Zusammenfassung
Hintergrund: Spätfolgen wie Coxarthrose, Hüftkopfnekrose und periartikuläre Ossifikationen (PAO) können das Outcome nach Azetabulumfrakturen trotz guter Reposition einschränken. In dieser Studie wurden Behandlungsergebnis sowie die Ausprägung von PAO in Abhängigkeit des Frakturtyps und des operativen Zugangsweges analysiert. Besonderes Interesse galt der Frage, inwieweit durch Verringerung des begleitenden Weichteilschadens ein besseres Outcome erreicht wird. Patienten und Methoden: Insgesamt wurden 55 Patienten nachuntersucht: Durchschnittsalter 40,4 Jahre (20-81 J), Untersuchungsintervall 7,7 J (4,4-12,3 J) und Geschlechtsverteilung (M 43/W 12). Die Frakturen wurden gemäß der AO eingeteilt, das funktionelle Ergebnis nach D'Aubigné-Postel ermittelt und die Ausprägung der Ossifikationen nach Brooker bestimmt. Ergebnisse: Verteilung der Frakturen nach AO: Typ A: 24 (44 %), Typ B: 23 (42 %) und Typ C: 8 (15 %). Der mittlere D'Aubigné-Postel-Index war insgesamt 15,2 Punkte (max. 18) und wie folgt auf die Frakturtypen verteilt: Typ A 15,9, Typ B 15,0 und Typ C 13,6 Punkte. Die Häufigkeit der PAO nach Brooker war: Grad 0 - 32 %, Grad I - 10 %, Grad II und Grad III jeweils 29 %, dabei fielen 2/3 der Brooker-III-Ossifikationen auf die Gruppen mit erweiterten Zugängen und auf Typ-C-Frakturen. Brooker VI sahen wir nicht. Tendenziell wurden beim iliofemoralen Zugang weniger Ossifikationen beobachtet als bei den kombinierten Zugängen. Schlussfolgerung: Der Minimierung des Operationstraumas kommt eine besondere Bedeutung zu. Aufgrund des höheren Risikos von Implantatfehllagen oder ungenügender Reposition durch die geringere intraoperative Exposition des Hüftgelenkes sollte postoperativ eine CT durchgeführt werden, um die Reposition und Osteosynthese zu überprüfen.
Abstract
Background: Arthrosis, necrosis of the femoral head and heterotopic ossification (HO) tend to decline the outcome of acetabular fractures despite of good fracture reduction. In this study functional outcome and degree of HO were analyzed due to fracture type and surgical approach. The aim of this study is to delineate wether minimization of soft tissue damage increases the functional outcome. Patients and methods: 55 patients with surgically treated acetabular fractures (mean age: 40.4 (20-81) years, male 43, female 12) where retrospectively evaluated with a mean follow-up of 7.7 (4.4-12.3) years. Fractures were classified according to the Orthopaedic Trauma Association (OTA), functional outcome was scored by D'Aubigné-Postel and the degree of HO was defined by Brooker's classification. Results: Following the OTA the distribution of fractures was: A-24 (44 %), B-23 (42 %) and C-8 (15 %). Mean D'Aubigné Index (max. 18 points) was 15.2, distributed to fracture type: A-15.9, B-15.0 and C-13.6. 32 % of all heterotopic ossifications were classified as Brooker 0, 10 % as Brooker 1, 29 % as Brooker 2 and Brooker 3 each, whereas Brooker 4 ossifications were not observed. 2/3 of the severe ossifications were observed using extended approaches or in case of type C fractures. The iliofemoral approach showed the tendency of fewer ossifications compared to extended approaches. Conclusion: Decrease of soft tissue damage during acetabular surgery plays an important role to improve outcome. Due to the higher risk of wrong implant position and insufficient reduction using a soft tissue sparing approach, we recommend a CT scan postoperatively to evaluate reduction and osteosynthesis.
Schlüsselwörter
Azetabulumfrakturen - heterotope Ossifikationen - operative Therapie - Langzeitergebnisse
Key words
acetabular fractures - heterotopic ossification - operative treatment - long-term results
Literatur
-
1
Brooker A F, Bowerman J W, Robinson R A, Riley Jr L H.
Ectopic ossification following total hip replacement. Incidence and a method of classification.
J Bone Joint Surg [Am].
1973;
55
1629-1632
-
2
Burd T A, Hughes M S, Anglen J O.
Heterotopic ossification prophylaxis with indomethacin increases the risk of long-bone nonunion.
J Bone Joint Surg [Br].
2003;
85
700-705
-
3
Burd T A, Lowry K J, Anglen J O.
Indomethacin compared with localized irradiation for the prevention of heterotopic ossification following surgical treatment of acetabular fractures.
J Bone Joint Surg [Am].
2001;
83
1783-1788
-
4
D'Aubigné R M, Postel M.
Function al results of hip arthroplasty with acrylic prosthesis.
J Bone Joint Surg [Am].
1954;
36
451-475
-
5
Daum W J, Scarborough M T, Gordon Jr W, Uchida T.
Heterotopic ossification and other perioperative complications of acetabular fractures.
J Orthop Trauma.
1992;
6
427-432
-
6
Eberl R, Muller E J, Kaminski A, Muhr G.
[The postoperative control CT after a fracture of the acetabulum. A useful quality control measure or an unnecessary exposure to radiation?].
Unfallchirurg.
2003;
106
741-745
-
7
Eulert J, Knelles D, Barthel T.
[Heterotopic ossifications].
Unfallchirurg.
1997;
100
667-674
-
8
Ghalambor N, Matta J M, Bernstein L.
Heterotopic ossification following operative treatment of acetabular fracture. An analysis of risk factors.
Clin Orthop.
1994;
305
96-105
-
9
Kirschner S, Walther M, Bohm D, Matzer M, Heesen T, Faller H, Konig A.
German short musculoskeletal function assessment questionnaire (SMFA-D): comparison with the SF-36 and WOMAC in a prospective evaluation in patients with primary osteoarthritis undergoing total knee arthroplasty.
Rheumatol Int.
2003;
23
15-20
-
10
Konig A, Walther M, Matzer M, Heesen T, Kirschner S, Faller H.
[II. Validity and sensitivity to change of the Musculoskeletal Functional Assessment Questionnaire in primary gonarthrosis and total endoprosthetic joint replacement].
Z Orthop Ihre Grenzgeb.
2000;
138
302-305
-
11
Letournel E.
Les fractures du cotyle, etude d' une serie de 75 cas.
J de Chirurgie.
1961;
82
47-87
-
12
Letournel E.
Fractures of the acetabulum. A study of a series of 75 cases. 1961.
Clin Orthop.
1994;
305
5-9
-
13
Martin D P, Engelberg R, Agel J, Snapp D, Swiontkowski M F.
Development of a musculoskeletal extremity health status instrument: the Musculoskeletal Function Assessment instrument.
J Orthop Res.
1996;
14
173-181
-
14
Matta J M.
Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective.
Clin Orthop.
1994;
305
10-19
-
15
Matta J M, Siebenrock K A.
Does indomethacin reduce heterotopic bone formation after operations for acetabular fractures? A prospective randomised study.
J Bone Joint Surg [Br].
1997;
79
959-963
-
16
Meissner A, Fell M.
[Late results of acetabulum fractures].
Aktuelle Traumatol.
1994;
24
121-127
-
17
Moed B R, Maxey J W.
The effect of indomethacin on heterotopic ossification following acetabular fracture surgery.
J Orthop Trauma.
1993;
7
33-38
-
18
Moed B R, Yu P H, Gruson K I.
Functional outcomes of acetabular fractures.
J Bone Joint Surg [Am].
2003;
85
1879-1883
-
19
Mousavi M, Pajenda G, Kolonja A, Seitz H, Vecsei V.
Acetabular fractures: operative management and long term results.
Wien Klin Wochenschr.
1999;
111
70-75
-
20
Murphy D, Kaliszer M, Rice J, McElwain J P.
Outcome after acetabular fracture. Prognostic factors and their inter-relationships.
Injury.
2003;
34
512-517
-
21
Nooraie H, Ensafdaran A, Arasteh M M, Droodchi H.
Surgically treated acetabular fractures in adult patients.
Arch Orthop Trauma Surg.
1996;
115
227-230
-
22
Pantazopoulos T, Mousafiris C.
Surgical treatment of central acetabular fractures.
Clin Orthop.
1989;
246
57-64
-
23
Rath E M, Russell Jr G V, Washington W J, Routt Jr M L.
Gluteus minimus necrotic muscle debridement diminishes heterotopic ossification after acetabular fracture fixation.
Injury.
2002;
33
751-756
-
24
Rommens P M, Broos P L, Vanderschot P.
[Preparation and technique for surgical treatment of 225 acetabulum fractures. 2 year results of 175 cases].
Unfallchirurg.
1997;
100
338-348
-
25
Rommens P M, Hessmann M H.
[Acetabulum fractures].
Unfallchirurg.
1999;
102
591-610
-
26
Routt Jr M L, Swiontkowski M F.
Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure.
J Bone Joint Surg [Am].
1990;
72
897-904
-
27
Rumi M N, Deol G S, Singapuri K P, Pellegrini Jr V D.
The origin of osteoprogenitor cells responsible for heterotopic ossification following hip surgery: an animal model in the rabbit.
J Orthop Res.
2005;
23
34-40
-
28
Stockle U, Hoffmann R, Sudkamp N P, Reindl R, Haas N P.
Treatment of complex acetabular fractures through a modified extended iliofemoral approach.
J Orthop Trauma.
2002;
16
220-230
-
29
Weise K, Maurer F, Schrade J.
[Hip dislocations and hip fractures - acetabular fractures. Indication, technique and results of conservative treatment].
Orthopade.
1997;
26
336-347
Dr. med. Bernd Roetman
BG-Kliniken Bergmannsheil · Universitätsklinik · Chirurgische Klinik und Poliklinik
Bürkle-de-la-Camp-Platz 1
44789 Bochum
Phone: 02 34/3 02 35 75
Fax: 02 34/3 02 65 42
Email: bernd.roetman@rub.de
