Knee Surg Sports Traumatol Arthrosc (2014) 22:867–870 DOI 10.1007/s00167-013-2799-y
HIP
Arthroscopic reduction and internal fixation of acetabular fractures Hyangkyoung Kim • Ji-Hoon Baek Sang-Min Park • Yong-Chan Ha
•
Received: 4 May 2013 / Accepted: 25 November 2013 / Published online: 5 December 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Arthroscopic reduction and screw fixation of acetabular fractures have not been reported. In this case report, arthroscopic treatment for acetabular fracture is reported for two patients. A 49-year-old man diagnosed with acetabular posterior wall fracture was treated by arthroscopic reduction and fixation using two screws. A 20-year-old woman who diagnosed with anterior column fracture was fixed using a screw using the arthroscopic technique prior to open reduction and internal fixation in the iliac bone fracture. Arthroscopic reduction and fixation in some case of acetabular fracture could be good indication with additional advantages of joint debridement and loose body removal. Level of evidence V.
distal radius, and scaphoid [1, 2, 7]. However, arthroscopic management for fractures of the hip joint is challenging because of the deep surgical field and confined working space [5]. Several studies have reported the use of arthroscopic treatment for traumatic fractures of the hip joint [4, 10, 11], but no study have documented completely arthroscopic reduction and internal fixation of acetabular fractures. In this report, two cases of arthroscopic reduction and internal fixation are presented in the management of two young patients with acetabular posterior wall fracture or anterior column fracture.
Case report Keywords Arthroscopic reduction Arthroscopic internal fixation Acetabular fracture Hip arthroscopy
Introduction The use of arthroscopic-assisted fixation is useful for treating several intra-articular fractures, such as tibial plateau, ankle joint, calcaneus, glenoid, radial head, coronoid,
H. Kim Department of Surgery, Chung-Ang University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, South Korea J.-H. Baek (&) S.-M. Park Y.-C. Ha Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, South Korea e-mail: [email protected]
Case 1 A 49-year-old man was injured in a car accident while driving, sustaining a fracture and dislocation of his right hip joint (Fig. 1). After no other problems were verified in the emergency room, closed reduction was initially attempted and the right hip joint was reduced to an anatomical position. After post-reduction radiological and computed tomography evaluation, the displaced posterior wall fracture was found and the absence of impaction of the articular joint was confirmed. We decided to perform arthroscopic reduction and internal fixation with screws. Under general anaesthesia, the patient was positioned supine on a fracture table with the affected limb in traction and the opposite limb in 40° to 45° of abduction. A C-arm was used to provide an anteroposterior view of the affected side. Adequate traction was applied to the affected limb to provide sufficient distraction by 10–12 mm at the hip joint. First, we used an anterolateral portal as a viewing portal
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Knee Surg Sports Traumatol Arthrosc (2014) 22:867–870
Fig. 1 a Pelvis anteroposterior view of the patient in case 1 shows fracture and dislocation of the right hip joint. b Two 4.0mm-diameter cannulated screws were used to fixate fracture site under direct arthroscopic visualization. c Reduction in intra-articular fracture gap was confirmed by arthroscopy. d Post-operative pelvis anteroposterior view shows anatomical reduction in posterior wall fracture
under fluoroscopic guidance, and other two portals (anterior and posterolateral portals) were made additionally. The fracture fragment of the acetabular posterior wall was visualized after haematoma evacuation and was displaced posteriorly. The fracture fragment was reduced into the intact acetabular side using two 0.45-inch Kirschner-wires (K-wires) via the anterolateral and posterolateral portals, and the reduced fracture fragment was temporarily fixed by two K-wires. After anatomical reduction in the fracture site was confirmed by arthroscopy, we used two 4.0-mm-diameter cannulated screws to fixate the fragment under direct arthroscopic visualization (Fig. 1). The patient was instructed to walk with partial weight-bearing with the aid of two crutches for 6 weeks after surgery. By 3 months post-operatively, he had no pain and recovered full activities. At the minimum 2-year follow-up period, the fracture was completely united. Case 2 A 20-year-old woman was injured in a car accident while driving, sustaining a displaced fracture of the anterior column involving the right acetabular dome. Positioning of the patient was the same as detailed in case 1. Initially, arthroscopic debridement and haematoma evacuation were performed, and the displaced fracture of acetabular anterior column was visualized. We used a 3.5-mm-diameter
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cortical screw to compress and fixate the gap of the dome from the anterior to the posterior direction under direct arthroscopic visualization. An additional plate and screws were fixed on the iliac wing via open approach (Fig. 2). By 3 months post-operatively, the patient was pain-free and had recovered full activities. At the minimum 2-year follow-up period, the fracture was completely united.
Discussion The arthroscopic reduction and internal fixations were successful in the management of acetabular posterior wall fracture and simple anterior column fracture in these two patients. Although several reports have described arthroscopic treatment for traumatic hip fracture dislocations [3, 4, 6, 10, 11], only two cases reported arthroscopic treatment for acetabular fracture. Yamamoto et al. [10] reported reduction and percutaneous fixation in patients with acetabular fracture, and recently, Yang et al. [11] reported arthroscopic guided percutaneous screw fixation of minimal displaced acetabular fractures. In these cases, percutaneous screw fixation of the anterior column of the acetabulum was performed under guidance of hip arthroscopy to enable direct visual confirmation of the quality of the reduction and avoid any acetabular penetration with the screws. However, the previous two cases should have involved
Knee Surg Sports Traumatol Arthrosc (2014) 22:867–870
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Fig. 2 a Preoperative computed tomography of the patient in case 2 reveals a displaced fracture of the anterior column involving the right acetabular dome. b One 3.5-mm-diameter cortical screw was used to
fix the fracture site under direct arthroscopic visualization. c Postoperative pelvis anteroposterior view shows an antegrade screw fixation of the anterior column and a plate fixation of the iliac wing
Table 1 Comparison of arthroscopic surgery in traumatic hip fracture patients References
Number of operative patients
Number of basic procedures
Number of osteosynthesis of femoral head
Number of osteosynthesis of acetabular fracture
Other
Yamamoto et al. [10]
10
8
1
1
Percutaneous pinning
Mullis et al. [6]
33
33
0
0
Only loose body removal
Owens et al. [8] Matsuda [4]
11 1
11 0
0 1
0 0
Only loose body removal Arthroscopic reduction and internal fixation
Yang et al. [11]
2
0
0
2
Percutaneous pinning
Present study
2
0
0
2
Arthroscopic reduction and internal fixation
screw fixation using the percutaneous technique (Table 1). In the present cases, we performed reduction and internal fixation using arthroscopic viewing and working portals. To our knowledge, we are the first to report the use of hip arthroscopic reduction and screw fixation of acetabular fractures. Advantages of arthroscopic surgery as a minimally invasive procedure include minimized blood loss, early joint mobilization, relatively rapid post-operative rehabilitation, and outstanding cosmesis [1, 9]. However, this study has several limitations. First, this type of surgery can be done only by surgeons who are highly specialized in arthroscopic hip surgical technique. Second, the indications of hip arthroscopic surgery are narrow and can be made only for those cases with minimal and moderate displaced acetabular fractures. Third, arthroscopic instruments for fixation of reduced acetabulum require further improvement. In case of obese patients, arthroscopic screw fixation is not feasible because of shortening of conventional guide and drills.
In conclusion, arthroscopic reduction and fixation could be indicated for hip injury in some cases of acetabular fracture with additional advantages of joint debridement and loose body removal. Conflict of interest
None.
References 1. Atesok K, Doral MN, Whipple T, Mann G, Mei-Dan O, Atay OA, Beer Y, Lowe J, Soudry M, Schemitsch EH (2011) Arthroscopyassisted fracture fixation. Knee Surg Sports Traumatol Arthrosc 19:320–329 2. Chan YS, Chiu CH, Lo YP, Chen AC, Hsu KY, Wang CJ, Chen WJ (2008) Arthroscopy-assisted surgery for tibial plateau fractures: 2- to 10-year follow-up results. Arthroscopy 24:760–768 3. Ilizaliturri VM Jr, Gonzalez-Gutierrez B, Gonzalez-Ugalde H, Camacho-Galindo J (2011) Hip arthroscopy after traumatic hip dislocation. Am J Sports Med 39(Suppl):50S–57S 4. Matsuda DK (2009) A rare fracture, an even rarer treatment: the arthroscopic reduction and internal fixation of an isolated femoral head fracture. Arthroscopy 25:408–412
123
870 5. McCarthy JC, Lee JA (2006) Hip arthroscopy: indications, outcomes, and complications. Instr Course Lect 55:301–308 6. Mullis BH, Dahners LE (2006) Hip arthroscopy to remove loose bodies after traumatic dislocation. J Orthop Trauma 20:22–26 7. Ono A, Nishikawa S, Nagao A, Irie T, Sasaki M, Kouno T (2004) Arthroscopically assisted treatment of ankle fractures: arthroscopic findings and surgical outcomes. Arthroscopy 20:627–631 8. Owens BD, Busconi BD (2006) Arthroscopy for hip dislocation and fracture-dislocation. Am J Orthop (Belle Mead NJ) 35: 584–587
123
Knee Surg Sports Traumatol Arthrosc (2014) 22:867–870 9. Stevens MS, Legay DA, Glazebrook MA, Amirault D (2010) The evidence for hip arthroscopy: grading the current indications. Arthroscopy 26:1370–1383 10. Yamamoto Y, Ide T, Ono T, Hamada Y (2003) Usefulness of arthroscopic surgery in hip trauma cases. Arthroscopy 19: 269–273 11. Yang JH, Chouhan DK, Oh KJ (2010) Percutaneous screw fixation of acetabular fractures: applicability of hip arthroscopy. Arthroscopy 26:1556–1561
HIP
Arthroscopic reduction and internal fixation of acetabular fractures Hyangkyoung Kim • Ji-Hoon Baek Sang-Min Park • Yong-Chan Ha
•
Received: 4 May 2013 / Accepted: 25 November 2013 / Published online: 5 December 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Arthroscopic reduction and screw fixation of acetabular fractures have not been reported. In this case report, arthroscopic treatment for acetabular fracture is reported for two patients. A 49-year-old man diagnosed with acetabular posterior wall fracture was treated by arthroscopic reduction and fixation using two screws. A 20-year-old woman who diagnosed with anterior column fracture was fixed using a screw using the arthroscopic technique prior to open reduction and internal fixation in the iliac bone fracture. Arthroscopic reduction and fixation in some case of acetabular fracture could be good indication with additional advantages of joint debridement and loose body removal. Level of evidence V.
distal radius, and scaphoid [1, 2, 7]. However, arthroscopic management for fractures of the hip joint is challenging because of the deep surgical field and confined working space [5]. Several studies have reported the use of arthroscopic treatment for traumatic fractures of the hip joint [4, 10, 11], but no study have documented completely arthroscopic reduction and internal fixation of acetabular fractures. In this report, two cases of arthroscopic reduction and internal fixation are presented in the management of two young patients with acetabular posterior wall fracture or anterior column fracture.
Case report Keywords Arthroscopic reduction Arthroscopic internal fixation Acetabular fracture Hip arthroscopy
Introduction The use of arthroscopic-assisted fixation is useful for treating several intra-articular fractures, such as tibial plateau, ankle joint, calcaneus, glenoid, radial head, coronoid,
H. Kim Department of Surgery, Chung-Ang University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, South Korea J.-H. Baek (&) S.-M. Park Y.-C. Ha Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, South Korea e-mail: [email protected]
Case 1 A 49-year-old man was injured in a car accident while driving, sustaining a fracture and dislocation of his right hip joint (Fig. 1). After no other problems were verified in the emergency room, closed reduction was initially attempted and the right hip joint was reduced to an anatomical position. After post-reduction radiological and computed tomography evaluation, the displaced posterior wall fracture was found and the absence of impaction of the articular joint was confirmed. We decided to perform arthroscopic reduction and internal fixation with screws. Under general anaesthesia, the patient was positioned supine on a fracture table with the affected limb in traction and the opposite limb in 40° to 45° of abduction. A C-arm was used to provide an anteroposterior view of the affected side. Adequate traction was applied to the affected limb to provide sufficient distraction by 10–12 mm at the hip joint. First, we used an anterolateral portal as a viewing portal
123
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Knee Surg Sports Traumatol Arthrosc (2014) 22:867–870
Fig. 1 a Pelvis anteroposterior view of the patient in case 1 shows fracture and dislocation of the right hip joint. b Two 4.0mm-diameter cannulated screws were used to fixate fracture site under direct arthroscopic visualization. c Reduction in intra-articular fracture gap was confirmed by arthroscopy. d Post-operative pelvis anteroposterior view shows anatomical reduction in posterior wall fracture
under fluoroscopic guidance, and other two portals (anterior and posterolateral portals) were made additionally. The fracture fragment of the acetabular posterior wall was visualized after haematoma evacuation and was displaced posteriorly. The fracture fragment was reduced into the intact acetabular side using two 0.45-inch Kirschner-wires (K-wires) via the anterolateral and posterolateral portals, and the reduced fracture fragment was temporarily fixed by two K-wires. After anatomical reduction in the fracture site was confirmed by arthroscopy, we used two 4.0-mm-diameter cannulated screws to fixate the fragment under direct arthroscopic visualization (Fig. 1). The patient was instructed to walk with partial weight-bearing with the aid of two crutches for 6 weeks after surgery. By 3 months post-operatively, he had no pain and recovered full activities. At the minimum 2-year follow-up period, the fracture was completely united. Case 2 A 20-year-old woman was injured in a car accident while driving, sustaining a displaced fracture of the anterior column involving the right acetabular dome. Positioning of the patient was the same as detailed in case 1. Initially, arthroscopic debridement and haematoma evacuation were performed, and the displaced fracture of acetabular anterior column was visualized. We used a 3.5-mm-diameter
123
cortical screw to compress and fixate the gap of the dome from the anterior to the posterior direction under direct arthroscopic visualization. An additional plate and screws were fixed on the iliac wing via open approach (Fig. 2). By 3 months post-operatively, the patient was pain-free and had recovered full activities. At the minimum 2-year follow-up period, the fracture was completely united.
Discussion The arthroscopic reduction and internal fixations were successful in the management of acetabular posterior wall fracture and simple anterior column fracture in these two patients. Although several reports have described arthroscopic treatment for traumatic hip fracture dislocations [3, 4, 6, 10, 11], only two cases reported arthroscopic treatment for acetabular fracture. Yamamoto et al. [10] reported reduction and percutaneous fixation in patients with acetabular fracture, and recently, Yang et al. [11] reported arthroscopic guided percutaneous screw fixation of minimal displaced acetabular fractures. In these cases, percutaneous screw fixation of the anterior column of the acetabulum was performed under guidance of hip arthroscopy to enable direct visual confirmation of the quality of the reduction and avoid any acetabular penetration with the screws. However, the previous two cases should have involved
Knee Surg Sports Traumatol Arthrosc (2014) 22:867–870
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Fig. 2 a Preoperative computed tomography of the patient in case 2 reveals a displaced fracture of the anterior column involving the right acetabular dome. b One 3.5-mm-diameter cortical screw was used to
fix the fracture site under direct arthroscopic visualization. c Postoperative pelvis anteroposterior view shows an antegrade screw fixation of the anterior column and a plate fixation of the iliac wing
Table 1 Comparison of arthroscopic surgery in traumatic hip fracture patients References
Number of operative patients
Number of basic procedures
Number of osteosynthesis of femoral head
Number of osteosynthesis of acetabular fracture
Other
Yamamoto et al. [10]
10
8
1
1
Percutaneous pinning
Mullis et al. [6]
33
33
0
0
Only loose body removal
Owens et al. [8] Matsuda [4]
11 1
11 0
0 1
0 0
Only loose body removal Arthroscopic reduction and internal fixation
Yang et al. [11]
2
0
0
2
Percutaneous pinning
Present study
2
0
0
2
Arthroscopic reduction and internal fixation
screw fixation using the percutaneous technique (Table 1). In the present cases, we performed reduction and internal fixation using arthroscopic viewing and working portals. To our knowledge, we are the first to report the use of hip arthroscopic reduction and screw fixation of acetabular fractures. Advantages of arthroscopic surgery as a minimally invasive procedure include minimized blood loss, early joint mobilization, relatively rapid post-operative rehabilitation, and outstanding cosmesis [1, 9]. However, this study has several limitations. First, this type of surgery can be done only by surgeons who are highly specialized in arthroscopic hip surgical technique. Second, the indications of hip arthroscopic surgery are narrow and can be made only for those cases with minimal and moderate displaced acetabular fractures. Third, arthroscopic instruments for fixation of reduced acetabulum require further improvement. In case of obese patients, arthroscopic screw fixation is not feasible because of shortening of conventional guide and drills.
In conclusion, arthroscopic reduction and fixation could be indicated for hip injury in some cases of acetabular fracture with additional advantages of joint debridement and loose body removal. Conflict of interest
None.
References 1. Atesok K, Doral MN, Whipple T, Mann G, Mei-Dan O, Atay OA, Beer Y, Lowe J, Soudry M, Schemitsch EH (2011) Arthroscopyassisted fracture fixation. Knee Surg Sports Traumatol Arthrosc 19:320–329 2. Chan YS, Chiu CH, Lo YP, Chen AC, Hsu KY, Wang CJ, Chen WJ (2008) Arthroscopy-assisted surgery for tibial plateau fractures: 2- to 10-year follow-up results. Arthroscopy 24:760–768 3. Ilizaliturri VM Jr, Gonzalez-Gutierrez B, Gonzalez-Ugalde H, Camacho-Galindo J (2011) Hip arthroscopy after traumatic hip dislocation. Am J Sports Med 39(Suppl):50S–57S 4. Matsuda DK (2009) A rare fracture, an even rarer treatment: the arthroscopic reduction and internal fixation of an isolated femoral head fracture. Arthroscopy 25:408–412
123
870 5. McCarthy JC, Lee JA (2006) Hip arthroscopy: indications, outcomes, and complications. Instr Course Lect 55:301–308 6. Mullis BH, Dahners LE (2006) Hip arthroscopy to remove loose bodies after traumatic dislocation. J Orthop Trauma 20:22–26 7. Ono A, Nishikawa S, Nagao A, Irie T, Sasaki M, Kouno T (2004) Arthroscopically assisted treatment of ankle fractures: arthroscopic findings and surgical outcomes. Arthroscopy 20:627–631 8. Owens BD, Busconi BD (2006) Arthroscopy for hip dislocation and fracture-dislocation. Am J Orthop (Belle Mead NJ) 35: 584–587
123
Knee Surg Sports Traumatol Arthrosc (2014) 22:867–870 9. Stevens MS, Legay DA, Glazebrook MA, Amirault D (2010) The evidence for hip arthroscopy: grading the current indications. Arthroscopy 26:1370–1383 10. Yamamoto Y, Ide T, Ono T, Hamada Y (2003) Usefulness of arthroscopic surgery in hip trauma cases. Arthroscopy 19: 269–273 11. Yang JH, Chouhan DK, Oh KJ (2010) Percutaneous screw fixation of acetabular fractures: applicability of hip arthroscopy. Arthroscopy 26:1556–1561
