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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 6  |  Page : 862-868

Effects of the incısıon preference ın acetabular surgery on the postoperatıve functıonal outcomes


1 Department of Orthopaedic Surgery and Traumatology, Medical Faculty, Trakya University, Edirne, Turkey
2 Department of Anesthesiology, Medical Faculty, Trakya University, Edirne, Turkey

Date of Acceptance25-Mar-2019
Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. M Erem
Trakya Universitesi Tip Fakultesi Ortopedi ve Travmatoloji AD, Edirne
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_455_18

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   Abstract 


Background: Many factors are known to affect the functional outcomes of the acetabular surgery. The aim of this study is to evaluate the effects of incision preferences and number of incision on scores and clinical functional outcomes. Patients and Methods: Forty-seven adult patients who had undergone acetabular surgery and had been followed up for at least 1 year in our clinic were included in the study. Demographic data, trauma type, acetabular fracture type based on the Judet ve Letournel classification, presence of any additional traumatic fractures, time to surgery, operation duration, surgical technique, and postoperative complications were recorded. Range of motion measurements, SF-36 and Harris Hip function scale score, and full weight-bearing times were evaluated on the postoperative first year follow-up and reviewed retrospectively. Results: Our study suggests that use of double incisions in the surgery of associated fractures shortens the full weight-bearing time. The localization and the number of incisions were found to be unrelated with the Harris Functional Hip scale, SF-36 (PCS, physical component score), and SF-36 (mental component score, MCS) scores. Conclusion: Incision type and number of incisions must be determined based on the fracture type and fracture localization for better functional outcomes. The factors that have the most effects on the functional outcomes are the type and the localization. In associated fractures, performing multiple incisions reduces the time for full weight bearing and enables patients to return to their daily routine early but have no effect on the functional outcomes.

Keywords: Acetabulum fractures, functional outcomes, incision, surgical treatment


How to cite this article:
Erem M, Copuroglu C, Copuroglu E, Ciftdemir M, Ozcan M, Saridogan K. Effects of the incısıon preference ın acetabular surgery on the postoperatıve functıonal outcomes. Niger J Clin Pract 2019;22:862-8

How to cite this URL:
Erem M, Copuroglu C, Copuroglu E, Ciftdemir M, Ozcan M, Saridogan K. Effects of the incısıon preference ın acetabular surgery on the postoperatıve functıonal outcomes. Niger J Clin Pract [serial online] 2019 [cited 2019 Sep 15];22:862-8. Available from: http://www.njcponline.com/text.asp?2019/22/6/862/260035




   Introduction Top


Surgical and conservative treatment outcomes have not accomplished the desired level in acetabular fractures as a result of factors such as the anatomical complexity of the region and these types of fractures being rare and thus surgeons being less experienced. Acetabular fractures are intra-articular fractures and there is no certain manual to achieve treatment success since authors have been controversial about the best treatment method.[1],[2]

Our study aims to evaluate the effects of incision types and the number of incisions on the functional outcomes of the acetabular fractures.


   Patients and Methods Top


The study was conducted in accordance with the Declaration of Helsinki and the study design was approved by the Local Ethical Committee (Trakya University Faculty of Medicine Ethical Committee, Decision No. 03/04). Forty-seven adult patients (age >18 years old) who had undergone acetabular surgery and had been followed up for at least 1 year in Trakya University Department of Orthopaedics and Traumatology between 2009 and 2014 were included in the study.

Demographic data (age, gender), trauma type, additional traumatic fractures, the duration between the operation and the trauma, operation duration, surgical technique, blood and blood products transfusion need, postoperative complications (neural deficit) were recorded retrospectively.

Radiography archives were reviewed in order to determine the type of the acetabular fractures based on the Judet ve Letournel classification and the complexity of the fractures were determined. All patients were invited to the follow-up examinations on the 3rd, 6th weeks, and the 6th, 12th months and all the examinations were performed by our team. Range of motion values, SF-36 and Harris Hip function scale scores, and full weight-bearing times were evaluated in the postoperative follow-up examinations.

Patients who did not pay the follow-up visits were not been able to contact and patients with no preoperative data were excluded from the study.

The most appropriate incision type for each patient was determined based on the type of fractures according to the Judet ve Letournel classification. Reduction criteria were accepted to be less than 2 mm joint stepping and adequate fracture stabilization. As the joint reconstruction being the priority, acetabular plates and screws were shaped appropriately and stabilization was performed using Buttress plates and screws. Passive joint exercises were applied on the 1st postoperative day to all the patients. Range of motion values (loss of flexion, internal rotation, external rotation, abduction) were measured with the goniometer and the lost motion based on the comparison of the opposite joint was recorded in degrees.

Extremity length measurements were performed by measuring the superior anterior iliac spine and medial malleolus distance. The circumference measurements were perfomed by taping the point 10 cm above the upper limbus of the patella and comparing with the other leg. Life quality scales (SF-36 scores, physical component score = PCS, mental component score = MCS)[3] and Harris Hip Function Scale[4] were applied to the patients in the outpatients clinic and their scores were recorded.

Standard prophylactic treatments for infection and thromboembolism were applied to all patients and neither infection nor thromboembolism occurred. No reduction loss and no material failure were present.

Statistical analyses were performed by using the SPSS Software, version 19.0. The conformability of the countable data to the normal distribution was checked using the one-sample Kolmogrov--Smirnov Test and group comparisons of the countable data with normal distribution were made using the independent group t-test, whereas in group, comparisons were evaluated by using the paired group's t-test. ANOVA test was used to evaluate the data with abnormal distribution pattern. P < 0.005 was accepted as statistically significant.


   Results Top


Forty-seven adult patients (mean age 45.34 ± 16.6 years) who had undergone acetabular fracture surgery with either the anterior or the posterior incisions and double incisions (both anterior and posterior) were included in our study. 80.9% (n = 38) were male and 19.1% (n = 9) were female.

Trauma origins were passenger car crashes in 53.2% (n = 25), motor vehicle/pedestrian crashes in 21.3% (n = 10), and fall from heights in 23.4% (n = 11).

Based on the Judet and Letournel classification, 44.7% (n = 21) were elementary fractures and 55.3% (n = 26) were associated fractures [Table 1].
Table 1: Comparing the loss in the range of motion based on the Judet and Letournel

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All patients underwent acetabular surgery about 5.32 ± 3.4 days after the trauma. In 76.6% (n = 36), single incision was performed, whereas in 23.4% (n = 11), double incisions were performed. Distribution of the incision types were anterior incision in 38.3% (n = 18), posterior incision in 38.3% (n = 18), and double incisions (both anterior and posterior) in 23.4% (n = 11).

Out of the 26 patients with associated fractures, single incision was performed in 65.4% (n = 17) and double incisions were performed in 34.6% (n = 11).

Mean hospitalization time was 16.66 ± 14.4 days, full weight-bearing time was 13.21 ± 3.1 weeks and the first year follow-up exam SF-36 subscores (PCS and MCS scores) and Harris Hip function scale score being 43.34 ± 13.2, 47.94 ± 10.66 and 84.31 ± 11.1, respectively.

When full weight-bearing times were compared between the elementary and associated fracture groups based on the Judet ve Letournel classification, full weight-bearing time was found to be 13.9 ± 3.41 weeks in elementary fractures and 12.61 ± 2.91 weeks in associated fractures. This difference was not statistically significant (P = 0.154).

Mean full weight-bearing time was found to be longer in the single incision group compared with the double incision group with 13.86 ± 16 weeks and 11.1 ± 2.25 weeks, respectively, and this difference was statistically significant (P = 0.004).

Mean full weight-bearing times were found to be 13.35 ± 3.53 weeks in the anterior incision group, 14.2 ± 2.79 weeks in the posterior incision group, and 11.1 ± 2.25 weeks in the double incision group. Mean full weight-bearing time was found to be significantly shorter in the double incision group compared with the anterior incision group and the posterior incision group (P = 0.042, P = 0.099, respectively) and no statistically significant difference was detected between the anterior incision group and the posterior incision group (P = 0.474) [Table 2].
Table 2: Evaluation of the full weight-bearing time, Harris Hip Function Scores, SF-36 (PCS), and SF-36 (MCS) scores based on the number and region of the incisions

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Harris Hip function scale scores and SF-36 (PCS and MCS) scores in relation to the number and the location of incisions are shown in [Table 2]. Regarding the incision location, no statistically significant difference in the Harris Hip function scale scores and mean SF-36 (PCS and MCS) scores was detected between groups (P > 0.05) [Table 2].

Range of motion loss values were compared between the elementary fracture and associated fracture groups. Although there were no statistically significant differences regarding the flexion and internal rotation range was detected between groups (P > 0.05), loss in external rotation and abduction were found to be significantly higher in the associated fracture group (P < 0.05) [Table 1]. There were no statistically significant differences between groups, when incision types and number of incisions were compared based on the range of motion values (P > 0.05).

Only one patient was found to have neural injury due to the operation.


   Discussion Top


Although decades ago the aim of the treatment in multi-trauma patients was to achieve survival, recently the life quality of the patient after the survival has gained certain importance. As most of the acetabular fractures occur during high energy traumas, the primary evaluation and the intervention should be performed on the vital functions. Acetabular fractures are treated after the vital findings are stable.

The diagnosis, classification, and treatment of the acetabular fractures have been controversial. In the older publications, acetabular fractures were named based on the direction of the dislocation, later the majority of cases with incomplete reduction were noticed and this led to fractures gaining more attention than the dislocations.[5],[6],[7]

Careful radiological evaluation is compulsory for better understanding of the fracture and the intra-articular fracture components in acetabular fractures. Therefore, radiography and CT evaluations are considered as adequate.[8],[9],[10],[11] According to the Letournel' s study in 1993, these methods do not supply accurate and detailed information about the fracture and in most cases the surgeon can only fully diagnose the fracture during the operation.[11] In our study, we classified patients based on the Judet and Letournel classification by reviewing the archived radiographies and CT scans in the PACS system. Thus, 21 patients were found to have elemantary fractures and 26 patients had associated fractures which showed that both fracture types similarly common in our study.

Many authors have concluded that the clinical outcomes depend on the reduction quality in surgically treated fractures and treatment outcomes are better in surgical treatment compared with the conservative treatment.[7],[11],[12],[13],[14] We aimed to provide anatomic reduction and early joint motion by performing open reduction and internal fxation and thus enabling patients to return to their normal daily routines [Figure 1]. It should be noticed that the displacement is not a factor to determine the treatment choice. Displacement region is as important as the extent.[15],[16] For example, milimetric disintegrations or steppings on the weight-bearing surface are more important than the displaced fractures of the anterior and posterior columns.[11],[17] Since the fundamental aim of the surgical treatment is to provide anatomical reduction, incision preference is also important. In some fractures, more than one incision is required for adequate reduction and stabilization. The most important factor for achieving a successful anatomical reduction is the incision preference.[11],[18] The main aim of the surgery is achieving the anatomical reduction and fixation with a simple incision if possible.[11]
Figure 1: Preoperative 3D CT (a-c) and postoperative standard anteroposterior pelvic radiography (d), Judet's 45° obturator pelvic radiography (e), Judet's 45° iliac pelvic radiography (f)

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When we evaluated the incision distribution and the fracture types based on the Judet and Letournel classification [Figure 2], we have found that double incisions are required in associated fractures. Therefore, preoperative preparation of the associated fractures was performed in accordance with the need of double incisions. Thus, surgery started with either anterior or posterior incision while reduction and fracture stabilization were performed. No additional incision was performed if the preoperative range of motion values were considered to be sufficient. In patients with insufficient stabilization, a second preoperatively planned incision was performed.
Figure 2: Judet and Letournel classification (Elemantary (simple) Fractures: Posterior wall fracture, posterior column fracture, transverse fracture, anterior column fracture, anterior wall fracture. Associated (complex) Fractures: Posterior column + posterior wall fractures, transverse + posterior wall fractures, T-shaped fracture, anterior wall/column + posterior hemitransverse fracture, bilateral-column fracture.) (Case courtesy of Dr Benoudina Samir, Radiopaedia.org, rID 46833)

Click here to view


Full weight-bearing times were shorter and duration of surgery was longer in patients with double incisions than in patients with single incision patients. When single incision and double incisions were compared regarding the range of motion values and hospitalization time, no statistically significant difference was detected. It was considered that range of motion values were closely related to the fracture type. Therefore, the range of motion values and fracture types based on the Judet and Letournel classification were re-compared. Since no problems which could affect the hospitalization time such as the surgical wound problems or infections were present, we suggest that the number of incisions does not affect the hospitalization time.

Surgery should not be postponed more than 10 days in cases with more than 2 mm displacements or open fractures with intra-articular fragments. Delay of surgery for more than 10 days will make reduction harder as a result of the granulation tissue formation. Many authors support the surgery to be performed within the 2nd--8th posttraumatic days.[11],[13],[14],[19] The mean time of acetabular surgery was 5.32 ± 3.4 days in our study.

Many surgical approaches regarding the acetabular fracture reduction have been identified. Some authors suggest limited incision while others suggest major surgical exploration. The common and the most important point in all the various fracture types is to achieve a prevailing approach to the fracture site.[11],[20],[21] As far as we know, there are no studies comparing the number and the types of incisions and functional outcomes in the literature. Therefore, we planned our study on this subject.

In our study, ilioinguinal approach via anterior incision was performed in 38.3% (n = 18), Kocher--Langenbeck posterior incision was performed in 38.3% (n = 18), and the combination of these two incisions was performed in 23.4% (n = 11). Medial stoppa incision was performed in one patient and this patient was included in the anterior incision group.

In their studies, Letournel,[11] Matta,[14] Ridder et al.,[22] Ruesch et al.,[23] Fica et al.,[24] and Meir Liebergall et al.[25] reported the surgical success rate as 87%, 84%, 75%, 81%, 68%, and 77%, respectively. In our study, we did not evaluate the radiological findings of reduction but rather evaluated the functional clinical outcomes. We suggest that the functional success of the treatment requires more attention. Better functional outcomes and less limitation in the functionality have been reported with the anatomical reduction of the joint surfaces in acetabular fractures.[26]

We must also draw attention to the fact that “the good anatomical reduction leads to good functional outcomes” motto does not always apply to the acetabular fractures.[27],[28] In his series, Matta emphasized that good reduction did not always guarantee great functional outcomes. Matta suggested that this was due to good anatomic reduction being based on the radiological imaging methods which could be deceptive. Matta also emphasized that conservative treatment still had an important role in the treatment of acetabular fractures.

Partial weight bearing could be started at the 8th postoperative weeks if no material failure or reduction loss findings are present. Full weight bearing can be started at the 12th--14th weeks.[11]

In our study, mean full weight-bearing time was 13.5 weeks in the anterior incision group, 14.2 weeks in the posterior incision group, and 11.2 weeks in the double incision group. There was a statistically significant difference between the incision preference and the full weight-bearing time. Full weight-bearing time was found to be shorter in the double incision group compared with the anterior incision and the posterior incision groups. There were no statistically significant differences regarding the full weight-bearing time between the anterior incision group and the posterior incision group. In accordance with the previous literature, our findings show that double incision leads to a stronger stabilization which enables earlier full weight bearing.

In our study we compared the range of motion values of the hip joint with the opposite joint. Limitation of degrees in motion was recorded as the result. There were no statistically significant differences regarding the limitations in flexion and internal rotation between the elementary and associated fractures. Limitations in external rotation and abduction were found to be significantly higher in elementary fractures. This can be as a result of most elementary fractures being either the posterior limbus fractures or the transverse fractures of the weight bearing parts which make the joint reduction harder. Most of the fractures in the associated fractures were the fractures of both columns. Therefore, reduction was performed better. We believe that the evaluation of the range of motion values in a more homogenous fracture group would provide more reliable results.

SF-36, which is a generic scale that enables wide range evaluations, was developed by the Rand Corporation in 1992. The availability and the reliability of the SF-36 into Turkish were performed by Kocyigit et al.[29] SF-36 which has 8 subscales is a gold standard scale for evaluating the health-related life quality.[30]

Use of SF-36 for evaluating the life quality after acetabular surgeries is rare in the literature.[31]

In their study, Sahin et al.[32] compared fracture types and SF-36 scale and found a statistically significant increase in elementary fractures compared with the associated fractures regarding the role limitations due to physical health, role limitations due to emotional problems, energy/fatigue, social functioning.

In our study, we compared the localization and the number of incisions with the SF-36 scores and did not find any statistically significant differences. We suggested this difference could have been a result of patient responses to SF-36 being affected by their characteristic features and emotional states. Therefore, we decided to add a more objective scale and added the Harris Hip function score to our evaluation.

There were no statistically significant differences between the groups regarding the number and the localization of incisions and the Harris Hip function scores. This finding supported the previous. Combination of two different scales enabled our evaluation to be more objective. Regarding the SF-36 scores, acetabular fractures due to high energy traumas were found to affect the life quality severely. Mean scores of the Harris Hip function scale showed that our surgical outcomes were good in average. Four patients had poor scores, 10 had fair scores, and 22 had good scores in our study. Three patients with poor scores had an associated fracture accompanied by an additional extremity fracture. One patient with poor score had an elementary posterior limb fracture and accompanied hip dislocation. Although the radiological evaluation of the surgery did not seem to be related with any problems, we suppose the functional scores being low in these patients were due to their concurrent injuries.

Our criticism about the Harris Hip function scale is that its scores are low in percentage, which indicates the priority of the scale is the daily adaptation of the patient rather than the range of motion values. For example, even if the patient regained full range of motion, the Harris Hip function score will be low if the patient cannot provide his/her daily needs due to pain.

Our study had short-term follow-up and we did not detect any radiological arthrosis. Our study has some limitations as being a restrospective study and having a limited study group.

In conclusion, in intra-articular acetabular fractures, the most possible anatomic reduction should be performed. Generally in elementary fractures, anatomic reduction and stable fracture fixation is provided with single incision. Especially in associated fractures, in order to achieve good surgical outcomes, the type and the number of incisions should be determined based on the type and the localization of the fracture. Our study suggests that use of double incisions in the surgery of associated fractures shortens the full weight-bearing time and thus enables the patients to return to their daily routines in a shorter period, although it has no effect on the functional outcomes.


   Conclusion Top


The limitations in abduction and external rotation being higher in the elementary fracture group suggest that the functional success of the treatment depends on the type and the localization of the fracture. Since good reduction does not always guarantee good functional outcomes in acetabular fractures, further long-term studies on the potential variables that affect the functional outcomes should be performed in larger groups.

Acknowledgements

We would like to acknowledge www.makaletercume.com for their outstanding scientific proofreading and editing services that was provided for this manuscript.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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