Prone or lateral? Use of the Kocher-Langenbeck approach to treat acetabular fractures

The Reliability of Postoperative Radiographic Matta Grading for Quality of Reduction of Acetabular Fractures

OBJECTIVES

To assess the reliability of the postoperative radiographic Matta grading for quality of reduction of acetabular fractures.

DESIGN

An inter-reliability and intrareliability study.

SETTING

Level I trauma center.

PARTICIPANTS

15 independent observers of different levels of experience who evaluated 115 sets of postoperative acetabulum radiographs in 35 consecutive patients with displaced acetabular fractures between January 2017 and January 2019.

MAIN OUTCOME MEASUREMENTS

To assess the interobserver and intraobserver reliability of Matta radiographic grading for postoperative quality of reduction of acetabular fractures.

RESULTS

The overall interobserver agreement was excellent among all groups with an average absolute intraclass correlation coefficient (ICC) of 0.91 (95% CI 0.93-0.97). When stratifying the agreement based on experience, the orthopaedic trauma fellow subgroup had the highest rate with an ICC of 0.92. The overall intraobserver agreement was good with an ICC of 0.81 (95% CI 0.74-0.85).

CONCLUSION

The Matta radiographic grading was a reliable tool for the evaluation of quality of reduction after surgical fixation of acetabular fractures with excellent interobserver and good intraobserver reliabilities among different levels of observers.

[Research progress of different surgical approaches in treatment of acetabular both-column fractures]

Objective

To review the research progress of different surgical approaches in the treatment of acetabular both-column fractures.

Methods

The domestic and foreign related research literature on surgical approaches for acetabular both-column fractures was extensively consulted. The anatomical characteristics, exposure ranges, advantages, disadvantages, and indications of various common surgical approaches for both-column fractures were mainly summarized.

Results

The ilioinguinal approach is more suitable for both-column fractures if the anterior column fracture is complicated or combined with the anterior wall fracture while the posterior column fracture is simple and stable. The modified Stoppa approach or the lateral (para) rectus abdominal approach is the preferred choice when both-column fractures are combined with a quadrilateral fracture or femoral head dislocation. What's more, the Kocher-Langenbeck approach is required when the posterior column fractures are complicated or combined with posterior wall fractures. In addition, the simultaneous ilioinguinal and Kocher-Langenbeck approaches are the first choices when the both-column fractures possessing extremely severe and obvious displacement.

Conclusion

The reasonable choice of surgical approach is extremely important for acetabular both-column fractures. Each surgical approach has its advantages and limitations. It is necessary to take the precise reposition of the acetabular joint surface as the principle, and comprehensively judge the fracture types and severity of anterior column, posterior column, and square area, and then select the optimal surgical approach for surgical treatment.

Acetabular Surgery in the Prone Position Resulting in a Life-Threatening Splenic Injury: A Case Report

CASE

The case reported involves a patient who developed an unexplained decrease in hemoglobin after acetabular fracture surgery in the prone position. Repeat abdominal computed tomography was remarkable for a massive subcapsular spleen hematoma secondary to rib fracture impingement, which required splenectomy.

CONCLUSION

The spleen can be injured by a fracture rib during prone positioning for fixation of an acetabular fracture. Prone surgical positioning may cause iatrogenic intra-abdominal organ injury in patients with displaced lower rib fractures. Lateral positioning should be considered for acetabular surgery in patients with rib fractures.

The use of Verbrugge forceps for reduction of the posterior column element in displaced acetabular fractures: clinical and radiological evaluation

PURPOSE

Different reduction techniques and tools are described to facilitate anatomical reduction of acetabular fractures. However, maintenance of reduction, plate placement, and fracture fixation remain a challenge owing to the large surface area occupied by the available reduction tools. This study aims at radiological and functional assessment of the effectiveness of a novel reduction technique for the posterior column element in displaced acetabular fractures.

METHODS

A prospective study was conducted for evaluation of a novel reduction technique; the use of the conventional large holding Verbrugge forceps for reduction of posterior column and transverse, with or without posterior wall, fractures. Intra-operative safety and reduction time were evaluated. The immediate postoperative quality of reduction was assessed using Matta radiographic criteria. The functional outcome was evaluated at the latest follow-up visit using the modified Merle d'Aubigne and Postel (MDP) score.

RESULTS

Thirty patients with a mean follow-up of 18.1 months were included. Fifteen had transverse/posterior wall, ten had transverse, and five had posterior column fractures. All fractures were displaced ≥ 2 mm on anteroposterior and/or Judet views of the pelvis without traction. The average operative time was 100.4 min with 12.5 min reduction time. No intra-operative complications were encountered. Twenty-three patients (76.6%) had anatomical while seven (23.3%) had imperfect reduction. The functional outcome score was excellent in three patients, good in 18, fair in four, and poor in five patients at the latest follow-up.

CONCLUSION

The use of the conventional large Verbrugge bone-holding forceps for the reduction of the posterior column element in displaced acetabular fractures using the Kocher-Langenbeck approach is a safe, effective, time-saving, and technically undemanding procedure.

The role of patient positioning on the outcome of acetabular fractures fixation through the Kocher-Langenbeck approach

BACKGROUND

Open reduction and internal fixation through the Kocher-Langenbeck approach is the treatment of choice for selected acetabular fracture patterns. Patient positioning (lateral vs prone) can affect the outcome and post-operative complications.

METHODS

A retrospective cohort of seventy-three adult patients' with acetabular fractures treated with open reduction and internal fixation through the Kocher-Langenbeck approach in either prone or lateral position. Primary outcome was the quality of radiographic fracture reduction; secondary outcomes included operative time, intra-operative estimated blood loss and pre-operative complications.

RESULTS

The demographics and fracture type were similar between the two groups. There was no difference in the quality of reduction using the Matta radiographic grading. Laterally positioned group demonstrated significant shorter surgical time and lower incidence of iatrogenic sciatic nerve injury. There was no difference in estimated blood loss, heterotopic ossification or infection.

CONCLUSION

This study showed no difference in the quality of fracture reduction, intraoperative blood loss, post-operative infection and heterotopic ossification between both groups. Hence, patients' condition, surgeon experience and preference are important factors for deciding patient positioning in the Kocher-Langenbeck approach for acetabulum fracture fixation.

The Kocher-Langenbeck Approach: State of the Art

Introduction

The Kocher-Langenbeck approach is the workhorse for the reduction and fixation of hip fractures that require fixation via a posterior approach^1,2.

Indications & Contraindications

Step 1 Preoperative Planning

Review the patient's general condition and imaging studies, plan the sequence of reduction and fixation, and make sure that all of the necessary equipment is available.

Step 2 Preparation and Patient Positioning

Induce anesthesia, administer intravenous antibiotics as per local hospital protocol, apply antiembolism stockings, and insert a Foley catheter to the bladder.

Step 3 Kocher-Langenbeck Approach

Make an incision that is 15 to 20 cm long and has 2 parts (proximal and distal), which are centered over the greater trochanter.

Step 4 Fracture Reduction and Fixation

The reconstruction of posteriorly based fractures depends on the specific fracture type, and the goal is to provide stable column fixation and anatomical reconstruction of the acetabular articular surface, with column fixation performed before the reconstruction of the posterior wall.

Step 5 Wound Closure and Postoperative Care

Meticulous hemostasis, application of drains, and watertight closure are the final steps of the operation.

Results

The Kocher-Langenbeck approach is the workhorse for the surgical management of acetabular fractures and provides sufficient access to the majority of posterior based acetabular fractures¹⁵.

Pitfalls & Challenges

Results of 167 consecutive cases of acetabular fractures using the Kocher-Langenbeck approach: a case series

Background

Acetabular fractures are quite challenging injuries for the orthopedic surgeon because of their low incidence and their deep and complex anatomy. The objective of this study was to evaluate surgeon-independent parameters that might influence radiographic outcome and early complication rates of high-energy acetabular fractures treated by open reduction and internal fixation via the Kocher-Langenbeck approach, the golden standard for posterior access.

Methods

One hundred sixty-seven consecutive patients (111 males and 56 females) with a mean age of 41.8 years and a mean follow-up period of 10 months were surgically treated by one experienced surgeon at a level I trauma center within 10 years. To quantify the radiographic outcome, the Matta, Brooker, and Epstein grades were used. Posttraumatic arthritis and avascular necrosis of the femoral head (defined as Helfet grades 3 or 4 and Ficat/Arlet stages 3 or 4, respectively) were evaluated. Furthermore, subgroup analyses according to fracture type, age, and gender were performed for each outcome measure and complication (infection, hemorrhagic shock, revision surgery, nerve damage, and need of a total hip arthroplasty).

Results

65 A1, 34 A2, 51 B1, and 17 B2 fractures were identified according to the AO/ASIF classification. Of all patients, reduction was rated anatomic in 63.5%, imperfect in 22.2%, and poor in 14.4%. Degenerative changes were observed in 49.7%; 37.9% were affected by heterotopic ossification, 21.6% by posttraumatic arthritis, and 5.4% by avascular necrosis of the femoral head. Fifteen percent were diagnosed with a nerve damage, and 4.8% sustained an infection. Total hip arthroplasty was performed in 10.2%. Revision surgery due to secondary loss of reduction, seroma/hematoma, and wound infection was indicated in 6.0%.

Conclusions

Fracture type, age, and gender are prognostic factors for the surgical outcome after ORIF of high-energy acetabular fractures.

Electronic supplementary material

The online version of this article (doi:10.1186/s13018-017-0563-6) contains supplementary material, which is available to authorized users.

A prospective randomized comparison of two skin closure techniques in acetabular fracture surgery

Background

Recent publications have shown an infection rate of 5–7 % for acetabular fractures treated with the Kocher-Langenbeck (K-L) approach. Using metallic staples to close hip skin incisions has been considered the gold standard. The purpose of this study was to answer the following: (1) will closure of a K-L incision after acetabular fracture surgery with a running subcuticular monocryl suture, then sealing the wound with 2-octyl cyanoacrylate (OCA), result in a lower infection rate compared to metallic staple closure? (2) Do incisions closed with subcuticular monocryl and OCA exhibit decreased drainage? (3) Is there a cost difference between these two methods?

Materials and methods

In a prospective clinical study, 103 patients with acetabular fractures treated using the K-L approach were randomized into two groups: skin closure with metallic staples (n = 52) versus subcuticular running monocryl suture sealed with OCA (n = 51).

Results

Two postoperative deep infections (4 %) in the staples group required multiple debridements; no infections developed in the OCA group. However, there was no statistical difference between the groups, (p = 0.495). There was a statistically significant difference (p = 0.032) comparing days from surgery to a dry incision favoring OCA (4.2 versus 5.85 days). The patient charge was approximately $900 greater on average in the OCA group due to the increased time in the operating room required for the subcuticular closure.

Conclusions

Closure with OCA and subcuticular monocryl showed no clinical disadvantages and appears to have a clinical advantage when compared to standard metallic staple skin closure in acetabular fracture surgery. However, additional patient costs may be incurred.

Level of evidence

II.

Surgical dislocation technique for the treatment of acetabular fractures

BACKGROUND

Surgical hip dislocation allows for a 360° view of the acetabulum and may facilitate a reduction in selected acetabular fractures. To our knowledge there is no description in the literature of the different techniques used to reduce acetabular fractures through this approach. The aims of this study are to describe a technique of hip surgical dislocation to treat a variety of acetabular fracture patterns and to ascertain the early results with this technique, including the quality of fracture reductions achieved, clinical results, operative time, and complications such as avascular necrosis and heterotopic ossification.

DESCRIPTION OF TECHNIQUE

The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. T-type, transverse fractures alone or associated with posterior wall could be reduced with specific clamps and reduction adequacy can be judged by direct view. Anterior column fixation could be performed with one or two screws; the posterior column could be fixed with a single posterior plate or with two plates if a transverse fracture is associated with a posterior wall fracture.

METHODS

Between 2005 and 2011, we used this approach selectively to manage those types of fractures; during the period in question, we treated 312 acetabular fractures surgically, of which 31 (10%) were treated using this approach. Patient demographic, injury, and surgical variables as well as complications were recorded. Outcomes were evaluated with the Merle d'Aubigné and Postel system. Radiographic outcome was scored according to Matta's criteria on postoperative radiographs (AP and Judet views). Minimum followup was 24 months (mean, 43 months; range, 24-87 months).

RESULTS

Fracture reduction was defined as anatomic in 65% cases, imperfect in 16%, and poor in 19%. Mean Merle d'Aubigné score was 15 points (out of 18, with higher scores being better). Two patients developed symptomatic femoral head avascular necrosis.

CONCLUSIONS

In complex cases, surgical dislocation presents several advantages; a single approach may reduce surgical time, permit direct intraarticular assessment, and facilitate screw placement closer to the articular surface. It also presents several limitations; some difficulties with bone-reduction clamp positioning, limited fixation of the anterior column, and a small risk of greater trochanter malunion.