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Where Do We Need More than One Approach for Acetabular Fractures and Which One First?

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:10-13 | Raju Vaishya, Vipul Vijay, Amit K Agarwal, Abhishek Vaish Author: Raju Vaishya [1], Vipul Vijay [1], Amit K Agarwal [1], Abhishek Vaish [2] [1] Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India, [2] Department of Orthopaedics, Canterbury […]

New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:3-4 | Dilip D Tanna, Govind S Kulkarni, Sudhir Babhulkar, S. C. Goel, Sushrut Babhulkar, Sunil Kulkarni, Amit Ajgaonkar, Ashok Shyam Author: Dilip D Tanna [1], Govind S Kulkarni [2], Sudhir Babhulkar [3], S. C. Goel [4], Sushrut Babhulkar [3], Sunil Kulkarni [2], Amit […]

Where Do We Need More than One Approach for Acetabular Fractures and Which One First?

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Full Sized Blog Element (Big Preview Pic)

Where Do We Need More than One Approach for Acetabular Fractures and Which One First?

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:10-13 | Raju Vaishya, Vipul Vijay, Amit K Agarwal, Abhishek Vaish

Author: Raju Vaishya [1], Vipul Vijay [1], Amit K Agarwal [1], Abhishek Vaish [2]

[1] Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi, India,
[2] Department of Orthopaedics, Canterbury Christ Church University, Kent, UK.

Address of Correspondence
Dr. Raju Vaishya,
Indraprastha Apollo Hospitals, New Delhi, India.
E-mail: raju.vaishya@gmail.com

Abstract

Acetabular fractures are often difficult to manage. The majority of fractures require anatomical reduction to prevent secondary
osteoarthritis and instability. Often a single approach is sufficient to fix these fractures. The choice of approach depends on the
major anatomical involvement of the acetabulum. However, some fracture patterns require more than a single approach to fixing the
fractured fragments adequately. This article addresses this particular issue.
Keywords: Acetabulum, fractures, pelvic, surgical approaches.

What to Learn from this Article?
The fixation of all the acetabular fractures cannot be achieved with a single approach, at all the times. Hence, it is necessary to do a good pre-operative planning and identify the fractures which may require a dual approach to achieve satisfactory fixation.

Introduction

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Here we present you a series of review of few Medical Apps which we regularly use and make a difference in our lives and the way we practice Orthopaedics and increase productivity.

Review

The basic fracture fixation principles in the lower extremity are anatomical reduction and the possibility of early rehabilitation. A combination of these two factors can help one achieve good prognosis and outcomes. The acetabular fractures are no different. They should be managed aggressively, and an attempt should be made to achieve anatomical reduction so as to prevent the most common complication of osteoarthritis (1). There are some restrictions on the surgical management of acetabulum fractures which may influence the decision of the treating surgeon towards an operative or conservative treatment. Factors like the proximity to important anatomical structures, the difficulty in achieving surgical exposure and the lack of experience in managing these fractures, all influence the decision-making (1).
With advances in imaging technology, a better understanding of anatomy and improved approaches for the management of the acetabulum fractures; focus is shifting towards an effort to achieve anatomical reduction (2). The first step in achieving anatomical reduction for any fracture is good surgical exposure. The most commonly used approaches are the Kocher Langenback and ilioinguinal approach, which have been the workhorse for acetabular surgeons. Recently, further modifications and some extensile approaches like iliofemoral, Stoppa’s, trochanteric osteotomy, etc have also been introduced (3-8). The type and combination of the surgical approach to be used is of paramount importance in achieving a good outcome.

Limitations of a Single Approach

The first step is to understand the anatomy, displacement and the direction of displacement of the fracture. The second step is to plan an approach which would allow proper visualization and accurate reduction of the fracture fragments (2). The ilioinguinal approach is useful for fixation of the anterior column and wall fractures, but they are unable to help in achieving an accurate reduction in cases of displaced posterior column fractures (1) (Figure 1). Similarly, the Kocher-Langenback approach can be used for good visualization of the posterior column and wall fractures, but they provide inadequate exposure to the anterior column and wall (1) (Figure 2).

Matta emphasized the need for anatomical reduction of the fracture fragments in acetabulum for optimal results (9). The key to anatomical reduction is good exposure and visualization of the fracture fragments. A single approach can adequately manage fractures involving a single column or wall. Also, certain bicolumnar fractures which have minimal displacement in one of the columns can also be managed by approaching the more displaced column directly.
However, in certain fractures like T-type fractures with significant displacement in both columns cannot be managed with a single approach. They require either the use of the described extensile approaches like iliofemoral, tri-radiate, etc. or the use of sequential approaches. These approaches are not without their sets of complications like increased rates of infection, delayed rehabilitation, higher rates of ectopic ossification and prolonged abductor weakness (2). Hence, whenever an extensile or a sequential approach is planned, the decision should be based on sound scientific judgement.

Fractures which can not be accessed through K-L approach alone
1. Both columns fractures
2. Anterior column fractures
3. Anterior column and posterior Hemi transverse fracture

Fractures which can not be accessed through ilioinguinal approach alone
1. T-type fractures
2. Isolated posterior column fractures

Fractures needing more than one approach
The fractures which may require more than one approach for an optimal result include –
1. T-type fractures
2. Selected both column fractures with significant displacement (>10mm) in both the columns.
3. Transtectal transverse fractures
4. Transverse fractures with posterior wall fracture with wide displacement
T-type and complete both column fractures
The T-type fractures and complete both column fractures need special mention. In these types of fractures, the femoral head is displaced medially, and both the columns rotate around the femoral head in opposite directions. This mechanism of rotation of the two columns can be understood as one similar to the two doors of a gate opening up in opposite direction around a central hinge. Any attempt at indirect reduction of the columns in these types of fractures will only lead to maintenance of the malrotation and the persistence of inaccurate reduction (1). These fractures are an absolute indication for open reduction, direct visualization, and internal fixation. Hence, these fractures may sometimes require the use of extensile approach or two sequential approaches for optimal fixation (2).

Transtectal fractures which have an anterior displacement also may require sequential approaches for fixation of these fractures. Some of the transtectal fractures may be fixed using a single anterior or posterior approach, especially if they have isolated posterior displacement. Some fractures with high anterior obliquity, on Judet views, with minimal displacement may also be fixed with an isolated posterior approach. Fractures with large displacement (>10 mm) in the anterior direction, usually need sequential surgical approaches (10).
In the transtectal fractures, the vertical nature of the fracture line makes it difficult to palpate the reduction through the greater sciatic notch (11). Moreover, since the fracture line passes through the supra-acetabular dome, imperfect reductions are very poorly tolerated (11). An adequate fixation may require in some of these fractures to utilize two approaches.
Transverse plus posterior wall fractures may make it difficult to be fixed through the isolated anterior approach. If approached through the K-L approach alone, the reduction of the transverse fractures may be difficult to assess through the posterior wall window, even after femoral head distraction. This may make it useful that the surgeon fixes the posterior wall using the K-L approach and then use the ilioinguinal approach for fixation and assessment of the transverse fracture reduction and fixation (1).

Decision making

The decision making for the choice of effective approach depends on the pre-operative CT scan (10). The first choice of fixation of the fractures mentioned is the Kocher-Langenback approach in preferably prone or lateral decubitus position. The pre-operative CT scan should be assessed and if there is a vertical fracture pattern or greater anterior displacement, then it would not be amenable to fixation through the isolated posterior approach but would require an additional anterior approach for optimal fixation (1,10).

Which approach first?

The decision of the first approach to be used depends on various factors. The amount of communication in one of the columns is one of the major determinants. The column which has a greater amount of communition should be fixed first. In the presence of a dislocation, the approach which gives direct access to the side of dislocation should be approached first. In case both the columns have equal comminution or are equally displaced, most of the surgeons prefer making the posterior approach first in the prone or the floppy lateral position (2). The anterior approach is made after making the patient supine.
The T-type fractures are a special case in the combined approach. It is often impossible to fix the posterior column through the K-L approach, without the screws passing through the anterior column fractures (11). Thus, the fractures of the anterior column must be reduced first, which makes the subsequent reduction of the posterior column and wall more amenable.
There have been some studies in the recent English literature, which have used the simultaneous anterior and the posterior approaches by two surgical teams (2). The advantages of simultaneous anterior and posterior approaches are decreased surgical time and simultaneous assessment of the reduction from anterior as well as the posterior directions. The disadvantages of this simultaneous approach are the requirement of two surgical teams which are equally adept and versed with acetabular fractures (2). Also, the anterior exposure is a bit difficult in the floppy lateral position, and the exposure is tough in obese patients (2).
Disadvantages
The disadvantages with the use of simultaneous or sequential approaches for acetabular fixation are –
1. Increased blood loss
2. Increased morbidity
3. Increased incidence of heterotopic ossification – due to increased soft tissue manipulation
4. Increased surgical time

Literature review

Combined exposures of the acetabulum have been used in the literature. Matta reported a very low incidence of 2% out of a total of 262 fractures operated (12). Letournel used a sequentially combined approach in only 3% of the cases, out of a total of 849 cases (3). Similarly, Mayo reported an incidence of 4% for combined approaches in their series of the acetabulum fractures (13).
The most important aim in acetabular fractures is anatomical reduction and adequate fixation. Even though all these studies emphasize that the number of fractures requiring more than one approach be limited, surgeon awareness is important so that an inaccurate reduction is not accepted. Adequate pre-operative planning using all the possible radiographic views and the CT scans available should be done, so that the surgeon is aware of the possibility of using two approaches based on the type of fracture and the displacement. This information can help the surgeon as well his team, including anaesthetists and assistants, be aware and prepared for the same.
The decision regarding whether the approach is made simultaneous or sequential and under the same or different anaesthesia, should be taken by surgeon expertise and OT backup. In most scenarios, the column with more comminution should be approached first and in the setting of equal comminution, the posterior column should be approached first.

References

1. Matta JM. Operative indications and choice of surgical approach for fractures of the acetabulum. Techniques Orthopaed 1986;1(1):13-22.
2. Harris AM, Althausen P, Kellam JF, Bosse MJ. Simultaneous anterior and posterior approaches for complex acetabular fractures. J Orthop Trauma. 2008 Aug;22(7):494-7.
3. Letournel E, Judet R, eds. Fractures of the Acetabulum. 2nd ed. Berlin, Germany: Springer-Verlag; 1993.
4. Mears DC, Rubash HE. Extensile exposures of the pelvis. Contemp Orthop. 1983;6:21–32.
5. Reinert CM, Bosse MJ, Poka A, et al. A modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg. 1988;70A:329–337.
6. Routt ML Jr, Swiontkowski MF. Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am. 1990;72:897–904.
7. Griffin DB, BeaulA ˜ PE, Matta JM. Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the
acetabulum. J Bone Joint Surg Br. 2005;87:1391–1396.
8. Wey J, DiPasquale D, Levitt L, et al. Operative treatment of acetabular fractures through the extensile Henry approach. J Trauma. 1999;46: 255–260.
9. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients operatively treated within three weeks after injury. J Bone Joint Surg. 1996;78A:1632–1644.
10. Bogdan Y, Dwivedi S, Tornetta P 3rd. A surgical approach algorithm for transverse posterior wall fractures aids in reduction quality. Clin Orthop Relat Res. 2014 Nov;472(11):3338-44.
11. Bucholz RW, Heckman JD, Court-Brown C, eds. Rockwood Green’s Fractures in adults. 6th edn. New York, USA: Lipincott William & Wilkin’s;2006.
12. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients operatively treated within three weeks after injury. J Bone Joint Surg. 1996;78A:1632–1644.
13. Mayo KA. Open reduction and internal fixation of fractures of the acetabulum: results in 163 fractures. Clin Orthop. 1994;305:31–37.

How to Cite this article: Vaishya R, Vijay V, Agarwal AK, Vaish A. Where Do We Need More Than One Approach for Acetabular Fractures and Which One First? Trauma International Jan-Apr 2017;3(1):10-13.
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New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

April 10, 2017/in Volume 3 | Issue 1 | Jan-April 2017

Vol 3 | Issue 1 | Jan – Apr 2017 | page:3-4 | Dilip D Tanna, Govind S Kulkarni, Sudhir Babhulkar, S. C. Goel, Sushrut Babhulkar, Sunil Kulkarni, Amit Ajgaonkar, Ashok Shyam

Author: Dilip D Tanna [1], Govind S Kulkarni [2], Sudhir Babhulkar [3], S. C. Goel [4], Sushrut Babhulkar [3], Sunil Kulkarni [2], Amit Ajgaonkar [5], Ashok Shyam [6,7]

[1] Saifee Hospital Medical research center, Mumbai , India.
[2] Sushrut Institute of Medical Sciences,Research Centre & Post-Graduate Instt of Orthopedics,Central Bazar Road,Ramdaspeth,Nagpur,INDIA 400 010
[3] Post Graduate institute of Swasthiyog Pratisthan Miraj, India
[4] Professor of Orthopaedics, Institute of Medical Sciences, BHU, Varanasi, India
[5] Zenith Hospital, Malad, Mumbai, India
[6] Indian Orthopaedic Research Group, Thane, India.
[7] Sancheti Institute for Orthopaedics & Rehabilitation, Pune, India.

Address of Correspondence
Dr. Ashok K. Shyam.
IORG House, A-203, Manthan Apts, Shreesh CHS, Hajuri Road, Thane, India. 400604
Email: drashokshyam@gmail.com

New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

Trauma as a faculty is developing rapidly along with understanding of fracture patterns, change in trauma scenario and also development in new implants. However outreach of these new developments and percolation and applicability of these new developments is still a big question. We see cases that are complicated by wrong choice of surgery, wrong choice of implant and improper use of principles. Trauma International tried to interview the core team of Trauma Society of India on these two question of new implants and education and research in field of Trauma. We have compiled the responses in this editorial
Dr DD Tanna: New implants like the precontoured anatomical plates are really good. They are definitely expensive but are good. Some Indian companies are also producing excellent variants of the anatomical plates and I believe these will definitely help in better management of complex articular fractures. However I also believe that not every new implant is a real improvement over the previous one. We have to wait for the clinical results and we have to be smart in selecting our cases to use these implants
Trauma education is an ongoing process and we are all students at the same time. We have to continue to learn how to learn, only then we can learn about the new methods and technologies and also learn them well. It is essential for our growth as a surgeon and helps us deliver best treatment to our patients
Dr Sudhir Babhulkar: New implants like fragment specific fixation and anatomic contoured plates are an excellent addition to armamentarium of a trauma surgeon. However we should learn to use them wisely and carefully
Teaching the young generation is the key to spreading trauma education. Traumacon has created that interest in young surgeons about trauma. We need to focus on them and help them develop proper understanding of principles and correct execution of surgical techniques. Conferences, courses workshops all are needed to achieve this aim. Also teaching about correct principles and techniques should reach periphery. My practice has been 50 to 60% complicated reffered cases. Most of the cases were complicated because of wrong application of surgical principles. I think teaching that will address these issues the correct solution for trauma education in India.
Dr GS Kulkarni: About new implants, some of them are really useful in certain situations like fragment specific fixation and contoured plates, but some new implants are not as useful as they are made to appear. New implants should be focussed on solving a surgical problem and should not be innovation for the sake of innovations. We have our innovation which is slotted plate for lengthening over a plate and it is aimed to solve a particular problem. I think that is how innovation should be aimed at.
The focus of trauma education should be basics of trauma surgery. That is where many complications arise. Especially as cases of road traffic accidents are rising, basics of management of open fracture should be emphasised more. Principles of debridements, wound closure, when to close the compound wound, methods of closing the wound, external fixation and stabilisation of compound fracture should all be reviewed and highlighted again and again. Another area is use of antibiotics in fracture surgery specifically local and systemic therapies. Current evidence and experience suggest that with proper surgical management, a single day antibiotic therapy is enough. However most surgeons will give either three day or five day antibiotic therapy which is not good for the patient as well as the fracture. If there is a need for prolonged infection control use of local antibiotics systems like cement beads or cement rods should be utilised to reduce the systemic load of antibiotics. Even in cases of closed fracture proper surgical principles should be followed. For example if a surgeon is using locking plates without understanding the principles of locked plates, it becomes a dangerous implant in his hands and is one of the main cause of complications.
Dr SC Goel: There are new implants launched every year and such developments should be taken with pinch of salt. Lot of these may be industry driven and we need good multicentric trails to validate the results before using them
About education and research, I feel we should have focus on basic sciences too. Unfortunately there are not many basic science labs in India. There are many surgeons who have innovative ideas and techniques but do not get a chance to promote their ideas. I think either TSI or IOA should take these projects ahead and give a chance to all innovators to come forward
Dr Sushrut Babhulkar: The science of orthopaedic trauma is evolving and our understanding of it is changing and that is reflected in development of new implants. New implants in trauma are very different from new implants in Arthroplasty where it is more industry driven rather than real evolution. As our understanding of fracture pattern and soft tissue injury improves and as we encounter more varied bone quality, the need for new implants will increase. These improvement in basic understanding is what fuels development of new implants in trauma and I think we are moving forward in sensible direction as far as trauma implants are concerned
Education should focus on accurate understanding of principles of trauma surgery and principles of various implants. Both should be used in perfect harmony to achieve excellent result. If either of these principles are not followed, it would lead to complications. This is the main teaching of Traumacon every year. Again research should be promoted but not enforced, if it is enforced, we will get more poor quality research and publications.
Sunil Kulkarni: We are facing new challenging in trauma surgery and number of complex and articular trauma has increased due to high energy accidents. I think new implants have helped us a lot in dealing with these complex injuries. Although simple trauma is still managed well with conventional implants, so proper patient selection is essential.
Trauma education should be about practical knowledge. Textbook knowledge is not of much use in clinical practice. Especially trauma is a branch where even after decades of practice, on can see a completely new case of face new surgical challenge. Education should be focussed on preparing trauma surgeons to face these challenges and difficult practical problems.
Dr Amit Ajgaonkar: New implants have definitely added more tools for trauma surgeons. Implants like Halifax nails, fragment specific fixation, far-cortex locking plates are based on sound principles and have definite advantages in properly selected cases
Trauma Education should focus on peripheral surgeons. In recent months I have travelled a lot across the country and especially in the interiors. I realised that maximum trauma work is done by the peripheral surgeon in rural settings. There is an urgent requirement to provide both training as well as infrastructure to these places. I think TSI, IOA and Traumacon can contribute a lot in terms of improving the training but government should also focus on improving the infrastructure.
If we carefully note the views of all the experts above we can deduce a chain of thought which can be summarised easily. New implants are good but understanding of the principles behind the implant and proper patient selection is must. As far as trauma education is concerned, all the experts believe basic principles are the building blocks and practical knowledge is of utmost importance. I too believe that trauma Education and research are not different entities, both are actually part of one spectrum. Academics originates from new research and initiation of research is from academics. Thus they both fulfil each other and through the churning of both these, innovative ideas and new implants are born.
We thanks our panel for sharing their thoughts with us and we leave the readers now to enjoy the current issue of TI
Dr Ashok Shyam
Editor – Trauma International.

How to Cite the article: Babhulkar S, Shyam AK. 10 years of Traumacon. Trauma International. Jan – April 2017;3(1):1-2.

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Where Do We Need More than One Approach for Acetabular Fractures and Which One First?

New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

Where Do We Need More than One Approach for Acetabular Fractures and Which One First?

New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

Full Sized Blog Element (Big Preview Pic)

Where Do We Need More than One Approach for Acetabular Fractures and Which One First?

Author: Raju Vaishya [1], Vipul Vijay [1], Amit K Agarwal [1], Abhishek Vaish [2]

Abstract

Introduction

Review

Limitations of a Single Approach

Decision making

Which approach first?

Literature review

References

(Abstract) (Full Text HTM L) (Download PDF)

New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

Author: Dilip D Tanna [1], Govind S Kulkarni [2], Sudhir Babhulkar [3], S. C. Goel [4], Sushrut Babhulkar [3], Sunil Kulkarni [2], Amit Ajgaonkar [5], Ashok Shyam [6,7]

New Implants in Trauma Surgery and Trauma Education – Viewpoints of Experts

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