Surgical Treatment and Prognosis of Acetabular Fractures Associated with Ipsilateral Femoral Neck Fractures

Abstract

Combined ipsilateral acetabular and femoral neck fractures are the result of high-energy trauma. Satisfactory treatment for this injury pattern remains a challenge, since traditional open reduction and internal fixation (ORIF) is always accompanied by a high prevalence of posttraumatic arthritis and avascular necrosis of the femoral head. Eight of 502 acetabular fractures from 1990 to 2008 were diagnosed with combined ipsilateral femoral neck fracture, in which 5 patients’ fractures were associated with hip dislocation. These patients were injured from falls, traffic accidents, or crushing accidents. Radiographs and computed tomography scans were taken to check acetabular and femoral neck fractures. All of the patients underwent surgery using appropriate approaches and techniques. Postoperative radiographs demonstrated anatomic or satisfactory reduction for acetabular fractures as well as excellent or good reduction for femoral neck fractures in all of the patients. Follow-up radiographs showed femoral head necrosis in the 5 patients with femoral head dislocations, but not in the other 3 patients. We have seen few patients with this injury pattern, which makes us unable to detect significant differences between the patients associated with femoral head dislocation and those without femoral head dislocation. But by considering the results of our study and those reported in the literature, we believe that for patients with ipsilateral acetabular and femoral neck fractures without hip dislocation, satisfactory results could be expected after ORIF. But for those cases associated with hip dislocation, alternative methods such as acute THR as primary treatment are worthy of consideration.

Combined ipsilateral acetabular and femoral neck fracture may be the result of high-energy trauma. The incidence of this injury pattern among acetabular factures in the literature ranged from 1.2% to 3.6%.^1-3 Among the 502 acetabular fractures admitted to our department from 1990 to 2008, only 8 cases were diagnosed with combined ipsilateral femoral neck fracture, yielding an incidence of 1.4% comparable to those of Judet et al¹ and Heeg et al.³

A few reports have described the clinical features of this injury pattern.^1-6 But how to treat it remains a great challenge. Traditional open reduction and internal fixation (ORIF) is accompanied by a high prevalence of posttraumatic arthritis and avascular necrosis of the femoral head, resulting in a need for total hip replacement (THR). Furthermore, part of this injury pattern may be associated with femoral head dislocation,⁴ which makes treatment decision making even more difficult. However, it is important that a preferable method be chosen if better outcomes are expected. This study presents 8 consecutive patients diagnosed with ipsilateral acetabular and femoral neck fractures between October 1990 and January 2008.

Materials and Methods

Between October 1990 and January 2008, eight consecutive patients suffered with ipsilateral acetabular and femoral neck fractures including 6 men and 2 women with a mean age of 38 years (range, 22-55 years). Five injuries resulted from a fall, 2 from traffic accidents, and 1 from a crushing accident.⁷ Of these patients associated with brain or visceral injuries, 5 were combined with shock, and 5 had other fractures. All patients were checked radiographically with anteroposterior (AP) and Judet views of the pelvis. Computed tomography (CT) scans and 3-D reconstructions were also taken. According to Letournel’s classification for acetabular fractures,⁸ 2 posterior wall fractures, 1 posterior column, and 1 posterior wall fracture, 2 transverse and posterior wall fractures, 1 transverse fracture, and 2 column fractures were found. Femoral neck fractures were classified using Garden’s criteria,⁹ resulting in 2 patients classified as stage III and 6 as stage IV. Radiographs and CT scans demonstrated ipsilateral superoposterior hip dislocations and femoral neck fractures in 5 of 8 patients. All fractures underwent primary ORIF 5 to 21 days after the injury following the treatment of concomitant life-threatening injuries. The Table presents the detailed demographic data of the 8 patients.

Surgical Technique

All patients underwent skeletal traction preoperatively. We treat femoral neck fractures using ORIF first, and then treat acetabular fractures are treated using ORIF. This sequence was used in the hope that the retinacular vessels of the femoral neck could be protected from further injury during acetabular fracture reduction. If the femoral neck fracture and hip dislocation had already been reduced satisfactorily via skeletal traction, the femoral neck fracture was fixed using cannulated screws under C-arm surveillance. Next, the patient was repositioned for ORIF of acetabular fractures. If the femoral neck fracture and hip dislocation were not reduced satisfactorily by skeletal traction, an appropriate approach fit for all fractures, if possible, was chosen. Likewise, the hip dislocation and femoral neck fractures were reduced and fixed first, followed by acetabular ORIF. As a rule, the Kocher-Langenbeck approach was chosen for posterior column and posterior wall fractures. A combined Kocher-Langenbeck and ilioinguinal approach was used for transverse and both column fractures.

Prophylactic antibiotics were administered routinely pre- and intraoperatively, and continued for 24 to 48 hours postoperatively. Suction drains were used for 24 to 48 hours. All patients sat up 3 to 4 days postoperatively. Moderately passive motion or static muscle contraction exercises of the affected extremities were encouraged. After staying in bed for 7 to 12 days, walking on crutches with partial weight bearing was allowed for 6 to 8 weeks, and then a single crutch was allowed for 4 to 6 weeks until discarded.

Evaluation Method

Reduction quality of the acetabular and femoral neck fractures were assessed, respectively, using criteria described by Matta¹⁰ and Haidukewych et al.¹¹ Follow-up radiographs were assessed for fracture healing, posttraumatic arthritis, heterotopic ossification and avascular necrosis of the femoral head. Heterotopic ossification was graded according to the Brooker et al method.¹² Long-term hip function and follow-up radiographs were assessed according to D’Aubigné and Postel¹³ and Epstein¹⁴ standards, respectively. To minimize interobserver error, 2 orthopedic fellows not involved in the management of the patients and blinded to the clinical and radiographic results reviewed all of the radiographs.

Results

No nerve or vascular complications, infections, or death occurred in this group. Postoperative radiographs demonstrated that anatomical reductions (no or <1 mm of displacement at the articular surface) of the acetabular fracture were achieved in 6 patients (75%) and satisfactory reductions (no more than 3 mm of displacement) in the remaining 2 (25%). All of the femoral neck fractures were reduced as excellent or good. No patients were lost to follow-up in this series. The patients were followed for an average of 9 years (range, 1-18 years), and the fractures in all patients healed eventually. All 5 patients with combined hip dislocations developed avascular necrosis of the femoral head (100%) (Figure). The majority of them occurred as early as 1 year postoperatively, and the others were ascertained 2 to 3 years postoperatively. They underwent THR 1 to 4 years after the primary ORIF because of severe loss of hip function.

Figure: A 31-year-old man involved in a traffi c accident who sustained ipsilateral acetabular and femoral neck fractures combined with a dislocated hip. Preoperative AP (A) and obturator oblique (B) radiographs of the hip. Radiographs taken immediately after ORIF (AP view [C], obturator oblique view [D]). AP radiograph taken 6 months postoperatively (E). All fractures healed successfully. Radiograph taken 1 year postoperatively showing avascular necrosis of the femoral head (F).

As for the 3 patients without femoral head dislocation, no radiographic signs of avascular necrosis or moderate or severe posttraumatic arthritis were discovered until recent follow-up. Among them, 1 patient who suffered from combined brain injury began to display Brooker stage III heterotopic ossification 6 months postoperatively. Mild posttraumatic arthritis signs were found on the latest radiographs for this patient, but hip functions were good. The other 2 patients exhibited good clinical and radiographic results.

Discussion

Mears et al⁷ reported that after ORIF, 14 of 15 patients (93%) suffered from combined ipsilateral femoral neck and acetabular factures developed into avascular necrosis of the femoral head. This incidence is higher than those for displaced femoral neck fractures (Garden III or IV, 30%-40%)¹⁵ and displaced acetabular fractures (5.6%),¹⁶  as well as acetabular fractures combined with hip dislocations (7.5%-9.6%).^8,17 Similarly, 5 of 8 patients (63%) in the present study suffering with the same injury developed avascular necrosis of the femoral head.

Displaced femoral neck fractures and fracture-disclocations of the hip are always accompanied by a high incidence of avascular necrosis of the femoral head, which may be caused by delayed reduction or the degree of the fracture displacement.^18-21 But Bhandari et al²² reported that the avascular necrosis incidences were not influenced by the period from injury to reduction. In this series, follow-up results showed that all of the patients who developed avascular necrosis of the femoral head were those who suffered with acetabular and femoral neck fractures combined with femoral head dislocation, while the prognosis seems not related to the delay of 5 to 21 days from injury to operation. Thus, we believe that the major reason for the high necrosis rate in this series may be the high-energy trauma that damaged the blood supply to the femoral head at the time of injury. Accordingly, we believe that high necrosis incidence is the main clinical feature of this complex injury pattern.

As for the treatment of this injury pattern, considering the fact that most of the patients suffering this sort of complex injury are relatively young manual laborers, ORIF as primary treatment is the preferred method. If initial ORIF is successful, the native joint, which is better than a prosthetic one, could be used for a lifetime. If severe posttraumatic arthritis or avascular necrosis of the femoral head develops, the primary ORIF can optimize acetabular bone stock and minimize pelvic deformity and bone defect, which is beneficial to the required THR.

Surgeons must keep in mind that the majority of patients may develop avascular necrosis of the femoral head after ORIF and need eventual THRs. This will increase not only trauma and suffering for patients, but also overall medical costs. Additionally, scar tissue, heterotopic bones, retained internal fixators, as well as possible infections after primary ORIF would present challenges to surgeons and may increase the complications related to THR.

Thus, another method may be considered, which was to perform acute THR under special conditions, including those acetabular fractures combined with a displaced femoral neck fracture.²³ The advantages of acute THR include the potential of 1-stage treatment with quicker recovery and avoidance of technical difficulties, as well as the possible complications related to the primary ORIF. The distinct disadvantages of acute THR for acetabular fractures are the major technical challenges of obtaining both socket and fracture stability simultaneously.^23,24 Another concern is that the majority of orthopedic surgeons may be reluctant to accept an acute THR because of the possible revision surgery later, especially for a young patient. But it is interesting that Mears et al²³ observed that the best late results of THR after acetabular fracture have been documented when the arthroplasties were performed acutely, and no convincing documented evidence that primary ORIF improves the success of a subsequent THR exists. Although the authors did not mean to advocate acute THR for acetabular fractures, it is a choice worthy of consideration.

We acknowledge that few patients were in this study as a result of the rare incidence of this injury pattern. Thus we are unable to detect significant differences between patients according to whether they had femoral head dislocations. However, Mears et al²³ reported that a small group of displaced acetabular fractures patterns, including those combined with displaced femoral neck fractures, as well as a delay between the injury and the surgery, have a low likelihood for a favorable outcome after ORIF. These are exactly the characteristics of the patients in the present study. By considering the results of the present study and keeping in mind the characteristics of such an injury pattern, we believe it is reasonable to conclude that for those associated with hip dislocation, acute THR seems to be a choice worthy of consideration, while for those without hip dislocation, primary ORIF may be a suitable method.    

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Authors

Dr Wei is from First People’s Hospital of Yibin, Yibin, and Mssrs Sun, Wang, and Yang are from First Affiliated Hospital of Soochow University, Jiangsu, China.

Dr Wei and Mssrs Sun, Wang, and Yang have no relevant financial relationships to disclose.

Correspondence should be addressed to: Jun-Ying Sun, MS, First Affiliated Hospital of Soochow University, 188 Shizi St, Suzhou, Jiangsu 215006, People’s Republic of China.

doi: 10.3928/01477447-20110317-30