Fractura Acetabular

REVIEW ARTICLE

Operative treatment of displaced fractures of the acetabulum
A META-ANALYSIS
P. V. Giannoudis, M. R. W. Grotz, C. Papakostidis, H. Dinopoulos
From St James’s University Hospital, Leeds, England
Over the past 40 years, the management of displaced fractures of the acetabulum has changed from conservative to operative. We have undertaken a meta-analysis to evaluate theclassification, the incidence of complications and the functional outcome of patients who had undergone operative treatment of such injuries. We analysed a total of 3670 fractures. The most common long-term complication was osteoarthritis which occurred in approximately 20% of the patients. Other late complications, including heterotopic ossification and avascular necrosis of the femoral head, were present inless than 10%. However, only 8% of patients who were treated surgically needed a further operation, usually a hip arthroplasty, and between 75% and 80% of patients gained an excellent or good result at a mean of five years after injury. Factors influencing the functional outcome included the type of fracture and/or dislocation, damage to the femoral head, associated injuries and co-morbidity whichcan be considered to be non-controllable, and the timing of the operation, the surgical approach, the quality of reduction and local complications which are all controllable. The treatment of these injuries is challenging. Tertiary referrals need to be undertaken as early as possible, since the timing of surgery is of the utmost importance. It is important, at operation, to obtain the mostaccurate reduction of the fracture which is possible, with a minimal surgical approach, as both are related to improved outcome.

P. V. Giannoudis, BSc, MB, MD, EEC(Ortho), Professor M. R. W. Grotz, MD, Senior Registrar C. Papakostidis, MD, Trauma Fellow H. Dinopoulos, MD, AO Trauma Fellow Department of Trauma & Orthopaedics, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK.Correspondence should be sent to Professor P. V. Giannoudis. ©2005 British Editorial Society of Bone and Joint Surgery doi:10.1302/0301-620X.87B1. 15605 $2.00 J Bone Joint Surg [Br] 2005;87-B:2-9. 2

The work of Judet and Letournel began the changes which have led to the management of displaced fractures of the acetabulum by operation rather than conservatively.1 They recognised that the principlesapplied to the treatment of displaced articular fractures should also be applied to the acetabulum.2 Subsequently, open anatomical reduction of the articular surface combined with rigid internal fixation and early mobilisation became the standard treatment for these injuries.3-7 This approach led to a reduction in the incidence of post-traumatic arthritis and an improvement in the overalloutcome.3,4,8-10 However, certain of these fractures require extensile approaches and complications such as the extensive formation of haematoma, local or systemic infection, iatrogenic nerve injury and heterotopic bone formation have been described.3,4,11-15 We have carried out a comprehensive review of the literature concerning the classification and surgical management of displaced acetabular fractures andsubjected it to a meta-analysis in order to assess the incidence of post-operative complications and the functional outcome.

Materials and Methods Manuscript retrieval. Publications dealing with the management of acetabular fractures were identified from a Medline search between January 1966 and February 2004 using the OVID search engine16 with “acetabulum”, “acetabular”, “fracture” and “surgery”as keywords and with MeSH (Medline/PubMed’s article indexing terminology) subject headings. Full articles were retrieved and assessed for their suitability for review. The criteria for inclusion included reports on surgical treatment of displaced acetabular fractures in adolescent and adult patients, classification according to Letournel,1 operative treatment within the first four weeks following...