O objetivo do presente artigo é revisar a literatura disponível sobre o uso da abordagem de Stoppa modificada em fraturas de acetábulo. Balbachevsky D, Pires RE, Faloppa F, Reis F. Tratamento das fraturas da pelve e acetábulo pela via de Stoppa modificada. Acta Ortop Bras. Lesões arteriais potencialmente mortais associadas a fraturas do acetábulo: A propósito de um caso clínico. Rev. Port. Ortop. Traum. [online]. , vol, n.2, .
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Prospective study on seventy-six cases of fractured acetabulum with surgical treatment. To conduct a prospective study on unstable and incongruent fractures of the acetabulum, in comparison with the literature, covering the type of access, fixation materials, degree of reduction, type of fracture and results after surgery.
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The authors evaluated 76 patients with unstable and incongruent fracture of the acetabulum between January and December The radiological evaluation was done in accordance with the Ruesch criteria, and good, excellent or perfect results were obtained for 64 patients The clinical evaluation was done in accordance with the Harris criteria, and good or excellent results were obtained for 62 patients The complications were assessed and, in comparison with the literature, were shown to be compatible with previous reports even after the statistical analysis.
It was concluded that anatomical reduction and stable fixation are important for good results. The first surgical treatment for a fracture of the acetabulum was performed by Levine, in 1. InCauchoix produced a study on the surgical approach to the acetabulum 2. A major change took place starting inthanks to Letournel and Judet 3,4who greatly influenced the knowledge and systematization of this surgical treatment.
These last authors introduced a didactic classification of fractures of the acetabulum that aids in dealing with them. They improved the radiological assessments by instituting specific radiographic views and publicized the ilioinguinal, Kocher-Langenbeck and iliofemoral access routes. More recently, Marvin Tile created a classification system for fractures of the acetabulum in an attempt to achieve better standardization of the approaches and treatments 5,6.
It has become essential to use computed tomography, in order to achieve better preparation and comprehension of the fracture 7. The aim of this study was to make a prospective evaluation in comparison with the literature, covering the type of access, fixation material, degree of reduction, type of fracture and results after surgery.
Seventy-six patients with unstable and incongruent fractures of the acetabulum were evaluated between January and December The Marvin Tile classification was used and all the patients were treated surgically in accordance with the technique recommended by the AO-ASIF group.
The mean length of follow-up was 4. The patients’ mean age was Regarding sex, 64 were male Regarding the type of trauma, there were 51 cases of car and motorcycle accidents Both sides were affected in three patients, but only one side was treated surgically and the other frathras was excluded Table 1.
The criterion for instability was hip misalignment associated with displacement of the wall or the anterior or posterior column. The criterion for incongruence was a deviation greater than 3 mm in fractures of the acetabular dp, transverse fractures, “T” fractures or fractures of fratugas two columns.
To evaluate the displacement, the Matta criteria were also taken into consideration in measuring the arch of the acetabular roof in the three Judet views 8,9. The fracture distribution according to the Marvin Tile classification 6 is shown in Table 2. Regarding the surgical approach, the access used for two patients 2.
All the patients underwent clinical and radiographic evaluations. They were then taken to the surgical block, where transkeletal traction was established on the distal femur on the day of admission. Exposed fractures or associated dislocations were treated as emergencies.
Treatment for the acetabular fractures was scheduled for a second occasion. All the patients received a prophylactic regimen against deep vein thrombosis, consisting of sodium heparin at a fraturaw of 5, UI subcutaneously, every eight hours, from the time of admission until discharge from hospital. They also received venous antibiotic therapy first-generation cephalosporin starting from the perioperative period, consisting of two grams intravenously at the time of induction of anesthesia and a fratyras two grams every six hours after the operation, for another acetbulo hours.
Radiographic examinations were performed during the postoperative period, in Judet views, in order to verify the remaining degree of displacement. The Ruesch criteria were used: If the patient achieved nine points, the result was considered perfect; eight points, excellent; seven points, good; and less than seven points, poor result taken to be a failure. Also during the postoperative period, the patients were assessed by means of a questionnaire in which they were classified according to the Harris scoring criteria, and this examination was repeated at all the return visits Evaluations were made on the 15th, 30th, 60th and 90th days after the operation, six months after the operation and annually thereafter.
At all these return visits, clinical and radiological assessments were made using the criteria of Harris 11 and Ruesch et al The patients were released for passive movements under guidance on the first day after the operation, and the loading placed on the operated joint was limited over the first 90 days.
No prophylaxis for heterotopic ossification was administered. A satisfaction questionnaire was applied, which included asking whether the patient would undergo this surgical procedure again. For each fracture, between one and four acetabular reconstruction plates were used. The patients were examined within the Harris criteria 11receiving scores from 0 to Their range of motion, pain levels and functional abilities were evaluated, and these results are shown in Table 3.
Regarding the patients’ degree of satisfaction, it was observed that The frafuras most often found were nerve injuries mostly neuropraxiaosteoarthrosis, infection, heterotopic ossification and loss of reduction, as shown in Table 4. The mean duration of the operation was two hours standard deviation of There was one case of preoperative lesion of the superior gluteal vein that required ligature, but without further complications.
Out of the five cases of heterotopic ossification, two were grade I and three were grade III of Brooker et al It was observed that fractures of types B and C presented worse prognoses and correlated with a greater number of postoperative complications. In the radiographic evaluations, it was seen that there were some perfect reductions Figures 1 and 2excellent reductions Figures 3 and 4 and good and poor reductions Table 5.
The distribution of the types of access in relation to the types of fracture is shown in Table 6. All the fractures consolidated and in acerabulo single case of deep infection, the plate was removed two months after the operation, without loss of the reduction.
Nevertheless, this patient evolved with chronic osteomyelitis and osteoarthrosis. There were two cases of avascular necrosis of the femoral head.
Reprodutibilidade da classificação de Tile para fraturas do acetábulo
In these cases, a displacement of 2 mm remained after the surgical reduction. These patients underwent reduction of their coxofemoral dislocation on the day of the trauma. At the most recent assessment, one of these patients presented total collapse of the head Figure 5.
As has been stated in several studies acetbaulo fractures of the acetabulum, the treatment of choice for displaced fractures with significant joint involvement is open reduction and anatomical internal fixation The number of excellent and good results The distribution of the fractures according to the Marvin Tile classification showed that the number of type B fractures This distribution is not in agreement with what is found in the literaturein which type A fractures predominate.
It is believed that this difference is due to the greater severity of the accidents attended at our clinic.
Moreover, exclusion of fractures of the posterior wall that were treated conservatively or by means of minimal fixation would also explain these differences. Only in the cases of heterotopic ossification was there any significant association between the type of surgical access and the complications found, and this occurred only with the Kocher-Langenbeck access.
Heterotopic ossification was found in only 6. The statistical analysis on the possible associations between the duration of the operation, age, color, sex and type of fracture did not find any significant values. It was noted that heterotopic ossification only occurred in cases with a posterior approach, which was in line with the literature Their fractures were of Marvin Tile type B3; their scores in the Harris classification were 72 and 70 points, and their radiological scores were poor in the Ruesch assessment.
It is believed that the low incidence found in the present study was due to early treatment. Sciatic nerve injuries were seen in 10 patients: Of these ten cases, seven already presented lesions before the surgery; the other three presented neuropraxia, with full recovery at the last assessment.
Only two patients with sciatic nerve injuries due to trauma did not recover. Out of the patients with Tile type C fractures, Seven patients who evolved with osteoarthrosis presented radiographic scores of less than seven.
Among these patients, one received a cemented total hip prosthesis. All of these patients had scores of lower than 75 points in the Harris assessment.
This demonstrates that there was a direct fratudas between evolution to osteoarthrosis and poor reduction of the fracture, with consequent patient dissatisfaction 2. Thus, early intervention, a correct approach, good stabilization and reduction are important for minimizing the number of complications , Other factors that influenced the prognosis for the fractures included deep infection 2. It was observed that tomography was extremely important for scheduling and good progression of the surgery.
It facilitates the approach and should be used routinely. Tomography was used in 53 cases, and it was observed that in the 23 cases The results found were compatible with those in the literature.
Among the material studied, surgical treatment of the deviated and unstable acetabular fractures produced excellent and good results in a significant proportion of the patients, with a mean follow-up of 1. A treatment acetaublo central fractures of the acetabulum.
J Bone Joint Surg.
Prospective study on seventy-six cases of fractured acetabulum with surgical treatment
Cauchoix J, Truchet P. Les fratures articulaires de la hanche. Les fratures du cotyle. Fractures of the acetabulum: J Bone Joint Surg Am. Fractures of the acetabulum. Orthop Clin North Am. J Bone Joint Surg Br. Computed tomography acegabulo surgery in complex acetabular fractures. Clin Orthop Relat Res. Early results of a prospective study.