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- Author: Steven C Herath x
- Trauma x
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Surgical treatment of acetabular fractures remains challenging even for experienced surgeons.
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Whilst the ilioinguinal and the Kocher-Langenbeck approach remain the standard procedures to expose the anterior or posterior aspects of the acetabulum, some modified anterior approaches for the stabilization of the acetabulum have been introduced.
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This article will provide an overview of approaches to the anterior aspect of the acetabulum and explain the efforts that have been made to improve the surgeon’s options for certain fracture modifications, such as fractures with separation of the quadrilateral surface.
Cite this article: EFORT Open Rev 2020;5:707-712. DOI: 10.1302/2058-5241.5.190061
TraumaEvidence @ German Society for Trauma Surgery, Berlin, Germany
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Department of Orthopaedic and Traumatology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Department of Orthopaedic and Traumatology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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Purpose
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To compare anterior plate fixation (SP fixation) both alone and in combination with an additional posterior sacroiliac screw (SP+SIS fixation) as a treatment for pelvic ring injuries with widening of the pubic symphysis and disruption to the anterior sacroiliac ligaments.
Methods
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To find studies with pelvic ring injuries (APC II; B2.3d) and SP or SP+SIS fixation, a systematic literature review was conducted by searching four databases. A protocol was published a priori at Open Science Framework (https://doi.org/10.17605/OSF.IO/3YHAV). Exclusion criteria included perineal injuries, chronic instability of the symphysis, complete sacroiliac separation, and pediatric patients (age <18 years). Primary outcomes of interest were defined as implant failure, health-related quality of life, and revision rate.
Results
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Altogether, 1861 studies were screened, and 40 studies qualified for full-text analysis. In total, 14 studies (two surveys, six biomechanical studies, and six retrospective clinical studies) were included. The surveys revealed that surgeons who had more recently begun practicing were more likely to use posterior fixation (SP+ISS). The biomechanical studies were heterogenous and did not yield a uniform pattern. In clinical studies, 117 patients (45%) received SP fixation, and 142 patients (55%) received SP+SIS fixation. Complications occurred in 31 SP patients (30%) and in five SP+SIS patients (3.5%).
Conclusion
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A high risk of bias was uncovered, and reporting was found to be incomplete. SP+SIS may have the potential to improve outcomes, but the evidence remains too inconclusive to draw reliable recommendations.
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Treatment of acetabular fractures is challenging and risky, especially when surgery is performed. Yet, stability and congruity of the hip joint need to be achieved to ensure early mobilization, painlessness, and good function. Therefore, coming up with an accurate decision, whether surgical treatment is indicated or not, is the key to successful therapy.
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Data from the German pelvic Trauma Registry (n = 4213) was evaluated retrospectively, especially regarding predictors for surgery. Furthermore, a logistic regression model with surgical treatment as the dependent variable was established.
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In total, 25.8% of all registered patients suffered from an acetabular fracture and 61.9% of them underwent surgery. The fracture classification is important for the indication of surgical therapy. Anterior wall fractures were treated surgically in 10.2%, and posterior column plus posterior wall fractures were operated on in 90.2%. Also, larger fracture gaps were treated surgically more often than fractures with smaller gaps (>3 mm 84.4%, <1 mm 20%). In total, 51.4% of women and 66.0% of men underwent surgery. Apart from the injury severity score (ISS), factors that characterize the overall picture of the injury were of no importance for the indication of a surgical therapy (isolated pelvic fracture: 62.0%, polytrauma: 58.8%). The most frequent reason for non-operative treatment was ‘minimal displacement’ in 42.2%.
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Besides fracture classification and fracture characteristics, no factors characterizing the overall injury, except for the ISS, and unexpectedly gender, are important for making a treatment decision. Further studies are needed to determine the relevance of these factors, and whether they should be used for the decision-making process, in particular surgeons with less experience in pelvic surgery, can orient themselves to.
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Fractures of the femoral head are rare injuries, which typically occur after posterior hip dislocation.
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The Pipkin classification, developed in 1957, is the most commonly used classification scheme to date.
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The injury is mostly caused by high-energy trauma, such as motor vehicle accidents or falls from a significant height.
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Emergency treatment consists of urgent closed reduction of the hip joint, followed by non-operative or operative treatment of the femoral head fracture and any associated injuries.
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There is an ongoing controversy about the suitable surgical approach (anterior vs. posterior) for addressing fractures of the femoral head. Fracture location, degree of displacement, joint congruity and the presence of loose fragments, as well as concomitant injuries are crucial factors in choosing the adequate surgical approach.
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Long-term complications such as osteonecrosis of the femoral head, posttraumatic osteoarthritis and heterotopic ossification can lead to a relatively poor functional outcome.
Cite this article: EFORT Open Rev 2021;6:1122-1131. DOI: 10.1302/2058-5241.6.210034
