Case We present the case of a thirteen-year-old female who sustained a posterior wall acetabular fracture dislocation. She underwent urgent closed reduction and subsequent uncomplicated open reduction and internal fixation. Post reduction computed tomography demonstrated a concentrically reduced hip joint with no evidence of femoroacetabular impingement (FAI). She subsequently healed her fracture and returned to running activities; however, one year later presented with aching pain in her thigh. Radiographs demonstrated the development of a large osseous prominence on her anterolateral femoral neck consistent with femoroacetabular impingement. Based on these findings she was evaluated by a hip preservation specialist. She subsequently underwent successful hip arthroscopy for labral repair and femoral osteochondroplasty. She was eventually able to return to running sports with little pain.  Summary We present a case of FAI presenting as a complication of acetabular fracture fixation. This should be discussed with patients presenting with traumatic hip dislocations as a possible complication of surgical fixation or possibly of the injury itself

Duncan, Stephen T.

Hayes, Christopher B.

Wright, Raymond D.

Zuelzer, David A.

English

University of Kentucky

University of KentuckyUKnowledgeOrthopaedic Surgery and Sports Medicine FacultyPublications Orthopaedic Surgery and Sports Medicine12-2018Femoroacetabular Impingement as a Complicationof Acetabular Fracture FixationDavid A. ZuelzerUniversity of Kentucky, david.zuelzer@uky.eduChristopher B. HayesUniversity of Kentucky, christopher.hayes@uky.eduRaymond D. WrightUniversity of Kentucky, raymond.wright@uky.eduStephen T. DuncanUniversity of Kentucky, stdunc2@uky.eduRight click to open a feedback form in a new tab to let us know how this document benefits you.Follow this and additional works at: https://uknowledge.uky.edu/orthopaedicsurgery_facpubPart of the Musculoskeletal System Commons, Orthopedics Commons, Sports MedicineCommons, Sports Sciences Commons, Surgery Commons, and the Trauma CommonsThis Article is brought to you for free and open access by the Orthopaedic Surgery and Sports Medicine at UKnowledge. It has been accepted forinclusion in Orthopaedic Surgery and Sports Medicine Faculty Publications by an authorized administrator of UKnowledge. For more information,please contact UKnowledge@lsv.uky.edu.Repository CitationZuelzer, David A.; Hayes, Christopher B.; Wright, Raymond D.; and Duncan, Stephen T., "Femoroacetabular Impingement as aComplication of Acetabular Fracture Fixation" (2018). Orthopaedic Surgery and Sports Medicine Faculty Publications. 16.https://uknowledge.uky.edu/orthopaedicsurgery_facpub/16Femoroacetabular Impingement as a Complication of Acetabular Fracture FixationNotes/Citation InformationPublished in Trauma Case Reports, v. 18, p. 56-59.© 2018 The Authors. Published by Elsevier Ltd.This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).Digital Object Identifier (DOI)https://doi.org/10.1016/j.tcr.2018.07.003This article is available at UKnowledge: https://uknowledge.uky.edu/orthopaedicsurgery_facpub/16Contents lists available at ScienceDirectTrauma Case Reportsjournal homepage: www.elsevier.com/locate/tcrCase ReportFemoroacetabular impingement as a complication of acetabularfracture fixationDavid A. Zuelzer⁎, Christopher B. Hayes, Raymond D. Wright, Stephen T. DuncanDepartment of Orthopaedics and Sports Medicine, University of Kentucky, 740 S. Limestone Rd, K403, Lexington, KY 40536-0284, USAA R T I C L E I N F OKeywords:Acetabular fractureFemoroacetabular impingementHip arthroscopyComplicationA B S T R A C TCase: We present the case of a thirteen-year-old female who sustained a posterior wall acetabularfracture dislocation. She underwent urgent closed reduction and subsequent uncomplicated openreduction and internal fixation. Post reduction computed tomography demonstrated a con-centrically reduced hip joint with no evidence of femoroacetabular impingement (FAI). Shesubsequently healed her fracture and returned to running activities; however, one year laterpresented with aching pain in her thigh. Radiographs demonstrated the development of a largeosseous prominence on her anterolateral femoral neck consistent with femoroacetabular im-pingement. Based on these findings she was evaluated by a hip preservation specialist. Shesubsequently underwent successful hip arthroscopy for labral repair and femoral osteochon-droplasty. She was eventually able to return to running sports with little pain.Summary: We present a case of FAI presenting as a complication of acetabular fracture fixation.This should be discussed with patients presenting with traumatic hip dislocations as a possiblecomplication of surgical fixation or possibly of the injury itself.IntroductionNumerous factors influence outcomes following open treatment of acetabular fractures including fracture pattern, age, associatedchondral damage, neurovascular injury, and associated dislocation. Traumatic hip dislocations often times have associated injuriesincluding chondral damage, labral tears, and ligamentum teres tears [1]. Interestingly, the current published literature has notdescribed the development of femoroacetabular impingement (FAI) following either traumatic hip dislocation or acetabular fracture.Here we present FAI development as a late complication following operative treatment of a posterior wall acetabular fracture dis-location. The authors have obtained the patient's informed written consent for print and electronic publication of the case report.Case reportA thirteen-year-old female presented to the emergency department as the restrained passenger in a motor vehicle collision athighway speed. She experienced loss of consciousness during the accident and complained of right hip pain on arrival. She wasdiagnosed with a right posterior wall acetabular fracture dislocation without marginal impaction or neurovascular deficit. She un-derwent procedural sedation for closed reduction in the emergency department and was placed into distal femoral traction tomaintain reduction and provide patient comfort. She was taken for open reduction and internal fixation on hospital day one.She was positioned prone on a radiolucent flat-top table. A Kocher-Langenbeck exposure was performed. A very peripheralhttps://doi.org/10.1016/j.tcr.2018.07.003Accepted 16 July 2018⁎ Corresponding author.E-mail address: david.zuelzer@uky.edu (D.A. Zuelzer).Trauma Case Reports 18 (2018) 56–59Available online 13 October 20182352-6440/ © 2018 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).acetabular fracture with substantial capsular attachments was identified. The fracture fragment was reduced, wired provisionally,and then secured with a spring plate pelvic reconstruction plate used in buttress fashion (Fig. 1). The obturator internus and pir-iformis tendons were approximated to the posterior aspect of the greater trochanter. Post-operative imaging demonstrated an ana-tomic reduction and no evidence of intra articular screw placement. She was discharged on hospital day 8 and remained weight of legweight bearing for six weeks. She maintained weight of leg weight bearing and was ambulatory with the use of a walker the followingday. She subsequently healed her acetabular fracture and advanced to weight bearing as tolerated at 3months. At six months post-opshe could run without pain. At one year she had complaints of right anterior thigh pain and occasional pain with rotation of the hipand was prescribed Ibuprofen. Radiography showed no evidence of osteoarthritis or degenerative changes. She then presented toclinic a month later outside of normal follow up for continued right hip pain and subjective instability after running in gym class. Atthis point she was referred to a hip preservation specialist for evaluation of femoroacetabular impingement that had advancedradiographically (Fig. 2).Upon presentation to the hip preservation consultant, she had complaints of pain and mechanical symptoms. Examination de-monstrated positive impingement signs including a positive Patrick test with significantly reduced hip flexion and internal rotation.Radiographically, she had reduced femoral head neck offset, most pronounced anterior and lateral, with alpha angle of ~90°, mildinferior joint space narrowing, and retained implants that would preclude adequate soft tissue visualization with MR. A CT scan wasobtained to better clarify the extent of the FAI lesion for operative planning. Hip arthroscopy was performed utilizing mid anterior,anterolateral, and distal anterolateral portals. She was found to have a degenerative and detached labrum from 12:00 to 3:00 positionas described by Philipon et al. [2], grade 1 changes of the posterolateral acetabular cartilage and delamination of the anterioracetabular cartilage from 10:00 to 2:00 position. There was a loose chondral flap in the central portion of the femoral head with grade3 changes present in the acetabular fossa. She had a loose chondral piece of bone within the acetabular fossa. She had reduced headneck offset seen extending from the anterior portion of the femoral head to the very lateral and posterior portion with adhesion andosteophyte formation within the joint itself. She underwent labral repair, capsular plication, and anterior femoral osteochon-droplasty. Her pain and feelings of instability improved post operatively and her pain decreased to approximately 3 out of 10. At oneyear following her arthroscopic procedure, she returned to athletic competition and has minimal complaints of hip pain despite apersistent posterior cam lesion (Fig. 3).Fig. 1. A–C. A). 3D Recon image of a right posterior wall acetabulum fracture. B). Immediate postoperative radiographs and C) immediate post-operative CT scan showing interval hardware placement and no preexisting CAM lesion.Fig. 2. A and B. Representative slices of CT scans at the same depth taken 2 years apart demonstrate the interval development of CAM lesion offemoral head. A). Immediate postoperative CT scan. B). 14months postoperatively the posterior wall fracture has healed with no degenerativechanges seen. There has been interval development of a CAM lesion.D.A. Zuelzer et al. Trauma Case Reports 18 (2018) 56–5957DiscussionFemoroacetabular impingement has garnered abundant clinical and academic attention recently. The exact etiology of FAI isunclear however is thought to involve abnormal torsion of the acetabulum and femoral neck. Acetabular retroversion and decreasedfemoral anteversion have been implicated in pincer and cam impingement mechanisms, respectively [3]. The subsequent impact ofthe acetabulum and femoral neck lead to progressive labral and articular cartilage damage leading to abnormal bony growth anddevelopment of FAI.There are no current reports of FAI development following acetabular fracture fixation. We have presented a case of FAI thatappears to have developed after a dislocation associated with a posterior wall acetabular fracture. Cam impingement is characterizedby bony deformity that develops on the femoral neck and typically spans the 1:00 to 3:00 position on the clock face [4]. Our patientdeveloped a lesion that was somewhat atypical in that it started more laterally at about 12:00 position and ending at about 2:00position. There was no associated pincer lesion of the acetabulum but a labral tear with associated grade III chondral changes wereidentified adjacent to the cam lesion. It is unclear whether the labral tear or the chondral changes were consequences of the dis-location, fracture fixation, or from development of FAI.Early reports demonstrated excellent outcomes for patients following acetabular fractures with posterior dislocation and were notthought to predispose to the development of osteoarthritis [5]. Follow up studies have shown poor functional outcomes followingposterior wall acetabular fractures in 10–30% of patients [6–8]. Even worse outcomes were found with those that sustained femoralhead cartilage damage with an elevated risk for post traumatic osteoarthritis [7]. This patient had a posterior wall fracture dislocationrequiring a reduction maneuver in the ER and was subsequently found to have chondral damage upon arthroscopic evaluation. Thesefindings placed her at an elevated risk for poor outcome.The exact etiology of FAI is not well understood. Prior hypotheses have involved the production of reactive bone due to abnormalimpingement and subsequent development of the cam lesion as well as labral tears and underlying chondral damage [9]. Despite hertimely anatomic fixation she developed a large anterolateral cam lesion with reduced head neck offset of the femoral neck. There wasno surgical treatment performed on the femoral side. She was also noted to have grade III chondral damage which likely occurredduring her dislocation and subsequent reduction. This may point to underlying cartilage damage as the etiology of the pathologicdeformity seen in cam type impingement. Likely, the bony cam lesion occurs immediately adjacent to the cartilage damage, ana-logous to osteophyte formation during osteoarthritic changes. Alternatively, it has been suggested that cam deformity occurs as aconsequence of abnormal growth plate modulation. It is possible that remaining growth potential combined with maintenance ofslight hip flexion for prolonged period may have resulted in abnormal growth and development of an accelerated cam deformity.Late complications of acetabular fractures that predispose to poor outcome have previously been elucidated. Poor postoperativereduction increases risk of avascular necrosis, heterotopic ossification, and post-traumatic arthritis [5, 10]. Here we have presented apreviously unreported complication following a posterior wall acetabular fracture that represents a poor clinical outcome that wassalvaged with hip arthroscopy and femoral osteochondroplasty. This represents the first known case of femoroacetabular impinge-ment occurring as a complication of posterior wall acetabular fracture fixation. Additionally, this may implicate chondral damage asthe underlying cause of the hallmark cam type impingement lesion. Finally, this case highlights the importance of prolonged followup and scrutinizing x-rays of patients with new onset pain and poor satisfaction following posterior wall acetabular fracture fixationfor possible reversible causes of hip pain including femoroacetabular impingement.Disclosure statementThe authors have nothing to disclose.Fig. 3. A–C. A). Preoperative radiograph taken before hip arthroscopy and femoral osteochondroplasty. B). Dunn view taken with fluoroscopyintraoperatively and C). Follow-up radiographs taken 1 year after hip arthroscopy and femoral osteochondroplasty. Note that there is no evidence ofrecurrence at 1 year following osteochondroplasty.D.A. Zuelzer et al. Trauma Case Reports 18 (2018) 56–5958References[1] M.J. Philippon, et al., Arthroscopic findings following traumatic hip dislocation in 14 professional athletes, Arthroscopy 25 (2) (2009) 169–174.[2] M.J. Philippon, et al., Arthroscopic management of femoroacetabular impingement: osteoplasty technique and literature review, Am. J. Sports Med. 35 (9)(2007) 1571–1580.[3] D. Tonnis, A. Heinecke, Acetabular and femoral anteversion: relationship with osteoarthritis of the hip, J. Bone Joint Surg. Am. 81 (12) (1999) 1747–1770.[4] A.B. Yanke, et al., Sex differences in patients with CAM deformities with femoroacetabular impingement: 3-dimensional computed tomographic quantification,Arthroscopy 31 (12) (2015) 2301–2306.[5] J.M. Matta, Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury, J. BoneJoint Surg. Am. 78 (11) (1996) 1632–1645.[6] B.R. Moed, S.E. WillsonCarr, J.T. Watson, Results of operative treatment of fractures of the posterior wall of the acetabulum, J. Bone Joint Surg. Am. 84-A (5)(2002) 752–758.[7] B.R. Moed, P.H. Yu, K.I. Gruson, Functional outcomes of acetabular fractures, J. Bone Joint Surg. Am. 85-A (10) (2003) 1879–1883.[8] A.M. Saterbak, et al., Clinical failure after posterior wall acetabular fractures: the influence of initial fracture patterns, J. Orthop. Trauma 14 (4) (2000) 230–237.[9] J.W.T. Byrd, Operative Hip Arthroscopy, Third edition, Springer, New York, 2013 (xxi, 553 pages).[10] P.V. Giannoudis, et al., Operative treatment of displaced fractures of the acetabulum. A meta-analysis, J. Bone Joint Surg. (Br.) 87 (1) (2005) 2–9.D.A. Zuelzer et al. Trauma Case Reports 18 (2018) 56–5959

Femoroacetabular Impingement as a Complication of Acetabular Fracture Fixation

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Femoroacetabular Impingement as a Complication of Acetabular Fracture Fixation

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