Extended surgical approach effective for complex hip fractures, but complications high

Almost 60% of patients experienced heterotopic ossification, which was associated with significantly worse clinical outcomes.

The extended iliofemoral approach can be effective for surgical repair of complex acetabulum fractures. However, the technique is challenging to perform and is associated with a high incidence of complications, a new retrospective study shows.

“The extended iliofemoral approach is the most challenging of the standard three approaches and we recommend use of the ilioinguinal or Kocher-Langenbeck exposures whenever possible,” the authors said in the study.

“These are challenging injuries and are most effectively managed by surgeons who have subspecialty training in this aspect of orthopedic trauma,” they noted.

Joel M. Matta, MD, an orthopedic surgeon at the University of Southern California’s Samaritan Hospital, Los Angeles, conducted the study with colleagues in Huntsville, Ala., and in Ottawa. The researchers reviewed Matta’s experience using the extended iliofemoral approach to surgically repair complex and malunited acetabular fractures.

Their study included 106 patients treated between 1980 and 1997 and who had a minimum of two years postoperative follow-up. This included 67 men and 39 women with a mean age of 34 years; 64 cases involved the left hip, 42 the right.

Using the Letournel system, the researchers classified fractures as follows:

both column fractures, 64 cases;
transverse plus posterior wall, 15 cases;
T-shaped, 12 cases;
T-shaped plus posterior wall, seven cases;
transverse, four cases;
anterior column plus posterior hemi-transverse, three cases; and
anterior column, one case.

All patients had radiological evidence of fracture union after a mean follow-up of 6.3 years. The researchers graded the reduction as anatomical in 76 hips (0 to 1 mm of displacement; 72%), imperfect in 23 hips (2 to 3 mm of displacement; 22%) and as poor in seven hips (more than 3 mm of displacement; 6%).

Using a modified Merle d’Aubigné and Postel grading system, 24 hips had excellent results (18 points; 23%), 44 had good results (15 to 17 points; 41%), 20 had fair results (13 to 14 points; 19%) and 18 had poor results (less than 13 points; 17%), according to the study.

The accuracy of the reduction significantly correlated with the clinical results (P<.009), the authors said. Despite the overall clinical outcomes being good to excellent in most patients, there was a high risk of complications, they noted.

At the latest follow-up point, 29 hips (31%) had developed post-traumatic arthritis and three hips (3%) showed evidence of avascular necrosis. Ten hips (9%) subsequently underwent total hip replacement, three (3%) underwent arthrodesis and nine (8%) underwent heterotopic bone excision, according to the study.

Twenty patients (19%) had postoperative complications, including seven cases of infection, two hematomas and one case of wound edge necrosis. Postoperative sciatic nerve palsy also occurred in four patients (3.7%).

Additionally, 63 patients (59%) experienced heterotopic ossification, which the researchers graded as mild (grade 1) in 31 cases and as moderate or severe (grade 2) in 32 cases.

“We used no formal prophylaxis and had an incidence of 30.2% of moderate to severe [heterotopic] ossification,” the authors said.

“Patients who develop moderate to sever heterotopic ossification have a significantly worse clinical outcome and subsequent excision did not appear to reverse this trend,” they said, noting their study may be too small to detect an impact. “Effective prophylaxis measures may be helpful, and we currently use Letournel's protocol combining indomethacin and single-dose radiation,” they added.

For more information:
Griffin DB, Beaulé PE, Matta JM. Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the acetabulum. J Bone Joint Surg Br. 2005;87-B:1391-1396.