[ORT-L] Images Acetabulum anterior wall.


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[ORT-L] Images Acetabulum anterior wall.

JMMUVI at terra
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Nov 21, 2006, 6:15 PM

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[ORT-L] Images Acetabulum anterior wall.	Can't Post

Sorry for the previous messages without pictures

Dear colleagues:
I'm seeking advice on a 25 yo woman that suffered a road traffic accident on Sunday.
Brought conscious and alert to the Emergency department she rapidly became tensionless
and was brought to the operation theater without any other examination than a thorax X-Ray
and a FAST positive for fluid.
On surgery there was about 750 ml inside the peritoneum, minimal liver laceration managed
with surgicel. Big, contained retroperitoneal hematoma. The general surgeons didn't see
any leakage from the bladder. The patient remained hypotensive all the time despite
transfusion of 18 units of packed red blood cells, plasma and platelets. A decision was
made to administer activated Factor VII (Novoseven) and finally normal blood pressure was
achieved.
Because they rushed for surgery, nobody inserted an urinary catheter until the end of this
initial operation. When it was inserted gross hematuria was found.
A CT scan was done

She was brought again to the operation room and the urologist
repaired multiple bladder lacerations on its posterior and right side.

The orthopaedic surgeon on call this night applied a sheeting on the patient and reduced an
anteromedial dislocation of the right femoral head and apllied a femoral traction.
The patient has been extubated today. Although confusional, there are no signs of lesion to
the femoral or sciatic nerve.

To me its clear it needs pelvic fixation on the right sacral fracture.
I'm dubious and seeking for your thoughts an advice on:

Can the right acetabular fracture be managed without open surgery?
An external frame + iliosacral screws would be enough?
Any warnings/tricks on performing an ilioinguinal approach after a supra-infraumbilical laparotomy
or a Stoppa approach (which I've never done) would be a more sensible approach.
Bilateral ramus screws?

Thanks for your answers

Dr. Josep M. Muñoz Vives
Hospital 'Dr. Josep Trueta'
Girona
Catalonia
Spain

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Attachments:

cotil25.jpg (47.7 KB)

cotil1.jpg (88.6 KB)

cotil2.jpg (76.9 KB)

cotil3.jpg (94.6 KB)

Bruce_Ziran at HMIS
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Nov 22, 2006, 5:26 AM

Post #2 of 5 (3501 views)
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Re: [ORT-L] Images Acetabulum anterior wall. [In reply to]	Can't Post

Dr. Munoz Vives
Very interesting case. My opinion is that the right acetabular injury and
pelvis should be fixed. The fracture seems to be "transitional" in the
sense that it seems to be more of a pelvic injury, e.g. bilateral rami (the
high rami that radiologist frequently call an acetabular fx) and sacrum fx,
but in this case, the right side has become a true acetabular injury. Your
ideas were my thoughts as well. We have been using what we term the
"subinguinal" window of the ilio inguinal approach, which is basically a
modified stoppa. We are exposing and developing the middle window, less and
less, and now I try to do these using the lateral window, and the medial
window, without exposing the vessel sheath. If you go to the other side of
the table ( in this case L) and use a large retractor (I use what we call a
sweetheart retractor) for the bladder, and another retractor to "lift" the
vessels, you get a great view of the inner pelvis and acetabulum. In this
fashion, the anterior wall/column, can be reduced. I would decide intra-op
whether this could be fixed with retrograde ramus screws, and if so, I
would also fix the left side for added stability. If not, then I would
consider a plate place in its standard position, but with a twist so it can
be attached from the middle window. The sacrum is a bit displaced, but
could probably be fixed in situ with a screw. Operating after a laparotomy
and a bladder tear, carries a bit higher risk, but we frequently do it
because we have not choice. I can't quote any high level studies but our
experience has been favorable. I would personally consider resorbable
antibiotic beads, using CaSu, and broad spectrum antibiotics for a while.
We just did this approach and I have enclosed a ppt with our pics. I look
forward to seeing your result. Best wishes.

Bruce H. Ziran, M.D.
Director of Orthopaedic Trauma
St. Elizabeth Health Center
Associate Professor of Orthopaedic Surgery
Northeast Ohio Universities College of Medicine(See attached file: Sub
ing.ppt)

Attachments:

Sub ing.ppt (2.57 MB)

jmmuvi at terra
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Nov 28, 2006, 10:41 AM

Post #3 of 5 (3430 views)
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RE: [ORT-L] Images Acetabulum anterior wall. [In reply to]	Can't Post

Dr. Ziran and list colleagues:
We've followed your thoughts and planned an Stoppa approach for fixing
the acetabular fracture. Helped with urologist and general surgeon we
reopened tha anterior mdiline approach, but we found pus in the Retzius
space so we thought it wasn't wise to insert a plate. We washed the cavity
throughoutly, inserted some drains and began antibiotics. We decided to
stabilize the right sacral fracture with an in situ iliosacral screw without
compression because the fracture was transforaminal. And span the pelvis
with an anterior frame.
�Should we have tried to reduce and fix the fracture anyway (the Retzius
collection was undoubtly infected (we are waiting for cultures))?
�What's next step?
A) Nothing. Just remove the anterior frame when the pelvic fracture
has healed.
B) Wait until infection subsides and try again (wait how long) (how
do we consider surgery is safe) (if it is longer than 2-3 weeks, is it
worthwhile?, or the reduction will be so difficult than it is not?)

Thanks all for your help

Dr. Josep M. Mu�oz Vives
Hospital 'Dr. Josep Trueta'
Girona
Catalonia
Spain

mlroutt at u
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Nov 28, 2006, 10:56 AM

Post #4 of 5 (3430 views)
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Re: [ORT-L] Images Acetabulum anterior wall. [In reply to]	Can't Post

Despite the assumed infection and after irrigation/debridement, it might
have been helpful to realign and reduce the ramus component in order to
isolate the hip joint from the local infection...a medullary screw secures
such reduction and provides minimal implant surface exposure.

Chip

> Dr. Ziran and list colleagues:
> We've followed your thoughts and planned an Stoppa approach for fixing the
> acetabular fracture. Helped with urologist and general surgeon we reopened tha
> anterior mdiline approach, but we found pus in the Retzius space so we thought
> it wasn't wise to insert a plate. We washed the cavity throughoutly, inserted
> some drains and began antibiotics. We decided to stabilize the right sacral
> fracture with an in situ iliosacral screw without compression because the
> fracture was transforaminal. And span the pelvis with an anterior frame.
> �Should we have tried to reduce and fix the fracture anyway (the Retzius
> collection was undoubtly infected (we are waiting for cultures))?
> �What's next step?
> A) Nothing. Just remove the anterior frame when the pelvic fracture
> has healed.
> B) Wait until infection subsides and try again (wait how long) (how do
> we consider surgery is safe) (if it is longer than 2-3 weeks, is it
> worthwhile?, or the reduction will be so difficult than it is not?)
>
> Thanks all for your help
>
>
>
>
>
>
> Dr. Josep M. Mu�oz Vives
> Hospital 'Dr. Josep Trueta'
> Girona
> Catalonia
> Spain
>
>
>
>
>
>
>

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
--

jmmuvi at terra
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Nov 28, 2006, 12:27 PM

Post #5 of 5 (3430 views)
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RE: [ORT-L] Images Acetabulum anterior wall. [In reply to]	Can't Post

Dear Dr. Routt:
I agree with you that a medullary screw would have been helpful to seal the
hip joint. But in the operation we founded granulation tissue over the
fracture line, my thought at that moment was that if I removed the
grannulation tissue to reduce the fracture I will certainly reopen the joint
and allow the infection to penetrate inside (naif?)
Would you retry to reduce the fracture? Or 1 try is enough for this joint,
bearing in mind that reduction is stable and the dome is intact?

Dr. Josep M. Mu�oz Vives

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