mlroutt at u
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Sep 23, 2007, 10:43 AM
Post #10 of 20
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Re: [ORT-L] Both column fracture
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It's not so difficult to find a busy center and visit for more than a day,
or travel when a regional center coordinates such operation with you, or
refer your patient and travel along, etc...there are numerous ways to
achieve this experience. Showing up on one day is probably not the best
choice.
When discussing complications, it¹s important to sort the Stoppa exposures
performed alone, and those performed as an interval of an ilioinguinal
exposure. It¹s reasonable to assume and likely that Stoppa exposures alone
may have higher complication rates than those done as a component of an
ilioinguinal exposure since the retraction is more difficult as you ³stretch
the exposure¹s limits².
I can¹t speak for the center in Amsterdam¹s clinical volumes and activity,
but it¹s likely that their early indications for this exposure may have
changed as their experience has improved...once one learns a helpful
exposure, one tends to use it more frequently and efficiently. It also
depends on how many surgeons are performing these operations at the
center...if all surgeons are treating all injuries without sub-specialty,
then their individual experiences become diluted. If one or two surgeons are
responsible for all injuries and they have sufficient patient volumes, then
the field can and should advance as experience grows.
Our Stoppa-ilioinguinal usage and complication rates do not parallel theirs,
and our usage has increased over time...we did however note a relevant
increase in ipsilateral lower extremity DVT when using this exposure as
compared to our other acetabular exposures. I¹ve had 3 iliac vein injuries
during Stoppa-ilioinguinal exposures since 1990...two were avoidable - one
due to a clamp tine puncture which was repaired...the other two were due to
ramus fragments impaled on the veins¹ undersurfaces which were noted at
dissection and repaired. I¹ve also excised a crushed obturator nerve segment
which was destroyed between two fracture surfaces. As far as
Stoppa-ilioinguinal exposure related vascular and neural issues, that sums
it.
I have had an iliac vein injury due to excess retraction during implant
application using the Stoppa exposure alone (without ilioinguinal
intervals).
The anatomy is the anatomy and should be respected but not feared...there
just aren¹t many leaks which you refer to...the fracture surfaces may bleed
but respond to reduction, the obturator tributary system can have a
fracture-related injury but responds to cautery or ligation or packing, and
the iliac system extremely rarely has injury and requires a vascular surgeon
to repair as mentioned above.
As for every operation, the surgeon must be precise with the exposure,
retraction, reduction, fixation, and closure to avoid iatrogenic injuries.
Jakob¹s recommended intervals are the working intervals that we have used
most commonly also...the iliopectineal fascia still must be released to
allow safe exposure and retraction.
Enclosed are some example slides...the intraop photos demonstrate the middle
window dissection without external inguinal ring violation.
Chip
>>> the misunderstanding about the Stoppa approach
>
> Ponsen et al from the Univ of Amsterdam, report
> 13 complications in 25 Stoppa approaches. J
> Trauma 2006
>
> http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Retrieve&dopt=AbstractP
> lus&list_uids=16967004&query_hl=5&itool=pubmed_DocSum
>
> It therefore seems justified to be a bit apprehensive before starting a
> Stoppa.
>
> Clearly, the best thing to do is to visit a
> trauma center where experts are routinely doing
> Stoppas and learn how it's done. However,
> according to Ponsen's article, it took 3 years to
> collect 25 cases. Chances are high that one could
> show up on the wrong day.
>
> There are some approach techniques published on the web e.g.
> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-78522006000400002
> &lng=en&nrm=iso&tlng=en
> but there seems to be some complicated wiring and
> plumbing issues along the way - i.e.
> http://www.hwbf.org/hwb/conf/pelvic/STOP2.JPG
>
> I wonder if there are any better references as to
> how to proceed without having to stopper the
> leaks?
>
> Also, there is a report from Jakob et al in
> Basel, J Trauma Volume 60(6), June 2006, pp
> 1364-1370 on a "less invasive" anterior
> intrapelvic approach
>
> http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-200606000-00034.htm;jse
> ssionid=G2dGxQVdQLMY3ZZ2s1ppNDpTGdKJ0pKD2YVTpZTJmcJn1yrGVNQN!29071008!18119562
> 8!8091!-1
>
> Has anyone had any experience with this?
>
> Bill Burman, MD
> HWB Foundation
> http://www.hwbf.org
>
>> Dear Dr. Routt:
>> Thank you very much for your advice.
>> I apologize for the misunderstanding about the Stoppa approach.
>> It wasn't my intention to critize the Stoppa approach, I was only
>> triying to clarify what was my 'emotion' 'now' about it. Nothing to do
>> with rationale thinking.
>> It is clear to me that it is the only approach that lets you address
>> the medial part of the acetabulum and counteract the lateral force that
>> produced the fracture.
>> Thanks again for your thoughts about the superior wall.
>> I'll post the result
>> Dr. Josep M. Muñoz Vives
>>
>>
>>
>>
>> Dr. Josep M. Muñoz Vives
>> Hospital Universitari de Girona 'Dr. Josep Trueta'
>> Girona
>> Catalonia
>> Spain
>>
>>
>>
>> ---
>> [This E-mail scanned for viruses by Declude Virus]
> ---
> [This E-mail scanned for viruses by Declude Virus]
>
M.L. Chip Routt, Jr.,M.D.
Professor-Orthopedic Surgery
Harborview Medical Center
325 Ninth Avenue
Box 359798
Seattle, WA 98104-2499
phone 206-731-3658
FAX 206-731-3227
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