Surgical management of acetabular fractures - A contemporary literature review.

Surgical management of acetabular fractures is now commonplace for almost all displaced or unstable fractures. Over the last 20 years however, the patient population has aged, and there have been significant changes to safety in motor vehicles and the work-place, and people's activity types and levels have changed. The surgical specialty has also developed with time, and as a result acetabular fracture surgery today is different to 20 years ago. We have repeated a meta-analysis originally published by Giannoudis et al in 2005, to evaluate contemporary aspects of acetabular fracture patients, injury mechanisms, management, complications and functional outcomes. This paper compares data from the last 15 years to that published in 2005. We have analysed a total of 8389 fractures from 8372 patients. The mean patient age has risen from 38.6 to 45.2. A change in injury mechanisms is seen, with road traffic accidents now accounting for 66.5% of cases (previously over 80%), and a rise in the number of fractures caused by falls from 10.7 to 25.8%. There has been a marked change in the fracture types seen, with a significant rise in anterior column-based fractures (Anterior column and Anterior column posterior hemi-transverse), whilst all other fracture patterns have fallen over time. Surgery is now taking place earlier, the Kocher-Langenbeck and Ilioinguinal approaches remain the major surgical approaches used, but the Anterior Intra-Pelvic approach has become relatively common. The most significant change in complications is a substantial drop in iatrogenic nerve damage, particularly to the sciatic nerve. Post-traumatic osteoarthritis remains the major complication of this injury, with 16.9% of cases developing Matta grade III/IV changes by 44 months in this review. Heterotopic ossification also remains a common problem. Despite these changes over time, functional outcomes after acetabular fracture appear to remain similar, although there is still a lack of good quality data on medium and longer-term functional outcomes from which to assess this.

Contemporary acetabular fracture surgery: treading water or swimming upstream?

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed. Cite this article: Bone Joint J 2017;99-B:1125-31.

Defining the pubic symphysis angle with respect to the coronal plane - Clinical and biomechanical considerations.

BACKGROUND: Fixation strength of constructs placed across the pubic symphysis after injury is dependent on screw length, maximisation of which requires knowledge of the bony anatomy. The aim of this study was to describe the ideal angle of drilling to achieve maximal safe screw placement within the pubic body. Furthermore, the influences of age and gender on the skeletal topography were investigated. METHODS: Three hundred CT scans of patients without pelvic injury were analysed to record the angle of the pubic body (APB) with respect to the coronal plane, and the depth of the pubic body (DPB) in the sagittal plane. RESULTS: Mean APB and DPB were 54.69° and 55.35mm, respectively. Females had a significantly higher mean APB than males (57.29° vs. 52.41°; p<0.001), whereas males had a significant larger mean DPB (59.13mm vs. 51.03mm; p<0.001). Age had no effect on the mean APB. Mean width of the pubic body at the base was 9.38mm. CONCLUSION: The anatomy of this region is reliable in terms of angles and sizes; a drill angle of 55° with respect to the operating table will allow maximal screw length, which should be in the region of 55mm. The mean width of the pubic body should allow for placement of a 3.5 or 4.5mm diameter screw.

Acetabular Fractures in the Elderly: Midterm Outcomes of Column Stabilisation and Primary Arthroplasty.

Background. Interest in arthroplasty techniques for periarticular or intra-articular fractures in the elderly/osteoporotic patient continues to rise, including for geriatric acetabular fractures. In line with this, many acetabular fracture surgeons are now undertaking acute total hip arthroplasty in elderly/osteoporotic patients. Little is known however of the outcomes of this procedure, beyond the first year after surgery. Questions/Purposes. We determined the clinical outcomes of a series of elderly osteoporotic patients (mean age at surgery 77.4 years) treated for acetabular fractures with column fixation and simultaneous total hip arthroplasty, at a mean of 49 months after surgery. Methods. 24 patients (25 hips) were reviewed at a mean of 49 months after surgery. The surgical technique employed has previously been described. Radiographs were obtained, and clinical outcomes were assessed using Harris Hip Scores and the Merle d'Aubigné score. Results. 14 hips were available for assessment (9 deceased, 2 lost to follow-up). No patient suffered any complications beyond the perioperative period, no acetabular components were loose clinically or on latest radiographs, and the mean Harris Hip Score was 92. All but one patient scored good or excellent on the Merle d'Aubigné score. Conclusions. Column fixation and simultaneous total hip arthroplasty are a viable option for complex geriatric acetabular fractures, with encouraging midterm results. We conclude that THR is a viable long-term solution in this situation provided that the acetabular columns are stabilised prior to implantation, but more research is needed to aid in overall management decision making.

Hip and knee arthroplasty implants contraindicated in obesity.

INTRODUCTION: High patient weight is a risk factor for mechanical implant failure and some manufacturers list obesity as a contraindication for implant use. We reviewed data from the 2012-2013 UK National Joint Registry to determine whether surgical practice reflects these manufacturer recommendations. METHODS: The product literature for the most commonly used hip and knee implants was reviewed for recommendations against use in obese patients (body mass index [BMI] ≥ 30kg/m(2)). The total number of obese patients undergoing hip and knee arthroplasty was calculated, as was the proportion receiving implants against manufacturer recommendations. RESULTS: Out of 200,054 patient records, 147,691 (74%) had a recorded BMI. The mean BMI for patients undergoing primary total hip arthroplasty was 29kg/m(2), compared with 31kg/m(2) for total knee arthroplasty. Of the 25 components reviewed, 5 listed obesity as a contraindication or recommended against implant use in obese patients. A total of 10,745 patients (16% of all obese patients) received implants against manufacturer recommendations. CONCLUSIONS: A high proportion of patients are receiving implants against manufacturer recommendations. However, there are limitations to using BMI for stratifying risk of implant fatigue failure and manufacturers should therefore provide more detailed guidelines on size specific implant load limits to facilitate surgical decisions.

The ongoing relevance of acetabular fracture classification.

The most widely used classification system for acetabular fractures was developed by Judet, Judet and Letournel over 50 years ago primarily to aid surgical planning. As population demographics and injury mechanisms have altered over time, the fracture patterns also appear to be changing. We conducted a retrospective review of the imaging of 100 patients with a mean age of 54.9 years (19 to 94) and a male to female ratio of 69:31 seen between 2010 and 2013 with acetabular fractures in order to determine whether the current spectrum of injury patterns can be reliably classified using the original system. Three consultant pelvic and acetabular surgeons and one senior fellow analysed anonymous imaging. Inter-observer agreement for the classification of fractures that fitted into defined categories was substantial, (κ = 0.65, 95% confidence interval (CI) 0.51 to 0.76) with improvement to near perfect on inclusion of CT imaging (κ = 0.80, 95% CI 0.69 to 0.91). However, a high proportion of injuries (46%) were felt to be unclassifiable by more than one surgeon; there was moderate agreement on which these were (κ = 0.42 95% CI 0.31 to 0.54). Further review of the unclassifiable fractures in this cohort of 100 patients showed that they tended to occur in an older population (mean age 59.1 years; 22 to 94 vs 47.2 years; 19 to 94; p = 0.003) and within this group, there was a recurring pattern of anterior column and quadrilateral plate involvement, with or without an incomplete posterior element injury.

Acetabular fractures in patients aged > 55 years: a systematic review of the literature.

The increasing prevalence of osteoporosis in an ageing population has contributed to older patients becoming the fastest-growing group presenting with acetabular fractures. We performed a systematic review of the literature involving a number of databases to identify studies that included the treatment outcome of acetabular fractures in patients aged > 55 years. An initial search identified 61 studies; after exclusion by two independent reviewers, 15 studies were considered to meet the inclusion criteria. All were case series. The mean Coleman score for methodological quality assessment was 37 (25 to 49). There were 415 fractures in 414 patients. Pooled analysis revealed a mean age of 71.8 years (55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven studies the results of open reduction and internal fixation (ORIF) were presented: this was combined with simultaneous hip replacement (THR) in four, and one study had a mixture of these strategies. The results of percutaneous fixation were presented in two studies, and a single study revealed the results of non-operative treatment. With fixation of the fracture, the overall mean rate of conversion to THR was 23.1% (0% to 45.5%). The mean rate of non-fatal complications was 39.8% (0% to 64%), and the mean mortality rate was 19.1% (5% to 50%) at a mean of 64 months (95% confidence interval 59.4 to 68.6; range 12 to 143). Further data dealing with the classification of the fracture, the surgical approach used, operative time, blood loss, functional and radiological outcomes were also analysed. This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients.

The management of complex acetabular fractures in the elderly with fracture fixation and primary total hip replacement.

Osteoporosis and associated fragility fractures are an increasing problem across the developed world. The elderly osteoporotic acetabular fracture presents a difficult problem due to high failure rates and poor outcomes. Standard management may or may not include fracture fixation, but generally includes a period of protected weight bearing, even if total hip replacement has been performed. We present a series of 12 cases of complex osteoporotic acetabular fractures in elderly patients, managed successfully using primary fracture fixation and total hip replacement with trabecular metal technology. Immediate weight bearing was allowed in all cases, few complications have been seen, and no component migration has been identified in any case.

Open reduction and internal fixation of a traumatic diastasis of the pubic symphysis: one-year radiological and functional outcomes.

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year. In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group. We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Failure of conventional retrograde cystography to detect bladder ruptures in pelvic trauma.

Conventional retrograde cystography is often used to investigate patients with suspected bladder ruptures in pelvic trauma. Clinical indicators suggestive of a rupture include haematuria and suprapubic tenderness and should increase the suspicion of bladder and urinary tract injury and prompt the clinician to undertake further investigations. Two patients with high-energy pelvic fractures had bladder ruptures detected intraoperatively despite normal preoperative retrograde cystogram. Both patients had significant clinical indicators suggestive of underlying bladder and urinary tract injury. In both cases, a routine conventional retrograde cystogram was performed but failed to identify the full extent of the bladder injury. A possible reason for misdiagnosis in these cases is the delay between injury and investigation due to tertiary referral of care.

Fine wire frame arthrodesis for the salvage of severe ankle pathology.

Ankle arthrodesis is an accepted method of treatment for severe ankle pathology, but no single method of treatment is universally successful. Compression is usually applied across the ankle joint and maintained with either internal or external fixation; both are associated with complications such as infection, non-union and pain. We present our experience of 13 difficult cases managed by fine wire external frames, and describe the surgical technique used.A sound arthrodesis was achieved in 12 out of 13 cases, though one case required a repeat procedure, giving a union rate of 92% of cases or 86% of procedures. The mean period of fixation was 24 weeks (range 12-82), followed by a mean period of cast immobilisation of 7 weeks (range 0-10). Using Mazur's functional ankle score there were seven good results, four fair, one poor and one failure, which resulted in a below knee amputation. We believe this method represents a significant improvement on previously published results, but accept that it requires considerable experience and should not be considered for primary ankle arthrodesis. We would recommend its usage for the salvage of failed arthrodesis or severe fracture non-union, particularly in the presence of infection.

Carbohydrate and fluid intake affect the saliva flow rate and IgA response to cycling.

PURPOSE: The purpose of this study was to examine the effect of regular CHO beverage ingestion and restricted fluid intake on various salivary parameters during prolonged cycle exercise. METHODS: In a randomized block design, 15 recreationally active men cycled for 2 h at 60% VO2max on three occasions, separated by 1 wk. On the CHO and placebo (PLA) treatments, subjects consumed either a glucose (60 g x L(-1)) or placebo drink before (400 mL), during (150 mL every 15 min), and after (400 mL) the exercise. On the restricted fluid intake (RFI) treatment subjects were given a total of 200 mL of placebo fluid to take as desired every 15-min during the exercise. Timed, unstimulated saliva samples were collected preexercise, at 1, 1.5, and 2 h of exercise and at 1 h postexercise. Blood samples were obtained from a subset of 8 subjects preexercise, postexercise, and at 1 h postexercise. RESULTS: Postexercise plasma glucose levels were 18% and 20% lower on the PLA and RFI treatments, respectively, compared with the CHO treatment (P < 0.01). Saliva flow rates were significantly higher on the CHO treatment compared with the RFI treatment at 1.5 h and 2 h of exercise (P < 0.01 and P < 0.05, respectively). Salivary IgA (s-IgA) concentration was significantly lower on the CHO treatment compared with the RFI treatment throughout the exercise (P < 0.05). No other differences were seen between treatments for either saliva flow rate or s-IgA concentration. Neither s-IgA secretion rate, alpha-amylase activity, nor alpha-amylase secretion rate were affected by treatment. CONCLUSIONS: These findings suggest that CHO and fluid intake influence the s-IgA and saliva flow rate response to prolonged submaximal exercise.

Vascular complications of osteotomies in limb reconstruction.

Osteotomies are commonly carried out in orthopaedic surgery, particularly in limb reconstruction. Complications are uncommon provided that sufficient care is taken and a sound technique used. We describe three cases of formation of false aneurysm after osteotomy, with acute, delayed and asymptomatic onset. The diagnosis was supported by ultrasound investigation, and confirmed by angiography. Embolisation with coils was a successful method of treatment. We recommend a safe method of osteotomy with good bone exposure and adequate soft-tissue protection.

Individual differences in freezing and cortisol in infant and mother rhesus monkeys.

Freezing is an adaptive defensive behavior that is expressed in response to an imminent threat. In prior studies with rhesus monkeys, stable individual differences in animals' propensities to freeze have been demonstrated. To understand the factors associated with these individual differences, freezing behavior was examined in infant rhesus monkeys and their mothers, in conjunction with levels of the stress-related hormone cortisol. In both mothers and infants, basal cortisol levels were positively correlated with freezing duration. Additionally, the number of offspring a mother had was negatively correlated with her infant's cortisol level. These findings suggest a link between basal cortisol levels and an animal's propensity to freeze, as well as a mechanism by which maternal experience may affect infants' cortisol levels.

External fixation of children's fractures: use of the Orthofix Dynamic Axial Fixator.

We have reviewed 48 children's diaphyseal fractures of the femur and tibia managed with the Orthofix Dynamic Axial Fixator between 1987 and 1994. The indications for external fixation included open fractures, multiple injuries, failed conservative management, and unstable fracture configurations. All fractures healed without further surgical intervention, and the incidence of serious complications was low. Although pin track sepsis was common, compromise of the fixation as a result of this occurred in only one case. We conclude that use of the Orthofix for children's fractures is a safe and effective management option.

Fracture of the tibial diaphysis treated by external fixation and the axial alignment grid: a single surgeon's experience.

The results of tibial fracture fixation for 50 unstable closed and open fractures, using the dynamic axial fixator (DAF) and the limb axial alignment grid have been assessed both clinically and radiologically. Each patient has been carefully followed up in a dedicated clinic and each procedure was conducted or directly supervised by the senior author. All patients achieved union, although 16 per cent required a further procedure such as bone grafting or fibula osteotomy to secure this and a further 6 per cent were revised to intramedullary nails. There was a malunion rate of 16 per cent, but no patients requested further treatment for functional problems. The incidence of pin-site infection was 10.4 per cent, each patient taking responsibility for their own pin-site care. There were no deep infections. The results achieved in this series compare favourably with those of other treatment modalities for this fracture, which may often be difficult to manage. Given the stringent adherence to the important principles of fixator application and well supervised follow-up which are practised on this unit, we believe that the results as presented here may well represent the limit achievable with this device. Furthermore, the authors would recommend that the technique remains an important option in tibial fracture management, particularly for the unstable closed and open fractures.

Electrophysiological evidence of nonlinear distortion products to two-tone stimuli.

Spectral analysis of auditory-evoked potential recordings from ten normal-hearing subjects to two-tone signals revealed energy at difference tone (DT = f2-f1) and cubic difference (CDT = 2f1-f2) frequencies that was not present in the acoustic signal. Control experiments and calibrations provided substantial evidence supportive of the biological nature of these auditory nonlinearities, suggesting that they are not the result of electromagnetic, acoustic, or analytic artifact. Amplitudes of DT- and CDT-evoked responses were evaluated for rarefaction and condensation signals with f1 = 510 and 800 Hz across frequency ratios (f2/f1) of 1.16, 1.26, 1.36, and 1.46. Additionally, time-domain summation and subtraction of separately collected evoked responses to rarefaction and condensation signals were performed to demonstrate that these electrophysiological DT and CDT responses reflect their expected quadratic and cubic nature. Suggestions for development of clinical applications of assessing auditory nonlinearities using this methodology are provided.