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Re: Нелеченный перелом вертлужной впадины
послал Christian Veillette 23 Март 2007, 17:58
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Alex
What is your indication for surgical management? What kind of fracture do you think it is? It looks like a transverse type although it has been a couple of years since I looked at an acetabular fracture.
Displaced acetabular fractures: indications for operative and nonoperative management.
Tornetta P 3rd. Department of Orthopaedic Surgery, Boston University School of Medicine,
Boston, MA, USA.
Displaced acetabular fractures are a challenging problem. In contradistinction to most conditions in which surgery is based on specific operative indications, displaced acetabular fractures should be considered an operative problem unless specific criteria for nonoperative management are met. These include a congruent hip joint on the anteroposterior and oblique (Judet) radiographs, an intact weight-bearing surface (as defined by roof arc and subchondral arc measurements on computed tomographic scans), and a stable joint. The final decision about the treatment method must also consider the patients functional demands, expectations, and physical condition and the physicians experience and institutional support for dealing with this type of injury. Displaced both-column fractures with secondary congruence may have better results than other displaced fractures.
In older patients, nonoperative management may be effectively utilized.
Understanding the current criteria for effective use of nonoperative treatment will help the surgeon make these difficult decisions.
J Am Acad Orthop Surg. 2001 Jan-Feb;9(1):18-28.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Ab
stractPlus&list_uids=11174160&query_hl=5&itool=pubmed_docsum
Can you improve the reduction at this stage or will you end up with an OIF (Open internal fixation) and leave it malreduced?
Delayed reconstruction of acetabular fractures 21-120 days following injury.
Johnson EE, Matta JM, Mast JW, Letournel E.
Department of Orthopaedic Surgery, University of California, Los Angeles
90024.
A retrospective review was performed of 207 patients treated by delayed reconstruction of acetabular fracture between 21 and 120 days following injury. Nineteen patients were lost to followup. One hundred eighty seven patients had 188 fractures classified as follows; 35 posterior wall, 9 posterior column, 5 anterior wall, 4 anterior column, 13 transverse, 49 transverse/posterior wall, 21 T shape, 8 posterior column/posterior wall, 8 anterior column posterior hemitransverse, and 34 both column fractures. The
average preoperative delay was 43 days. Followup averaged 6.5 years (range, 9 months-30 years). Overall good to excellent results were achieved in 65% of patients, fair in 9%, and poor in 26%. Good to excellent results by fracture type were; posterior wall (51%), posterior column (89%), anterior wall (60%), anterior column (100%), transverse (69%), transverse/posterior wall (59%), T shape (62%), posterior column/posterior wall (88%), anterior column/posterior hemitransverse (75%), and both column (72%). Heterotopic ossification developed in 49 of 168 patients without prophylactic treatment, in 6 of 12 treated prophylactically with diphosphonate, and in 2 of 27 receiving prophylactic indomethacin therapy. There were 20 postoperative sciatic nerve palsies, 3 immediate and 5 delayed infections, 5 cases of
pulmonary embolism, and 26 cases of avascular necrosis. Delayed management
of acetabular fractures increases the difficulty of operative treatment and may result in a significant reduction in good to excellent results. Simple anterior or posterior wall fractures, associated transverse + posterior wall
fractures, and T shape fractures have an increased risk of failure when treated within this time period.
Clin Orthop Relat Res. 1994 Aug;(305):20-30.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Ab
stractPlus&list_uids=8050229&query_hl=3&itool=pubmed_DocSum
My concern would be that the risk of leaving it malreduced is very high. It appears to be primarily a gap rather than a step in the articular surface. Do you have any CT views that show an articular step?
Regards
Christian
****************************************
Christian Veillette M.D., FRCSC, M.Sc., B.Sc.(Hon)
Upper Extremity Reconstruction & Trauma Fellow
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