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A technique for percutaneous placement of cannulated screws in the acetabulum is presented. Surgical technique is described, and fluoroscopic imaging techniques used to guide screw placement are also illustrated. The technique was used to limit soft tissue dissection in three patients. Results and examples are presented.
The case of a patient who sustained an avulsion fracture of the femoral head (Pipkin Type I) that was unrecognized is described. The patient was referred to the authors' institution four months after injury, and radiographic studies showed a malunited avulsion fracture of the femoral head to the acetabulum. The patient subsequently went on to an excellent result after surgical debridement. The authors recommend additional radiographic studies in cases to exclude unrecognized fractures where a possible hip subluxation may have occurred.
A 67-year-old woman sustained a pubic-type anterior dislocation of the hip associated with a comminuted fracture of the anterosuperior part of the acetabulum and the anteroinferior iliac spine following a fall on the knee. Because of interposition of the iliopsoas tendon, closed reduction followed by skeletal traction failed to achieve reduction of the acetabular fragment. An abnormally high degree of anteversion of the femoral neck is suggested as a possible predisposing factor in this injury.
Blunt trauma patients with acetabular fractures can lose as much as 2 L of blood after injury, and approximately 40% of these patients require blood transfusions. Fractures involving the anterior and posterior columns may require more than 1 surgery for adequate fracture fixation, increasing the potential for greater blood loss. Although blood transfusions may be medically necessary in these cases, Jehovah's Witnesses often refuse transfusion as a matter of religious conviction. The religious tenets of this faith preclude the use of blood transfusions and certain other blood products, based on an interpretation of Acts 15:29. To treat patients with these beliefs, various techniques have been developed to minimize blood loss as an alternative to transfusion. Temporary arterial balloon occlusion, also known as an "internal tourniquet," was first reported in 1954 for use in severe penetrating abdominal trauma. It was later used to control basilar artery bleeding and to limit blood loss in Jehovah's Witness patients undergoing revision total hip or knee arthroplasty. This case report documents the successful use of temporary balloon occlusion to minimize blood loss during an open reduction internal fixation of a both-column acetabulum fracture in a Jehovah's Witness patient. The method used for achieving this intra-iliac balloon occlusion is described in detail so that others also may implement this technique.
This technique article presents a small-incision, gluteal-splitting approach for the treatment of select fractures involving the posterior acetabulum. The approach essentially involves the proximal portion of the Kocher-Langenbeck incision, and it can be extended to a larger exposure if needed. It is ideally suited for posterior-wall fractures, along with select transverse and posterior column fractures.
STUDY DESIGN: A case report of a complex spondylo-pelvic injury combining a traumatic spondylolysis and burst fracture of the fifth lumbar vertebra, with an open pelvic ring disruption and a fracture of the acetabulum. OBJECTIVES: To describe the mechanism, diagnostic approach, and rationale for treatment of this very rare and complex injury pattern, and finally to present the results of the treatment. SUMMARY OF BACKGROUND DATA: Traumatic spondylolysis of the fifth lumbar vertebra is a very uncommon type of injury, with few cases being reported in the literature. Combination of such an injury with pelvic ring and acetabular fractures has never been reported in the past. METHODS: The patient was referred to our institution for definitive treatment after initial treatment at a local hospital involving laparotomy, defunctioning colostomy, and symphyseal plating. Accurate delineation of the complex injury pattern was established on computerized tomography with 3-dimensional multiplanar reconstruction, and magnetic resonance imaging of both the spine and pelvis. Definitive stabilization of the injury was made by posterior lumbopelvic segmental fixation with posterolateral fusion and open reduction and internal fixation of the acetabular fracture. RESULTS: At 2 years after surgery, the patient was ambulatory, with an ankle-foot orthosis, and almost completely pain free. He was able to perform manual work. CONCLUSIONS: Complex associated injuries of the spondylo-pelvic junction and pelvis are always a challenge to treat because they demand careful assessment, stabilization of the patient, meticulous imaging, and a multidisciplinary approach.
A template that allows a simple three-dimensional assessment of the hip joint is presented. The total surface of a sphere is subdivided into spherical quadrangles and triangles that cover areas of exactly identical size. On the template, these quadrangles and triangles are projected onto a plane. Each segment represents 0.5% of the total surface of the sphere. Calculation of any surface area is achieved by adding the number of segments involved of a template of appropriate radius. In addition, various angles can be measured. The template is drawn in various sizes on transparent foil. The template of the appropriate size is laid on the anteroposterior radiograph of the hip joint. It allows measurement of the contact area between the acetabulum and the femoral head and also acetabular orientation. A cadaver study showed good reliability of the measurements.
The standard lateral positions of the acetabulum in injured patients may induce additional trauma. The authors devised a lateral projection which is more comfortable to maintain than the standard views and is potentially less dangerous.
For the patient with a traumatized acetabulum, accurate radiographic diagnosis and classification are the cornerstone of effective clinical care. The classification system of Judet and Letournel has led to improved management of such injuries. However, trauma-related acetabular fractures are often complex, with multiple fragments and secondary fracture lines. Furthermore, the Judet and Letournel system is complicated and easily misunderstood, reflecting the nature of the anatomy itself. Computed tomography (CT) provides information regarding the extent of the fracture and is complementary to radiography for ascertaining the spatial arrangement of fracture fragments. Three-dimensional (3D) reconstruction of CT data can be helpful in understanding the complex fracture patterns. These are divided into two main types: elementary fractures, which consist of injuries to a single structural component, and associated fractures, which are combinations of the elementary types. Three-dimensional CT is especially helpful in gaining perspective on the fracture orientation. Although questions remain as to its clinical application, 3D CT is a useful teaching tool for demonstrating the different types of acetabular fractures.
Information about the loading of the human acetabulum during walking is necessary for a functional understanding of the morphology of the pelvic girdle and the hip joint as well as for the optimization of endoprosthetic therapy in osteoarthritis. For this purpose, experimental data of the forces acting on the femur in walking taken from the literature [Bergmann et al.: J. Biomech. 1993;26: 969-990] were combined with our own kinematic and morphometric data, to transform the force vectors from the femoral into a pelvic and an acetabular frame. During the walking cycle, the resultant force vector takes a rather constant course relative to the pelvis and its orientation seems to be highly regulated to act within a small range of angles. Only small deviations occur from the angles against the vertical which the resultant peak force forms in the frontal plane (F = 11 degrees, medially orientated) and in the sagittal plane (S = 5 degrees, ventrally orientated). The experimental results form the basis for a model of the incongruous hip joint as an elastic joint, the femoral head being centered between compliant elements.
The results of using the Ring uncemented polyethylene-to-metal (UPM) prosthesis in patients with protrusio acetabuli or dysplasia are reported. Fifty-four cases of protrusio were analysed and a modified method of measuring the deformity is described; after operation, remodelling of the medial wall had improved, on average, by 29.6%. For the dysplastic acetabulum the main difficulty is the lack of lateral support for the cup. In order to test the hypothesis that this support improves with an uncemented prosthesis, 38 hips with an average follow-up of 31 months were studied. Lateral support, measured radiographically, showed an average increase of 21%. The remodelling effect may be attributed to the biomechanical design of the prosthesis.
We studied cartilage degeneration in 45 canine acetabula after implantation of prostheses with articulating surfaces of low-temperature isotropic (LTI) pyrolytic carbon, cobalt-chromium-molybdenum alloy and titanium alloy for periods ranging from two weeks to 18 months. Gross specimens and histological sections were compared with the nonoperated (control) acetabulum of the same animal. Cartilage articulating with LTI pyrolytic carbon exhibited significantly lower levels of gross wear, fibrillation, eburnation, glycosaminoglycan loss, and subchondral bone change than with metallic surfaces. Survivorship analysis showed a 92% probability of survival for cartilage articulating with LTI pyrolytic carbon at 18 months, as compared to only a 20% probability of survival for cartilage articulating with either of the metallic alloys.
Radiographs of 155 Indian children were examined to identify the acetabular changes which occur in Perthes' disease. These changes included osteoporosis of the acetabular roof, irregularity of contour, premature fusion of the triradiate cartilage, hypertrophy of articular cartilage and changes in dimensions. These changes tended to be more marked in older children and when more than half of the femoral epiphysis was involved. Comparison with 25 cases of Perthes' disease from Liverpool showed the same picture. Several of the acetabular changes noted during the active stages were also seen in a series of 24 adult hips after Perthes' disease. Radio-isotope scans of the hips of 27 children with Perthes' disease showed a consistently increased uptake in the acetabulum on the affected side, indicative of a local increase in vascularity and metabolic activity. It was possible to postulate a working model for the pathogenesis of all the acetabular changes. A number of statistical correlations suggest that most of the changes have a bearing on the final outcome.
We describe a 15-year-old boy with a posterior dislocation of the hip, fracture of the posterior column of the acetabulum and separation of the femoral capital epiphysis. To our knowledge no previous case in a child has been reported. Such high-energy injuries are extremely rare, and a poor outcome is expected. We advocate early referral to a specialised tertiary centre, and the use of a modification of Delbet's classification to reflect the complexity and displacement which may occur with this injury.
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.
We aimed to identify variables associated with clinical and radiological outcome following fractures of the acetabulum associated with posterior dislocation of the hip. Using a prospective database of 1076 such fractures, we identified 109 patients with this combined injury managed operatively within three weeks and followed up for two or more years. The patients had a mean age of 42 years (15 to 79), 78 (72%) were male, and 84 (77%) had been involved in motor vehicle accidents. Using multivariate analysis the quality of reduction of the fracture was identified as the only significant predictor of radiological grade, clinical function and the development of post-traumatic arthritis (p < 0.001). All patients lacking anatomical reduction developed arthritis whereas only 25.5% (24 patients) with an anatomical reduction did so (p = 0.05). The quality of the reduction of the fracture is the most important variable in forecasting the outcome for patients with this injury. The interval to reduction of the dislocation of the hip may be less important than previously described.
We describe two patients aged 16 and 25 years with osteogenesis imperfecta who sustained displaced fractures of the acetabulum following minor trauma. The femoral heads were deformed by impact against the acetabular margin and both cases underwent surgical reconstruction. The quality of the bone and soft tissues made the operations challenging. There were potential complications specific to osteogenesis imperfecta, including bleeding, the creation of secondary fracture lines and shredding of the soft-tissue. The cases provide useful guidelines for addressing these difficulties.
Eleven patients who had sustained a periprosthetic fracture of the acetabulum at a mean of 6.2 years (range, one month to thirteen years) after a total hip arthroplasty were managed at our institution between 1985 and 1991. Five patients had a fracture of the medial wall; three, a fracture of the posterior column; two, a transverse fracture; and one, a fracture of the anterior column. Six fractures were displaced by two millimeters or more. Eight fractures were caused by blunt trauma or a fall, and three occurred spontaneously. A fracture was classified as type 1 if the acetabular component was clinically and radiographically stable (eight patients) and as type 2 if the component was unstable (three patients). One patient, who had a displaced type-2 fracture of the posterior column, died of an associated intrapelvic vascular injury. The other two patients who had a type-2 fracture were managed with revision of the acetabular component without supplemental plate fixation, immediately after the diagnosis of the fracture. The eight patients who had a type-1 fracture initially were managed with limitation of weight-bearing or modification of activity; in six of these patients, the fracture united without additional treatment. The ten surviving patients were followed for a mean of sixty-two months after the fracture. Eight of these patients-including four in whom a type-1 fracture had united after non-operative treatment-had a revision of the acetabular component because of pain, loosening, or non-union by the time of the most recent follow-up. Two patients (one of whom had a type-1 fracture and the other, a type-2 fracture) had multiple revisions of the acetabular component; both had supplemental internal fixation with a plate. All ten patients ultimately had a stable, functioning prosthesis. We conclude that periprosthetic acetabular fractures are associated with a poor prognosis with regard to the survival of the acetabular component but that it is possible to achieve union and to salvage a functional prosthesis in patients who have sustained such a fracture.