Radiological outcomes according to Matta radiographic criteria after surgical fixation of acetabular fracture.

doi:10.21203/rs.3.rs-4979820/v1

Background.

Acetabular fractures, a rising concern in developing countries, pose a significant challenge due to their complexity and association with post-operative complications. Often caused by high-energy mechanisms like falls and motor vehicle accidents, these fractures require accurate reduction to prevent long-term issues and potential need for hip replacement. This study investigates the radiological outcomes of acetabular fracture surgery at six months, focusing on the effectiveness of achieving anatomical reduction using the Matta criteria in a low- and middle-income country (LMIC) setting.

Methods and material.

This prospective study was conducted at a tertiary care center in Pakistan from May 2023 to December 2023, with ethical approval. Patients with isolated acetabular fractures were recruited. Preoperative X-rays and CT scans classified fractures using the Judet and Letournel Classification. Six-month postoperative X-rays were assessed using Matta radiographic criteria. Appropriate statistical analysis was deployed with a significance level set at p < 0. 05.

Results

A total of 33 cases met the study criteria, with an average patient age of 43.2 years. Males constituted 87.9% of the cases. Longer hospital stays were associated with poorer outcomes (p < 0.001). Fracture patterns were significant predictors of outcomes (p < 0.001). Six months post-surgery, 45.5% of patients had excellent results, 24.2% had good results, and 15.2% each had fair and poor results according to the Matta radiographic criteria. Avascular necrosis (AVN) developed in 9.1% of patients. Of the ten patients with femoral head dislocation, only one developed AVN

Conclusion.

This LMIC-based study investigated factors affecting outcomes in patients with acetabular fractures treated using ORIF. We found a younger patient population compared to high-income countries, and injury patterns suggested a link to the local environment (e.g., traffic accidents). Optimizing hospital stay and timely surgery improved radiological outcomes as assessed by Matta criteria. While limitations exist, the study supports using Matta criteria in LMICs. Future research with larger, multicenter designs incorporating function is needed. Importantly, our findings highlight the need for a new LMIC-specific classification system considering factors like comminution and femoral head dislocation to improve surgical planning and outcomes.

Acetabular fractures

developing countries

demographics

hospital stay

fracture patterns

Matta criteria

radiological outcomes

ORIF

LMIC-specific classification

Acetabular fractures, primarily resulting from high-energy trauma are complex and challenging injuries. Treating these fractures has consistently posed significant challenges for orthopedic surgeons.(1–3). With an annual incidence of 8.1 per 100,000 persons these fractures are rare. (4) However, the incidence is increasing, particularly in developing countries. (5) The majority of acetabular fractures are caused by high-energy trauma, with 80.5% resulting from road accidents and 10.7% from falls from height. (6) Although less common, acetabular fractures can also result from low-energy falls, such as fragility fractures in osteoporotic patients. (7–9)

These fractures are more often seen in young active patients and have been associated with a high rate of post injury complications. (10) The displacement of the fracture fragments causes hip joint incongruency, leading to pain and an inability to bear weight, which results in functional disability. If left untreated, this can lead to necrosis of the femoral head and hip arthritis, necessitating second and third surgical intervention to prevent further complications.(7)

It is well known fact that displaced fractures of the acetabulum are best treated with anatomical reduction and rigid internal fixation. The main goals are joint surface congruency, stability and early mobilization. However, the anatomical complexity of the hip joint makes it very difficult for reduction and internal fixation. (7) If accurate reduction (displacement of less than 3mm) is achieved these complications can be prevented and the need for total hip arthroplasty can be delayed for approximately 25 years in 79% of the patients even in the elderly population.(11–13) On the contrary, poor reduction, fracture displacement of more than 2mm, dislocation and later surgery would likely have poor outcomes in terms of functionality and pain.(8, 14, 15)

Open Reduction and Internal Fixation of the Acetabulum is a common procedure at our institute. The objective of this study is to determine the radiological outcomes of the acetabular fractures, six months post-procedure using the Matta radiographic criteria. (7) The Matta radiographic criteria provide a convenient, fast, and effective tool for assessing and grading the radiological outcomes of surgical repair of acetabular fractures.

Although numerous studies have evaluated outcomes following acetabular fracture repairs, our study addresses a critical gap by focusing on a low- and middle-income country (LMIC) setting. This is significant because the challenges and limitations in LMICs such as limited resources, varying levels of surgical expertise, and diverse patient demographics can profoundly influence treatment outcomes. By providing data specific to an LMIC context, our study aims to offer insights that are currently underrepresented in the literature.

This prospective study was conducted at a tertiary care center hospital in one of the largest cities of Pakistan attracting a diverse population from all sorts of background. All the appropriate ethical approvals were obtained (ERC reference number: 2022-0525-22307). Between May 2023 and December 2023, all patients presenting to the clinic or emergency department with acetabular fractures were recruited. Only patients with isolated acetabular fractures were included, while those with concomitant femoral head injuries or other fractures, as well as those undergoing arthroplasty within six months of initial acetabular osteosynthesis, were excluded. Additionally, patients without a six-month follow-up and those initially operated outside AKUH were excluded from recruitment.

Upon recruitment, preoperative X-rays and CT scans were meticulously reviewed to determine the type of fracture according to the Judet and Letournel Classification. (16) Subsequently, X-rays taken at the six-month postoperative follow-up were examined, and the Matta radiographic criteria were calculated based solely on radiological outcomes.(14) The collected data were tabulated and then thoroughly reviewed to generate the results presented in this paper.

During the review of X-rays, variables that could potentially influence the procedure's outcome and, consequently, the Matta radiographic criteria were also assessed. These variables included the types of fractures, the presence or absence of femoral head dislocation, and the visibility of intra-articular fragments in the preoperative radiographs.

The results were analyzed using descriptive statistics and comparisons among various groups. Categorical data were summarized as proportions and percentages, while discrete (quantitative) data were presented as means with standard deviations (SD).

A total of 33 cases met the criteria for this study. The average age of patients was 43.2 years. years. Age distribution showed a statistically significant relationship with injury severity (p = 0.509), with individuals aged 25–30 and those over 50 years old comprising the majority of cases. Gender also exhibited a notable correlation (p < 0.001), with males (87.9%) constituting a significantly higher proportion of injuries compared to females (12.1%). Length of hospital stay (LOS) demonstrated a strong association with outcomes (p < 0.001), with a longer LOS being linked to poorer outcomes. Detailed descriptive and analytical analysis of the variables are given in Table 1 and Table 2 respectively.

Table 1

Radiological outcomes using Matta score
Variable	Excellent	Good	Fair	Poor	Total	P value
Age						0.509
25–30	11	4	3	2	20
< 25	0	1	0	0	1
> 50	5	2	2	3	12
Gender
						< 0.001
Male	15	7	5	2	29
Female	1	0	0	3	4
LOS						< 0.001
< 7	10	2	2	1
> 7	6	5	3	4
ASA Grade						0.766
1	5	2	2	1
2	5	3	1	2
3	6	1	2	1
4	0	1	0	1
Days between injury						0.048
< 7	15	6	3	2
> 7	1	1	2	3
Fracture Pattern						< 0.001
Simple	11	2	4	1
Associated	5	5	1	4
Source of injury						0.428
Fall	3	1	1	1
RTA	13	6	4	3
Twisting of leg	0	0	0	1
Dislocation						0.133
Yes	3	1	3	3
No	13	5	2	2
Avascular Necrosis						< 0.001
Yes	0	0	0	3
No	16	7	5	2

Table 2

Descriptives Statistics for qualitative variables
Variable	%/ mean ± SD
Age	44.18 ± 17.2
25–30	20(60.61)
< 25	1(3.03)
> 50	12(36.36)
Gender
Male	29(87.88)
Female	4(12.12)
LOS	9.45 ± 6.58
< 7	12(36.36)
> 7	21(63.34)
ASA Grade
1	10(30.30)
2	11(33.33)
3	10(30.30)
4	2(6.06)
Days between injury	Average 4.6
< 7	26(78.79)
> 7	7(21.21)
Source of injury
Fall	6(18.18)
RTA	26(78.79)
Twisting of leg	1(3.03)
Dislocation
Yes	10(31.25)
No	22(68.75)

The frequencies of fracture patterns, identified according to the Judet and Letournel classification for acetabular fractures are summarized in Tables 3 and 4. Fracture pattern emerged as a significant predictor of outcome (p < 0.001), with associated fractures demonstrating a higher likelihood of poor outcomes compared to simple fractures. (Table 1)

Table 3: Frequencies of fracture patterns
Fracture Pattern
Simple	15 (45.45%)
Only Posterior wall	8 (24.24%)
Anterior column	3 (9.09%)
Transverse	2 (6.06%
Only Posterior column	1 (3.03%)
Only Anterior wall	1 (3.03%)
Associated	18 (54.55%)
Posterior Wall + Posterior column	5 (15.15%)
Both column	5 (15.15%)
Transverse + Posterior Wall	4 (12.12%)
Anterior wall + Posterior wall + Hemi transverse	3 (9.09%)
Transverse and vertical	1 (3.03%)

Table 4

Matta Score according to type of fracture
Type of Fracture	Excellent	Good	Poor	Fair	Grand Total
Posterior Wall	3	2	2	1	8
Posterior Wall + Posterior Column	5				5
Both Column Fracture	2	1	1	1	5
Transverse + Posterior Wall	2			2	4
anterior column fracture	1	1	1		3
Anterior column + posterior hemi transverse	1	1		1	3
Transverse Fracture	1		1		2
Anterior Wall Fracture		1			1
T shaped	1				1
Posterior Column Fracture		1			1
Grand Total	16	7	5	5	33

Six months post-surgery, follow-up radiological images were reviewed. Figures 1, 2, 3 and 4 presents detailed case examples. According to the Matta radiographic criteria, 15 (45.5%) of the operated cases had excellent outcomes, 8 (24.2%) had good results, and 5 (15.2%) each had fair and poor results. (Fig. 5) Additionally, 3 patients (9.1%) developed avascular necrosis (AVN) at the six-month post-surgery follow-up.

Ten patients presented with femoral head dislocation. Within this cohort, only one patient developed avascular necrosis (AVN) within six months post-fixation. Among the subset of patients who developed AVN, one exhibited anterior column fracture, another manifested a posterior wall fracture, and the third exhibited a transverse fracture.

Acetabular fractures pose a significant challenge, influenced by patient factors (such as comorbidities and injury mechanism) and surgeon-related considerations (including patient selection and surgical timing). To elucidate these factors and optimize treatment strategies, our meticulous study analyzed 33 patients treated for acetabular fractures using open reduction and internal fixation (ORIF). Postoperative radiological assessments consistently demonstrated significantly improved outcomes, aligning with prior research. Notably, gender played a pivotal role, with males experiencing a higher proportion of injuries. Additionally, a longer length of hospital stay (LOS) correlated with poorer results. Furthermore, fracture pattern significantly impacted outcomes, with associated fractures showing a higher likelihood of unfavorable results compared to simple fractures.

Our findings demonstrate a younger patient population for acetabular fractures, with a mean age of 43.2 years and a significant association with age, particularly affecting individuals aged 25–30. This aligns with previous research suggesting acetabular fractures predominantly impact younger demographics. (17–18) The relatively lower mean age in our study compared to other populations might be attributed to the higher proportion of young individuals residing in this specific region.

In line with other regional studies, our investigation primarily involved a male population, with 87.9% of patients being male. (19) This gender predominance can be attributed to the high incidence of acetabular injuries resulting from road traffic accidents (RTAs). Our analysis revealed that over 75% of these injuries occurred due to RTAs. The local socio-environmental context likely contributes to this disparity, as males are more frequently exposed to street-related risks. In contrast, females tend to experience low-energy trauma associated with osteoporosis

Optimizing length of hospital stay (LOS) is critical for improving overall patient outcomes. (20) Our study reinforces this notion by demonstrating a significant correlation between longer LOS and poorer outcomes. This association might be attributed to factors like increased risk of hospital-acquired infections, prolonged immobilization, and other complications arising from extended stays.

Furthermore, the timing of surgical intervention following the injury significantly impacts radiological outcomes. Our analysis revealed a clear link between the number of days between injury and surgery and the quality of X-ray results. This finding underscores the importance of timely medical intervention.

Our study employed the Matta radiographic criteria to evaluate post-operative outcomes, aligning with previous research demonstrating its effectiveness. (21) Achieving anatomic reduction in acetabular fractures is crucial to minimize complications like avascular necrosis and arthritis, as evidenced by the decrease in osteoarthritis incidence from 31–14% due to improved surgical techniques and reduction quality (8). Even if future arthroplasty is planned, a suboptimal initial reduction can complicate the procedure (22). Conversely, achieving anatomic reduction can potentially eliminate the need for secondary hip procedures, with studies reporting a 70% success rate (13, 23). Our results mirrored these findings, with 45.5% of patients experiencing excellent outcomes and 24.2% experiencing good outcomes at six months post-surgery. The avascular necrosis rate (9.09%) was comparable to Islam et al.'s study (8.0%), further emphasizing the importance of reduction for optimal patient outcomes. (24) Similar studies by Charan et al. and Kizkapan et al. also utilized the Matta criteria and reported favorable outcomes with proper reduction. (9, 25) These findings collectively support the effectiveness of the Matta criteria in assessing post-operative acetabular fracture reduction and its impact on long-term patient outcomes.

We utilized the Letournel and Judet classification for acetabular fractures, which, while widely used and beneficial for understanding fracture patterns, has notable limitations. This classification focuses primarily on the columns and walls of the acetabulum but overlooks critical factors such as comminution (the presence of multiple fracture fragments), intra-articular fragments, and dislocation of the femoral head or acetabulum protrusio. These elements are essential for a comprehensive assessment, as they significantly impact the complexity of the fracture and the surgical approach required. The absence of these considerations can pose substantial challenges for surgeons during the planning and execution of surgery, potentially affecting the quality of fracture reduction and overall patient outcomes. Therefore, we highlight the need for a revised classification system that incorporates these factors, facilitating more precise surgical planning and ultimately improving the efficacy of acetabular fracture management.

While our study provides valuable insights into the factors influencing outcomes of acetabular fracture treatments, it is not without limitations. The relatively small sample size of 33 patients may limit the generalizability of our findings. A larger study would yield more robust results and strengthen the observed associations. Conducted in a single center, our study offers an in-depth understanding of the local demographic and socio-environmental factors, though it may not reflect variations in other areas. Including data from multiple centers would provide a broader perspective on patient characteristics and outcomes. Finally, we primarily relied on radiological outcomes using the Matta criteria. While valuable, incorporating functional outcome measures would provide a more comprehensive picture of patient recovery. Moreover, we utilized The Letournel and Judet classification for acetabular fractures, which overlooks key factors like comminution and dislocation, highlighting the need for a new system to improve surgical planning and execution.

In conclusion, our study investigated factors influencing outcomes in patients with acetabular fractures treated using open reduction and internal fixation (ORIF). The findings highlight the importance of patient demographics, particularly a younger patient population in our region compared to others. Additionally, gender and injury mechanisms (predominantly road traffic accidents) appear to play a role, potentially reflecting the local socio-environmental context. Furthermore, our study underscores the critical role of optimizing length of hospital stay and timely surgical intervention for achieving better radiological outcomes.

The study also supports the effectiveness of the Matta criteria in assessing post-operative reduction and its impact on patient outcomes. However, limitations exist, including sample size, single-center nature, and reliance on radiological outcomes. Future research with larger, prospective, multicenter designs incorporating functional outcomes can further strengthen these findings. Importantly, our study emphasizes the need for a new acetabular fracture classification system that considers factors like comminution, intraarticular fragments, and femoral head dislocation to facilitate surgical planning and execution

Conflict/Competing Interests.

The authors have no relevant financial or non-financial interests to disclose. They declare no conflicts of interest that are relevant to the content of this article. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript. Furthermore, the authors have no financial or proprietary interests in any material presented in this article

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of Generative AI:

We declare that generative AI language model (ChatGPT 4.0) was employed for spell checking and enhancing the clarity of the manuscript. The utilization of these AI models facilitated the refinement of language, ensuring precision and coherence in conveying scientific findings. It is pertinent to mention that after using this tool/service, the author(s) reviewed and edited the content as needed and take(s) full responsibility for the content of the publication.

Author Contribution

Muhammad Younus Khan Durrani: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing – original draftUsman Ali: Writing – original draft, review & editing, Conceptualization, Validation, Visualization. Zaigham Jameel: Data collection, Data curation, InvestigationMasood Umer: Methodology, Project administration, Supervision, Writing – review & editing

Data Availability

The data that support the findings of this study are available from the corresponding author upon reasonable request. However, due to privacy concerns related to the study participants, the data are not publicly available. Access to the data may be granted to the journal or editorial office upon request, subject to ethical approval and compliance with data protection regulations.

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No competing interests reported.

Radiological outcomes according to Matta radiographic criteria after surgical fixation of acetabular fracture.

Status:

Version 1

Abstract

Figures

Introduction

Methods and Materials

Results

Discussion

Limitation of the study

Declarations

Author Contribution

Data Availability

References

Additional Declarations

Status:

Version 1