Certain acetabular fractures involve impaction of the weight-bearing dome and medialisation of the femoral head. Intra-operative fracture reduction is made easier by traction on the limb, ideally in line with the femoral neck (lateral traction). However, holding this lateral traction throughout surgery is very difficult for a tiring assistant. We detail a previously undescribed technique of providing intra-operative lateral femoral head traction via a pelvic reduction frame, to aid fixation of difficult acetabular fractures. The first 10 consecutive cases are reviewed (Group 1) and compared with a retrospective control (Group 2, n=18) of case-matched patients, treated prior to introducing the technique. The post-operative X-rays and CT scans were assessed to identify quality of fracture reduction according to the criteria of Tornetta and Matta. Operative time, blood loss and early complication rates were also compared. All cases in both groups were acute injuries with medial and/or superior migration of the femoral head. The majority were either associated both column or anterior column posterior hemi-transverse. There was no statistical difference between the groups in age, time to surgery, BMI or ASA grade. Fracture reduction was assessed as excellent in seven, good in three and poor in one. This was not significantly different from the control group (p=0.093). The mean operative time was 232 minutes in Group 1 and 332.78 minutes in Group 2 (p = 0.0015). There was no difference between the groups for blood loss or complication rates. We conclude that this new technique is at least equivalent to using manual traction and early results suggest it reduces operative time and technical difficulty in treating these complex acetabular fractures.
We present a series of 16 patients who have had a failed ankle arthroplasty converted to an ankle arthrodesis using a surgical technique of bone grafting with internal fixation. We describe our technique using tricortical autograft from the iliac crest to preserve length and an emphasis is placed on maintaining the malleoli and subtalar joint. A successful fusion was achieved in all cases with few complications. Our post operative AOFAS improved to a mean of 70 with good patient satisfaction and compares well to other published series. From this series and an extensive review of the literature we have found fusion rates following failed arthroplasty in patients with degenerative arthritis to be very high. In this group of patients a high fusion rate and good clinical result can be achieved when the principles of this surgical technique are adhered to. It would appear that a distinction should be made between treating patients with poor quality bone and more extensive bone loss, as is often the case with rheumatoid patients; and the patients with a non inflammatory arthropathy and better bone quality. The intramedullary nail would appear to be the preferred option in patients with inflammatory polyarthropathy where preservation of the subtalar joint is probably not of relevance as it is usually extensively involved in the disease process, and a higher rate of complications can be anticipated with internal fixation.
This study also discusses various issues regarding operative techniques (surgical approaches, debridement of joint and capsular releases).