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Re: Acetabular Fx Surgical Approach
Jeff Brooks 15 Июль 2006, 23:06
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Thanks to all who have commented. This case has generated a very nice set of 'pearls'. (In part,by posting this case I wanted to generate a discussion of when to approach any acetab fx thru 2 approaches but it has expanded nicely into a great overall advice session!)
a couple more discussion points:
1) from the back thru KL, if the ant column is off rotationally as assessed by palpation thru the GS notch and fluoro, I'd try a pin and t-handle in the ischium to derotate, then AC antegrade screw. Any other tricks for AC reduction thru the KL approach?
2) also, has anyone had experience with ilioinguinal approach thru a previously-operated belly (with scars all over the place and probable
adhesions nearby where you're working along the brim??)
3) If hospital has no Judet table (but something close that doesn't rotate or allow boot-attachment for flexion of the knee to relax the nerve while DF pin is in traction), does one still go prone, say, on the radiolucent board with +/- femoral distractor from ilium to femur (although wrong Tx vector) or prone with a strong assistant to pull (along with, of course, the appropriate reduction/distraction clamps)?
Thanks for everyone's comments, and thanks Chip for sending those great case examples.
Jeff
Jeffrey J. Brooks, MD
Stamford, CT
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Re: Acetabular Fx Surgical Approach
Chip Routt 16 Июль 2006, 00:08
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>1) from the back thru KL, if the ant column is off rotationally as assessed
> by palpation thru the GS notch and fluoro, I'd try a pin and t-handle in the
> ischium to derotate, then AC antegrade screw. Any other tricks for AC
> reduction thru the KL approach?
1. clamp it.
2) also, has anyone had experience with ilioinguinal approach thru a
> previously-operated belly (with scars all over the place and probable
> adhesions nearby where you're working along the brim??)
2. yes...more than I'd like...the anatomy is fibrous/dense/stiff and varied
depending on what's been done before.
>3) If hospital has no Judet table (but something close that doesn't rotate
> or allow boot-attachment for flexion of the knee to relax the nerve while DF
> pin is in traction), does one still go prone, say, on the radiolucent board
> with +/- femoral distractor from ilium to femur (although wrong Tx vector)
> or prone with a strong assistant to pull (along with, of course, the
> appropriate reduction/distraction clamps)?
3. I've never used a Judet table...only seen pictures and they look fancy, but we're not so fancy... and to my knowledge, I haven't needed one yet... but maybe I have and just didn't realize it. We just isolate the perineum, prep the lumbodorsal areas, flanks, and injured lower extremity in its entirety.
You'll need an assistant on the opposite side to retract, and another one on the injured side with you is ideal to provide suction and ipsilateral knee flexion... the ipsilateral assistant can also apply gentle distal-lateral hip traction using a trochanteric ridge bone hook or proximal femoral pin to disengage the head from socket in order to remove debris... your ability to view the joint is determined by the wall size and caudal transverse
segment's instability... the bigger the wall fragment retracted away and the more unstable the caudal transverse segment then the better the joint visualization...you can also use a universal distractor or external fixateur to distract the joint but it never fatigues (which is bad for a tensioned nerve), it must be applied in an appropriate vector, it may interfere with your visualization and obstruct your working into the joint zone, and it leaves holes in the supra-acetabular zone where you might like to apply implants later...so be smart when applying it. You don't need strong assistants, you need smart ones.
Thank you-
Chip
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