Complications With Delayed Or Revision Surgical Treatment

The most common serious complications following operative treatment of an acetabulum fracture include operative wound infection, iatrogenic nerve palsy, periarticular ectopic bone formation, and thromboembolic complications. Post trauma arthritis is the most common sequelae that can occur (Fig. 4) (1-3).

Post Wall Acetabular Fracture

Figure 2A—H Revision reconstruction of acetabular fracture. (Case contributed by Phil Kregor, MD.) (A) A displaced transverse plus posterior wall acetabular fracture with associated ipsilateral sacroiliac joint injury. (B-D) Postoperative anteroposterior (AP), iliac oblique, obturator oblique radiographs of the acetabular fracture operated through a Kocher-Langenbach approach (Continued).

Extensile Kocker Langebach
Figure 2A—H (Continued) (E) Postoperative computed tomography with illustration of malre-duction (Continued).

If the patient's general condition is good, and no associated injuries are present, the risk of infection should not be higher than for other types of hip surgery. Unfortunately, most patients with acetabulum fractures have associated injuries. These can include injuries of the abdominal or pelvic viscera or of the extremities. A bladder rupture or a bowel, rectal, or vaginal injury can increase the chance of operative wound infection and can influence the indications for operation (2,3). Open fractures of the ipsilateral lower extremity can also increase the risks for wound infection in the aceta-bulum fracture. Revision open reduction should not be performed until the original surgical wound is dry and free of signs of infection (4).

Wound infection does remain a danger, however, even without associated injuries. Infection occurred in 8 of 207 delayed acetabular repairs and 3 of 64 revision fixations

Risk Fracture Risk With Acetabular Met

Figure 2A—H (Continued) (F) The patient underwent revision open reduction internal fixation through an extended iliofemoral approach at 24 days post the original surgery. The obturator oblique radiograph is shown in this view. (G) Iliac oblique view film. (H) AP radiograph status postrevision open reduction.

Figure 2A—H (Continued) (F) The patient underwent revision open reduction internal fixation through an extended iliofemoral approach at 24 days post the original surgery. The obturator oblique radiograph is shown in this view. (G) Iliac oblique view film. (H) AP radiograph status postrevision open reduction.

Risk Fracture Risk With Acetabular Met

Figure 3A—F Case of a revision open reduction internal fixation of an acetabular fracture. (A) Initial anterioposterior (AP) radiograph demonstrating displaced both column acetabular fractures. (B) Postoperative fixation. The patient was operated through a Smith-Petersen approach with detachment of all of his abductors from the iliac wing. (C) Iliac oblique view of initial fixation demonstrating residual articular displacement (Continued).

Figure 3A—F Case of a revision open reduction internal fixation of an acetabular fracture. (A) Initial anterioposterior (AP) radiograph demonstrating displaced both column acetabular fractures. (B) Postoperative fixation. The patient was operated through a Smith-Petersen approach with detachment of all of his abductors from the iliac wing. (C) Iliac oblique view of initial fixation demonstrating residual articular displacement (Continued).

Late Complication Acetabular Fracture

Figure 3A—F (Continued) (D and E) AP, obturator oblique, and iliac oblique views following revision open reduction internal fixation through ilioinguinal approach. This revision open reduction was performed at two weeks following the original surgical intervention. (F) Follow-up AP radiograph at eight months post-revision surgery. The patient fortunately had regained near normal abductor function postoperatively.

Figure 3A—F (Continued) (D and E) AP, obturator oblique, and iliac oblique views following revision open reduction internal fixation through ilioinguinal approach. This revision open reduction was performed at two weeks following the original surgical intervention. (F) Follow-up AP radiograph at eight months post-revision surgery. The patient fortunately had regained near normal abductor function postoperatively.

Figure 4A-H A failed posterior wall reconstruction. (A) Obturator oblique radiograph of initial injury at presentation. The patient has a transverse plus posterior wall acetabular fracture with the major displacement in the transverse component in the posterior column. Instability of the hip is noted in these radiographs. (B) Demonstrates anterio-posterior (AP) radiograph following open reduction internal fixation. Careful examination of the radiograph illustrates that a substantial portion of the posterior wall is missing following open reduction internal fixation. This portion of the ilioischial line is also displaced. (C) Illustrates an iliac oblique view following initial open reduction internal fixation. The posterior column is seen to be malre-duced on this view. (D) Demonstrates instability of the hip with frank dislocation following open reduction internal fixation (Continued).

Late Complication Acetabular Fracture

Figure 4A— H (Continued) (E) Postoperative computed tomography scan illustrating that the majority of the posterior wall is missing, having been excised in the original open reduction internal fixation. (F) Attempt at reconstruction with an iliac crest bone graft is performed. (G) Demonstrates subsequent failure with erosion of the femoral head secondary to intra-articular wear and displacement of the femoral shaft. (H) Reveals salvage of this case with a hip arthrod-esis. With improvements in modern arthroplasty implants and results, hip fusion may be well accepted by patients and should be considered as a viable alternative.

Figure 4A— H (Continued) (E) Postoperative computed tomography scan illustrating that the majority of the posterior wall is missing, having been excised in the original open reduction internal fixation. (F) Attempt at reconstruction with an iliac crest bone graft is performed. (G) Demonstrates subsequent failure with erosion of the femoral head secondary to intra-articular wear and displacement of the femoral shaft. (H) Reveals salvage of this case with a hip arthrod-esis. With improvements in modern arthroplasty implants and results, hip fusion may be well accepted by patients and should be considered as a viable alternative.

(2,3). There is an increased risk of postoperative hematoma formation in the large wounds that are necessary for acetabulum surgery. Liberal use of suction drains should be employed (1). Hemostasis at the time of wound closure is always desirable. During the procedure, the large areas of exposed soft tissue should be kept moist and irrigated frequently with solution. It is often helpful to place moist sponges over exposed soft tissue to prevent desiccation. The surgeon should always strive to preserve soft tissue pedicles to all bone fragments to maintain vascularity of the bone (1-3). If a fragment is devascularized, it generally revascularizes rapidly as long as no infection develops. In the presence of infection, however, bacteria rapidly colonize an avascular fragment and it will usually need to be debrided and excised. Some bloody drainage can seep from the wound for the first one or two days after operation, although this should subside rapidly. It is not uncommon for a clear, yellow, serous drainage to be present for as long as 10 days after surgery without infection being present. If the wound has been benign for a number of days, however, and bloody or cloudy yellowish drainage then occurs, the patient should be returned to the operating room immediately for irrigation and debridement of the wound. If a wound hematoma is present, the amount of hematoma is usually much greater than initially suspected by inspecting the wound, and surgical drainage is indicated (1).

If infection is suspected, the surgeon should not wait for definitive results of wound culture but should proceed with reopening the wound on the clinical basis alone (1,10). If it is later found that no infection was present, little harm has been done, and a possible infection has been prevented. If an infection was present at the time of the earliest clinical suspicion, then the surgeon has acted properly by treating the infection expeditiously (10).

After evacuation of a wound hematoma, the wound is usually closed over suction drainage. In the case of debridement for infection, all implants that are stable and aid in the fixation are left in place. Avascular and infected bone fragments must be removed. If the diagnosis of infection is made early, before abscess formation, the wound can be closed over suction drainage tubes and appropriate antibiotic therapy instituted. Also, use of resorbable calcium sulfate mixtures that can be mixed with antibiotics and shaped into beads using molds can be used as local depots. These agents are useful when implants are left behind in an infected tissue bed and do not require removal as do traditional bone cement antibiotic depot methods. If the infection is extra-articular, it can probably be controlled successfully and the functional result will not be impaired. In the case of an intra-articular infection, however, the cartilage of the joint is almost invariably destroyed and hip function is significantly impaired (1-3,9).

Iatrogenic nerve palsy is caused almost exclusively by vigorous or prolonged retraction of the sciatic nerve. Sciatic nerve palsy occurred in 25 of 207 delayed fixations of acetabular fractures and 2 of 64 revision fixations, substantially more than in acute injuries (1-3). This occurs primarily with the Kocher-Langenbeck approach, and mainly involves the peroneal branch of the sciatic nerve. There is also a small chance of a stretch injury to the sciatic nerve with the extended iliofemoral approach, and a slight possibility of injuring the femoral nerve by stretch injury during the ilioinguinal approach, but this is unusual (1 -3).

The surgeon must constantly monitor the force and duration of pull that the surgical assistants place on the sciatic nerve. It is helpful to keep the patient's knee flexed at least 60°, and the hip extended whenever the Kocher-Langenbeck or extended iliofemoral approach is used (1). Neurologic monitoring with somatosensory evoked potentials and/or electromyography has been reported by several authors (11,12). This technique is not available in every center. If a nerve palsy develops, it is best treated with an ankle-foot orthosis. There is some chance for recovery of the sciatic nerve for up to three years following injury. Iatrogenic nerve palsies are often a form of axonotm-esis. The superior gluteal nerve can also be injured at the time of injury or at the time of surgical repair. Electromyography can be helpful in determining reinnervation of affected muscle groups. Tendon transfer procedures to correct a footdrop should not be performed during the initial three years.

Ectopic bone formation occurs almost exclusively with the lateral exposure of the innominate bone (1-3,7). The incidence of significant ectopic bone formation is highest with the extended iliofemoral approach, followed by the Kocher-Langenbeck approach; it is almost nonexistent with the ilioinguinal approach (1). Three of 207 fractures developed Brooker grade III or IV ectopic bone following delayed fixation of acetabular fractures [all occurred with the extended iliofemoral approach (EIF) approach] (3). Three of 64 fractures developed Brooker grade III or IV ectopic bone following revision fixation (2). Part of the prevention of ectopic bone formation should be directed toward choosing the ilioinguinal approach, whenever possible, and limiting muscle trauma during surgery by careful soft tissue handling. Indomethacin given in a dose of 25 mg tid perioperatively, and for several months following surgery, has been reported to be helpful in decreasing the incidence and extent of ectopic bone formation (13). A single dose of low dose (e.g., 500 Gray) radiation therapy is also very effective for prevention of hetertopic bone and may avoid the gastrointestinal side effects of indomethacin. The combination of indomethacin and postoperative radiation has been reported to be very effective at preventing nearly all heterotopic ossification (13). The surgical field should be debrided, devitalized tissue following completion of internal fixation of the acetabular fracture. Ectopic bone formation is influenced by the surgical approach, and probably also by the initial muscle trauma suffered by the patient. The combination of the two creates an inflammatory response that triggers the formation of bone.

Avascular necrosis of the femoral head occurred in 26 of 188 fractures with delayed reduction and fixation (3). Significant vascular injury occurred in 2 of 64 patients with revision fixation, both through the ilioinguinal approach (2).

There is significant potential for deep venous thrombosis and pulmonary embolism with fractures of the acetabulum (1,10). A 33% incidence of preoperative proximal deep venous thrombosis (DVT) detected with magnetic resonance imaging (MRI) venography has been reported (14). We normally use pneumatic compression boots on both lower extremities from the time of admission until the patient is fully ambulatory. In older patients and high-risk patients, partial anticoagulation is begun with heparin postoperatively (15). The patient is discharged to home with warfarin anticoagulation until they are ambulating actively, typically for three to four weeks following surgery (15). The level of anticoagulation with warfarin is maintained at about 1.5 times the normal international normalized ratio (INR) of 2 to 3. As warfarin management may be difficult and require frequent hematologic monitoring, as well as potentially complicating any emergent surgical procedure, the recent utilization of low molecular weight heparins has mostly supplanted oral coumadin use. The injections are well tolerated and side effects are minimal. Furthermore, if emergent procedures are required, their short half life avoids the issues found with warfarin. The duration of anticoagulation is not well elucidated but most commonly done for somewhere between 4 to 12 weeks and highly dependent on regional and individual preference. Although the potential for thromboembolic complications is always present, the surgeon must be cautious about too much anticoagulation because a large wound hematoma can have a devastating effect on the patient if a deep infection to the hip results.

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