The Outcome of Bicolumnar Acetabular Fracture Treated by Single Anterior Ilioinguinal Approach

Background: Acetabular fracture therapy, being complicated, is generally treated by non-operative methods due to a lack of surgeons’ expertise in pelvis surgery. The surgical exposure and reduction of acetabular fractures may become more direct and practical with the altered technique since it is closer to the acetabular quadrilateral plate. This study aimed to determine the efficacy of a single anterior illio-inguinal approach for the management of a Bi-columnar acetabulum fracture. Methods: Sixty patients, fulfilling the selection criteria were selected for descriptive case series from Orthopedic Surgery Department at Lahore General Hospital, from 02-12-2020 to 02-06-2021. After informed consent, surgery was performed on all patients under general anesthesia . Patients were followed-up and evaluated for efficacy in OPD after 12 weeks of surgery with a Harris hip score. All demographic and other information was recorded on a Proforma. SPSS 22 was used to assess data. Post-stratification, efficacy was compared by using chi-square, p -value ≤0.05 was considered significant. Results: Out of 60 patients, 45(75 %) were male, whereas 15(25%) were female (Mean age 52.71±10.50yrs). The Mean of duration fracture (in days) and Harris score are 11.03±5.29 and 2.83±0.45 respectively. The efficacy concerning lateral side was 60% for left side and 26.7% for right side. Efficacy was higher in less than 10 days old fractures at 55.0% while after 10 days it was 31.7%. We found that the percentage of efficacy was 86.7%. Conclusion: The current study concluded that the anterior illio-inguinal approach is highly effective ( p =0.001) in the management of acetabular fractures.


INTRODUCTION
Despite being relatively rare, acetabulum fractures are associated with high morbidity and death 1 . These involve high-intensity trauma, and due to their complexity, care calls for comprehension of the pertinent surgical anatomy, proper radiographic assessment of the injury, and choosing the most appropriate action plan 2 . Adult pelvic fractures account for 3-6% of all fractures and up to 20% of polytrauma patients. Men sustain about 75% of all pelvic injuries. With obese patients, the risk of blunt trauma-related pelvic fracture rises 3 .
With the increased use of automobiles in recent years, it has been rising 4 . Post-traumatic hip osteoarthritis is one of the most significant side effects of acetabular fracture; it has been linked to poor fracture reduction, the kind of fracture, and delays in the reduction and fixation of acetabular fracture (surgery timing) 5 . Patients who suffer from acetabular fractures and who are elderly represent the fastest-growing and most challenging-to-treat population 6 . Extrapelvic constructs can be utilized alone or in conjunction with intrapelvic-extrapelvic constructs during surgical treatment 7 . The question of which fixation offers the fracture more stability during osteosynthesis of the bicolumnar fracture arises 8 . Acetabular fractures are internally fixed using the ilioinguinal technique. Although the results of this technique have received extensive reporting, information on potential side effects is sparse 9 . The impact on the iliopsoas muscle in particular, whose iliac attachments are virtually entirely freed, has not been well assessed 10 . Chen et al. reported that a single anterior ilioinguinal approach had an efficacy of 95.5% (>80 Harris hip score) for the management of Bi-columnar acetabulum fracture 11 . While Gupta et al. reported in a study that a single anterior ilioinguinal approach had an efficacy of 81.8% (>80 Harris hip score) for the management of Bi-columnar acetabulum fracture 12 .
The rationale of this study was to determine the efficacy of a single anterior ilioinguinal approach for the management of bi-columnar acetabulum fracture. Through literature, it has been observed that the anterior ilioinguinal approach is highly effective in the management of acetabular fractures but not much work has been done in this regard. In routine, the posterior approach is used, but it is associated with many complications. This may be due to a lack of local evidence and that is why we want to conduct this study. Instead, the anterior ilioinguinal approach is found to be effective in >80% of cases. Therefore, to obtain local data that can be implemented in a local setting in the future with an anterior ilioinguinal approach for the management of bi-columnar acetabulum fracture and improve the patient's outcome. This study aimed to determine the efficacy of a single anterior ilioinguinal approach for the management of bio-columnar acetabulum fracture.

METHODS
This was a descriptive case series conducted at the Department of Orthopedics Surgery, Lahore General Hospital, Lahore conducted from December 2020 to June 2021. A sample size of 60 cases is calculated with a 95% confidence level, 10% margin of error, and taking an expected percentage of efficacy i.e., 81.8% with a single anterior ilioinguinal approach for the management of Bi-columnar acetabulum fracture 10 . Sample selection was done with the help of non-probability consecutive sampling. To choose the sample, predetermined inclusion and exclusion criteria were developed. The study comprised patients between the ages of 40 and 80 who presented with a bicolumnar acetabulum fracture (as per the operational definition). The following patients were excluded from the study. i.e., bilateral cases, ASA III and IV, diabetes (BSR>20mg/dl), infection at fracture site (x-rays), chronic case (i.e., h/o >7 days of fracture), osteoporosis (BMD< -1.0 on DEXA).
Patients (n=60) who met the inclusion and exclusion criteria were chosen from the emergency room of the orthopedic department at Lahore General Hospital in Lahore after receiving approval from the hospital ethics council. Written consent was obtained. Name, age, gender, laterality, cause, and length of fracture were noted along with other demographic data. A single surgical team operated on all the patients while the patients were all under general anesthesia, with the help of the researcher. The patient was placed on a flat, radiolucent operating table in the supine position. The three markers for the incision were the symphysis pubis, anterior superior iliac spine, and navel, which together formed a triangle. The 10 cm incision began at the intersection of the middle and medial third of the line linking the ipsilateral anterior superior iliac spine with the navel and concluded at the intersection of the middle and lateral third of the line. Patients were moved into post-surgical wards when the reduction was completed. When patients could walk with a stick or stand unassisted, they were then released from the hospital. After 12 weeks following surgery, patients were checked on in the OPD. Patients were evaluated for Harris Hip Score. If a hip score >80 was achieved within 12 weeks, then efficacy was labeled (as per the operational definition). A Proforma was used by the researcher to calculate all the data.
SPSS 22 was used to enter and evaluate the data. quantitative information such as age and fracture duration. Harris Hip Score was presented by Mean±SD. Qualitative data like gender, lateral side, cause of fracture and efficacy was presented by frequency and percentages. Data was stratified for age, gender, lateral side, duration and cause of fracture to control effect modifiers. Post-stratification, efficacy was compared by using the chi-square test for stratified groups keeping p-value ≤0.05 as significant.

After 60 patients fulfilling inclusion and exclusion
criteria were selected to determine the efficacy (>80 Harris score) of a single anterior ilioinguinal approach for the management of Bi-columnar acetabulum fracture. The patient was subjected to a postoperative x-ray. Depending on the associated injury and patient stability, mobilization with physical therapy on the bed was starting on post-op day one (Figure 1 A,B).
Age distribution of the patients shows that out of 60 patients, 49(81.7%) were in the age group of 40-60 years and 11(18.3%) were in the age group of 61-80 and the mean age was calculated as 52.71±10.50 years (Table 1)   The distribution of duration of fracture and Harris Hip score show 11.03± 5.29 and 2.83±0.45 respectively ( Figure 3). The efficacy with respect to the lateral side is 60% for the left side and 26.7% for the right side. Efficacy was higher in less than 10 days old fractures as 55.0% while in more than 10 days old fractures it is 31.7%. We found that the Percentage of efficacy was 86.7%. The data was stratified for age, gender, lateral side, duration and cause of fracture shown in Table 2.

DISCUSSION
Acetabulum fractures typically occur in young adults as a result of high-velocity injuries (e.g., high-speed vehicle or falls on the floor from height); they are frequently linked to other potentially fatal injuries. The hip joint develops articular incongruity as a result of the fracture pieces being displaced, which causes aberrant pressure to be distributed on the articular cartilage surface. This may cause the cartilage surface to rapidly deteriorate, which can cause crippling hip joint arthritis. One of the most complicated injuries that orthopedic surgeons treat is acetabular fractures. Our grasp of surgical procedures, reduction strategies, problems, and outcomes were introduced by Gupta and Ziran's work 12,13 . After 20 years, up to 80% of acetabular fractures that had surgery reported good to outstanding functional outcomes 14,15 .
The clinical prognosis of an acetabular fracture may be influenced by a variety of variables, including pre-existing disorders, injury-related factors, surgical concerns, and postoperative sequelae. Clinical success has been demonstrated to be highly dependent on the quality of the articular reduction 15,16 . Case reports of the surgical fixation of acetabular fractures were the first results to be published. A study used plates and screws to treat an acetabular fracture into the inner side of the ilium 1943. In 1949, the anterior iliofemoral technique for surgically stabilizing an acetabular fracture was described 13 .
In the current study, the age distribution of the patients was done, and it shows that out of 60 patients, 49(81.7 %) were in the age group of 40-60 years and 11(18.3%) were in the age group of 61-80 and mean age was calculated as 52.71±10.50 years. There were 75%(45) were male whereas 25% (15) were females. In this study, we determined the efficacy of a single anterior ilioinguinal approach for the management of bi-columnar acetabulum fracture and we found that the percentage of efficacy was 86.7%. Another study reported that a single anterior ilioinguinal approach had an efficacy of 95.5% (>80 Harris hip score) for the management of bi-columnar acetabulum fracture 11 . Gupta et al. reported in a study that a single anterior ilioinguinal approach had an efficacy of 81.8% (>80 Harris Hip Score) for the management of bi-columnar acetabulum fracture 12 .
The "gold standard" for treating displaced acetabular fractures for the past 40 years has been surgery.
A virtually perfect open reduction and internal fixation can significantly lower fracture complications and improve clinical outcomes for patients 17 .
However, for acetabular fracture surgery, picking the right strategy is essential. previously, the majority of acetabular anterior column and anterior wall fracture cases were successfully treated with the typical ilioinguinal. A second incision exposing a lateral window along the iliac crest is utilized to enable reduction and fixation in fractures with a high anterior column component (exiting the iliac crest) or those needing posterior column lag screws.
Patients were classified based on BMI in a retrospective examination of 169 consecutive surgically repaired acetabular fractures to determine postoperative complications 18 . The results showed that the participants with a BMI of 30 or higher had a 2.1-fold increased risk of estimated blood loss of more than 750 cc and a 2.6-fold increased risk of deep vein thrombosis, while those with a BMI of 40 or higher had a 5-fold increased risk of wound infection. Obese patients occasionally require surgical treatment, but we can use this knowledge to educate patients about their elevated risk of problems and look into ways to reduce them 19 .
In a retrospective analysis of 53 patients with surgically treated acetabular fractures who were followed for two years, age, fracture complexity, and injury to the head of femurs were statically meaningful markers of poor outcome 2 . Patients under the age of 40 had a better prognosis than those who were older. The authors believe that osteoporosis, which makes surgical reduction and fixation difficult, is a contributing factor in older patients' inferior outcomes. A bigger trial by Matta, which also included 262 fractures followed for a minimum of two years revealed that age is an independent risk factor for clinical prognosis. Only 68% of patients 40 years of age or older showed a G-E result compared to 81% of patients under the age of 40. In a more recent investigation, it was determined what characteristics in individuals above the age of 55 affected radiographic and clinical outcomes 20 .
In a dataset consisting, Carroll et al. found that 50% of patients had concomitant injuries: 35% had lower extremity injuries, which were most common, 19% had chest injuries, 18% had head injuries, 13% had nerve palsies, 8% had abdomen injuries, 6% had genitourinary injuries, and 4% had spine injuries 21 . As many as 35% of isolated acetabular fractures necessitate blood transfusions, according to one research 22 . Upon admission, the sciatic nerve injury must also be examined. The peroneal division of the sciatic nerve is usually invariably injured, though less frequently the tibial division is as well. A foot drop will occur if the peroneal nerve division of the sciatic nerve is injured 23,24 . The surgical exposure and reduction of acetabular fractures may become more straightforward and practical with the improved method because it was closer to the acetabular quadrilateral plate 11,25 .

CONCLUSION
The current study determined the efficacy of a single anterior ilioinguinal approach for the management of bi-columnar acetabulum fracture. The percentage of efficacy was 86.7%. Therefore, it is concluded that the use of the single anterior ilioinguinal approach for the treatment of acetabular fractures provides an excellent result. Furthermore, there were fewer complications, thus the single anterior ilioinguinal approach might be a preferable choice for the treatment of bicolumnar acetabular fracture.