Clinical Research And Meta-analysis Of Operative Treatment Of Acetabular Fractures

Although the incidence of acetabular fractures is relatively low which represents less than2%of all fractures, it has a high rate of mortality and disability as it is always caused by traffic accidents and associated with polytrauma. The pathological mechanism and treatment has long been studied by many researchers, and the philosophy and method of treatment has developed rapidly during the past decades based on the pioneering work of Letournel and Judet. Operation is a common sense for the displaced acetabular fractures nowadays, and early operation could not only shorten the time to ambulation and hospital discharge, and motivate the patient to rehabilitation exercise early, but also could avoid complications and reduce the rate of disability. The knowledge about acetabular fractures of the average orthopaedists is relatively limited because of the low incidence. The management of these injuries has become a sub-speciality with orthopaedics, and generally takes place in a tertiary referral setting.The factors which could affluence the outcome of acetabular fractures can be divided into controllable factors and uncontrollable factors according to the role of surgeons. The uncontrollable factors including patient age, fracture type, femoral head damage, dislocation of hip, medical comorbidities and associated injuries were decided during and even before the trauma which cannot be changed. Controllable factors which are under surgeon control and could be improved and reformed include surgical approach, reduction achieved and the avoidance of further complications.The department of trauma and orthopaedic of Nanfang hospital began the operation of the acetabular fractures comparatively early in our region. We knew how much the outcome of displaced acetabular fractures depends on the operative treatment and learn advantages of the modified Stoppa approach from experience. There are no convincing comparisons yet between the modified Stoppa approach and traditional ilioinguinal approach for the small number of cases. It is necessary to summarize the literature now available by the statistical method to compare the two approaches, evaluate the incidence of the complications and the influencing factors of acetabular fracture operations, and sum up the experience of the preventive measures.Part1:The clinical study of acetabular operative treatment of acetabular fracturesObjective:To investigate the clinical outcome of the operative treatment of acetabular fractures and sum up the relevant operation techniques and experiences.Methods:A consecutive cohort of47patients was treated operatively with use of modified Stoppa approach from March2008to April2012in our hospital. The major data including operation time, blood loss, blood transfusion, fracture reduction, the clinical evaluation score of Merle D’ Aubigne and postoperative complications.Results:47cases were analyzed in this study, including31men and16women with a mean age of37.4±11.7y (range,13to58y). The mean operation time was162.1±46.4min(range:80to260min) and the mean blood loss was693.8±129.7ml(range:500to1100ml) with a mean blood transfusion of306.4±196.9ml(range:0to600ml). There were32cases with anatomic reduction,11cases with satisfactory reduction and4case with unsatisfactory reduction with a satisfying reduction rate of91.5%. Based on the Merle D’ Aubigne clinical grading system modified by Matta,14cases show excellent results,20cases good,5fair and2poor. The excellent and good rate was82.9%.The radiographic manifestation was evaluated according to the Matta criteria.12cases were rated as excellent,19cases as fine,8cases as fair and2 case as poor with an excellent and good rate of75.6%. The complications are listed behind.1)1case of bladder laceration (3.2%):The bloody urine was not observed during the operation in the operative view, but the catheter was palpable before abdominal closure which indicated the laceration of bladder. The laceration was sutureed by a consultant from urinary surgery department. There was no postoperative infection after the drainage for2weeks.2) Heterotopic ossification was not observed in cases approached by the modified Stoppa.8cases (9.7%) which were approached by the combined K-L approach and anterior approach are diagnosed first grade heterotopic ossification.3)1case (3.2%) of femoral head necrosis was observed during the2year follow-up and the total hip arthroplasty was performed。4)3cases of sciatic nerve injury were observed before the operation. After neurotrophic treatment and rehabilitation therapy1case recovered completely, and2case recovered sense perception partly but remains nerve symptom of motion function. There were no cases of iatrogenic sciatic nerve injury, infection and deep vein thrombosis.Conclusion:The satisfying reduction rate of our casess is more than90%and the excellent and good rate according to the Matta criteria is near80%which is considered the outcome of the operative treatment with establishing satisfied reduction in acetabular fractures. According to our experience, a correct approach is of great importance for the acetabular fractures treatment to have adequate surgical view, reduce and fix the fracture. It could reduce the blood loss, shorten the operation time and avoid complications. According to our experience, the modified approach has the six following advantages comparing to the traditional ilioinguinal approach.1) It has a relatively simple anatomical structure. It is not necessary in ilioinguinal approach to sever inguinal canal as to avoid the damage to the femoral nerve, external iliac vessels bundle and spermatic cord or round ligament of uterus.2) It can expose the broad area from the symphysis ossium pubis to articulationes sacroiliaca especially the quadrilateral surface, and the surgeon can gain direct access to the acetabular fractures in the above area which could shorten the operation time notably. 3) The modified Stoppa approach dose not stip off the posterior lateral muscle of the hip from the joint, so the muscle around the hip recover sooner and the patient could gain vast majority of the abductor strength after the operation.4) Tendo conjunctivis inguinalis was spared and the possibility of abdominal hernia was reduced.5) It could be used to manage the bilateral acetablar fractures through one surgical approach.6) There is less soft tissue scar for the relative simple anatomical structure which could avoid the happening of heterotopic ossification around the hip and is convenient for the late total hip arthroplasty. But the above advantages could not be affirmed statistically for the lack of enough cases.Part2:Meta-analysis of the modified Stoppa approach comparing the traditional ilioinguinal approach in the operative treatment of acetabular fracturesObjective:To compare the modified Stoppa approach and traditional ilioinguinal approach in the operative treatment of acetabular fractures summarizing the literature now available.Methods:Clinical studies of modified Stoppa approach and ilioinguinal approach were searched in the data base of Pubmed、Cochrane library、Web of Science、Biosis Previews and Chinese sci-tech periodical full-text database from January1,1961to January1,2004. A proportion meta-analysis across the studies was performed for the operation time, blood loss, blood transfusion, anatomical reduction, clinical outcome and complications after acetabular operation with the use of R software.Results:16articles were analyzed in this study, including2perspective studies and14retrospective observational studies with a total of954patients. The clinical outcome satisfactory rate, anatomical reduction rate and specified complication rate in the relevant studies were homogeneity tested by the statistics of I2. There were8studies reporting clinical outcome with I2=0%,10studies reporting infection with I2=0%,11studies reporting serious heterotopic ossification with I2=35.4%,11studies reporting thrombogenesis with I2=25%,10studies reporting iatrogenic vascular injury with I2=7.2%and8studies reporting abdominal hernia with I2=0%during which the fixed effect model was used for the I2<50%. There are13studies reporting anatomical reduction with I2=79.8,12studies reporting total complication rate with I=85.1%and11studies reporting Iatrogenic vascular injury with I=79.1%during which the random effect model was used for the I2>50%.A proportion meta-analysis across the studies was performed with the use of R software. The incidence of infection, serious heterotopic ossification, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia with the modified Stoppa approach was4.74%(95%CI:2.87%to7.72%),1.54%(95%CI:0.69%to3.38%),5.04%(95%CI:2.80%to8.91%),3.42%(95%CI:1.87%to6.16%),2.6%(95%CI:1.24%to5.37%) and2.08%(95%CI:0.97%to4.42%). The incidence of infection, serious heterotopic ossification, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia with the ilioinguinal approach was6.31%(95%CI:4.06%～9.70%),7.76%(95%CI:4.2%～13.91%),3.11%(95%CI:1.56%～6.11%),8.86%(95%CI:2.93%～23.85%),4.54%(95%CI:2.04%～9.81%) and3.33%(95%CI:0.47%～20.20%).The P value between the two approaches was0.39,0.02,0.29,0.13,0.31and0.65. The total complication rate with the modified approach was12.49%(95%CI:7.78%～19.44%) and the total complication rate with the ilioinguinal approach was28.91%(95%CI:13.77%～50.87%). The difference between the two approaches is not of statistical significance with a P value greater than0.05. The anatomical redution rate of the modified appraoch and the ilioinguinal was70.46%(95%CI:61.33%～78.20%) and52.35%(95%CI:39.41%～64.98%) with a random effect model for the12=79.8%>50%. The diffenrece between the modified appraoch and the ilioinguinal was significant (P=0.02<0.05). The excellent and good rate of the modified appraoch and the ilioinguinal was87.06%(95%CI:81.27%～91.26%) and82.84%(95%CI:76.13%～87.97%) with a fixed effect model for the12=0%<50%. The diffenrece between the modified appraoch and the ilioinguinal was insignificant (P=0.28>0.05). Conclusion:Comparing with the ilioinguinal approach, the modified approach has a higher anatomical reduction rate and a lower complication rate such as serious heterotopic ossification, infection, thrombogenesis, iatrogenic nerve injury, iatrogenic vessle injury and abdominal hernia, but the difference between the approaches was only of statistical significance in the serious heterotopic ossification. The modified approach and the ilioinguinal approach has similar clinical outcome according to the long time follow-up.Part3:Mata-analysis of complications of operative treatment for the acetabular fracturesObjective:To provide a cumulative data about the complications of the operative treatment of acetabulum fractures in the literature with statistical methods and to sum up the influencing factors and preventive measures.Methods:A comprehensive search for all relevant articles in the data base of Pubmed、Cochrane library、Web of Science、Biosis Previews and Chinese sci-tech periodical full-text database published in English and Chinese from January1,2001to December1,2012was conducted. A proportion meta-analysis across the studies was performed for the complications such as heterotopic ossification, serious heterotopic ossification, osteoarthritis, avascular femoral head necrosis, iatrogenic nerve injury, postoperative infection and deep venous thrombosis after acetabular operation with the use of R software.Results:41articles were analyzed in this study, including9perspective studies and32retrospective observational studies with a total of3205patients. The specified complication rate in the relevant studies were homogeneity tested by the statistics of I2. There were34studies reporting heterotopic ossification with I2=92.6%,27studies reporting serious heterotopic ossification with I2=77.7%,29studies reporting serious osteoarthritis with I=81.0%,34studies reporting iatrogenic nerve injury with I2=76.9%,32studies reporting infection with I2=57.9%and20studies reporting deep venous thrombosis with I2=58.9%during which the random effect model was used for the I2>50%. There are27studies reporting avascular femoral head necrosis with I2=25.2%during which the fixed effect model was used for the I2<50%. The incidence of heterotopic ossification, serious heterotopic ossification, osteoarthritis, avascular femoral head necrosis, iatrogenic nerve injury, postoperative infection and deep venous thrombosis was20.1%(95%CI:14.6%to26.2%),5.3%(95%CI:3.2%to7.7%),15.2%(95%CI:11.8%to19.0%),5.6%(95%CI:4.6%to6.7%).5.1%(95%CI:3.3%to7.2%)、3.3%(95%CI:2.2%to4.7%) and1.4%(95%CI:0.4%to2.9%). The preventive effect of indomethacin is not of statistical significance with a P value greater than0.05.Conclusion:The overall incidence of heterotopic ossification is as high as20.1%(95%CI:14.6%to26.2%), but the incidence of serious heterotopic ossification is just5.3%(95%CI:3.2%to7.7%) which grades more than Brooker III and really affects the clinical outcome of acetabular fractures. The major preventive methods of heterotopic ossification include low dose irradiation, diphosphonates and non-steroidal anti-inflammatory. The irradiation could affects rapidly dividing cells by altering DNA transcription and preventing osteoblastic precursor cells from multiplying and forming active osteoblasts, but this prophylactic method has a trivial procedure and obvious side effects with relatively inexact curative effect which limit its clinic application. Diphosphonates is negated by relevant researches and the preventive effect of indometacin is also not supported by the statics data for the difference of the incidence of heterotopic ossification between the groups is not of significance (P=0.08>0.05) which cause the gastrointestinal bleeding, renal insufficiency, renal toxicity, and delay fracture healing.The leading cause of total hip arthroplasty is osteoarthritis and avascular femoral head necrosis. But the incidence of osteoarthritis and avascular femoral head necrosis was15.2%(95%CI:11.8%to19.0%) and5.6%(95%CI:4.6%to6.7%) with a sum percentage much more than the total hip arthroplasty rate during the follow-up which could be caused by the refusal of the less symptomatic patients and the possibility of data loss. So a longer and closer follow-up after the acetabular fracture operation is needs. The overall incidence of iatrogenic nerve injury is5.1%(95%CI:3.3%to7.2%), but the relevant incidence of a specified iatrogenic nerve injury differs according to the approach which indicate the preventive methods should also change with the approach. In general keeping the joint flexed according to the direction of the nerve, severing carefully and gentle traction during the operation will do help avoiding the iatrogenic nerve injury.According to our research deep venous thrombosis has the lowest incidence of1.4%(95%CI:0.4%to2.9%) among the common complications. But the data was only exactly accurate for the literature only recorded the symptomatic deep venous thrombosis and always ignored the asymptomatic ones. The actual incidence of deep venous thrombosis may be much larger than1.4%. Some researchers recommend the use of low molecular weight heparin during perioperative period with a good safety, but the data during this research is not enough to analysis its preventive effect.The incidence of infection after the operation is3.3%, and is not unusual according to our research. The infection is related to the approach, injury severity, obesity and local traumatic condition. The treatment of infection is troublesome, always need a long time to recovery and has a relative worse outcome. Prophylactic method should be recruited to avoid the occurrence of infection.