1054 R. L.

WATERS, DONALD MCNEAL, AND JACQUELIN PERRY

walking. stimulation is initiated in the terminal swing tremity to perform other functional tasks. In the future, it
phase of gait following a preset delay after heel lift-off, is conceivable that groups of muscles may be activated
causing the knee to extend in preparation for heel strike synchronously using a multichannel system.
(Fig. 9). Stimulation is continued throughout stance to Only a small percentage of patients are candidates for
stabilize the knee until the next heel lift-off. the peroneal Neuromuscular Assist. Only orthopaedic
Similarly, another patient rendered hemiplegic after a surgeons familiar with neurologically disabled patients
stroke required a cane because of inactive hip-extensor and gait mechanics should undertake this procedure. The
muscles. An electrode placed around the inferior gluteal necessity of attending to the details of patient selection
nerve stimulated the gluteus maximus muscle during the cannot be over-emphasized. Finally, because of frequent
stance phase. Following surgery she was able to walk equipment failure the patient must have convenient access
without a cane. freeing her single non-involved upper ex- to the surgeon and engineering personnel for repairs.

References
I . FINAL REPORT: Development of Orthotic Systems Using Functional Electrical Stimulation in Myoelectric Control. University of Ljubljana,
Faculty of Electrical Engineering. Ljubljana, Yugoslavia. I 971.
2. L1RERs0N. \V. T.: HOLNIQUEST. H. J.: ScoT. DAVID: and Dow. MARGOT: Functional Electrotherapy: Stimulation of the Peroneal Nerve Syn-
chronized with the Swing Phase ofthe Gait of Hemiplegic Patients. Arch. Phys. Med., 42: 101-lOS, 1961.
3. TASIAKI. T.. MCNEAL. D.: and WILEMON, W. K.: Recorded Neurophysiological Effects of Patient Implanted Peripheral Nerve Stimulators. Read
at the Neuroelectric Conference, Las Vegas. Nevada. March 1970.
4. TRAFTON. P. G. : Tendon Transfers for Adult Spastic Equinovarus Feet: A Follow-up Study. In Orthopedic Seminars. Vol. 6. Downey. Califor-
nia. Rancho Los Amigos Hospital. 1973-1974.
5. WATERS. RoHIRT. and MONTGOMERY. JACQUELINE: Lower Extremity Management of Hemiparesis. Clin. Orthop.. 102: 133-143. 1974.
6. VATERS, R. L. : MNEAI., D. R. : and TASTO. JAMES: Peroneal Nerve Conduction Velocity After Chronic Electrical Stimulation. Arch. Phys.
Med.. 56: 240-243. 1975.

Acetabular Disruption and

Central Fracture-Dislocation of the Hip
A LONG-TERM STUDY*

BY PETER G. CARNESALE, M.D.t, MARCUS J. STEWART, M.D.t, AND

STEPHEN N. BARNES, M.D.1, MEMPHIS, TENNESSEE

From i/ic Campbell C/ini. Memphis

ABSTRACT: Displaced acetabular fractures are manent disability. They also are frequently associated
serious injuries often resulting in permanent disability. with other injuries which may be life-threatening. Treat-
Fifty-five patients with fifty-six such injuries seen at the ment as described in the literature has included manipula-
Campbell Clinic between 1927 and 1970 had either cen- tion, traction, immobilization in a plaster cast, and open
tral dislocation with or without fracture of the weight- reduction, methods used with varying success.
bearing dome, or acetabular disruption usually as- This report concerns a study of acetabular fractures
sociated with posterior displacement of the hip. After which were associated with either central fracture-
an average follow-up of 8.6 years, 56 per cent of those dislocation of the hip or total acetabular disruption. From
treated without surgery had good or satisfactory re- this review of a large series of these rare injuries, most of
suits compared with 54 per cent good or satisfactory them followed for long periods, we attempted to identify
results in those treated surgically. Patients with dis- the types of injury most likely to benefit from open reduc-
placed fractures of the acetabular dome not reduced by tion.
manipulation and traction should be considered candi-
Historical Review
dates for open reduction.
The first central acetabular fracture was reported by
Displaced acetabular fractures are serious injuries Caliisen in 1788, and in 1909 Schroeder produced ex-
which require prolonged treatment and often result in per- perimental acetabular fractures in cadavera by striking the
* Read at the Annual Meeting of The American Academy of Or- greater trochanter with a pendulum. The earliest treatment
thopaedic Surgeons. San Francisco. California. March 4. 1975. usually consisted of manipulation and immobilization in a
. Campbell Clinic. 869 Madison Avenue. Memphis, Tennessee
38104. plaster cast. When skeletal traction became available, Ion-

THE JOURNAL OF BONE AND JOINT SURGERY

 ACETABULAR DISRUPTION AND CENTRAL FRACTURE-DISLOCATION OF THE HIP 1055

gitudinal traction and later lateral traction as well were the patients had sustained violent injuries. Thirty-six had
used to treat central dislocations. had car or truck accidents; three had motorcycle injuries:
The first open reduction was performed by Vaughn in two were pedestrians hit by cars; and ten had fallen from a
1912, but Levine was the firstto use internal fixation in the height or from a horse. Three elderly patients were injured
treatment of central acetabular fractures, in 1943. He rec- in minor falls; one of them, an invalid with rheumatoid ar-
ognized that satisfactory results could be achieved without thritis, simply fell out of bed. Two had had other
reduction ofthe medial wall. In 1954, Stewart and Milford mechanisms of injury. Thirty-seven were males and eigh-
reported on twenty-eight central fracture-dislocations teen, females. Their ages ranged from fifteen to
treated at the Campbell Clinic, eighteen of which were fol- seventy-five years. Thirty-four were between the ages of
lowed up. In nine the results were considered excellent or twenty and fifty. Thirty-five had significant associated in-
good and in five avascular necrosis of the femoral head juries, including six sciatic-nerve palsies, but no patient
developed. Early motion and muscle-strengthening exer- died while under treatment. Thirty-five injuries involved
cises were emphasized in treatment. The lack of correla- the left hip and nineteen, the right. One patient had a bilat-
tion between the clinical course and roentgenographic ap- eral injury.
pearance was pointed out. Four years later Knight and All patients with these injuries seen at the Campbell
Smith analyzed eight central fracture-dislocations treated Clinic were included in this study regardless of whether
by open reduction at the Campbell Clinic. In this study the they had received their initial care there, on the grounds
fractures were simply classified as horizontal or vertical that the epidemiological data provided warranted their in-
and the classification was correlated with the specifics of clusion. These patients were followed up for this study as
operative treatment. Careful planning before surgery was follows: by review of their records and roentgenograms
emphasized, but no complications were mentioned. only in forty-one, by these means as well as a recent ques-
In a review of their experience at the Massachusetts tionnaire in four, and by review of records and roentgeno-
General Hospital, Rowe and Lowell, in 1961 , emphasized grams supplemented by a recent examination and recent
that good results were obtained after closed treatment of roentgenograms in ten. Three patients had no follow-up:
inner wall fractures if the femoral head had been re- one who left against medical advice, another who trans-
duced and maintained under an intact acetabular dome. ferred to a hospital near his home and did not answer
However, the results were less desirable in bursting follow-up letters, and a third who died at home of a
fractures unless an accurate reduction of the acetabular myocardial infarction two months after injury.
dome was achieved. Twelve patients (eleven with non-operative and one
Judet and associates, in 1964, advised open reduction with operative treatment) were followed for less than one
and internal fixation of all displaced acetabular fractures, year. Of these, five were listed as having undetermined
proposing a detailed anatomical classification which was results; two were classified as having bad results because
correlated with the surgical approach. Long-term results they had required reconstructive surgery, both cup arthro-
were not available at the time of publication. Complica- plasties; one had a bad result following postoperative in-
tions included three surgical deaths but only one infection fection; one had a full range of hip motion and roentgeno-
after operations on 129 fractures. grams showing a good cartilage space at eleven months
Larson, in 1973, reported on thirty-five patients with (Figs. 4-A and 4-B) and was rated as having a good result;
fracture-dislocations followed for five years or longer. He another was listed as having a good result at six months
concluded that fractures with an intact acetabular dome because he had practically normal roentgenograms and full
could be treated satisfactorily by traction but that treat- motion of the hip (he subsequently died, so no further
ment of fractures with a displaced dome usually was un- follow-up was possible); and two were listed as having un-
satisfactory unless an accurate open reduction was accom- satisfactory results at four and five months, respectively,
plished. because of significant degenerative changes apparent on
their roentgenograms.
Material The remaining patients, thirty-four with non-
Fifty-five patients with fifty-six central dislocations operative and ten with operative treatment, had been fol-
of the hip or disrupted acetabula were seen at the Campbell lowed for from one to forty-three years. The average
Clinic during the years 1927 to 1970. These included follow-up for all fifty-five patients included in this study
seven of the eight patients previously reported by Knight was 8.6 years. Twenty-seven (twenty-two treated non-
and Smith and presumably most, if not all, of the twenty- operatively and five, operatively) had been followed for
eight patients described by Stewart and Milford (the exact five years or more.
number could not be determined from the record). The one For this study we adopted a new classification (Fig. 1)
patient reported by Knight and Smith who was excluded which is simpler than the ones previously proposed and
from this study had a fracture which was not thought to be has the advantage of serving as a guide to both treatment
sufficiently displaced to warrant a diagnosis of central and prognosis. In the cases included in this study and in
fracture-dislocation of the hip. Incidentally, this patients those by Stewart and Milford and by Knight and Smith, no
long-term result after open reduction was good. Most of attempt was made to correlate the results with the three

VOL. 57.A, NO. 8, DECEMBER 1975

1056 P. G. CARNESALE, M. J. STEWART, AND S. N. BARNES

:::
. . .,

. -:

TYPE I TYPE U TYPE flI

FIG. I

The simplified classification used in this study. Type I, central disloca-

tion without involvement of the weight-hearing dome of the acetabulum;
Type II. central dislocation with involvement of the weight-bearing
dome: and Type III, acetabular disruption usually associated with pos-
FIG. 2-A
tenor subluxation of the hip.

different classifications. Our simplified classification was

as follows:
I. Central fracture-dislocation without involvement of
the weight-bearing dome of the acetabulum.
II. Central fracture-dislocation with involvement of
the weight-bearing dome.
III. Acetabular disruption usually associated with
posterior subluxation of the hip.
Nine of the fifty-six fractures could not be classified
because the original roentgenograms had been lost or de-
stroyed. leaving fourteen disrupted acetabula, twelve cen-
tral dislocations with the weight-bearing dome intact, and Figs. 2-A and 2-B: Central dislocation with fracture of the weight-
bearing dome in a thirty-two-year-old man who sustained this injury. as
twenty-one central dislocations with the weight-bearing well as a fracture of the left patella and a ligament injury of the left knee,
dome fractured. Considering all fifty-six fractures, in an automobile accident. He was treated in traction followed by im-
mobilization in a one and one-half spica cast. When last seen, seven and
forty-five had been treated by manipulation, traction, im- one-half years after operation. he was working regularly and had occa-
mobilization in a plaster cast. simple bed rest, or a combi- sional pain. His range of motion of the hip was 75 per cent of normal.
Note the intra-articular hone fragment. The result was rated satisfactory.
nation of these, followed by rehabilitative exercises; and
eleven had been treated by open reduction and internal limp. No support. or perhaps a cane, was necessary for
fixation. walking. Hip motion was 75 per cent of normal or better,
The period covered by this review spanned several and roentgenograms showed no or minimum evidence of
decades, during which concepts of treatment changed con- arthros is.
siderably. Our current management protocols bear little In a satisfactory result the symptoms and signs were
resemblance to those of the 1940s. the same as in a good result but hip motion was reduced to
50 to 75 per cent of normal and roentgenograms might
Results show moderate degenerative changes.
Results were rated good, satisfactory. or unsatisfac- In an unsatisfactory result the patient had definite
tory. A rating ofexcellent was not included because no pa- pain, limitation of activity. and limp. and required
tient had a normal hip. The criteria used to define the dif- crutches. Hip motion was less than 50 per cent of normal
ferent ratings were the patients symptoms and level of ac- and roentgenograms showed more than moderate de-
tivity. the need for external support. presence of limp, hip generative changes, so that reconstructive surgery was ad-
motion, and roentgenographic appearance ofthejoint. The vised. In evaluating the roentgenograms. no attempt was
data were obtained by personal interview and examination made to distinguish avascular necrosis of the femoral head
and by review of each patients record and roentgeno- from traumatic arthritis: each was considered an arthrosis.
grams. Since forty-five patients could not be re-examined, Of the forty-five hips treated without surgery, seven
a scoring system such as the Iowa Hip Scale could not be (16 per cent) had good results: eighteen (40 per cent),
used. Also, the data permitted only an estimate of over-all satisfactory results (Figs. 3-A and 3-B): and fifteen (33 per
percentage of hip motion. This percentage was the cent), unsatisfactory results. The other five (I 1 per cent)
examiners estimate of total hip motion as compared with could not be graded because of inadequate follow-up.
normal. Complications occurred in four of the patients treated
In a good result the patient had no or minimum pain. without surgery: one had peroneal palsy; one, a kidney
no or slight limitation of activity, and no or minimum stone; one, hepatitis: and one, loss of reduction.

THE JOURNAL OF BONE AND JOINT SURGERY

 ACETABULAR DISRUPTION AND CENTRAL FRACTURE-DISLOCATION OF THE HIP 1057

all three treated by open reduction had good or satisfactory

results. Thus, the treatment of fracture-dislocations with
the weight-bearing dome intact probably should be by
closed methods while the proper treatment of disrupted
acetabula remains uncertain. Fracture-dislocations with
fracture of the weight-bearing dome, on the other hand,
probably should be treated by open reduction.
Of the nineteen unsatisfactory results, fifteen occur-
red after non-operative and four after operative treatment.
The reasons for the poor results were: (1 ) failure to reduce
the femoral head under the reduced weight-bearing dome
in ten; (2) loss of position of the femoral head after it was
initially reduced under the weight-bearing dome, because
skeletal traction was not maintained long enough (twelve
weeks) in one; (3) postoperative infection in four: and (4)
failure to remove intra-articular osteocartilaginous frag-
ments in one. Analysis ofthe other three unsatisfactory re-
sults failed to disclose an obvious reason for the poor result.

Discussion
In the literature there is confusion about the treatment

FIG. 3-B

Figs. 3-A and 3-B: Disrupted acetabulum in a forty-one-year-old

woman who incurred this injury of the left hip and a closed head injury in
an automobile accident. The hip was treated in traction, accepting the
dislocated position. When last seen. almost fifteen years later. she de-
scribed minimum limitation of her activities as a homemaker but had oc-
casional pain. Hip motion was limited to flexion from 35 to 90 degrees
with no other motion. The left lowerextremitv was 3.8 centimeters shor-
ter than the right. The result was rated satisfactory.

Of the eleven hips treated surgically, two (18 per

cent) had good results (Figs. 5-A through 6-B): four (36
per cent), satisfactory results; and four (36 per cent), un-
satisfactory results. In one of these hips, with roentgeno-
grams that were almost normal seven and a half years after
FIG. 4-A
surgery. the result could not be determined because no
record of symptoms or the physical examination could be
obtained.
Eight of these eleven patients had operative complica-
tions: four had infections (36 per cent), three had ectopic
ossification, and one had thrombophiebitis. Most of the
unsatisfactory results were caused by infection after
surgery. There were no operative deaths.
The type of fracture was correlated with the method
of treatment (Table I) in an effort to determine the most
effective treatment for specific fractures. In the twelve
central fracture-dislocations with an intact weight-bearing
dome of the acetabulum, the results were good or satisfac-
tory in ten and unsatisfactory in one after closed treatment,
and undetermined in one after open reduction. Of the four-
teen hips with disrupted acetabula, six of nine treated FIG. 4-B
closed and three of five treated by open reduction had good Figs. 4-A and 4-B: Central dislocation with fracture of the weight-
or satisfactory results. However, of the twenty-one hips bearing dome in a sixty-four-year-old man who fell from a ladder. He
was treated by manipulation and traction and when last seen. eleven
with a central fracture-dislocation and fracture of the months later. he was working regularly and had no pain and a full range
weight-bearing dome, seven ofeighteen treated closed and of hip motion. He was rated as having a good result.

VOL. 57-A, NO. 8. DECEMBER 1975

1058 P. G. CARNESALE, M. J. STEWART, AND S. N. BARNES

FIG. 5-B

Figs. 5-A and 5-B: Central dislocation with displacenient of the

weight-bearing dome in a seventeen-year-old girl who also had a fracture
Of the left humerus. Both injuries were caused by an automobile acci-
dent. She was treated hs open reduction ofthc acetahulum and when last
seen, seventeen and one-half years later. she was an active homemaker
with no pain and an almost normal range of hip motion. She was rated as
having a good result.

FIG. 6-B
of central fracture-dislocations of the hip and disrupted
Figs. 6-A and 6-B: Disrupted acetabulum in a twenty-four-year-old
acetabula. several treatments having been recommended, woman after an automobile accident. Open reduction was performed and
while there is more agreement about the treatment of un- when she was last seen, three years later, she had no pain or limp and
was an active homemaker. Her hip motion was 80 per cent of normal.
displaced acetabular fractures and posterior dislocations of She was rated as having a good result.
the hip associated with fractures of the posterior acetabular
lip. The present review is concerned only with central weight-bearing dome are satisfactorily reduced by ma-
fracture-dislocations and disrupted acetabula. nipulation can be treated successfully by closed means,
In general, the simplest method likely to yield a good but we emphasize that accurate realignment (near-
result is best. We, like Rowe and Lowell and Larson, anatomical reduction) of the acetabular dome must be ob-
found that the results of closed treatment of central tamed and that prolonged traction is necessary to maintain
fracture-dislocation without fracture of the weight- the reduction. If any intra-articular bone fragments are
bearing dome of the acetabulum are satisfactory provided present they must be removed (Figs. 2-A and 2-B).
the femoral head is reduced and maintained under the Open reduction of acetabular fractures is justified
dome. Ten of our eleven patients so treated had good or when closed treatment of a displaced fractured weight-
satisfactory results (Table I). Usually manipulation under bearing dome fails to reduce both the femoral head and
anesthesia, as described by Rowe and Lowell, best acetabular fragments accurately. provided the following
achieves this reduction: however, our experience suggests conditions can be met: ( I ) the general condition of the pa-
that prolonged traction (usually twelve weeks) is neces- tient must permit extensive surgery: (2) if there is corn-
sary to maintain reduction. Early active motion in traction minution of the acetabular fracture the fragments must be
is encouraged. We have used combined longitudinal and large enough to be fixed internally: and (3) the surgeon
lateral traction for at least part of the time. Traction must, must be well trained and preferably experienced. and the
of course. be followed by a program of muscle- operating room where the procedure is to be done must be
strengthening exercises and graduated weight-bearing. well equipped.
The central fracture-dislocations with fracture of the It should be noted that of the eleven hips treated by
weight-bearing dome in which the femoral head and the open reduction in this series. four (36 per cent) became in-

THE JOURNAL OF BONE AND JOINT SURGERY

 ACETABULAR DISRUPTION AND CENTRAL FRACTURE-DISLOCATION OF THE HIP I 059

TABLE I suits are obtained considering the deformity. the final re-
RESULTS* suit resembling a central displacement arthroplasty (Figs.
3-A and 3-B).
Non-Operative Operative
Treatment Treatment When an open reduction is indicated, the roentgenog-
raphic analysis and surgical exposures described by Judet
Central dislocation - weight-bearing
dome intact
and associates in 1964 are recommended. Careful plan-
Good 4 0 ning and a review of the pelvic anatomy are essential. An
Satisfactory 6 0 array of internal fixation devices - plates, screws, and
Unsatisfactory I 0
Undetermined 0 I
Knowles pins should - be available at surgery.
Disrupted acetabulum Primary reconstructive surgery as described by Wes-
Good I I terborn was not carried out in this series and we believe
Satisfactory 5 2
that it is not advisable. However, reconstruction may be
Unsatisfactory 3 2
Undetermined 0 0 required later. In nine of our patients late reconstruction
Central dislocation - weight-bearing was necessary: arthroplasty in six (five cup arthroplasties
dome fractured and one total hip replacement) and arthrodesis in three.
Good 2 I
Satisfactory 5 2
Conclusions
Unsatisfactory 8 0
Undetermined 3 0 Displaced central fracture-dislocations of the hip and
* Results in the forty-seven acetabular fractures which could be
disrupted acetabula are serious injuries. prone to result in
classified. Nine could not be classified because the original roentgeno- permanent disability.
grams had been lost or destroyed. Any patient whose follow-up was Most of these injuries can and should be treated with-
thought to be insufficient was listed as having an undetermined result.
out open reduction. However, given certain well defined
fected - a clearly unacceptable figure. Although none of circumstances, open reduction is indicated: then careful
our four patients so treated since 1970 had infections, the planning and surgical treatment carried out by an experi-
message from the past speaks loud and clear. Most of enced surgeon are necessary. The methods of open reduc-
these early infections were probably the result of limited tion proposed by Judet and associates are preferred.
operative exposure (three of the four had lateral ap- We believe that primary reconstructive surgery is not
proaches). advisable, but reconstruction may be necessary as a sec-
In some central fracture-dislocations with extensive ondary procedure.
comminution involving the weight-bearing dome,
5Oi I: The intl sur.n ish t( hank heir coilciguc. it i),e (.iinptrcll Cl sic tv periniuing heir
minimum treatment is indicated and surprisingly good re- pailenis It) he used in his studs.

References
1. JUDET, ROBERT; JUDET, JEAN; and LETOURNEL, E. : Fractures of the Acetabulum: Classification and Surgical Approaches for Open Reduction.
Preliminary Report. J. Bone and Joint Surg.. 46-A; 1615-1646, Dec. 1964.
2. KNIGHT, R. A., and SMITH, HUGH: Central Fractures of the Acetabulum. J. Bone and Joint Surg.. 40-A: 1-16. Jan. 1958.
3. LARSON, C. B.: Fracture Dislocations of the Hip. Clin. Orthop.. 92: l47-154. 1973.
4. LEVINE, M. A.: Treatment of Central Fractures of the Acetabulum. A Case Report. J. Bone and Joint Surg. . 25: 902-906. Oct. 1943.
5. ROWE, C. R.. and LOWELL, J. D.: Prognosis of Fractures of the Acetabulum. J. Bone and Joint Surg.. 43-A: 30-59, Jan. 1961.
6. SCHROEDER, W. E. : Fracture of the Acetabulum with Displacement of the Femoral Head into the Pelvic Cavity (Central Dislocation of Femur).
Quart. Bull. Northwestern Univ. Med. SchI., 11: 9-42, 1909.
7. STEWART, M. J., and MILFORD, L. W.: Fracture-Dislocation ofthe Hip. An End-Result Study. J. Bone and Joint Surg.. 36-A: 315-342, April
1954.
8. VAUGHN, G. T.: Central Dislocations ofthe Femur. Surg.. Gynec. and Obstet., 15: 249-251. 1912.
9. WESTERBORN, ANDERS: Central Dislocation ofthe Femoral Head Treated with Mold Arthroplasty. J. Bone and JointSurg.. 36-A: 307-314. April
1954.

voL. 57-A, NO. 8, DECEMBER 1975