Академический Документы
Профессиональный Документы
Культура Документы
walking. stimulation is initiated in the terminal swing tremity to perform other functional tasks. In the future, it
phase of gait following a preset delay after heel lift-off, is conceivable that groups of muscles may be activated
causing the knee to extend in preparation for heel strike synchronously using a multichannel system.
(Fig. 9). Stimulation is continued throughout stance to Only a small percentage of patients are candidates for
stabilize the knee until the next heel lift-off. the peroneal Neuromuscular Assist. Only orthopaedic
Similarly, another patient rendered hemiplegic after a surgeons familiar with neurologically disabled patients
stroke required a cane because of inactive hip-extensor and gait mechanics should undertake this procedure. The
muscles. An electrode placed around the inferior gluteal necessity of attending to the details of patient selection
nerve stimulated the gluteus maximus muscle during the cannot be over-emphasized. Finally, because of frequent
stance phase. Following surgery she was able to walk equipment failure the patient must have convenient access
without a cane. freeing her single non-involved upper ex- to the surgeon and engineering personnel for repairs.
References
I . FINAL REPORT: Development of Orthotic Systems Using Functional Electrical Stimulation in Myoelectric Control. University of Ljubljana,
Faculty of Electrical Engineering. Ljubljana, Yugoslavia. I 971.
2. L1RERs0N. \V. T.: HOLNIQUEST. H. J.: ScoT. DAVID: and Dow. MARGOT: Functional Electrotherapy: Stimulation of the Peroneal Nerve Syn-
chronized with the Swing Phase ofthe Gait of Hemiplegic Patients. Arch. Phys. Med., 42: 101-lOS, 1961.
3. TASIAKI. T.. MCNEAL. D.: and WILEMON, W. K.: Recorded Neurophysiological Effects of Patient Implanted Peripheral Nerve Stimulators. Read
at the Neuroelectric Conference, Las Vegas. Nevada. March 1970.
4. TRAFTON. P. G. : Tendon Transfers for Adult Spastic Equinovarus Feet: A Follow-up Study. In Orthopedic Seminars. Vol. 6. Downey. Califor-
nia. Rancho Los Amigos Hospital. 1973-1974.
5. WATERS. RoHIRT. and MONTGOMERY. JACQUELINE: Lower Extremity Management of Hemiparesis. Clin. Orthop.. 102: 133-143. 1974.
6. VATERS, R. L. : MNEAI., D. R. : and TASTO. JAMES: Peroneal Nerve Conduction Velocity After Chronic Electrical Stimulation. Arch. Phys.
Med.. 56: 240-243. 1975.
ABSTRACT: Displaced acetabular fractures are manent disability. They also are frequently associated
serious injuries often resulting in permanent disability. with other injuries which may be life-threatening. Treat-
Fifty-five patients with fifty-six such injuries seen at the ment as described in the literature has included manipula-
Campbell Clinic between 1927 and 1970 had either cen- tion, traction, immobilization in a plaster cast, and open
tral dislocation with or without fracture of the weight- reduction, methods used with varying success.
bearing dome, or acetabular disruption usually as- This report concerns a study of acetabular fractures
sociated with posterior displacement of the hip. After which were associated with either central fracture-
an average follow-up of 8.6 years, 56 per cent of those dislocation of the hip or total acetabular disruption. From
treated without surgery had good or satisfactory re- this review of a large series of these rare injuries, most of
suits compared with 54 per cent good or satisfactory them followed for long periods, we attempted to identify
results in those treated surgically. Patients with dis- the types of injury most likely to benefit from open reduc-
placed fractures of the acetabular dome not reduced by tion.
manipulation and traction should be considered candi-
Historical Review
dates for open reduction.
The first central acetabular fracture was reported by
Displaced acetabular fractures are serious injuries Caliisen in 1788, and in 1909 Schroeder produced ex-
which require prolonged treatment and often result in per- perimental acetabular fractures in cadavera by striking the
* Read at the Annual Meeting of The American Academy of Or- greater trochanter with a pendulum. The earliest treatment
thopaedic Surgeons. San Francisco. California. March 4. 1975. usually consisted of manipulation and immobilization in a
. Campbell Clinic. 869 Madison Avenue. Memphis, Tennessee
38104. plaster cast. When skeletal traction became available, Ion-
gitudinal traction and later lateral traction as well were the patients had sustained violent injuries. Thirty-six had
used to treat central dislocations. had car or truck accidents; three had motorcycle injuries:
The first open reduction was performed by Vaughn in two were pedestrians hit by cars; and ten had fallen from a
1912, but Levine was the firstto use internal fixation in the height or from a horse. Three elderly patients were injured
treatment of central acetabular fractures, in 1943. He rec- in minor falls; one of them, an invalid with rheumatoid ar-
ognized that satisfactory results could be achieved without thritis, simply fell out of bed. Two had had other
reduction ofthe medial wall. In 1954, Stewart and Milford mechanisms of injury. Thirty-seven were males and eigh-
reported on twenty-eight central fracture-dislocations teen, females. Their ages ranged from fifteen to
treated at the Campbell Clinic, eighteen of which were fol- seventy-five years. Thirty-four were between the ages of
lowed up. In nine the results were considered excellent or twenty and fifty. Thirty-five had significant associated in-
good and in five avascular necrosis of the femoral head juries, including six sciatic-nerve palsies, but no patient
developed. Early motion and muscle-strengthening exer- died while under treatment. Thirty-five injuries involved
cises were emphasized in treatment. The lack of correla- the left hip and nineteen, the right. One patient had a bilat-
tion between the clinical course and roentgenographic ap- eral injury.
pearance was pointed out. Four years later Knight and All patients with these injuries seen at the Campbell
Smith analyzed eight central fracture-dislocations treated Clinic were included in this study regardless of whether
by open reduction at the Campbell Clinic. In this study the they had received their initial care there, on the grounds
fractures were simply classified as horizontal or vertical that the epidemiological data provided warranted their in-
and the classification was correlated with the specifics of clusion. These patients were followed up for this study as
operative treatment. Careful planning before surgery was follows: by review of their records and roentgenograms
emphasized, but no complications were mentioned. only in forty-one, by these means as well as a recent ques-
In a review of their experience at the Massachusetts tionnaire in four, and by review of records and roentgeno-
General Hospital, Rowe and Lowell, in 1961 , emphasized grams supplemented by a recent examination and recent
that good results were obtained after closed treatment of roentgenograms in ten. Three patients had no follow-up:
inner wall fractures if the femoral head had been re- one who left against medical advice, another who trans-
duced and maintained under an intact acetabular dome. ferred to a hospital near his home and did not answer
However, the results were less desirable in bursting follow-up letters, and a third who died at home of a
fractures unless an accurate reduction of the acetabular myocardial infarction two months after injury.
dome was achieved. Twelve patients (eleven with non-operative and one
Judet and associates, in 1964, advised open reduction with operative treatment) were followed for less than one
and internal fixation of all displaced acetabular fractures, year. Of these, five were listed as having undetermined
proposing a detailed anatomical classification which was results; two were classified as having bad results because
correlated with the surgical approach. Long-term results they had required reconstructive surgery, both cup arthro-
were not available at the time of publication. Complica- plasties; one had a bad result following postoperative in-
tions included three surgical deaths but only one infection fection; one had a full range of hip motion and roentgeno-
after operations on 129 fractures. grams showing a good cartilage space at eleven months
Larson, in 1973, reported on thirty-five patients with (Figs. 4-A and 4-B) and was rated as having a good result;
fracture-dislocations followed for five years or longer. He another was listed as having a good result at six months
concluded that fractures with an intact acetabular dome because he had practically normal roentgenograms and full
could be treated satisfactorily by traction but that treat- motion of the hip (he subsequently died, so no further
ment of fractures with a displaced dome usually was un- follow-up was possible); and two were listed as having un-
satisfactory unless an accurate open reduction was accom- satisfactory results at four and five months, respectively,
plished. because of significant degenerative changes apparent on
their roentgenograms.
Material The remaining patients, thirty-four with non-
Fifty-five patients with fifty-six central dislocations operative and ten with operative treatment, had been fol-
of the hip or disrupted acetabula were seen at the Campbell lowed for from one to forty-three years. The average
Clinic during the years 1927 to 1970. These included follow-up for all fifty-five patients included in this study
seven of the eight patients previously reported by Knight was 8.6 years. Twenty-seven (twenty-two treated non-
and Smith and presumably most, if not all, of the twenty- operatively and five, operatively) had been followed for
eight patients described by Stewart and Milford (the exact five years or more.
number could not be determined from the record). The one For this study we adopted a new classification (Fig. 1)
patient reported by Knight and Smith who was excluded which is simpler than the ones previously proposed and
from this study had a fracture which was not thought to be has the advantage of serving as a guide to both treatment
sufficiently displaced to warrant a diagnosis of central and prognosis. In the cases included in this study and in
fracture-dislocation of the hip. Incidentally, this patients those by Stewart and Milford and by Knight and Smith, no
long-term result after open reduction was good. Most of attempt was made to correlate the results with the three
:::
. . .,
. -:
Discussion
In the literature there is confusion about the treatment
FIG. 3-B
FIG. 5-B
FIG. 6-B
of central fracture-dislocations of the hip and disrupted
Figs. 6-A and 6-B: Disrupted acetabulum in a twenty-four-year-old
acetabula. several treatments having been recommended, woman after an automobile accident. Open reduction was performed and
while there is more agreement about the treatment of un- when she was last seen, three years later, she had no pain or limp and
was an active homemaker. Her hip motion was 80 per cent of normal.
displaced acetabular fractures and posterior dislocations of She was rated as having a good result.
the hip associated with fractures of the posterior acetabular
lip. The present review is concerned only with central weight-bearing dome are satisfactorily reduced by ma-
fracture-dislocations and disrupted acetabula. nipulation can be treated successfully by closed means,
In general, the simplest method likely to yield a good but we emphasize that accurate realignment (near-
result is best. We, like Rowe and Lowell and Larson, anatomical reduction) of the acetabular dome must be ob-
found that the results of closed treatment of central tamed and that prolonged traction is necessary to maintain
fracture-dislocation without fracture of the weight- the reduction. If any intra-articular bone fragments are
bearing dome of the acetabulum are satisfactory provided present they must be removed (Figs. 2-A and 2-B).
the femoral head is reduced and maintained under the Open reduction of acetabular fractures is justified
dome. Ten of our eleven patients so treated had good or when closed treatment of a displaced fractured weight-
satisfactory results (Table I). Usually manipulation under bearing dome fails to reduce both the femoral head and
anesthesia, as described by Rowe and Lowell, best acetabular fragments accurately. provided the following
achieves this reduction: however, our experience suggests conditions can be met: ( I ) the general condition of the pa-
that prolonged traction (usually twelve weeks) is neces- tient must permit extensive surgery: (2) if there is corn-
sary to maintain reduction. Early active motion in traction minution of the acetabular fracture the fragments must be
is encouraged. We have used combined longitudinal and large enough to be fixed internally: and (3) the surgeon
lateral traction for at least part of the time. Traction must, must be well trained and preferably experienced. and the
of course. be followed by a program of muscle- operating room where the procedure is to be done must be
strengthening exercises and graduated weight-bearing. well equipped.
The central fracture-dislocations with fracture of the It should be noted that of the eleven hips treated by
weight-bearing dome in which the femoral head and the open reduction in this series. four (36 per cent) became in-
TABLE I suits are obtained considering the deformity. the final re-
RESULTS* suit resembling a central displacement arthroplasty (Figs.
3-A and 3-B).
Non-Operative Operative
Treatment Treatment When an open reduction is indicated, the roentgenog-
raphic analysis and surgical exposures described by Judet
Central dislocation - weight-bearing
dome intact
and associates in 1964 are recommended. Careful plan-
Good 4 0 ning and a review of the pelvic anatomy are essential. An
Satisfactory 6 0 array of internal fixation devices - plates, screws, and
Unsatisfactory I 0
Undetermined 0 I
Knowles pins should - be available at surgery.
Disrupted acetabulum Primary reconstructive surgery as described by Wes-
Good I I terborn was not carried out in this series and we believe
Satisfactory 5 2
that it is not advisable. However, reconstruction may be
Unsatisfactory 3 2
Undetermined 0 0 required later. In nine of our patients late reconstruction
Central dislocation - weight-bearing was necessary: arthroplasty in six (five cup arthroplasties
dome fractured and one total hip replacement) and arthrodesis in three.
Good 2 I
Satisfactory 5 2
Conclusions
Unsatisfactory 8 0
Undetermined 3 0 Displaced central fracture-dislocations of the hip and
* Results in the forty-seven acetabular fractures which could be
disrupted acetabula are serious injuries. prone to result in
classified. Nine could not be classified because the original roentgeno- permanent disability.
grams had been lost or destroyed. Any patient whose follow-up was Most of these injuries can and should be treated with-
thought to be insufficient was listed as having an undetermined result.
out open reduction. However, given certain well defined
fected - a clearly unacceptable figure. Although none of circumstances, open reduction is indicated: then careful
our four patients so treated since 1970 had infections, the planning and surgical treatment carried out by an experi-
message from the past speaks loud and clear. Most of enced surgeon are necessary. The methods of open reduc-
these early infections were probably the result of limited tion proposed by Judet and associates are preferred.
operative exposure (three of the four had lateral ap- We believe that primary reconstructive surgery is not
proaches). advisable, but reconstruction may be necessary as a sec-
In some central fracture-dislocations with extensive ondary procedure.
comminution involving the weight-bearing dome,
5Oi I: The intl sur.n ish t( hank heir coilciguc. it i),e (.iinptrcll Cl sic tv periniuing heir
minimum treatment is indicated and surprisingly good re- pailenis It) he used in his studs.
References
1. JUDET, ROBERT; JUDET, JEAN; and LETOURNEL, E. : Fractures of the Acetabulum: Classification and Surgical Approaches for Open Reduction.
Preliminary Report. J. Bone and Joint Surg.. 46-A; 1615-1646, Dec. 1964.
2. KNIGHT, R. A., and SMITH, HUGH: Central Fractures of the Acetabulum. J. Bone and Joint Surg.. 40-A: 1-16. Jan. 1958.
3. LARSON, C. B.: Fracture Dislocations of the Hip. Clin. Orthop.. 92: l47-154. 1973.
4. LEVINE, M. A.: Treatment of Central Fractures of the Acetabulum. A Case Report. J. Bone and Joint Surg. . 25: 902-906. Oct. 1943.
5. ROWE, C. R.. and LOWELL, J. D.: Prognosis of Fractures of the Acetabulum. J. Bone and Joint Surg.. 43-A: 30-59, Jan. 1961.
6. SCHROEDER, W. E. : Fracture of the Acetabulum with Displacement of the Femoral Head into the Pelvic Cavity (Central Dislocation of Femur).
Quart. Bull. Northwestern Univ. Med. SchI., 11: 9-42, 1909.
7. STEWART, M. J., and MILFORD, L. W.: Fracture-Dislocation ofthe Hip. An End-Result Study. J. Bone and Joint Surg.. 36-A: 315-342, April
1954.
8. VAUGHN, G. T.: Central Dislocations ofthe Femur. Surg.. Gynec. and Obstet., 15: 249-251. 1912.
9. WESTERBORN, ANDERS: Central Dislocation ofthe Femoral Head Treated with Mold Arthroplasty. J. Bone and JointSurg.. 36-A: 307-314. April
1954.