Management of Complex Pelvic Ring and Acetabular Fracture Associated With Open Tibia Fracture in Severe Polytrauma Patient: A Case Report
Figure 1: Open injury of the diaphysis of left shin bones (type 3B according to the Gustilo-Anderson classification).
Despite that CTA had not shown active internal bleeding or brain injury, the patient was hemodynamically unstable and unconscious from the start of the admission. Immediately, the patient underwent open repair of bladder rupture, debridement of left thigh and external fixation by linear fixator, and closed reduction of left hip (Figure 2).
Figure 2: X-ray after closed reduction of left hip joint.
The arrow shows markedly displaced posterior wall of acetabulum. Left side pelvic ring fracture (type B1.1 according to the Orthopaedic Trauma Association {OTA} classification), transverse undisplaced fracture of the right acetabulum, left acetabular transverse + posterior wall (according to Judet and Letournel classification) are present.
Skeletal traction was applied to left hip joint because it was highly unstable. From the third day, patient required hemodialysis because of kidney failure and the palsy of tibial and peroneal nerves were present. Furthermore, elevated inflammatory markers and fever up to 39°C were present, which was an expression of systemic inflammatory response syndrome (SIRS) caused by trauma. Until the resolution of the syndrome, definitive management of pelvic fracture and soft tissue defect was postponed; the vacuum-assisted closure (VAC system) and repeated debridement of the wound on third, fifth, ninth, and 13th day were carried out. On 13th day after the accident, open reduction and internal fixation (ORIF) of the posterior column of the left acetabulum (through the Kocher-Langenbeck approach) and closed reduction and internal fixation (CRIF) of left side sacroiliac joint were performed (Figure 3).
Figure 3: ORIF of the posterior column of the left acetabulum and CRIF fixation of left side sacroiliac joint.
ORIF: open reduction and internal fixation; CRIF: closed reduction and internal fixation
Syndesmosis and anterior column were not fixed because of the previous bladder injury. We did not use external fixator for the anterior pelvic ring, because sacroiliac joint fixation provides sufficient stability in type B1 fractures. Excessive soft tissue damage was found: complete rupture of gluteus maximus muscle belly and gluteal fascia, ruptures of external rotators of hip, and necrosis of abductor minimus muscle. Furthermore, fragment of the posterior wall of acetabulum was found dislocated distal to calcar of femur (Figure 2). The following day, extubation of the patient was followed by delirium, which took five days to resolve. On 20th day after the accident, reconstruction of soft tissues of tibia using a latissimus dorsi pedicle flap was performed (Figure 4).
Figure 4: Healed soft tissues of left tibia after a latissimus dorsi pedicle flap reconstruction.
In the following few weeks, linear external fixator was exchanged to Ilizarov fixator. At four months, there were no signs of tibia healing and the external fixator was exchanged to intramedullary locking nail with bone grafting from iliac crest. At seven months, the patient regained the ability to walk without any assistance and there was full healing of left tibia (Figure 5). But 13 months after the accident, he presented to the clinic with a severe left hip pain - six points on visual analog scale, pain in left inguinal area during physical activity, an inability to step on his left leg, and a feeling of its shortening.
Figure 5: Complete union of left tibia after intramedullary nailing with iliac crest bone graft.
After a CT assessment, we diagnosed avascular necrosis of the femoral head and posterior wall of acetabulum (Video 1), therefore an uncemented THA through posterolateral approach was performed, using Taperloc stem and Continuum acetabular system (Warsaw, Indiana: Zimmer Biomet) (Figure 6).
Figure 6: Uncemented THA of the left hip joint.
THA: total hip arthroplasty
Further postoperative period was uneventful. At 18 months after the initial trauma, the patient was able to walk short distances without any aid, for longer distances he used single left crutch (Video 2). The function of tibial and peroneal nerve improved, although paresis of the left foot remained. The patient's hip disability and osteoarthritis scores at the final follow-up were pain 75, other symptoms 50, function in daily activity 84, function in sport and recreation 83, and hip-related quality of life 50.
Masionis P, Vileikis T, Giedrius P, et al. (January 18, 2022) Management of Complex Pelvic Ring and Acetabular Fracture Associated With Open Tibia Fracture in Severe Polytrauma Patient: A Case Report. Cureus 14(1): e21356. doi:10.7759/cureus.21356