Injury, Int. J. Care Injured 45 (2014) 732–737
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Management of acetabular fractures with modified posterior approach to spare external hip rotators Ahmet Y. Sarlak a,*, Ozgur Selek a, Murat Inanir b, Resul Musaoglu a, Tuncay Baran a a b
Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey Department of Physical Medicine and Rehabilitation, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 11 November 2013
Introduction: In the present study the quality of reduction and incidence of complications in hip external rotator sparing modified posterior approach was assessed in both simple and complex acetabular fractures. Materials and methods: This retrospective study includes 37 patients (38 hips) with a mean age of 42.1 years (range 21–60), that had been treated for displaced acetabular fractures from June 2007 through May 2011. They were reviewed at a mean of 3 years (20–67 months). Results: The fractures were classified according to the Letournel–Judet classification. Anatomic reduction and stable fixation of the fracture with less than 2 mm residual displacement was achieved in 28 of 38 hips. At the final follow up the patients were evaluated clinically according to Merle d’Aubigne and Postel scoring system which had been modified by Matta and radiologically based on the criteria described by Matta. The clinical results were excellent in 20, good in 8, fair in 8, and poor 2 hips. Complications included two superficial local wound infection and 10 heterotopic ossification with 7 of the cases having grade I heterotopic ossification. Avascular necrosis of the femoral head was not seen in any of the 38 hips. One patient with preoperative sciatic nerve palsy had complete recovery of neurologic function. There were no cases of deep vein thrombosis or pulmonary embolism. Conclusion: The functional outcome was satisfactory in most of the cases and comparable with other larger series. Using the limited part of Henry’s sciatic nerve exposure skin incision – working in the plane between gluteus maximus and the tensor fascia lata as in the classical Gibson approach and two portal external rotator hip sparing approach resulted in good fracture reduction without approach related complications. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Acetabular fracture Short external rotator sparing Modified posterior acetabular approach
Introduction The Kocher–Langenbeck (K–L) approach is the most commonly used surgical exposure for the stabilization of acetabular fractures involving a displaced posterior component [1–3]. With the K–L approach access to transverse or posterior column fractures extending cranially to the angle of the greater sciatic notch can be difficult [4]. To address this shortcoming, both the osteotomy of the greater trochanter and K–L modification in the proximal dissection have been described [4–6].
* Corresponding author at: Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Izmit, Kocaeli, Turkey. Tel.: +90 2623038771. E-mail address: [email protected] (A.Y. Sarlak). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.11.010
The conventional K–L approach involves splitting of the gluteus maximus and division of the short rotators of the hip [3]. To decrease approach related soft tissue trauma and lessen the incidence of heterotropic ossification, postoperative nerve injury, abductor weakness and joint stiffness; short external rotator sparing modified K–L approach have been described mostly in displaced, isolated posterior wall fractures without marginal impaction [7,8]. We report our experience with short external rotator sparing modified posterior approach in both simple and complex acetabular fractures involving the posterior wall-column or both to assess the quality of reduction and incidence of complications in such patients. Materials and methods From June 2007 through May 2011, 41 patients (42 hips) with displaced acetabular fractures were treated with open reduction
A.Y. Sarlak et al. / Injury, Int. J. Care Injured 45 (2014) 732–737
733
Table 1 Demographic data of the patients. Demographic data Number of patients Number of hips Male:female Average age Average follow up Mechanism Posterior hip dislocation
37 38 30:8 42.1 years (range 21–60) 35.8 months (range 20–67) Traffic accident: 31, falling: 7 9
and internal fixation using a modified posterior approach with sparing of short external rotators of the hip. All patients were operated by the senior author. One patient died because of comorbid medical conditions during follow-up; 3 patients were excluded due to incomplete data. 37 patients (38 hips) were enrolled for evaluation. None of these 37 patients had anterior procedure for acetabular fracture. Anterior column posterior hemitransverse, T shape fracture with significant anterior displacement and both column fractures operated with simultaneous anterior–posterior approaches were excluded in our series. The details of the patient demographics and fracture types were given in Tables 1 and 2 Surgical technique The patients were placed in a prone position on the radiolucent operating table under general anaesthesia. We used only a limited part of Henry’s sciatic nerve exposure skin incision [9]. The proximal and distal extremes of the original Henry’s incision were not used. An incision beginning a handbreadth superior to posterior superior iliac spine on the iliac crest advancing laterally to the greater trochanter and then curving posteriorly towards the gluteal fold was used (Fig. 1). Gluteus maximus origin was not detached from the iliac crest; the plane between tensor fascia lata and gluteus maximus was used to reflect the gluteus maximus posteriorly. Distal part of the gluteus maximus insertion to femur was not divided. Then gluteus maximus was reflected posteriorly to provide exposure of the entire posterior pelvis and direct visualization of the sciatic nerve. Working in the superficial plane to external hip rotators, fracture site and when necessary the joint capsule were exposed between either gluteus medius and piriformis or piriformis and superior gemellus interval (superior portal) (Fig. 2). The interval between the sciatic nerve and posterior cutaneous nerve of the thigh gives direct access to ischium. Releasing the semimembranosus origin and medial retraction of biceps femoris origin, the posterolateral wall of ischium was reached. Bending template was used for plate contouring. In most fractures gentle
Table 2 Fracture pattern and reduction quality of the patients. Fracture type
Elementary Posterior wall Posterior column Transverse Associated Posterior column + wall Transverse + posterior wall T shaped Total
Number of hips
Reduction quality Anatomic
Imperfect
16(42.1%) 1(2.6%) 6(15.8%)
15 4
1 1 2
5(13.1%) 6(15.8%)
4 4
1 1
1
4(10.5%)
1
2
1
8(21%)
2(5%)
38(100%)
28(74%)
Poor
Fig. 1. The skin incision for the modified posterior approach. The thick dotted lines show the proximal and distal extremes of the original Henry’s incision which was not used.
retraction of the gluteus medius to widen the superior portal is sufficient to reduce the displaced posterior fragment gently compressing it with a periosteal elevator. In transverse fractures one of the two superior portal may be used to place a reduction clamp from ilium to sciatic notch compressing the fracture (Fig. 3a). A curved 4.5 mm reconstruction plate was passed underneath the spared piriformis and short external rotators extending from lateral ischium to the inferior iliac wing compressing the fractured fragment. The plate was temporarily fixed to ischium by Kirschner wires (Fig. 3b). After reduction of the fracture, fixation was achieved (Fig. 4a and b). Passive range of motion exercises of the hip was applied to all patients just after the operation. Isotonic (hip flexor, abductor muscle groups) and isometric strengthening exercises (hip adductor and knee extensor muscle groups) were applied. Continuous passive motion (CPM) was applied to those patients having hip joint limitation. The patients were mobilised toe touch weight bearing with a walker or double crutches for 6–12 weeks. The patients were evaluated clinically and radiographically at an immediate postoperative period of 2 weeks, 6 weeks, 3 months, 6 months, one year and annually thereafter. Clinical and radiological grading was assessed at the final follow-up. Clinical grading was evaluated by Merle d’Aubigne and Postel scoring which has been modified by Matta [10–12]. The radiographic results were graded according to the criteria described by Matta [11–13]. Follow-up reduction was assessed on anteroposterior and Judet views of the pelvis. A displacement of 1 mm or less was considered as anatomic, 2–3 mm as imperfect, and greater than 3 mm as poor [11–13]. Heterotopic ossification was graded according to the criteria established by Brooker et al. [14].
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Fig. 2. The gluteus maximus muscle is reflected posteriorly. The sciatic nerve, short external rotators of the hip and ischium are exposed. (1) Posterior cutaneous nerve of thigh, (2) gluteus maximus, (3) gluteus medius, (4) piriformis, (5) superior gemellus, (6) obturator externus, (7) greater trochanter, (8) inferior gemellus, (9) sciatic nerve, (10) quadratus femoris, (11) ischium, and (12) distal tendon of gluteus maximus (protected).
Results In all cases, the modified posterior approach with sparing of short external hip rotators was completely adequate to obtain
fracture reduction and internal fixation (Figs. 5–7). The average follow-up of all the patients was 35.8 months (range 20–67 months). The average duration of surgery was 2.5 h (range 1.5–4 h), and the average blood loss during the surgery was 730 ml (range 400–1250 ml). The postoperative reduction was graded as anatomic in 28 hips (74%), imperfect in 8 hips (21%) and poor in two hips (5%). The radiographic results according to the criteria developed by Matta at the final follow-up were excellent in 18 hips (47%), good in 11 hips (29%), fair in 7 hips (18%), and poor in two hips (5%). The clinical outcome results according to the modified Merle d’Aubigne and Postel scoring were as follows: excellent in 20 (53%), good in 8 (21%), fair in 8 (21%), and poor 2 hips (5%). 10 patients developed heterotopic ossification, of which seven had grade I; two grade II; and one grade III. Posterior hip dislocation was seen in nine patients. All of these nine patients had different degrees of short external rotator muscle damage confirmed intraoperatively. Three of nine patients with posterior hip dislocation had marginal impaction fracture that were treated with standard reduction and bone grafting. Avascular necrosis of the femoral head was not seen in any of the 38 hips. In two of our cases, superficial local wound infection that was diagnosed in the early postoperative period was treated with antibiotics without debridement. There was no iatrogenic sciatic nerve palsy postoperatively. One patient with preoperative sciatic nerve palsy had complete recovery of neurologic function. There were no cases of deep vein thrombosis or pulmonary embolism. Discussion Most acetabular fractures primarily involving the posterior elements of the acetabulum are treated through a Kocher– Langenbeck (K–L) approach [1–3]. By using the K–L approach access to the posterosuperior and superior wall of the acetabulum is limited [4]. Therefore, various alternatives have been suggested to address this shortcoming, often incorporating an osteotomy of greater trochanter [4,5]. Moed described the modified Gibson
Fig. 3. (a) Intraoperative photograph showing the fracture reduction in the superior portal. (b) A 4.5 mm reconstruction plate is passed underneath the piriformis and short external rotator muscles and temporarily fixed with Kirschner wires. (1) Gluteus maximus, (2) gluteus medius, (3) piriformis, (4) fracture line, (5) greater trochanter, (6) conjoint tendon (superior gemellus, obturator externus, inferior gemellus), (7) sciatic nerve, and (8) Kirschner wire.
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Fig. 4. (a) Fracture reduction is achieved mostly between the piriformis and gemellus superior muscles. The plate is then, fixed with screws to the inferior iliac wing and ischium after fracture reduction. (1) Gluteus maximus, (2) gluteus medius, (3) piriformis, (4) reconstruction plate, (5) conjoint tendon, (6) sciatic nerve, (7) greater trochanter, and (8) ischium. (b) Intraoperative photograph showing the same step of the surgical technique. (1) Posterior cutaneous femoral nerve, (2) sciatic nerve, and (3) spared short external rotators.
approach working in the interval between gluteus maximus and tensor fascia lata both to extend access and also avoid injury to the neurovascular supply of the gluteus maximus muscle anterior portion [5].
Recently modified K–L approach sparing the short external hip rotators achieving osteosynthesis by two portals had been described by Magu and Josten mostly on selected posterior wall fractures [7,8]. The aim of this mini-invasive surgery from a
Fig. 5. A 25-year-old man sustained a posterior wall acetabular fracture (R: right). (a) Preoperative anteroposterior pelvic radiograph of the patient. (b) Preoperative computed tomography scan showed the posterior dislocation of the femoral head with posterior wall fracture extending to posterosuperior acetabulum. (c) Early postoperative radiograph after open reduction and internal fixation through a modified posterior approach. (d) Postoperative anteroposterior radiograph of pelvis at 5 years follow-up. His reduction is graded as anatomic.
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Fig. 6. A 47-year-old man sustained bilateral transverse acetabular fracture (R: right). (a) Preoperative anteroposterior pelvic radiograph of the patient. (b) Preoperative 3 dimensional computed tomography scan showed the bilateral transverse acetabular fracture. (c) Early postoperative radiograph after open reduction and internal fixation through a modified posterior approach. His reduction is graded as anatomic. (d) Postoperative anteroposterior radiograph of pelvis at 3 years follow-up.
Fig. 7. A 48-year-old man sustained a transverse and posterior wall acetabular fracture (R: right). (a) Preoperative anteroposterior pelvic radiograph of the patient. (b) Preoperative computed tomography scan showed the posterior dislocation of the femoral head with transverse and posterior wall fracture. His reduction is graded as imperfect. (c) Early postoperative radiograph after open reduction and internal fixation through a modified posterior approach. (d) Postoperative anteroposterior radiograph of pelvis at 3 years follow-up. He has grade 1 heterotrophic ossification.
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relatively wide incision is to avoid extensive soft tissue dissectionfragment avascularity, prevent iatrogenic damage to vascularity of head of femur and enable earlier rehabilitation [7,8]. The blood supply to the weight bearing portion of the head of femur is derived from medial femoral circumflex artery (MFCA) [15,16]. Iatrogenic trauma to the MFCA or its peripheral anastomosis has been thought to be one of the reasons for the increased incidence of avascular necrosis (AVN) in operatively treated posterior fracture dislocations. MFCA can be identified in the space between quadratus femoris and the inferior gemellus. The deep branch has been shown to be vulnerable to injury during tenotomy of external rotator muscles which can also be injured during reattachment leading to secondary avascular necrosis [15,16]. Theoretically short external rotator sparing modified K–L approach might prevent iatrogenic AVN. Magu mostly preferred screws rather than plates in short external rotator sparing modified K–L approach of 14 posterior wall fractures. He used the piriformis–gluteus medius interval as the superior portal and short external hip rotators–ischial tuberosity interval as the inferior portal [7]. Josten used the similar approach in 18 simple and complex fractures involving the posterior column. He used piriformis-superior gemellus as a superior and quadratus femoris-inferior gemellus as an inferior portal [8]. We think that working in the plane between gluteus maximus and tensor fascia lata as in the classical Gibson approach might be useful in proximal deep dissection for the short external rotator sparing approach both to easily access posterosuperior and superior acetabulum and also to avoid gluteus maximus muscle denervation. Short external rotator sparing does not limit indirect access to the true pelvis and anterior column. Defining a stationary superior portal in short external rotator sparing approach might not be reliable due to different fracture configurations. We have used either one of each superior portal as defined by Magu and Josten depending on the fracture lines. In the inferior portal our preference has always been like Magu from the short external hip rotators–ischial tuberosity interval as Josten’s inferior portal from the quadratus femoris-inferior gemellus might theoretically be risky with respect to medial femoral circumflex artery iatrogenic injury. In the short external rotator sparing approach, most fractures can easily be managed either superior or inferior to piriformis muscle. The main difficulty of the approach is mostly in the distal portal in between sciatic nerve and posterior cutaneous femoral nerve with a venous plexus which needs meticulous dissection to avoid unpleasant bleeding. Removing loose intraarticular bony fragments may be difficult when the muscles are intact. We think that the main limitation of this technique is the comminuted fracture extending to posteroinferior wall of the acetabulum which are to be reduced in the limited window in between superior gemellus, obturator internus and inferior gemellus. It has been reported that if the surgical trauma is minimised, heterotopic ossification (HO) may be lessened resulting in an increased range of motion [8]. Both Magu and Josten reported a lower HO rate with less vigorous retraction and less iatrogenic soft tissue damage [7,8]. We have seen 10 cases of HO; in seven having grade 1 HO with six of these patients having had traumatic posterior hip dislocation with acetabular fracture. This high rate of HO in our cases; mostly in patients with traumatic posterior hip dislocation might be due to more extensive soft tissue trauma in such cases.
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This retrospective study has several limitations; like several types of acetabular fractures with no control group and a relatively short follow up. In our series there were 74% excellent or good clinical outcome with a medium follow up of 35.8 months. 64% of the hips with anatomical reduction had an excellent clinical result at follow up. We were able to demonstrate anatomic reduction in nearly 60% of associated fractures, 67% of transverse fractures, 94% of posterior wall fractures all comparing favourably with the previous data [13,17–19]. T type fractures showed the least accuracies of reduction in accordance with the series of Matta [13]. Conclusion The modified posterior approach decreases the operating time, results in good fracture reduction without approach related complications; thus seems to be a promising surgical procedure both in simple and selected complex acetabular fractures. Conflict of interest None declared. References [1] Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. J Bone Joint Surg Am 1964;46:1615– 75. [2] Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res 1980;151:81–106. [3] Mehlman CT, Meiss L, DiPasquale TG. Hyphenated-history: the Kocher–Langenbeck surgical approach. J Orthop Trauma 2000;14:60–4. [4] Siebenrock KA, Gautier E, Ziran BH, Ganz R. Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using a Kocher–Langenbeck approach. J Orthop Trauma 2006;20(Suppl. 1):S52–6. [5] Moed BR. The modified Gibson posterior surgical approach to the acetabulum. J Orthop Trauma 2010;24:315–22. [6] Hadjicostas PT, Thielemann FW. The use of trochanteric slide osteotomy in the treatment of displaced acetabular fractures. Injury 2008;39:907–13. [7] Magu NK, Rohilla R, Arora S, More H, Modified. Kocher–Langenbeck approach for the stabilization of posterior wall fractures of the acetabulum. J Orthop Trauma 2011;25:243–9. [8] Josten C, Trabold O. Modified ‘‘2-portal’’ Kocher–Langenbeck approach: a minimally-invasive procedure protecting the short external rotator muscles. J Orthop Trauma 2011;25:250–7. [9] Wey J, DiPasquale D, Levitt L, Quitkin H. Operative treatment of acetabular fractures through the extensile Henry approach. J Trauma 1999;46:255–60. [10] d’Aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36:451–75. [11] Matta JM, Mehne DK, Roffi R. Fractures of the acetabulum. Early results of a prospective study. Clin Orthop Relat Res 1986;205:241–50. [12] Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. Clin Orthop Relat Res 1994;305:10–9. [13] Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78:1632–45. [14] Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement: incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629–32. [15] Ganz R, Gill TJ, Gautier E, Ganz K, Kru¨gel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119–24. [16] Gautier E, Ganz K, Kru¨gel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implication. J Bone Joint Surg Br 2000;82:679–83. [17] Petsatodis G, Antonarakos P, Chalidis B, Papadopoulos P, Christoforidis J, Pournaras J. Surgically treated acetabular fractures via a single posterior approach with a follow-up of 2-10 years. Injury 2007;38:334–43. [18] Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. J Bone Joint Surg Br 2005;87:2–9. [19] Deo SD, Tavares SP, Pandey RK, El-Saied G, Willett KM, Worlock PH. Operative management of acetabular fractures in Oxford. Injury 2001;32:581–6.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Management of acetabular fractures with modified posterior approach to spare external hip rotators Ahmet Y. Sarlak a,*, Ozgur Selek a, Murat Inanir b, Resul Musaoglu a, Tuncay Baran a a b
Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey Department of Physical Medicine and Rehabilitation, Kocaeli University School of Medicine, Umuttepe, Kocaeli, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 11 November 2013
Introduction: In the present study the quality of reduction and incidence of complications in hip external rotator sparing modified posterior approach was assessed in both simple and complex acetabular fractures. Materials and methods: This retrospective study includes 37 patients (38 hips) with a mean age of 42.1 years (range 21–60), that had been treated for displaced acetabular fractures from June 2007 through May 2011. They were reviewed at a mean of 3 years (20–67 months). Results: The fractures were classified according to the Letournel–Judet classification. Anatomic reduction and stable fixation of the fracture with less than 2 mm residual displacement was achieved in 28 of 38 hips. At the final follow up the patients were evaluated clinically according to Merle d’Aubigne and Postel scoring system which had been modified by Matta and radiologically based on the criteria described by Matta. The clinical results were excellent in 20, good in 8, fair in 8, and poor 2 hips. Complications included two superficial local wound infection and 10 heterotopic ossification with 7 of the cases having grade I heterotopic ossification. Avascular necrosis of the femoral head was not seen in any of the 38 hips. One patient with preoperative sciatic nerve palsy had complete recovery of neurologic function. There were no cases of deep vein thrombosis or pulmonary embolism. Conclusion: The functional outcome was satisfactory in most of the cases and comparable with other larger series. Using the limited part of Henry’s sciatic nerve exposure skin incision – working in the plane between gluteus maximus and the tensor fascia lata as in the classical Gibson approach and two portal external rotator hip sparing approach resulted in good fracture reduction without approach related complications. ß 2013 Elsevier Ltd. All rights reserved.
Keywords: Acetabular fracture Short external rotator sparing Modified posterior acetabular approach
Introduction The Kocher–Langenbeck (K–L) approach is the most commonly used surgical exposure for the stabilization of acetabular fractures involving a displaced posterior component [1–3]. With the K–L approach access to transverse or posterior column fractures extending cranially to the angle of the greater sciatic notch can be difficult [4]. To address this shortcoming, both the osteotomy of the greater trochanter and K–L modification in the proximal dissection have been described [4–6].
* Corresponding author at: Department of Orthopaedics and Traumatology, Kocaeli University School of Medicine, Umuttepe, Izmit, Kocaeli, Turkey. Tel.: +90 2623038771. E-mail address: [email protected] (A.Y. Sarlak). 0020–1383/$ – see front matter ß 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.injury.2013.11.010
The conventional K–L approach involves splitting of the gluteus maximus and division of the short rotators of the hip [3]. To decrease approach related soft tissue trauma and lessen the incidence of heterotropic ossification, postoperative nerve injury, abductor weakness and joint stiffness; short external rotator sparing modified K–L approach have been described mostly in displaced, isolated posterior wall fractures without marginal impaction [7,8]. We report our experience with short external rotator sparing modified posterior approach in both simple and complex acetabular fractures involving the posterior wall-column or both to assess the quality of reduction and incidence of complications in such patients. Materials and methods From June 2007 through May 2011, 41 patients (42 hips) with displaced acetabular fractures were treated with open reduction
A.Y. Sarlak et al. / Injury, Int. J. Care Injured 45 (2014) 732–737
733
Table 1 Demographic data of the patients. Demographic data Number of patients Number of hips Male:female Average age Average follow up Mechanism Posterior hip dislocation
37 38 30:8 42.1 years (range 21–60) 35.8 months (range 20–67) Traffic accident: 31, falling: 7 9
and internal fixation using a modified posterior approach with sparing of short external rotators of the hip. All patients were operated by the senior author. One patient died because of comorbid medical conditions during follow-up; 3 patients were excluded due to incomplete data. 37 patients (38 hips) were enrolled for evaluation. None of these 37 patients had anterior procedure for acetabular fracture. Anterior column posterior hemitransverse, T shape fracture with significant anterior displacement and both column fractures operated with simultaneous anterior–posterior approaches were excluded in our series. The details of the patient demographics and fracture types were given in Tables 1 and 2 Surgical technique The patients were placed in a prone position on the radiolucent operating table under general anaesthesia. We used only a limited part of Henry’s sciatic nerve exposure skin incision [9]. The proximal and distal extremes of the original Henry’s incision were not used. An incision beginning a handbreadth superior to posterior superior iliac spine on the iliac crest advancing laterally to the greater trochanter and then curving posteriorly towards the gluteal fold was used (Fig. 1). Gluteus maximus origin was not detached from the iliac crest; the plane between tensor fascia lata and gluteus maximus was used to reflect the gluteus maximus posteriorly. Distal part of the gluteus maximus insertion to femur was not divided. Then gluteus maximus was reflected posteriorly to provide exposure of the entire posterior pelvis and direct visualization of the sciatic nerve. Working in the superficial plane to external hip rotators, fracture site and when necessary the joint capsule were exposed between either gluteus medius and piriformis or piriformis and superior gemellus interval (superior portal) (Fig. 2). The interval between the sciatic nerve and posterior cutaneous nerve of the thigh gives direct access to ischium. Releasing the semimembranosus origin and medial retraction of biceps femoris origin, the posterolateral wall of ischium was reached. Bending template was used for plate contouring. In most fractures gentle
Table 2 Fracture pattern and reduction quality of the patients. Fracture type
Elementary Posterior wall Posterior column Transverse Associated Posterior column + wall Transverse + posterior wall T shaped Total
Number of hips
Reduction quality Anatomic
Imperfect
16(42.1%) 1(2.6%) 6(15.8%)
15 4
1 1 2
5(13.1%) 6(15.8%)
4 4
1 1
1
4(10.5%)
1
2
1
8(21%)
2(5%)
38(100%)
28(74%)
Poor
Fig. 1. The skin incision for the modified posterior approach. The thick dotted lines show the proximal and distal extremes of the original Henry’s incision which was not used.
retraction of the gluteus medius to widen the superior portal is sufficient to reduce the displaced posterior fragment gently compressing it with a periosteal elevator. In transverse fractures one of the two superior portal may be used to place a reduction clamp from ilium to sciatic notch compressing the fracture (Fig. 3a). A curved 4.5 mm reconstruction plate was passed underneath the spared piriformis and short external rotators extending from lateral ischium to the inferior iliac wing compressing the fractured fragment. The plate was temporarily fixed to ischium by Kirschner wires (Fig. 3b). After reduction of the fracture, fixation was achieved (Fig. 4a and b). Passive range of motion exercises of the hip was applied to all patients just after the operation. Isotonic (hip flexor, abductor muscle groups) and isometric strengthening exercises (hip adductor and knee extensor muscle groups) were applied. Continuous passive motion (CPM) was applied to those patients having hip joint limitation. The patients were mobilised toe touch weight bearing with a walker or double crutches for 6–12 weeks. The patients were evaluated clinically and radiographically at an immediate postoperative period of 2 weeks, 6 weeks, 3 months, 6 months, one year and annually thereafter. Clinical and radiological grading was assessed at the final follow-up. Clinical grading was evaluated by Merle d’Aubigne and Postel scoring which has been modified by Matta [10–12]. The radiographic results were graded according to the criteria described by Matta [11–13]. Follow-up reduction was assessed on anteroposterior and Judet views of the pelvis. A displacement of 1 mm or less was considered as anatomic, 2–3 mm as imperfect, and greater than 3 mm as poor [11–13]. Heterotopic ossification was graded according to the criteria established by Brooker et al. [14].
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Fig. 2. The gluteus maximus muscle is reflected posteriorly. The sciatic nerve, short external rotators of the hip and ischium are exposed. (1) Posterior cutaneous nerve of thigh, (2) gluteus maximus, (3) gluteus medius, (4) piriformis, (5) superior gemellus, (6) obturator externus, (7) greater trochanter, (8) inferior gemellus, (9) sciatic nerve, (10) quadratus femoris, (11) ischium, and (12) distal tendon of gluteus maximus (protected).
Results In all cases, the modified posterior approach with sparing of short external hip rotators was completely adequate to obtain
fracture reduction and internal fixation (Figs. 5–7). The average follow-up of all the patients was 35.8 months (range 20–67 months). The average duration of surgery was 2.5 h (range 1.5–4 h), and the average blood loss during the surgery was 730 ml (range 400–1250 ml). The postoperative reduction was graded as anatomic in 28 hips (74%), imperfect in 8 hips (21%) and poor in two hips (5%). The radiographic results according to the criteria developed by Matta at the final follow-up were excellent in 18 hips (47%), good in 11 hips (29%), fair in 7 hips (18%), and poor in two hips (5%). The clinical outcome results according to the modified Merle d’Aubigne and Postel scoring were as follows: excellent in 20 (53%), good in 8 (21%), fair in 8 (21%), and poor 2 hips (5%). 10 patients developed heterotopic ossification, of which seven had grade I; two grade II; and one grade III. Posterior hip dislocation was seen in nine patients. All of these nine patients had different degrees of short external rotator muscle damage confirmed intraoperatively. Three of nine patients with posterior hip dislocation had marginal impaction fracture that were treated with standard reduction and bone grafting. Avascular necrosis of the femoral head was not seen in any of the 38 hips. In two of our cases, superficial local wound infection that was diagnosed in the early postoperative period was treated with antibiotics without debridement. There was no iatrogenic sciatic nerve palsy postoperatively. One patient with preoperative sciatic nerve palsy had complete recovery of neurologic function. There were no cases of deep vein thrombosis or pulmonary embolism. Discussion Most acetabular fractures primarily involving the posterior elements of the acetabulum are treated through a Kocher– Langenbeck (K–L) approach [1–3]. By using the K–L approach access to the posterosuperior and superior wall of the acetabulum is limited [4]. Therefore, various alternatives have been suggested to address this shortcoming, often incorporating an osteotomy of greater trochanter [4,5]. Moed described the modified Gibson
Fig. 3. (a) Intraoperative photograph showing the fracture reduction in the superior portal. (b) A 4.5 mm reconstruction plate is passed underneath the piriformis and short external rotator muscles and temporarily fixed with Kirschner wires. (1) Gluteus maximus, (2) gluteus medius, (3) piriformis, (4) fracture line, (5) greater trochanter, (6) conjoint tendon (superior gemellus, obturator externus, inferior gemellus), (7) sciatic nerve, and (8) Kirschner wire.
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Fig. 4. (a) Fracture reduction is achieved mostly between the piriformis and gemellus superior muscles. The plate is then, fixed with screws to the inferior iliac wing and ischium after fracture reduction. (1) Gluteus maximus, (2) gluteus medius, (3) piriformis, (4) reconstruction plate, (5) conjoint tendon, (6) sciatic nerve, (7) greater trochanter, and (8) ischium. (b) Intraoperative photograph showing the same step of the surgical technique. (1) Posterior cutaneous femoral nerve, (2) sciatic nerve, and (3) spared short external rotators.
approach working in the interval between gluteus maximus and tensor fascia lata both to extend access and also avoid injury to the neurovascular supply of the gluteus maximus muscle anterior portion [5].
Recently modified K–L approach sparing the short external hip rotators achieving osteosynthesis by two portals had been described by Magu and Josten mostly on selected posterior wall fractures [7,8]. The aim of this mini-invasive surgery from a
Fig. 5. A 25-year-old man sustained a posterior wall acetabular fracture (R: right). (a) Preoperative anteroposterior pelvic radiograph of the patient. (b) Preoperative computed tomography scan showed the posterior dislocation of the femoral head with posterior wall fracture extending to posterosuperior acetabulum. (c) Early postoperative radiograph after open reduction and internal fixation through a modified posterior approach. (d) Postoperative anteroposterior radiograph of pelvis at 5 years follow-up. His reduction is graded as anatomic.
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Fig. 6. A 47-year-old man sustained bilateral transverse acetabular fracture (R: right). (a) Preoperative anteroposterior pelvic radiograph of the patient. (b) Preoperative 3 dimensional computed tomography scan showed the bilateral transverse acetabular fracture. (c) Early postoperative radiograph after open reduction and internal fixation through a modified posterior approach. His reduction is graded as anatomic. (d) Postoperative anteroposterior radiograph of pelvis at 3 years follow-up.
Fig. 7. A 48-year-old man sustained a transverse and posterior wall acetabular fracture (R: right). (a) Preoperative anteroposterior pelvic radiograph of the patient. (b) Preoperative computed tomography scan showed the posterior dislocation of the femoral head with transverse and posterior wall fracture. His reduction is graded as imperfect. (c) Early postoperative radiograph after open reduction and internal fixation through a modified posterior approach. (d) Postoperative anteroposterior radiograph of pelvis at 3 years follow-up. He has grade 1 heterotrophic ossification.
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relatively wide incision is to avoid extensive soft tissue dissectionfragment avascularity, prevent iatrogenic damage to vascularity of head of femur and enable earlier rehabilitation [7,8]. The blood supply to the weight bearing portion of the head of femur is derived from medial femoral circumflex artery (MFCA) [15,16]. Iatrogenic trauma to the MFCA or its peripheral anastomosis has been thought to be one of the reasons for the increased incidence of avascular necrosis (AVN) in operatively treated posterior fracture dislocations. MFCA can be identified in the space between quadratus femoris and the inferior gemellus. The deep branch has been shown to be vulnerable to injury during tenotomy of external rotator muscles which can also be injured during reattachment leading to secondary avascular necrosis [15,16]. Theoretically short external rotator sparing modified K–L approach might prevent iatrogenic AVN. Magu mostly preferred screws rather than plates in short external rotator sparing modified K–L approach of 14 posterior wall fractures. He used the piriformis–gluteus medius interval as the superior portal and short external hip rotators–ischial tuberosity interval as the inferior portal [7]. Josten used the similar approach in 18 simple and complex fractures involving the posterior column. He used piriformis-superior gemellus as a superior and quadratus femoris-inferior gemellus as an inferior portal [8]. We think that working in the plane between gluteus maximus and tensor fascia lata as in the classical Gibson approach might be useful in proximal deep dissection for the short external rotator sparing approach both to easily access posterosuperior and superior acetabulum and also to avoid gluteus maximus muscle denervation. Short external rotator sparing does not limit indirect access to the true pelvis and anterior column. Defining a stationary superior portal in short external rotator sparing approach might not be reliable due to different fracture configurations. We have used either one of each superior portal as defined by Magu and Josten depending on the fracture lines. In the inferior portal our preference has always been like Magu from the short external hip rotators–ischial tuberosity interval as Josten’s inferior portal from the quadratus femoris-inferior gemellus might theoretically be risky with respect to medial femoral circumflex artery iatrogenic injury. In the short external rotator sparing approach, most fractures can easily be managed either superior or inferior to piriformis muscle. The main difficulty of the approach is mostly in the distal portal in between sciatic nerve and posterior cutaneous femoral nerve with a venous plexus which needs meticulous dissection to avoid unpleasant bleeding. Removing loose intraarticular bony fragments may be difficult when the muscles are intact. We think that the main limitation of this technique is the comminuted fracture extending to posteroinferior wall of the acetabulum which are to be reduced in the limited window in between superior gemellus, obturator internus and inferior gemellus. It has been reported that if the surgical trauma is minimised, heterotopic ossification (HO) may be lessened resulting in an increased range of motion [8]. Both Magu and Josten reported a lower HO rate with less vigorous retraction and less iatrogenic soft tissue damage [7,8]. We have seen 10 cases of HO; in seven having grade 1 HO with six of these patients having had traumatic posterior hip dislocation with acetabular fracture. This high rate of HO in our cases; mostly in patients with traumatic posterior hip dislocation might be due to more extensive soft tissue trauma in such cases.
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This retrospective study has several limitations; like several types of acetabular fractures with no control group and a relatively short follow up. In our series there were 74% excellent or good clinical outcome with a medium follow up of 35.8 months. 64% of the hips with anatomical reduction had an excellent clinical result at follow up. We were able to demonstrate anatomic reduction in nearly 60% of associated fractures, 67% of transverse fractures, 94% of posterior wall fractures all comparing favourably with the previous data [13,17–19]. T type fractures showed the least accuracies of reduction in accordance with the series of Matta [13]. Conclusion The modified posterior approach decreases the operating time, results in good fracture reduction without approach related complications; thus seems to be a promising surgical procedure both in simple and selected complex acetabular fractures. Conflict of interest None declared. References [1] Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction. J Bone Joint Surg Am 1964;46:1615– 75. [2] Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res 1980;151:81–106. [3] Mehlman CT, Meiss L, DiPasquale TG. Hyphenated-history: the Kocher–Langenbeck surgical approach. J Orthop Trauma 2000;14:60–4. [4] Siebenrock KA, Gautier E, Ziran BH, Ganz R. Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using a Kocher–Langenbeck approach. J Orthop Trauma 2006;20(Suppl. 1):S52–6. [5] Moed BR. The modified Gibson posterior surgical approach to the acetabulum. J Orthop Trauma 2010;24:315–22. [6] Hadjicostas PT, Thielemann FW. The use of trochanteric slide osteotomy in the treatment of displaced acetabular fractures. Injury 2008;39:907–13. [7] Magu NK, Rohilla R, Arora S, More H, Modified. Kocher–Langenbeck approach for the stabilization of posterior wall fractures of the acetabulum. J Orthop Trauma 2011;25:243–9. [8] Josten C, Trabold O. Modified ‘‘2-portal’’ Kocher–Langenbeck approach: a minimally-invasive procedure protecting the short external rotator muscles. J Orthop Trauma 2011;25:250–7. [9] Wey J, DiPasquale D, Levitt L, Quitkin H. Operative treatment of acetabular fractures through the extensile Henry approach. J Trauma 1999;46:255–60. [10] d’Aubigne RM, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36:451–75. [11] Matta JM, Mehne DK, Roffi R. Fractures of the acetabulum. Early results of a prospective study. Clin Orthop Relat Res 1986;205:241–50. [12] Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. Clin Orthop Relat Res 1994;305:10–9. [13] Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 1996;78:1632–45. [14] Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement: incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629–32. [15] Ganz R, Gill TJ, Gautier E, Ganz K, Kru¨gel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 2001;83:1119–24. [16] Gautier E, Ganz K, Kru¨gel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implication. J Bone Joint Surg Br 2000;82:679–83. [17] Petsatodis G, Antonarakos P, Chalidis B, Papadopoulos P, Christoforidis J, Pournaras J. Surgically treated acetabular fractures via a single posterior approach with a follow-up of 2-10 years. Injury 2007;38:334–43. [18] Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. J Bone Joint Surg Br 2005;87:2–9. [19] Deo SD, Tavares SP, Pandey RK, El-Saied G, Willett KM, Worlock PH. Operative management of acetabular fractures in Oxford. Injury 2001;32:581–6.
