RESUMEN
PURPOSE OF THE STUDY: Revision total hip arthroplasty (THA) after hip arthrodesis is an uncommon and challenging operation. The task would appear to be even more difficult if the arthrodesis was performed because of septic arthritis due to the theoretical risk of recurrent infection. We report our fifteen-year experience. MATERIAL AND METHODS: This retrospective study concerned 17 procedures performed in 17 patients (11 women, 6 men) between 1988 and 2003 on 5 right and 12 left hips. All of the patients had arthrodesis for sepsis: eight subsequent to tuberculosis and nine subsequent to septic arthritis (Staphylococcus aureus). We examined the impact of the initial arthrodesis (surgical technique, position, leg length) on neighboring joints and indications for de-fusion. Mean age was 53 years (range 32-74) and on average, the patients had a fixed hip for 36 years (range 7-59). Mean follow-up was six years (range 11 months to 15 years). Revision surgery was performed via a posterolateral approach for 12 hips (nine trochanterotomies) and via an anterolateral approach for five hips for implantation of nine cemented implants, six press fit implants, and two hybrid implants (cemented cup and press fit stem). Clinical assessment at last follow-up noted pain, walking capacity and joint motion. Leg length discrepancy was measured and complications were noted. RESULTS: The position of the original arthrodesis was considered satisfactory (flexion 20 degrees , adduction 0-10 degrees , external rotation 0-20 degrees ) for eight hips; leg length discrepancy was 4 cm (2-8 cm). Neighboring joints involved concerned the lumbar spine in 15 patients, the ipsilateral knee in ten patients, the contralateral knee in eight and the contralateral hip in six. The decision to remove the arthrodesis was based on functional needs related to lumbar pain (n=6), the homolateral knee (n=10, limping and leg length discrepancy), or an operation on the ipsilateral knee. After surgery, 14 hips (83%) were free of pain with improvement of the lumbar pain and pain of the homolateral knee. Six patients walked without support but 16 still had a limp. Flexion was 78 degrees . Leg length discrepancy was 2.5 cm on average and seven patients had balanced limbs. The postoperative period was uneventful for 14 of 17 patients (one paresia of the common fibular nerve, one femoral phlebitis, one early infection). Six late complications were noted: nonunion of the greater trochanter (n=2), recurrent ankylosis (n=1) and loosening (n=3). DISCUSSION AND CONCLUSION: An earlier history of infection does not appear to be a contraindication for implantation of a total hip arthroplasty after hip arthrodesis. Despite the long recovery period and the modest gain in joint motion, 80% of patients were satisfied after having had a blocked hip for 36 years on average.
Asunto(s)
Artritis Infecciosa/cirugía , Artrodesis/métodos , Artroplastia de Reemplazo de Cadera/métodos , Articulación de la Cadera/cirugía , Adulto , Anciano , Artralgia/etiología , Artrodesis/efectos adversos , Cementación/métodos , Femenino , Fémur/cirugía , Estudios de Seguimiento , Marcha/fisiología , Humanos , Prótesis Articulares , Diferencia de Longitud de las Piernas/etiología , Dolor de la Región Lumbar/etiología , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/etiología , Rango del Movimiento Articular/fisiología , Reoperación , Estudios Retrospectivos , Infecciones Estafilocócicas/cirugía , Tuberculosis Osteoarticular/cirugía , Caminata/fisiologíaRESUMEN
PURPOSE OF THE STUDY: Total hip arthroplasty (THA) is generally proposed for renal transplant patients with invalidating hip disease. For patients on chronic dialysis, the few published series report a higher rate of complications. These patients are considered more vulnerable. We report the results of a retrospective mid-term analysis of 28 renal failure patients (37 hips) with THA comparing renal transplant recipients with chronic dialysis patients. MATERIAL AND METHODS: THA was performed on 37 hips in 28 patients with renal failure between January 1993 and 2004. Treatment for the renal disease was transplantation or chronic dialysis. Mean patient age at the time of the arthroplasty was 56 years. Nine patients had bilateral THA. At review, four patients had died and none were lost to follow-up. Mean time between transplantation and hip arthroplasty was 9.9 years. Among the fourteen dialysis patients (21 hips), five had had a renal transplant. Mean time from onset of dialysis to arthroplasty was 12.3 years. At mean postoperative follow-up of six years (range 24 months to 12 years), 24 patients were living. Thirty-five hips had no surgical history. Aseptic osteonecrosis was the dominant etiology (75% of operative indications in the graft group and 52% in the dialysis group). The preoperative Postel-Merle-d'Aubigné score was 7.6 in the dialysis group and 10.3 in the graft group. Most of the cups were not cemented (n=31, 84%), as were most of the stems (n=29, 78%). All survivors were reviewed. The PMA score was determined. RESULTS: Early postoperative complications in the dialysis patients were: deep vein thrombosis (n=3), pulmonary embolism (n=4), operative site hematoma (n=2) and immediate septic complication with prompt revision and preservation of the implants (n=1). For the graft group, complications were: early dislocation (n=2), lung disease (n=3). Four patients, all in the dialysis group, died. At review, the mean PMA score was 14.2 in the dialysis patients and 15.7 in the graft patients. There were no radiological signs of loosening, nor of polyethylene wear, and no ectopic ossifications could be identified. There were no late infections. DISCUSSION: In renal transplant recipients, total hip arthroplasty is a reliable treatment for hip disease, providing good mid-term results and a morbidity close to that observed in the general population. Conversely, dialysis patients have a greater perioperative morbidity. Use of non-cemented implants is not associated with a higher rate of loosening than with cemented implants. It can be recalled that this type of surgery must be performed within the framework of careful pluridisciplinary patient management.
Asunto(s)
Artroplastia de Reemplazo de Cadera , Fallo Renal Crónico/terapia , Trasplante de Riñón , Diálisis Renal , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Estudios de Seguimiento , Hematoma/etiología , Articulación de la Cadera/cirugía , Prótesis de Cadera , Humanos , Fallo Renal Crónico/cirugía , Masculino , Persona de Mediana Edad , Osteonecrosis/cirugía , Complicaciones Posoperatorias , Diseño de Prótesis , Infecciones Relacionadas con Prótesis/etiología , Embolia Pulmonar/etiología , Estudios Retrospectivos , Tasa de Supervivencia , Trombosis de la Vena/etiologíaRESUMEN
We report a case of Aspergillus fumigatus infection of a total hip arthroplasty. This rare infection was demonstrated at surgical revision of a loosened prosthesis with migration of the cup into the pelvis associated with a false aneurysm of the femoral artery. A vascular time was required before the orthopedic revision. This case illustrates the importance of the preoperative work-up in the event of cup migration. The double approach was required in our patient to control and repair the vascular structures. The difficult treatment of Aspergillus fumigatus is also discussed.
Asunto(s)
Aneurisma Falso/etiología , Aspergilosis/etiología , Aspergillus fumigatus , Arteria Femoral , Migración de Cuerpo Extraño/etiología , Prótesis de Cadera/efectos adversos , Infecciones Relacionadas con Prótesis/etiología , Anciano , Humanos , Masculino , PelvisRESUMEN
PURPOSE OF THE STUDY: The aim of this retrospective analysis was to examine complications and technical difficulties observed during implantation of total hip arthroplasty (THA) after treatment of an acetabular fracture. MATERIAL AND METHODS: Forty patients (thirty men and ten women), mean age 50 years, were included in the study. The acetabular fracture had been treated surgically in 23 and orthpedically in 17. Mean time from initial trauma to implantation of the THA was eleven years. Hydroxyapatite-coated cups were inserted without cement in 32 patients. Cemented cups in eight (with two Kerboull cross, one Muller ring, and five simple polyethylene). Five femoral stems were cemented. Preoperative planning was designed to restore the center of the initial hip rotation to avoid excessive cup medialisation. Acetabular defects found intra-operatively were significantly greater in the group of patients treated orthopedically than in those treated surgically (p = 0.02). Autografts were thus used more frequently in the former (65%). RESULTS: One patient presented an intraoperative complication. The postoperative complications included phlebitis (n = 1), infection (n = 1), fibular nerve paralysis (n = 2), dislocation (n = 4), and heterotopic ossification (n = 7). The rate of postoperative complications was significantly higher in the group of patients treated surgically (52.2% versus 17.6%, p < 0.02). At last follow-up, mean 52 months, the mean Postel-Merle-d'Aubigne function score was 16.7. The rate of acetabular revision was 15% with four cemented cups being replaced at more than ten years due to aseptic loosening. Two press-fit cups were replaced early for infection in one patient and disassembly in another. DISCUSSION: Despite the high rate of complications, the mid-term results were good, encouraging us to continue this procedure as the first intention treatment using either a press fit cup with or without an autograft, or a cemented cup with a metal ring (Kerboull or Burch-Schneider).
Asunto(s)
Acetábulo/lesiones , Acetábulo/cirugía , Artroplastia de Reemplazo de Cadera , Fracturas Óseas/cirugía , Complicaciones Posoperatorias , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Desmoplastic fibroma or desmoid bone tumor is a rare tumor described for the first time by Jaffe in 1958. It accounts for 0.1 to 0.3% of all benign bone tumors. To date, about 150 cases involving the locomotor system have been reported. Histology is required for certain diagnosis of desmoplastic fibroma. The tumor is composed of sparse fibroblasts in a rich background of collagen fibers, a histological presentation exactly the same as soft tissue desmoid fibroma. We report two new cases of desmoplastic fibroma of the locomotor system. The observations illustrate the radiological diagnosis. MRI was used to search for local extension in bone or soft tissues. Biopsy is necessary to confirm the diagnosis. The histological presentation may be difficult to recognized and distinguish from low grade fibrosarcoma. After treatment, the rate of local recurrence is high in the event of partial resection. Surgery is the optimal treatment, with tumor resection as wide as possible depending on the localization.
Asunto(s)
Neoplasias Óseas , Fibroma Desmoplásico , Fibromatosis Agresiva , Huesos Pélvicos , Tibia , Adulto , Neoplasias Óseas/diagnóstico , Neoplasias Óseas/cirugía , Femenino , Fibroma Desmoplásico/diagnóstico , Fibroma Desmoplásico/cirugía , Fibromatosis Agresiva/diagnóstico , Fibromatosis Agresiva/cirugía , Humanos , MasculinoRESUMEN
We have previously described several receptors on the chondrocyte membrane. In an attempt to further characterize the coupling mechanisms of serotoninergic receptors, here we examined the involvement of serotonin in the phospholipase A2 activity. Serotonin dose-dependently stimulated phospholipase A2. This activation enhanced collagenase type II activity and had no effect on proteoglycanase activity.
Asunto(s)
Cartílago Articular/enzimología , Metaloendopeptidasas , Colagenasa Microbiana/biosíntesis , Osteoartritis/enzimología , Fosfolipasas A/biosíntesis , Serotonina/fisiología , Anciano , Cartílago Articular/patología , Endopeptidasas/metabolismo , Activación Enzimática , Humanos , Colagenasa Microbiana/metabolismo , Persona de Mediana Edad , Fosfolipasas A/metabolismo , Fosfolipasas A2RESUMEN
In this study, footprint and ground reaction forces (GRF) were simultaneously recorded from 32 male subjects running barefoot. Angle between the rearfoot and the forefoot in static (alpha S) and in running (alpha R) conditions, and orientation of both, rearfoot (alpha rf) and forefoot (alpha ff) with the direction of running (DOR), were measured and correlated to selected GRF parameters. The dynamic rearfoot/forefoot angle (alpha R) was correlated, positively with arch deformation (r = 0.58, P < 0.001), vertical Fz loading peak (r = 0.60, P < 0.001), mediolateral, and anteroposterior force rates (r = 0.47 and 0.48, P < 0.01), and negatively with stance time (r = -0.41, P < 0.05) and total course of the force application point path (r = -0.71, P < 0.001). Both a medial and a lateral rotation were observed on footprint between the rearfoot and the forefoot in the horizontal plane. A medially rotated forefoot ("closed foot") was associated to a rigid and inverted foot, whereas a laterally rotated forefoot ("open foot") was associated to a flexible and everted foot.
Asunto(s)
Pie/fisiología , Movimiento/fisiología , Carrera/fisiología , Adulto , Fenómenos Biomecánicos , Humanos , Masculino , PronaciónRESUMEN
Lipoma arborescens is a rare intra-articular tumor usually found in the knee joint. The reported lesion involved the inferomedial recess of the right hip synovium, in a 29-year-old male. The clinical findings were nonspecific. Both arthrography and computerized tomography (CT) of the hip disclosed the tumor which, on CT examination, showed an inhomogeneous low density, due to its fat content. The final diagnosis was given by histological examination of the resected mass. No recurrence was observed after one year. The long-term prognosis probably depends more on the underlying disorder of the joint than on the lipoma itself.
Asunto(s)
Articulación de la Cadera , Lipoma/diagnóstico por imagen , Neoplasias de los Tejidos Blandos/diagnóstico por imagen , Membrana Sinovial , Adulto , Artrografía , Humanos , Masculino , Tomografía Computarizada por Rayos XRESUMEN
Seventy-two patients with a localized osteosarcoma were treated between September 1979 and December 1987 by neoadjuvant chemotherapy, local surgery and post-operative chemotherapy. Chemotherapy regimens varied throughout the years but always comprised high dose methotrexate with leucovorin rescue and adriamycin pre-operatively for children under the age of 15, and ifosfamid and cis platinum in adults. Post-operative chemotherapy for bad responders (greater than 10% of residual malignant cells), was at first an association of adriamycin and cis platinum, and later of holoxan and cis platinum. Surgery changed from amputation to local conservative surgery (graft or prosthesis) which is now the most frequent surgery--61% of the patients are alive and disease-free at 5 years. Good responders to pre-operative chemotherapy have a much better prognosis (81% at 5 years) than bad responders (45%). There is no significant difference according to age or pre-operative chemotherapy regimen.
Asunto(s)
Neoplasias Óseas/terapia , Osteosarcoma/terapia , Adolescente , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Neoplasias Óseas/tratamiento farmacológico , Neoplasias Óseas/cirugía , Niño , Cisplatino/uso terapéutico , Terapia Combinada , Doxorrubicina/uso terapéutico , Femenino , Humanos , Ifosfamida/uso terapéutico , Masculino , Recurrencia Local de Neoplasia , Osteosarcoma/tratamiento farmacológico , Osteosarcoma/cirugía , Pronóstico , Estadística como Asunto , Factores de TiempoRESUMEN
The proposed study consists in moving several bones such as pelvis, femur and tibia in conditions as similar as possible to those obtained in a walking subject, to evidence the functioning of this hip and knee joints. The analysis is performed during the stance phase when the joints are loaded. This study is the first phase of a research consisting in: (i) the visualization of the motion of joints in both normal and pathologic subjects; and (ii) the calculation in real time of articular loading caused by muscular forces when sustaining both the external and inertial loads. This research will provide the kinematic and dynamic boundary conditions applied to both a knee and a hip prosthesis of the patient in movement.
Asunto(s)
Procesamiento de Imagen Asistido por Computador/métodos , Caminata/fisiología , Artrografía , Fenómenos Biomecánicos , Huesos/diagnóstico por imagen , Huesos/fisiología , Gráficos por Computador , Simulación por Computador , Marcha , Humanos , Articulaciones/fisiología , Movimiento (Física)RESUMEN
Difficult diagnostic and therapeutic problems are raised by perforations of the cervical oesophagus or hypopharynx in patients undergoing surgery to the cervical spine via an anterior approach. Based on their experience of three recent cases, the authors review the diagnostic approach, based on clinical examination and diatrizoate sodium oesophageal series, and propose conservative treatment consisting of surgical drainage with or without suture of the perforation and without removal of the osteosynthesis material, appropriate antibiotic therapy and hypercaloric enteral nutrition via nasogastric tube. The prevention of this complication is based on correct use of surgical retractors.
Asunto(s)
Vértebras Cervicales/cirugía , Perforación del Esófago/etiología , Fracturas Óseas/cirugía , Hipofaringe/lesiones , Complicaciones Posoperatorias , Adulto , Perforación del Esófago/diagnóstico , Perforación del Esófago/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Factores de Tiempo , Heridas Penetrantes/diagnóstico , Heridas Penetrantes/etiología , Heridas Penetrantes/terapiaRESUMEN
Vascular injuries during orthopaedic hip surgery are rare. However, they must always be feared because they threaten life and limb. We present 11 vascular injuries observed over a 12-year period. Seven women and 4 men, treated by elective surgery, presented 14 vascular injuries (6 arterial, 5 venous and 3 prosthetic vascular graft). Four injuries occurred during revision procedures. They were all operated as an emergency for ischaemic syndrome (6 cases) and/or haemorrhage (7 cases). Four patients (37%) died and 4 developed sequelae, various directly attributable to the vascular injury. In the light of these cases, we tried to determine the various mechanisms of the injury and the orthopedic and vascular risk factors. Preoperative detection and well defined therapeutic rules are very important for the prevention of these severe vascular accidents.
Asunto(s)
Artroplastia de Reemplazo de Cadera/efectos adversos , Vasos Sanguíneos/lesiones , Enfermedad Iatrogénica/prevención & control , Enfermedades Vasculares/prevención & control , Adulto , Anciano , Anciano de 80 o más Años , Artroplastia de Reemplazo de Cadera/mortalidad , Urgencias Médicas , Femenino , Humanos , Masculino , Persona de Mediana Edad , Cuidados Preoperatorios , Radiografía , Reoperación , Estudios Retrospectivos , Factores de Riesgo , Enfermedades Vasculares/diagnóstico por imagen , Enfermedades Vasculares/etiologíaRESUMEN
In 45 patients, 65 hips with CDH were given a THR after 5 years or more, with an average follow up of 8.5 years. The results and the technical problems are discussed. Of those 65 hips, there were 46 anterior dislocations, 15 intermediate dislocations and 4 cases of posterior dislocation. The mean shortening was 58.3 mm. In all cases, the authors performed a total arthroplasty on the original acetabulum, after lowering and reconstruction of the acetabulum by grafts taken from the femoral head. There are some immediate postoperative complications: 12 thromboembolic complications, hematomas and 2 cases of paralysis of the peroneal nerve. There was loosening in 8 patients (12%), with 3 infections. The functional results were good in 85% and poor in 7.5%. Nevertheless, the limp was maintained in 49 patients. There was residual low back pain in 7 patients. In 14% a second operation on the homolateral knee was performed after an average time of 2 years. The technical problems are discussed: the cup should be placed in the original acetabulum and in evaluating the lowering of the acetabulum, the condition of the lumbar spine should be considered. Posterior luxation is discussed as well; the authors recommend prudence in the indication for THR operations with lowering of the acetabulum shell.
Asunto(s)
Luxación Congénita de la Cadera/complicaciones , Prótesis de Cadera , Osteoartritis de la Cadera/cirugía , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis de la Cadera/etiología , Complicaciones Posoperatorias/etiologíaRESUMEN
Between 1965 and 1989, 46 desmoid tumors were observed in the hospitals of Lyon. Twenty-eight patients with an extra-abdominal tumor, with a follow-up of at least 6 months were observed. In this group, there were 12 males and 16 females with an average of 26.7 years. Surgical treatment was performed in 26 cases (in one case no treatment was given and in another case isolated chemotherapy was given). In 21 cases (80%) a recurrence of the tumor was seen after the first excision, incomplete in 6 cases. The highest rate of recurrence was seen in the neck, the girdles and the lower limbs; at the end of our review, 9 patients still had a tumor. No primary amputation were performed but two late amputations, one of which was major, were necessary. One tumor evolved into a sarcoma and in another case, lung metastases were seen. Associated radiotherapy was given in 9 cases with resolution in 55%. Tamoxifen was used in 5 cases with stabilization of the tumor. The risk of recurrence was higher in males (p = 0.0147). Age less than 30 years, and incomplete removal of the tumor were the other predictive factors for recurrence (the difference was not significant).
Asunto(s)
Fibroma/cirugía , Neoplasias de los Tejidos Blandos/cirugía , Adolescente , Adulto , Transformación Celular Neoplásica , Niño , Preescolar , Terapia Combinada , Femenino , Fibroma/patología , Fibroma/terapia , Humanos , Masculino , Persona de Mediana Edad , Metástasis de la Neoplasia , Recurrencia Local de Neoplasia , Sarcoma/patología , Neoplasias de los Tejidos Blandos/patología , Neoplasias de los Tejidos Blandos/terapiaRESUMEN
PURPOSE OF THE STUDY: The technique, results and indications for arthroscopic ankle fusion are detailed and compared with open technics. MATERIAL AND METHODS: 10 arthroscopic ankle fusions were performed between 1991 and 1993. This procedure was used in 4 cases of rheumatoid arthritis, 5 cases of osteoarthritis and 1 case of joint destruction consecutive to hemophilia. All patients were followed until fusion with an average follow-up of 12 months. The quality and position of the fusion were analyzed clinically and on radiograms. RESULTS: 9 patients obtained fusion in a neutral position and were able to walk with normal shoes. The average time to fusion was 14.5 weeks (8 to 40). 1 case failed and required reoperation after 15 months. No local complications were observed. DISCUSSION: Arthroscopic ankle fusion is a safe procedure with good results in cases with relatively little deformities. Its main interest lies in the low rate of complications. The technique does not increase the rate of fusion when compared to open technics. CONCLUSION: Arthroscopic fusion is recommended in cases with little to moderate deformities in the presence of poor wound healing factors.
Asunto(s)
Articulación del Tobillo/cirugía , Artrodesis/métodos , Artroscopía , Adulto , Anciano , Anciano de 80 o más Años , Traumatismos del Tobillo/complicaciones , Traumatismos del Tobillo/cirugía , Artrodesis/efectos adversos , Tornillos Óseos , Endoscopía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Osteoartritis/etiología , Osteoartritis/cirugía , Rango del Movimiento ArticularRESUMEN
This study reviews a series of 75 total hip prosthesis (THP) after high femoral osteotomy operated on between 1968 and 1986. The mean delay between osteotomy and THP was 14 years. 53 prosthesis were available for long term follow-up with a mean follow up of 7 years. It was included in the category of total hip prosthesis operations considered as difficult. The lateral view is indispensable to plan the operation. Valgus intertrochanteric osteotomies and moderate internal translations posed no problems. Trochanteric osteotomy did not have to be systematic; it's inconveniences were not neglectible. It was reserved for isolated varizations for it modifies the axis of entry of the stem. The reamer was used in cases of narrowing of the femoral canal; notably after significant medializations. Derotation osteotomy was the last resort when it was impossible to position the stem secondary to a subtrochanteric osteotomy or significant angulation in the sagittal plane. An intertrochanteric osteotomy, when correctly realised, posed few problems during placement of a total hip prosthesis and licits a continued use in young subjects. Results of THP after intertrochanteric osteotomy compared well with primary THP, with 77.5 per cent good results and 15 per cent loosening. In addition to problems posed by etiologies (congenital dislocations), subtrochanteric osteotomies rendered cementing extremely difficult, even impossible. At long term, only 14.5 per cent of the results were good and the loosening rate was 45 per cent. Fortunately subtrochanteric osteotomies are practically abandoned.
Asunto(s)
Fémur/cirugía , Prótesis de Cadera , Osteotomía , Adolescente , Adulto , Niño , Estudios de Seguimiento , Prótesis de Cadera/efectos adversos , Prótesis de Cadera/métodos , Humanos , Persona de Mediana Edad , Osteotomía/efectos adversos , Osteotomía/métodos , Estudios Retrospectivos , Factores de TiempoRESUMEN
The authors have reviewed 25 cases of associated fractures of neck and shaft of the same femur. Some were treated conservatively, others were operated on. They conclude that the best treatment should be surgical on both foci. They recommend nailing of the shaft, the nail being introduced in the anterior aspect of the greater trochanter, and screwing of the neck, the screws being located behind the nail. In cases of low diaphyseal fractures plating was used. However a high rate of non-unions was noted in such cases.
Asunto(s)
Fracturas del Fémur/complicaciones , Fracturas del Cuello Femoral/complicaciones , Clavos Ortopédicos , Placas Óseas , Fracturas del Fémur/cirugía , Fracturas del Cuello Femoral/cirugía , HumanosRESUMEN
After trochanteric fractures, the rate of survival of old patients was best when treated by the Ender method: 15% died during 3 months following the fracture. The procedure is uneasy and an excellent radiologic technique is necessary. The position of the proximal end of the first nail in the femoral head is most important. Excessive external rotation was frequent, but little desabling. Secondary displacement of the nails toward the distal end occurred in 25% of the cases and was difficult to avoid but remained moderate. The procedure is indicated in old people with porotic bones. It should not be done in subtrochanteric fractures.
Asunto(s)
Clavos Ortopédicos/efectos adversos , Fracturas de Cadera/cirugía , Adulto , Factores de Edad , Anciano , Femenino , Humanos , Masculino , Métodos , Persona de Mediana Edad , Complicaciones PosoperatoriasRESUMEN
PURPOSE OF THE STUDY: We report our experience with percutaneous sacroiliac screwing for unstable pelvic ring fracture. MATERIAL AND METHODS: Twenty unstable pelvic ring fractures with sacroiliac disjunction (9 cases), trans-sacral fracture (9 cases), or bilateral posterior fractures (5 cases) were managed with percutaneous sacroiliac fixation using 1 or 2 screws. There was also pubic disjunction in 7 cases, managed by osteosynthesis in 5 cases. No fixation of fractures of one or both of the obturator rings, present in 13 cases, was attempted. The posterior screwing was performed under fluoroscopic guidance in 15 cases and computed tomographic guidance in 5. RESULTS: There were no infectious or neurological complications. Radiographically, anatomic reduction of the posterior fracture was achieved in 10 cases. A vertical ascension persisted in 4 patients and a rotation in 6. Radiographic results were correlated with delay to surgery: correction of the vertical displacement was achieved in 80% of the patients operated before five days and in 55% of the others. Two patients experienced a secondary displacement. There was no cases of nonunion of either the anterior or posterior fracture. Follow-up was available for 14 patients (2 patients died and follow-up was too short for 4). The mean Majeed score was 92/100 and none of the patients experienced anterior pain. Three patients had moderate pain in the sacroiliac area. DISCUSSION: The ventral position appears to be best adapted for percutaneous sacroiliac screwing but can be contraindicated by concomitant lesions. We prefer fluoroscopic guidance for these emergency procedures. Two views, ascending and descending, appear sufficient. The better stability provided by two screws can be achieved under computed tomographic guidance without risk of neurovascular damage. CONCLUSION: Percutaneous sacroiliac screwing is a good management strategy for unstable pelvic ring fractures with little risk of morbidity.
Asunto(s)
Tornillos Óseos , Fijación Interna de Fracturas/métodos , Fracturas Óseas/cirugía , Luxaciones Articulares/cirugía , Huesos Pélvicos/lesiones , Articulación Sacroiliaca/lesiones , Actividades Cotidianas , Adolescente , Adulto , Anciano , Femenino , Fluoroscopía/métodos , Estudios de Seguimiento , Fijación Interna de Fracturas/efectos adversos , Fijación Interna de Fracturas/instrumentación , Curación de Fractura , Fracturas Óseas/clasificación , Fracturas Óseas/complicaciones , Fracturas Óseas/diagnóstico por imagen , Humanos , Puntaje de Gravedad del Traumatismo , Luxaciones Articulares/clasificación , Luxaciones Articulares/complicaciones , Luxaciones Articulares/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Traumatismo Múltiple/complicaciones , Dolor Postoperatorio/etiología , Radiografía Intervencional/métodos , Tomografía Computarizada por Rayos X/métodos , Resultado del TratamientoRESUMEN
PURPOSE OF THE STUDY: The aim of this study was to analyze clinical and radiographic results after surgical treatment of acetabular fractures. MATERIAL AND METHODS: We reviewed 60 consecutive fractures of the acetabulum with loss of joint congruency at mean 5-years follow-up after treatment. There were 49 men and 11 women, mean age 41 years. According to the R.O. grading, the fractures were: 22 class A (33.3%) including 17 type A1, 23 class B (38%) including 10 type B1a2, 14 class C (23.3%) and 1 unclassifiable. Eight of the patients had associated pelvic injury, 40 had hip dislocations and 9 had sciatic nerve injury. Ten femoral head fractures were discovered during the surgical procedure. Three surgical approaches were used: 1) Kocher Langenbeck approach (28 cases), 2) Mears and Rubash triradiate approach (8 cases), 3) extended iliofemoral approach (22 cases), 4) other approaches (2 cases). Anteroposterior and 45 degrees oblique view of the pelvis were obtained for all patients following admission. Computerized tomography scans were performed in all cases. Fracture displacement and congruency of the femoral head with the roof were documented according to the SOFCOT radiographic criteria. The quality of reduction was assessed using the Matta criteria and the Duquennoy and Senegas criteria. Clinical outcome was assessed at follow-up using the Postel-Merle-d'Aubigné score. RESULTS: Anatomic reduction was achieved in 62% of the cases (1 mm or less displacement on all views) and congruency of the femoral head with the roof was excellent in 73% of the cases. Clinical outcome was satisfactory in 80% (excellent or good). Operative complications included significant ectopic bone in 21, and in 2 others sciatic nerve palsy that had resolved at 1 year follow-up. Three patients developed avascular necrosis of the femoral head. DISCUSSION: Clinical outcome depends on the quality of the reduction. Class C and class B fractures with roof injury should thus be treated by large surgical exposure. The triradiate approach increases the incidence of ectopic bone. The higher incidence of ectopic bone in patients treated by osteotomy of the trochanter compared with patients without osteotomy of the trochanter was significant (p<0.05). Avascular necrosis of the femoral head was associated with delayed reduction (66% of the cases). CONCLUSION: Our good clinical results are encouraging; we are pursuing the use of surgical treatment for displaced acetabular fractures. Clinical outcome depends on the use of the appropriate surgical approach.