The Kocher-Langenbeck Approach: State of the Art

Different coupling mechanisms for a novel modular plate in acetabular fractures-a comparison using a laparoscopic model

Introduction

Acetabular fractures are among the most challenging injuries in traumatology. The complex anatomy usually requires extensive surgical approaches baring the risk for iatrogenic damage to surrounding neurovascular structures. As a viable alternative, minimally invasive endoscopic techniques have emerged during the recent years. This paper reports on the feasibility of different coupling mechanisms for a novel suprapectineal plate especially designed for minimally invasive acetabular surgery.

Methods

A total number of 34 participants contributed to the present study, who differed in their arthroscopic and surgical experience. A laparoscopic model was used to compare four different coupling mechanisms by the number of failed attempts, the time required for plate fixation, the influence of surgical experience as well as the learning success for each individual coupling mechanism. Moreover, the feasibility of each mechanism was evaluated by a questionnaire.

Results

The results demonstrate that plates employing grooved and pressure-sliding coupling mechanisms exhibit fewer failed attempts and reduce trial times, especially in contrast to sole sliding mechanisms. Furthermore, our study revealed that proficiency in endoscopic procedures significantly influenced the outcome. Notably, the subjective evaluation of the participants show that the pressure base and pressure-slide base plate designs are the most supportive and feasible designs.

Conclusions

In summary, the present study evaluates for the first-time different plate and coupling designs for minimal-invasive surgery, indicating a superior feasibility for plates with a grooved and pressure-sliding mechanism.

Anatomical study of the modified direct posterior gluteal splitting approach for acetabular fractures

BACKGROUND

In this study, we investigated the area that can be addressed with an approach in which the skin incision is made directly above the dorsal column with Thiel cadaveric specimens.

METHODS

Six Thiel cadaveric specimens were prepared. A skin incision was made directly above the dorsal column. The accessible proximal end from the proximal part of the greater sciatic notch to the gluteal ridge and the accessible distal end of the ischium were marked with a flat chisel. A molded 8-hole reconstruction plate was placed from the base of the ischium toward the gluteal ridge and fixed with 3 screws proximally and 2 screws distally. The length of the skin incision and the distance from each reference point on the bone to the reachable markings were assessed after the muscles were removed.

RESULTS

Mean skin incision length was 9.3 ± 0.7 (range, 8.0-10.0) cm. In 3 of 6 cases, proximal screws were inserted through different spaces between muscle fibers. In all cases, we were able to reach at least the greater sciatic notch, the gluteal ridge at the level of superior border of the acetabulum, and the base of the ischial tuberosity. In all cases, an 8-hole plate could be placed from the gluteal ridge to the base of the ischium. There were no superior gluteal artery or sciatic nerve injuries in any of the cases.

CONCLUSION

We anatomically investigated the area that can be addressed with an approach in which the skin incision was made directly above the dorsal column. In all cases, we were able to access the areas needed to reduce the fracture and place the plates necessary to stabilize the fracture through a 9.3 ± 0.7 cm skin incision. This approach can be a useful minimally invasive posterior approach for acetabular fractures.

Transformation of transverse fractures of the acetabulum in T-shaped fractures and sequential approaches

Transverse acetabular fractures are difficult to reduce and generally associated with poorer clinical outcomes than other types of acetabular fractures. For these fractures affecting both columns, the surgical strategy is subject to controversy and there is currently no optimal method of management. The transformation of these transverse fractures in to a T-shaped fracture makes it possible to make the anterior and posterior components of the fracture independent and to reduce them sequentially. This technique has made it possible to obtain a satisfactory reduction of the fracture in certain cases and gives hope for good long-term functional results. LEVEL OF EVIDENCE: IV.

Does a simultaneous ventral/dorsal approach provide better reduction quality in treating acetabular fracture involving both columns with displaced posterior wall?

INTRODUCTION

Various surgical techniques have been proposed to manage acetabular fractures involving both columns with posterior wall displacement. However, the optimal surgical approach to achieve satisfactory reduction quality remains controversial.

MATERIALS AND METHODS

This retrospective study evaluated 34 patients with fractures who were treated at a single medical institution. The patients were divided into two groups according to the ventral/dorsal surgical approach employed: simultaneous (SI) and sequential (SE). Perioperative parameters, as well as radiological and functional outcomes, were analyzed and compared between the two groups.

RESULTS

The SI and SE groups comprised 9 and 23 out of the 34 patients, respectively. The SI group exhibited a significantly shorter surgical time and lower estimated blood loss than the SE group (p = 0.04 and 0.03, respectively). The quality of reductions of the anterior and posterior columns was similar between the two groups; however, superior reduction in the fracture gap of the posterior wall was observed in the SI group, as revealed by axial and coronal computed tomography scans.

CONCLUSIONS

A simultaneous ventral and dorsal approach through the pararectus and the modified Gibson approach confer clinical advantages in reducing the fracture gap, surgical time, and intraoperative blood loss when managing acetabular fractures involving both columns and a displaced posterior wall. Therefore, these surgical approaches may be considered to be optimal for achieving satisfactory reduction quality in such fractures.

[Single Kocher-Langenbeck approach combined with anterograde channel screw technique in treatment of acetabular transverse and posterior wall fractures]

Objective

To assess the effectiveness of the single Kocher-Langenbeck approach combined with anterograde channel screw technique for the treatment of acetabular transverse and posterior wall fractures.

Methods

Between March 2020 and October 2022, 17 cases of acetabular transverse and posterior wall fractures were treated with the single Kocher-Langenbeck approach combined with anterograde channel screw technique. There were 11 males and 6 females, with an average age of 53.6 years (range, 42-64 years). Causes of injury included traffic accident in 12 cases, and falling from height in 5 cases. The time from injury to operation ranged from 4 to 16 days with an average of 8.8 days. The operation time, intraoperative blood loss, and fluoroscopy frequency were recorded; X-ray films were reviewed regularly after operation to observe the fracture healing, and postoperative complications were recorded. At last follow-up, Matta score was used to evaluate the reduction of fracture, Harris score and modified Merle D'Aubigné-Postel scores system were used to evaluate the hip joint function.

Results

The operation time was 150-230 minutes (mean, 185.9 minutes), the intraoperative blood loss was 385-520 mL (mean, 446.2 mL), and the fluoroscopy frequency was 18-34 times (mean, 27.5 times). Postoperative fat liquefaction occurred in 1 case and the other incisions healed by first intention; 3 cases had limb numbness after operation, and the symptoms disappeared after active symptomatic treatment; no urogenital system and intestinal injury occurred. All patients were followed up 12-28 months (mean, 19.9 months). Bone union was achieved in all cases with an average healing time of 10.8 weeks (range, 8-14 weeks). There was no complication such as loosening and breakage of internal fixators. At last follow-up, according to Matta score, 12 cases achieved anatomic reduction, 3 satisfactory reduction, and 2 fair reduction, the satisfactory rate was 88.2%; according to Harris hip function score, 12 cases were excellent, 3 good, and 2 fair, the excellent and good rate was 88.2%; according to the modified Merle D'Aubign Aubigné-Postel scoring system, the results were excellent in 11 cases, good in 3 cases, and fair in 3 cases, with an excellent and good rate of 82.4%.

Conclusion

The single Kocher-Langenbeck approach combined with anterograde channel screw technique is a minimally invasive method for the treatment of acetabular transverse and posterior wall fractures with less complications, simple operation, and satisfactory effectiveness.

The Association between Acetabulum Fractures and Subsequent Coxarthrosis in a Cohort of 77 Patients-A Retrospective Analysis of Predictors for Secondary Hip Osteoarthritis

OBJECTIVE

the aim of this study was to document the occurrence of THA after acetabulum surgery and examine the factors that predict its occurrence.

METHODS

This study included 77 consecutive patients who were admitted for acetabulum fracture surgery between 2012 and 2019. The inclusion criteria were acetabular fractures and indications for operative management. The exclusion criteria were acetabular fractures treated non-operatively, fractures requiring primary THA, and periprosthetic acetabular fractures. Data concerning demographics, date of injury, date of surgery, surgical approach, stabilization, and further reconstructive surgery were collected retrospectively. The number of patients who underwent THA and their risk factors were recorded. The minimum follow-up for each patient was 2 years of observation. A total of 77 patients with a mean age of 53 years were included.

RESULTS

At a mean follow-up of 2 years, THA was performed in 16 (20.8%) patients due to post-traumatic arthritis. An analysis of the surgical approaches showed that the Kocher-Langenbeck approach increased the risk of THA nearly 12 times compared with the ilioinguinal approach (p = 0.016). Furthermore, the duration of the waiting period for surgery significantly impacted the occurrence of THA, with each additional day leading to an 89% increase in the risk of prosthesis usage (p = 0.001).

CONCLUSIONS

This study suggests that acetabular fractures may lead to post-traumatic hip osteoarthritis. The surgical approach and the waiting time for surgery are potential factors that may predict secondary hip osteoarthritis and the need for subsequent THA. However, further investigations should be performed to establish predictors for secondary hip osteoarthritis, and especially to determine the impact of the surgical approach.

The anterior transmuscular intrapelvic approach for the treatment of acetabular fractures-a new anterior surgical strategy

The anterior ilioinguinal and the posterior Kocher-Langenbeck approach have long been the standard surgical approaches to the acetabulum. The last decade has witnessed the development of so-called intrapelvic approaches for anterior pathologies because they provide better exposure of the quadrilateral plate. Currently, the modified Stoppa approach and the pararectus approach are frequently used by surgeons for the treatment of acetabular fractures. We investigated an even more direct access to the entire anterior column and the quadrilateral plate via the abdominal wall muscles, between the incisions for the ilioinguinal and the pararectus approach.After intensive study of anatomic specimens, a cadaver dissection was performed prior to clinical application. The approach was then used in 20 patients who were assessed retrospectively.Postoperative CT scans showed that, according to the Matta scoring system, the quality of fracture reduction was "anatomical" (≤ 1 mm) in 12 (60%), "imperfect" (2-3 mm) in four (20%), and "poor" (> 3 mm) in four (20%) patients. Numerous minor complications were observed; the majority of these had resolved at the time of discharge.In conclusion, the anterior transmuscular intrapelvic approach (ATI) is a safe and effective alternative to the ilioinguinal and pararectal approaches, and may be regarded as an evolutionary advancement of traditional procedures.

Comparison of Postoperative Complications Between Trochanter Flip Osteotomy and Kocher-Langenbeck Approaches for the Treatment of Femoral Head Fractures: A Systematic Review and Meta-analysis

Purpose

The study aims to identify the optimal approach for femoral head fracture (FHF) by comparing the postoperative complications and outcome score of the Kocher-Langenbeck posterior approach (KLP) and trochanteric flip osteotomy (TFO) through a systematic review and meta-analysis.

Methods

MEDLINE, Embase and the Cochrane Library were systematically searched for studies published up to 22 January 2023, which compared TFO to the KLP for FHF treatment. The main outcomes of this meta-analysis were the rate of postoperative complications including osteonecrosis of the femoral head (ONFH), heterotopic ossification (HO), and total hip replacement (THR) conversion rate and Thompson-Epstein (T-E) score at the final follow-up.

Results

We included four studies with 57 cases of FHFs; 27 and 30 patients underwent TFO and the KLP, respectively. Following the pooled analysis, HO incidence was significantly higher in TFO than in the KLP (OR = 4.03; 95% CI 1.10-14.81; P = 0.04; I 2 = 0%), but there were no differences in other variables, including the incidence of ONFH (OR = 0.41; 95% CI 0.07-2.35; P = 0.32; I 2 = 0%), THR conversion rate (OR = 0.82; 95% CI 0.16-4.29; P = 0.81; I 2 = 0%), and number of inferior results in the T-E score (OR = 0.49; 95% CI 0.14-1.73; P = 0.27; I 2 = 0%).

Conclusions

Amongst the posterior approaches for FHFs, the KLP and TFO did not present significant clinical and radiological differences; hence, the approach can be selected depending on the surgeon's experience and preference.

Intra-articular fragment mapping in associated both-column acetabular fractures

INTRODUCTION

Associated both-column acetabular fractures (ABC-AF) are complex. A detailed description of the morphology of the articular surface of the acetabulum is not reported. This study was designed to describe the morphology of the intra-articular fragments using a fracture mapping technique to provide reference in more appropriate approach selection in surgical treatment of the fractures.

MATERIALS AND METHODS

Three-dimensional reconstruction CT images from 100 cases of ABC-AFs were retrospectively analyzed using Mimics and 3-matic software. The fractured as well as the reduced three-dimensional models were investigated, and the intra-articular fragments were identified. The distribution of the fracture lines of each main fragment and the overlapping lines of all the fragments were verified on the images.

RESULTS

The articular surface of ABC-AFS consist of three types of fragments: column fragment (CF), wall fragment (WF) and isolated fragment (IF), with the total number varying from 2 to 6. CF characterized by long fracture lines exited to periphery of innominate bone while the lines of WF were confined to the walls. IF was a free fragment found in the dome and in the quadrilateral plate. The surface was composed only by CFs in 17 cases (17%), by CFs and WFs in 59 cases (59%) and by all fragments in 24 cases (24%). The distribution of the overall fracture lines was a "dumbbell shaped" pattern, starting from the infero-anterior aspect, passing through the junction of the fossa to the anterior lunate surface and extending into the posterior region of the acetabulum.

CONCLUSIONS

The articular fragments of ABC-AFs were composed of CFs, WFs and IFs. The junction of the fossa to the anterior lunate surface and the posterior region of the rim were mostly involved. The location of the articular fragments and their connections to the periphery of the innominate may be considered in selection of approaches.

Tricortical iliac crest graft as a salvageable option in the reconstruction of comminuted posterior wall acetabular fractures: our experience from a level 1 trauma centre

BACKGROUND

Comminuted fractures of the posterior acetabular wall, pose a significant challenge in the reduction and fixation of the fracture fragments and usually result in dubious functional outcomes. Primary reconstruction of the severely comminuted posterior wall using the autologous tricortical iliac crest graft has shown promising results, especially in fractures not amenable for anatomical reduction and fixation. Thus, the present study analyses the functional and radiological outcomes of severely comminuted posterior wall acetabular fractures, primarily reconstructed with an autologous tricortical iliac crest graft.

METHODOLOGY

This is a retrospective study, where all cases of comminuted posterior wall acetabulum fractures treated primarily with reconstruction using ipsilateral autologous tricortical iliac crest graft between January 2011 and November 2018 were included. The data of patients were retrieved from the hospital records and all the patients were assessed clinically and radiologically at the final follow-up.

RESULTS

Fourteen patients (ten males and four females) were operated on with a mean operative time of 160 min (range 125 to 190 min) and a mean blood loss of 410 ml (range 320 ml to 830 ml). At 2 years of follow-up, 11 patients (78.57%) had good to excellent functional outcomes based on the modified Merle d'Aubigne and Postel scoring system. The radiological assessment using Matta's criteria indicated excellent outcomes in two patients (14.48%), good in six patients (42.85%), fair in six patients (42.85%).

CONCLUSION

Primary reconstruction of the comminuted posterior wall acetabulum fractures is a potential alternative and salvageable option with favourable outcomes. However, it ought to be considered in severely comminuted fractures where anatomical reduction and internal fixation is not feasible.

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.

The Impact of Surgical Approaches for Isolated Acetabulum Fracture on Sexual Functions: A Prospective Study

OBJECTIVES

To investigate the effects of surgical modalities for isolated acetabular fractures on the sexual functions of patients and their partners.

DESIGN

Prospective.

SETTING

Level I trauma centre.

PATIENTS/PARTICIPANTS

Sixty-five patients who had undergone open reduction and internal fixation because of isolated acetabular fractures who were sexually active before, together with their partners.

INTERVENTION

Patients operated on for isolated acetabular fractures were divided into 3 groups according to surgical approaches: the Kocher-Langenbeck approach (n = 36), ilioinguinal approach (n = 16), and modified Stoppa approach (n = 13).

MAIN OUTCOME MEASUREMENTS

Sexual functions of patients and their partners were evaluated with the 5-item version of the International Index of Erectile Function score and Female Sexual Function Index score preoperatively and at the postoperative first year after the rehabilitation period.

RESULTS

The mean age of the patients was 41.8 ± 13.0 (18-69) years. In male patients, the mean 5-item version of the International Index of Erectile Function score had changed from 24.3 to 20.0 at the postoperative first year and the decrease in sexual function scores was less with the Kocher-Langenbeck approach. In female patients, the Female Sexual Function Index scores had decreased statistically significantly from 24.9 to 18.3 at the postoperative first year, but there was no statistically significant difference between surgical groups. Both male and female patients' partners' sexual function scores were also decreased at the postoperative first year.

CONCLUSIONS

As a result of our study, it was observed that the posterior approach is more advantageous than anterior approaches in preserving the sexual functions of male patients in acetabular fracture surgery. However, the surgical approach did not affect the sexual functions of female patients.

LEVEL OF EVIDENCE

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

Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum: an anatomical feasibility study

Pelvic ring injuries or acetabular fractures present a challenge to trauma surgeons. Recently, endoscopic dissection techniques for visualization of the anterior pelvic ring and acetabulum have been presented. Robotic-assisted surgical systems offer advantages in terms of improved visualization and easier instrument handling. The aim of this pilot anatomic study was to verify the feasibility of robotic-assisted plate osteosynthesis on the anterior pelvic ring and acetabulum. The experiment was performed on a human whole body specimen. The DaVinci system with standard instruments as used in RARP was used. After docking the system, the anterior pelvic ring was first prepared as previously described for the endoscopic techniques. This was followed by dissection of both acetabula analogous to pelvic lymphadenectomy as performed during RARP. After the dissection was performed along the pelvic brim up to the iliosacral joint, the complete anterior column of the acetabulum including quadrilateral surface and incisura ischiadica major could be visualized. Finally, robotic-assisted endoscopic plate osteosynthesis was performed on the symphysis and anterior acetabular column as previously described in the endoscopic techniques. Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum is feasible with the available robotic-assisted systems. Due to the excellent freedom of movement of the robotic arms, combined with the magnifying 3D visualization of the system, highly accurate preparation of the situs in preparation for plate osteosynthesis can be performed. The question of reduction of dislocated fractures remains open and is the subject of further investigation. Compared with conventional laparoscopy, robotic-assisted preparation nevertheless appears to offer an advantage in view of the complexity of the operation.

Effectiveness of Online Video Instruction on Time to Start Ambulation and Duration of Hospital Stay, Satisfaction and Functional Recovery in Patients Undergoing Total Hip Arthroplasty

BACKGROUND

At the end of 2014, we implemented an online video to inform patients of the entire process from admission to rehabilitation after total hip arthroplasty (THA). In this study, we investigated the effectiveness of online video instruction in THA patients.

METHODS

Electronic medical records of 184 patients undergoing THA in 2014 (pre-video group) and 182 patients in 2015 (post-video group) were reviewed. We compared 1) the time to start wheelchair ambulation, 2) walker or crutch ambulation, 3) the length of hospital stay, 4) postoperative satisfaction using visual analogue scale (0-10 points), and 5) modified Harris Hip Score (mHHS) at postoperative 6 weeks.

RESULTS

In the post-video group, the time to start wheelchair ambulation (1.8 ± 0.6 vs. 2.4 ± 3.2 days, P = 0.021) and walker/crutch ambulation were faster (2.9 ± 1.2 vs. 3.8 ± 1.0 days, P = 0.016), and the hospital stay was shorter (8.2 ± 4.7 vs. 9.9 ± 7.8 days, P = 0.001) compared to the pre-video group. The visual analogue scale for satisfaction (7.84 ± 1.62 vs. 7.68 ± 1.85 points) and mHHS (89.59 ± 9.47 vs. 89.58 ± 8.59) were similar.

CONCLUSION

Online video instruction is an effective tool to expedite ambulation and reduce the hospital stay without compromising the clinical outcome and postoperative complications after THA.

Clinical and functional outcomes of posterior wall fractures of the acetabulum fixed with spring plates by a posterolateral rotator-sparing approach

BACKGROUND

Posterior wall fractures are the most frequent and account for up to 25% of all acetabular fractures, open reduction and internal fixation by a Kocher Langenbeck approach is the gold standard for this injury but even with anatomic reduction poor outcomes are higher than expected, The present study proposes a technique for open reduction and internal minimizing soft tissue and periosteal injury through a modified Kocher-Langenbeck and spring plate fixation.

METHODS

This case series, descriptive, longitudinal study assessed the clinical and functional outcomes of patients with isolated posterior wall fractures of the acetabulum, the study included 24 consecutive patients from January to December 2018 who underwent open reduction and internal fixation with spring plates by a Rotator Sparing Kocher Langenbeck approach RESULTS: Clinical and radiographic assessment at 3 and 12 months using the Harris Hip Score (HHS), Merle d'Aubigné and Postel (MDP) score, and EQ-5D-3L score.

RESULTS

Twenty-four patients were included in the study (5 females [20.8%], 19 males [79.2%]; mean age, 33.5 ± 13.1 years; range: 15-64 years). 41.7% of patients were admitted for hip dislocation, with 75% of these presenting a displacement greater than 20 mm; 21% for marginal impaction; 8.3% for acetabular dome involvement; and 25% for femoral head involvement. Based on the HHS, MDP, and EQ-5D-3L scores, the 12-month follow-up showed excellent outcomes in 95.8% of patients, and only one patient presented a poor functional outcome that was associated with posttraumatic arthrosis due to sequelae of femoral head necrosis.

CONCLUSIONS

Excellent and good outcomes are considerably higher with this technique compared to previous papers in the literature. It is still early to assess femoral head necrosis and osteoarthritis, but these are promising results.

LEVEL OF EVIDENCE

IV.

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.

Single column plate plus other column lag screw fixation vs. both column plate fixation for anterior column with posterior hemitransverse acetabular fractures - a biomechanical analysis using different loading protocols

OBJECTIVES

Open reduction and internal fixation of both columns is considered the treatment of choice for displaced anterior column with posterior hemitransverse (ACPHT) fractures in non-geriatric patients. Plate fixation of one column combined with lag screw fixation of the other column allows to decrease operative time and approach-related morbidity compared to conventional both column plating. The aim of this biomechanical study was to evaluate whether single column plate plus other column lag screw fixation confers similar stability to both column plate fixation. Physiological loads were simulated using both the single-leg stance (SLS) as well as the sit-to-stand (STS) loading protocols.

METHODS

A clinically relevant ACPHT fracture model was created using fourth-generation composite hemipelves. Fractures were stabilized with three different fixation constructs: (1) anterior column plate plus posterior column screw fixation (AP+PCS), posterior column plate plus anterior column screw fixation (PP+ACS) and anterior column plate plus posterior column plate fixation (AP+PP). Specimens were loaded from 50 to 750 N with a ramp of 100 N/s. Fracture gap motion (FGM) and relative interfragmentary rotation (RIFR) between the three main fracture fragments were assessed under loads of 750 N using an optical 3D measurement system.

RESULTS

STS loading generally resulted in higher mean FGM and RIFR than STS loading in the AP+PCS and AP+PP groups, while no significant differences were found in the PP+ACS group. Compared to conventional both column plate fixation (AP+PP), PP+ACS displayed significantly higher FGM and RIFR between the iliac wing and the posterior column during SLS loading. No significant differences in FGM and RIFR were identified between the AP+PCS and the AP+PP group.

CONCLUSION

Overall, single column plate plus other column lag screw fixation conferred similar stability to conventional both column plate fixation. From a clinical point of view, AP+PCS appears to be the most attractive alternative to conventional AP+PP for internal fixation of ACPHT fractures.

Medium-Term Patient-Reported Quality of Life and Activities of Daily Living in Surgically Treated Trauma Patients With Pelvic, Acetabular or Combined Pelvic and Acetabular Fractures in a Retrospective Single-Center Study

OBJECTIVE

To gain more insights in the medium-term patient-reported quality of life (QoL), activities of daily living (ADL), and number of complications in trauma patients with an acetabular fracture (AF), a pelvic fracture (PF), and those with a surgically combined pelvic and AF (PAF).

DESIGN

Retrospective single-center study.

SETTING

Level I academic trauma center.

PATIENTS/PARTICIPANTS

51 trauma patients with PF, AF, or PAF who were surgically treated between 2014 and 2017.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures are patient-reported outcome questionnaire, which includes 2 items, the QoL, as measured with the Short Form-12, and the ADL, as measured with the Lower Extremity Functional Scale. The secondary outcome parameter was the occurrence of complications during a follow-up of at least 2 years.

RESULTS

The mean physical component score (PCS) of the QoL (P = 0.03) and the ADL (P = 0.03) were significantly higher in patients with AF compared with patients with PF. The incidence of the overall postoperative complications did not significantly differ between the PF, AF, and PAF groups (P = 0.28).

CONCLUSIONS

This study found that the PCS of the QoL and the ADL in surgically treated trauma patients with PF were significantly lower compared with patients with AF. No significant differences were found in overall complication rate between the PF, AF, and PAF groups.

LEVEL OF EVIDENCE

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

The efficiency and safety of intravenous tranexamic acid administration in open reduction and internal fixation of pelvic and acetabular fractures

PURPOSE

This study aimed to investigate the efficiency and safety of tranexamic acid use in open reduction and internal fixation of pelvis and acetabulum fractures.

MATERIALS AND METHODS

73 consecutive patients were included. 1000 mg TXA was administered intravenously to all patients before surgery. The patients were evaluated on the basis of preoperative, postoperative first and third day hemoglobin-hematocrit values, amount of drainage collected, total blood loss, transfusion rates and complications.

RESULTS

Mean operative time was 120.1 min. Average decrease in hematocrit levels between preoperative and postoperative first day was 2.1 g/dL. Average collected blood from the drain was 177 mL. Mean total blood loss was 1137 mL. Transfusion rate of the patients was 21%. Mean transfused units was 0.9 units. Three patients died within 3 weeks after the operation due to myocardial infarction, acute kidney failure and pneumonia. There were no cases of symptomatic venous or pulmonary thromboembolism during the 90 days of follow-up.

CONCLUSION

Use of TXA in pelvic and acetabular fractures was found to be effective in reducing total blood loss, hemoglobin drop and transfusion rates without increasing venous and pulmonary thromboembolism in our series.

Complications of surgical approaches for osteosynthesis treatment of acetabular fractures: Analysis of pitfalls and how to avoid them

BACKGROUND

Fractures of the acetabulum are rare injuries. The indication for surgical stabilization depends on the grade of instability and dislocation. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of anatomical structures and possible risks of the different approaches, are important.

METHODS

Over a period of 15 years, we analyzed all patients with acetabular fractures, treated in our Level I Trauma Center with special interest in surgical and approach-related complications. Based on our complication rates, we describe the used different surgical approaches and the accessible anatomical structures respectively. Finally, we focus on strategies to reduce the risk of approach-related complications in acetabular surgery.

RESULTS

Between January 2003 and December 2017, 523 patients with an acetabular fracture were treated in our Tertiary Referral Hospital. Of these, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. 296 patients underwent surgical treatment of the acetabular fracture, while 227 patients were treated non-operatively. Surgically treated patients had a significantly higher complication rate of 21.2% (63/296) compared to conservatively treated patients with a complication rate of 16.7% (38/227). Neurovascular and thromboembolic adverse events were the most often complications.

CONCLUSIONS

Patients with acetabular fractures are at a high risk for different kind of complications. The most common risks are neuro-vascular and thromboembolic incidents. The risk of getting a complication is increased in surgically treated patients, therefore both the indication for surgical treatment and the surgical approach should be carried out carefully, including individual patient parameters and fracture types as well as the surgeons expertise.

[Application of self-made spring plate for treatment of acetabular posterior wall fractures]

OBJECTIVE

To investigate the application and effectiveness of self-made spring plate in surgical treatment of acetabular posterior wall fracturejavascript:void(0)s.

METHODS

Between June 2013 and June 2017, 38 patients with acetabular posterior wall fractures were treated. There were 27 males and 11 females with an average age of 53 years (range, 28-68 years). The injury caused by traffic accident in 18 cases, falling from height in 15 cases, and tumble in 5 cases. There were 4 cases of simple posterior wall fracture, 18 cases of posterior wall fracture with posterior dislocation of hip joint, 10 cases of posterior wall fracture with posterior column fracture, and 6 cases of posterior wall fracture with transverse fracture. The time from injury to admission was 1-4 days (mean, 2.5 days). The time from injury to operation was 4-8 days (mean, 5 days). After fracture reduction via the Kocher-Langenbeck approach (35 cases) or the combined ilioinguinal approach (3 cases), the spring plate was used to press the posterior wall fracture, and then the reconstruction plate was pressed against the spring plate and fixed to the posterior column.

RESULTS

All the incisions healed by first intention. All patients were followed up 12-36 months (mean, 28 months). Five cases of post-traumatic sciatic nerve injury and 2 cases of sciatic nerve injury caused by traction during operation were fully recovered at 3 months after operation. The imaging examination showed that all the fractures healed. The fracture healing time was 10-16 weeks (mean, 12 weeks). There was no ruptures or failures of internal fixation during the follow-up period. There were 2 cases of femoral head necrosis, 1 case of traumatic arthritis, and 1 case of osteomyositis at last follow-up. The hip joint function was rated as excellent in 27 cases, good in 5 cases, fair in 2 cases, and poor in 4 cases according to the Harris scores at 12 months after operation.

CONCLUSION

For the acetabular posterior wall fracture, it has the advantages of easy to use and reliable fixation that the posterior wall fracture is fixed with spring plate firstly, and the spring plate is pressed to fix the posterior column with the reconstruction plate finally.