Different factors associated with an adverse functional outcome of acetabular fractures involving the posterior wall have been well documented. Among these is marginal impaction. From 1998 until mid-2006, 105 cases were prospectively reviewed to assess the functional and radiological results of simple and complex acetabular fractures associated with a posterior wall component, with special reference to the marginal impaction. Associated posterior wall components associated with marginal impaction were compared to the pattern of fractures without marginal impaction. The exclusion criteria were non-anatomic reductions i.e. > 2 mm displacement, avascular necrosis, deep infection, heterotropic ossification grade III, IV, chondrolysis and nerve injuries. All marginal impaction fractures were identified on the pre-operative CT scan. They were openly reduced, elevated and autografted from the greater trochanter, followed by rigid internal fixation for early post-operative mobilisation i.e. CPM use. Results were assessed clinically by the modified Merle d'Aubigné and Postel score and radiologically by Kellgren and Laurence method of grading of osteoarthritis. 40 cases were excluded for the reasons above. This left 27 cases of marginal impaction and 38 cases of control. The average period of follow-up was 35.7 months. The functional results of the marginal impaction grafting group revealed 13 (48.1%) excellent, 7 (25.9%) very good, 6 (22.2%) good and one (3.8%) fair, while the control group showed 18 (47.4%) excellent, 10 (26.3) very good, 8 (21%) good, one (2.6%) fair and one (2.6%) poor result. The functional and radiological outcome of the posterior wall component fractures associated with marginal impaction showed very satisfactory results in comparison with a control group in the short and mid-term period. An integral part of this is careful recognition of this injury pattern and its management as part of the open reduction and fixation.
A rare case of malignant transformation of fibrous dysplasia to chondrosarcoma involving the pelvis, treated by hemipelvectomy, was described by our team in a published case report. Twenty-four years later, the patient remains recurrence-free, with a good functional outcome that allows him to be independent in everyday activities and work in full time employment. Functional outcome following hemipelvectomy for pelvic malignancy is an evolving topic, as improved imaging and surgical techniques result in earlier diagnosis and a better overall prognosis. Sarcomas involving the pelvis still represent a challenging topic for surgeons. During the last twenty-four years, there have been some advances in the limb- salvage treatment of pelvic tumours. An internal hemipelvectomy is currently considered to be a reasonable treatment option, with good functional outcomes and achievement of satisfactory tumour clearance margins, in well- selected cases. In all cases however, the main focus should be in the adequate resection of the lesion, followed by restoration of maintenance of stability. We report a fascinating case of a patient who underwent internal hemipelvectomy without reconstruction for chondrosarcomatous transformation of pelvic fibrous dysplasia, with emphasis on the clear surgical resection margins and disease-free status of the patient and satisfactory functional outcome. We support that internal hemipelvectomy is an acceptable treatment option in well- selected cases and can achieve clear tumour resection margins, resulting in long term disease-free results, and a good limb- salvage functional outcome. We believe that joint stability in this patient is mainly a result of preservation of the adductor muscle group, which prevents the hip joint from upward migration and allows the patient to use his left leg for walking.
Neglected fractures of the acetabulum have been defined as those fractures that present to the surgical team after 3 weeks from the time of injury. Total hip arthroplasty in these cases often require a major acetabular reconstruction. From 1989 until 2005, 38 total hip replacements were implanted in Cairo, Egypt for neglected acetabular fractures, with a follow up between 6 months and 192 months. The male to female distribution was 33/5. The age distribution ranged from 22 to 70 years with a mean value of 47.7 years. In 30 cases, hip arthroplasty was carried out as a primary procedure due to associated acetabular cartilage damage beyond reconstruction and/or associated articular cartilage or structural damage to the femoral head. 8 cases were done after a previous attempt of open reduction and internal fixation due to failure of the reduction and fixation, avascular necrosis and/or infection. 34 acetabular components were treated by internal fixation of the columns if still mobile, autografts from the femoral head with cemented acetabular components. Four uncemented acetabular components were used in selected cases when a stable reconstructed acetabular rim was achieved. All femoral stems were cemented with the exception of five cementless stems. At the last follow up, all grafted acetabular defects were taken with very satisfactory fixation in cemented cups. Three delayed acetabular loosening occurred at 13 years due to uncoupling of metal backed cemented acetabular components. Cementless acetabular components showed union of the fracture with stable acetabular fixation. The Merle D’Aubigne score was changed in all the cases from a range of 4/5 to 15/18. We believe that neglected acetabular fractures can be satisfactorily treated by cemented total hip replacement using internal fixation of the columns and acetabular grafting.
Malignant transformation of fibrous dysplasia to chondrosarcoma is rare. We report a case in which malignancy developed in an area of fibrous dysplasia in the ilium. We believe this to be the second reported case at this site. Treatment was by excision of the hemipelvis including the ala of the sacrum. A review of the literature is presented.
