Patterns, Complications and Early Functional Outcomes of Acetabular Fractures in Three Urban Hospitals in Kenya

Abstract

Background: Acetabular fractures are a subset of pelvic fractures commonly occurring due to high-energy trauma, and present a unique challenge to orthopaedic surgeons due to their inherent complexity. Motor vehicle crashes constitute approximately 1.24 million global deaths annually, with a further 20 – 50 million suffering either a minor or major injury. Kenya has an estimated road fatality rate of 27.8 per 100,000 population, according to a 2018 World Health Organization report. Road crash statistics for Kenya as at 31st October 2020 released by the National Transport and Safety Authority (NTSA) indicate a 5.8% increase in fatalities compared to the same period in 2019. There is limited local and regional data on acetabular patterns and outcomes. Study objective and justification: To determine patterns, complications, and early outcomes of acetabular fractures in patients at three urban hospitals in Kenya. This will inform policy, training, prevention and resource allocation. Study Setting and Design: A prospective cohort study undertaken at Kenyatta National, Nakuru County Referral, and Coptic Hospitals. Methods: Fourty six adult patients who presented to the Accident and Emergency departments of the participating hospitals that met the inclusion criteria were recruited. Fracture classification was based on images of plain antero-posterior radiographs and CT scans. Observations for early outcomes were made in the course of their inpatient stay and clinic follow-up. A Harris Hip Scores and lower limb length discrepancy was measured at 12 weeks post-management. Data analysis: Data were collated using a data collection sheet, and analysed using the

IBM®Statistical Package of Social Sciences (SPSS)® Statistics version 26. Fracture patterns, complications, fracture management modalities and Harris Hip Score measures were analyzed descriptively and presented in graphical and tabular form. Harris Hip Scores were correlated with fracture patterns, time to surgery and management modalities using Pearson’s Chi- square test and Fisher's exact test. Multiple regression analysis was be employed for multivariate analysis of collected data. Study Utility: This study set out to draw associations between fracture morphology, complications, treatment methods and early functional outcomes. It is hoped that it will inform the practice of acetabular fracture management. Results: Fourty six patients were included in the study, with most (89.1%) being males. The age ranged from 18 – 72 years (Mean 34.9yrs ± 13.1yrs). A majority of the patients, (67.4%) were treated at the Kenyatta National Hospital, 14 (30.4%) at NCRH and only 1 (2.2%) had complete data at Coptic Hospital at the end of the study. The patients’ Harris hip scores ranged from 51 – 95 with a mean score 76.6 (± 9.7) considered a fair score. Fracture displacement ranged from 0 – 44 mm with a mean of 19.5mm (± 13.9mm) using 2-Dimensional CT cuts. The posterior wall and the transverse with posterior wall fracture patterns were the most prevalent patterns (23.9%). Operative treatment undertaken in most patients (58.7%). There was a statistically significant correlation between HHS and fracture displacement (p<0.001), operative fracture management (p< 0.001) and duration of hospital stay (p<0.024). Conclusion: Operative management is best suited for displaced fractures, with non-operative care reserved for those with minimal displacement or those unfit for surgery. A majority of patients underwent surgical fixation (58.7%), indicative of the severity of injury and fracture displacement necessitating operative care. Of note is the poorer HHS in patients with initially

large fracture displacement, and longer hospital stay. Higher HHS were seen in operatively managed patients. The HHS performed early showed agreement with scores done a year after surgery, suggesting that early scoring may help predict future functional outcomes. Recommendations: Acetabular fractures have the potential for sequelae that hamper activities of daily living, with pain and disability. They pose a risk for the development of post traumatic arthritis of the hip joint, that may necessitate total hip arthroplasty. Measures to ensure anatomical reduction, early surgery, reduced length of hospital stay, and operative management for displaced fractures should be undertaken, which include prioritization of these patients for surgery, and increasing the pool of expertise able to tackle these complex fractures. Educating road users of all cadres and other occupations at risk on safe and considerate road use and workplace safety is paramount to reducing the occurrence of these high energy injuries.