Sequential intramedullary nailing of open tibial shaft fractures after external fixation

Abstracts: We reviewed 32 tibial shaft fractures in 31 patients treated with sequential intramedullary nailing after primary external fixation. There were 30 open fractures and 2 closed injuries with severe blunt trauma requiring fasciotomy. Fifty per cent of the fractures were classified as Gustilo type III A and B injuries [13]. The mean external fixation treatment averaged 6.6 weeks, and secondary intramedullary nailing was done on average 7.4 weeks after injury. In 50% of the fractures, secondary nailing was done at the same procedure as removal of the external fixation. Overall, the incidence of osteomyelitis and nonunion was 3.1% each and of malunion 19%. The time to full weight-bearing averaged 31.2 weeks. The results were separately analyzed according to Gustilo types and subtypes. In the Gustilo type III B injuries, the incidence of osteomyelitis and non-union was 11 %, while malunion occurred in 33%. The time to full weight-bearing averaged 53 weeks. These results support the conclusion that this treatment modality is a valid alternative to other treatment options. However, previous pintract infections should be regarded as a contraindication for secondary nailin

Long-term outcome after traumatic anterior dislocation of the hip

Introduction: Traumatic anterior dislocation of the hip joint is rare. Additional injuries to the hip due to dislocation are even more infrequent. Outcome is limited by osteoarthritic joint degeneration or the occurrence of avascular necrosis of the femoral head. Method: Anterior hip dislocation occurred in ten of 100 patients with traumatic hip dislocations (8 men, mean age: 43, 22-62years) at two major trauma centres, between January 2001 and December 2008. Four patients had impaction fractures of the femoral head and three patients had fractures of the anterior acetabular wall. One patient presented with an open dislocation. In three of the ten patients surgical treatment was necessary. Results: Nine patients were evaluated retrospectively at a follow-up of 4.8±2.3years (mean±SD). The mean scores were 88±19 (Harris Hip-Score), 15±23 (WOMAC-Score), level 6 (UCLA-Score). Four cases presented with only fair clinical or radiological results according to Epstein. AVN with collapse of the femoral head was observed in one. Conclusion: Traumatic anterior hip dislocations presented in six of the ten cases with additional injuries to the hip. Surgical treatment in cases with deep impaction fractures of the femoral head or with large fragments of the acetabulum may improve the outcom

Femoral Morphology Differs Between Deficient and Excessive Acetabular Coverage

Structural deformities of the femoral head occurring during skeletal development (eg, Legg-Calvé-Perthes disease) are associated with individual shapes of the acetabulum but it is unclear whether differences in acetabular shape are associated with differences in proximal femoral shape. We questioned whether the amount of acetabular coverage influences femoral morphology. We retrospectively compared the proximal femoral anatomy of 50 selected patients (50 hips) with developmental dysplasia of the hip (lateral center-edge angle [LCE]≤25°; acetabular index≥14°) with 45 selected patients (50 hips) with a deep acetabulum (LCE≥39°). Using MRI arthrography we measured head sphericity, epiphyseal shape, epiphyseal extension, and femoral head-neck offset. A deep acetabulum was associated with a more spherical head shape, increased epiphyseal height with a pronounced extension of the epiphysis towards the femoral neck, and an increased offset. In contrast, dysplastic hips showed an elliptical femoral head, decreased epiphyseal height with a less pronounced extension of the epiphysis, and decreased head-neck offset. Hips with different acetabular coverage are associated with different proximal femoral anatomy. A nonspherical head in dysplastic hips could lead to joint incongruity after an acetabular reorientation procedure. Level of Evidence: Level IV, retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidenc

Therapie des femoroazetabulären Impingements über die chirurgische Hüftluxation: Technik und Ergebnisse

Zusammenfassung: Die chirurgische Hüftluxation ist eine sichere und etablierte Technik für die Behandlung des femoroazetabulären Impingements. Die Komplikationsrate ist niedrig und mit der korrekten Technik, welche die Blutversorgung respektiert, tritt eine Femurkopfnekrose nicht auf. Die häufigsten Komplikationen sind milde ektope Ossifkationen und die Trochanterpseudarthrose. Die intraartikuläre Chirurgie schließt sowohl die azetabuläre wie auch femorale Korrektur ein. Klinisch kann in ca. 75-80% der Fälle ein gutes bis sehr gutes Resultat erzielt werden. Allerdings fällt die Erfolgschance beim Vorliegen fortgeschrittener degenerativer Veränderungen, welche eine Grad-1-Arthrose nach Tönnis überschreiten, rapide ab. Der Erhalt des Labrums hat einen signifikanten Einfluss auf das klinische Ergebnis und die radiologische Progression der Arthrose. Das Erhalten des Labrums scheint deshalb unabdingbar zu sei

Rationales for the Bernese approaches in acetabular surgery

Purpose: To present two new approaches to acetabular surgery that were established in Berne, and which aim at enhanced visualization and anatomical reconstruction of acetabular fractures. Method: The trochanteric flip osteotomy allows for surgical hip dislocation, and was introduced as a posterior approach for acetabular fracture management involving the posterior column and wall. For acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach is described. Results: Full exposure of the hip joint, as provided by the trochanteric flip osteotomy, facilitates anatomical reduction of acetabular or femoral head fractures and safe positioning of the anterior column screw in transverse or T-shaped fractures. Additionally, the approach enables osteochondral transplantation as a salvage procedure for severe chondral femoral head damage and osteoplasty of an associated inadequate offset at the femoral head-neck junction. The Pararectus approach allows anatomical restoration with minimal access morbidity, and combines advantages of the ilioinguinal and modified Stoppa approaches. Conclusions: Utilization of the trochanteric flip osteotomy eases visualization of the superior aspect of the acetabulum, and enables the evaluation and treatment of chondral lesions of the femoral head or acetabulum and labral tears. Displaced fractures of the anterior column with a medialized quadrilateral plate can be addressed successfully through the Pararectus approach, in which surgical access is associated with minimal morbidity. However, long-term results following the two presented Bernese approaches are needed to confirm that in the treatment of complex acetabular fractures the rate of poor results in almost one-third of all cases (as currently yielded using traditional approaches) might be reduced by the utilization of the presented novel approache

Anteriore Zugänge zum Acetabulum

Zusammenfassung: Seit den 1960er Jahren hat sich zur Versorgung von Acetabulumfrakturen mit der Hauptdislokation im vorderen Pfeiler der ilioinguinale Zugang nach Letournel mit den drei anatomischen Fenstern bewährt. Der frühere Standardzugang, der iliofemorale Zugang nach Smith-Petersen, hat seine Bedeutung noch bei Vorderwandfrakturen oder isolierten Femurkopffrakturen. Durch den Anstieg von Acetabulumfrakturen im Alter mit lateralen Kompressionsfrakturen nach seitlichem Sturz, gekennzeichnet durch die mediale Dislokation der quadrilateralen Fläche und die superomediale Domimpression, hat sich in den 1990er Jahren der intrapelvine modifizierte Stoppa-Zugang mit oder ohne Eröffnung des 1. Fensters des ilioinguinalen Zugangs etabliert. Um die Vorteile der 2. und 3. Fenster des ilioinguinalen und die mediale Sicht beim modifizierten Stoppa-Zugang zu kombinieren, hat die Berner Arbeitsgruppe kürzlich den Pararectus-Zugang für die Acetabulumchirurgie eingeführt, der als weniger invasiver Zugang mit kleinen Inzisionen speziell bei alten Patienten einsetzbar is

Posteriore Zugänge zum Acetabulum

Zusammenfassung: Die posterioren Zugänge zum Hüftgelenk waren im 19. Jahrhundert von Langenbeck und Kocher beschrieben worden. Letournel schuf die Bezeichnung des Kocher-Langenbeck-Zugangs und beschrieb damit einen der wichtigsten Zugänge zum Hüftgelenk. Die Weiterentwicklung durch eine digastrische Trochanterosteotomie und zusätzliche chirurgische Hüftluxation ermöglicht die vollständige Gelenkeinsicht mit visueller Kontrolle des Schadens, der Güte der Reposition und der extraartikulären Implantatlage. Mit der Zunahme von Acetabulumfrakturen bei alten Menschen mehrt sich auch die Zahl komplizierender Faktoren wie multifragmentäre Hinterwandausbrüche, Domimpressionen, marginale Impaktionen und Femurkopfschäden. Diese Faktoren sind für schlechte Ergebnisse bei Acetabulumfrakturen verantwortlich. Nur bei direkter Gelenkeinsicht können diese Faktoren zuverlässig erkannt und soweit wie möglich anatomisch korrigiert werden. Die chirurgische Hüftluxation bietet deshalb bei komplexen Hinterwand-, Quer- und T-förmigen Frakturen mit und ohne Hinterwandbeteiligung große Vorteile. Sie stellt deshalb bei diesen Frakturformen in unseren Händen einen Standardzugang da

Hip Damage Occurs at the Zone of Femoroacetabular Impingement

Although current concepts of anterior femoroacetabular impingement predict damage in the labrum and the cartilage, the actual joint damage has not been verified by computer simulation. We retrospectively compared the intraoperative locations of labral and cartilage damage of 40 hips during surgical dislocation for cam or pincer type femoroacetabular impingement (Group I) with the locations of femoroacetabular impingement in 15 additional hips using computer simulation (Group II). We found no difference between the mean locations of the chondrolabral damage of Group I and the computed impingement zone of Group II. The standard deviation was larger for measures of articular damage from Group I in comparison to the computed values of Group II. The most severe hip damage occurred at the zone of highest probability of femoroacetabular impact, typically in the anterosuperior quadrant of the acetabulum for both cam and pincer type femoroacetabular impingements. However, the extent of joint damage along the acetabular rim was larger intraoperatively than that observed on the images of the 3-D joint simulations. We concluded femoroacetabular impingement mechanism contributes to early osteoarthritis including labral lesions. Level of Evidence: Level II, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidenc

The Iliocapsularis Muscle: An Important Stabilizer in the Dysplastic Hip

Background: The iliocapsularis muscle is a little known muscle overlying the anterior hip capsule postulated to function as a stabilizer of dysplastic hips. Theoretically, this muscle would be hypertrophied in dysplastic hips and, conversely, atrophied in stable and well-constrained hips. However, these observations have not been confirmed and the true function of this muscle remains unknown. Questions/purposes: We quantified the anatomic dimensions and degree of fatty infiltration of the iliocapsularis muscle and compared the results for 45 hips with deficient acetabular coverage (Group I) with 40 hips with excessive acetabular coverage (Group II). Patients and Methods: We used MR arthrography to evaluate anatomic dimensions (thickness, width, circumference, cross-sectional area [CSA], and partial volume) and the amount of fatty infiltration. Results: We observed increased thickness, width, circumference, CSA, and partial volume of the iliocapsularis muscle in Group I when compared with Group II. Additionally, hips in Group I had a lower prevalence of fatty infiltration compared with those in Group II. The iliocapsularis muscle typically was hypertrophied, and there was less fatty infiltration in dysplastic hips compared with hips with excessive acetabular coverage. Conclusion: These observations suggest the iliocapsularis muscle is important for stabilizing the femoral head in a deficient acetabulum. This muscle serves as an anatomic landmark when performing a periacetabular osteotomy. Additionally, preoperative evaluation of morphologic features of the muscle can be used as an adjunct for decision making when treating patients with borderline hip dysplasia or femoroacetabular impingemen

Estimation of pelvic tilt on anteroposterior X-rays—a comparison of six parameters

Objective: To compare six different parameters described in literature for estimation of pelvic tilt on an anteroposterior pelvic radiograph and to create a simple nomogram for tilt correction of prosthetic cup version in total hip arthroplasty. Design: Simultaneous anteroposterior and lateral pelvic radiographs are taken routinely in our institution and were analyzed prospectively. The different parameters (including three distances and three ratios) were measured and compared to the actual pelvic tilt on the lateral radiograph using simple linear regression analysis. Patients: One hundred and four consecutive patients (41 men, 63 women with a mean age of 31.7 years, SD 9.2 years, range 15.7-59.1 years) were studied. Results: The strongest correlation between pelvic tilt and one of the six parameters for both men and women was the distance between the upper border of the symphysis and the sacrococcygeal joint. The correlation coefficient was 0.68 for men (P<0.001) and 0.61 for women (P<0.001). Based on this linear correlation, a nomogram was created that enables fast, tilt-corrected cup version measurements in clinical routine use. Conclusion: This simple method for correcting variations in pelvic tilt on plain radiographs can potentially improve the radiologist's ability to diagnose and interpret malformations of the acetabulum (particularly acetabular retroversion and excessive acetabular overcoverage) and post-operative orientation of the prosthetic acetabulu