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Re: Acetabular Fx Surgical Approach
Bruce Ziran 17 Июль 2006, 14:51
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Some of this discussion does not make sense. The sciatic notch is no different anatomically whether prone or lateral. The imaging is not difficult in the lateral positoin. The traction used is not sustained either. It suspends the leg and is only used when needed. The literature on traction for femoral nailing emphasized the use of wider and well padded posts, and unsustained use. The operative times for most KL approaches are well below 2 hours and traction is used for the brief moments to help with reduction and to look into the joint. The patient is well positioned, gravity actually helps with exposure and is overcome by equipment. I used to be younger and learned both methods from the same experts. They both work and the surgeon just needs to pick what they feel most comfortable using. Now I am older and I use and teach the lateral approach successfully. I respect Chip's opinion and expertise but either I am one of the three 0.01% of ortho trauma surgeons who use the lateral, or that 99.99%
figure may be a bit skewed! My previous partners both used lateral without any traction and did a nice job as well.
I dont think it makes sense to espouse one technique too strongly. Just as in femoral nailing (supine or lateral) and in total joints (posterior, lateral, or anterior), there are several ways and many opinions. What is the best for the patient, is what the surgeon does best. I began with the prone positoin but felt it was too restrictive and developed a way to make the lateral position work although there are times I use the prone as well. Others feel differently and I would never chastise another acceptable way of doing these cases. Lets face it in the pool of orthopedists, very few are willing, or able to do this type of surgery, The bottom line is that whatever approach or method used, if it is done properly and with attention to the principles, it will work.
BZ
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
Chip Routt 17 Июль 2006, 20:14
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See below comments...no chastise, espouse, etc-
Chip
BZ> Some of this discussion does not make sense.
This statement is absolutely true.
BZ> The sciatic notch is no different anatomically whether prone or lateral.
This is true from an osseus standpoint, but it’s 90 degrees different geometrically and that has great impact on the local soft tissue behavior.
BZ>The imaging is not difficult in the lateral positoin.
This is not true...please.
BZ> The traction used is not sustained either.
OK... some forget to release when not in use.
BZ>It suspends the leg and is only used when needed.
Sometimes it’s needed for prolonged times while doctors work hard trying to assemble a fracture.
BZ> The literature on traction for femoral nailing emphasized the use of wider and well padded posts, and unsustained use.
The bigger the post, the smaller the operative field and the more obstructed the imaging.
BZ> The operative times for most KL approaches are well below 2 hours and traction is used for the brief moments to help with reduction and to look into the joint.
Wow!! You are really fast... it takes most surgeons 30-45” just to get the patient positioned on a fracture table.
BZ>The patient is well positioned, gravity actually helps with exposure and is overcome by equipment. I used to be younger and learned both methods from the same experts. They both work and the surgeon just needs to pick what they feel most comfortable using. Now I am older and I use and teach the lateral approach successfully.
Good.
BZ> I respect Chips opinion and expertise but either I am one of the three 0.01% of ortho trauma surgeons who use the lateral, or that 99.99% figure may be a bit skewed! My previous partners both used lateral without any traction and did a nice job as well.
Good.
BZ>I dont think it makes sense to espouse one technique too strongly. Just as in femoral nailing (supine or lateral) and in total joints (posterior, lateral, or anterior), there are several ways and many opinions. What is the best for the patient, is what the surgeon does best.
Think about what you just said.... what if my “best” is my spica casting technique? This is not about the surgeon and his/her “comfort”... it’s about the patient.
BZ>I began with the prone positoin but felt it was too restrictive and developed a way to make the lateral position work although there are times I use the prone as well. Others feel differently and I would never chastise another acceptable way of doing these cases. Lets face it in the pool of orthopedists, very few are willing, or able to do this type of surgery, The bottom line is that whatever approach or method used, if it is done properly and with attention to the principles, it will work.
Good enough...you know what you know.
Chip
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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Re: Acetabular Fx Surgical Approach
Отправитель: Bruce Ziran 17 Июль 2006, 20:48
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It seems to be a pretty emotional topic. Did not mean to throw gas on the fire. Very enlightening discussion, nonetheless. Hope it is ok to agree to disagree sometimes. Guess I will continue to mame the public as before.
Our weapons of choice may be different but the end result should be the same. Cheers.:)
BZ
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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