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Controversies in treatment of acetabular fracture.

Grubor P, Krupic F, Biscevic M, Grubor M - Med Arch (2015)

Bottom Line: Functional outcome (after follow-up of 18 months), according to the Harris hip score of surgical treatment in 82 patients, was as follows: good 46 (56%), satisfactory 32 (39%) and poor 4 (5%).Indications for surgical treatment are incongruent or unstable fractures with verified dislocation greater than 5 mm, as well as when the radiography measured by JM Matta shows incongruence of acetabular roof less than 40° in all planes.Kocher-Langenbeck approach is the choice of surgical approach for the management of posterior column / wall, and Letournel's (ilioinguinal) approach is the choice for the management of anterior wall/column.

View Article: PubMed Central - PubMed

Affiliation: Clinic of Traumatology, Banja Luka, Bosnia and Herzegovina.

ABSTRACT

Introduction: Acetabular fractures treatment represents a great controversy, challenge and dilemma for an orthopedic surgeon.

Aim: The aim of the paper was to present the results of treatment of 96 acetabular fractures in the Clinic of Traumatology Banja Luka, in the period from 2003 to 2013, as well as to raise awareness regarding the controversy in the methods of choice in treating acetabulum fractures.

Material and methods: The series consists of 96 patients, 82 males and 14 females, average age 40.5 years. Traffic trauma was the cause of fractures in 79 patients (85%), and in 17 patients (15%) fractures occurred due to falls from height. Polytrauma was present in 31 patients (32%). According to the classification of Judet and Letournel, representation of acetabular fractures was as follows: posterior wall in 32 patients, posterior column in 28, anterior wall in 4, anterior column in 2, transverse fractures in 8, posterior wall and posterior column in 10, anterior and posterior wall in 6, both- column in 4 and transversal fracture and posterior wall in 2 patients. 14 patients were treated with traction, that is, 6 patients with femoral traction and 8 patients with both lateral and femoral traction. 82 patients (86.4%) were surgically treated. Kocher-Langenbeck approach was applied in the treatment of 78 patients. In two patients from the Kocher-Langenbeck's approach, the Ollier's approach had to be applied as well. Two acetabular were primarily treated with Ollier's approach. Extended Smith- Peterson's approach was applied 4 times, and Emile Letournel's (ilioinguinal) approach 14 times.

Results: Functional outcome (after follow-up of 18 months), according to the Harris hip score of surgical treatment in 82 patients, was as follows: good 46 (56%), satisfactory 32 (39%) and poor 4 (5%). Results of acetabulum fractures treated with traction were: good 8 (57%), satisfactory 4 (28%) and poor 2 (15%). According to the Brook's classification of heterotopic ossification, periarticular hetero-tropic calcifications after surgical treatment were: 0° in 65 patients (79%), I-II° in 9 patients (11%) and III-IV ° in 8 patients (10%). Calcifications in 14 patients treated with traction of heterotopic ossification by Brook-s classification were as follows: 0° in 10 patients (72%), I-II ° in 3 patients (22%) and III-IV° in 1 patient (6%).

Conclusion: At the occurrence of acetabular fracture, it is necessary to start the treatment immediately, with an obligatory application of thromboembolic and antibiotic prophylaxis. Conservative treatment is acceptable if the dislocation of fracture is less than 5 mm. Indications for surgical treatment are incongruent or unstable fractures with verified dislocation greater than 5 mm, as well as when the radiography measured by JM Matta shows incongruence of acetabular roof less than 40° in all planes. Kocher-Langenbeck approach is the choice of surgical approach for the management of posterior column / wall, and Letournel's (ilioinguinal) approach is the choice for the management of anterior wall/column.

No MeSH data available.


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Results of conservative and surgical treatment of acetabulum fractures by Harris hip score after 18 months of follow-up
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Figure 2: Results of conservative and surgical treatment of acetabulum fractures by Harris hip score after 18 months of follow-up

Mentions: Patients underwent anamnestic, clinical and radiographic analysis. Average duration of the follow-up was 18 months (9 to 35). Harris Hip Score was used for the assessment of the condition of the hip, while standard radiographic images, CT and 3D reconstruction were used for the assessment of post-traumatic arthrosis and the occurrence of avascular necrosis. During the treatment of patients who were treated with traction, 3 patients suffered from the emergence of decubitus and skin dehiscence over the gluteal region, while the heel was affected in 7 patients. Transient infections around the pins occurred in 4 patients, and respiratory complications in 2 patients. For the prevention of skin decubitus, we used static exercise during bed rest and we placed ring shaped cotton under the heel. Iatrogenic complication of Kocher-Langebeck approach was on lesion of circumflexae superior when a. iliaca interna needed to be accessed in order for it to be liasoned. Postoperatively, tansitoral paresis of n. ischiadicus occurred in 4 patients. The most severe complications of Kocher- Langebeck approach occurred in one patient as a result of Homan’s hooks’ pressure on peritoneum, whereupon a rectal contusion, that is, rectal dehiscence occurred. Due to insufficient diagnosis, anus praeter needed to be done 10 days afterwards. One patient had a retroperitoneal hematoma, which was solved by making an incision and drainage. Incongruent and unstable reposition of the posterior acetabular column occurred in 3 patients, which led to subluxation of the hip joint, accompanied by pain and avascular necrosis of the femoral head. Averagely, 2.5 months after the surgical treatment of acetabular, the complication was eliminated with cementless total hip prosthesis. Pulmonary embolism was identified and diagnosed on the third postoperative day, on average–clinically and radiographically in 5 patients, and clinically and PE scintigraphy (perfusion and inhalation) in 2 patients. Functional outcome (after 18 months of follow-up) according to the Harris hip score of surgical treatment of 82 patients was as follows: good in 36 patients (43.90%), satisfactory in 32 (39.03%) and poor in 14 patients (17.07%). Results of acetabulum fractures treated with traction were as follows: good, in 8 patients (57%), satisfactory in 4 (28%), poor in 2 patients (15%) (Figure 2). Chi-square test showed that there was no statistically significant difference between patients treated surgically or conservatively (p = 0.659).


Controversies in treatment of acetabular fracture.

Grubor P, Krupic F, Biscevic M, Grubor M - Med Arch (2015)

Results of conservative and surgical treatment of acetabulum fractures by Harris hip score after 18 months of follow-up
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4384876&req=5

Figure 2: Results of conservative and surgical treatment of acetabulum fractures by Harris hip score after 18 months of follow-up
Mentions: Patients underwent anamnestic, clinical and radiographic analysis. Average duration of the follow-up was 18 months (9 to 35). Harris Hip Score was used for the assessment of the condition of the hip, while standard radiographic images, CT and 3D reconstruction were used for the assessment of post-traumatic arthrosis and the occurrence of avascular necrosis. During the treatment of patients who were treated with traction, 3 patients suffered from the emergence of decubitus and skin dehiscence over the gluteal region, while the heel was affected in 7 patients. Transient infections around the pins occurred in 4 patients, and respiratory complications in 2 patients. For the prevention of skin decubitus, we used static exercise during bed rest and we placed ring shaped cotton under the heel. Iatrogenic complication of Kocher-Langebeck approach was on lesion of circumflexae superior when a. iliaca interna needed to be accessed in order for it to be liasoned. Postoperatively, tansitoral paresis of n. ischiadicus occurred in 4 patients. The most severe complications of Kocher- Langebeck approach occurred in one patient as a result of Homan’s hooks’ pressure on peritoneum, whereupon a rectal contusion, that is, rectal dehiscence occurred. Due to insufficient diagnosis, anus praeter needed to be done 10 days afterwards. One patient had a retroperitoneal hematoma, which was solved by making an incision and drainage. Incongruent and unstable reposition of the posterior acetabular column occurred in 3 patients, which led to subluxation of the hip joint, accompanied by pain and avascular necrosis of the femoral head. Averagely, 2.5 months after the surgical treatment of acetabular, the complication was eliminated with cementless total hip prosthesis. Pulmonary embolism was identified and diagnosed on the third postoperative day, on average–clinically and radiographically in 5 patients, and clinically and PE scintigraphy (perfusion and inhalation) in 2 patients. Functional outcome (after 18 months of follow-up) according to the Harris hip score of surgical treatment of 82 patients was as follows: good in 36 patients (43.90%), satisfactory in 32 (39.03%) and poor in 14 patients (17.07%). Results of acetabulum fractures treated with traction were as follows: good, in 8 patients (57%), satisfactory in 4 (28%), poor in 2 patients (15%) (Figure 2). Chi-square test showed that there was no statistically significant difference between patients treated surgically or conservatively (p = 0.659).

Bottom Line: Functional outcome (after follow-up of 18 months), according to the Harris hip score of surgical treatment in 82 patients, was as follows: good 46 (56%), satisfactory 32 (39%) and poor 4 (5%).Indications for surgical treatment are incongruent or unstable fractures with verified dislocation greater than 5 mm, as well as when the radiography measured by JM Matta shows incongruence of acetabular roof less than 40° in all planes.Kocher-Langenbeck approach is the choice of surgical approach for the management of posterior column / wall, and Letournel's (ilioinguinal) approach is the choice for the management of anterior wall/column.

View Article: PubMed Central - PubMed

Affiliation: Clinic of Traumatology, Banja Luka, Bosnia and Herzegovina.

ABSTRACT

Introduction: Acetabular fractures treatment represents a great controversy, challenge and dilemma for an orthopedic surgeon.

Aim: The aim of the paper was to present the results of treatment of 96 acetabular fractures in the Clinic of Traumatology Banja Luka, in the period from 2003 to 2013, as well as to raise awareness regarding the controversy in the methods of choice in treating acetabulum fractures.

Material and methods: The series consists of 96 patients, 82 males and 14 females, average age 40.5 years. Traffic trauma was the cause of fractures in 79 patients (85%), and in 17 patients (15%) fractures occurred due to falls from height. Polytrauma was present in 31 patients (32%). According to the classification of Judet and Letournel, representation of acetabular fractures was as follows: posterior wall in 32 patients, posterior column in 28, anterior wall in 4, anterior column in 2, transverse fractures in 8, posterior wall and posterior column in 10, anterior and posterior wall in 6, both- column in 4 and transversal fracture and posterior wall in 2 patients. 14 patients were treated with traction, that is, 6 patients with femoral traction and 8 patients with both lateral and femoral traction. 82 patients (86.4%) were surgically treated. Kocher-Langenbeck approach was applied in the treatment of 78 patients. In two patients from the Kocher-Langenbeck's approach, the Ollier's approach had to be applied as well. Two acetabular were primarily treated with Ollier's approach. Extended Smith- Peterson's approach was applied 4 times, and Emile Letournel's (ilioinguinal) approach 14 times.

Results: Functional outcome (after follow-up of 18 months), according to the Harris hip score of surgical treatment in 82 patients, was as follows: good 46 (56%), satisfactory 32 (39%) and poor 4 (5%). Results of acetabulum fractures treated with traction were: good 8 (57%), satisfactory 4 (28%) and poor 2 (15%). According to the Brook's classification of heterotopic ossification, periarticular hetero-tropic calcifications after surgical treatment were: 0° in 65 patients (79%), I-II° in 9 patients (11%) and III-IV ° in 8 patients (10%). Calcifications in 14 patients treated with traction of heterotopic ossification by Brook-s classification were as follows: 0° in 10 patients (72%), I-II ° in 3 patients (22%) and III-IV° in 1 patient (6%).

Conclusion: At the occurrence of acetabular fracture, it is necessary to start the treatment immediately, with an obligatory application of thromboembolic and antibiotic prophylaxis. Conservative treatment is acceptable if the dislocation of fracture is less than 5 mm. Indications for surgical treatment are incongruent or unstable fractures with verified dislocation greater than 5 mm, as well as when the radiography measured by JM Matta shows incongruence of acetabular roof less than 40° in all planes. Kocher-Langenbeck approach is the choice of surgical approach for the management of posterior column / wall, and Letournel's (ilioinguinal) approach is the choice for the management of anterior wall/column.

No MeSH data available.


Related in: MedlinePlus