Asetabulum Kırıklarının Değerlendirilmesi ve Tedavisi
Özet
Asetabulum kırıkları, ortopedi alanındaki en karmaşık yaralanmalardan olup klinik sonuçları eklem redüksiyonunun kalitesi, hastanın yaşı ve travmanın enerjisi gibi birçok değişkene bağlıdır. Gençlerde yüksek, yaşlılarda ise düşük enerjili travmalarla ortaya çıkan bu kırıklar; sıklıkla kafa travması, batın ve nörovasküler yaralanmalar gibi hayati risklerle birlikte seyretmektedir. Teşhis ve değerlendirme süreçlerinde AP ve Judet oblik grafilerinin yanı sıra, kırık paterninin tam olarak anlaşılmasını sağlayan 2D ve 3D bilgisayarlı tomografi (BT) yöntemleri kritik rol oynar. Sınıflandırmada dünya genelinde en çok kabul gören sistem Judet ve Letournel yaklaşımı olup kırıkları basit ve kompleks (ilişkili) olmak üzere iki ana gruba ayırır; ayrıca AO grubu tarafından da bilgisayarlı kodlamaya dayalı bir sistem geliştirilmiştir. Tedavinin temel amacı anatomik redüksiyon, stabil fiksasyon ve erken mobilizasyonun sağlanmasıdır. 2 mm’den fazla deplasman, eklem içi serbest parçalar veya nörovasküler komplikasyonların varlığında cerrahi olarak açık redüksiyon ve internal fiksasyon uygulanırken; genel durumu uygun olmayan veya parçalı kırığı bulunan bazı hastalarda operatif olmayan takip tercih edilebilmektedir.
Acetabular fractures are among the most complex injuries in orthopedics, and clinical outcomes depend on many variables such as the quality of joint reduction, patient age, and trauma energy. Occurring with high energy in young individuals and low energy in the elderly, these fractures often present with life-threatening risks such as head trauma, abdominal, and neurovascular injuries. In the diagnosis and evaluation processes, AP and Judet oblique radiographs, as well as 2D and 3D computed tomography (CT) methods that provide a full understanding of the fracture pattern, play a critical role. The most widely accepted system in classification is the Judet and Letournel approach, which divides fractures into two main groups as simple and complex (associated); additionally, a system based on computerized coding has been developed by the AO group. The primary goal of treatment is to achieve anatomical reduction, stable fixation, and early mobilization. Surgical open reduction and internal fixation are applied in the presence of displacement greater than 2 mm, intra-articular free fragments, or neurovascular complications, whereas non-operative follow-up may be preferred in some patients with poor medical status or highly comminuted fractures.
Referanslar
Judet R, Judet J, Letournel É. Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am. 1964;46:1615–46.
Letournel É. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;151:81–106.
Tannast MM, Najibi SS, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am. 2012;94(17):1559–67.
Letournel E, Judet R. Fracture of the acetabulum. 2nd edition. Berlin: Springer-Verlag; 1993.
Hanschen M, Pesch S, Huber-Wagner S, Biberthaler P. Manegement of acetabular fractures in the geriatric patient. SICOT-Journal. 2017;3:37
Meshabi SAR, Ghaemmaghami A, Ghaemmaghami S, Farhadi P. Outcome afte surgical management of acetabular fractures: A 7-year experience.
Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: Classification by mechanism is key to pattern of organ injury, resuscitative requirements and outcome. The Journal of Trauma. 1989;29:981-1000
Liebergall M, Moshieff R, Safran O, Peyser A, Segal D. The floating hip injury: Pattern of injury. Injury. 2002;33:717-722
Papadakos N, Pearce R, Bircher M. Low energy fractures of the acetabulum. Annals of The Royal College of Surgeons of England. 2014;96(4):297-301
Porter SE, Schroeder AC, Dzugan SS, Graves ML, Zhang L, et al. Acetabular fractures patterns and their associated injuries. Journal of Orthopaedic Trauma. 2008;22:165-170
CL1 S, Trentz O, L2 L. Management of Morel-Lavallee Lesion Associated with pelvic and/or Acetabular fractures. European Journal of Trauma and Emergency Surgery. 2008 Dec;34(6):554-560
JL1 F, Reimer BL, Raves JJ. Traumatic iliofemoral arterial injury: An association with high anterior acetabular fractures. Journal of Vascular Surgery. 1989 Aug;10(2):198-201
Richard A, Ruffin J, Marsh L. Sıperior gluteal artery distruption with pelvic and acetabular fractures. The Iowa Orthopaedic Journal. 1989;9:55-57
RA M, Tressler MA, Obremskey WT, Kregor PJ: Predicting blood loss in isolated pelvic and acetabular high-energy trauma. Journa of Orthopaedic Trauma. 2007 Oct;21(9):603-607
Goulet JA, Bray TJ. Complex acetabular fractures. Clinical Orthopaedics an Related Research. 1989;240:9-20
Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Heidelberg, Germany: Springer-Verlag; 1993
Harris JH Jr, Couple KJ, Lee JS, Trotscher T. Acetabular fractures revisited. Part 2. A new CT-based classification. AJR. 2004;182:1367-1375
Brandser E, Marsh JL. Acetabular fractures: Easier classification with a systematic approach. AJR. 1998;171:1217-1228
Martinez CR, Di Pasquale TG, Helfet DL, Graham AW, Sanders RW, Ray LD: Evaluation of acetabular fractures with two- and three-dimensional CT. Radiographics. 1992;12:227-242
Hunter JC, Brandser EA, Tran KA. Pelvic and acetabular trauma. Radiologic Clinics of North America. 1997;35:559-590
Ohashi K, El-Khoury GY, Abu-Zahra KW, Berbaum KS. Interobserver agreement for letournel acetabular fracture classification with multidetector CT: Are standard Judet radiographs necessary? Radiology. 2006;241(2):386-391
Tosun HB, Serbest S, Gümüştaş SA, Uludag A, Celik S. Learning curve for surgical treatment of Acetabular fractures: A retrospective clinical study of a practical and theoretical training course. Medical Science Monitor. 2017 Nov 2;23:5218-5229
Jarrod Durkee N, Jacobson J, Jamadar D, Karunakar MA, Morag Y, Hayes C. Classification of common acetabular fractures: Radiographic and CT appearances. American Journal of Roentgenology. 2006;187(4):915-925
Marsh JL et al. Fracture and dislocation classification compendium-2007. Ortjopaedic Trauma Association classification, datebase and outcomes Committee. Journal of Orthopaedic Trauma. November-December 2007
Scheinfeld MH, Dym AA, Spektor M, Avery LL, Joshua Dym R, Amanatullah DF. Acetabular fractures: What radiologists should know and how 3D CT can aid classification. Radiographics. 2015;35(2):555-577
Herman A, Tenenbaum S, Ougortsin V, Shazar N. There is no column: A new classification for Acetabular fractures. The Journal of Bone and Joint Surgery. American Volume. 2018 Jan 17;100(2):e8(1-10)
Thakkar CJ, Magu NK. Principles of management of acetabular fractures.Indian Journal of Orthopaedics. 2002;36:13-16
