For both column, acetabular and high anterior column acetabular fractures (62A3.2, 62A3.3, 62B3.2, 62B3.3, and 62C), we reduced and fixed all pelvic ring injuries and high acetabular fractures (which exited above the AIIS) sequentially from posterior to anterior. The anterior fixation was with an INFIX for rami or symphysial injuries. Then, low fracture lesions were subsequently addressed (Fig. 3, see Figure 3, Supplemental Digital Content 2, http://links.lww.com/JOT/A624) similar to that described by Cai et al.3
All patients had heterotopic ossification (HO) prophylaxis with single dose radiation. Patients were progressed to full weightbearing status at 12 weeks postoperatively. The INFIX was removed at 12–20 weeks. We coordinated its removal with procedures for other injuries if possible.
The mortality rate for pelvic fracture patients at our institution was 8.5% (103/1193); for acetabular fracture patients, it was 4% (20/504); and for combined injury patients, it was 5.7% (10/174 combined patients were included in both acetabular and pelvic fracture data). The average ISS was reported as 15.5 for pelvic fractures, 12.03 for acetabular injuries, and 12.5 for all combined injuries. For the 39 operated patients in this study, average ISS was 21.7. The mortality rate and ISS for our combined injury patients are similar to those reported in the literature (see Table 1, Supplemental Digital Content 3, http://links.lww.com/JOT/A621).
Of the 174 combined injuries, those excluded from study were injuries that required the pelvic ring or acetabulum fracture reduced and fixed but not both, were lost to follow-up, or were not treated according to protocol (before 2009). Therefore, 39 patients with 41 acetabular injuries (2 bilateral) were included for study. Three of the pelvic ring injuries were open (see Table 2, Supplemental Digital Content 4http://links.lww.com/JOT/A622). Of these 39 patients, 27 were male and 13 were female with an average age 37.5 years (range 16–79 years). Five patients had posterior hip dislocations, which required relocation. Initial femoral traction was used preoperatively to maintain the femoral head reduced in the acetabulum for a number of the patients. AO/OTA and Young and Burgess pelvic ring and acetabular fracture classifications are listed in Supplemental Digital Content 4 (see Table 2, http://links.lww.com/JOT/A622).
Twenty-three patients had initial temporizing fixation followed by definitive fixation, and 16 patients had complete fixation at one setting. Temporizing measures included external anterior pelvic fixation (23 pts) ± antishock SI screws (5 pts)16 and traction for the acetabular injury either shanz pins in the femur connected to the external pelvic fixation or with a femoral traction pin. The 39 patients had on average 2.15 surgeries for pelvic and acetabular fixation during their initial hospitalization range 1–3. One patient had 9 surgeries due to infection. The average follow-up was 22 months, ranging from 6 to 96 months. Reductions of the acetabulum were anatomic in 25 (61%), imperfect in 12 (29%), and poor in 4 (10%) by the Matta criteria. The pelvic reductions measured by the KI are shown in Supplemental Digital Content 4 (see Table 2, http://links.lww.com/JOT/A622). There were 39 excellent and 2 good reductions with regard to pelvic symmetry. The 3 vertical shear injuries were all reduced to less than 1-cm superior displacement. All the fractures healed and were progressed to full weightbearing by 12 weeks postoperatively, as per protocol.
Majeed outcome scores were included for 36 patients with follow-up greater than 6 months, being excellent in 13, good in 15, fair in 3, and poor in 5. Three of the 5 patients with poor outcomes had a sciatic nerve palsy from their injury, 2 had severe HO (1 patient with both a sciatic nerve palsy and HO) related to pelvic ring and femoral shaft fractures, and 1 patient had chronic low-back pain, an occipital condyle injury and was not walking despite healing of her pelvic/acetabular injury with anatomic acetabular reduction even a year after the injury. We were unable to correlate excellent outcomes with excellent reductions because some patients with excellent reductions had a poor outcome and our numbers were limited. There were 3 patients who went on to THA (ages 35, 37, 47) and another that was scheduled at the time of latest follow-up and was doing poorly with their original fixation.
Major complications include 3 patients with deep infection (one that required 9 surgeries to stabilize the infection and one secondary to an extensive Morel-Lavallee lesion), 4 patients with significant HO of which 2 had surgical excision (Fig. 4), and 3 patients with persistent sciatic nerve palsy (1 iatrogenic).
Combination injuries of the pelvis and acetabulum make up between 5% and 14% of cases that present with pelvic ring or acetabular injuries in reported series5 and in our series 10%. These injuries may be undisplaced or have a major pelvic or acetabular component with a minor component of the other injury that does not require much attention.5 They need to be evaluated according to the ATLS protocol14 to treat initial hemodynamic instability, placement of pelvic binders/sheets, and identify concomitant injuries, open fractures, and neurological deficits. Displaced combination injuries need to be treated in a coordinated fashion at a hospital with multidisciplinary capability. The use of temporary external pelvic stabilization may not be adequate when a high anterior column or a both column acetabular fracture is present. The use of a pelvic sheet with femoral traction in one or both legs is simple and may accomplish what is required until a definitive plan is organized.
Combination pelvic/acetabular injuries have a higher ISS than isolated acetabular injures and similar to pelvic injuries at our institution. Although the 174 patients only had an ISS score of 12.5, the 39 operated patients in our report had an ISS of 21.7 ± 11.6, which was higher than the collective group of pelvic, acetabular, or combined injuries in our database and similar to operated pelvic injuries that we have previously reported 22.75 ± 11.2 (median 21, range 5–57)13 and similar to reported by Osgood et al.1
Mortality rates for combination injuries (174) were reported as 5.7%, which is lower than that reported for pelvic fractures 8.5% at our institution (not significant). This is something that has been reported previously.5 At our institution, early deaths are caused by hemorrhage in the first 24 hours followed by head injury and multisystem organ failure after 48 hours.17
Our treatment protocol for these injuries considered if the acetabular fracture is a component of the pelvic ring injury as in an associated both column acetabular fracture or with an anterior column injury exiting above the AIIS (62A3.2, 62A3.3, 62B3.2, 62B3.3, and 62C). For these injuries, we fixed the pelvic ring posteriorly and then worked back to front considering each iliac wing separately finally connecting the anterior ring with an INFIX device. The remaining low acetabular injury is treated subsequently. In acetabular fractures that were transverse, T type, or wall fractures (62A1, 62A2, 62A3.1, 62B1, 62B2, and 62B3.1), we fixed the pelvis first and dealt with the acetabular fracture after. In these injuries, reducing the pelvis first often helped with acetabular fracture reduction and in some cases allowed for percutaneous fixation of the acetabulum or using only a subsequent Kocher-langenbeck approach. The INFIX device was helpful in holding the reduction in these cases just as an external fixator would, but we could leave the INFIX in and mix it with internal fixation in these cases (Fig. 3). Also in the past, using rigid fixation in the front of the pelvis (ie, a plate) before fixing a posterior column fracture often lead to trouble with reduction, this is not affected with INFIX because the front remains mobile (Fig. 4). We have no comparison with any other protocol in treating these injuries to say that our approach is better or even as good as another protocol, and we found that this approach served its purpose for all the injuries that we have cared for. Cai et al3 recommended a posterior to anterior fixation approach as well.
We had a fair amount of reductions we deemed anatomic from the Matta criteria on Anterior–Posterior and Judet views in the early post-op period. Lefaivre et al felt that this criteria was difficult to reproduce or may have poor interobserver reliability.18 Unfortunately, there is no validated criteria of acetabular reduction, and the judgment of perfect or offset on the 3 acetabular views is likely as good a criteria as any, and this is the most used criteria in acetabular surgery articles. Determining pelvic reduction is another issue. The KI that assesses pelvic asymmetry is a good measure for lateral compression injuries as it can tell asymmetry, but for APC injuries, it is not as reliable as symmetrical displacement returns good scores. We also added an excellent, good, and fair–poor scale for this, which is loosely based on <10% excellent, 10%–20% good, and >20% fair or poor. For vertical shear injuries, vertical displacement was assessed on the AP or outlet view to gauge displacement as well as the KI and was assessed as decently reduced in all cases.
Pelvic fractures tend to heal and so do acetabular injuries, and we did not find any nonunions in this series.
Outcomes scores showed 28/36 (78%) of the patients with good (15) or excellent (13) outcome and 22% with a fair (3) or (5) poor outcome. A fair or poor outcome was associated with severe HO in 1 patient, an imperfect reduction and severe HO in 1, imperfect or poor acetabular reduction and a persistent sciatic nerve palsy in 3, a poor acetabular reduction in 2, and in 1 patient with an anatomic acetabular reduction but chronic lumbar back pain and inability to mobilize independently. Hip replacement has good outcomes and is a good solution when there is a poor outcome with an acetabular fracture caused by malreduction. This will not solve a sciatic nerve palsy or HO. Unfortunately, patients who went on to total hip replacement were young (35, 37, and 47 years old).
Complications included 3 deep infections. They were dealt with a return to the operating room obtaining deep cultures, retention of hardware, debridement and irrigation with closure of a suction drain, or a wound vac. One patient had an extensive hospital stay due to 9 surgeries for this issue, which included antibiotic beads and delayed primary closure. Despite HO prophylaxis with a single dose of radiation, 4 patients developed significant HO to the point that it needed to be excised as the hip had ankylosed. Three patients did well, and 1 patient reankylosed his hip and walks with essentially a hip fusion but little pain (He also had a head injury) Figure 3.
The limitations of this article include the fact that it is a small case series of a complex problem, which is not that prevalent. So, many questions about treatment cannot be definitively answered except that we used this protocol, and it seemed to work for us. As more articles are published about combination injuries, a consensus can eventually be formed.
We feel from our limited work on this topic that these injuries are associated with multiple other injuries (high ISS), and their mortality rates are similar to pelvic injuries. These injuries tend to heal, and we did a good job of reducing the pelvic component of the injury. Functional outcomes of the injury at our institution depended on how well we reduced the acetabulum and if we avoided complications such as infection or severe HO. A persistent sciatic nerve palsy also resulted in a poor outcome in 3 patients.
1. Osgood GM, Manson TT, O'Toole RV, et al. Combined pelvic ring disruption and acetabular fracture
: associated injury patterns in 40 patients. J Orthop Trauma. 2013;27:243–247.
2. Suzuki T, Smith WR, Hak DJ, et al. Combined injuries of the pelvis and acetabulum: nature of a devastating dyad. J Orthop Trauma. 2010;24:303–308.
3. Cai L, Lou Y, Guo X, et al. Surgical treatment of unstable pelvic fractures with concomitant acetabular fractures. Int Orthop. 2017;41:1803–1811.
4. Gänsslen A, Pohlemann T, Paul C, et al. Epidemiology of pelvic ring injuries. Injury. 1996;27(suppl 1):S-A13–S-A20.
5. Halvorson JJ, Lamothe J, Martin CR, et al. Combined acetabulum and pelvic ring injuries. J Am Acad Orthop Surg. 2014;22:304–314.
6. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;151:81–106.
7. Vaidya R, Colen R, Vigdorchik J, et al. Treatment of unstable pelvic ring injuries with an internal anterior fixator and posterior fixation: initial clinical series. J Orthop Trauma. 2012;26:1–8.
9. Dalal S, Burgess A, Siegel J, et al. Pelvic fracture
in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989;29:981–1000.
10. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78:1632–1645.
11. Keshishyan RA, Rozinov VM, Malakhov OA, et al. Pelvic polyfractures in children: radiographic diagnosis and treatment. Clin Orthop Relat Res. 1995;320:28–33.
12. Lefaivre KA, Blachut PA, Starr AJ, et al. Radiographic displacement in pelvic ring disruption: reliability of 3 previously described measurement techniques. J Orthop Trauma. 2014;28:160–166.
13. Majeed SA. Grading the outcome of pelvic fractures. The J Bone Joint Surg Br. 1989;71:304–306.
14. ATLS Subcommittee; American College of Surgeons' Committee on Trauma; International ATLS working group. Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg. 2013;74:1363–1366.
15. Vaidya R, Oliphant BW, Hudson I, et al. Sequential reduction and fixation for windswept pelvic ring injuries (LC3) corrects the deformity until healed.Int Orthop. 2013;37:1555–1560.
16. Gardner MJ, Chip Routt ML Jr. The antishock iliosacral screw. J Orthop Trauma. 2010;24:e86–e89.
17. Vaidya R, Scott AN, Tonnos F, et al. Patients with pelvic fractures from blunt trauma: what is the cause of mortality
and when? Am J Surg. 2016;211:495–500.
18. Dodd A, Osterhoff G, Guy P, et al. Radiographic measurement of displacement in acetabular fractures: a systematic review of the literature. J Orthop Trauma. 2016;30:285–293.
pelvic fracture; acetabular fracture; combined injury; INFIX; mortality; injury severity score; outcome score
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