Reconstruction acetabular surgery with bone stock loss is still a difficult and challenging problem for the orthopaedic surgeon. The goals of acetabular revision are: stable bone coverage that can support the new acetabular component, restoration of the anatomy and bone stock for future revisions, equalization of leg length and restoration of the centre of hip motion. These goals are difficult to achieve when the pelvic defect is particularly severe. We examine the case of a female 73 years old who underwent a third revision arthroplasty of the hip joint because of extensive bony defect of the acetabular cavity (massive protrusio defect-type III –D’Antonio- combined segmental/cavitary acetabular defect). The femoral component which was revised in a previous operation with a mega stem (type Kotz), was radiologically stable and symptomless. Preoperative radiological assessment was performed using standard radiographic views, Judet views and CT scan. The surgical approach that we used was a slight modification of the previous incision achieving a better visualization of the entire acetabulum and iliac wing. The loose acetabular cup as well as soft tissue and debris were removed from the acetabulum. The large acetabular defect was filled with a massive allograft (tibial plateau) properly cut and shaped. The stability of the allograft was achieved fixing the allograft to the iliac bone with screws. A large amount of particulate allograft bone was placed in the depths of the acetabular defect restoring a proper level of the acetabular floor. Then a Burke-Schneider cage was firmly seated and fixed with screws in the prepared acetabular bed. A polyethylene cup was cemented into the acetabular shell. The superior part of the Kotz femoral prosthesis was also revised with a new one. Postoperatively we din not have any complications, the graft incorporation was successful with a satisfactory functional result. We believe that the use of structural allograft bone is essential for the reconstruction of large segmentalace-tabular defects. The results however are less predictable because of important technical difficulties and sometimes serious complications occur.
This paper reports on the results of intramedullary nailing in open tibial fractures. We studied 20 patients (18 men, 2 women) with open fractures of the tibia diaphysis treated with intramedullary nailing between 1998–2002. The mean age at surgery was 29 years (range 18–57 years). Fractures were the result of motor vehicle accidents (12 cases), car accidents (4 cases), or falling from a height (4 cases). We treated 5 type É, 11 type ÉÉ and 4 type ÉÉÉÁ fractures (Gustilo classification). Patients were operated within the first 8 hours after injury. The mean follow-up was 22 months. The treatment protocol included extensive and thorough cleansing of the wound and aggressive debridement, intramedullary nailing and wound closed primarily, when possible, and somministration of parenteral prophylactic antibiotics. The mean hospital stay was 6 days, and the mean time of healing was 25 weeks. The protocol management included also early postoperative mobilization of the knee and of the ankle joint and toe touch weight bearing till the second post-op day. Complications in this group included 3 infections, in one case we had to perform an osteotomy of the fibula and bone grafting because of delated healing and in 2 cases we had to remove failed screws. In the last follow-up examination, the range of motion of the knee and ankle joints was quite normal in the majority of the patients. Success rate in this study compares favourably with other groups of patients treated with “less aggressive” methods. The overall complication rate (including infection) was not higher in the open fractures treated with nailing compared with other operative methods. This technique allowed early mobilization on a partial weight-bearing regimen and rapid recovery. There were few re-operations only. These results suggested that intramedullary-nailing technique is at least as effective, if not more so, than external fixation for the treatment of open fractures of the tibia, since the method has been found to be safe, and complication rate is acceptable.
