Treatment of Traumatic Acetabulum Lesions in an African Orthopaedic Trauma Department

Background: The management of traumatic acetabular injuries (TAI), which are often complex and diverse, is difficult and costly in the context of low-income African countries. Objective: To evaluate the treatment of traumatic acetabular lesions in the Orthopedics and Traumatology Department of the Yalgado Ouedraogo University Hospital, for their better management. Patients and Methods: This was a retrospective study, conducted in our department from January 2012 to December 2016. Sixty-three patients with TAI and complete records were selected. The mean age of patients with coxofemoral dislocations was 34.2 years and 36.4 years for acetabulum fractures with male predominance in both injury types. The injuries were mainly caused by a violent road traffic accident (RTA) (90.5%). Forty hip dislocations and 41 acetabular fractures were reported, with a prevalence of iliac dislocations (52.5%) and posterior wall fractures of the acetabulum (24.4%). Results: The average time to manage TAI was 15.9 hours (range 2 - 100). Medical treatment was performed in all patients. Thirty-eight coxofemoral dislocations and 34 acetabular fractures were treated by orthopedic methods. Seven complex acetabular fractures and two coxo-femoral dislocations were performed by surgical method. Two patients died (3.2%), one in a hemorrhagic shock table and the other in a septic shock table. Immediate and late complications were identified. Conclusion: Early and adequate management of our TAI, requires a modern technical platform and a sufficient number of qualified medical personnel to improve their functional outcomes.


Patients and Methods
This was a descriptive and analytical study with retrospective collection of medical records of patients with TAI between January 1, 2012 and December 31, 2016.

Inclusion Criteria
Patients with traumatic dislocation and/or fracture of the acetabulum and aged at least 15 years, admitted to the Orthopedic-Traumatology Department of the Yalgado Ouedraogo Teaching Hospital, and having a complete clinical file, were selected.

Criteria of Non-Registration
Excluded from our study: − Patients whose files were incomplete and therefore unusable; − Patients who have not been followed and treated in our service; − Patients who have been discharged against medical advice before being treated; − Patients with non-traumatic conditions of acetabulum.
We performed an exhaustive collection of patient data from medical records, open rum registers, trauma emergency registers, surgeon's consultation records and medical certificates. The data was collected on an individual file, entered on a microcomputer and analyzed with Epi Info TM Version 7.2.1.0 statistical analysis and statistics software in its French version. The graphics were made with the Microsoft Office Excel 2010 softwares.
The socio-demographic variables (age, origin, sex, occupation), etiological variables (circumstances, mechanisms and type of collision) and the consultation period were collated. The anatomo-clinical variables (affected side, functional signs, physical signs, anatomical type of dislocation, type of acetabular fracture, lesion association) were identified.
Therapeutic variables (time to treatment, reduction methods, post-reduction contentions, post-reduction outcomes and complications, post-treatment outcomes) were collected and the anonymity of the patients and the confidentiality of the medical information were collected. We have adopted the rating of Postel Merle d'Aubigné which takes into account both subjective and objective criteria (pain, walking and mobility) to evaluate our functional results; each parameter is rated from 0 to 6 ( The congruence between the femoral head and the roof of the acetabulum, and between the femoral head and the entire acetabulum, was evaluated according to the criteria of Duquennoy et al. [10]. This head/roof congruity "TT" has been qualified: − "TT3" Perfect: when the femoral head was well placed under the roof with normal spacing. − "TT2" Good: when there was a tilting of the roof but without loss of parallelism of the spacing. − "TT1" Passable: when there was a loss of parallelism between the lines without loss of total contact between the head and the roof. − "TT0" Bad: when there was a loss of contact between the roof and the femoral head.
The congruence head/acetabulum was qualified: − "TC3" Perfect: when independently of displacement, there is a parallelism between the femoral head and the roof of the acetabulum. − "TC2" Good: when one of the elements of the remaining acetabulum was no longer cast on the femoral head. − "TC1" Fair: when the femoral head was initially in a very oval acetabulum. − "TC0" Bad: when there was no longer any relationship between the head and the acetabulum.

Epidemiogical Aspects
A total of 63 exploitable records of patients with traumatic acetabulum injuries (TAI) have been identified in 5 years. The annual frequency was 12.6 patients. TAI accounted for 0.8% of the reasons for consultations. Forty patients (63.5%) consulted for coxofemoral dislocations associated or not with an acetabulum fractures. Forty-one patients (65.1%) consulted for a fractures of the acetabulum associated with or not to coxo-femoral dislocations, ie an annual frequency of 8 patients. More than half of the patients (54%) were transported by the National Fire Brigade. Patients referred (32%), direct admissions (13%) and patients transferred from another department (1%) constituted the other modes of admission to traumatic emergencies.
Forty-five men (71.4%) and 18 women (28.6%) presented TAI, a sex ratio of 2.5. Thirty-one men (77.5%) and nine women (22.5%) presented coxo-femoral dislocations. Acetabular fractures occurred in 29 men (70.7%) and 12 women (29.3%). All our patients were autonomous; no medical pathology was found in 56 patients (88.9%). In contrast, 7 patients presented with hypertension (4 cases), diabetes, asthma and schizophrenia (1 case each). Road traffic accidents  Table 2 shows the distribution of patients according to the type of collision and the type of injury. Injuries involving a car and a motorcycle were the most common (34.9%). The traumatic mechanism was most often direct (73%). In the indirect mechanism (27%), the point of impact was mainly the anterior flexion of the knee (dashboard), (17.5%).

Anatomical and Clinical Characteristics
The average consultation time was 11.6 hours (1 -96 Conventional radiography in incidence (face, profile and three quarters wing and obturator) was prescribed to confirm the diagnosis of the varieties of hip dislocations, but also for the diagnosis of fractures of the acetabulum. Computed tomography (CT) was performed in 16 patients (25.4%) and the lesions were clarified in 2 cases of pure irreducible coxofemoral dislocations and in 14 cases of acetabulum fractures. Four patients had a CT scan for severe CT and 1 patient a thoracic CT scan for thoracic trauma with ribs.
Our patient was released against medical advice (lack of financial means for surgical reduction) after 38 days of glued traction. We counted 22 pure hip-femoral dislocations; an association with acetabulum fractures was noted in 18 cases.
Associated lesions are shown in Table 5.
Serious and life-threatening lesions caused a general poor state of health with shock in 13 patients and poly-trauma in 7 patients. These lesions are illustrated in

Therapeutic Aspects
The average time to manage TAI was 15.9 hours (2 -100). Patients with coxofemoral dislocation were treated within an average of 17 hours (2 -74). The average time to treat victims of acetabular fractures was 20 hours (2 -100).       Figure 5). Table 8 provides summary of 7 patients treated by surgical method. Figure 5. 43-year-old patient, teacher, following a car crash against a tree, presented: A-a transverse juxta-articular and posterior wall fracture of the acetabulum; associated with iliac dislocation on the initial image of the right hip from the front; B-postoperative image in incidence 3/4 wing of a screwed plate osteosynthesis after orthopedic reduction of dislocation by the Boëhler method. The functional result was considered good. The post-reduction clinical assessment carried out in the event of coxofemoral dislocation associated or not with acetabular fractures had found a stable hip in 32 cases, long iso pelvic limbs in 38 cases, complete hip mobility found in 35 cases and no piston in 37 cases. Post-reduction medical imaging confirmed 36 concentric reductions (90%) in coxofemoral dislocations. The associated cutaneous openings were treated within an average of 5 hours (3 -12 hours). Fractures associated with TAI were treated within an average of 12.7 hours (2 -73 days).

Evolutionary Aspects
Two cases of death were reported (3.2%), one in a hemorrhagic shock table and the other in a septic shock table. Post-treatment complications included 13 pressure ulcers, 1 bronchopneumonia, 5 hypertensive attacks, 1 urinary tract infection, 1 secondary pubic dislocation after orthopedic reduction of acetabular fracture, 1 iatrogenic lesion of the ischial nerve, 1 peroperative hemorrhage, 1 surgical site infection, 1 periarticular ossification, 3 necrosis of the femoral head and 3 hip osteoarthritis. The average duration of hospitalization was 26.7 days (1 -63). A post-therapeutic improvement was observed in 31 victims of hip dislocations (77.5%) and 31 fractures of the acetabulum (75.6%). Only 7 patients (11.1%) were reviewed and evaluated. Only one patient had consolidated his fracture at 7 months. The reduction was good in one patient at 6 months of follow-up, but he suffered from persistent pain in the hip. As for the quality of life, one patient had total autonomy, five patients had partial autonomy and one patient was not autonomous. According to Merle d'Aubigné, Matta and Duquennoy et al. [9] [10], the reduction was anatomical in 1 case, satisfactory in 5 cases, unsatisfactory in 1 case, with satisfactory head-to-head congruence; the functional results were very good (1 case), good (5 cases) and bad (1 case). The evolutionary results are specified in Table 9.

Discussion
Despite some limitations and constraints, our five-year retrospective study of recent acetabular trauma allows us to make some comments. The mean age of 34.2 years of patients with hip dislocation and 36.3 years of acetabulum fractures in our series, is in the age range indicated by Rabah et al. [11] (31 -35). The male predominance of TAIs can be explained by the fact that the male population appears to be the most active, the most mobile, the most reckless and also the most vulnerable in traffic accidents. This fact is corroborated by the report of the Ouagadougou municipal police on road accidents in the capital in 2013, which indicates that 68.4% of accident victims were men [9]. Left hip dislocations accounted for (52.5%), left acetabulum fractures (48.8%) predominated with 4 bilateral forms (9.8%). Seven irregular dislocations were noted. Of the 33 regular dislocations, the posterior variety was the most common (51.5%) followed by pubic varieties (15.2%). The predominance of iliac or posterior hip dislocation, may be explained by the mechanism of injury, physiology, and anatomical structure of the posterior hip area. According to the Letournel and Judet  classification, elementary acetabular fractures were the most common (57.8%).
Fractures of the posterior wall predominated (26.8%). Because of the velocity and violence of the trauma, TAIs occur in a context of poly trauma. The seat and the severity of the associated lesions vary. All parts of the body are prone to injury. This is the finding already made by Chagou et al. [12], who noted 45% associated lesions, 20% of which were serious lesions, mainly cranioencephalic (10%) and thoracic (10%) trauma. Standard radiography is the main method of diagnosing acetabulum trauma. As pointed out by Burdin et al. [13], the threequarter wing and obturator incidences of the acetabulum make it possible to confirm the types of lesions. The mean duration of management was 15.9 hours (2 -100) in our study. Orthopedic reduction by the Boëhler method was performed in 95% of hip dislocations. Surgical reduction by the Kocher-Langenbeck approach was performed in two cases of irreducible coxofemoral dislocations (5%). Pietu [1] reports that 96.67% of patients received orthopedic treatment compared to 3.33% for blood reduction. The average orthopedic reduction time was 17.5 hours (4 -102) while the blood reduction time was 14 hours (12 -16). These reduction times are longer than those recommended by Pietu [1] who specified that the ideal time should not exceed 6 hours and if possible be less Open Journal of Orthopedics than 24 hours. The predominance of orthopedic reduction may be explained by the fact that this method is inexpensive, easier to perform and does not require a particular strategy or longer experience. The insufficiency of our technical platform and the absence of a qualified surgeon for the acetabulum surgery, reinforce the choice of the orthopedic method. The reduction period is a crucial element in the evolution and prognosis of coxo-femoral dislocations. The long reduction period of our series (11.6 hours) can be explained by the long consultation time (on average 11.6 hours). Orthopedic reduction by acetabular fracture bed traction was the most common in our series (82.2%). On the other hand, Meyer et al. [2], Chagou et al. [12] performed orthopedic treatment (62.5%), in trans-tibial or condylar traction for 15 to 45 days. Our insalubrious hospital environment obliges us to prefer glued traction to transosseous traction which carries an infectious risk. Only 07 acetabular fractures were surgically treated after orthopedic traction. The Kocher-Langenbeck approach was used for the osteosynthesis of acetabular fractures, while Hue et al. [3] recommend the extended ilio-femoral approach, which allows a strictly anatomical surgical reduction of complex acetabular fractures, to "save" the hip. Mean operative time for acetabular fractures was 33.8 days (12 -90). Like Chagou et al. [12], four screwed plate and three screw fixation osteosyntheses were performed in the acetabular fractures of our series. The insufficient number of orthopedic surgeons, the low socio-economic level of the patients, the high cost of the surgical interventions, the under-equipment of our technical platform, the long delay of care and the non permanent availability of the products of resuscitation (globules red, whole blood and platelet concentrates), explain the predominant choice of the orthopedic method in our series. Like Pietu et al. [1], Burdin et al. [13], Barsotti et al. [14], the post-reduction traction of the coxo-femoral dislocations of our series was performed for 26.2 days (1 -48). This traction was followed by a discharge for three weeks, followed by four weeks of loading and functional rehabilitation of the hip. In our series, transosseous traction was not performed due to poor hospital hygiene. The average duration of traction was 25.8 days (2 -50). Nazarien et al. [15], Pietu et al. [1] proposed a functional treatment of 5 to 6 weeks without traction in case of stable fracture, the passive mobilization is possible after one week and increases between 2 and 5 weeks; full support may be allowed between 75 and 90 days. In case of displaced fracture, they recommend transcondylar traction for 45 days with decreasing weight; a loading is then possible after three months. Iatrogenic lesions of the ischial nerve, infection of the operative site, and extensive bleeding were perioperative and postoperative complications. Decubitus complications included 13 pressure ulcers, one urinary tract infection, one bronchopulmonary disease and three hypertensive attacks. A pubic dislocation secondary to a reduction of fracture dislocation of the acetabulum was noted. Late complications included necrosis of the femoral head, periarticular ossification, and three hip osteoarthritis. Osteosynthesis of acetabular fractures yielded 1 very good, 5 good and 1 poor result. Except for the small number of cases observed, our evolutionary results are much weaker than those of the li-terature. This low rate could be explained by the fact that a small number of our patients were reviewed as well as the very high number of discharges against medical advice (22%). The rehabilitation of the degraded and narrow roads, the intensification of the sensitization of the populations on the respect of the elementary rules of the highway code (eviction of the drunk driving, the speeding, the surcharges) can contribute to reduce the frequency of traffic accidents. The training of firefighters on emergency medical procedures in addition to emergency care, a medical transport system for the wounded through the UAS (Universal Hospitality Service), the increase in the number of orthopedic surgeons will allow early and more effective TAI management. The fight against the poverty of the populations, the application of the universal health insurance for all the patients of emergencies, the modernization of our technical platform, the reinforcement of the organization and the coordination of the work (institution of protocols taking into traumatological emergencies, postgraduate teaching on the management of polytrauma and TAI) may facilitate the treatment of these lesions in order to obtain more perforating functional results.

Conclusion
The profile of the TAI patient is this active young man, aged 25 to 35, who suffered a violent hip injury following a traffic accident. This violence of the shock also explains the lesional association. Radiography of the front pelvis and 3/4 wing and obturator oblique X-rays allow the diagnosis of TAI; CT is sometimes a contributory factor in the lesional balance of acetabulum fractures. The left hip is the most affected. Among the 40 coxofemoral dislocations recorded, the iliac or posterior high variety predominated. Of the 41 acetabular fractures, 4 were bilateral; elementary fractures (57.8%), represented mainly by posterior wall fractures (42.3%), predominated. Treatment of TAI was mainly orthopedic: 95% of coxofemoral dislocations and 82.2% of acetabular fractures. Reduction difficulties were found in two cases of obturator dislocation, which led us to perform the surgical reduction. Only 7 acetabular fractures were treated by the surgical method. The non-respect of the follow-up appointments, did not allow us to correctly analyze the evolutionary aspects. Improving the therapeutic management of TAI requires the improvement of our technical platform. To do this, a comprehensive prospective study incorporating all these parameters is essential.