Routine Sciatic Nerve Exploration in posterior wall

Report
+
Routine Sciatic Nerve
Exploration in posterior
wall/column acetabular
fractures ORIF
Cesar Alcantara
Canseco
MD
Eric Hazan Lasri
MD
Orthopedic Trauma
Department
Head of Orthopedic
Trauma Division
Michell Ruiz
Suarez
PhD, MD
Ernesto Pineda
Gomez MD
Orthopedic Trauma
Department
Chief of Orthopedic
Trauma Department
Instituto Nacional de Rehabilitacion
Orthopedic Trauma Division
Mexico City
+INTRODUCTION

3% to 8% of all fractures
Halvorson, J. J., Lamothe, J., Martin, C. R., Grose, A., Asprinio, D. E., Wellman, D., & Helfet, D. L. (2014).
Combined acetabulum and pelvic ring injuries. The Journal of the American Academy of Orthopaedic
Surgeons, 22(5), 304–314. doi:10.5435/JAAOS-22-05-304

Anatomically complex fx, surgically demanding
+INTRODUCTION

Goals of managing acetabular fractures

Stabilize the hemodynamically unstable patitent

Restore native pelvic ring anatomy

Restore functional hip mobility and stability

Prevent posttraumatic arthrosis, HO, nerve injury, PE/DVT
+INTRODUCTION

Sciatic nerve injuries are associated with acetabular fractures
Issack, P. S., & Helfet, D. L. (2009). Sciatic nerve injury associated with acetabular fractures. HSS Journal, 5(1),
12–18. doi:10.1007/s11420-008-9099-y

Posttraumatic (30%): during trauma

Perioperative (5-15%): iatrogenic injury

Postoperative (5-15%) : fibrosis, HO
+
PURPOSE

To review clinical results of routine sciatic nerve exploration
at the time of ORIF of posterior column/wall fracture of the
acetabulum
+METHOD

Retrospective review (2007 - 2013)

Skeletal maturity

Review of chart and phone
interview

Image review with PACS system
+METHOD

Preoperative and Postoperative
evaluation

5 radiological views


CT scan with 3D reconstruction


AP, inlet, outlet, obturator and iliac oblique of the pelvis
GE Lightspeed VCT Select 64-bit CT Scanner (GE
Healthcare, Waukesha, WI)
Somatosensory evoked potentials and
electromyography

Nicolet Viking
+SURGICAL TECHNIQUE

One surgeon (EPG)

Kocher Langenbeck approach


Trochanteric osteotomy
The sciatic nerve was carefully visualized
and explored

From the fracture site to the greater sciatic
notch

15cm distal to the fracture
Meticulous debridement of all soft tissues,
removed necrotic tissue and finally an
irrigation of the exposed area



Fracture fixation with 3.5mm reconstruction
and LCP plates
No drains were left
+
RESULTS
2007-2013

101 patients acetabular fx (all types)

Mean age = 37 (14-70)

Average follow-up: 14 months (9-57)

98 fractures healed (3 non-unions)

2 severe deep infections

3 late THR subsequently
+RESULTS - gender
77
67
24
34
Male
Female
+
RESULTS - acetabulum involved
67
67
34
28
Right
8
Left
Both
+
RESULTS - fracture pattern (Judet)
JUDET, R., JUDET, J., & Letournel, E. (1964). FRACTURES OF THE ACETABULUM: CLASSIFICATION AND SURGICAL
APPROACHES FOR OPEN REDUCTION. PRELIMINARY REPORT. The Journal of Bone and Joint Surgery (American), 46, 1615–
1646.
Isolated Posterior Wall
Isolated Posterior Column
Posterior Wall + Posterior Column
Posterior Wall + Transverse
Posterior Columnn + Transverse
Posterior Wall + Posterior Column + Transverse
12
3
Isolated Posterior Wall
2
1
Isolated Posterior Column
Posterior Wall + Posterior
Column
Posterior Wall + Transverse
2
Posterior Columnn + Transverse
3
Posterior Wall + Posterior
Column + Transverse
+
RESULTS - associated hip
dislocation
17/101 associated hip dislocation : 17%
Isolated Posterior Wall
Posterior Wall + Posterior Column
2
Isolated Posterior Wall
3
Posterior Wall + Posterior Column
1
Posterior Wall + Posterior Column + Transverse
+
RESULTS - sciatic nerve injury

23/101 patients = 22.77%

22 PreOperative (trauma)

1 PeriOperative (iatrogenic)

None PostOperatively

6/17 w/ hip dislocation (35% NS)

NO HO on last film
Right
18
Left
1
5
+
RESULTS - sciatic nerve injury recovery
- Full clinical recovery: 18
- Partially recovered: 4
- Did not recover:1
• All but ONE patient return to
previous level of activity
•
ALL satisfied w/ procedure
+
RESULTS - floating hip

1/23

Hip fracture was treated first with a proximal femur nail and in
the same surgical time the treatment of the acetabulum was
performed

Patient had partial recovery; ambulatory with walking brace
+
DISCUSSION

ORIF for acetabular fractures helps early mobilization and faster
pain reduction
O'Toole RV, Hui E, Chandra A, Nascone JW. How often does open reduction and internal fixation of geriatric acetabular fractures
lead to hip arthroplasty? Journal of Orthopaedic Trauma. 2014;28(3):148–153. doi:10.1097/BOT.0b013e31829c739a.

Fractures treated with acute arthroplasty is not the best option in
patients with column fractures; ORIF allows anatomical fracture
healing making arthroplasty simpler
O'Toole RV, Hui E, Chandra A, Nascone JW. How often does open reduction and internal fixation of geriatric acetabular fractures
lead to hip arthroplasty? Journal of Orthopaedic Trauma. 2014;28(3):148–153. doi:10.1097/BOT.0b013e31829c739a.

Detailed radiographic diagnosis in acetabulum fractures
required for an adecuate classification (Judet/Letournel)and
treatment
Lawrence, D. A., Menn, K., Baumgaertner, M., & Haims, A. H. (2013). Acetabular Fractures: Anatomic and Clinical Considerations.
American Journal of Roentgenology, 201(3), W425–W436. doi:10.2214/AJR.12.10470
+
DISCUSSION

Few reports on surgical decompression of the sciatic nerve
following acetabular fractures or reconstructive surgery of the
acetabulum and/or pelvis
Issack, P. S. (2007). Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum. The Journal of Bone
and Joint Surgery (American), 89(7), 1432. doi:10.2106/JBJS.F.00904
Benson, E. R., & Schutzer, S. F. (1999). Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. The
Journal of Bone and Joint Surgery (American), 81(7), 941–949.

Surgical nerve release and neurolysis is only described as a
treatment for postoperative complications of nerve
compression
Zhang Y, Xie Y, Xu S, Zhang C. Massive heterotopic ossification associated with late deficits in posterior wall of acetabulum after
failed acetabular fracture operation. BMC Musculoskelet Disord. 2013;14(1):368. doi:10.1186/1471-2474-14-368.
Burd TA, Lowry KJ, Anglen JO. Indomethacin compared with localized irradiation for the prevention of heterotopic ossification
following surgical treatment of acetabular fractures. J Bone Joint Surg (Br). 2001.
Beauchesne RP, Schutzer SF. Myositis ossificans of the piriformis muscle: an unusual cause of piriformis syndrome. A case
report. J Bone Joint Surg Am. 1997;79(6):906–910.
Johnson EE, Kay RM, Dorey FJ. Heterotopic ossification prophylaxis following operative treatment of acetabular fracture. Clin
Orthop Relat Res. 1994;(305):88–95.
+
DISCUSSION

Poor Prognostic Factors: older age, delay to OR, reduction gap,
osteonecrosis, loss of joint space. Moed BR, Carr SEW, Watson TJ. Posterior wall fractures
of the acetabulum: prognostic factors for poor outcome. Orthopedic Trauma Directions 2005:02;9-20

Intraoperative SSEP/EMG monitoring did not decrease rate
iatrogenic sciatic nerve palsy. Haidukewych GJ, Scadutto JM, DiPasquale TG,
Herscovici D Jr, Sanders R. Iatrogenic nerve injury during acetabular fracture surgery: a
comparison of monitored and unmonitored patients. J Orthop Trauma 2002; 16(5); 297-301

Indomethacin 6 wk Tx did not reduce HO + increase posterior wall
non-union. Sagi HC, Jordan CJ, Barei DP et al. J Orthop Trauma 2014; 28(7):377-383

Only 5/23 cases were polytrauma patients. ORIF within 1 week but
not immediately. Significance?
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DISCUSSION

Weakness of the study:


needs for longer follow-up,

no use of intraop surgical nerve monitoring,

no QOL score
Strengths of the study:

Single surgeon experience,
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CONCLUSION

Sciatic nerve injuries associated with acetabulum
fracture of posterior wall/column were
posttraumatic

78% full clinical recovery without sequelae

91% functional recovery

Acetabular wall necrosis, heterotopic ossification,
were not observed in this series

We recommend a sciatic nerve surgical release
and neurolysis as a part of the surgical technique
using a Kocher-Langenbeck approach
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