External iliac artery thrombosis associated with the ilio-inguinal approach in the management of acetabular fractures: a case report

<p>Abstract</p> <p>Introduction</p> <p>The ilio-inguinal approach has come to be used routinely in the management of acetabular fractures involving the anterior wall. Thrombotic complications following surgery via this route are a serious, but rare, complication.</p> <p>Case presentation</p> <p>We report the case of a 66-year-old male patient who slipped on an icy pavement and fell on his left hip. He sustained a comminuted acetabular fracture (a transtectal T-fracture with an incomplete posterior stem through the ischial tuberosity), and was operated on five days later, via an ilio-inguinal approach. In the recovery room, his left lower limb was found to be cool and pale. Immediate re-exploration showed a left external iliac artery thrombosis, and thrombectomy was performed. In the surgical management of acetabular fractures, thrombosis of a major pelvic artery is a rare but potentially devastating complication. We discuss the possible aetiology (initial vessel trauma versus iatrogenic, intraoperative arterial injury) and pathomechanism, and wish to draw attention to this complication and to recommend ways in which it can be prevented.</p> <p>Conclusion</p> <p>We recommend circulation monitoring in patients with acetabular fractures, especially where nerve blocks and/or deep sedation/analgesia have been used. High-risk patients should be identified and subjected to intensive preoperative screening, including ultrasonography and if necessary angiography.</p

The use of a retrograde fixed-angle intramedullary nail for tibiocalcaneal arthrodesis after severe loss of the talus

Tibiocalcaneal arthrodesis may be the only means of obtaining a painless and stable limb when there is loss of the talus. We present the early results of a prospective study on tibiocalcaneal arthrodesis using a latest-generation retrograde intramedullary nail. In the period 2006–2007, nine patients underwent tibiocalcaneal arthrodesis with retrograde intramedullary nailing. Five of these patients had infection-related loss of the talus. SF-36, AOFAS ankle-hindfoot, and Mazur Ankle Arthrodesis scores were obtained pre-fusion, and at 6 weeks, 6 months and 1 year post-fusion. The patients were also followed up clinically and radiologically. Previous surgical procedures, chronic musculoskeletal problems and other comorbidities, and complications were recorded and analyzed. All patients were available for initial follow-up and were subjectively satisfied with their outcomes. Solid fusion was achieved and fully confirmed in nine cases. One subject died 8 weeks postoperatively of a pulmonary embolism. One patient had recurrent infection. At 1 year, only one patient still needed NSAIDs regularly for pain relief. The AOFAS score improved significantly (P = 0.012) from 32.1 pre-fusion to 71.5 points at 1 year as did the Mazur score, which rose by 31.2 to 72.5 points at 1 year (P = 0.012). The SF-36 score improved significantly in the domains physical functioning, role limitations due to physical problems, bodily pain, vitality, social functioning and mental health, as did the Physical Component Summary Score. Retrograde intramedullary nailing for tibiocalcaneal arthrodesis can produce a good outcome. However, in the presence of infection, patient selection for intramedullary procedures must be carefully considered on a case-by-case basis

2D-fluoroscopic navigated percutaneous screw fixation of pelvic ring injuries - a case series

<p>Abstract</p> <p>Background</p> <p>Screw fixation of pelvic ring fractures is a common, but demanding procedure and navigation techniques were introduced to increase the precision of screw placement. The purpose of this case series was the evaluation of screw misplacement rate and functional outcome of percutaneous screw fixation of pelvic ring disruptions using a 2D navigation system.</p> <p>Methods</p> <p>Between August 2004 and December 2007, 44 of 442 patients with pelvic injuries were included for closed reduction and percutaneous screw fixation of disrupted pelvic ring lesions using an optoelectronic 2D-fluoroscopic based navigation system. Operating and fluoroscopy time were measured, as well as peri- and postoperative complications documented. Screw position was assessed by postoperative CT scans. Quality of live was evaluated by SF 36-questionnaire in 40 of 44 patients at mean follow up 15.5 ± 1.2 month.</p> <p>Results</p> <p>56 iliosacral- and 29 ramus pubic-screws were inserted (mean operation time per screw 62 ± 4 minutes, mean fluoroscopy time per screw 123 ± 12 seconds). In post-operative CT-scans the screw position was assessed and graded as follows: I. secure positioning, completely in the cancellous bone (80%); II. secure positioning, but contacting cortical bone structures (14%); III. malplaced positioning, penetrating the cortical bone (6%). The malplacements predominantly occurred in bilateral overlapping screw fixation. No wound infection or iatrogenic neurovascular damage were observed. Four re-operations were performed, two of them due to implant-misplacement and two of them due to implant-failure.</p> <p>Conclusion</p> <p>2D-fluoroscopic navigation is a safe tool providing high accuracy of percutaneous screw placement for pelvic ring fractures, but in cases of a bilateral iliosacral screw fixation an increased risk for screw misplacement was observed. If additional ramus pubic screw fixations are performed, the retrograde inserted screws have to pass the iliopubic eminence to prevent an axial screw loosening.</p

Treatment of chronic syndesmotic rupture – What is the current evidence?

Akute Verletzungen im oberen Sprunggelenk ko¨nnen langfristig in bis zu 30% der Fa¨lle zu chronischen Instabilita¨ten fu¨hren. Ein anatomisch widerhergestelltes distales Tibiofibulargelenk stellt einen wesentlichen Faktor fu¨r das klinische Outcome von Patienten dar. Auffa¨lligkeiten in der klinischen Untersuchung bei Verdacht auf eine chronische Syndesmosenverletzung sollten zur weiteren Diagnostik fu¨hren. Stabile La¨sion sollte mittels konservativer Maßnahmen therapiert werden. Zur operativen Versorgung der instabilen chronischen Syndesmosenverletzung ist eine große Vielfalt an Therapiemethoden in der Literatur beschrieben. Die publizierten Operationsmethoden reichen vom arthroskopischen De´bridement bis hin zu komplexen operativen Versorgungen mittels Syndesmosenrekonstruktion oder auch der tibiofibula¨rer Fusion. Die Evidenz der verschiedenen Therapiemethoden ist gering und beruht maßgeblich auf Expertenempfehlungen. Zum aktuellen Zeitpunkt kann kein Therapieregime uneingeschra¨nkt bevorzugt empfohlen werden (2023).Acute injuries to the ankle joint can lead to chronic instability in up to 30% of cases in the long term. An anatomically restored distal tibiofibular joint is a significant factor in the clinical outcome of patients. Abnormalities in the clinical examination when a chronic syndesmosis injury is suspected should lead to further diagnostics. Stable lesions should be treated with conservative measures. A wide variety of treatment methods have been described in the literature for the surgical treatment of unstable chronic syndesmosis injuries. The published surgical methods range from arthroscopic debridement to complex surgical treatment using syndesmosis reconstruction or tibiofibular fusion. The evidence for the various treatment methods is limited and is largely based on expert recommendations. At the present time, no treatment regimen can be recommended without reservation (2023)