Transcript Routine Sciatic Nerve Exploration in posterior wall
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Exploration in posterior wall/column acetabular fractures ORIF
Cesar Alcantara Canseco MD Orthopedic Trauma Department Eric Hazan Lasri MD Head of Orthopedic Trauma Division Michell Ruiz Suarez PhD, MD Orthopedic Trauma Department Ernesto Pineda Gomez MD Chief of Orthopedic Trauma Department Instituto Nacional de Rehabilitacion Orthopedic Trauma Division Mexico City
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INTRODUCTION
3% to 8% of all fractures Halvorson, J. J., Lamothe, J., Martin, C. R., Grose, A., Asprinio, D. E., Wellman, D., & Helfet, D. L. (2014). Combined acetabulum and pelvic ring injuries. The Journal of the American Academy of Orthopaedic Surgeons, 22(5), 304–314. doi:10.5435/JAAOS-22-05-304
Anatomically complex fx, surgically demanding
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INTRODUCTION
Goals of managing acetabular fractures Stabilize the hemodynamically unstable patitent Restore native pelvic ring anatomy Restore functional hip mobility and stability Prevent posttraumatic arthrosis, HO, nerve injury, PE/DVT
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INTRODUCTION
Sciatic nerve injuries are associated with acetabular fractures Issack, P. S., & Helfet, D. L. (2009). Sciatic nerve injury associated with acetabular fractures. HSS Journal, 5(1), 12–18. doi:10.1007/s11420-008-9099-y Posttraumatic (30%): during trauma Perioperative (5-15%): iatrogenic injury Postoperative (5-15%) : fibrosis, HO
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PURPOSE
To review clinical results of routine sciatic nerve exploration at the time of ORIF of posterior column/wall fracture of the acetabulum
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METHOD
Retrospective review (2007 - 2013) Skeletal maturity Review of chart and phone interview Image review with PACS system
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METHOD
Preoperative and Postoperative evaluation 5 radiological views AP, inlet, outlet, obturator and iliac oblique of the pelvis CT scan with 3D reconstruction GE Lightspeed VCT Select 64-bit CT Scanner (GE Healthcare, Waukesha, WI) Somatosensory evoked potentials and electromyography Nicolet Viking
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SURGICAL TECHNIQUE
One surgeon (EPG) Kocher Langenbeck approach Trochanteric osteotomy The sciatic nerve was carefully visualized and explored From the fracture site to the greater sciatic notch 15cm distal to the fracture Meticulous debridement of all soft tissues, removed necrotic tissue and finally an irrigation of the exposed area Fracture fixation with 3.5mm reconstruction and LCP plates No drains were left
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RESULTS
2007-2013 101 patients acetabular fx (all types) Mean age = 37 (14-70) Average follow-up: 14 months (9-57) 98 fractures healed (3 non-unions) 2 severe deep infections 3 late THR subsequently
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RESULTS - gender
67 34 77 Male 24 Female
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RESULTS - acetabulum involved
67 34 67 Right 28 Left 8 Both
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RESULTS - fracture pattern (Judet)
JUDET, R., JUDET, J., & Letournel, E. (1964). FRACTURES OF THE ACETABULUM: CLASSIFICATION AND SURGICAL APPROACHES FOR OPEN REDUCTION. PRELIMINARY REPORT. The Journal of Bone and Joint Surgery (American), 46, 1615– 1646 .
Isolated Posterior Wall Isolated Posterior Column Posterior Wall + Posterior Column Posterior Wall + Transverse Posterior Columnn + Transverse
12 3
Isolated Posterior Wall
1 2 2 3
Isolated Posterior Column Posterior Wall + Posterior Column Posterior Wall + Transverse Posterior Columnn + Transverse Posterior Wall + Posterior Column + Transverse
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RESULTS - associated hip dislocation 17/101 associated hip dislocation : 17%
Isolated Posterior Wall Posterior Wall + Posterior Column
2 3 1
Posterior Wall + Posterior Column Posterior Wall + Posterior Column + Transverse Isolated Posterior Wall
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RESULTS - sciatic nerve injury
23/101 patients = 22.77%
22 PreOperative (trauma) 1 PeriOperative (iatrogenic) None PostOperatively 6/17 w/ hip dislocation (35% NS) NO HO on last film Right 18 1 5 Left
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RESULTS sciatic nerve injury recovery
- Full clinical recovery: 18 - Partially recovered: 4 - Did not recover:1
• All but ONE patient return to previous level of activity • ALL satisfied w/ procedure
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RESULTS - floating hip
1/23 Hip fracture was treated first with a proximal femur nail and in the same surgical time the treatment of the acetabulum was performed Patient had partial recovery; ambulatory with walking brace
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DISCUSSION
ORIF for acetabular fractures helps early mobilization and faster pain reduction O'Toole RV, Hui E, Chandra A, Nascone JW. How often does open reduction and internal fixation of geriatric acetabular fractures lead to hip arthroplasty? Journal of Orthopaedic Trauma. 2014;28(3):148–153. doi:10.1097/BOT.0b013e31829c739a.
Fractures treated with acute arthroplasty is not the best option in patients with column fractures; ORIF allows anatomical fracture healing making arthroplasty simpler O'Toole RV, Hui E, Chandra A, Nascone JW. How often does open reduction and internal fixation of geriatric acetabular fractures lead to hip arthroplasty? Journal of Orthopaedic Trauma. 2014;28(3):148–153. doi:10.1097/BOT.0b013e31829c739a.
Detailed radiographic diagnosis in acetabulum fractures required for an adecuate classification (Judet/Letournel)and treatment Lawrence, D. A., Menn, K., Baumgaertner, M., & Haims, A. H. (2013). Acetabular Fractures: Anatomic and Clinical Considerations. American Journal of Roentgenology, 201(3), W425–W436. doi:10.2214/AJR.12.10470
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DISCUSSION
Few reports on surgical decompression of the sciatic nerve following acetabular fractures or reconstructive surgery of the acetabulum and/or pelvis Issack, P. S. (2007). Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum. The Journal of Bone and Joint Surgery (American), 89(7), 1432. doi:10.2106/JBJS.F.00904
Benson, E. R., & Schutzer, S. F. (1999). Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. The Journal of Bone and Joint Surgery (American), 81(7), 941–949.
Surgical nerve release and neurolysis is only described as a treatment for postoperative complications of nerve compression Zhang Y, Xie Y, Xu S, Zhang C. Massive heterotopic ossification associated with late deficits in posterior wall of acetabulum after failed acetabular fracture operation. BMC Musculoskelet Disord. 2013;14(1):368. doi:10.1186/1471-2474-14-368.
Burd TA, Lowry KJ, Anglen JO. Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures. J Bone Joint Surg (Br). 2001.
Beauchesne RP, Schutzer SF. Myositis ossificans of the piriformis muscle: an unusual cause of piriformis syndrome. A case report. J Bone Joint Surg Am. 1997;79(6):906–910.
Johnson EE, Kay RM, Dorey FJ. Heterotopic ossification prophylaxis following operative treatment of acetabular fracture. Clin Orthop Relat Res. 1994;(305):88–95.
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DISCUSSION
Poor Prognostic Factors: older age, delay to OR, reduction gap, osteonecrosis, loss of joint space. Moed BR, Carr SEW, Watson TJ. Posterior wall fractures of the acetabulum: prognostic factors for poor outcome. Orthopedic Trauma Directions 2005:02;9-20 Intraoperative SSEP/EMG monitoring did not decrease rate iatrogenic sciatic nerve palsy. Haidukewych GJ, Scadutto JM, DiPasquale TG, Herscovici D Jr, Sanders R. Iatrogenic nerve injury during acetabular fracture surgery: a comparison of monitored and unmonitored patients. J Orthop Trauma 2002; 16(5); 297-301 Indomethacin 6 wk Tx did not reduce HO + increase posterior wall non-union. Sagi HC, Jordan CJ, Barei DP et al. J Orthop Trauma 2014; 28(7):377-383 Only 5/23 cases were polytrauma patients. ORIF within 1 week but not immediately. Significance?
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DISCUSSION
Weakness of the study: needs for longer follow-up, no use of intra op surgical nerve monitoring, no QOL score Strengths of the study: Single surgeon experience,
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CONCLUSION
Sciatic nerve injuries associated with acetabulum fracture of posterior wall/column were posttraumatic 78 % full clinical recovery without sequelae 91% functional recovery Acetabular wall necrosis, heterotopic ossification, were not observed in this series We recommend a sciatic nerve surgical release and neurolysis as a part of the surgical technique using a Kocher-Langenbeck approach
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