Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the acetabulum

Fluroscopy-assisted transiliac antegrade lag screw placement technique in both columns of acetabulum: A novel procedure

The use of pelvic osseous fixation corridors and lag screw fixation in acetabular and pelvic surgery has gained popularity, especially with the recent development of intraoperative imaging and navigation techniques. However, advanced intraoperative imaging and navigation techniques require technical equipment and are costly. Therefore, traditional fluoroscopic techniques still maintain their importance. In this article, we describe a novel pelvic osseous fixation corridor that traverses both columns of the acetabulum, along with the detailed methodology of its fluoroscopic imaging and the techniques for fluoroscopy-assisted screw placement. The technique of placing screws in this current fixation corridor is only under fluoroscopy assistance, without using any specially produced guide or navigation device. LEVEL OF PROOF: IV.

External iliac artery thrombosis as a result of acetabular fixation through the ilioinguinal approach: a case report

Introduction and importance

Acetabular fractures mostly occur in young people who are involved in high-energy trauma and they are treated by orthopedic trauma surgeons. Patients with acetabular fractures are at high risk for different kinds of complications. We report a case of postoperative thrombosis of the external iliac artery following fixation surgery performed by an ilioinguinal approach while receiving thromboprophylaxis during admission to the hospital.

Case presentation

A 57-year-old healthy woman presented with a left both-column acetabular fracture and underwent acetabular fixation through the ilioinguinal approach. The patient was receiving antithrombotic prophylaxis medications in the course of treatment.

Clinical discussion

During her convalescence, while at the hospital, she was diagnosed with left external iliac artery thrombosis, needing surgical thrombectomy. These severe and rare complications will lead to uncertainty about a commonly used ilioinguinal approach. Postoperative arterial thrombosis may be rare in patients undergoing acetabular fixation surgery but searching for signs and symptoms of this condition is always necessary.

Conclusion

It is possible to prevent severe complications by performing a routine measurement of the distal arterial pressure after similar surgeries.

[Possibilities and limits of intraoperative 2D imaging in trauma surgery]

BACKGROUND

The two-dimensional (2D) imaging represents an essential and cost-effective component of intraoperative position control in fracture stabilization, even in the era of new three-dimensional (3D) imaging capabilities.

OBJECTIVE

The aim of the present study, in addition to a current literature review, was to examine whether the intraoperative use of 2D images leads to a quality of fracture reduction comparable to postoperative computed tomographic (CT) analysis including 3D reconstructions.

MATERIAL AND METHODS

A comparative retrospective analysis of intraoperative 2D and postoperative 3D image data was performed on 21 acetabular fractures stabilized via a pararectus approach according to an established protocol using the Matta criteria.

RESULTS

The assessment of fracture reduction in intraoperative fluoroscopy compared with postoperative CT revealed a difference only in one case with respect to the categorization of the joint step reduction in the main loading zone.

CONCLUSION

In the intraoperative use of 2D imaging for fracture treatment it is important to select the correct adjustment planes taking the anatomical conditions into account in order to achieve optimum assessability. In this way, the reduction result can be adequately displayed in fluoroscopy and is also comparable to the postoperative CT control. In addition, depending on the findings, optional intraoperative dynamic fluoroscopic assessment can have a direct influence on the further surgical procedure.

Comparison between Novel Anatomical Locking Guide Plate and Conventional Locking Plate for Acetabular Fractures: A Finite Element Analysis

The treatment of complex acetabular fractures remains a complicated clinical challenge. Our self-designed novel anatomical locking guide plate (NALGP) has previously shown promising potential in T-shaped acetabular fractures (TAF), but a direct comparison with conventional fixations is yet to be made. The TAF model was established based on a volunteer's computer tomography data and then fixed with double column locking plates (DLP), a posterior column locking plate with anterior column screws (LPACS), and our NALGP. Forces of 200 N, 400 N, and 600 N were then loaded on the model vertically downward, respectively. The stress distribution and peaks and maximum displacements at three sites were assessed. We found that the stress area of all three plates was mainly concentrated around the fracture line, while only the matching screws of the NALGP showed no obvious stress concentration points. In addition, the NALGP and DLP showed significantly less fracture fragment displacement than the LPACS at the three main fracture sites. The NALGP was found to have less displacement than DLP at the posterior column and ischiopubic branch sites, especially under the higher loading forces of 400 N and 600 N. The fixation stability of the NALGP for TAF was similar to that of DLP but better than that of LPACS. Moreover, the NALGP and its matching screws have a more reasonable stress distribution under different loads of force and the same strength as the LPACS.

Surgical approach of T-type acetabular fractures does not affect quality of reduction on postoperative CT or the likelihood of postoperative complications

INTRODUCTION

T-type acetabular fractures are rare but challenging injuries. The purpose of this study was to evaluate for associations between chosen surgical approach for T-type acetabular fracture fixation, reduction quality, and complications.

METHODS

Retrospective, single institution study of T-type acetabular fractures who underwent surgical fixation. Surgical interventions included open reduction and internal fixation (ORIF) through an anterior intrapelvic approach (AIP) (modified Rives-Stoppa) and/or posterior (Kocher-Langenbeck [KL]), or percutaneous screw fixation. The primary outcome was reduction quality on routine postoperative computed tomography (CT) scan and postoperative complications.

RESULTS

During the study period (March 2016 - October 2022), 22 patients presented with T-type acetabular fractures. Surgical approaches included AIP [31.8% (7/22)], percutaneous [27.3% (6/22)], AIP+KL [22.7% (5/22)], and KL [18.2% (4/22)]. On CT scans, 9.0% (2/22) had anatomic reductions, 27.2% (6/22) had fair reductions, and 63.6% (14/22) had poor reductions based on Matta Reduction Criteria. There was no observed difference in reduction quality between surgical approaches. Poor reductions (> 3 mm) were not associated with surgical approach, fracture classification, unstable pelvic ring injuries, posterior wall fractures, T-stem component, transverse component, preoperative articular displacement, preoperative femoral head protrusion, or surgeon experience. Complications occurred in 50.0% (11/22) of patients. No observed difference in complication rates was noted between the surgical approaches.

CONCLUSION

T-type acetabular fractures are challenging injuries with few patients achieving anatomic reduction on postoperative CT scans and half of patients developing complications.

Clinical efficacy and its influencing factors of surgical treatment for T-shaped associated with posterior wall acetabular fractures using combined surgical approaches

BACKGROUND

The objective of this study was to evaluate the outcomes of surgical treatment for T-shaped associated with posterior wall acetabular fractures using combined surgical approaches and its influencing factors.

METHODS

Between January 2009 and June 2018, a total of 21 patients with T-shaped acetabular fractures involving posterior wall were treated with combined approaches. The combined approaches were a combination of the Kocher-Langenbeck (KL) approach and the anterior approach (Stoppa or Ilioinguinal). The acetabular fractures in this study were divided into two groups respectively according to surgical approach and surgical timing: KL + Ilioinguinal (IL) approaches and KL + Stoppa approaches, early surgery and late surgery.

RESULTS

13 cases were treated within 14 days of injury. 15 cases were treated using the KL + Stoppa approaches and remaining 6 cases were treated using the KL + IL approaches. Anatomical and imperfect reduction were achieved in 12 cases (57.1%) with excellent to good clinical outcome in 42.9% of cases. Early surgery had a statistically significant improvement over late surgery in terms of quality of reduction and clinical outcomes. In the early surgery, the incidence of preoperative chest and abdomen injuries and postoperative deep vein thrombosis was significantly lower than that of the late surgery. There was no statistical difference between the KL + IL approaches and KL + Stoppa approaches in the demographics, preoperative associated injuries, quality of reduction, clinical outcomes and postoperative complications.

CONCLUSIONS

The results of this study indicate that T-shaped associated with posterior wall acetabular fractures are difficult to treat surgically. Early surgery can improve the quality of fracture reduction, promote the recovery of hip function, and decrease the incidence of postoperative deep vein thrombosis. The main factor that affects surgical timing is the presence of preoperative chest and abdominal injuries. Compared with the KL + IL approaches, the KL combined with Stoppa approach can not significantly improve the clinical outcomes of such acetabular fractures.

The effect of an infra-acetabular screw for anatomically shaped three-dimensional plate or standard plate designs in acetabulum fractures: a biomechanical analysis

Background

Various plate shapes and implant configurations are used for stabilization of acetabulum fractures via anterior approaches. Little is known about the biomechanical stability of a two-dimensionally shaped “conventional” plate (“J-Plate”—JP) in comparison to three-dimensionally shaped plate configurations (3DP). In addition, the augmentary effect of an infra-acetabular lag-screw (IACS) fixation for anterior column and posterior hemi-transverse acetabulum fractures has not been clarified in comparison of JP and 3DP constructs. This study analyzed the difference between the biomechanical stability of JP compared to 3DP and the role of an IACS in a standardized acetabular fracture model in a single-leg stance loading configuration.

Methods

In an artificial bone substitute pelvis model (Synbone^© Malans, Switzerland), a typical and standardized fracture pattern (anterior column and posterior hemi-transverse) was created with osteotomy jigs. After anatomic reduction the stabilization was performed using JP or 3DP. Eight pelvises per group were axially loaded in a single-leg stance model up to 400 N. After the load cycle, an additional infra-acetabular screw was placed and the measurement repeated. Fragment displacement was recorded by an optical tracking system (Optitrack Prime 13®, Corvallis, USA).

Results

In the pure placement, 3DP provided significantly superior stability when compared to JP. Augmentation of JP by IACS increased the stability significantly, up to the level of 3DP alone, whereas augmentation of the 3DP did not result in further increase of overall stability.

Conclusion

The anatomically shaped plate alone provides a superior biomechanical stability in fixation of an anterior column and posterior hemi-transverse fracture model. In a JP fixation the augmentation by IACS provides similar strength as the anatomically shaped 3DP. By use of the anatomically shaped 3DP the need of a clinically risky application of IACS might be avoidable.

Level of evidence

IV, Experimental study.

Acetabular Fractures with Central Hip Dislocation: A Retrospective Consecutive 50 Case Series Study Based on AO/OTA 2018 Classification in Midterm Follow-Up

Introduction

Management of acetabular fractures is challenging, especially when a medial acetabular fracture is complicated by central hip dislocation. We retrospectively investigated the clinical outcome and risk factors of secondary hip osteoarthritis requiring total hip arthroplasty after the surgical treatment of acetabular fractures with central hip dislocation.

Materials and Methods

The medical records of all patients who had acetabular medial wall fractures with central hip dislocation treated with open reduction and internal fixation by a single surgeon between January 2015 and June 2017 were reviewed. Surgical reduction was performed with the modified Stoppa with/without the Kocher-Langenbeck (KL) approach. Patients were followed for a minimum of three years, and the Majeed scoring system was used for functional evaluation. Multivariate logistic regression analysis was used to assess the association of patients' characteristics with the likelihood of advanced posttraumatic arthritis developing with conversion to total hip arthroplasty.

Results

Fifty patients were included in this study, with disease classified as AO/OTA 2018 62B/62C. Thirty-five patients (70%) had good or excellent Majeed pelvic scores. Eleven patients (22%) eventually received total hip arthroplasty because of end-stage posttraumatic arthritis. Three risk factors identified for total hip arthroplasty were male sex, initial marginal impaction, and sciatic nerve injury. Kaplan-Meier survivorship analysis estimated that the cumulative probability of free-from-end-stage arthritis was 78% (95% confidence interval, 73%–90%) at the 5-year follow-up.

Conclusion

Surgical fixation with the modified Stoppa and the KL approach for acetabular medial wall fractures with central hip dislocation is an effective approach with a satisfactory functional outcome. A prodromal factor was marginal impaction concomitant with articular damage. The trauma of high axial loading and the occupational distribution (males performing heavy manual labor and heavy lifting) with preoperative sciatic nerve injury increased the odds of developing end-stage arthritis.

Functional outcome and complication following THA through modified direct anterior approach correlated to cadaveric study: are there any differences in Asian hip?

BACKGROUND

Direct anterior approach (DAA) has several advantages including shorter length of hospital stay, faster recovery, and better functional outcome while this approach may cause damage to the lateral femoral cutaneous nerve (LFCN) as high as 81% in the works of literature. Not much data has identified the LFCN pattern in the Asian population. Therefore, the purpose of our study was to identify characteristics of the LFCN patterns representing an Asian hip, which would aid to provide the most appropriate incision of modified direct anterior approach (MDAA) for total hip arthroplasty (THA), and to identify the clinical outcome and complications following THA through MDAA correlated with cadaveric hip in the Asian population.

METHODS

After IRB approval, a cadaveric study was done to identify pattern and course of the LFCN in Asian population. The MDAA defined as the incision 2 fingerbreadths posteriorly to anterior superior iliac spine to avoid injury to the LFCN. The clinical phase identified 32 patients who underwent THA because of late-stage osteoarthritis of the hip. The anterolateral skin numbness was measured along tensor fascia lata between 2 weeks until 2 years. The functional outcome assessed by Harris Hip Score (HHS) and complications were evaluated in all patients.

RESULTS

The characteristics of the LFCN from cadaveric study (phase 1) was predominantly in sartorius type (60.0%) followed by posterior type (26.6%), fan type (6.7%), and variant type (6.7%). The clinical phase demonstrated that 23 patients (71.9%) had no numbness while 9 patients (28.1%) came with numbness after undergoing THA through the MDAA. Finally, a small area of skin numbness remained in only 3 patients (9.4%) at 2 years follow-up. Additionally, there was no significant difference in functional score at 2 years follow-up (89.0 vs 91.2, p = 0.422) between those with LFCN injury and those without LFCN injury.

CONCLUSIONS

The LFCNs were divided into four types. Modified direct anterior approach, which is an alternative approach for THA, allowing for a lower rate of skin numbness and faster recovery without hip dislocation, abductor weakness, and serious nerve complication. Functional outcome was comparable with and without LFCN injury.

LEVEL OF EVIDENCE

Level II, prospective observation study.

A guide to resecting tumors of the sciatic notch

Sciatic notch tumors are rare and have numerous etiologies. Tumor presentation varies widely and no uniform recommendations exist for approaching resection. Most studies on the topic have been small case series, with the approach dictated by surgeon experience and comfort. We provide an overview of surgical approaches for resecting sciatic notch tumors reported in the literature, as well as a conceptual framework for application of these approaches based on standard oncologic principles. The advantages and disadvantages of each approach are described on the basis of anatomic location of the tumor. For tumors that span the notch with intra- and extra-pelvic extension, notchplasty is a novel technique that provides superior visualization and access for en-bloc excision.

The Anatomical Course of the Lateral Femoral Cutaneous Nerve in Relation to Various Skin Incisions Used for Primary and Revision Total Hip Arthroplasty With the Direct Anterior Approach

BACKGROUND

Although the direct anterior approach (DAA) has become a standard for primary and revision total hip arthroplasty, it involves a high risk of injuring the lateral femoral cutaneous nerve (LFCN). The aim of this study is to examine the course of the LFCN in relation to various skin incisions and approach extensions used for the DAA.

METHODS

We obtained 44 limbs and hemipelves from 22 formalin-preserved cadavers, in which LFCN was identified. All nerve branches of the LFCN were carefully traced. The branching pattern and the distribution in the thigh were described in relation to the standard approach for primary total hip arthroplasty, the skin crease bikini incision, the longitudinal extension, and the lazy S extension of the DAA.

RESULTS

We found 31 (70.5%) Sartorius-type, 6 (13.6%) posterior-type, and 7 (15.9%) fan-type branching patterns of the LFCN. We observed 2.02 branches per hemipelvis. All fan-type LFCNs had 3 or more than 3 branches. We found that the main branch of the LFCN was medial to the primary DAA approach as well as to the lazy S extended DAA approach. The bikini incision and the incision for the longitudinal extension of the DAA crosses the main branch of the LFCN in 100% of cases.

CONCLUSION

The fan-type pattern of the LFCN might be harmed by all skin incisions. Chances are high that LFCN branches could be jeopardized with a bikini-type incision and the longitudinal extension of the DAA. The risk of jeopardizing the LFCN with a lazy S-type distal extension is reduced.

Can patients with complex acetabular fractures be operated by combined anterior and posterior approaches in a single anesthetic sitting?

INTRODUCTION

While there is a consensus that complex acetabular fractures require anatomical reduction and stable fixation for their management, there is no agreement on the surgical approaches to be used for achieving that goal. Invariably two surgical approaches are needed for management of such fractures. Whether these approaches should be performed in different anesthetic sittings or in the same sitting, sequentially or simultaneously, is debatable.

MATERIALS AND METHODS

41 patients with complex acetabular fractures were operated in floppy lateral position by combined anterior and posterior approaches during the same anesthetic sitting and were followed for a minimum of one year. Patient related parameters as well as the details of their clinical outcome assessed by Merle D' Aubigne (MD'A) score, radiological outcome by Matta's method, Harris Hip score and complications encountered were recorded. Correlations of the clinical outcomes with other parameters were analyzed along with other statistical details.

RESULTS

The mean surgical duration was 3.5 h. Anatomical reduction was achieved in 17 patients, congruent reduction in 19 and incongruent reduction in 5 patients. MD'A scores were excellent in 8 cases, good in 18 cases, fair in 5 cases and poor in 10 cases. Radiological outcome was excellent in 5, good in 16, fair in 13 and poor in 7 patients. Statistically significant correlation was noted between the MD'A score with reduction quality, cartilage damage and radiological outcome. Delay in surgery and choice of surgical approach had no correlation with the clinical outcome.

CONCLUSION

Combined approaches in the same anesthetic sitting can be used for satisfactory management of complex acetabular fractures. These offer the ease of assessing reduction during surgery, can potentially save time and expenses without unduly affecting the clinical and radiological outcomes and without increasing the rate of complications when compared to approaches performed sequentially.

Fractures of the acetabulum: from yesterday to tomorrow

Purpose

The aim of this article is to present history, state of the art, and future trends in the treatment of acetabular fractures.

Methods

Review of recent and historical literature.

Results

Acetabular fractures are difficult to treat. The first descriptions of this injury already appeared in ancient Greek history, but intensive development started in the second half of the twentieth century after Judet and Letournel’s seminal work. Their classification is still the gold standard today. It is actually a pre-operative planning system and is used to determine the most appropriate surgical approach. The therapy of choice for dislocated fractures is open reduction and internal fixation. Recent modern techniques based on high-tech computerized planning systems and 3D printing have been successfully integrated into orthopaedic trauma practice.

Conclusion

There is no ideal surgical approach for acetabulum fracture treatment, so new approaches have been developed in recent decades. The best outcome series have shown good or excellent results, between 70 and 80%.

The Pararectus Approach in Acetabular Surgery: Radiological and Clinical Outcome

OBJECTIVES

To evaluate radiological fracture reduction and clinical results using the pararectus approach in complex acetabular fractures involving the anterior column.

DESIGN

Retrospective database analysis of prospectively collected data.

SETTING

Level 1 trauma center.

PATIENTS/PARTICIPANTS

61 patients (48 male and 13 female) with a median age of 55 (range 17-91) years were included. According to the chosen surgical approach, they were divided into 2 groups. The P-group included 43 patients, among them 32 male and 11 female patients with a median age of 55 (range 17-90) years. Eighteen patients [16 male, 2 female; median age: 53 (range 23-91) years] were treated through the ilioinguinal approach (I-group).

INTERVENTION

Anterior surgical procedures through the pararectus or the ilioinguinal approach.

MAIN OUTCOME MEASURED

Reduction results were rated according to the modified Matta criteria using a measurement protocol of hip joint gaps and steps in computed tomography scans. Operation time, complications, and clinical outcomes median one year postoperatively were compared.

RESULTS

In the pararectus group reduction was anatomical in 21 out of 40 analyzed patients (52.5%), imperfect in 11 patients (27.5%), and poor in 8 patients (20%). The mean joint step reduction was 3.7 mm, and the mean joint gap reduction was 12.1 mm. In the ilioinguinal group reduction was anatomical in 9 out of 18 patients (50%), imperfect in 4 patients (22%), and poor in 5 patients (28%). The mean joint step reduction was 1 mm, and the mean joint gap reduction was 7 mm. Operation time was significantly shorter in the P-group (mean: 49 minutes; P < 0.001).

CONCLUSIONS

This study indicates that acetabular fracture reduction using the pararectus approach is at least comparable with the ilioinguinal approach independent of patients' age. A relevant advantage of the pararectus approach was seen in a significantly shorter operation time.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of two reinforcement rings for primary total hip arthroplasty addressing displaced acetabular fractures: a biomechanical analysis

INTRODUCTION

Aim of this study was to biomechanically compare two different acetabular cup fixation constructs in terms of fracture fixation for displaced acetabular fractures involving the anterior column with hemitransverse fracture under partial and full weight-bearing conditions.

METHODS

Two different reinforcement rings designed as cages for primary THA were biomechanically tested in terms of managing a complex acetabular fracture. Single-leg stance cyclic loading was performed to assess fracture gap movement and fragment rotation. Twelve hemi pelvis Sawbones were divided into two groups: primary THA with acetabulum roof reinforcement plate (ARRP) (n = 6) and primary THA with Burch-Schneider reinforcement cage (BSRC) (n = 6).

RESULTS

During loading under partial weight-bearing (250 N) fracture gap movement tended to be larger in the BSRC group as compared to the ARRP group. Under full weight-bearing conditions, the ARRP showed 60% significantly less motion (p = 0.035) of the os ilium to os ischii gap compared to BSRC. Fracture gap movements between the os ilium and spina iliaca fragments were significantly reduced by 76% (p = 0.048) for ARRP in contrast to BSRC. The ARRP group also demonstrated significantly less movement in the fracture gaps os ischii to quadrilateral plate (62% reduction, p = 0.009) and quadrilateral plate to spina iliaca (87% reduction, p < 0.001). Significantly less rotational movement of the quadrilateral plate to the os ilium was exhibited by the ARRP group (p = 0.015).

CONCLUSIONS

The presented acetabulum roof-reinforcement plate (ARRP) provides stable conditions at the acetabular component with adequate stabilization of a displaced acetabular fracture.

Delayed presentation of complex acetabular fractures: Review of literature on outcome of internal fixations with reference to extended ilio-femoral approach

OBJECTIVE

Delayed presentation of complex acetabular fractures isn't uncommon. Surgical treatment of such fractures demand special consideration with respect to surgical approach, reduction techniques, fixation and avoidance of complications. This paper intends to review the literature with regard to the suggested treatment modalities and the reported outcome in late presentations and conclude any recommendations appropriate to the practice in current times.

BACKGROUND

Displaced fractures of acetabulum, when remained untreated for more than three weeks, pose significant challenge to fracture reduction due to rapid callus formation. In 1976, Letournel described the "Extended Ilio-Femoral Approach"(EIFA) to provide adequate exposure for effective reduction of such fractures. It offered greater exposure of both anterior and posterior columns through a single window, which allowed more precise and controlled reduction of the complex fractures under vision. But despite early enthusiasm in its practice, there has been a steep decline in its application due to reported higher risk of complications. Despite the challenges, the accuracy of fracture reduction in complex acetabular fractures with late presentation was found to be superior in EIFA than the reduction that were achieved by other approaches. Hence a debate to find out the utility of this approach for late reconstruction of complex acetabular fractures (in the face of reported risks of complications) is worthwhile especially in younger patients, who are not suitable candidates for an acute hip replacement surgery and who need their native hip to function well at least for a few years, for their professional and personal high demand activities in their active youthful period.

METHODS

The articles for review were retrived using Google Scholar for data retrieval as Pubmed didn't yield any meaningful results due to paucity of publication in this subject. There were only very few papers in the English literature since 1979, which focused on this condition and were considered for this review. We have included our experience on using EIFA in late presentations of complex acetabular fractures spanning from 1999 to 2019, an experience over two decades to this report.

RESULTS

It was observed that despite delayed presentation, good articular reduction was possible by using EIFA even in complex acetabular fractures. Ultimate functional outcomes were directly related to the accuracy of fracture reduction thus achieved. The risk of heterotrophic ossification in EIFA, though emphasized as significant in the published literature, was found to be least of a problem in our experience.

DISCUSSION

Surgical fixation in delayed cases of complex acetabular fractures was found to be challenging. The choice of surgical approach was found to have a great bearing on the accuracy of fracture reduction and long term functional outcome. In complex acetabular fractures, despite delay in presentation, precise reduction of such fractures was found to be possible when operated using EIFA. CONCLUSION: It was concluded that Every effort must be made to reconstruct the displaced fractures of acetabulum, even in the complex types,despite when they present late, provided the fracture fits into the selection criteria described by Letournel and operated using EIFA. This is very much appropriate to younger patients, who are not great candidate for total hip replacement surgery.

Effects of lateral circumflex femoral artery ligation on blood flow to the surrounding muscles in the direct anterior approach

BACKGROUND

The direct anterior approach to the hip joint enables the identification and ligation of the lateral circumflex femoral artery. However, the effect of lateral circumflex femoral artery ligation on blood flow to the muscles surrounding the hip remains unknown. This study clarified the changes in blood flow to the surrounding muscles following ascending branch ligation of this artery.

METHODS

We included 36 consecutive patients (8 male and 28 female) who underwent total hip arthroplasty via the direct anterior approach for hip osteoarthritis between April 2015 and July 2016. The intraoperative blood flow to the tensor fascia latae (TFL), vastus lateralis (VL), rectus femoris (RF), and subcutaneous tissue (control) was measured using a laser Doppler blood flow meter. Measurements were repeated after artery ligation and at the end of surgery. We compared the means (±SD) of these measurements at each location and time point.

RESULTS

The patients' mean age was 64.2 ± 9.0 years, systolic and diastolic blood pressures were 92.8 ± 13.6 and 54.9 ± 9.1 mmHg, respectively, and body mass index was 23.1 ± 3.9 kg/m². Hypertension was noted in 35.9% patients and dyslipidemia in 27.8%. The mean surgical duration was 101 (70-158) min. The preligation blood flow in TFL, VL, RF, and subcutaneous tissue was 3.91 ± 1.93, 5.15 ± 2.19, 4.51 ± 2.24, and 3.03 ± 0.99 mL/min/100 g, respectively.

CONCLUSIONS

Blood flow to TFL significantly decreased post ligation and at the end of surgery. However, there was no change in blood flow to VL and RF.

A Single Lateral Rectus Abdominis Approach for the Surgical Treatment of Complicated Acetabular Fractures: A Clinical Evaluation Study of 59 Patients

Background

This study aimed to evaluate outcome following a single lateral rectus abdominis surgical approach for complicated acetabular fractures, involving anterior and posterior columns.

Material/Methods

From January 2012 to March 2016, 59 patients, including 36 anterior column hemitransverse fractures, 18 two-column fractures, and five T-type complicated acetabular fractures, were treated with a single lateral rectus abdominis approach and fixed by plates and cannulated lag screws. Anterior column fractures were fixed with 3.5 mm reconstruction plates; posterior column fractures were fixed with 6.5 mm cannulated lag screws. The quality of surgical reduction (using the Matta criteria), functional outcome (using the modified Merle d’Aubigné and Postel scoring system), and postoperative complications were assessed with 24-month follow-up.

Results

Fifty-nine patients (mean age, 45 years; range, 18–64 years) including 39 men and 20 women underwent surgery. Mean intraoperative blood loss was 514.6 ml (range, 150–830 ml) and mean operating time was 86.3 min (range, 42–145 min). Anatomical reduction was good in 40 cases (67.8%), fair in 15 cases (25.4%), and poor in four cases (6.8%). The modified Merle d’Aubigné score was excellent in 39 cases (66.1%), good in 14 cases (23.7%), fair in five cases (8.5%), and poor in one case (1.7%). At follow-up, there were five cases of peritoneal damage, eight cases of obturator nerve dysfunction, and four cases of postoperative traumatic arthritis.

Conclusions

The single lateral rectus abdominis surgical approach for the treatment of complicated acetabular fractures was minimally invasive with good anatomical exposure and good outcomes.

Complex fractures of the acetabulum: Should the enlarged iliofemoral approach be abandoned? Results at 20 years' follow-up

INTRODUCTION

Among the various options for internal fixation of acetabular fractures, the enlarged iliofemoral approach is less often used, being more invasive, although providing greater exposure enabling control of all components in complex fractures. Even so, the impact of its invasiveness has not been confirmed, and long-term results are not known. We therefore performed a retrospective study, aiming: to assess long-term functional outcome, and; to assess associated morbidity.

HYPOTHESIS

The enlarged iliofemoral approach allows precise reduction, with favorable long-term outcome.

MATERIAL AND METHODS

Between 1992 and 1997, 15 patients were operated on for complex acetabular fracture by a single surgeon using an enlarged iliofemoral approach. Two patients were excluded due to lack of follow-up data, leaving 13 patients for analysis: 3 simple transverse fractures, 4 transverse+posterior wall fractures, 4 anterior column+posterior hemi-transverse fractures, one T-shaped fracture and one 2-column fracture. There were 4 cases of posterior dislocation of the hip, and 8 of intrapelvic protrusion. Surgical morbidity was assessed in terms of operative time, number of packed red blood cell transfusions, iatrogenic lesions or postoperative complications, rehabilitation time, and hospital stay. Functional assessment at follow-up used the WOMAC index and Harris score; radiologic assessment used the Kellgren-Lawrence score for osteoarthritis and Brooker score for ossification.

RESULTS

Reduction was in all cases anatomic. There were no intra- or post-operative complications. Median number of packed red blood cell transfusions was 5 [range, 3-10]. Median operative time was 4hours [3-6]. Median hospital stay was 6 weeks [6-8], to allow systematic traction with early postoperative mobilization. Weight-bearing was resumed at a median 8 weeks [8-12]. At a median 22 years' follow-up [20-24], median Harris score was 83.5 [63-92] and median WOMAC index 24.5 [1-52]. All patients showed Brooker 1 or 2 ectopic ossification and moderate osteoarthritis. Two underwent subsequent arthroplasty (at 1 and 11 years after the index procedure).

DISCUSSION

The enlarged iliofemoral approach allowed anatomic reduction of acetabular fracture. It provided very good long-term results, without excessive morbidity.

LEVEL OF EVIDENCE

IV, retrospective non-controlled study.

Use of Spring Plates in Fixation of Comminuted Posterior Wall Acetabular Fractures

OBJECTIVES

Surgical management of comminuted posterior wall acetabular fractures with marginal fragments remains difficult. The purpose of this study was to evaluate the use of spring plates as adjunctive fixation in comminuted posterior wall acetabular fractures.

METHODS

A retrospective review of patients treated for posterior wall acetabular fractures with the use of customized spring plates as adjunctive fixation between 2000 and 2017 was performed. Patients were evaluated radiographically according to the grading criteria of Matta. Complications including subsequent revision surgery and hardware failure were recorded.

RESULTS

Fifty-two patients underwent surgical fixation of posterior wall acetabular fractures with the use of customized 3.5-mm spring plates combined with posterior buttress compression plating over the spring plates as definitive fixation. Mean follow-up was 13.9 months (range: 3-140 months). Forty-two patients had radiographic grades of excellent, with 6 good, 1 fair, and 3 poor. There were no hardware complications. Five patients underwent revision surgery, including 4 patients (7.7%) who underwent a total hip arthroplasty due to advanced arthritis.

CONCLUSIONS

The use of customized spring plates is a viable method of adjunctive fixation for comminuted posterior wall fractures with marginal fragmentation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Internal fixation of acetabular fractures in an older population using the TIMI approach - Midterm results of a prospective study

INTRODUCTION

The incidence of geriatric acetabular fractures continues to increase due to demographic changes. In the elderly, anterior column fractures are common, and standard approaches are associated with a considerable risk for surgery-associated complications. Therefore, a minimally invasive approach was developed in our department. The aim of this study was to examine early and mid-term results regarding the use of this novel two-incision minimally invasive (TIMI) approach in patients aged over 55 years with acetabular fractures.

METHODS

From July 2007 to April 2014, 47 patients aged over 55 years were treated via the TIMI approach; these patients were included in the present prospective study. The patients' characteristics, data, and early phase of care were assessed during acute care. A radiological evaluation comprised pre- and postoperative CT scans and x-rays, including Judet views at follow-up. Follow-up examinations were performed after 6 and 24 months and comprised a clinical and radiological examination and an evaluation of hip function (Harris Hip Score) and health-related quality of life (EQ-5D).

RESULTS

The mean age of the patients was 74±11years, with a gender ratio of 35/12 (m/f). The average operation time was 93±30min, and perioperative blood loss amounted to 858±463ml. In total, five (11%) complications associated with the operative procedure occurred, and revision surgery was necessary in three patients. We observed no wound infections, abdominal wall hernias or cases of heterotopic ossification in our sample. The Harris Hip Score at six months after surgery was 81, and it slightly improved to 84 after 24 months. The mean EQ5D index was 0.91 at six months after surgery and 0.92 at 24 months after surgery.

CONCLUSION

The TIMI approach represents a valuable alternative to the ilioinguinal and modified Stoppa approach for the treatment of acetabular fractures located in the anterior column, which are often observed in geriatric patients.

LEVEL OF EVIDENCE

Therapeutic Level II (Prospective cohort study).

The efficacy of posterior plating and anterior column screw fixation in the management of T-shaped acetabular fractures - CART analysis of prospective cohort study

T-shaped acetabular fractures are challenging injuries. The goal of surgical treatment is to achieve a stable and a concentric reduction of the femoral head under the anatomically reduced weight-bearing dome. There is an ongoing debate about the ideal approach and fixation method for T-shaped fractures. In this study, a group of 34 patients with T-shaped acetabular fractures were treated by posterior plating and anterior column screw. All patients, were followed for at least two years or until hip replacement. The aim of this prospective cohort study was to report the rate of postoperative radiological results together with the early clinical outcome. Anatomical reduction was achieved in 62%, satisfactory reduction of the anterior column with restoration of hip congruency in 82% with excellent to good clinical outcome in 75% of cases. We used classification regression trees (CART) to select the important predictors and generate hypotheses on interaction among them. Residual anterior column displacement >3.5mm was associated with poor clinical results. In cases with residual displacement <3.5mm, the presence of a posterior wall fracture was an independent negative predictor.

Outcome of alternative approach to displaced acetabular fractures

INTRODUCTION

Anatomical reduction of displaced acetabular fracture is not without its' limitations and complications. This study is conducted to assess clinical and radiological outcomes as well as complications of treating displaced acetabular fractures with emphasis on anatomical reduction in weight-bearing area, mainly the posterior column, and imperfect reduction of the anterior column is acceptable. However, stability of both columns is mandatory.

METHODS

It was a retrospective study carried out in a Level 1 arthroplasty and trauma centre. 23 patients (17 males, 6 females) with average age of 50.1 years (range, 36-68 years) with displaced acetabular fracture treated with combined incisions and plate-cable systems were included. There were 3 elementary and 18 associated fractures according to Letournel classification. Average follow-up was 23.5 months (range, 12-38.7 months). Mean operation time was 160min (range: 75-320min). Functional scores were evaluated using Harris Hip Score (HHS) whilst reduction was assessed by Matta criteria. Any displacement of reduction, osteoarthritis, heterotopic ossification, and other complications was recorded.

RESULT

65.2% (15/23) of the patients obtained excellent HHS and 21.7% (5/23) had good HHS. There were 12 anatomical, 6 imperfect, and 5 poor reductions. No displacement was recorded in final follow-up. Complications documented: three lateral femoral cutaneous nerve injuries, two conversions to total hip arthroplasty, three Brooker stage 1 heterotrophic ossification, one pulmonary embolism and one screw irritation. No incidence of wound breakdown, infection and radiological osteoarthritis was reported.

CONCLUSIONS

Imperfect reduction of the anterior column provided clinical outcomes that are as good as total anatomical reduction. This approach minimizes soft tissue damage and reduces perioperative morbidities.

Heterotopic Ossification following acetabular fixation: Incidence and risk factors: 10-year experience of a tertiary centre

BACKGROUND

Heterotopic Ossification (HO) is a well-recognized complication following acetabular fracture fixation and its presence is prognostic for suboptimal clinical outcome. There are many controversies pertaining to its aetiology, including surgical approach, associated injuries and the use of HO prophylaxis. Long term data from high volume centres is necessary to address these issues.

AIM

To determine the incidence of HO post open reduction and internal fixation (ORIF) of acetabular fractures and to examine the associated risk and prognostic factors.

METHOD

We studied a cohort of 369 consecutive acetabular fractures that underwent ORIF at our institution over a 10 year period. Data was analyzed using univariate and multivariate logistic regression.

RESULTS

The existence of HO was evident in 65 patients (17.62%), of these 39 (60.0%) were Class I, 16 (24.6%) were Class II, 8 (12.3%) were Class III, and 2 (3.1%) were Class IV according to Brooker Classification. We found a significant association between admission to an Intensive Care Unit (ICU) (P-value=0.039), chest injury (P-value=0.013), multiple fractures (P-value=0.005), and the time lapse between injury and operation (P-value=0.025), and some statistical significance with surgical approach, ipsilateral fractures, open fractures, tibial and patellar fractures. Age over 30 years as the only prognostic factor for severe HO. Prophylaxis with Indomethacin did not appear to confer any benefit in our patient group.

CONCLUSION

The risk factors for developing HO following acetabular fracture fixation are multifactorial and include admission to ICU, associated chest injuries, multiple fractures and delay between injury and surgery. Surgical approach, ipsilateral fractures and tibia and patellar fractures may also play a role. Age over thirty years was the only prognostic factor for developing severe HO.

Evaluation of the muscle morphology of the obturator externus and piriformis as the predictors of avascular necrosis of the femoral head in acetabular fractures

Avascular necrosis (AVN) of femoral head is a recognised complication of fracture dislocation of the hip joint but is not studied frequently in relation to acetabulum fractures. The aim was to establish the relationship between obturator externus and piriformis muscle morphology in acetabulum fractures and potenital development of AVN of the femoral head. Twenty-five fractures were included in this prospective study and were subjected to radiological assessment and computed tomography of the pelvis. Magnetic resonance imaging (MRI) of the hip was performed to assess the morphology of obturator externus and piriformis, and findings were compared intraoperatively (in 15 cases). Serial radiographs were taken at monthly intervals to assess the development of avascular necrosis. The patients with no evidence of AVN on radiographs at 6 months had additional MRI scans to look for such changes. Three patients developed AVN of femoral head and two had complete tears of piriformis and/or obturator externus muscles on the pre-operative MRI with the findings confirmed intraoperatively (p = 0.013). None of the patients without changes of AVN at 6-month follow-up had complete tears of either or both muscles. Of these patients, there was one case each of T-type fracture, isolated posterior wall fracture with hip dislocation, and posterior wall with transverse fracture of the acetabulum. Complete tears of obturator externus and/or piriformis muscles are a strong predictor of future development of AVN of the femoral head.

The Anatomical Course of the Lateral Femoral Cutaneous Nerve with Special Attention to the Anterior Approach to the Hip Joint

BACKGROUND

Injury to the lateral femoral cutaneous nerve (LFCN) is a risk during the operative anterior approach to the hip joint. Although several anatomical studies have described the proximal course of the nerve in relation to the anterior superior iliac spine (ASIS) and the inguinal ligament, the distal course of the LFCN in the proximal aspect of the thigh has not been sufficiently studied. The aim of this cadaveric study was to examine the branching pattern of the nerve, with special consideration to the anterior approach to the hip joint.

METHODS

Twenty-eight cadaveric hemipelves from 18 donors (10 paired and 8 unpaired specimens) were dissected. The LFCN branches were localized proximal to the inguinal ligament and traced distally into the area of the proximal aspect of the thigh. Distribution patterns of the nerve with respect to its relationship to the ASIS and the internervous plane of the anterior approach to the hip joint were recorded.

RESULTS

We found 3 different branching patterns of the LFCN: sartorius-type (in 36% of the specimens), characterized by a dominant anterior nerve branch coursing along the lateral border of the sartorius muscle with no, or only a thin, posterior branch; posterior-type (in 32%), characterized by a strong posterior nerve branch; and fan-type (in 32%), characterized by multiple spreading nerve branches of equal thickness. In 50% of the specimens, the LFCN divided into ≥2 branches superior to the inguinal ligament. Sixty-two percent of the LFCN branches entered the proximal aspect of the thigh medial to the ASIS; 27%, above; and 11%, lateral to the ASIS. The LFCN consistently coursed within the deep layer of the subcutaneous fat tissue.

CONCLUSIONS

Injury to branches of the LFCN cannot be avoided in approximately one-third of surgical dissections that use the anterior approach to the hip joint. To protect the anterior branch of the LFCN, the skin incision should be as lateral as possible. The posterior branch of the LFCN is most vulnerable in the proximal aspect of the anterior approach to the hip joint, where it can be expected to course within the deep layer of the subcutaneous tissue.

Modified Kocher-Langenbeck approach in combined surgical exposures for acetabular fractures management

BACKGROUND

Displaced fractures of the acetabulum are best treated with anatomical reduction and rigid internal fixation. Adequate visualization of some acetabular fracture types may necessitate extensile or combined anterior and posterior approaches. Simultaneous anterior iliofemoral and posterior Kocher-Langenbeck (K-L) exposures with two surgical teams have also been described. To assess whether modified Kocher-Langenbeck (K-L) approach can substitute standard K-L approach in the management of elementary acetabular fractures other than the anterior wall and anterior column fractures and complement anterior surgical approaches in the management of complex acetabular fractures.

MATERIALS AND METHODS

20 patients with transverse and associated acetabular fractures requiring posterior exposure were included in this prospective study. In 9 cases (7 transverse, 1 transverse with posterior wall, and 1 posterior column with posterior wall), stabilization was done through modified K-L approach. In 11 cases (3 transverse and 8 associated fractures), initial stabilization through iliofemoral approach was followed by modified K-L approach.

RESULTS

The average operative time was 183 min for combined approach and 84 min for modified K-L approach. The postoperative reduction was anatomical in 17 patients and imperfect in 3 patients. The radiological outcome was excellent in 15, good in 4, and poor in one patient. The clinical outcome was excellent in 15, good in 3 and fair and poor in 1 each according to modified Merle d'Aubigne and Postel scoring system.

CONCLUSION

We believe that modified K-L approach may be a good alternative for the standard K-L approach in the management of elementary fractures and associated fractures of the acetabulum when combined with an anterior surgical approach. It makes the procedure less invasive, shortens the operative time, minimizes blood loss and overcomes the exhaustion and fatigue of the surgical team.

Rationale for more consistent choice of surgical approaches for acetabular fractures

OBJECTIVES

All acetabular fractures are difficult to treat surgically, but there are four types involving two columns that are particularly challenging. The choice of surgical approach is crucial. The purpose of the study was to determine and evaluate the factors influencing the choice of surgical approach for two-column acetabular fractures. We hypothesised that more accurate preoperative planning, sophisticated technical capabilities, and evolution of surgeon experience will result in more consistent use of non-extensile single surgical approaches. We also evaluated the outcomes of surgical treatment and the correlation with the surgical approach used.

DESIGN

Retrospective cohort study.

PATIENTS AND METHODS

A total of 156 patients with 157 acetabular fractures involving two columns (Letournel T-types and both-column) treated surgically in a 25-year period (1988-2013) were included in the study. The acetabular fractures in this study were divided into two groups according to the date of surgery: 81 in Group 1 (1998-2002) and 76 in Group 2 (2003-2013). All fractures were classified preoperatively according to the Judet and Letournel classification system and Matta's categorisation of surgical approach. Four surgical approaches were used: single Kocher-Langenbeck (KL), single ilioinguinal (II), combined Kocher-Langenbeck and ilioinguinal (KL+II), and extended iliofemoral (EIF). The efficacy of the surgical approach utilised was assessed using three parameters: anatomical reduction, surgical time and intraoperative complications.

RESULTS

There was no statistical difference between Group 1 and Group 2 in the distribution of T-type (p=0.424) and both-column (p=0.425) fractures. In Group 2 more acetabular fractures were treated through single non-extensile approaches compared with Group 1 (90.8% vs. 54.3%, p<0.001). Increase in single approach surgery resulted in shorter mean surgical time (p<0.001) and significant increase in anatomical reduction (p=0.039). The frequency of intraoperative complications was not statistically different (p=0.07) between the two groups, but there was a trend to fewer complications in Group 2.

CONCLUSIONS

The surgical approaches chosen for acetabular fractures that involve two columns (Letournel T-types and both-column) should become more consistent. The results of this study indicate that the majority of such acetabular fractures can be treated successfully through single surgical approaches.

Potential Risk to the Superior Gluteal Nerve During the Anterior Approach to the Hip Joint: An Anatomical Study

BACKGROUND

The anterior approach to the hip joint is widely used in pediatric and adult orthopaedic surgery, including hip arthroplasty. Atrophy of the tensor fasciae latae muscle has been observed in some cases, despite the use of this internervous approach. We evaluated the nerve supply to the tensor fasciae latae and its potential risk for injury during the anterior approach to the hip joint.

METHODS

Cadaveric hemipelves (n = 19) from twelve human specimens were dissected. The course of the nerve branch to the tensor fasciae latae muscle, as it derives from the superior gluteal nerve, was studied in relation to the ascending branch of the lateral circumflex femoral artery where it enters the tensor fasciae latae.

RESULTS

The nerve supply to the tensor fasciae latae occurs in its proximal half by divisions of the inferior branch of the superior gluteal nerve. The nerve branches were regularly coursing in the deep surface on the medial border of the tensor fasciae latae muscle. In seventeen of nineteen cases, one or two nerve branches entered the tensor fasciae latae within 10 mm proximal to the entry point of the ascending branch of the lateral circumflex femoral artery.

CONCLUSIONS

Coagulation of the ascending branch of the lateral circumflex femoral artery and the placement of retractors during the anterior approach to the hip joint carry the potential risk for injury to the motor nerve branches supplying the tensor fasciae latae.

CLINICAL RELEVANCE

During the anterior approach, the ligation or coagulation of the ascending branch of the lateral circumflex femoral artery should not be performed too close to the point where it enters the tensor fasciae latae. The nerve branches to the tensor fasciae latae could also be compromised by the extensive use of retractors, broaching of the femur during hip arthroplasty, or the inappropriate proximal extension of the anterior approach.

Effect of a selective COX-2 inhibitor, celecoxib, on heterotopic ossification after total hip arthroplasty: a case-controlled study

Heterotopic ossification (HO) is a well-known complication of total hip arthroplasty (THA), especially when the direct lateral approach is used. In this study, we examined the effect of the selective COX-2 inhibitor, celecoxib, on the rates of HO after THA. A control group consisting of 108 patients that did not receive celecoxib was compared with a study group consisting of 106 patients that did receive celecoxib. We assessed the presence and grade of HO using the Brooker classification and Harris hip scores were determined pre- and postoperatively to better quantify clinical outcomes. In this retrospective study of prospectively collected data, celecoxib is associated with a significant reduction in the incidence of HO in patients undergoing THA.

Risk factors for the development of heterotopic ossification after acetabular fracture fixation

BACKGROUND

Heterotopic ossification (HO) is a common complication of the operative treatment of acetabular fractures. Although the surgical approach has been shown to correlate with the development of ectopic bone, specific risk factors have not been elucidated.

QUESTIONS/PURPOSES

The purposes of this study were to determine specific risk factors associated with the development of severe HO and the frequency with which patients develop severe HO after acetabular fracture fixation through an isolated Kocher-Langenbeck approach.

METHODS

Using an institutional orthopaedic trauma database at a regional Level I trauma center, patients undergoing open treatment of acetabular fractures during the study period (January 2000 to January 2010) were identified. A review of medical records and imaging studies was performed on 508 patients who were treated by the senior author (MR) through an isolated Kocher-Langenbeck approach. During the study period, the senior author used indomethacin for HO prophylaxis in patients who had ipsilateral femur fracture treated with antegrade reamed medullary nailing or severe local soft tissue injury; 49 (10%) of the patients he treated with the Kocher-Langenbeck approach received prophylaxis, and they were excluded from this study, leaving a total of 459 patients who met inclusion criteria. Of those, 147 (29%) were lost to followup or did not have radiographs both before and at a minimum of 6 weeks (median, 1 week; range, 0-3 weeks), leaving 312 (61% of the patients treated with the Kocher-Langenbeck approach during this time) available for this analysis. Demographic data as well as information related to cause of injury, associated periacetabular findings, other system injuries, and treatment were gathered. Final followup radiographs were assessed for the presence of ectopic bone by two of the authors (TJO, AS) using the modified Brooker classification. Logistic regression was performed to identify possible predictors of development of severe ectopic bone.

RESULTS

The only predictor we identified for the development of severe HO was the need for prolonged mechanical ventilation (odds ratio, 7.1; 95% confidence interval, 2.9-17.3; p=0.001). Injury Severity Score, sex, presence of comminution, femoral head impaction, dislocation, degloving injury, debris in the joint, number of other fractures, and head and chest Abbreviated Injury Score>2 did not correlate with severe HO. Severe HO (Brooker Class III or IV) developed in 38 of 312 patients (12%).

CONCLUSIONS

Patients with prolonged mechanical ventilation might benefit from HO prophylaxis given the increased risk of developing severe HO in this patient population. However, future prospective studies need to be performed to verify this finding given the fact that a considerable number of patients were prophylactically treated in this study.

LEVEL OF EVIDENCE

Level IV, prognosticstudy. See Guidelines for Authors for a complete description of levels of evidence.

Indomethacin prophylaxis for heterotopic ossification after acetabular fracture surgery increases the risk for nonunion of the posterior wall

OBJECTIVES

To determine if indomethacin has a positive clinical effect for the prophylaxis of heterotopic ossification (HO) after acetabular fracture surgery. To determine whether indomethacin affects the union rate of acetabular fractures.

DESIGN

Prospective randomized double-blinded trial.

SETTING

Level 1 regional trauma center.

PATIENTS

Skeletally mature patients treated operatively for an acute acetabular fracture through a Kocher-Langenbeck approach.

INTERVENTION

Patients were randomly allocated to 1 of 4 groups comparing placebo (group 1) to 3 days (group 2), 1 week (group 3), and 6 weeks (group 4) of indomethacin treatment.

MAIN OUTCOME MEASUREMENTS

Factors analyzed included the overall incidence, Brooker class and volume of HO, radiographic union of the acetabular fracture, and pain. Patients were followed clinically and radiographically at 6 weeks, 3 months, 6 months, and 1 year. Serum levels of indomethacin were drawn at 1 month to assess compliance. Computed tomographic scans were performed at 6 months to assess healing and volume of HO.

RESULTS

Ninety-eight patients were enrolled into this study, 68 completed the follow-up and had the 6-month computed tomographic scan, and there was a 63% compliance rate with the treatment regimen. Overall incidence of HO was 67% for group 1, 29% for group 2 (P = 0.04), 29% for group 3 (P = 0.019), and 67% for group 4. The volume of HO formation was 17,900 mm for group 1, 33,800 mm for group 2, 6300 mm for group 3 (P = 0.005), and 11,100 mm for group 4. The incidence of radiographic nonunion was 19% for group 1, 35% for group 2, 24% for group 3, and 62% for group 4 (P = 0.012). Seventy-seven percent of the nonunions involved the posterior wall segment. Pain visual analog scores (VASs) were significantly higher for patients with radiographic nonunion (VAS 4 vs. VAS 1, P = 0.002).

CONCLUSIONS

Treatment with 6 weeks of indomethacin does not appear to have a therapeutic effect for decreasing HO formation after acetabular fracture surgery and appears to increase the incidence of nonunion. Treatment with 1 week of indomethacin may be beneficial for decreasing the volume of HO formation without increasing the incidence of nonunion.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Simultaneous ilioinguinal and Kocher-Langenbeck approaches for the treatment of complex acetabular fractures

Complex acetabular fractures are best treated by a surgical approach. Although some other variables such as comminution or cartilage lesion of the femoral head are related to the final outcome, early anatomic reduction is the only way to get good results; this has made the appropriate type of surgical approach of overwhelming importance. Seeing the fracture and also having the possibility of manoeuvring its fragments as much as required are the keys for reduction of these sort of fractures. In this paper we have studied the results of the treatment of complex acetabular fractures by simultaneous ilioinguinal and Kocher-Langenbeck approaches. Ten cases of complex fractures out of 260 surgically treated acetabular fractures were chosen for simultaneous combined approaches. In cases of comminution of both the anterior and the posterior columns together with circumferential shortening of the pelvic ring, reduction and stable internal fixation could be accomplished only by simultaneous combined accesses.

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.

Quantitative measures of damage to subchondral bone are associated with functional outcome following treatment of displaced acetabular fractures

Current analysis of displaced acetabular fractures is limited in its ability to predict functional outcome. This study aimed to (1) quantify initial acetabular damage following acetabular fracture through measurement of subchondral bone density and fracture lines, and (2) evaluate associations between acetabular damage and functional outcomes following fracture. Subchondral bone intensity maps were created for 24 patients with unilateral acetabular fractures. Measures of crack length and density differences between corresponding regions in the fractured acetabuli, normalized by the unfractured side, were generated from preoperative CT images. Damage measures were compared to quality of life survey data collected for each patient at least 2 years post-injury (Musculoskeletal Functional Assessment [MFA] and Short Form-36 [SF-36], with specific focus on parameters that best describe patients' physical health). CT image quantification of initial damage to acetabular subchondral bone was associated with functional outcome post-injury. In general, damage as quantified through differences in density in the superior dome region (zones 8 and 12) and the central anterior region of the acetabulum (zone 3) were found to be the strongest significant predictors of functional outcome (adjusted R(2) = 0.3-0.45, p < 0.05). Damage to the superior dome was predictive of worse functional outcome whereas damage to the central anterior region indicated a better functional outcome. Once automated, this approach may form a basis to score acetabular fractures toward improving clinical prognoses.

Combined pelvic ring disruption and acetabular fracture: associated injury patterns in 40 patients

OBJECTIVES

Combined pelvic ring disruptions and acetabular fractures are thought to be uncommon. Our objectives were to characterize concomitant injury patterns and to compare them with historically observed rates for each injury in isolation.

DESIGN

Retrospective review comparing a study group with historical controls. Fracture patterns were compared with our institution's isolated injury patterns and with isolated injury patterns of other published series.

SETTING

Level I academic medical center.

PATIENTS

Between 1997 and 2001, 854 pelvic ring disruptions and 457 acetabular fractures were evaluated. Forty patients sustained combined injuries.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Fracture patterns, Injury Severity Scores, and mortality rates.

RESULTS

Our series of combined injuries included 5% posterior wall fractures. This was significantly different from the 30% incidence of posterior wall fractures among isolated acetabular fractures at our institution (P < 0.006). No posterior column or posterior column with associated posterior wall fractures occurred. Fifty-three percent of the patients sustained anterior-posterior compression pelvic ring injuries, exceeding our center's 19% norm for isolated pelvic ring injuries (P < 0.001). For combined injuries, the mean injury severity score was 27.9 and the overall mortality rate was 13%. Early death occurred in 19% of patients with combined anterior-posterior compression injuries and 6% with lateral compression injuries.

CONCLUSIONS

Patients with combined pelvic and acetabular injuries have multiple system injuries and high Injury Severity Scores. Fracture patterns differ from those observed with isolated injuries. Posterior acetabular fractures are uncommon components. Anterior-posterior compression pelvic injuries seem much more frequent in cases of combined injuries than isolated injuries and are associated with high mortality rates.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Quadrilateral plate fractures of the acetabulum: an update

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures, which are not specifically defined by any current classification system. Their incidence is increasing due to the rising number of elderly osteoporotic fractures. They have always been notoriously difficult fractures to treat. We present a systematic review of conservative and operative management and their respective outcomes over the last century.

The Pararectus approach for anterior intrapelvic management of acetabular fractures

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues.

In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

Traumatic damage to the cartilage influences outcome of anatomically reduced acetabular fractures: a medium-term retrospective analysis

We reviewed 77 patients with an acetabular fracture, treated operatively through a non-extensile approach after an average time of 45 months. The ilioinguinal approach was chosen in 41, the Kocher-Langenbeck approach in 36 patients. Following the Letournel classification, the most frequent lesions were posterior wall (26%), two-column (22.1%) and anterior column (14.3%) fractures. Subchondral impaction, intra-articular fracture fragments and fracture comminution, called modifiers, could be identified in the preoperative CT-data of 38 patients (49.4%). Patients were operated after an average of 4 days. Average hospital stay was 19 days. Sciatic nerve and peroneal nerve palsy were registered in 5.6%. Deep venous thrombosis was seen in 10.4%, peri-articular ossifications in 7.8%. During the 45-months follow-up, 10.4% patients needed secondary total hip arthroplasty. Using the Merle d'Aubigné score, 15 patients had an excellent, 39 a good, 15 a moderate, and 8 a bad result. In accordance with the Harris Hip Score, 29 patients achieved an excellent, 26 a good, 9 a moderate and 13 a bad result. Twenty of twenty-three (Merle d'Aubigné score) and twenty of twenty-two (Harris Hop Score) patients with moderate or bad results had one or more modifiers. Patients with operatively treated acetabular fractures, who had CT-findings such as subchondral impaction, fracture comminution or intra-articular fracture fragments in their preoperative examination, score significantly lower at middle term in the Harris Hip and Merle d'Aubigné scoring systems.

Modified Kocher-Langenbeck approach for the stabilization of posterior wall fractures of the acetabulum

This article describes a modification of Kocher-Langenbeck approach for the treatment of select posterior wall fractures of acetabulum. The technique aims at achieving osteosynthesis by creating two windows: between the gluteus medius and piriformis superiorly and between the external rotators and ischial tuberosity inferiorly. The approach spares the division of external rotators and of the abductors of the hip, thus preventing iatrogenic damage to the vascularity of the head of the femur and of the fracture fragments. The reconstruction plate can be slid under the piriformis and the short external rotators, thus preserving the soft tissue sleeve of the hip posteriorly. The gluteus minimus is not stripped from the ilium. The technique is ideally suited for isolated, displaced, noncomminuted posterior wall fractures of acetabulum of less than 10 days' duration without marginal impaction. The technique is biologic, takes a shorter operative time in our hands, and prevents further damage to vascularity of the head of the femur and heterotopic ossification.

Anterior hip subluxation following fixation of a T-shaped acetabular fracture through an extended iliofemoral approach

We report the case of a 34-year-old female patient who, six week following her acetabular fracture ORIF through an extended iliofemoral approach, presented with anterolateral incomplete dislocation of the femoral head. In the absence of joint incongruence as demonstrated on radiographs and CT images, a capsular tightening was performed via the anterior Hueter approach. This capsular plasty stabilized the hip for 2 years, but gradual osteoarthritis deterioration resulted in the need for arthroplasty. At the 2-year follow-up, this secondary arthroplasty showed satisfactory result. The substantial muscle exposure of the lateral aspect of the acetabulum and the circumferential capsulotomy related to the use of the iliofemoral approach were retained as factors promoting this complication. In case early postoperative mobilization is impossible, temporarily maintaining the limb in abduction and flexion can be recommended after an extended iliofemoral approach with circumferential capsulotomy.

Changes in the treatment of acetabular fractures over 15 years: Analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU)

Epidemiological, clinical and radiological data of 1266 patients with a unilateral acetabular fracture of up to 29 hospitals was reviewed. Three time periods, 1991-1993 (Registry I; n=359), 1998-2000 (Registry II; n=503), and 2005-2006 (Registry III; n=404) were compared with regard to injury pattern and severity, fracture type, and chosen nonoperative vs. operative treatment to elucidate changes over time in the treatment of acetabular fractures. In the operatively treated group, time to operation, surgical approach, fracture fixation implants and fracture reduction quality were examined. 641 (50.6%) patients with isolated acetabular fractures, 410 (32.4%) multiple injured and 215 (17.0%) polytrauma patients with 642 (50.7%) simple and 624 (49.3%) associated acetabular fractures were evaluated. In the time period from 1991 to 2006, the rate of operative treatments increased nationwide to 77% (rho<0.001). The distribution of fracture types involving the anterior and posterior wall changed with age (rho<0.001). Across all registries, 583 (68.0%) operations were performed within 7 days, 212 (24.7%) operations between 7 and 14 days and 54 (6.3%) operations were performed later than 14 days after injury. An anatomical reduction (0-1mm displacement) was achieved in 551 (64%) acetabular fractures. The obtained reduction quality did not correlate with time to operation, was lower in associated than in simple fracture types, and also lower in patients with isolated acetabular fractures than in polytrauma patients. Most importantly, the fracture reduction quality did not improve over time despite a higher frequency of surgical interventions. The Kocher-Langenbeck approach was preferred in the nineties in nearly three quarters of all operative procedures. Currently, the Kocher-Langenbeck and the ilioinguinal approaches are used equally often. The fracture fixation did not change over time and is achieved in 51% with plates in combination with single screws. This multisurgeon series illustrates a nationwide performance in acetabular fracture management. Despite changes in the chosen approaches and an increased surgical frequency, the operative treatment of acetabular fractures of the last 15 years did not lead to an increased reduction quality. Therefore, the rarity and complexity of acetabular fractures demands further specific teaching by experienced acetabular surgeons, scientific research and clinical outcome evaluation.

The history of the anterior approach to the hip

The anterior approach is a safe, reliable, and feasible technique for total hip arthroplasty, permitting optimal soft tissue preservation. Since Hueter first described this interval, many surgeons have approached the hip anteriorly to perform a myriad of surgical procedures. The anterior approach allows optimal muscle preservation, and it is a truly internervous approach to the hip. An understanding of the evolution of the anterior approach to the hip will help the orthopedic community understand these advantages and why so many have used this approach in the treatment of hip pathology and for the implantation total hip arthroplasty.