Management of acetabular fractures with modified posterior approach to spare external hip rotators

Posterior Exposure in Kocher-Langenbeck With Gluteus Minimus Debridement vs. the Gibson Approach: A Cadaveric Study

OBJECTIVE

To quantify the posterior acetabular exposure achieved with the Kocher-Langenbeck (K-L) with gluteus minimus debridement and Gibson approaches.

METHODS

A Kocher-Langenbeck approach and a subsequent Gibson approach on the contralateral hip were performed in the prone position on 9 fresh frozen cadavers. Calibrated digital images were obtained of the Kocher-Langenbeck exposure, Kocher-Langenbeck exposure after gluteus minimus debridement, and Gibson exposure. The surface area of the posterior hip and pelvis visualized with each approach was calculated and compared with the contralateral side to assess for the difference between exposures.

RESULTS

In 5 of the 9 cadavers, the Kocher-Langenbeck exposure before gluteus minimus debridement yielded an increased exposure in comparison with the Gibson approach, and the exposure was equivocal in 3 specimens. An increase of greater than 10% was considered significant. The exposure increased anteriorly and cranially by an average of 13.1 cm 2 after debridement of the gluteus minimus caudal to the superior gluteal neurovascular bundle in the Kocher-Langenbeck approach.

CONCLUSIONS

Debridement of the gluteus minimus caudal to the level of the superior gluteal neurovascular bundle can significantly increase anterior and cranial exposure in the Kocher-Langenbeck approach and provide similar areas of access when compared with that in the Gibson approach.

Exposure Provided by the Gibson Versus the Kocher-Langenbeck Approaches With and Without Trochanteric Osteotomy: A Cadaveric Mapping Study

OBJECTIVE

To determine if prevalent approaches in acetabular fracture surgery provide enhanced anterior and cranial exposure in a cadaveric model.

METHODS

A Kocher-Langenbeck (K-L) approach (followed by a Gibson approach on the contralateral hip) was performed in the lateral position on 8 cadavers. A Steinmann pin was used to create holes outlining the bony surfaces available for instrumentation before and after a trochanteric osteotomy. All soft tissue was then removed from the pelvis, and a calibrated digital picture was taken. The surface area of the pelvis visualized through each approach was calculated and compared with the contralateral side to assess for a difference in exposure between the Gibson approach and the K-L approach. An increase in exposure of greater than 10% was considered significant. The extent of anterior exposure (with and without a trochanteric osteotomy) was then measured from the greater sciatic notch.

RESULTS

In 2 of 8 cadavers (25%), the Gibson approach yielded an increase in exposure when compared with a K-L approach. The addition of a trochanteric osteotomy yielded on average 1.6 cm (range, 0.7-2.6 cm) of increased anterior exposure in the K-L approaches and 1.5 cm (range 0.9-3.1 cm) in the Gibson approaches.

CONCLUSION

The Gibson approach did not reliably provide increased anterior exposure compared with a K-L approach in a cadaver model. A trochanteric osteotomy can be expected to add 1-2 cm of increased anterior exposure in both approaches.

Learning Curve for Surgical Treatment of Acetabular Fractures: A Retrospective Clinical Study of a Practical and Theoretical Training Course

Background

Surgical treatment of acetabular fracture and the anatomic reconstruction of the hip joint are difficult to achieve due to the complex pelvic anatomy, and surgical training requires a prolonged and steep learning curve. The aim of this study was to evaluate the effects of an applied training course, including cadaveric dissection, for the surgical treatment of acetabular fractures.

Material/Methods

This retrospective study included 35 patients who underwent surgical treatment for acetabulum fractures between 2012–2016. Patients were divided into three groups during two training courses, for the first two years and second two years. The surgical treatment was performed through single or combined standard approaches, according to the fracture pattern. The radiological outcome was evaluated using Matta’s criteria to grade postoperative reduction and final radiological outcome and the restoration of the hip joint center (HJC). The clinical outcome was evaluated using the modified the Merle d’Aubigné-Postel (DAP) hip score.

Results

Both post-course groups had statistically better functional and radiological outcomes compared with the pre-course group. Depending on the learning curve, the mean duration of surgery decreased from 153 minutes to 82.3 minutes. Although there was no statistical difference between groups in the vertical shift of the HJC, there was a statistically significant in the amount of horizontal shift of the HJC in the second two years of training, compared with the other groups.

Conclusions

Functional and radiological outcome of surgical treatment of acetabular fracture may be improved with increased training, depending on the learning curve.

Early reduction of acetabular fractures decreases the risk of post-traumatic hip osteoarthritis?

BACKGROUND

Acetabular fractures are complex high-energy injuries. Increasing in recent years with the increased use of high-speed motor vehicles. One of the most important complications of acetabular fracture is the post-traumatic hip osteoarthritis; this complication has been associated to poor fracture reduction, type of fracture and delay in the reduction and fixation of acetabular fracture (Timing surgery). The aims of this study were to determine the incidence of post-traumatic hip osteoarthritis after acetabulum fracture and demonstrate whether the delay surgery is associated to early post-traumatic hip osteoarthritis.

METHODS

Using the database of patients with acetabular fractures treated with open reduction and internal fixation (ORIF) over 3 years (2011-2014) with minimum of 2 years follow-up. Data was acquired and saved in a digital format. Demographic information was obtained from each patient with minimum of 2 years follow-up. Acetabular fracture was distributed according to the classification of Judet. The quality of reduction was classified in anatomic (0-1 mm) and non-anatomic (>1 mm) and the timing surgery, early (<7 days) and delay (>7 days). Clinical and radiographic follow-up was generally performed at six weeks, three months, one and two years after fracture fixation. Multivariate logistic regression analyses were performed to assess the strength of the covariates in relation to the development of post-traumatic hip osteoarthritis.

RESULTS

59 (48%) patients of 122, developed post-traumatic hip osteoarthritis before 2 years. Posterior wall fracture with or without transverse fracture was associated with higher post-traumatic hip osteoarthritis compared with other types of fractures (p < 0.05). Patients with better anatomical reduction had less post-traumatic hip osteoarthritis compared with those who had nonanatomic reduction (p < 0.05). There was no evidence of association between early timing of the surgical procedure and the presence post-traumatic hip osteoarthritis (p = 7092).

CONCLUSIONS

According to our results, the anatomical reduction of the articular surface in acetabular fractures is the most important factor in hip osteoarthritis prevention. This factor is strongly associated with early surgical treatment, preferably done within seven days. The timing surgery it is not a factor associated with post-traumatic osteoarthritis.

Surgical Approaches to the Acetabulum and Modifications in Technique

Acetabular injuries are often difficult to treat because the acetabulum is surrounded by many important structures, making access difficult and sometimes dangerous. Surgical exposures of the acetabulum are complex and require significant skill and in-depth knowledge of pelvic anatomy. Each approach has its limitations, and the potential morbidity associated with these exposures can be daunting. Recent modifications to traditional acetabular approaches have been developed to address these issues. Knowledge of the ilioinguinal, Kocher-Langenbeck, and extended iliofemoral surgical exposures and the potential drawbacks associated with each approach are essential to optimize treatment and minimize morbidity.

External rotator sparing with posterior acetabular fracture surgery: does it change outcome?

This study analyses the results of the treatment with external rotator sparing approach in acetabular fractures to determine whether muscle sparing has a positive impact on functional outcome. 20 patients with a mean age of 45.9 years (range: 26-64) that had been treated for displaced acetabular fractures were included in this series. Short Musculoskeletal Function Assessment (SMFA) questionnaire and hip muscle strength measurement were done at the 24-month of follow-up period. The radiographic results at the final followup were excellent in 9 hips (45%), good in 6 hips (30%), fair in 4 hips (20%), and poor in one hip (5%) according to the criteria developed by Matta. The average SMFA score for all of the patients was 18.3 (range: 0-55.4). The mean dysfunctional and bother indexes were 17.2 and 20.6, respectively. The overall muscle strength deficit was 11.8%. The greatest loss of strength was in internal rotation. In patients with better postoperative reduction quality of acetabular fracture, peak torque, and maximum work of hip flexion, extension and also internal rotation maximum work deficit were significantly lower (P < 0.05). Accurate initial reduction and longer postoperative muscle strengthening exercise programs seem critical to decrease postoperative hip muscle weakness after acetabular fractures.