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Re: Acetabular Fx Surgical Approach
Jeff Brooks 17 Июль 2006, 21:25
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In this erudite, and very helpful, discussion Chip has commented several times about clamping a transverse fracture.
I am familiar with all the assorted clamps, repositioning forceps, etc, available and I'm trying to picture what you describe when youention clamping "thru the notch". What type of clamp do you use most frequently (pointed reduction, offset clamp with a toothed "foot", Farabeufs or "repositioning forceps" secured to screws on either side of the Fx)? How do you clamp a transverse Fx thru the greater sciatic notch? Do you mean across it (cephalo-caudally?) Where (anatomically) do you prefer to put the teeth of the clamp?
I've used small or large "repositioning forceps" or Farabeufs in the past in fxs like this (tsvs/PW) to reduce & hold the PC Fx with temp
screws cephalad and #2 screw in the caudal seg, then manipulate & clamp these 'screw-bone-units' together with a repo/Farabeuf, palpate thru notch to assess AC reduction as well as luoroscopically, and then apply first plate near notch, then reduce & fix PW with AC screw antegrade thru second, more lateral, buttress plate for the reduced &
grafted/supported PW.
If Chip or anyone has a trick or pearl on clamping technique to reduce a tsvs Fx like this one I'd be interested in hearing it.
Thanks again to everyone for a great discussion & debate.
Jeff
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Re: Acetabular Fx Surgical Approach
Chip Routt 17 Июль 2006, 21:43
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I¹ll send along some clinical pics, models, clamps, and the fluoro images to go with it... I¹ll also make a step by step clinical and fluoro tutorial on the next transverse or Tr/PW that we do.
Based on this discussion line, clamping thru the notch is clearly not a familiar technique.
There¹s no need to do these fractures prone if you aren¹t going to exploit the quadrilateral surface access.... this is why some are stuck using the
lateral position... they aren¹t working thru the notch so the soft tissue gains of prone are not apparent.
If you¹d examine any routine CT scan of a normal non-variant pattern transverse fracture, and imagine where you¹d place your ideal clamp for compression of the fracture line, then it¹s typically with one tine applied to the quadrilateral surface and the other tine applied in the area between the AIIS and the posterior wall (or the wall itself in some instances)... the
pictures will ³make more sense².
My best guess is that most are clamping the posterior column component of a transverse fracture using a Farabeuf or similar clamp because you can see this portion of the fracture... it¹s just so difficult to do this and only addresses one fracture limb... this clamp application fills the wound, obstructs the imaging and implant applications, complicates access to the anterior column, etc. I¹ve done this too... it¹s insufficient.
If you¹d simply elevate the periosteum of the greater notch, then work thru the notch to elevate the obturator internus from the quadrilateral surface, then you can palpate thru the notch the transverse fracture offset/displacement at the quadrilateral surface and often all the way to
the anterior column. You can then lateralize/lengthen the caudal transverse segment uniformly however you¹d choose and clamp it thru the notch... then palpate thru the notch to better assess the near entirety of the transverse fracture... the C-arm images confirm the restoration of the 3 line landmarks and you can adjust the C-arm beam to be tangential to the true fracture line if you¹re still in disbelief that you¹ve finally gotten a transverse reduction!! The transverse¹s anterior column component can next be
stabilized with a medullary antegrade ramus screw inserted using standard inlet and obturator-oblique combination imaging for safety... the medullary ramus screw will secure the transverse sufficiently about 90-95% of the time so that the clamp can be removed, the impaction segments elevated and supported, the wall fragments reduced and secured with temporary K-wires, then the wall buttressed and transverse neutralized with a contoured plate...remove the K-wires, debride the regional necrosis, wash and close.
I¹ll send some pictures as soon as I can get to it-
Chip
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