髋臼骨折术后异位骨化的手术治疗

目的 探讨髋臼骨折术后严重异位骨化手术切除松解的疗效.方法 2005年10月至2007年4月共收治髋臼骨折术后严重异位骨化患者5例,均为男性,平均年龄34岁(22～45岁).髋臼骨折手术后平均14.2个月(3～30个月)发生异位骨化.原始手术入路分别为:Kocher-Langenbeck入路4例,前后联合入路1例.根据Brooker分型,Ⅳ级4例,Ⅲ级1例.5例患者术前患髋活动范围平均为8°.所有患者手术前后均接受一次放射治疗,剂量为7～8 Gy.所有患者均取KoeherLangenbeck入路,术中使用神经探测仪探查并保护坐骨神经.完全切除异位骨化的骨组织,1例患者因股骨头和髋臼发生融合而行全髋关节置换.所有患者术后即开始无痛下功能锻炼,口服吲哚美辛预防异位骨化发生.结果 所有患者均获随访,平均随访时间8个月(4～22个月),伤口均Ⅰ期愈合,最终复查时均无异位骨化复发,患髋总活动范围平均为160°.结论 对于髋臼骨折术后严重异位骨化而导致髋关节活动障碍的患者,在骨折愈合后尽早手术切除,并配合药物和放射治疗可获得满意疗效.     

Surgical dislocation of the femoral head for joint debridement and accurate reduction of fractures of the acetabulum

OBJECTIVES: To evaluate fracture reduction, femoral head viability, and outcome of selected acetabular fractures treated operatively using a modified Kocher-Langenbeck approach with a trochanteric flip osteotomy and surgical dislocation of the femoral head. DESIGN: Prospective. PATIENTS: Twelve patients predominantly with combined transverse and posterior wall fractures or multifragmentary posterior wall fractures. OUTCOME EVALUATION: Clinical and radiographic analysis after a minimum 2-year follow-up. METHODS: A single modified approach, including anterior ( = 8) or posterior ( = 4) surgical dislocation of the femoral head, was done in 12 patients for one or more of following reasons: intra-articular assessment of reduction in fractures with comminution, marginal impaction and involvement of the anterior column, removal of intra-articular fragments, and confirmation of extra-articular screw placement. RESULTS: At a mean follow-up of 35 months (24-48 months), the 12 patients presented with a good to excellent clinical result according to the D'Aubigné score. One patient developed postoperative osteoarthritic changes after an imperfect reduction. No heterotopic ossification interfering with hip function was found. None of the hip joints developed signs of avascular necrosis of the femoral head, even though seven patients sustained a posterior dislocation at time of the injury. CONCLUSION: This study indicates that this technique for surgical dislocation of the femoral head is safe and facilitates assessment of fracture reduction in selected acetabular fractures.     

Gluteus minimus necrotic muscle debridement diminishes heterotopic ossification after acetabular fracture fixation

OBJECTIVE: The aetiology and pathogenesis of heterotopic ossification (HO) are still obscure. We evaluated the impact of necrotic gluteus minimus muscle (GMM) debridement on the formation of HO after operative treatment of posterior wall (PW) and associated transverse-posterior wall acetabular fracture (Tr/PW) fixations utilizing a Kocher-Langenbeck surgical exposure. METHODS: Thirty-one consecutive patients with displaced PW or associated Tr/PW acetabular fracture-dislocations were operatively treated by a single surgeon using a Kocher-Langenbeck surgical exposure. Strict soft tissue technique was observed and self-retaining retractors were not used. Necrotic GMM was debrided in an attempt to diminish ectopic bone formation. RESULTS: Twenty-nine patients were available for post-operative clinical and radiographic evaluations. HO occurred in 12 patients. Significant HO (Brooker class III or IV) was noted in only three patients (10%). There were no complications associated with debridement of necrotic GMM. CONCLUSIONS: Necrotic GMM resection diminishes HO formation comparably to other reported series in which non-steroidal anti-inflammatory medications were used. Resection of the necrotic GMM from the zone of injury has proved to be an efficient and safe method of preventing significant HO in patients after operative fixation of PW and associated Tr/PW acetabular fractures treated through a Kocher-Langenbeck approach.     

Long-term results after acetabular fractures with respect to heterotopic ossifications

BACKGROUND: Arthrosis, necrosis of the femoral head and heterotopic ossification (HO) tend to decline the outcome of acetabular fractures despite of good fracture reduction. In this study functional outcome and degree of HO were analyzed due to fracture type and surgical approach. The aim of this study is to delineate wether minimization of soft tissue damage increases the functional outcome. PATIENTS AND METHODS: 55 patients with surgically treated acetabular fractures (mean age: 40.4 (20-81) years, male 43, female 12) where retrospectively evaluated with a mean follow-up of 7.7 (4.4-12.3) years. Fractures were classified according to the Orthopaedic Trauma Association (OTA), functional outcome was scored by D'Aubigné-Postel and the degree of HO was defined by Brooker's classification. RESULTS: Following the OTA the distribution of fractures was: A-24 (44 %), B-23 (42 %) and C-8 (15 %). Mean D'Aubigné Index (max. 18 points) was 15.2, distributed to fracture type: A-15.9, B-15.0 and C-13.6. 32 % of all heterotopic ossifications were classified as Brooker 0, 10 % as Brooker 1, 29 % as Brooker 2 and Brooker 3 each, whereas Brooker 4 ossifications were not observed. 2/3 of the severe ossifications were observed using extended approaches or in case of type C fractures. The iliofemoral approach showed the tendency of fewer ossifications compared to extended approaches. CONCLUSION: Decrease of soft tissue damage during acetabular surgery plays an important role to improve outcome. Due to the higher risk of wrong implant position and insufficient reduction using a soft tissue sparing approach, we recommend a CT scan postoperatively to evaluate reduction and osteosynthesis.     

Surgical treatment of displaced acetabular fractures - 72 cases followed for 10 (6-14) years

Seventy-two displaced acetabular fractures managed surgically were evaluated retrospectively. The follow-up period was 10 (6-14) yr. The commonest fractures were posterior wall (28) and both columns (10). The surgical approaches were Kocher-Langenbeck (47), ilioinguinal (19) and extended iliofemoral (6). No neural monitoring was used in operations and no preventive agents for heterotopic ossification or thromboembolism were used perioperatively. Reduction was rated congruent in 59 (81.9%) and noncongruent in 13 (18.1%). The early postoperative complications were 1 vascular injury, 1 iatrogenic sciatic nerve injury, 1 deep vein thrombosis and 2 wound infections. The late complications were heterotopic ossification in 20 patients, avascular necrosis of the femoral head in 4 and symptomatic arthritis in 10. Functional outcomes were rated as excellent in 31, good in 23, fair in 7 and poor in 11. Our results show that traditional management is effective enough for displaced acetabular fractures.     

内固定治疗移位髋臼骨折的疗效分析

目的 探讨内固定治疗移位髋臼骨折的疗效.方法 2004年7月至2009年4月共收治64例移位髋臼骨折患者,男40例,女24例;平均年龄47.6岁.按Letournel-Judet方法分型:后壁骨折16例,后柱骨折2例,前柱骨折2例,横行骨折8例,后柱伴后壁骨折8例,横行伴后壁骨折6例,T形骨折6例,前柱伴后壁横行骨折2例,双柱骨折14例.根据不同骨折类型,手术采用Kocher-Langenbeck(K-L)入路32例,髂腹股沟入路16例,前后联合入路(髂腹股沟切口+K-L入路)16例,复位后应用骨盆重建钢板、拉力螺钉内固定. 结果 平均手术时间为3 h,术中平均失血量为800mL.所有患者术后获8～40个月(平均18个月)随访.根据Matta影像学评分,患者伤后2周内手术者53例,其中解剖复位39例,满意复位10例,不满意复位4例,复位优良率为92.5%.伤后2～3周后手术者11例,其中解剖复位4例,满意复位5例,不满意复位2例,复位优良率为81.8%.临床疗效评定结果:优37例,良13例,可8例,差6例,优良率为78.1%.发生创伤性关节炎2例,异位骨化3例(Ⅱ～Ⅲ度),股骨头缺血性坏死1例. 结论 对于移位髋臼骨折,根据不同骨折类型采用不同开放复位策略、尽早选择合理的手术方法是提高疗效的关键.     

Open reduction and internal fixation of acetabular fractures: heterotopic ossification and other complications of treatment.

Open reduction and internal fixation was performed on 50 displaced acetabular fractures in 49 patients by nine different attending surgeons over a 10-year period. At an average follow-up of 38 months, poor results were noted clinically in 38% and radiographically in 40%. The incidence of short- and long-term complications was greater than in other studies. Particularly distressing was the 58% incidence of heterotopic ossification (HO). Twenty-four percent had grade III or IV; five hips were autofused and the remainder had 40-60% loss of motion. There was no correlation of HO with age, sex, fracture type, degree of comminution, associated femoral head fracture or dislocation, delay to surgery, or operative time. However, 26 of 28 patients who had a trochanteric osteotomy as part of the operative exposure developed HO. Other complications included wound infection (12%), avascular necrosis of the femoral head (10%), nerve palsy (8%), and deep vein thrombosis/pulmonary embolism (8%). The data suggest formulation of specific treatment protocols, an awareness of surgical risks, and that staff specialization may reduce complications and improve outcome. Avoiding a trochanteric osteotomy at surgery and using prophylactic postoperative irradiation or indomethacin are suggested to reduce HO.     

The Role of Surgical Hip Dislocation in the Treatment of Acetabular and Femoral Head Fractures

Abstract Background and Purpose: Surgical hip dislocation by trochanteric flip osteotomy facilitates access to acetabular and femoral head fractures. Furthermore, it allows evaluation of cartilage damage and vascularity of the femoral head. In this study the potential benefits of this procedure for improved fracture management and for prognostic assessment were investigated. Patients and Methods: From July 1997 to October 1999, 20 selected patients with displaced acetabular fractures (n = 12), femoral head fractures (n = 7), or combined injuries (n = 1) were included. Inclusion criteria for acetabular fractures were either displaced posterior wall fragments with cranial extension or complex acetabular fractures involving a displaced transverse fracture line. Open reduction and fixation of either complex acetabular fractures or femoral head fractures were carried out through Kocher-Langenbeck approach, trochanteric flip osteotomy, and complete surgical hip dislocation. Additionally, the extent of cartilage destruction and femoral head perfusion were assessed. Results: Anatomic reduction ( 1 mm displacement) of acetabular fractures was achieved in 69% of patients and good reduction ( 3 mm) in 31%. In patients with acetabular fractures, severe cartilage destruction of the acetabulum was found in 38% and of the femoral head in 15%, while patients with isolated femoral head fractures revealed severe cartilage damage of the femoral head in 57%. Arterial bleeding from the femoral head, tested by drilling, was observed in all patients. Secondary dislocation of the trochanteric osteotomy occurred in one patient and made refixation necessary. Patients were reexamined at least 2 years after intervention. 77% of patients with acetabular fractures and all patients with femoral head fractures showed good or excellent results after 32.6 ± 6.1 months according to the functional score of DAubigné & Postel. Conclusion: Surgical hip dislocation allows adequate reconstruction of complex acetabular and femoral head fractures and intraoperative evaluation of local cartilage damage and femoral head perfusion.     

可吸收螺钉治疗股骨头骨折伴髋关节后脱位

目的探讨应用可吸收螺钉治疗股骨头骨折伴髋关节后脱位的效果。方法髋后外侧入路手术治疗26例股骨头骨折伴髋关节后脱位患者,股骨头骨折均采用可吸收螺钉固定;Ⅲ型合并股骨颈骨折者采用钛质空心螺钉固定,Ⅳ型合并髋臼骨折者采用髋臼三维记忆内固定系统固定髋臼骨折。结果26例均获随访,时间15～48个月。按D′Aubigue-Postel评分法：优10例,良13例,中1例,差2例（1例股骨头缺血性坏死,1例股骨头缺血性坏死合并髋周异位骨化）。未出现可吸收螺钉断裂及异物反应现象,无深部感染及创伤性关节炎等并发症发生。结论股骨头骨折伴髋关节后脱位采用髋后外侧入路、可吸收螺钉及髋臼三维记忆内固定可获得理想的治疗效果。     

复杂性髋臼骨折合并同侧股骨颈骨折及多处骨折的治疗与对策

目的:探索复杂性髋臼骨折(complex acetabular fractures,CAF)合并同侧股骨颈骨折及多处骨折的治疗方法与对策。方法:2000年8月-2005年3月,收治复杂性髋臼骨折合并同侧股骨颈及多处骨折12例,男7例,女5例;年龄24～51岁,平均37.5岁,皆系高能量损伤。合并其他部位骨折23处,平均2.6处。采用改良髋臼入路,应用髋臼三维记忆内固定系统(ATMFS)、空心加压螺钉、Richard钉、交锁髓内钉、天鹅记忆接骨器(SMC)等固定骶髂关节分离、复杂性髋臼骨折、股骨颈、股骨干、胫骨干、肱骨、尺桡骨骨折。结果:术后随访6～31个月,平均13.5个月。12例复杂性髋臼骨折均获解剖复位并达骨性愈合;同侧股骨颈骨折也获解剖复位,10例达骨性愈合。术后3～7个月(平均4.6个月),髋关节功能达到健侧水平;1例出现股骨头缺血性坏死行关节置换;1例股骨头坏死合并异位骨化导致关节骨性融合。4例骶髂关节分离获解剖复位;其他23处骨折,均获骨愈合。根据髋关节功能评分标准:优3例,良6例,一般1例,差2例。结论:采用改良髋臼入路、应用髋臼三维记忆内固定系统固定髋臼骨折,同时固定股骨颈骨折及合并的多处骨折,配合术后早期的功能锻炼,可以使髋关节获得良好的功能。     

Acetabular fractures. Clinical outcome of surgical treatment

Sixty patients with acetabular fractures were treated surgically. All fractures were a result of high energy trauma, most with significant associated injuries. Fifty-three of the patients were followed up for at least 2 years. Clinical outcome was analyzed clinically using the Harris hip score and radiographically. In 41 (77.4%) of the patients, the surgical procedure was judged successful (Harris hip score greater than 80 points). Three factors were found to be statistically significant predictors of such an outcome: patient age younger than 40 years; simple fractures based on the classification of Letournel and Judet; and absence of damage to the femoral head. Possible influential factors that were not found to be statistically significant in this population included additional injuries, immediate complications, quality of reduction, heterotopic ossification, ipsilateral femoral fracture, and sciatic nerve damage. Open reduction and internal fixation of the displaced acetabular fracture, although a demanding procedure, can result in a satisfactory clinical outcome given a consistent approach with a dedicated team.     

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.     

单纯改良后路切口后柱重建板前柱空心加压钉内固定治疗髋臼双柱骨折

目的探讨单纯改良后路切口后柱重建板前柱空心加压钉内固定治疗髋臼双柱骨折的临床疗效。方法对12例髋臼双柱骨折患者,均采用单纯改良后路切口后柱重建板前柱空心加压钉内固定治疗。结果 12例平均随访18(10~36)个月。骨折复位和关节功能按Matta标准进行评价:解剖复位10例,满意复位2例;关节功能优10例,良2例。术前合并坐骨神经损伤的2例均完全恢复,未出现股骨头坏死、创伤性关节炎;3例出现轻微异位骨化。结论单纯改良后路切口后柱重建板前柱空心加压钉内固定治疗髋臼双柱骨折疗效优良,创伤较联合切口小。     

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。     

Femoral head injuries: Which treatment strategy can be recommended?

Despite different operative and non-operative treatment regimens, the outcome after femoral head fractures has changed little over the past decades. The initial trauma itself as well as secondary changes such as posttraumatic osteoarthritis, avascular necrosis or heterotopic ossification is often responsible for severe loss of function of the afflicted hip joint. Anatomic reduction of all fracture fragments seems to be a major influencing factor in determining the outcome quality. Eight years ago we inaugurated a new surgical approach for better access and visualisation for the treatment of femoral head fractures, using the "trochanteric flip" (digastric) osteotomy. Thus inspection of the entire hip joint and accurate fragment reduction under direct visual control are possible. After good initial experiences with this operative procedure we changed our standard treatment regimen to this approach in an attempt to achieve the most accurate anatomic reduction of the femoral head in every affected patient. Between 1998 and 2006 we operated on 12 patients with femoral head fractures associated with posterior hip dislocation, using the new surgical approach. Patients were followed for 2-96 months and outcome was documented with the Merle d'Aubigne and Postel score as well as the Thompson and Epstein score. The posttraumatic formation of heterotopic bone was documented with the Brooker score. Retrospective analysis of these 12 patients showed good or excellent results in 10 patients (83.3%). The two patients with poor outcome developed an avascular necrosis of the femoral head and underwent total hip arthroplasty. Periarticular heterotopic ossification was seen in five patients. In four patients this caused a significantly reduced range of motion and was therefore considered as a posttraumatic complication. The two patients with the most severe heterotopic bone formation (Brooker III and IV) had initially sustained multiple injuries including brain injury. Comparing our results with earlier published series including our own before changing the treatment protocol, the data suggest a favorable outcome in patients with trochanteric flip (digastric) osteotomy for the treatment of femoral head fractures.     

Surgically treated acetabular fractures via a single posterior approach with a follow-up of 2-10 years

The results of operative treatment of acetabular fractures as well as its role in the occurrence of post-traumatic osteoarthritis (OA) are presented. From 1990 to 2000, 50 patients (32 male and 18 female), aging from 18 to 71 years (mean: 37.8 years) underwent an open reduction and internal fixation of their displaced acetabular fracture. They were reviewed at a mean of 5.8 years (2-10 years). A typical Kocher-Langebeck approach was selected in all the patients and in 14 cases a trochanteric osteotomy was added to enhance exposure. The fractures were classified according to the Letournel-Judet classification. The aim of the operation was the anatomic reduction and stable fixation of the fracture with less than 2mm residual displacement, which was achieved in 39 of 50 cases. Post-operative protocol included low-molecular-weight heparin (LWMH) as antithrombotic prophylaxis and 75 mg of indomethacin against heterotopic ossification (HO). At the final follow-up, the patients were evaluated clinically according to D'Aubigne-Postel scoring system and radiologically based on the criteria described by Matta. The clinical results were excellent in 20 patients, good in 18, fair in 5 and poor in 7. The radiological results were excellent in 20 patients, good in 16, fair in 5 and poor in 9. Early post-operative complications included 2 peroneal nerve palsies and 3 wound infections and late complications included 1 patient with avascular necrosis of the femoral head (ANFH), 5 patients with grade III and IV heterotopic ossification according to Brooker classification and 12 patients with post-traumatic osteoarthritis of the hip joint. Although the rates of early and late complications were relatively common, the functional outcome was satisfactory in most of the cases and comparable with other larger series. We concluded that operative treatment of most of the displaced acetabular fractures--except of isolated anterior column or/and anterior wall - could be attempted via a single posterior approach, leading to good to excellent results in the majority of the cases.     

Surgical approach of T-type acetabular fractures does not affect quality of reduction on postoperative CT or the likelihood of postoperative complications

IntroductionT-type acetabular fractures are rare but challenging injuries. The purpose of this study was to evaluate for associations between chosen surgical approach for T-type acetabular fracture fixation, reduction quality, and complications.MethodsRetrospective, single institution study of T-type acetabular fractures who underwent surgical fixation. Surgical interventions included open reduction and internal fixation (ORIF) through an anterior intrapelvic approach (AIP) (modified Rives-Stoppa) and/or posterior (Kocher-Langenbeck [KL]), or percutaneous screw fixation. The primary outcome was reduction quality on routine postoperative computed tomography (CT) scan and postoperative complications.ResultsDuring the study period (March 2016 – October 2022), 22 patients presented with T-type acetabular fractures. Surgical approaches included AIP [31.8% (7/22)], percutaneous [27.3% (6/22)], AIP+KL [22.7% (5/22)], and KL [18.2% (4/22)]. On CT scans, 9.0% (2/22) had anatomic reductions, 27.2% (6/22) had fair reductions, and 63.6% (14/22) had poor reductions based on Matta Reduction Criteria. There was no observed difference in reduction quality between surgical approaches. Poor reductions (> 3 mm) were not associated with surgical approach, fracture classification, unstable pelvic ring injuries, posterior wall fractures, T-stem component, transverse component, preoperative articular displacement, preoperative femoral head protrusion, or surgeon experience. Complications occurred in 50.0% (11/22) of patients. No observed difference in complication rates was noted between the surgical approaches.ConclusionT-type acetabular fractures are challenging injuries with few patients achieving anatomic reduction on postoperative CT scans and half of patients developing complications.     

The impact of heterotopic ossification prophylaxis after surgical fixation of acetabular fractures: national treatment patterns and related outcomes

BackgroundHeterotopic ossification (HO) is a common complication after surgical fixation of acetabular fractures. Numerous strategies have been employed to prevent HO formation, but results are mixed and optimal treatment strategy remains controversial. The purpose of the study was to describe current national heterotopic ossification (HO) prophylaxis patterns among academic trauma centers, determine the association between prophylaxis type and radiographic HO, and identify if heterogeneity in treatment effects exist based on outcome risk strata.MethodsWe used data from a subset of participants enrolled in the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. We included only patients with closed AO-type 62 acetabular fractures that were surgically treated via a posterior (Kocher-Langenbeck), combined anterior and posterior, or extensile exposure. PREPARE Clinical Trial Registration Number: NCT03523962 Patient population This cohort study was nested within the Pragmatic Randomized Trial Evaluating Pre-Operative Alcohol Skin Solutions in Fractured Extremities (PREPARE) trial. The PREPARE trial is a multicenter cluster-randomized crossover trial evaluating the effectiveness of two alcohol-based pre-operative antiseptic skin solutions. All PREPARE trial clinical centers that enrolled at least one patient with a closed AO-type 62 acetabular fracture were invited to participate in the nested study.Results277 patients from 20 level 1 and level 2 trauma centers in the U.S. and Canada were included in this study. 32 patients (12%) received indomethacin prophylaxis, 100 patients (36%) received XRT prophylaxis, and 145 patients (52%) received no prophylaxis. Administration of XRT was associated with a 68% reduction in the adjusted odds of overall HO (OR 0.32, 95% CI, 0.14 – 0.69, p = 0.005). The overall severe HO (Brooker classes III or IV) rate was 8% for the entire cohort; XRT reduced the rate of severe HO in high-risk patients only (p=0.03).ConclusionHO prophylaxis patterns after surgical fixation of acetabular fractures have changed dramatically over the last two decades. Most centers included in this study did not administer HO prophylaxis. XRT was associated with a marked reduction in the rate of overall HO and the rate of severe HO in high-risk patients. Randomized trials are needed to fully elucidate the potential benefit of XRT. PREPARE Clinical Trial Registration Number: NCT03523962.     

Extensile triradiate approach in the management of combined acetabular fractures

Introduction We investigated the results of combined acetabular fractures that were treated through the extensile triradiate approach in this study.Materials and methods Between January 1996 and January 2001, a total of 48 acetabular fractures were treated surgically (mainly combined fractures). Twenty-five of the combined acetabular fractures that were surgically treated through the triradiate approach with a minimum of 2 years follow-up were included in the study. The mean patient age was 42 years. There were 8 both-column, 6 T-shaped, 2 anterior column/posterior hemitransverse, 4 transverse with comminuted roof area, 4 posterior wall with comminuted roof area, and 1 posterior column/posterior wall fracture. Associated injuries included two full-thickness chondral injuries of the head, one Pipkin type II fracture, five posterior and one central dislocation of the ipsilateral femoral head, and acetabular marginal impaction in four hips. The average follow-up was 44 months.Results The postoperative reduction was graded as excellent in 68% and imperfect in 8% of the patients. The hips were evaluated functionally according to the modified Postel-DAubigne score and rated as excellent in 7 patients (28%), good in 13 patients (52%), fair in 3 patients (12%) and poor in 2 patients (8%). There were 2 deep infections (8%), 2 avascular necroses of the head (8%), and 4 (16%) non-disabling heterotopic ossifications.Conclusion Our results support the idea that open reduction with the triradiate approach provides good visualization and direct reduction of combined acetabular fractures. Its learning curve for combined fractures is shorter than that for single approaches and provides at least the same rate of anatomical reduction. It should be in the armamentarium of a surgeon dealing with such fractures.