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Phelps KD, Crickard CV, Li K, Harmer LS, Andrews McArthur E, Sample Robinson K, Sims SH, Hsu JR. Why Make the Cut? Trochanteric Slide Osteotomy Can Improve Exposure to the Anterosuperior Acetabulum. J Orthop Trauma 2021; 35:106-109. [PMID: 32658016 DOI: 10.1097/bot.0000000000001900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To define relative increases in visual bony surface area and access to critical landmarks with the addition of a trochanteric slide osteotomy to a Kocher-Langenbeck approach. METHODS A Kocher-Langenbeck approach followed by a trochanteric slide osteotomy was sequentially performed on 10, fresh-frozen, hemipelvectomy cadaveric specimens. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J. RESULTS The acetabular surface area exposed was 27.66 (±6.67) cm2 for a Kocher-Langenbeck approach. This increased to and 41.82 (±7.97) cm2 with the addition of a trochanteric osteotomy. The exposed surface area was increased by 51.2% for the trochanteric osteotomy (P < 0.001). The superior margin of the acetabulum could be visualized and palpably accessed in both exposures. Access to the more anterosuperior portions of the acetabulum was consistently possible in the trochanteric osteotomy but not with the Kocher-Langenbeck approach. CONCLUSIONS A trochanteric osteotomy may visually improve access to the most anterosuperior acetabulum but does not significantly improve surgical access to relevant portions of the superior acetabulum when compared with a Kocher-Langenbeck approach.
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Affiliation(s)
- Kevin D Phelps
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Colin V Crickard
- Commander, Medical Corps, United States Navy, Naval Medical Center Portsmouth, Portsmouth, VA
| | - Katherine Li
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Luke S Harmer
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Erica Andrews McArthur
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | | | - Stephen H Sims
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
| | - Joseph R Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC; and
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2
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Chen MJ, Wadhwa H, Tigchelaar SS, Frey CS, Gardner MJ, Bellino MJ. Trochanteric osteotomy for acetabular fracture fixation: a case series and literature review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:161-165. [PMID: 32743685 DOI: 10.1007/s00590-020-02753-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 07/25/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE This study examined osteotomy union and heterotopic ossification (HO) after performing digastric trochanteric osteotomies during open reduction and internal fixation (ORIF) of acetabular and combined femoral head fractures. Femoral head osteonecrosis and trochanteric screw removal were secondarily assessed. METHODS Twenty-six patients treated at a Level I trauma center, from years 2003 to 2019, who received a digastric trochanteric osteotomy during acetabular and combined femoral head fracture ORIF through a posterior surgical approach were retrospectively identified. Osteotomies were fixed with two 3.5 mm cortical lag screws. Rates of osteotomy union, HO, femoral head osteonecrosis, and trochanteric screw removal were determined. RESULTS All osteotomies went onto union without displacement or failure of fixation. Only three (12%) patients developed severe HO (modified-Brooker class III-IV). There were no instances of femoral head osteonecrosis and only one (7%) patient required trochanteric screw removal. CONCLUSIONS The digastric trochanteric osteotomy heals reliably with low rates of severe HO, femoral head osteonecrosis, and screw removal for soft-tissue irritation. A review of the literature is presented and found comparable findings.
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Affiliation(s)
- Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA.
| | - Harsh Wadhwa
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Seth S Tigchelaar
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Christopher S Frey
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
| | - Michael J Bellino
- Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Pavilion C, 4th Floor, Redwood City, CA, 94063-6342, USA
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León SA, Mei XY, Sanders EB, Safir OA, Gross AE, Kuzyk PRT. Does Trochanteric Osteotomy Length Affect the Amount of Proximal Trochanteric Migration During Revision Total Hip Arthroplasty? J Arthroplasty 2019; 34:2718-2723. [PMID: 31353250 DOI: 10.1016/j.arth.2019.06.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 06/03/2019] [Accepted: 06/17/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Nonunion and proximal trochanteric migration is a known complication of trochanteric osteotomy. This study examines the effect of osteotomy length on proximal greater trochanter (GT) migration. METHODS We analyzed 113 modified trochanteric slide osteotomies and 73 extended trochanteric osteotomies performed between 2008 and 2016. All osteotomies were fixed using cerclage wires and had minimum 6-month radiographic follow-up. Spearman correlations were used to assess association between osteotomy length and GT migration distance. Chi-squared test and logistic regression were used to assess association between patient and surgical factors and GT migration >1 cm. Receiver operating characteristic curves were constructed to determine the optimal cutoff osteotomy length for predicting GT migration >1cm. RESULTS Mean osteotomy length was 6.1 cm (range 3-12) for modified trochanteric slide osteotomies and 14.8 cm (range 8-23) for extended trochanteric osteotomies. Osteotomy length was negatively correlated (r = -0.340, P < .001) with GT migration distance. Longer osteotomy length was protective against GT migration >1 cm (odds ratio 0.67, P = .002). Receiver operating characteristic curve analysis demonstrated an optimal cutoff osteotomy length of 9.8 cm for predicting GT migration >1 cm (sensitivity 0.971, specificity 0.461). Among osteotomies <10 cm, those fixed using at least one distal wire below the lesser trochanter and vastus ridge demonstrated less mean GT migration (3.86 vs 7.12 mm, P = .009) and higher mean union rate (68.8% vs 31.2%, P < .001). CONCLUSION Osteotomies shorter than 10 cm are at higher risk of developing proximal GT migration >1 cm. A distal cerclage wire below the lesser trochanter and vastus ridge may help decrease the amount of GT migration. LEVEL OF EVIDENCE Prognostic Level IV.
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Affiliation(s)
- Sebastián A León
- Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Xin Y Mei
- Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ethan B Sanders
- Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Oleg A Safir
- Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Allan E Gross
- Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul R T Kuzyk
- Division of Orthopaedic Surgery, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Mei XY, Bhanot K, Tsvetkov D, Rajgopal R, Safir OA, Kuzyk PR. Current Uses of the Transtrochanteric Approach to the Hip: A Systematic Review. JBJS Rev 2018; 6:e2. [PMID: 29979233 DOI: 10.2106/jbjs.rvw.17.00180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The indications and technique for the transtrochanteric approach to the hip have evolved greatly since its initial popularization in the 1960s. The purpose of this systematic review was to assess current uses of this approach on the basis of indications, osteotomy technique, trochanteric fixation method, complications, and functional outcome. METHODS A comprehensive search of MEDLINE and Embase databases from January 2000 to July 2017 was performed in accordance with the PRISMA guidelines. Articles were divided into 3 major categories on the basis of the type of hip surgery performed: (1) primary arthroplasty, (2) revision arthroplasty, and (3) joint-preserving procedures. Patient data were then analyzed according to these 3 categories. RESULTS Seventy-six studies (5,028 hips), mainly of Level-IV evidence, were included. Four types of osteotomy were reported for a variety of indications. Rates of nonunion were 6.0% (303 of 5,028) across all studies, 4.2% (39 of 921) for primary arthroplasty, 6.7% (114 of 1,690) for revision arthroplasty, and 4.4% (56 of 1,278) for joint-preserving procedures. Rates of dislocation were 1.5% (14 of 921) for primary arthroplasty and 4.6% (77 of 1,690) for revision arthroplasty. The rate of osteonecrosis after joint-preserving procedures was 1.1% (14 of 1,278). Rates of deep infection were 1.1% (55 of 5,028) across all studies, 0.1% (1 of 921) for primary arthroplasty, 2.1% (36 of 1,690) for revision arthroplasty, and 0.6% (8 of 1,278) for joint-preserving procedures. CONCLUSIONS The transtrochanteric approach remains useful in cases requiring extensile exposure of the acetabulum or femoral medullary canal. However, trochanteric complications continue to pose a clinical challenge. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Xin Y Mei
- Division of Orthopaedic Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
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Gupta S, Singh J, Virk JS. The role of trochanteric flip osteotomy in fixation of certain acetabular fractures. Chin J Traumatol 2017; 20:161-165. [PMID: 28526613 PMCID: PMC5473740 DOI: 10.1016/j.cjtee.2016.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 11/05/2016] [Accepted: 11/11/2016] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Complete visualization of certain acetabular fractures of posterior wall or column with cranial extension involving superior dome from standard surgical exposures is a challenge. Osteotomy of the greater trochanter has been used to enhance fracture visualization, especially the dome, in posterior and lateral exposures of the acetabulum. It also decreases the need for excessive muscle retraction. The purpose of the study was to investigate the outcome associated with trochanteric flip osteotomy in the management of certain acetabulum fractures. METHODS From January 2011 to December 2013, 25 displaced acetabular fractures were treated by open reduction and internal fixation. The fractures were managed using a Kocher-Langenbeck approach along with trochanteric flip osteotomy. At 3rd, 6th and 24th month follow-up, all patients had radiographic examination and underwent a final clinical evaluation based on the modified Merle d'Aubigne and Postel score. The strength of the abductors was assessed according to the Medical Research Council (MRC) grading system. RESULTS Congruent reduction was achieved in all patients and all osteotomies healed within an average period of 3.8 months. All our patients were allowed full weight bearing at the end of 3 months and with no abductor lurch at the end of 6 months follow-up. There were no cases of avascular necrosis of femoral head. None of the patients had any neurovascular complication or infection by the end of the follow-up period. CONCLUSION Trochanteric flip osteotomy is a very effective technique to fix certain acetabular fractures especially those with dome involvement. It is more accurate and associated with no significant complications compared with conventional way.
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Affiliation(s)
- Sandeep Gupta
- Department of Orthopaedics, Government Medical College and Hospital (GMCH), Chandigarh, India
| | - Jagdeep Singh
- Department of Orthopaedics, Guru Gobind Singh Medical College and Hospital (GGSMCH), Faridkot, India
| | - Jagandeep Singh Virk
- Department of Orthopaedics, Government Medical College and Hospital (GMCH), Chandigarh, India,Corresponding author.
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Haefeli PC, Marecek GS, Keel MJB, Siebenrock KA, Tannast M. Patients undergoing surgical hip dislocation for the treatment of acetabular fractures show favourable long-term outcome. Bone Joint J 2017; 99-B:508-515. [DOI: 10.1302/0301-620x.99b4.37681] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 11/10/2016] [Indexed: 11/05/2022]
Abstract
Aims The aims of this study were to determine the cumulative ten-year survivorship of hips treated for acetabular fractures using surgical hip dislocation and to identify factors predictive of an unfavourable outcome. Patients and Methods We followed up 60 consecutive patients (61 hips; mean age 36.3 years, standard deviation (sd) 15) who underwent open reduction and internal fixation for a displaced fracture of the acetabulum (24 posterior wall, 18 transverse and posterior wall, ten transverse, and nine others) with a mean follow-up of 12.4 years (sd 3). Results Clinical grading was assessed using the modified Merle d’Aubigné score. Radiographic osteoarthritis was graded according to Matta. Kaplan-Meier survivorship and a univariate Cox-regression analysis were carried out using the following endpoints: total hip arthroplasty, a Merle d’Aubigné score of < 15 and/or progression of osteoarthritis. Conclusion The ten-year cumulative survivorship was 82% (95% confidence interval 71 to 92). Predictors for the defined endpoints were femoral chondral lesions, marginal impaction, duration of surgery, and age of patient. Cite this article: Bone Joint J 2017;99-B:508–15.
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Affiliation(s)
- P. C. Haefeli
- University of Bern, Freiburgstrasse
16, 3010 Bern, Switzerland
| | - G. S. Marecek
- University of Southern California, Keck
School of Medicine, 1975 Zonal Ave., Los Angeles, CA
90033, USA
| | - M. J. B. Keel
- University of Bern, Freiburgstrasse
16, 3010 Bern, Switzerland
| | | | - M. Tannast
- University of Bern, Freiburgstrasse
16, 3010 Bern, Switzerland
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Luo Z, Chen M, Hu F, Ni Z, Ji X, Zhang X, Cheng P, Shang X. Cementless total hip arthroplasty with extended sliding trochanteric osteotomy for high congenital hip dislocation: A retrospective study. Medicine (Baltimore) 2017; 96:e6581. [PMID: 28383440 PMCID: PMC5411224 DOI: 10.1097/md.0000000000006581] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Total hip arthroplasty (THA) for high congenital hip dislocation (CHD) is technically demanding. The purpose of this retrospective study was to evaluate the results of cementless THA combined with extended sliding trochanteric osteotomy. We also assessed whether chronic low back pain was relieved after surgery.The study included 19 patients (23 hips) with high CHD treated with cementless THA using extended sliding trochanteric osteotomy technique. Clinical and radiographic outcomes were evaluated.Harris Hip Score, WOMAC score, visual analog scale for low back pain and Trendelenburg sign were significantly improved (P < 0.01) compared with the preoperative. Average limb-length discrepancy in the 15 unilateral hips was reduced from 38.2 ± 7.9 mm to 6.7 ± 4.1 mm (P < 0.01). No dislocation, deep vein thrombosis, or infection occurred. Two patients (8.7%) developed sciatic nerve palsy. One (4.3%) developed symptomatic greater trochanteric bursitis. Two (8.7%) sustained proximal femur shaft fracture during implantation of the femoral component. All femoral components showed successful bony ingrowth at the final follow-up. No stem subsidence was detected. There was no acetabular loosening. Bony union of the reattached greater trochanter was obtained in all hips. Wire breakage occurred in 3 hips (13%).Cementless THA with extended sliding trochanteric osteotomy may be appropriate options for patients with high CHD.
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Dubina AG, Wickramaratne N, O'Toole RV, Manson TT. Assessment of trochanteric osteotomy fragment union after acetabular fracture surgery. Injury 2017; 48:384-387. [PMID: 27955824 DOI: 10.1016/j.injury.2016.08.028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 05/23/2016] [Accepted: 08/28/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trochanteric osteotomies are performed in conjunction with standard approaches to improve surgical exposure during open reduction and internal fixation (ORIF) of acetabular fractures. The literature on total hip arthroplasty reports nonunion rates as high as 30% associated with trochanteric osteotomies; however, few data exist regarding the outcomes of trochanteric osteotomies for acetabular fracture surgery. Our hypotheses were 1) patients receiving trochanteric osteotomies during ORIF of acetabular fractures have a low rate of nonunion of the osteotomy fragment, and 2) hip abduction precautions are not necessary with digastric type osteotomies. PATIENTS AND METHODS A retrospective review was conducted to identify patients with acetabular fractures between July 2002 and June 2010 (n=734 fractures) who required trochanteric osteotomies (n=64, 9% of fractures). Forty-seven met inclusion criteria of adequate follow-up (>56days). No excluded patient experienced a complication. Fractures were classified using the Letournel-Judet classification system. RESULTS Only seven (20%) of 35 patients who received digastric osteotomies had hip abduction precautions applied during the postoperative period. All study patients were shown to have radiographic union at the trochanteric osteotomy site (100% union rate, n=47). Hip abduction precautions intended to protect the osteotomy site and reduce the risk of nonunion and fixation failure were infrequently applied to patients with digastric osteotomies (20%) in this cohort. Multiple protective factors against nonunion were present in this study population compared with previous arthroplasty studies from other institutions. CONCLUSIONS Trochanteric osteotomies are not associated with a significant nonunion rate, and digastric osteotomies might be safely managed without hip abduction precautions.
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Affiliation(s)
- Andrew G Dubina
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Niluka Wickramaratne
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Robert V O'Toole
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Theodore T Manson
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, United States.
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Dodd A, Osterhoff G, Guy P, Lefaivre KA. Assessment of functional outcomes of surgically managed acetabular fractures. Bone Joint J 2016; 98-B:690-5. [DOI: 10.1302/0301-620x.98b5.36292] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 11/25/2015] [Indexed: 01/06/2023]
Abstract
We performed a systematic review of the literature pertaining to the functional outcomes of the surgical management of acetabular fractures. A total of 69 articles met our inclusion criteria, revealing that eight generic outcome instruments were used, along with five specific instruments. The majority of studies reported outcomes using a version of the d’Aubigne and Postel score, which has not been validated for use in acetabular fracture. Few validated outcome measures were reported. No psychometric testing of outcome instruments was performed. The current assessment of outcomes in surgery for acetabular fractures lacks scientific rigour, and does not give reliable outcome data for either scientific comparison or patient counselling. Take home message: The use of non-validated functional outcome measures is a major limitation of the current literature pertaining to surgical management of acetabular fractures; future studies should use validated outcome measures to ensure the legitimacy of the reported results. Cite this article: Bone Joint J 2016;98-B:690–5.
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Affiliation(s)
- A. Dodd
- University of British Columbia, Third
floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - G. Osterhoff
- University of British Columbia, Third
floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - P. Guy
- University of British Columbia, Third
floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
| | - K. A. Lefaivre
- University of British Columbia, Third
floor, 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada
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Maini L, Kumar S, Batra S, Gupta R, Arora S. Evaluation of the muscle morphology of the obturator externus and piriformis as the predictors of avascular necrosis of the femoral head in acetabular fractures. Strategies Trauma Limb Reconstr 2016; 11:105-11. [PMID: 27116689 PMCID: PMC4960055 DOI: 10.1007/s11751-016-0253-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 04/05/2016] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Lalit Maini
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Santosh Kumar
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Sahil Batra
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Rajat Gupta
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Sumit Arora
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India. .,, C/o Mr. Sham Khanna, 2/2, Vijay Nagar, Delhi, 110009, India.
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Gusic N, Sabalic S, Pavic A, Ivkovic A, Sotosek-Tokmadzic V, Cicvaric T. Rationale for more consistent choice of surgical approaches for acetabular fractures. Injury 2015; 46 Suppl 6:S78-86. [PMID: 26549668 DOI: 10.1016/j.injury.2015.10.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- N Gusic
- Department of Traumatology and Orthopaedics, Pula County Hospital, Pula, Croatia.
| | - S Sabalic
- Clinic of Traumatology, Clinical Hospital Centre "Sestre milosrdnice", Zagreb, Croatia
| | - A Pavic
- Department of Traumatology, Clinical Hospital Centre Split, Split, Croatia
| | - A Ivkovic
- Department of Orthopaedic Surgery, University Hospital Sveti Duh, Zagreb, Croatia
| | - V Sotosek-Tokmadzic
- Department of Anaesthesiology, Reanimatology and Intensive Care, Clinical Hospital Centre Rijeka, Rijeka, Croatia
| | - T Cicvaric
- Department of Traumatology, Clinical Hospital Centre Rijeka, Rijeka, Croatia
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12
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Niu Y, An X, Xu S, Wu D, Zhang C, Li M. Posterior trochanteric osteotomy in acetabular fractures for 32 cases. Cell Biochem Biophys 2014; 70:1393-9. [PMID: 25113643 DOI: 10.1007/s12013-014-0069-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The aim of this study is to explore the method and clinical outcome of posterior trochanteric osteotomy in acetabular fractures. From January 2000 to January 2008, 32 cases of acetabular fractures involving the dome of acetabulum underwent posterior trochanteric osteotomy for a better exposure and internal fixation with acetabular tridimensional memory fixation system. 28 cases (16 men and 12 women, mean age 39.9 years, range 16-73 years) were followed up with an average of 48.9 months (range of 19-95 months) and four were lost during follow up. Of 28 cases, 19 were fresh fractures and 9 were old fractures. The reduction was evaluated with Matta criteria. Clinical evaluation was based on modified Merle d'Aubigne and Postel scoring. Motor strength of the abductors was evaluated according to the Medical Research Council grading system. Ectopic ossification was classified according to Brooker criteria. Anatomical reduction was achieved in 17 cases and satisfied reduction in 10 patients. Poor reduction happened in an old fracture. All acetabular fractures got a direct bone union and no displacement and deep infection occurred. All osteotomies healed within 3.5 months without any nonunion, proximal migration of the greater trochanter, loosing or broken of instrumentation, and deep infection. Two superficial infections were healed with a regular dressing. Two patients underwent removal of implants from greater trochanter because of irritation. The strength of the abductors was of Grade 3/5 in two patients, Grade 4/5 in five patients, and normal in the rest. Clinical scoring was excellent to good in 84 %. Ectopic ossification occurred in five patients, grade 1 in two patients, grade 2 in two, and grade 3 in one. But function of hip joint was not seriously affected. Posterior trochanteric osteotomy can provide an adequate exposure of the dome of acetabulum without the associated complications like nonunion, proximal replacement, and weak of the abductors which often occur with standard oblique osteotomy.
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Affiliation(s)
- Yunfei Niu
- Department of Orthopaedics, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China
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Maini L, Batra S, Arora S, Singh S, Kumar S, Gautam VK. Surgical dislocation of the hip for reduction of acetabular fracture and evaluation of chondral damage. J Orthop Surg (Hong Kong) 2014; 22:18-23. [PMID: 24781607 DOI: 10.1177/230949901402200107] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To assess the outcome of open reduction and internal fixation combined with surgical dislocation of the hip for displaced acetabular fractures. METHODS 20 men and 2 women aged 20 to 55 (mean, 28) years underwent open reduction and internal fixation combined with surgical dislocation of the hip for displaced acetabular fracture. The most common fracture pattern was bicolumnar (n=12), followed by transverse (n=6) and T-type (n=4). Femoral head chondral lesions were classified as grade 0 (no defect) to grade 4 (osteochondral defect). Fracture fragments were fixed with titanium plates and screws, and the femoral head was redislocated to inspect for intraarticular screws. The association between functional status and acetabular fracture pattern and femoral head chondral lesions was explored. RESULTS Nine patients had chondral lesions in the femoral head (mostly in the anterosuperior zone), but none in the acetabulum. All femoral heads were viable. Reduction was anatomic in 6 patients and satisfactory in 16. Functional outcome was very good in 6 patients, good in 13, medium in 2, and fair in one. No patient developed avascular necrosis of the femoral head. Four patients had iatrogenic sciatic nerve palsy. One patient developed early degenerative hip arthritis and underwent total hip arthroplasty 14 months later. CONCLUSION Surgical dislocation of the hip facilitated anatomic reduction and inspection of any chondral lesions. It did not result in avascular necrosis of the femoral head.
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Affiliation(s)
- Lalit Maini
- Department of Orthopaedic Surgery, The Maulana Azad Medical College & Associated Lok Nayak Hospital, New Delhi, India
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Sarlak AY, Selek O, Inanir M, Musaoglu R, Baran T. Management of acetabular fractures with modified posterior approach to spare external hip rotators. Injury 2014; 45:732-7. [PMID: 24360076 DOI: 10.1016/j.injury.2013.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2013] [Revised: 08/09/2013] [Accepted: 11/11/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In the present study the quality of reduction and incidence of complications in hip external rotator sparing modified posterior approach was assessed in both simple and complex acetabular fractures. MATERIALS AND METHODS This retrospective study includes 37 patients (38 hips) with a mean age of 42.1 years (range 21-60), that had been treated for displaced acetabular fractures from June 2007 through May 2011. They were reviewed at a mean of 3 years (20-67 months). RESULTS The fractures were classified according to the Letournel-Judet classification. Anatomic reduction and stable fixation of the fracture with less than 2mm residual displacement was achieved in 28 of 38 hips. At the final follow up the patients were evaluated clinically according to Merle d'Aubigne and Postel scoring system which had been modified by Matta and radiologically based on the criteria described by Matta. The clinical results were excellent in 20, good in 8, fair in 8, and poor 2 hips. Complications included two superficial local wound infection and 10 heterotopic ossification with 7 of the cases having grade I heterotopic ossification. Avascular necrosis of the femoral head was not seen in any of the 38 hips. One patient with preoperative sciatic nerve palsy had complete recovery of neurologic function. There were no cases of deep vein thrombosis or pulmonary embolism. CONCLUSION The functional outcome was satisfactory in most of the cases and comparable with other larger series. Using the limited part of Henry's sciatic nerve exposure skin incision - working in the plane between gluteus maximus and the tensor fascia lata as in the classical Gibson approach and two portal external rotator hip sparing approach resulted in good fracture reduction without approach related complications.
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Affiliation(s)
- Ahmet Y Sarlak
- Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey.
| | - Ozgur Selek
- Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey
| | - Murat Inanir
- Department of Physical Medicine and Rehabilitation, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey
| | - Resul Musaoglu
- Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey
| | - Tuncay Baran
- Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey
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Abstract
The incidence of acetabular fractures in elderly patients is increasing. Poor bone quality and concomitant diseases are the main features of these patients. Fracture patterns are marked by a high degree of variability in terms of patient and fracture characteristics. Preoperative planning with plain radiographs and computed tomography, including 3-dimensional reconstructions, is recommended. Treatment remains challenging because of precarious general health, severe osteopenia, comminution, and associated femoral head damage. Treatment options available include closed management, open reduction with internal fixation, percutaneous fixation in situ, and acute or staged total hip arthroplasty (THA) whether alone or combined with osteosynthesis. In the case of significant destruction of the articular cartilage, primary THA may provide the best solution. Whichever surgical method is chosen, the objective is rapid mobilisation of the patient on a walker or crutches. Late local complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, malunion, wound infection, dislocation, intrusive hardware, nerve palsy, and heterotopic bone formation. In this article an overview of the current trends in the management of acetabulum fractures in the elderly is presented.
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Affiliation(s)
- E Guerado
- Department of Orthopaedic Surgery and Traumatology, Hospital Costa del Sol, University of Malaga, Marbella (Malaga), Spain.
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Giannoudis PV, Tzioupis C, Papathanassopoulos A, Obakponovwe O, Roberts C. Articular step-off and risk of post-traumatic osteoarthritis. Evidence today. Injury 2010; 41:986-95. [PMID: 20728882 DOI: 10.1016/j.injury.2010.08.003] [Citation(s) in RCA: 148] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The goal of treatment in intra-articular fractures is to obtain anatomical restoration of the articular surface and stable internal fixation. Studies have attempted to specify how accurately an articular fracture needs to be reduced to minimise the chances of a poor clinical outcome. In this study, the current evidence with regard to articular step-offs and risk of post-traumatic osteoarthritis (POA) is evaluated. A literature review based on pre-specified criteria, revealed 36 articles for critical analysis related to intra-articular injuries of distal radius, acetabulum, distal femur and tibial plateau.In the distal radius, step-offs and gaps detected with precise measurement techniques have been correlated with a higher incidence of radiographic POA, but in the second 5 years after injury, a negative clinical impact of these radiographic changes has not been convincingly demonstrated. Restoring the superior weight-bearing dome of the acetabulum to its pre-injury morphology decreases POA and improves patient outcomes. Involvement of the posterior wall, however, seems to bean adverse prognostic sign. This effect may be independent of articular reduction. In the tibial plateau, articular incongruities appear to be well tolerated, and factors only partially related to articular reduction are more important in determining outcome than articular step-off alone;these include joint stability, retention of the meniscus, and coronal alignment. Based on observational approach and evaluation of the studies, factors other than just the extent of articular displacement affect the management of articular fractures. Different joints and even different areas of the same joint appear to have different tolerances for post-traumatic articular step-offs.
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Affiliation(s)
- P V Giannoudis
- Academic Dept. of Trauma and Orthopaedics, School of Medicine, University of Leeds, UK.
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Tannast M, Krüger A, Mack PW, Powell JN, Hosalkar HS, Siebenrock KA. Surgical dislocation of the hip for the fixation of acetabular fractures. ACTA ACUST UNITED AC 2010; 92:842-52. [DOI: 10.1302/0301-620x.92b6.22994] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9). Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports. Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.
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Affiliation(s)
- M. Tannast
- Department of Orthopaedic Surgery, Inselspital University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - A. Krüger
- Department of Orthopaedic Surgery, Inselspital University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - P. W. Mack
- Shriner’s Hospital for Children, 516 Carew St, Springfield, Massachussetts 01104-2396, USA
| | - J. N. Powell
- Department of Surgery, Orthopaedic Trauma and Lower Extremity Reconstruction, University of Calgary, AC 144E, 1403-29th Street N.W. Calgary, Alberta T2N 2T9, Canada
| | - H. S. Hosalkar
- Rady Children’s Hospital, 3030 Children’s Way, San Diego, California 92123, USA
| | - K. A. Siebenrock
- Department of Orthopaedic Surgery, Inselspital University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
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Management, complications and clinical results of femoral head fractures. Injury 2009; 40:1245-51. [PMID: 19897188 DOI: 10.1016/j.injury.2009.10.024] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Revised: 10/12/2009] [Accepted: 10/15/2009] [Indexed: 02/02/2023]
Abstract
A systematic review of the literature was conducted to investigate data regarding femoral head fractures, particularly focusing on their management, complications and clinical results. Twenty-nine eligible articles, meeting prespecified inclusion criteria, reported on 453 femoral head fractures in 450 patients (mean age of 38.9 years with a mean follow-up of 55.6 months). 84.3% of patients had been victims of an automobile accident. The most widespread classification scheme used was that of Pipkin (65.4% of cases) whereas clinical results were evaluated mainly according to Thompson-Epstein criteria (63.3% of cases). Fracture-dislocations, in their majority, were managed with emergent closed reduction, followed by definite treatment (closed or open), aiming at anatomic restoration of both fracture and joint incongruity. Regarding Pipkin 1 subtype, fractured fragment excision seems to give better results compared to ORIF (p=0.07), while for the more challenging Pipkin 2 fractures the principles of anatomic reduction and stable fixation should be applied. Wound infection was encountered with a rate of 3.2% of surgical cases and sciatic nerve palsy complicated 3.95% of fracture-dislocations. Major late complications included avascular necrosis (11.9%), post-traumatic arthritis (20%) and heterotopic ossification (16.8%). Neither the trochanteric-flip nor the anterior approach seems to put in more danger the femoral head blood supply compared to the posterior one, with the former giving promising long-term functional results and lower incidence of major complication rates.
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Osgood GM. Posterior wall acetabular fractures: update on surgical indications, fixation techniques and outcome measurements. CURRENT ORTHOPAEDIC PRACTICE 2009. [DOI: 10.1097/bco.0b013e3181b3a5f2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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