Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures

IntroductionPatients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures.MethodsAdults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality.ResultsAfter propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality.ConclusionCirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture.Level of EvidencePrognostic Level III.     

髋臼螺钉对非骨水泥全髋置换术中假体稳定性的影响

目的探讨髋臼螺钉在非骨水泥全髋置换术中对髋臼假体稳定性的影响。 方法回顾性分析2009年8月至2015年8月在深圳市龙岗区人民医院骨科行非骨水泥全髋置换术114例(117髋)病例资料，患者根据术中是否植入髋臼螺钉分成两组，其中A组无螺钉组59髋，B组螺钉固定组58髋。分别在术后3个月、12个月、24个月和末次随访时对病人进行随访，评估并比较影像学的改变及Harris评分。A组57髋B组56髋获得完整随访资料，平均随访(5.7±1.6)年。以Kaplan-Meier法分析两组假体生存率。 结果A组平均手术时间(t＝2.213, P<0.05)、术中出血量均小于B组(t＝2.342, P<0.05)；随访末期，A、B组术后平均Harris评分为(95.0±2.1)分及(93.0±5.5)分(P>0.05)；A、B组术后3个月、12个月、24个月分别有4髋(7.0%)、3髋(5.3%)、1髋(1.8%)和1髋(1.8%)、2髋(3.6%)及2髋(3.6%)出现髋臼周围透亮线；A组1髋术后4年出现骨溶解，B组2髋出现骨溶解。以影像学证明假体松动作为失败标准，计算两组假体平均随访(5.7±1.6)年生存率分别为97%和95%，两者差异无统计学意义(P >0.05)。 结论髋臼骨质条件良好时是否使用髋臼螺钉固定对臼杯的稳定性无明显影响，全髋关节置换术中植入髋臼螺钉不是必需的。     

Complications in patients of acetabular fractures and the factors affecting the quality of reduction in surgically treated cases

IntroductionAcetabulum fractures, though relatively uncommon, are associated with significant morbidity and mortality. These involve high energy trauma and due to their complex nature, the management requires understanding the relevant surgical anatomy, defining the injury via appropriate radiographic assessment and determining a suitable treatment plan. Literature is scarce for the demographic data, fracture patterns, associated injuries, management and early complications in the Indian scenario. These factors play a pivotal role in the ultimate recovery of the patients. Therefore this study was conceptualised to assess the epidemiology and evaluate the complications of these fractures. Furthermore the effects of various factors determining the quality of reduction in surgically treated patients were also assessed.MethodologyThis was a prospective observational study in which patients presenting to the advance trauma centre of our institute with acetabulum fractures were included. Demographical data of the patients, mechanisms of injuries, fractures morphologies, complications and radiological outcomes were recorded prospectively.Results116 patients with acetabular fractures were included in the study. 81% of these were males, with average age of 39.95 ± 15.87 years; with road traffic accidents being the predominant mode of injuries. Mortality was reported in 5 patients; 4 patients had deep venous thrombosis and sciatic nerve injuries were seen in 12 patients of which 4 were iatrogenic. 8 patients had some form of infection, out of which 4 required multiple debridements. 4 cases developed heterotrophic ossification while 2 cases had loss of reduction. The timing of surgery and other associated fractures had significant effect on the quality of reduction (p < 0.05); while age, gender, mode of injury or individual fracture patterns had no such effect.ConclusionsProper radiological assessment and evaluation of fracture configuration is important for management of acetabulum fractures. When indicated, this should be followed by early open reduction and internal fixation to achieve anatomical reduction, with management of associated injuries for better outcomes.     

CT三维重建模型下模拟髋臼前柱2种经皮置钉方法的比较

目的对比CT三维重建模型下模拟髋臼前柱2种经皮置钉方法的效果。方法选取55例正常成人骨盆CT资料构建三维模型,共110侧髋臼前柱,调整模型透明度使其类似常规X线片,分别用2种置钉方法进行置钉,A组利用出口闭孔位和入口髂骨位引导置钉,B组利用髋臼前柱轴位引导置钉,置钉完成后恢复图像为不透明状态,记录螺钉是否进入髋关节及与耻骨支的位置关系。结果55例110侧髋臼,4侧未能找到髋臼前柱轴位影像予以剔除,106侧髋臼前柱纳入研究。2组模型均无螺钉进入髋臼。A组螺钉置入优秀、良好、尚可率分别为59.4%、17.0%、23.6%,B组分别为59.4%、22.6%、17.9%,2组总体置钉质量差异无统计学意义(Z=-0.829,P=0.407)。A组女性骨盆置钉优秀、良好、尚可率分别为7.1%、21.4%、71.4%,B组分别为28.6%、21.4%、50.0%,B组置钉质量显著高于A组(Z=-3.000,P=0.003)。A组男性骨盆置钉优秀率78.2%,良好率15.4%,尚可率6.4%,B组分别为70.5%、23.1%、6.4%,2组差异无显著性(Z=-0.969,P=0.333)。结论髋臼前柱轴位可以作为引导置钉的一种手段,尤其适用于女性患者,对于男性患者,2种方法均可实现较好的置钉。     

Does use of a quadrilateral surface plate improve outcome in elderly acetabular fractures?

BackgroundAcetabular fractures in the elderly frequently involve segmental quadrilateral plate injury, yet no consensus exists on how to best control the femoral head medial displacement. Quadrilateral surface plates (QSP) were developed to help buttress these challenging fractures. The study aims to 1) Determine the prevalence of segmental quadrilateral plate fractures (SQPF) in elderly patients; and 2) Assess if utilization of a QSP is associated with improved acetabulum fracture reduction and outcome.MethodsThis was a retrospective study conducted at a level-1 trauma centre. . All patients over 60-years that sustained an acetabular fracture between 2007 and 2019 were reviewed. Pre-operative pelvic radiographs and CT imaging were reviewed for 96 patients, to assess for SQPF. From the 96 patients reviewed, over one third of patients (n = 40, 41.6%) sustained a SQPF. Patients that had an acute-THA (n = 7) were excluded as were patients that underwent an ORIF but did not have a QSP or an anterior column buttress plate (n = 3). The remaining 30 formed the study’s cohort. We assessed the ability to achieve and maintain reduction in this elderly population, and compared outcomes using traditional anterior column buttress plates (ilioingual or intra-pelvic approach) versus an intra-pelvic pre-contoured buttress suprapectineal plate (QSP). Outcome measures included: fracture reduction using the Matta classification (desirable: anatomical/imperfect and poor), re-operations, conversion to THA and Oxford Hip Score (OHS) (for the preserved hips).ResultsTen patients had an ORIF with utilization of a QSP (QSP-group), and 20 had an ORIF but did not have the QSP (non-QSP-group). There was no difference in patient demographics between groups. Fracture patterns were also similar (p = 0.6). Postoperative fracture reduction was desirable (anatomical/imperfect) in 17 patients and poor in 13. Improved ability to achieve a desirable reduction was seen in the QSP-group (p = 0.02). Conversion to THA was significantly lower in patients that had a desirable fracture reduction (appropriate: 3/17; poor: 7/13). No patients in the QSP-group have required a THA to-date, compared to 10/20 patients in the non-QSP-group (p = 0.01). The mean time to THA was 1.6 ± 2.1 year. There was no difference in OHS between the two groups (34.4 ± 10.3).ConclusionElderly acetabulum fractures have a high incidence (approaching 40%) of segmental QPF. Desirable (anatomical/imperfect) fracture reduction was associated with improved outcome. The use of a QSP was associated with improved ability to achieve an appropriate reduction. A QSP should be considered as they are both reliable and reproducible with a significantly improved fracture reduction and lower conversion to THA.     

Treatment results for acetabulum fractures using the modified Stoppa approach

Objectives

The aim of this study was to evaluate the clinical and radiological results of the surgical treatment of acetabular fractures using modified Stoppa approach.

偏心髋臼旋转截骨术的生物力学机制及初步临床疗效

 目的 探讨偏心髋臼旋转截骨术治疗髋关节发育不良的生物力学机制及其初步临床疗效。方法 取6具经福尔马林防腐处理的女性尸体骨盆标本,建立髋关节生物力学模型,在模型上模拟偏心髋臼旋转截骨术。对骨盆缓慢施加连续纵向压力0~500 N,测量术前和术后载荷100、200、300、400、500 N时的股骨头承重区应变值,计算应力值。2007年7月至2014年10月应用偏心髋臼旋转截骨术治疗髋关节发育不良25例（26髋）,男6例,女19例;年龄11~57岁,平均31岁。术后以Harris髋关节评分评价髋关节功能,摄骨盆正位X线片测量头臼指数、中心边缘角（center-edge-angle,CE角）及Sharp角。结果-随着脊柱纵向压力加大,股骨头上的应力值随之增加。偏心髋臼旋转截骨术后应力值在载荷超过300 N后由上升趋势转变为下降趋势,总体呈抛物线状。100~500 N载荷下偏心髋臼旋转截骨术后的应力值与术前差异均无统计学意义。临床随访18例（19髋）,随访率72%。随访时间7~85个月,平均40个月。Harris髋关节评分由术前（64.3±7.2）分提高至末次随访时（85.6±5.3）分;头臼指数平均增加36.5%、CE角平均增加33.1°、Sharp角平均减少12.3°,与术前比较差异均有统计学意义。结论-偏心髋臼旋转截骨术具有较好的矫正髋臼畸形的能力,可增大股骨头的髋臼覆盖面和降低承重区压力。     

髋臼方形区骨折的治疗及研究进展

髋臼是人体的重要承重关节,髋臼方形区是髋臼内侧壁的重要结构,具有特殊的形态结构和重要功能。方形区骨折是髋臼骨折中常遇到的骨折,由于髋臼方形区处于骨盆内侧,所以手术中的显露及复位十分困难。同时,髋臼方形区骨质较薄较难固定,外侧有髋关节,选择合适的内固定和对相关解剖的了解十分重要。方形区骨折后,股骨头容易向内侧移位,甚至突入盆腔造成嵌顿,其复位和治疗一直是骨科中的难点。对于方形区骨折不同的治疗方法,其疗效也不一。本文就方形区的解剖学特点、手术入路选择、内固定治疗方式、治疗要点和疗效等做一综述。     

Fate of bone grafting for acetabular defects in total hip replacement

Background:

The use of allografts and autografts in the management of acetabular defects have been reported with varying results. Trabecular metal is an expensive option in the management of these defects. This study aims to assess the fate and efficacy of bone grafting for acetabular bone defects in total hip arthroplasty.

Materials and Methods:

A total of 30 hips in 28 patients with acetabular deficiencies were treated with bone grafting and total hip replacement (THR). Seventeen hips had American Academy of Orthopedic Surgeons (AAOS) type 2 (Paprosky type 2c) deficiency and 13 had AAOS type 3 (Paprosky type 3a) defects of the acetabulum. Allografts were used in 15 patients and autografts were used in the remaining 13. Cemented total hip arthroplasty was done in 18 hips and uncemented THR in 12. Seven patients underwent the procedure for, acetabular erosion and symptoms following hemiarthroplasty (4 out of 7), or, acetabular revision for failure (3 out of 7) following total hip arthroplasty. Acetabular deficiencies in other patients were due to posttraumatic causes, advanced primary hip arthritis and second stage treatment of postinfective arthritis. A mesh was used in 6 hips and screws were used in 13 hips for graft fixation.

Results:

Patients were followed up clinicoradiologically for a period of 10 months to 4 years (mean 23.4 months). One patient required staged revision due to infection. Two patients had early asymptomatic cup migration. One patient had graft lysis and change in cup inclination with persistent pain. He was not keen on further intervention at last followup. Other patients were pain free at the time of followup with radiographs showing maintenance of graft and implant position.

Conclusion:

Bone grafting is a suitable option in the management of acetabular defects in total hip arthroplasty, especially in resource challenged countries.