Preoperative angiographic assessment of the superior gluteal artery in acetabular fractures requiring extensile surgical exposures

Extensile exposures used for complex acetabular fracture reconstructive surgery often create abductor muscle flaps pedicled on the superior gluteal artery. Preoperative arteriograms were performed in eight patients who required extended iliofemoral or modified extended iliofemoral surgical approaches to assess the integrity of the superior gluteal artery. All of the patients had complex acetabular fractures, with significant displacement of the fracture into the sciatic notch. Abnormalities of the superior gluteal artery were found in three patients. One patient demonstrated a complete laceration of the superior gluteal artery, one patient a complete arterial occlusion, and one patient had a compressive entrapment of the artery at the fracture site. Preoperative angiographic evaluation of the superior gluteal artery is suggested for patients with acetabular fractures that are displaced into the sciatic notch and who will require an extensile surgical exposure creating an abductor muscle flap supplied by the superior gluteal artery.     

A modified extensile exposure for the treatment of complex or malunited acetabular fractures

A modification of the extended iliofemoral incision of Letournel and Judet facilitates the operative exposure of T-type, complex transverse, and both-column acetabular fractures and malunions. The modification includes the utilization of a T-shaped skin incision with large flaps, and osteotomies of the iliac crest, greater trochanter, and anterior superior iliac spine. The iliotibial band is transected and the abductor muscle mass is rotated posteriorly, hinged on the superior gluteal neurovascular bundle. Twenty patients had open reduction and internal fixation of a complex acetabular fracture using this surgical approach. Excellent surgical exposure allowed good or excellent reduction of the acetabulum in all patients. No flap necrosis developed, and all fractures healed. One non-union of a trochanteric osteotomy needed revision. This approach provides increased exposure of the posterior column and visualization of the entire surface of the joint and it allows fixation of the fracture from both sides of the iliac wing. The T-shaped skin incision allows utilization of a standard posterior approach with conversion to the extensile exposure if necessary. Options for late reconstruction are not compromised. Lagscrew fixation of the osteotomies allows aggressive rehabilitation of the joint.     

Rekonstruktion komplexer Azetabulum-frakturen über den erweiterten Kocher-Langenbeck-Zugang (modifizierter Maryland-Approach)

Summary Goal of Surgery Approach to the essential bony parts of the pelvis which can be adapted to the fracture pattern and which causes minimal soft tissue damage. It allows exposure of the posterior and anterior columns and the roof of the acetabulum. Indications Complex acetabular fractures such as 2-column fractures, T-fractures, displaced transverse fractures with posterior rim fragment, fractures of 1 column. Contraindications Fractures which can be approached through smaller incisions, preexisting lesions of the superior gluteal artery, arterial occlusive diseases, particularly of the pelvis. Preoperative Work Up Radiographs of the pelvis in anterior-posterior and two oblique news. Special radiographs and CT. Positioning and Anaesthesia Lateral decubitus with free draping of the leg. Endotracheal anaesthesia. Cell saver optional. Surgical Technique T-shaped skin incision and gradual extension of the Kocher-Langenbeck approach depending on the fracture pattern. First extensile step: Transverse division of the fascia lata and osteotomy of the greater trochanter. Second extensile step: Osteotomy of part of the iliac crest and exposure of the outer and inner cortex of the iliac wing. Postoperative Management Operated leg rests in a foam padded splint. Careful wound drainage, routine low dose radiation or indomethacin to prevent heterotopic ossification. CPM starting the 2nd postoperative day, mobilization starting the 2nd or 3rd day with partial weight bearing of 15 kg. Full weight bearing depends on fracture type and consolidation. Possible Complications Delayed wound healing with risk of infection. Injury to the superior gluteal artery with danger of necrosis of the abductor muscles. Injury through stretching of the sciatic nerve. Injury of the lateral femorocutaneous nerve. Results Seven patients with complex acetabular fractures were operated between June 1993 and January 1994. Use of the 1st extensile step was sufficient in 3 patients and 3 times all 4 steps were used. Postoperative necrosis of fatty tissue necessitated 2 revisions. All fractures consolidated. During the follow-up examination 1 case of heterotopic ossification was seen (Brooker grade II). Using the classification of Merle D'Aubigné we had 1 excellent, very good, 2 good and 1 satisfactory result.

     

复杂髋臼骨折后侧手术入路损伤臀上动脉的处理

目的 探讨复杂髋臼骨折后侧手术入路损伤臀上动脉的原因、诊断手段和治疗方法。方法 回顾性分析1998年6月～2004年9月收治的6例复杂髋臼骨折后侧手术入路致臀上动脉损伤的患者。结果 4例转入病例中2例为臀上动脉浅支撕裂，1例为臀上动脉出梨状肌上孔处损伤，1例未发现搏动性出血点。2例缝扎损伤的臀上动脉浅支，1例腹膜外入路结扎臀上动脉。笔者手术组损伤的2例采用腹膜外入路，结扎臀上动脉。结论 臀上动脉浅支的损伤容易被忽视，术后臀部血肿是其表现。臀上动脉出梨状肌上孔处的损伤可以导致致命的大出血，必须紧急处理，一般经腹膜外入路结扎臀上动脉。     

Unusual complications in traumatic dislocation of the hip in children

Four cases of unusual complications following traumatic dislocation of the hip in children are presented along with a review of the literature. All patients presented with posterior or posterosuperior dislocations, and two had associated pelvic or acetabular fractures. One patient had a small, shallow acetabulum caused by premature closure of the triradiate cartilage and damage to the superior gluteal nerve. The combination of triradiate epiphyseal closure and abductor muscle weakness secondary to superior gluteal nerve damage contributed to subsequent femoral head subluxation. One patient presented with a previously unrecognized fracture dislocation. Two patients presented with recurrent dislocations, one with a posterior capsular defect indicated by arthrography. The patient with this defect was treated with surgical repair, whereas the other patient was treated nonsurgically.     

改良髂股延长入路治疗复杂髋臼骨折

目的 探讨改良髂股延长入路在复杂髋臼骨折切开复位内固定中的作用。方法 1999年6月～2005年12月，36例髋臼骨折按Letournel-Judute分型，其中前壁＋横形9例，T形5例，横形＋后壁11例，双柱6例，前壁＋前柱＋后壁＋后柱5例；合并股骨头脱位13例；病程1～3周。均采用改良髂股延长入路行切开复位内固定治疗。结果 术后均获7～46个月临床随访，平均23．8个月。X线片骨折复位按Matta复位标准，其中解剖复位24例，良好复位8例，差复位4例。根据改良的d’Aubigne和Postel的髋臼骨折临床评分标准获优22例，良好9例，较差5例。结论 改良髂股延长入路在复杂髋臼骨折切开复位时，能同时显露髋臼的前壁、前柱和后壁、后柱，同时采用骨与骨的方式重建外展肌群的起止点。使患肢能够早期活动。有利于髋臼的磨造和髋关节功能的恢复。     

Traumatic iliofemoral arterial injury: an association with high anterior acetabular fractures

Two patients with documented anteroposterior compression injuries to the pelvis sustained concomitant injury to the iliofemoral artery and fracture of the acetabulum involving the high anterior column (the portion of the ilium forming the anterior component of the acetabulum). In a series of 800 major pelvic fractures similar arterial injuries have not occurred in association with other documented mechanisms. A high index of suspicion for iliofemoral artery injuries should be held by the clinician treating patients with acetabular fractures of the high anterior column sustained from anteroposterior compressive forces.     

真骨盆缘完整的髋臼高位前柱骨折的治疗

 目的 探讨真骨盆缘完整的髋臼高位前柱骨折的治疗方法。方法 2006年 1月至 2010 年 1月, 治疗 12例真骨盆缘完整的髋臼高位前柱骨折, 男 8例, 女 4例;年龄 29~46岁, 平均 35.6岁;挤 压伤 7例, 压砸伤 3例, 高处坠落伤 2例。术前常规摄骨盆正位、闭孔斜位、髂骨斜位 X线片及 CT扫描。 根据是否合并后壁骨折及髂骨骨折块的完整性分为单纯型 5例, 合并后壁型 6例, 粉碎型 1例。 5例单纯型及 2例合并较小的无移位后壁型骨折者采用髂股入路行髂嵴支持钢板加髂骨前缘拉力螺钉固定; 4例合并明显移位的后壁型骨折者采用前后联合入路行拉力螺钉、支持钢板固定;1例粉碎型骨折采用 扩展髂股入路行钢板螺钉固定。结果 12例患者均获得随访, 随访时间 14~37个月, 平均 26.7个月。术后按 Matta影像学评定标准, 优 8例, 良 3例, 差 1;优良率为 92%。无一例发生骨折不愈合及内固定断 裂。末次随访按 Matta改良的 Merled爷Aubigne和 Postel功能评分系统评分为 11~18分, 平均 16.8分;优 7例, 良 4例, 差 1例;优良率为 92%。 1例发生异位骨化和轻度的创伤性关节炎。结论 选择合理的手 术入路、解剖复位、坚强固定是治疗真骨盆缘完整的髋臼高位前柱骨折的关键。     

Treatment of complex acetabular fractures through a modified extended iliofemoral approach

OBJECTIVES: To assess the rate of anatomic reconstructions as well as approach-related morbidity and complications in the treatment of complex acetabular fractures through a modified extended iliofemoral approach. DESIGN: Prospective clinical study. SETTING: Level I trauma center, University Hospital. PATIENTS: Inclusion criteria were as follows: (a) associated acetabular fracture or transverse fracture with comminuted roof area stated as not sufficiently reconstructable through a single approach, and (b) age between sixteen and sixty-five years. A total of forty-nine patients with fifty complex acetabular fractures could be included out of the series of ninety-six acetabular fractures treated operatively from August 1992 to February 1996. Open reduction and internal fixation of complex acetabular fractures through the modified extended iliofemoral approach were performed. RESULTS: In 80 percent of the fifty fractures the reduction was anatomic with a remaining displacement of less than or equal to one millimeter, in eight cases there was a persistent displacement of two millimeters, and two fractures had a poor result with a three-millimeter displacement. Complications included 8 percent loss of reduction, 13 percent heterotopic ossification grade 3, and 4 percent avascular femoral head necrosis. At the two-year follow-up there were 74 percent good or excellent radiographic and clinical results. Two patients had already been reoperated with total hip replacement, and the two patients with femoral head necrosis are currently scheduled for arthroplasty. CONCLUSIONS: The modified extended iliofemoral approach proved to be appropriate to achieve anatomic reduction in complex acetabular fractures. The high rate of approach-related morbidity has to be considered carefully and may lead to a decreased incidence of extended approaches.     

Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the acetabulum

There remains uncertainty about the most effective surgical approach in the treatment of complex fractures of the acetabulum. We have reviewed the experience of a single surgeon using the extended iliofemoral approach, as described by Letournel.A review of the database of such fractures identified 106 patients operated on using this approach with a minimum follow-up of two years. All data were collected prospectively. The fractures involved both columns in 64 (60%). Operation was undertaken in less than 21 days after injury in 71 patients (67%) and in 35 (33%) the procedure was carried out later than this. The reduction of the fracture was measured on plain radiographs taken after operation and defined as anatomical (0 to 1 mm of displacement); imperfect (2 to 3 mm) or poor (> 3 mm). The functional outcome was measured by the modified Merle d'Aubigné and Postel score. The mean follow-up was for 6.3 years (2 to 17).All patients achieved union of the fractures. The reduction was graded as anatomical in 76 (72%) of the patients, imperfect in 23 (22%), and poor in six (6%). The mean Merle d'Aubigné and Postel score was 15 (5 to 18) with 68 patients (64%) showing good or excellent and 38 (36%) fair or poor results. Function correlated significantly with the accuracy of the reduction (p < 0.009). Significant heterotopic ossification developed in 32 patients (30%) and was associated with a worse mean Merle d'Aubigné and Postel score of 13.7.The extended iliofemoral approach can be performed safely in selected complex acetabular fractures with an acceptable clinical outcome and rate of complications. Effective prophylaxis against heterotopic ossification should be strongly considered.     

Screw fixation of acetabular fractures

Between 1992 and 1995, 50 patients with 51 acetabular fractures underwent internal fixation using 3.5 mm cortical screws. There were 21 simple and 30 associated fracture types, as described by Letournel. Most of the patients had sustained multiple injuries with an average injury severity score (ISS) of 20 points. The modified extended iliofemoral approach was used in 32 cases, the Kocher Langenbeck approach in 9 cases, the ilioinguinal approach in 7 cases, the extended iliofemoral in 2 cases and the Kocher-Langenbeck approach combined with an ilioinguinal approach in a second stage procedure in 1. Anatomical reduction could be achieved with persistent displacement of no more than 1 mm in 40 fractures. Implant failure with loss of reduction occurred in 3 patients who underwent a revision procedure. At 2 year follow-up, 38 out of 44 of the patients had excellent or good clinical and radiological results. In acetabular fractures with sufficiently large fragments, screw fixation with 3.5 mm cortical screws proved satisfactory. In very comminuted fractures or where there is poor patient compliance an additional buttress plate should be used.     

The anatomy and function of the gluteus minimus muscle

In order to investigate the functional anatomy of gluteus minimus we dissected 16 hips in fresh cadavers. The muscle originates from the external aspect of the ilium, between the anterior and inferior gluteal lines, and also at the sciatic notch from the inside of the pelvis where it protects the superior gluteal nerve and artery. It inserts anterosuperiorly into the capsule of the hip and continues to its main insertion on the greater trochanter. Based on these anatomical findings, a model was developed using plastic bones. A study of its mechanics showed that gluteus minimus acts as a flexor, an abductor and an internal or external rotator, depending on the position of the femur and which part of the muscle is active. It follows that one of its functions is to stabilise the head of the femur in the acetabulum by tightening the capsule and applying pressure on the head. Careful preservation or reattachment of the tendon of gluteus minimus during surgery on the hip is strongly recommended.     

Fractures of the acetabulum. Early results of a prospective study

One hundred two patients with 105 displaced fractures of the acetabulum were treated for fractures involving at least one column of the acetabulum and displaced at least 5 mm (rim fractures were excluded). The patients were primarily young adults with multiple injuries secondary to motor-vehicle-associated trauma. Fractures were classified according to the classification of Letournel. The most common fractures were the complex associated types with 44 complete both column, 19 T-shaped, and 18 associated transverse and posterior wall. Seventeen fractures were treated closed, and 88 were treated operatively. Closed treatment with skeletal traction was undertaken if roof arc measurements demonstrated a satisfactory remaining acetabular dome following fracture and in some cases of apparent congruence following complete both column fractures. Fractures not meeting these criteria were operated upon through the Kocher-Langenbeck, extended iliofemoral, or ilioinguinal approach. Ninety percent of the operations produced a satisfactory reduction of the fracture (3 mm or less displacement). A follow-up study longer than one year was obtained for 50 fractures. Clinical results were 80% satisfactory overall. Operative complications included 3% infection, 5% nerve palsy, and 7% significant ectopic bone. Operative treatment can produce satisfactory fracture reductions and clinical results with an acceptably low complication rate.     

直接前方入路联合直接后方入路治疗PipkinⅣ型股骨头骨折

目的探讨直接前方入路(direct anterior approach,DAA)联合直接后方入路(direct posterior approach,DPA)治疗PipkinⅣ型股骨头骨折的疗效。方法回顾性分析2016年1月至2019年4月采用DAA联合DPA入路治疗18例PipkinⅣ型股骨头骨折患者资料,男13例,女5例;年龄19~56岁,平均43.2岁;车祸伤15例,高处坠落伤3例;13例股骨头骨折线位于股骨头凹下方,5例骨折线位于股骨头凹上方;髋臼骨折按Letournel-Judet分型:后壁骨折14例,后柱伴后壁骨折2例,横断伴后壁骨折2例。采用DAA入路处理股骨头骨折,采用DPA入路处理髋臼骨折。术后行骨盆X线及CT检查,评价骨折复位、愈合情况及股骨头坏死、坐骨神经损伤、臀上血管神经损伤、异位骨化等情况;按照Matta影像学标准评价髋臼复位质量;采用Thompson-Epstein评分系统评价髋关节功能。结果18例患者手术时间75~205 min,平均133 min;术中出血240~600 ml,平均371 ml。所有患者手术切口一期愈合。18例患者均获得随访,随访时间6~36个月,平均15.7个月;骨折均愈合,愈合时间10~14周。3例患者伤后出现坐骨神经损伤症状,均于术后6~12周恢复。股骨头骨折均获得复位,Matta影像学标准示髋臼解剖复位13例,满意复位3例,不满意复位2例,总体满意率88.9%(16/18)。术后2例患者发生异位骨化,均为BrookerⅠ级;无一例发生医源性血管损伤、股骨头缺血性坏死、感染、内固定物断裂等并发症。末次随访,根据Thompson-Epstein评价系统评价髋关节功能,其中优7例,良8例,可2例,差1例。结论DAA联合DPA入路治疗PipkinⅣ型股骨头骨折手术创伤相对较小,术中能直视下复位、固定股骨头及髋臼后部骨折,可有效保护旋股内侧动脉、坐骨神经、股外侧皮神经等重要结构,降低股骨头缺血性坏死、异位骨化等并发症的发生,术后临床疗效满意。     

Superior gluteal artery laceration, a complication of iliac bone graft surgery.

In the 2 cases cited, laceration of the superior gluteal artery occurred when removing bone from the posterior ilium. A review of the anatomy shows how the superior gluteal artery, as it exists the sciatic notch, can be compressed locally and exposed for clipping or ligation. The internal iliac artery can be occluded by embolization of a Fogerty catheter. The bony origin of the gluteus maximus is a good landmark to help avoid entering the sciatic notch and a special retractor provides the necessary exposure.     

Surgical approaches, choice of approach and surgical techniques for internal stabilization of acetabulum fractures]

The choice of surgical approach to fractures of the acetabulum is determined by the type of fracture. The most popular approaches are the Kocher-Langenbeck, the ilio-inguinal and the extended iliofemoral. The techniques of reduction and internal fixation using special instruments and implants are demonstrated.     

Intraoperative electromyography of the superior gluteal nerve during lateral approach to the hip for arthroplasty: a prospective study of 12 patients

The purpose of this study was to evaluate the incidence of intraoperative superior gluteal nerve irritation and to identify specific surgical maneuvers that may harm the nerve. Continuous intraoperative electromyography (EMG) monitoring of the superior gluteal nerve-innervated muscles (gluteus medius and tensor fascia lata muscles) was performed in 12 patients undergoing total hip arthroplasty. A modified lateral approach was used, including a partial anterior osteotomy of the greater trochanter with splitting of the gluteus medius and vastus lateralis muscles. All patients had a clinical follow-up examination 1 year postoperatively to evaluate abductor muscle function. Irritation of the nerve occurred first during splitting of the gluteus medius muscle, then with increased gluteus medius retraction for exposure of the acetabulum, and finally during positioning of the leg for preparation of the femur. The detected EMG alterations were important because they were found in a single patient with persistent abductor muscle weakness.     

A new type of acetabular fracture: "true" posterosuperior fracture, a case report

We report a new variety of acetabular fracture. This posterosuperior fracture affected the acetabular roof and the iliac wing as other superior fractures and presented a supplementary fracture line disjoining the major part of the posterior wall. Two our knowledge, in a series of 940 fractures of the acetabulum, Letournel alone described two cases of superior fractures involving the roof with a slightly anterior fracture line in the iliac wing but with an intact posterior wall in both cases. The patient was treated by osteosynthesis via the iliofemoral approach described by Judet-Letournel. This approach was warranted to achieve simultaneous exposure of both columns and the posterior wall which was separated from the proximal fragment by a secondary fracture line. At six months, the functional result was considered good as assessed by the Postel-Merle-d'Aubigné score. This case widens the Letournel classification and emphasizes the importance of computed tomography to evaluate, in superior fractures of the acetabulum, the volume of the posterior wall fragment and its continuity with the cranial portion of the acetabulum and the iliac wing. For fixation, the surgical approach must be chosen individually according to the position of the fracture lines visualized on the preoperative computed tomography.