Non-union acetabulum fractures: reconstruction operations

The acetabulum, capsule, ligaments, and head of the femur make up the hip joint. In addition to various diseases in which degenerative-dystrophic tissue damage occurs, the joint can also be damaged by a fracture. The risk of a fracture increases if the following factors are present:

• metabolic disorders in bone tissue;
• tumors;
• infections.

With untimely and illiterate treatment, a fracture that has healed even with a slight displacement of fragments can ultimately lead to disability, since the hip joint bears a large load and is responsible for its uniform redistribution to the legs. In some cases, the fracture heals poorly and slowly; in older people, fusion may no longer occur. In this case, mobility is significantly limited, often leading to death due to the fact that the person becomes bedridden. The situation can only be corrected by replacing the joint with an artificial one.

Acetabular cavity: types of fractures and treatment methods

About 20% of cases of mechanical violation of the integrity of the pelvic bones concern the acetabulum. Injury can occur directly (for example, from a side impact in a car accident) and indirectly (for example, from a fall). In the anatomical structure of the acetabulum, there are anterior and posterior columns. The first is formed by the anterior part of the ilium together with the pubis, the second by the posterior part of the ilium and the ischium. The rear column is more durable, but in accidents it is the one that breaks more often.

Fractures can be:

1. Simple. These include fractures of the posterior and anterior edges, posterior column, and transverse fractures.
2. Complex. With this type, a simultaneous fracture of the posterior wall and column occurs, a fracture of the posterior wall combined with a transverse one, a fracture of the anterior column together with a transverse fracture of the posterior one, or damage to both columns simultaneously. Complex fractures are usually comminuted.

The exact type of fracture can only be determined using a plain X-ray of the pelvic area. Often, when a patient with fractures is admitted, the x-ray taken is not of very high quality; it is not always possible to see small details. Therefore, for the clearest picture, a CT scan (transverse or three-dimensional) is recommended.

After an accurate diagnosis using CT, the degree of displacement of the pelvic bones is revealed. If the displacement is minimal, then traction (traction) is applied and healing is carried out during the rehabilitation period. If the displacement is significant, and there is also a dislocation, then after reduction, skeletal traction is used. After traction, an analysis of the condition of the joint is performed: if the fragments coincide successfully, traction and rehabilitation are performed; if the remaining displacement is present, the issue of surgical intervention is decided. If the fracture is inoperable at a given time, then endoprosthetics is performed after 4-6 months. If the operation is possible, the following methods are used: arthrotomy, reposition, stable fixation.

A comminuted fracture is considered inoperable. In this case, necrosis of the head, as well as deforming arthrosis of the joint, may occur. Osteosynthesis is not recommended; joint replacement is the best option. Loose bone particles must be removed because they cause pain and deform the joint tissue.

Minimally invasive endoprosthetics in the Czech Republic: doctors, rehabilitation, terms and prices.

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The structure of the acetabulum

Translated from Latin, the acetabulum is translated as vinegar and has the shape of a hemisphere with a recess inside. The surface is covered with cartilage and resembles a crescent, for which it received the name of the same name. Since the socket is involved in the formation of the hip joint, there is an articular lip to increase its surface. This part of the pelvis is formed by the bodies of the pubic, ilium and ischium bones, which fuse in humans by the age of 16.

There are front and rear walls, as well as columns and a vault of the same name. Together with the head, the socket forms the hip joint, covered with a capsule that secretes synovial fluid. Due to the columns, the joint acquires additional strength.

Conservative treatment is possible in the following cases

• if no displacement has occurred;
• no more than 25% of the posterior edge of the acetabulum is broken;
• low transverse fracture;
• low fracture of the anterior column;
• fracture of two columns while the arch of the cavity connecting them is preserved.

If after a given period of time no healing occurs, the fracture is considered non-union. In such cases, the solution is complete or partial replacement of the joint with an implant. If necessary, additional bone material is used.

This type of operation is high-tech, but is already available in many cities of Russia. However, many people prefer to use the experience of European doctors when going to Germany or Israel for treatment. The quality there is undoubtedly high, but the prices are also not affordable for everyone. A good alternative is the Czech Republic. Clinics in this country provide services at the European level, but the cost is significantly lower than in Germany. For many years now, all the hassles of finding a clinic, contacting doctors, and paperwork have been taken care of, through which Russian patients are sent to the Czech Republic for treatment. At a reasonable price, they receive not only restoration of motor function of the joints, but also consolidation of the results during rehabilitation at the resort.

Causes of damage

The factors that result in an acetabular fracture can be very diverse. A strong mechanical force must be applied to the human skeleton, causing the bone to break. The impact can be direct with a direct or lateral impact to the hip joint. The head of the femur hits the bone with force, causing damage. Direct impact occurs as a result of:

• car accidents;
• falling from a height;
• accidents at work;
• falling heavy objects onto the pelvis.

There is also an indirect mechanism of damage, which is rare. The reason is a violation of safety rules when engaging in heavy sports. Separately, it is worth highlighting the dislocation of the femoral head, when a fracture occurs during displacement.

R.Ya. KHABIBYANOV

Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan

Khabibyanov Rovil Yarhamovich

Candidate of Medical Sciences, Head of Research Department

420064, Kazan, st. Orenburgsky Trakt, 138, tel. (843) 296-31-40, e-mail:

A low-traumatic approach to the posterior edge of the acetabulum is proposed for repositioning and fixing fragments of its upper and posterior sections. The peculiarities of the topographic anatomy of the gluteal region are taken into account. The technique of surgical intervention is described depending on the level of fracture of the posterior edge of the acetabulum.

Key words
: pelvis, access, hip joint, posterior edge of the acetabulum.
R.Y.A. KHABIBYANOV

Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan, Kazan

Operative treatment of fractures of the posterior border of cotyloid cavity

In this article is offered
a low-impact access to the posterior border of cotyloid cavity for the reduction and fixation of bone fragments of its upper and posterior parts.
Is considered a feature of topographic anatomy of the gluteal region. The operative technique depending on the level of fracture of the posterior border of cotyloid cavity is described. Key words:
pelvis, access, pelvis joint, posterior border of cotyloid cavity.
Fractures of the posterior edge of the acetabulum, as well as transacetabular ones in general, mainly occur due to the so-called acceleration injury: road accident, fall from a height. The young working population is susceptible to this injury [1, 2]. Fractures are accompanied by dislocations of the femur, displacement of a fragment or fragments, destruction of articular surfaces and cartilage, which causes the further development of deformities, deforming arthrosis and contractures in the hip joint [3-5].

The most common injury to the hip joint due to acceleration trauma is traumatic hip dislocation. However, according to our data, isolated dislocations occur in 12% of cases. In 57%, hip dislocations were accompanied by fractures of the posterior or posterosuperior part of the acetabulum. Of this number, in 20% of cases, after reduction of the dislocation, its recurrence was observed. Fracture of the anterior edge of the acetabulum - 0.7%. The remaining 31.3% are isolated fractures of the anterior and posterior columns, fractures of both columns in various combinations. Only in 3% of cases was there a combination of hip dislocation with mild traumatic brain injury.

Primary clinical and radiological diagnosis in the emergency department is based on the peculiarities of the forced position of the lower limb (extremely rarely - both lower limbs), a gentle examination of the victim and data from plain radiography of the pelvis. Initially, as an emergency, under intravenous anesthesia, spinal or epidural anesthesia, the dislocation is reduced and the stability in the reduced joint is checked. After this, a final diagnosis of damage to the hip joint is made, which includes radiography in standard settings (survey, obturator oblique and iliac projections), computed tomography. These studies allow us to obtain a complete picture of damage to the acetabulum: the nature of the fracture, the size of the fragments, their location, including in the joint cavity or outside it, the presence of areas of impression and compression, as well as features of the dislocation of the femoral head, if any.

To select one type of treatment or another, the size of the fragments of the edge of the acetabulum is essential. Marginal fractures up to 4-5 mm wide, as a rule, are undisplaced or with slight displacement. Such an x-ray picture is not an indication for osteosynthesis.

When the width of the fragments is more than 5 mm (it reaches 30 mm or more) and after reduction of the dislocations, the displacement of the fragment or fragments remains. This is a manifestation of the “splinting” effect of the short external rotators of the hip and gluteus minimus muscle for displaced fragments in the process of hip dislocation. The presence of a displaced fragment or fragments of the posterior edge of the acetabulum is an absolute indication for their open reduction and stabilization. Moreover, the reposition must be anatomical, and stabilization is carried out with sufficient compression (while preventing the fragment from splitting). Otherwise, the synovial fluid of the joint serves as an interposer, which leads to delayed healing of the fracture or to the formation of a false joint.

Like any injury (bruises, fractures), a fracture of the posterior edge of the acetabulum is accompanied by compensated or subcompensated disruption of the microcirculation of articular and paraarticular tissues. This determines the search for low-traumatic surgical approaches to the posterior edge of the acetabulum and the posterior column, taking into account the principle of sufficiency for each specific case.

The well-known and fairly widely used posterior external approach to the hip joint according to Kocher-Langenbeck, in some cases accompanied by osteotomy of the greater trochanter, is quite traumatic and is accompanied by blood loss of up to 700 ml.

Since 1997, we have been using a surgical approach to the posterior edge of the acetabulum, which meets the principles of anatomy, is therefore minimally traumatic and provides a sufficient view of the posterior edge of the acetabulum.

When planning an operation, the surgeon must, based on the results of X-ray studies, determine the location of the fragment or fragments in relation to easily identifiable anatomical formations, in this case this is the greater trochanter of the femur and the distal sacroiliac joint. The line connecting these landmarks will, with some assumptions, correspond to the superior edge of the piriformis muscle or suprapiriformis space. According to the results of X-ray studies, the fragment lying at the level and above this line belongs to the upper part of the posterior wall of the acetabulum. The fragment projecting onto the drawn line and below it belongs to the middle and lower sections of the posterior wall.

Fractures of the upper part of the posterior edge of the cavity are more common. This is understandable, since the position in the car seat, especially for passengers, ensures flexion of the lower extremities at the hip joints at an angle of 100-120 degrees. For fractures of the middle and lower parts of the posterior edge, the angle of flexion in the hip joint is 90 degrees. Such fractures and dislocations occur mainly in drivers. Almost all of the victims were not wearing seat belts.

In the case when the fragment is localized above the reference line (Fig. 1a, 1b), the incision is made to the fascia of the gluteus maximus muscle directly along this line or slightly higher from the projection of the base of the sacroiliac joint to the apex of the greater trochanter.

Figure 1a.

Plain X-ray of the pelvis. Posterosuperior hip dislocation. Fracture of the upper part of the posterior edge of the acetabulum with displacement of the fragment.

Figure 1b.

Plain X-ray of the pelvis. Reduced hip dislocation. Fracture of the upper part of the posterior edge of the acetabulum with displacement of the fragment

The fascia is opened along the muscle fibers. It is possible to palpate to determine the most prominent part of the fragment. The muscle fibers are pulled apart bluntly. Deep in the wound is the gluteus medius muscle or its lower edge. The gluteus medius muscle with the underlying minimus muscle is retracted upward, and the piriformis muscle, located deeper and lower, is retracted downward. The fragment is examined without disturbing its connections with the capsular-ligamentous apparatus. The condition of the cartilage of the head of the femur and the cartilage on the fragment of the posterior edge is assessed, the joint cavity is washed, and the fragment is installed “tooth to tooth.” Fixation of the fragment with a screw or screws with acceptable compression, and they are installed at the maximum possible distance from the subchondral layer according to the situation. Checking the stability of the fragment fixation. The wound is sutured.

For early activation of the patient, the operation ends with the installation of an external fixation device. The device allows for guaranteed stabilization of the hip joint with a specified or controlled unloading, which creates conditions not only for healing of the fracture, but also for straightening or replenishing areas of impression or compression with restoration of the structure of the subchondral layer (Fig. 2, 3).

Figure 2.

Plain X-ray of the pelvis. Condition after open reduction and fixation of the upper part of the posterior edge of the acetabulum with a screw. Stabilization and unloading of the hip joint in an external fixation device

Figure 3.

X-ray of the hip joint in two projections (direct and axial). Duration after surgical treatment - 6 years

If the patient refuses the external fixation device or if there are contraindications, skeletal traction is performed for a period of 3-4 weeks. When the fragment is projected at or below the reference line (Fig. 4), the incision is made 1 cm below it. The fibers of the gluteus maximus muscle are also bluntly separated.

Figure 4.

X-ray of the hip joint before and after reduction. Displaced fracture of the middle part of the posterior edge of the acetabulum

The gluteus maximus, medius and minimus muscles, together with the piriformis, are abducted upward, and the superior twin - downward. You should remember about the exit of the sciatic nerve from the small pelvis under the piriformis muscle in its proximal section. The condition of the cartilage of the head of the femur, the fragment is also reviewed, it is installed after washing the joint cavity, stable fixation is carried out with compression elements (Fig. 5, 6).

Figure 5.

Plain X-ray of the pelvis. Condition after open reduction and fixation of the middle part of the posterior edge of the acetabulum with 2 screws. Stabilization and unloading of the hip joint in an external fixation device

Figure 6.

X-ray of the hip joint in two projections (direct and axial). Period after surgical treatment - 3 years

To improve visibility in the wound and greater freedom of manipulation, the assistant imparts external rotation to the limb by holding it by the shin in this position. This reduces the degree of tension on the short external rotators of the hip. Rotation of the hip also prevents the fixing screw from entering the joint cavity. When working in critical proximity to the sciatic nerve, the assistant monitors the motor response of the foot to irritation of the outer portion of the sciatic nerve, which in the distal parts of the limb represents the peroneal nerve.

Using a developed approach to the posterior edge of the acetabulum, 68 patients were operated on: 54 of them at a period of up to 2 weeks, 14 at a period of 3-5 weeks (due to late admission). The average blood loss was 120 ml. Postoperative neuropathies of the peroneal nerve were observed in 3 patients. After rehabilitation courses, including electrotherapy, acupuncture, exercise therapy massage, drug therapy, the neurological deficit was eliminated for a period of 6-8 months.

Long-term outcome in the form of stage III coxarthrosis. at a period of 2-6 years was observed in 5 patients, and 3 of them were operated on at a period of 3-5 weeks. Two had a comminuted fracture of the superior posterior margin of the acetabulum. Subsequently, they underwent hip replacement.

LITERATURE

1. Ezhov Yu.I., Smirnov A.A., Labazin A.L. Diagnosis and treatment of marginal fractures of the acetabulum // Bulletin of traumatology. and orthopedics. them. N.N. Priorova. - 2003. - No. 3. - P. 72-74.

2. Van der Bosch EW, Van der Kleyn R., Van Vugt AB // J. Trauma. - 1999. - No. 4. - R. 65-371.

3. Lazarev A.F., Kostenko Yu.S. Major problems of the pelvis // Bulletin of traumatology. and orthopedics. them. N.N. Priorova. - 2007. - No. 4. - P. 83-86.

4. Mitskevich V.A., Zhilyaev A.A., Popova T.P. Distribution of the load on the lower limbs during the development of unilateral and bilateral coxarthrosis of different etiologies. Bulletin of traumatology. and orthopedics. them. N.N. Priorova. - 2001. - No. 4. - P. 47-50.

5. Romano L., Frigo CR, Pedotti C. Ibid 1996. - 78A. - No. 10. - R. 1468-1473.

Rehabilitation

Activities designed to rehabilitate the patient can only begin several weeks after the injury. Typically this period is 7-8 weeks. In order to make sure that the healing of broken bones is proceeding normally, the specialist prescribes another x-ray procedure for the patient. It must show that callus has grown in the place where the integrity of the bones was damaged. This is a good sign indicating that healing is proceeding properly and rehabilitation of the patient can begin.

Even while under skeletal traction, the victim is advised to gradually begin to carry out simple motor movements that will involve the injured part of the body. Those. You can gradually raise the pelvis and move the limb a little. After all the obstacles to preventing normal motor activity are finally removed by specialists who have carefully studied the person’s condition, the latter must make every effort to restore full mobility.

First, for this he needs to use crutches and relearn how to stand on his sore leg. But it is necessary to completely transfer the weight of the entire body onto it very carefully and only after the patient feels that his injury is sufficiently healed and no longer brings severe pain. During the entire period of rehabilitation, the patient must be strictly under the supervision of doctors and not deviate from their recommendations, so as not to aggravate the situation and not to fracture the still weakened bones again.

Symptoms of damage

Immediately after an injury, a fracture of the acetabular arch or any part of it can be difficult to suspect. The following symptoms will help guide you to the right idea:

• pain in the groin or hip area;
• limited mobility of the lower limb;
• the pain becomes stronger when you try to move your leg;
• the victim is unable to walk, the same is observed if there is a dislocation.

The appearance of the victim is characteristic.

1. On the side of the injury, the lower limb is slightly shorter than the healthy one, and somewhat turned outward. This occurs when the acetabulum is fractured with displacement.
2. Active and passive movements are severely limited and painful.
3. A person is unable to lift his leg from a horizontal surface.
4. With central dislocation, movements are sharply limited, painful and springy in nature.

Treatment

After an injury, there are two ways to deal with damage: conservatively and surgically. It all depends on the type of injury, the degree of displacement and the presence of fragments. Damage to the acetabulum can be treated conservatively, provided there is no displacement or fragments. In other cases, an operation is indicated in which the fragments are fastened with metal.

Conservative approach

Such treatment is indicated when the articular component is not affected and there is no displacement. Plaster immobilization can be used, in which a bandage is applied to the leg and waist. The duration of wearing it is at least three months, after which the rehabilitation period begins.

However, plaster has recently been inferior in treatment effectiveness to external fixation devices. It is mounted using special rods in the pelvic bones, which are fixed using metal slats. Such a device allows you to get the patient out of bed as quickly as possible, allowing him, despite the fracture, to walk. After fusion of the bone tissue of the acetabulum, the device is removed. Traction is rarely used for an acetabulum fracture due to the length of treatment and non-rigid fixation.

Drug therapy

To speed up fusion, medications are used, primarily calcium. The absorption of calcium in the body increases vitamin D, which is produced by skin cells. Doctors use the following drugs: “Calcium D3 Nycomed”, “Structum”, “Kalcemin”, “Osteogenon”. Vitamin D production is increased by ultraviolet irradiation or sunbathing.

Additionally, non-steroidal anti-inflammatory drugs (NSAIDs) are indicated. The choice of such drugs is amazing; the most common drugs are:

• Xefocam;
• Movalis;
• Revmoxicam;
• Almiral;
• Aertal.

Additionally, vascular (Latren, Tivortin, Pentoxifylline) and diuretic (Trifas, Veroshpiron) are used to prevent edema. Immediately after injury, an element of anti-shock therapy is the administration of saline solutions. The infusion volume is up to two liters, since blood loss from pelvic fractures can reach three liters. Among saline solutions, priority is given to the following drugs: Trisol, Ringer's solution, 0.9% sodium chloride solution.

In case of damage to the acetabulum, chondroprotectors and agents that restore articular cartilage become relevant. The following drugs are used: “Protekon”, “Chondroitin complex”, “Hialual”, “Mukosat”. Chondroprotective drugs are prescribed in courses for about three months; the effect should not be expected immediately, but after stopping the drug it lasts for some time.

Operation

When a displaced fracture of the floor of the acetabulum or another part of it is diagnosed, surgical intervention is indicated. The essence of the surgical intervention is to perform metal osteosynthesis. After injury, the intervention should be postponed for about 10 days. During this period, the victim goes through traumatic shock, bleeding stops, tissue swelling decreases, which interferes with the intervention.

But if you delay the procedure for more than three weeks, it will be difficult to achieve a positive result. The reason for this is callus, which prevents the normal alignment of inert tissue. Prescription of antibacterial drugs is indicated per day. Moreover, their appointment lasts two more days after the intervention.

Diagnostics

A fracture of the acetabulum floor can be accurately diagnosed using an X-ray machine. It will not only help confirm the doctor’s diagnosis, but will also provide the most complete information about the existing injury, help determine its severity and prescribe the necessary treatment.

Since this type of fracture is very difficult to detect, if the first symptoms appear, the doctor needs to conduct an X-ray examination using the following projections:

• oblique internal and external projection at an angle of 45 degrees;
• anterior and posterior pelvic;
• hip and femoral anteroposterior projection of the injured side.

CT scan of a pelvic fracture in the acetabulum area
. In order to be completely confident in the diagnosis, the doctor also prescribes a CT scan. Thanks to this diagnostic method, displacement or the presence of a comminuted fracture can be accurately detected. To identify an open fracture, a rectal and vaginal examination is performed.

Often such damage is accompanied by a violation of the integrity of nerve endings and blood vessels. To promptly detect such disorders, it is necessary to visit a neurologist and neurosurgeon.

Early complications of injury

The clinical picture may be supplemented by symptoms of damage to other bones or organs. In such a situation, the victim’s blood pressure drops and shock develops. After a blow or fall or accident, the following is observed:

• violation of the integrity of the pelvic organs (rupture of the intestine or bladder);
• external or internal bleeding develops;
• ruptured or pinched nerves (sciatic, superior gluteal or femoral);
• fracture or dislocation of the femur.

Such injuries only aggravate the victim’s condition and increase the pain shock.

Types of fractures

Acetabular fractures are divided into two types:

1. Simple - with such injuries, the integrity of only one component element of the above recess occurs (for example, only the front or only the back wall).
2. Complex (also called combined) - a split or split occurs in several constituent elements of the cavity at once (for example, a fracture simultaneously affects its walls, as well as the anterior or posterior column or other parts of the cavity).

Displaced fractures often occur. In this case, parts of the injured bone can extend beyond the joint and into the soft tissue, which is fraught with additional ruptures and complications. A fracture of the acetabulum without displacement may be accompanied by a dislocation of the hip joint and a fracture of the femoral neck.

First aid

The first thing to do if you suspect a fracture is to call an ambulance. Then the victim should be given an anesthetic, which is in your home medicine cabinet. Next, the injured person must be placed on a hard and flat surface.

It is advisable to place small bolsters under the knee and hip joints. The head in this position should be slightly raised.

Under no circumstances should you suddenly change the patient's position. If the injury is of an open type, then it is necessary to stop the bleeding by applying a tourniquet. In case of a displaced fracture, do not try to set the bone fragments yourself.

Consequences of injury

With such an injury, the hip joint and its function are primarily affected. Pathological changes may develop on the surface of the joint. The femoral head or socket tissue may be affected by avascular necrosis. Coxarthrosis often develops, in which the articular cartilage is affected. Large fragments can damage the sciatic nerve. An open fracture is always complicated by infection in the wound.

When the full anatomy of the cavity is restored, the prognosis is favorable. If complications arise, the doctor takes measures aimed at eliminating them. By following all the specialist’s recommendations, complications can be avoided.