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Re: Acetabular Fx Surgical Approach
Dan Schlatterer 15 Июль 2006, 23:49
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good morning,
the case that I found is a 20yo male, MCC. his AP pelvis shows an interesting position of his bladder. it is pushed aside by a hematoma from SGA injury. we did a limited lateral window approach for the anterior column first, pt bumped up/supine. then closed and repositioned for KL. I could not find intra-op photos of cases when we did only a small incision for the AC screw (but they do exist!!). the lateral window is available for reduction assessment if a KL approach is being used. in the lateral position this window is available. the prone position definitely takes pressure off of the post column and facilitates reduction. in the lateral position a schantz pin in the ischial tub +/- bone hook in sciatic notch helps with PC reduction. the lateral position also gives better airway access for anesthesia. airway problems are rare, but prone position seems to be a bit more of a challenge to exchange the tube, or reintubate altogether. just something further to debate!
dan schlatterer
atlanta
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Re: Acetabular Fx Surgical Approach
Chip Routt 16 Июль 2006, 00:18
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Your lateral intraop image actually made me nauseated... truly a visceral response when I saw it... it's an image which brings back the horrid memories of my past... struggling to achieve my daily malreduction... flipping and flopping the poor patient... reprepping... wasting time... praying... trying to get a C-arm in place... gag... until some kind soul taught me a prone KL.... ahhh, what a great day that was.
I've heard all the anesthesia issues over the years... believe me.
Prone seems to work very well for the spine team...prone is also now used by ICU teams for improved pulmonary work, and once you learn it, you'll never go back lateral.
Remember to put your toe in the water with someone who knows how to swim.
Chip
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Re: Acetabular Fx Surgical Approach
Отправитель: Zholt Balogh 16 Июль 2006, 00:22
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K-L approach was described for prone position. the lateral positioning is coming from elective orthppaedics (hip arthroplasty). Lateral position works against your reduction especially in the transverse fracture cases like this was. You can manage isolated posterior wall fractures from lateral positioning.... but you do not need to struggle with it.
Zsolt Balogh
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Re: Acetabular Fx Surgical Approach
Отправитель: Dan Schlatterer 16 Июль 2006, 00:39
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thank you for your thoughts. it is interesting how you knew that I am afraid of the water. one
of these days I will learn to swim:)
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Re: Acetabular Fx Surgical Approach
Отправитель: Peter Krause 16 Июль 2006, 00:43
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I agree with Chip. I trained with the lateral position, but have converted to prone for most of these cases. I think the prone postion is extremely helpful not just for transverse posterior walls, but also for the very unstable
extensive posterior walls. In these cases you really need gravity on your side.
The exception for me is the extremely rare combined (operative) femoral head + posterior wall where I have done the surgical dislocation. I have not had a Judet table available to me so I I use manual traction.
Peter Krause, MD
Assistant Professor
LSU Department of Orthopaedic Surgery
New Orleans, LA
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Re: Acetabular Fx Surgical Approach
Отправитель: Jeff Brooks 16 Июль 2006, 00:56
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Are those who do these Fxs prone using a radiolucent flat board, Jackson Spine, standard table, Fx table?
I do most all pelvic cases on the OSI modular table with the flat board which is entirely radiolucent and very easy to work with. My hospital does not have the fancy Fx table attachment for this, however, as our Fx table is separate.
Jeff
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Re: Acetabular Fx Surgical Approach
Отправитель: Bruce Ziran 16 Июль 2006, 01:02
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It seems that there are a lot of strong opinions on this matter. Just to stir it up a bit more, I will propose that using a Jackson table, lateral position, with traction, and using the peroneal post with the vertical height adjustment gets the best of both worlds. The vertical post overcomes gravity quite easily and facilitates surgical luxation of the head when longitudinal traction is added. The set up is easy, all of the vectors of forces that those who propose prone positioning can be accounted for, and if a troch osteotomy is needed (for whatever reason), it allows access to more anterior structures. I am definitely not a fan of floppy lateral with manual traction. I agree with Chip, this is absolute torture, but I have used all of the described methods and settled on what seemed easiest. Over come the vectors of deformity, eliminate human fatigue (manual traction), and its not so bad. If a T or bad transverse is tough, it is probably not going to be solved, or caused by the position, but probably justifies a sequential procedure with a second postioning and anterior approach. Acetabular and pelvic surgery seemed to bring out the dogma in us all..
Bruce H. Ziran, M.D.
Director of Orthopaedic Trauma
St. Elizabeth Health Center
Associate Professor of Orthopaedic Surgery
Northeast Ohio Universities College of Medicine
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Re: Acetabular Fx Surgical Approach
Отправитель: Chip Routt 16 Июль 2006, 09:38
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> It seems that there are a lot of strong opinions on this matter. Just to stir
> it up a bit more, I will propose that using a Jackson table, lateral position,
> with traction, and using the peroneal post with the vertical height adjustment
Simple as this, 99.99% of surgeons can't safely work and clamp through the notch with the patient positioned laterally...it's just not anatomically possible... and it's all about the reduction... we know that.
Imaging is so easy with a prone patient on a radiolucent table, and it's so troublesome with a laterally positioned patient on a fracture table...we know this too.
Fracture tables with perineal posts and sustained traction (to maintain an approximate and "soft tissue tensioned" based reduction) cause complications that we're all very familiar with... if you are too young, ask those who remember the history and evolution of femoral nailing...it's written.
This is not dogma, it's just reality...it is what it is...you know what you know, but you don't know what you don't know.
These details only matter to the patients and those that you try to teach.
That's enough from me-
Chip
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Re: Acetabular Fx Surgical Approach
Отправитель: Flavio Restrepo 16 Июль 2006, 15:16
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I'm with Dr. Chip
The classical papers are:
JBJS 1964; 46A: 1615-46 Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification and surgical approaches for open reduction.Clin Ortthop 1980; 151: 81-106.
Letournel E: Acetabular fractures: Classification and manegament. Springer Verlag 1993. Letournel E, Judet R: Fractures of acetabulum. ed 2, Berlin, Germany
Flavio
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