Sekundär- und Späteingriffe nach Beckenring- und Azetabulumfrakturen

Secondary or delayed reconstructions following mal- or nonunited fractures of the pelvic ring and acetabulum are challenging procedures. Three different healing problems have to be distinguished: malunion, nonunion, and fractures and/or dislocations that have healed incompletely. Combinations of these three pathologies are also possible. Delayed reconstructions have no chance of success unless the patient’s signs and symptoms are clearly attributable to the malunion or nonunion. This means that extensive clinical and radiological evaluation is mandatory preoperatively. Risks involved and the results that can be expected must be discussed thoroughly with the patient once the surgery has been planned in detail. For the treatment of nonunion or delayed union, the unstable zone must be debrided, and autologous bone grafting with cancellous bone and stable internal fixation are then required. Malunion requires careful mobilization of the malunited fracture fragments, which is often a very demanding procedure. If there is already advanced damage to the acetabulum little functional improvement can be expected after a corrective osteotomy. Viable treatment alternatives are hip fusion and endoprosthetic joint replacement. Possible complications include damage to neurovascular structures, impaired wound healing, infections and implant failure. Extensive experience in the management of acute fractures of the pelvic ring and acetabulum is essential if delayed reconstruction is to be successful.     

Transverse Fracture-Dislocation of the Sacrum: a Diagnostic Pitfall and a Surgical Challenge

Transverse fracture-dislocations of the sacrum are rare. Associated lesions of the lumbosacral spine as well as neurological injuries are common. Conventional radiographs of the pelvis often fail to clearly visualize the fracture. Delayed diagnosis increases the risk of progressive neurological disfunction. True lateral sacral views and CT-scans with 3-dimensional reconstructions are very helpful in establishing the full extent of the injury. These examinations should be considered in all patients with a history of high energy trauma and clinical signs indicating lumbosacral injury, such as severe low back pain and neurological disturbances of the lower extremities.

The management of transverse sacral fracture-dislocations with or without associated neurological damage is controversial. Conservative treatment is associated with a high rate of persistent deformity and residual neurological dysfunction. Surgical management allows for anatomical fracture reduction, stable fixation and revision of the spinal canal and lumbosacral nerve roots. The dorsal approach is preferred.

Two patients with transverse sacral fracture-dislocations and neurological disturbances are presented. One patient had an additional fracture-dislocation of the lumbar spine at the L4L5 level with intrusion of the lumbosacral spine into the pelvis. Both lesions in this patient were successfully stabilized using an internal fixator system. The other patient presented with a bilateral transforaminal sacral fracture. The transverse component was not recognized on the initial radiographs, which resulted in loss of reduction and progressive neurological disfunction after sacroiliac screw fixation.     

Staged reconstruction of pelvic ring disruption: differences in morbidity, mortality, radiologic results, and functional outcomes between B1, B2/B3, and C-type lesions

OBJECTIVE: To analyze injury pattern, surgical therapy, radiologic results, and functional outcome in unstable B-type and C-type pelvic ring fractures. DESIGN: Retrospective study. SETTING: Level I University Trauma Center. PATIENTS: Two-hundred-twenty-two consecutive patients, admitted during a nine-year period with unstable B-type (n = 100) and C-type (n = 122) pelvic ring injuries, of whom 122 (61.3 percent of surviving patients) were eligible for evaluation with a minimum follow-up of one year. INTERVENTIONS: Staged reconstruction dependent upon injury pattern. Emergency external compression of the pelvic ring in case of hemodynamic instability. Management of associated lesions. Secondary open reduction and internal fracture fixation. MAIN OUTCOME MEASURES: Assessment of perioperative and postoperative mortality and morbidity depending on fracture pattern. Fifty-five B-type and sixty-seven C-type lesions were evaluated clinically and radiologically an average of 21.6 months after trauma. RESULTS: Perioperative mortality was 5 percent in B-type and 15 percent in C-type fractures. External fixation was part of the definitive treatment in 52 percent of B-type and in 38 percent of C-type lesions. Planned secondary operative procedures were performed in 15 percent of B-type and in 26.2 percent of C-type fractures. Radiologic results were anatomic in 93.5 percent of B1, 75 percent of B2/B3, and 62.7 percent of C-type lesions. Functional results were excellent or good in 74 percent of the B1, 92 percent of the B2/B3, and in 71 percent of the C-type fractures. CONCLUSIONS: Unstable pelvic ring fractures require a staged approach. Mortality is higher in C-type than in B-type lesions. Functional outcome is worse in C-type than in B-type lesions. Within the B-type group, B1 lesions have a worse functional end result than B2/B3 fractures. These findings are not only related to the stability and symmetry of the pelvic ring, as seen in the radiologic picture, but also depend on the severity and amount of damage to the soft tissues around the pelvis.     

Acetabular fractures in the elderly. Results of a sophisticated treatment concept

Acetabular fractures in elderly patients are rare injuries, but their incidence is increasing. Poor bone quality due to osteoporosis and an increased operative risk due to concomitant disease are factors complicating surgical therapy. Literature does not provide generally accepted treatment protocols.In a 4-year period, 27 patients who were 65 years or older and who had an acute displaced fracture of the acetabulum were admitted to our department. Four minimally displaced and stable fractures were managed conservatively. Internal fixation was performed in 16 cases. According to the Merle d'Aubigné score, in 15 out of 18 surviving patients excellent or good results were found.Treatment strategy should be planned individually for each fracture, taking into account the patients biological age and general condition, fracture type, bone quality and associated injuries. Primary endoprosthetic replacement should only be considered when the acetabular bone stock allows stable cup fixation. Osteosynthesis in combination with early endoprosthetic replacement should be considered in acetabular fractures with associated femoral head or neck fractures or when significant articular steps and/or bone defects remain after open reduction and internal fixation.     

Posterior wall fractures of the acetabulum: characteristics, management, prognosis

A consecutive series of 60 fractures of the posterior wall of the acetabulum, treated operatively in a Level I Trauma center, is reviewed retrospectively. Characteristics of the lesion, type of treatment, early and late postoperative complications and two-year functional results were recorded. In 27 patients (45%), additional damage to the cartilage of the acetabular cavity such as subchondral impaction, free articular fragments or separation of the posterior wall into several pieces was present. Seven patients (11.6%) showed preoperative neurological deficit. All fractures were treated with open reduction and internal fixation through a Kocher-Langenbeck approach. Secondary nerve damage was present in 8.3%. Early secondary surgery was necessary in 8.3%. During the first two years, additional surgery was performed in 7 patients (15.2%). The rate of periarticular ossifications was 26.1%. The rate of excellent and good results was 69.5%. The posterior wall fracture of the acetabulum is a more complex injury than generally is accepted. A large variety of articular lesions with varying degree of complexity is collected in this fracture type. Even in experienced hands, excellent and good long-term results will not exceed 75%. Poor results are due to suboptimal reconstruction of the posterior wall, partial osteonecrosis and/or complications of the Kocher-Langenbeck approach.     

Die Kleeblattplatte zur Versorgung der Humeruskopffraktur

Zusammenfassung In der vorliegenden prospektiv angelegten Studie wurden die funktionellen und radiologischen Ergebnisse von 62 Patienten mit Humeruskopffraktur, die mittels einer Kleeblattplatte versorgt wurden, postoperativ nach 14 Wochen und nach einem Follow-up von durchschnittlich 75 Wochen untersucht. Bei 9 (14,5%) Patienten handelte es sich um eine dislozierte 2-Segment-Fraktur, in 36 Fällen waren es 3-Segment-Frakturen (58%, zusätzliche Tuberculum majus- oder Tuberculum minus Absprengungen), bei 13 Patienten (21%) waren es 4-Segment-Frakturen und bei 4 (6,5%) Patienten Luxationsfrakturen. Die physiotherapeutische frühfunktionelle Behandlung begann ab dem 3. postoperativen Tag.Folgende Komplikationen wurden beobachtet: 2 subkutane Wundinfekte (3,2%), 2 Hämatome (3,2%), eine temporäre neurologische Beeinträchtigung des N. axillaris (1,6%). Es kam nur bei 4 (6,5%) Patienten zur Ausbildung einer Humeruskopfnekrose (3-mal partiell, 1-mal total), bei 2 Patienten wurde ein Verfahrenswechsel durchgeführt (3,2%): beide Male führte eine erhebliche Varusstellung im Verlauf zu einem klinisch schlechten Ergebnis.Um eine im Verlauf aufgetretene schlechte Beweglichkeit zu verbessern, wurden nach radiologischer Durchbauung im Rahmen einer Metallentfernung 8 Arthrolysen (12,9%) und 10 Akromioplastiken (16,1%) durchgeführt.In der vorliegenden Studie erreichten unsere Patienten nach Versorgung einer Humeruskopffraktur mittels offener Reposition und innerer Fixation mit Kleeblattplatte durchschnittliche 77±13 im Neer-Score (NS) und 72,4±18 im Constant-Score (CS) funktionelle Ergebnisse bei niedriger Komplikations- und Revisionsrate. Bei 59% der behandelten Patienten konnte ein gutes oder sehr gutes Ergebnis im Constant-Score erreicht werden.Auch Patienten mit komplexen 4-Fragment-Frakturen kamen durchschnittlich auf 72,7 Punkte im Constant-Score (gut). Als wichtige Parameter, welche das funktionelle Ergebnis beeinflussen, konnten wir die Exaktheit der Tuberculum majus-Refixierung, die ausreichend tiefe Lage der Kleeblattplatte und eine Reposition des Humeruskopfes unter Vermeidung einer Varisierung herausarbeiten.