Modified Kocher-Langenbeck approach in combined surgical exposures for acetabular fractures management

Background:

Displaced fractures of the acetabulum are best treated with anatomical reduction and rigid internal fixation. Adequate visualization of some acetabular fracture types may necessitate extensile or combined anterior and posterior approaches. Simultaneous anterior iliofemoral and posterior Kocher-Langenbeck (K-L) exposures with two surgical teams have also been described. To assess whether modified Kocher-Langenbeck (K-L) approach can substitute standard K-L approach in the management of elementary acetabular fractures other than the anterior wall and anterior column fractures and complement anterior surgical approaches in the management of complex acetabular fractures.

Materials and Methods:

20 patients with transverse and associated acetabular fractures requiring posterior exposure were included in this prospective study. In 9 cases (7 transverse, 1 transverse with posterior wall, and 1 posterior column with posterior wall), stabilization was done through modified K-L approach. In 11 cases (3 transverse and 8 associated fractures), initial stabilization through iliofemoral approach was followed by modified K-L approach.

Results:

The average operative time was 183 min for combined approach and 84 min for modified K-L approach. The postoperative reduction was anatomical in 17 patients and imperfect in 3 patients. The radiological outcome was excellent in 15, good in 4, and poor in one patient. The clinical outcome was excellent in 15, good in 3 and fair and poor in 1 each according to modified Merle d’Aubigne and Postel scoring system.

Conclusion:

We believe that modified K-L approach may be a good alternative for the standard K-L approach in the management of elementary fractures and associated fractures of the acetabulum when combined with an anterior surgical approach. It makes the procedure less invasive, shortens the operative time, minimizes blood loss and overcomes the exhaustion and fatigue of the surgical team.     

扩展型髂股切口手术治疗复合型髋臼骨折

目的探讨扩展型的髂股切口的优缺点和手术方法治疗复杂髋臼骨折的疗效。方法回顾性总结了2002年至2005年收治的资料完整的手术治疗髋臼骨折26例．按照Letournel—Judet分型：横行伴后壁骨折2例．T型骨折8例，前方伴后方半横行骨折3例和完全双柱骨折13例，均采用扩展型的髂股切口手术治疗，根据不同骨折类型采用重建钢板和拉力螺钉固定。结果全部患者均得以随访，平均随访14个月．复位情况按Matta评分标准，解剖复位20例，满意复位4例，不满意复位2例。髋关节功能参照Matta评分系统进行评估，优21例，良2例，一般2例，差1例。结论手术治疗是复杂髋臼骨折的有效治疗方法，扩展型髂股人路对复杂髋臼骨折手术治疗是一个良好的选择。     

对99例髋臼骨折内固定治疗的分析

从1972年11月到1994年3月,401例髋臼骨折病人中的99例经手术治疗并获随访,包括30例双柱骨折,13例横骨折伴后壁骨折,9例后壁骨折,9例后柱骨折,9例前往骨折伴前壁骨折,13例T形骨折和16例横骨折.平均随访时间为7年(2～14).外科手术入路的选择,后入路53次,髂腹股沟入路23次,延长的髂股骨入路11次,放射状入路9次和结合性入路6次.复位情况用X线平片来评判,解剖复位的有59例(59.6%),接近解剖复位(<2mm的错位)的有19例(19.2%).总结果用Harris Hip Score来评判,优秀的有53例(53.5%),良好的有25例(25.3%),一般的有14例(14.1%),差的有7例(7%).并发症中,有10例(53%)为感染,7例(37%)为静脉栓塞.这些结果表明,对于错位严重的髋臼骨折,切开复位内固定是一种可以选择的治疗方法.     

The Stoppa approach for acetabular fracture

Objective

Acetabular fractures pose a great surgical challenge for orthopedic trauma surgeons. We believe that the Stoppa approach with an iliac window extension, previously described as a modified Stoppa approach is adequate for the majority of acetabular fractures excluding those with predominant posterior wall involvement. In this paper we will present our experience in using the Stoppa approach, its indications, preparations, the detailed surgical approach, complications and the different tips used in this relatively modern approach.

Indications

All simple and combined fracture types that involve the anterior column of the pelvis including the quadrilateral plate.

Contraindications

Posterior wall or extensive posterior column involvement. Transverse and T-fractures with mainly posterior displacement.

Surgical technique

Suprapubic, intrapelvic approach, extending from the symphysis pubis anteriorly to the sacroiliac joint posteriorly. Superficial landmarks are identical to the Pfannenstiel approach, the rectus abdominis muscles are longitudinally dissected, the symphysis pubis is exposed and a sub-periosteal deep surgical dissection is carried out along the anterior column and the quadrilateral plate, and posteriorly toward the greater sciatic notch and the sacroiliac joint.

Results

In a 5-year review of 60 acetabular fractures that underwent open reduction and internal fixation using the modified Stoppa approach, there were 36% anterior column fractures, 28% both-column fractures, the rest being anterior column with posterior hemi transverse fractures, transverse and T-fractures. Any extension of the fracture to the iliac wing necessitated an additional lateral window (93% of cases). In cases with posterior displacement, an additional approach was utilized to address a posterior wall fracture. All fractures healed within 12?weeks. Mean Merle d’Aubigné score was 15.22. Postoperative radiological evaluation revealed anatomical reduction in 54% of the patients, satisfactory in 43%, and unsatisfactory in 3% of the patients. Overall there were 15?minor and major complications     

Cable fixation and early total hip arthroplasty in the treatment of acetabular fractures in elderly patients

Eighteen patients with acetabular fractures, with a mean age of 76 years, were treated with cable fixation and acute total hip arthroplasty. Nine were T-shaped fractures, 4 associated transverse and posterior wall, 2 transverse, 2 posterior column and posterior wall, and 1 anterior and posterior hemitransverse fractures. One patient experienced 3 episodes of hip dislocation within 10 months after surgery. All the others had a good outcome at a mean follow-up time of 36 months. Radiographic assessment showed healing of the fracture and a satisfactory alignment of the cup without loosening. This option provides good primary fixation, stabilizes complex acetabular fractures in elderly patients, and permits early postoperative mobilization.     

髋臼骨折的手术治疗

目的：报道切开复位内固定治疗髋臼骨折的方法和结果。方法：按照ＪｕｄｅｔＬｅｔｏｕｒｎｅｌ分型：髋臼前壁骨折２例,前柱骨折５例,前壁合并前柱骨折３例,双柱骨折５例,后壁骨折４例,后壁合并后柱骨折７例,横行骨折４例。手术入路：髂腹股沟切口１３例,Ｋｏｃｈｅｒｌａｎｇｅｂｅｃｋ切口１１例,髂股切口３例,髂腹股沟切口＋ＫｏｃｈｅｒＬａｎｇｅｎｂｅｃｋ切口３例。骨折复位后用预弯的骨盆钢板内固定。结果：随访６～１８个月,按照Ｍａｔａ标准：优１３例,良８例,中５例,差４例。结论：根据髋臼骨折类型选择切口入路,骨折复位满意,内固定可靠,功能恢复好。     

锁定加压重建钢板在髋臼骨折中的应用

目的探讨锁定加压重建钢板(重建LCP)治疗髋臼骨折的优点及应用原则。方法27例复杂髋臼骨折采用锁定加压重建钢板内固定,骨折按照Letoune1分类,后柱合并后壁骨折5例,横形合并后壁骨折4例,双柱骨折11例,前柱合并后半横形骨折7例。Kocher-Langenbeck入路9例,Kocher-Langenbeck入路联合髂腹股沟入路18例。结果27例中有24例获得随访,随访时间8~29个月(平均21个月),复位质量按照Matta评分,优13例,良9例,可2例;髋关节功能按Harris评分,优15例,良8例,可1例。术后发生骨关节炎1例,无感染、坐骨神经损伤、静脉血栓、异位骨化和股骨头缺血等并发症。结论锁定加压重建钢板具有对松质骨良好的把持力、锁定后的角稳定性、无需钢板帖服以及单皮质螺钉可以防止螺钉进入关节腔等优点,是治疗髋臼骨折比较理想的内固定材料,使用应遵循先加压后锁定、长钢板少螺钉的原则。     

Conservatively treated acetabular fractures: A retrospective analysis

Background:

There are a few studies reporting the long term outcome of conservatively treated acetabular fractures. The present study aims to evaluate the quality of reduction, and radiological and functional outcome in displaced acetabular fractures treated conservatively.

Materials and Methods:

Sixty-nine patients (55 men and 14 women) with 71 displaced acetabular fractures (mean age 38.6 years) managed conservatively were retrospectively evaluated. There were 11 posterior wall, 5 posterior column, 6 anterior column, 13 transverse, 2 posterior column with posterior wall, 9 transverse with posterior wall, 6 T-shaped, 1 anterior column with posterior hemi-transverse, and 18 both-column fractures. The follow-up radiographs were graded according to the criteria developed by Matta J. Functional outcome was assessed using Harris hip score and Merle d’Aubigne and Postel score at final followup. Average follow-up was 4.34 years (range 2–11 years).

Results:

Patients with congruent reduction (n=45) had good or excellent functional outcome. Radiologic outcome in incongruent reduction (n=26) was good or excellent in 6 and fair or poor in 20 hips. The functional outcome in patients with incongruent reduction was good or excellent in 16 and satisfactory or poor in 10 hips. Good to excellent radiologic and functional outcome was achieved in all patients with posterior wall fractures including four having more than 50% of broken wall. Good to excellent functional outcome was observed in 88.8% of both-column fractures with secondary congruence despite medial subluxation.

Conclusions:

Nonoperative treatment of acetabular fractures can give good radiological and functional outcome in congruent reduction. Posterior wall fractures with a congruous joint without subluxation on computed tomography axial section, posterior column, anterior column, infratectal transverse or T-shaped, and both-column fractures may be managed conservatively. Small osteochondral fragments in the cotyloid fossa or non–weight-bearing part of the hip with a congruous joint do not seem to adversely affect the functional outcome. Displaced transverse fractures with “V” sign may require operative treatment.     

手术治疗严重复杂髋臼骨折78例

目的探讨手术治疗严重复杂髋臼骨折的临床疗效。方法严重复杂髋臼骨折78例按照Letournel分型,复合型骨折78例,其中“T”形骨折16例,横形伴后壁骨折22例,后柱伴后壁骨折9例,前柱伴后半横形骨折2例,双柱骨折29例。手术入路:采用Kocher-Langenbeck(K-L)入路22例,髂腹股沟入路25例,扩展髂股入路7例,联合入路(髂腹股沟加K-L入路)24例。结果按Matta评定法,本组优26例,良35例,尚可15例,失败2例,优良率78.2%。结论正确分析骨折移位和类型、选择适当的手术路径是提高髋臼骨折治疗效果的重要保证,手术疗效与骨折复位质量密切相关。     

Single versus double column fixation in transverse fractures of the acetabulum: A randomised controlled trial

IntroductionBiomechanical studies have compared fixation methods in transverse acetabular fractures, yet there is not enough clinical data to suggest an optimal fixation method. The aim of this randomized controlled trail was to compare fracture stability in posterior plating alone versus posterior plating and anterior column lag-screw fixation in treatment of transverse and transverse with posterior wall acetabular fractures.MethodsThirty patients were randomized to one of two groups, either posterior fixation alone (single column group), or posterior plating and anterior fixation with percutaneous anterior column screw (double column group). Patients were followed up with serial radiographic assessments documenting any loss of reduction, utilizing Matta’s radiological criteria, measuring the roof arc angles and by measuring any change in the femoral head offset.ResultsFifteen patients were randomized to each group. Mean patient age was 31 years, mean follow up period was 19 months (range 12–24). There was no significant differences between the two groups with regards the quality of post-operative reduction, blood loss, hospital stay and functional score using the modified Merle D'Aubinge and Postel score. The operative time was significantly longer in the double column fixation group (130 min versus 104 min). There was no loss of reduction observed in either of the two groups.ConclusionSingle poster column fixation in transverse and transverse posterior wall fractures showed similar result to double column fixation, in terms of fractures stability in the follow up period, quality of reduction and early functional outcome.     

髋臼骨折并移位的手术治疗

目的 提高对复杂髋臼骨折的治疗水平。方法 总结１９９３年３月～１９９８年５月对５６例有移位髋臼骨折进行手术治疗的经验。按Ｌｅｔｏｕｒｎｅｌ－ｊｕｄｅｔ骨折分型,髋臼后壁骨折７例,后柱骨折６例,前柱骨折４例,横断骨折６例,Ｔ型骨折６例,后柱伴后壁骨折６例,前方伴后方半横形骨折２例,双柱骨折９例。根据不同骨折类型,分别采用Ｋｏｃｈｅｒ－Ｌａｎｇｅｎｂａｃｋ入路、髂腹股沟和、髂骨股骨入路、扩展的髂骨股骨     

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.     

髋臼骨折的手术治疗

目的 探讨髋臼骨折的分型、手术入路的选择及手术效果.方法 手术治疗22例髋臼骨折患者,后壁骨折和后柱加后壁骨折选择K-L入路,前柱、前壁骨折及横断骨折选择髂腹股沟入路,前后移位明显的横断骨折、T形骨折、双柱骨折选择前后联合入路.结果 22例均获随访,时间6个月~5年,骨折6~9个月均愈合.按Matta评定标准:解剖复位 9例,满意复位13例.根据改良的Merle d′Aubigne-Poster髋关节功能评分标准:优7例,良10例,可4例,差1例.1例股骨头坏死,3例创伤性关节炎,2例异位骨化.结论 按髋臼骨折的分型选择合适的手术入路和良好的骨折复位内固定是获得满意疗效的前提.     

手术治疗移位髋臼骨折31例

目的探讨移位髋臼骨折的手术方法和疗效。方法回顾分析2003年5月至2009年7月在我院治疗的31例移位髋臼骨折,按Letournel分类方法而采用不同手术入路使用重建钢板及螺钉内固定治疗后壁骨折6例,后柱骨折4例,前壁骨折2例,前柱骨折3例,横行骨折6例,横行伴后壁骨折3例,双柱骨折2例,后壁伴后柱骨折3例,T型骨折2例。结果所有病例获3-36个月随访,按美国矫形外科评价髋关节功能的方法进行评价,优20例,良6例,可3例,差2例,优良率为83.8%。结论术前结合X线CT正确判断髋臼骨折类型,选择合适的手术入路,使骨折复位精确,结合重建钢板和螺钉固定,可获得良好的治疗效果。     

前后路联合切口治疗严重移位的髋臼骨折

目的总结应用前后路联合切口治疗累及双柱髋臼骨折的治疗经验。方法应用前后路联合切口治疗累及双柱的髋臼骨折25例。根据Letournel分型：横形骨折3例，横形加后壁骨折8例，双柱骨折9例，T形骨折5例。手术首先在移位明显的一侧进行。15例先选择前入路，后采用后路；10例先选择后入路，后采用前路。结果平均随诊23．2个月。根据改良的Merled Aubigne和Postel评分标准评价临床结果，其中优4例，良14例，一般3例，差4例，优良率为72％。2例出现深部感染，2例发生股骨头坏死，严重异位骨化的发生率为12％。结论对累及双柱的髋臼骨折，当一侧入路不能完成复位及内固定时，选择前后路联合入路可提高手术效果。     

重建钢板联合记忆合金骑缝钉治疗髋臼骨折

目的探讨重建钢板联合记忆合金骑缝钉治疗髋臼骨折的可行性及临床效果。方法对2003年5月～2004年12月收治的17例髋臼骨折患者按照Letournel分类:T形骨折2例,后柱骨折3例,后柱并后壁骨折2例,后壁并横行骨折2例,前柱骨折1例,前柱并横行骨折2例,双柱骨折2例,双柱及前后壁骨折3例。根据骨折类型分别采用单一或联合髂腹股沟入路、髋臼后侧入路,行重建钢板联合记忆合金骑缝钉内固定治疗。结果本组患者骨折复位质量按照Matta的评分标准,16例达到解剖复位,1例复位欠佳。所有患者获得9～21个月(平均13个月)随访,采用Modified d’Aubigne and Postal功能评定标准:优14例,良2例,可1例,优良率为94．1％;本组有1例发生创伤性关节炎,未见异位骨化发生。结论术前骨折分类的明确、合适入路的选择、满意的解剖复位及可靠的内固定是治疗髋臼骨折的关键,采用重建钢板联合记忆合金骑缝钉的内固定方式是一种有效的治疗方法。     

经皮空心钉结合重建钢板治疗复杂髋臼骨折

目的 通过与传统双侧入路[髂腹股沟联合Kocher-Langerbeck(K-L)入路]对比研究,探讨单纯后路经皮空心钉固定前柱联合重建钢板固定后柱治疗复杂髋臼骨折的疗效. 方法 2004年4月至2007年5月,采用手术方法 治疗复杂髋臼骨折48例,横形合并后壁骨折22例,双柱骨折16例,前柱合并后壁骨折3例,"T"形骨折3例,前柱合并后半横形骨折4例.采用双入路(髂腹股沟入路和K-L入路)治疗22例,K-L入路经皮下空心钉从坐骨结节斜向上打入固定前柱骨折、重建钢板固定后壁后柱骨折26例.结果 40例患者获6个月～3年1个月(平均1年6个月)随访,双入路手术组19例,经皮空心钉组21例.双入路手术组和经皮空心钉组的手术时间分别为(175.56±50.32)、(92.82±20.56)min,手术出血量分别为(1830.22±655.40)、(988.55±321.64)mL;按Matta复位标准解剖复位分别为10、11例,满意复位8、10例,不满意复位1、0例;髋关节功能评价,优分别为8、12例,良6、7例,一般5、2例;术后并发症分别为8、3例.两组在满意复位率和髋关节功能优良率方面差异无统计学意义.但在手术时间与术中出血量方面,差异有统计学意义(P<0.05). 结论 单纯后路经皮从坐骨结节斜向上打入空心钉固定前柱联合重建钢板固定后柱治疗复杂髋臼骨折,使双侧入路简化为单侧K-L人路,从而减化了手术步骤,减少了术中出血及术后并发症.     

The modified Palmer lateral approach for calcaneal fractures: wound healing and postoperative computed tomographic evaluation of fracture reduction

In 32 consecutive intra-articular calcaneal fractures (28 patients, 4 bilateral), open treatment was done using the modified Palmer lateral approach and the reduction was assessed with postoperative radiography and computed tomography (CT) (coronal and axial images, 1-2 days after surgery). Retrospective analysis of the available radiographs and CT scans was done in 27 fractures (25 patients, 2 bilateral) to assess accuracy of reduction achieved; in five fractures the studies were not available. Sanders classification was type I in 2 (7%), type II in 20 (74%), and type III in 5 (19%) fractures; the calcaneocuboid joint was involved in 9 (33%) fractures. Reduction included elevation of the depressed lateral side of the posterior facet, reduction of the neck (anterior third of calcaneus) to the body (middle third of calcaneus), realignment of the posterior tuberosity, and reduction of lateral wall blowout; internal fixation was done with cannulated screws. Mean (+/-SD) values of the following displacement parameters were significantly improved after surgery: B?hler's angle, posterior facet angle, lateral posterior facet articular depression, heel width (coronal CT), and calcaneal height. There was no significant difference between preoperative and postoperative values of mean angle of Gissane, posterior tuberosity position, and body width and length on axial CT. One (3%) of the 32 fractures was associated with preoperative (traumatic) full-thickness skin necrosis at the sinus tarsi that required free muscle flap coverage. One (3%) postoperative wound healing complication occurred, consisting of wound dehiscence and drainage at the central portion of the surgical wound in a smoker, which resolved with dressing changes and antibiotics. In conclusion, the modified Palmer lateral approach enabled open reduction of major features of calcaneal fractures with less soft-tissue risk than more extensile approaches.     

Transitional transverse acetabular fractures: differences between fractures with a large posterio-superior fragment and the inverse T-fracture--a report of 10 unusual cases

BACKGROUND: Classification of fractures is crucial in decision making and planning of acetabular surgery. Transverse fractures with secondary vertical fracture lines--which constitute either a large posterio-superior fragment (floating dome) or an inverse T with the posterior ileum attached to the axial skeleton--have not been described in detail in the literature. METHODS: All acetabular fractures at Ullev?l University Hospital have been recorded prospectively since 1993 and classified according to Judet/Letournel. RESULTS: In 10/449 fractures (2%) there was a transverse fracture line through the acetabulum, with an additional vertical fracture line ascending either to the iliac crest or the SI-joint. In 6 of these fractures the vertical line started within the acetabulum, and the posterior part of the ileum with part of the articular surface was attached to the axial skeleton. In 4 fractures the vertical fracture line started posterior to the joint, constituting a very large posterio-superior fragment without any articular surface (a floating dome). INTERPRETATION: Open reduction and internal fixation of inverse T-fractures and transverse fractures with a floating dome require different surgical approaches. The latter can be treated through a single approach alone, while the inverse T-fracture may require extensile or combined approaches for adequate reduction and fixation.     

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.