200
and CT scans were reviewed (figure 4). Oxford Hip Scores were recorded at a
201
minimum one-year post injury[5].
202 203
Figure 4: Postoperative radiographs demonstrating bilateral internal fixation.
204 205
Table 1: Open reduction Internal Fixation (ORIF), Kocherlagenbeck (KL),
206
Trochanteric Flip (TF) osteotomy, Days Between Operation (DBO).
207 208
CONFLICT OF INTEREST and DISCLAIMER:
209
This study was supported by the NIHR Biomedical Research Centre at University
210
Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views
211
expressed in this publication are those of the author(s) and not necessarily those of the
212
NHS, the National Institute for Health Research or the Department of Health and
213
Social Care.
214 215 216 217 218 219 220 221
There is no grant money or financial support for this research or publication.
222
References:
223 224
1: Laird A, Keating JF. Acetabular fractures A 16-prospective epidemiology study.
225
JBJS(Br) 2005;87-B(7):969-973
226 227
2: Gary JL, Lefaivre KA, Gerold F, et al. Survivorship of the native hip joint after
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percutaneous repair of acetabular fractures in the elderly Injury, Int. J. Care Injured
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2001; 42:1144–1151
230 231
3: Papadakos N, Pearce R, Bircher MD. Low energy fractures of the acetabulum. Ann
232
R Coll Surg Engl 2014;96(4):297-301.
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4: Letournel E. Acetabulum fractures: classification and management. Clin Orthop
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Relat Res 1980;(151):81-106.
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5: Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of
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patients about total hip replacement. J Bone Joint Surg Br 1996;78(2):185-90
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6: Granhed HP, Karladani A. Bilateral acetabular fracture as a result of epileptic
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seizure: a report of two cases. Injury 1997; 28(2):65-68
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7: Friedberg r, Buras D. Bilateral Acetabular Fractures Associated With a Seizure: A
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Case Report. Annals of Emergency Medicine 2005; 46(3):260-262
245
246
8: Takahashi, Y., Ohnishi, H., Oda, K. et al. Bilateral acetabular fractures secondary
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to a seizure attack caused by antibiotic medicine. J Orthop Sci 2007 12;308-310
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9: Aynaci O, Kerimoglu S, Ozturk, C. et al. Bilateral non-traumatic acetabular and
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femoral neck fractures due to pregnancy-associated osteoporosis
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Trauma Surg 2008;128:313
Arch Orthop
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10: Rosa M, Maccauro G & D’Arienzo M. Bilateral acetabular fracture without
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trauma International Orthopaedics SICOT 1999;23:120
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11: Mauffrey C, Hao J, Cuellar D.O, et al. The Epidemiology and Injury Patterns of
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Acetabular Fractures Are the USA and China Comparable? Clin Orth and Rel
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Research. 2014;472(11):3332-3337
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12: Harvie P, Chesser TJS, Ward A. The Bristol regional pelvic and acetabular
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fracture service: Workload implications of managing the polytraumatised patient
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2008 Injury 39(8):839-43
263
24 Aug 2019 Journal of Orthopaedics Corresponding Author: Dr Jarrad M Stevens
Dear Editor and Team,
RE: Manuscript entitled - Bilateral Acetabular Fractures: Mechanism, Fracture Patterns and Associated Injuries.
CONFLICT OF INTEREST and DISCLAIMER: This study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research or the Department of Health and Social Care.
There is no grant money or financial support for this research or publication.
Dr Jarrad Stevens MBBS, ChM, FRACS, FAOrthA [email protected]
Age
Mechanism
Fracture Pattern according to Letournel
Treatment
Left
Right
Left
Right
DBO
Associated Injuries
Case 1
47
Mountain Bike
Transverse posterior wall
Posterior wall
ORIF, (KL)
ORIF (KL and TF)
2
Case 2
22
Road traffic collision
Transverse posterior wall
Transverse posterior wall
ORIF (KL)
ORIF (KL)
3
Stable thoracic vertebral fracture
Case 3
29
Fork lift crush injury
Anterior wall
Anterior Column posterior hemitransverse
ORIF (Stoppa)
ORIF Stoppa
Same
Open pelvis injury, Superficial femoral artery tear, complex mid-foot fracture
Case 4
16
Motor bike collision
Transverse posterior wall
Anterior Column posterior hemitransverse
ORIF (KL)
ORiF Stoppa
Same
Case 5
38
Road traffic collision
Posterior Wall
Anterior wall
Closed reduction, stable
ORIF KL
Same
Pelvic anterior-posterior compression 2 fracture, open femur fracture
Case 6
35
Road traffic collision
Transverse posterior wall
Transverse posterior wall
ORIF (KL TF)
ORIF (KL TF)
2
Pre-op sciatic nerve palsy, pneumothorax
Case 7
22
Road traffic collision
Posterior wall
Anterior wall
Closed reduction, stable
ORIF KL
Same
Case 8
45
Road traffic collision
Posterior wall
Posterior Wall
ORIF (KL)
ORIF (KL and TF)
1
Pipkin 4, scapula, bilateral lung contusions, Pelvic fracture lateral compression 1
Table 1: Open reduction Internal Fixation (ORIF), Kocherlagenbeck (KL), Trochanteric Flip (TF) osteotomy, Days Between Operation (DBO).
Bilateral Acetabular Fractures: Mechanism, Fracture Patterns and Associated Injuries.
AUTHORS: Jarrad M Stevens [1,2] , Sarah Shiels [1], Michael R Whitehouse[1,3,4], Anthony J Ward, [1], Tim J Chesser [1], Mehool Acharya [1]
Jarrad M Stevens, MBBS, ChM, FRACS, FAOrthA Sarah Shiels, MBChB, MRCS Michael R Whitehouse, BSc, MBChB, MSc, PhD, FRCS, PGCert, FHEA Anthony J Ward, FRCS Tim J Chesser, FRCS (Tr and Orth) Mehool Acharya, Bsc Hons, MBChB, FRCS(Tr and Orth)
INSTITUTION: 1: Department of Trauma and Orthopaedics , Southmead Hospital Bristol, BS10 5NB 2: St Vincent’s Hospital Melbourne, Australia 3: Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol, BS10 5NB 4: National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol
CORRESPONDING AUTHOR: JM Stevens Orthopaedic Surgeon Consultant Department of Trauma & Orthopaedics North Bristol Trust Southmead Hospital Bristol, BS10 5NB e-mail: [email protected]