Complex fractures of the acetabulum: Should the enlarged iliofemoral approach be abandoned? Results at 20 years' follow-up.

INTRODUCTION: Among the various options for internal fixation of acetabular fractures, the enlarged iliofemoral approach is less often used, being more invasive, although providing greater exposure enabling control of all components in complex fractures. Even so, the impact of its invasiveness has not been confirmed, and long-term results are not known. We therefore performed a retrospective study, aiming: to assess long-term functional outcome, and; to assess associated morbidity. HYPOTHESIS: The enlarged iliofemoral approach allows precise reduction, with favorable long-term outcome. MATERIAL AND METHODS: Between 1992 and 1997, 15 patients were operated on for complex acetabular fracture by a single surgeon using an enlarged iliofemoral approach. Two patients were excluded due to lack of follow-up data, leaving 13 patients for analysis: 3 simple transverse fractures, 4 transverse+posterior wall fractures, 4 anterior column+posterior hemi-transverse fractures, one T-shaped fracture and one 2-column fracture. There were 4 cases of posterior dislocation of the hip, and 8 of intrapelvic protrusion. Surgical morbidity was assessed in terms of operative time, number of packed red blood cell transfusions, iatrogenic lesions or postoperative complications, rehabilitation time, and hospital stay. Functional assessment at follow-up used the WOMAC index and Harris score; radiologic assessment used the Kellgren-Lawrence score for osteoarthritis and Brooker score for ossification. RESULTS: Reduction was in all cases anatomic. There were no intra- or post-operative complications. Median number of packed red blood cell transfusions was 5 [range, 3-10]. Median operative time was 4hours [3-6]. Median hospital stay was 6 weeks [6-8], to allow systematic traction with early postoperative mobilization. Weight-bearing was resumed at a median 8 weeks [8-12]. At a median 22 years' follow-up [20-24], median Harris score was 83.5 [63-92] and median WOMAC index 24.5 [1-52]. All patients showed Brooker 1 or 2 ectopic ossification and moderate osteoarthritis. Two underwent subsequent arthroplasty (at 1 and 11 years after the index procedure). DISCUSSION: The enlarged iliofemoral approach allowed anatomic reduction of acetabular fracture. It provided very good long-term results, without excessive morbidity. LEVEL OF EVIDENCE: IV, retrospective non-controlled study.

Embryology of the internal carotid artery dural crossing: apropos of a continuous series of 48 specimens.

The aim of this study was to describe the embryologic and foetal development of the anterior paraclinoid region and more precisely the relationship of the internal carotid artery to the dura mater. This has been done by examining a collection of histological sections, representing a continuous series of 48 embryologic and foetal specimens, covering the period of the first 6 months of intra-uterine life. Neurological and vascular elements develop during the embryologic period; the internal carotid artery is recognizable in the various sections of its course and acquires a histological adult parietal constitution. The foetal period corresponds to the development of the meningeal structures. The superior, medial and lateral walls appear on the fifteenth week of amenorrhoea and do not change after that. The internal carotid artery enters subarachnoid space accompanied by a sleeve of mesenchymatous cells, which fixes it to the anterior clinoid process. The constitution of this sleeve, arising from the superior wall of the lateral sellar compartment, remained independent of the principle vascular part, which allows the formation of a plan of cleavage. The foetal relations of the dura mater and the internal carotid artery were seen to be different from those of adult subjects described in the literature, suggesting an existence of period of maturation postnatally.

[Atlantoaxial synovial cyst. A case report]. / Kyste synovial atlanto-axoidien. Aspects cliniques et propositions chirugicales.

The case of a 62-year-old patient with an atlanto-axial synovial cyst is presented. The narrowing of the spinal canal was associated with anterior medullar compression and neurological deficit. A transoral approach with odontoid resection was performed. The diagnostic of synovial cyst was histologically confirmed. Secondary atlanto-axial instability required posterior fixation completed by C1-C2 transarticular screw fixation. The follow-up showed an improvement of the neurological deficit. Similar cases reported in the literature are reviewed and discussed.

Embryology of the walls of the lateral sellar compartment: apropos of a continuous series of 39 embryos and fetuses representing the first six months of intra-uterine life.

The aim of this study was a continuous and rather exhaustive description of the embryological development of the lateral sellar compartment. The histological sections of 39 embryos and fetuses were studied, and represent the first six months of intra-uterine life. The embryological period showed the organization of the content of the compartment. The medial and lateral walls appeared during the 15th week of amenorrhoea, and did not modify later. The medial wall was constituted in its rostral part by the hypophyseal lodge and in its caudal part by the periosteum of the sphenoid bone. Two layers formed the lateral wall: the superficial layer was an expansion of the dura mater that surrounded the oculomotor nerves along their course to the superior orbital fissure; the deep layer was weaker, and surrounded and joined the nerves together. The results of this study advocate the evolution of the nomenclature of this region, as the term "inter-periosto-dural space" would better reflect the real pattern of the lateral sellar compartment. Furthermore, the presence of a communication between the two lateral sellar compartments has led to a discussion of the previous hypothesis about the development of the lateral sellar compartment. The venous network was located on both the medial and lateral sides of the internal carotid artery, but expanded in the lateral wall of the lateral sellar compartment. That is of interest to surgeons and radiologists because it could explain some hemorrhagic complications.