Kyle F. Dickson, M.D. M.B.A. I Need a Special Table to Treat Some Acetabular Fractures. I Prefer a Special Table to Treat Most Acetabular Fractures

Transcription

1 Kyle F. Dickson, M.D. M.B.A. Professor Baylor College of Medicine Southwest Orthopaedic Group, Houston, Texas cell I Need a Special Table to Treat Some Acetabular Fractures Kyle Dickson MD, MBA Clinical Professor Baylor University Southwest Orthopadic Group, Houston, Texas I Prefer a Special Table to Treat Most Acetabular Fractures Kyle Dickson MD, MBA Clinical Professor Baylor University Southwest Orthopadic Group, Houston, Texas 1

2 Chip knows that a table would make life easier for him but he is too egotistical and proud to admit it plus he likes it hard Downsides to a Table Less ROM (Keith Mayo pushed the indications for the II instead of using the EIF) Posterior dislocation with posterior wall piece anterior to the head Need for a trochanteric slide with a surgical dislocation of the hip (femoral head fracture with a posterior wall) 2

3 Benefits of the Table Iron Resident (600 cases at Charity 600 cases at Tulane) Letournel, Letournel, Letournel Reduction, Reduction, Reduction Put the head in the anatomical position and anatomically reduce the acetabular fracture to the reduced head 3

4 The Orthopaedic Table Used from the beginning by Judet and Letournel Forgotten by many surgeons A major factor in limiting the surgical approach Minimally Invasive Surgery From the beginning, it has been Letournel s protocol to limit the surgical trauma as much as possible by operating through the KL or II alone and avoiding 2 approaches or the EIF whenever possible. 4

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6 JH Impacted AW(?AC) LG AC/AW/PW 6

7 CT Verify intact posterior column, iliac wing, and ischiopubic ramus Look for impaction?posterior wall fracture 7

8 DT 42 yo T-boned in mva Reported central dislocation unreducible DT-9/4/02 8

9 DT-9/4/02 DT-9/5/02 9

10 DT-9/5/02 DT-9/5/02 DT-9/5/02 10

11 Ilioinguinal Approach Developed by Letournel after extensive cadaveric anatomical study Approach to the anterior column and anterior articular surface Supine Ilioinguinal: Position Distal Femoral or Boot Traction Access to Greater Trochanter (Lateral Traction) Hip flexed 20 11

12 Ilioinguinal Approach: Access DT Timing? Stretch on the ascending branch of the medial circumflex Articular malreduction skeletal traction Treatment Anterior Wall Fractures Internal rotation and traction Pack graft and reduce impacted pieces (through fracture site or a separate drill hole above impaction) 12

13 DT-9/6/02 Treatment Anterior Wall Fractures Angled or straight Matta clamp or king tong from outside AIIS to anterior wall fragment derotates wall Weber clamp along brim for AC Reduction of AW or AC reduces head quadrilateral pieces can be ignored 13

14 Fixation Lag screws from anterior wall piece superiorly and inferiorly to intact bone 8 hole butress plate with 2 above and below close to brim to avoid joint penetration. 14

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16 DT-10/31/02 DT-10/31/02 DT-10/31/02 16

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18 Kocher Langenbeck: Access Jungbluth clamp 2-screws 18

19 Extended Iliofemoral Developed by Letournel (1975) Based on Smith- Peterson Approach Maximal Simultaneous access to both columns of the acetabulum Extended Iliofemoral: Position Lateral Position Distal Femoral Traction Knee flexed 45 19

20 EF BCEIF 20

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23 51 yo fall LG High AC Separate quadrilateral piece with posterior wall 23

24 LG LG 24

25 LG LG 25

26 Reduction Similar to anterior wall High fractures start at the brim with Farabeuf and Weber King tong with a disc under or around psoas and other between ASIS and AIIS (AC flexes) LG SM 26

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28 Reduction Farabeuf or Jungbluth clamp proximally and distally on anterior column Intra op lateral traction of femoral head Assess quadrilateral reduction Fixation Lag screws 1)AIIS into posterior column, 2)iliac fossa parallel to quadrilateral surface into posterior column, 3)iliac crest Unsafe zone inferior pectineal eminence to line from inferior AIIS to greater sciatic notch Butress plate along brim 28

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31 71 yo fall RB Htn, DM, CAD, s/p CABG L AC/AW elevation and impaction of dome vs elevation of AW or AC RB 31

32 RB RB RB 32

33 RB DD DD 33

34 RB RB RB 34

35 RB RB 35

36 43 yo MVA VL L sacrum, L proximal femur R AC/AW Modified Stoppa brim and quadrilateral plate 36

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38 VL VL 38

39 VL VL 39

40 VL VL 40

41 VL 41

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44 Chip knows that a table would make life easier for him but he is too egotistical and proud to admit it plus he likes it hard Benefits of the Table Iron Resident (600 cases at Charity 600 cases at Tulane) Letournel, Letournel, Letournel Reduction, Reduction, Reduction Put the head in the anatomical position and anatomically reduce the acetabular fracture to the reduced head 44