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Re: Застарелое повреждение таза
послал Chip Routt 22 Декабрь 2004, 21:40
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It¹s too bad to miss caring for her acutely.
The infection history and recurrence complicate the situation, and you will need to sort that out clinically and radiographically as necessary.
Should you deem her fit for surgery, the 3-D CT alone is insufficient for planning preoperatively. We can¹t see the healing response, soft tissue envelope, the right SI injury, nor the left SI joint problem well enough on the 3-D CT alone.
Based on what you¹ve shown-
1. Ignore the left sided SI joint malunion, assuming that it is stable...is that accurate? If not, start there with a debridement, reduction, and fixation of your preference.
2. Then plan for a long OR day and use a blood salvage suction system.
3. First approach the greater sciatic notch limb of the injury using a KL exposure, debride that portion of the fracture, and also sharply release the contracted local soft tissues such as the sacrospinous and sacrotuberous ligament complexes...then close and turn supine.
4. Use an ilioinguinal exposure to release all local soft tissue tethers, debride the iliac limb, the ipsilateral ramus, and the contralateral ramus injuries. You can also debride and mobilize the right sided SI joint if it¹s indicated.
5. Then start moving the right ³floating acetabular segment² back home. This may require clamps or other manipulation techniques. Sometimes the distractor can be used if the contralateral posterior pelvic ring is stable (which takes us back to the #1 comment above). Some like a traction table or other manipulating reduction techniques.
6. Fix the all fractures and their limbs with stable fixation of your choice. Lag screws, buttressing plates, and other ³smart² fixation would be good for her.
7. Some might prefer a period of postoperative traction, or other creative external skeletal support....you¹ve demonstrated skill with such devices in the past!
8. Have an ICU bed ready for her after surgery
Or you can just strategically insert some wires where they need to be, hook up some rings and threaded bars creatively, move it all around magically, and show us the perfect result without scars nor infection... at least that¹s been your history, so I remain suspicious!!
That¹s about it-
Chip
M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA
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