We reviewed 77 patients with an acetabular fracture, treated operatively through a non-extensile approach after an average time of 45 months. The ilioinguinal approach was chosen in 41, the Kocher-Langenbeck approach in 36 patients. Following the Letournel classification, the most frequent lesions were posterior wall (26%), two-column (22.1%) and anterior column (14.3%) fractures. Subchondral impaction, intra-articular fracture fragments and fracture comminution, called modifiers, could be identified in the preoperative CT-data of 38 patients (49.4%). Patients were operated after an average of 4 days. Average hospital stay was 19 days. Sciatic nerve and peroneal nerve palsy were registered in 5.6%. Deep venous thrombosis was seen in 10.4%, peri-articular ossifications in 7.8%. During the 45-months follow-up, 10.4% patients needed secondary total hip arthroplasty. Using the Merle d'Aubigné score, 15 patients had an excellent, 39 a good, 15 a moderate, and 8 a bad result. In accordance with the Harris Hip Score, 29 patients achieved an excellent, 26 a good, 9 a moderate and 13 a bad result. Twenty of twenty-three (Merle d'Aubigné score) and twenty of twenty-two (Harris Hop Score) patients with moderate or bad results had one or more modifiers. Patients with operatively treated acetabular fractures, who had CT-findings such as subchondral impaction, fracture comminution or intra-articular fracture fragments in their preoperative examination, score significantly lower at middle term in the Harris Hip and Merle d'Aubigné scoring systems.

aClinica de Ortopedia y Cirugia Traumatica, Clinica de Fulda, Alemania. bClinica y Policlinica de Cirugia Traumatica, Universidad Johannes Gutenberg de Maguncia, Alemania. Resumen Objetivo Restablecer la congruencia de la articulacion de la cadera. Evitar la formacion de escalones o huecos interfragmentarios, especialmente en la zona de carga maxima del acetabulo. Corregir una subluxacion de la cabeza del femur. Restablecer la estabilidad con objeto de posibilitar una movilizacion precoz del paciente.

Wiederherstellung der Kongruenz des Hüftgelenks. Vermeidung von Stufen- und Spaltbildungen, insbesondere im Bereich der Hauptbelastungszone des Azetabulums. Korrektur einer Subluxation des Hüftkopfes. Wiederherstellung der Stabilität mit dem Ziel einer frühen Mobilisierung des Patienten.

Das „komplexe regionale Schmerzsyndrom“ (CRPS) wird an der unteren Extremität selten beobachtet. Wir berichten über einen 19-jährigen Patienten mit typischen Symptomen am Unterschenkel und Fuß nach operativer Versorgung einer Luxationsfraktur des Acetabulums. Bei persistierenden oder progredienten körperfernen Schmerzen nach Acetabulumfraktur sollte das CRPS in die Differenzialdiagnose mit einbezogen werden. Eine frühzeitige Diagnose und eine frühzeitig eingeleitete zielgerichtete Therapie tragen wesentlich zum Behandlungserfolg bei.

Secondary or delayed reconstructions following mal-or nonunited fractures of the pelvic ring and acetabulum are challenging procedures. Three different healing problems have to be distinguished: malunion, nonunion, and fractures and/or dislocations that have healed incompletely. Combinations of these three pathologies are also possible. Delayed reconstructions have no chance of success unless the patient's signs and symptoms are clearly attributable to the malunion or nonunion. This means that extensive clinical and radiological evaluation is mandatory preoperatively. Risks involved and the results that can be expected must be discussed thoroughly with the patient once the surgery has been planned in detail. For the treatment of nonunion or delayed union, the unstable zone must be debrided, and autologous bone grafting with cancellous bone and stable internal fixation are then required. Malunion requires careful mobilization of the malunited fracture fragments, which is often a very demanding procedure. If there is already advanced damage to the acetabulum little functional improvement can be expected after a corrective osteotomy. Viable treatment alternatives are hip fusion and endoprosthetic joint replacement. Possible complications include damage to neurovascular structures, impaired wound healing, infections and implant failure. Extensive experience in the management of acute fractures of the pelvic ring and acetabulum is essential if delayed reconstruction is to be successful.

Sekundär- und Späteingriffe bei fehlverheilten Beckenring- und Azetabulumverletzungen sind komplex und anspruchsvoll. „Fehlverheilt“ beinhaltet nicht verheilte Frakturen und/oder Luxationen, unvollständig verheilte Verletzungen und in Fehlstellung verheilte Läsionen – auch Kombinationen können vorkommen. Korrektureingriffe haben nur Aussicht auf Erfolg, wenn die Beschwerden auf die Fehlheilung zurückzuführen sind. Somit sind eine differenzierte präoperative klinische und radiologische Abklärung unerlässlich. Nach detaillierter Planung des Operationsablaufs ist eine ausführliche Aufklärung des Patienten über die Risiken und den möglichen Erfolg der Therapie erforderlich. Bei Pseudarthrosen werden die Instabilitätszone ausgeräumt, mit autologer Spongiosa aufgefüllt und stabil osteosynthetisiert. Ausgeheilte Fehlstellungen erfordern eine vorsichtige, aber oft aufwändige Mobilisation der fehlverheilten Fragmente. Bei weit fortgeschrittenem Azetabulumschaden ist von einer Korrekturosteotomie funktionell wenig Besserung zu erwarten, alternativ sind Hüftgelenkarthrodese und endoprothetischer Gelenkersatz möglich. An Komplikationen können Schäden neurovaskulärer Strukturen, postoperative Wundheilungsstörungen, Infektionen und Implantatversagen mit Pseudarthrosenrezidiv auftreten. Für das Gelingen von Korrekturmaßnahmen am Becken und Azetabulum sind umfassende Erfahrungen bei der chirurgischen Behandlung akuter Beckenring- und Azetabulumfrakturen unabdingbar.

We retrospectively reviewed 79 patients (80 talar fractures) operated on between 1994 and 1997. The average follow-up was 6 (1-15) years. 15 patients had a Marti/Weber fracture type I, 14 patients a type II, 32 patients a type III, and 19 patients a type IV fracture. 46 patients suffered a fracture of the talar neck, Hawkins type I in 10 patients, type II in 18, type III in 17 and type IV in 1 patient. 18/23 patients directly placed in our department were operated on within 6 hours of admission. Primary arthrodesis of both the ankle and subtalar joint was performed twice. Secondary arthrodesis of the ankle joint was done in only 3 patients. Combined secondary arthrodesis of the ankle and subtalar joint was performed in 5 and arthrodesis of the talonavicular joint in 1 patient. According to the Hawkins score, 35/80 feet achieved good/very good function versus 43 with the Mazur score. Radiographs showed ankle or subtalar arthrosis in two thirds of the patients. A normal range of motion was achieved in 18 ankle and 19 subtalar joints. The overall rate of talar necrosis was 9/80 fractures.

Aim: We performed an investigation of factors for avascular necroses after talus fracture and on the reliability of the Hawkins Sign. Method: From 1984 until 1997 a total of 98 patients with 99 talus fractures were surgically treated. Of these, 79 patients with 80 fractures were examined clinically and radiologically. The average postoperative interval was 6 years and 2 months. Results: With respect to the 65 central fractures, the rate of necrosis amounted to 14%, that of collum fractures to 17%. Necroses arose solely in dislocated central fractures of the talus, type III and IV according to Marti/Weber fracture classification. The rate of necrosis rose with the degree of dislocation of the fractures. In 24 patients the Hawkins Sign could be retrospectively investigated. It proved to be a relatively reliable sign for vitality since only I out of 12 patients with positive or partial positive Hawkins Sign developed avascular necrosis. Neither a short interval between accident and operation, the age at the time of the accident, nor the ipsilateral fracture of the medial malleolus showed a necrosis preventive influence. In 5 out of 9 talus necroses the patients were very or mostly satisfied with the result of their treatment. Conclusion: The Hawkins Sign proved to be a relatively reliable sign for vitality of the talus after fracture. Risk for avascular necrosis increases according to the degree of fracture dislocation.

We retrospectively reviewed 79 patients (80 talar fractures) operated on between 1994 and 1997. The average follow-up was 6 (1-15) years. 15 patients had a Marti/Weber fracture type I, 14 patients a type II, 32 patients a type III, and 19 patients a type IV fracture. 46 patients suffered a fracture of the talar neck, Hawkins type I in 10 patients, type II in 18, type III in 17 and type IV in 1 patient. 18/23 patients directly placed in our department were operated on within 6 hours of admission. Primary arthrodesis of both the ankle and subtalar joint was performed twice. Secondary arthrodesis of the ankle joint was done in only 3 patients. Combined secondary arthrodesis of the ankle and subtalar joint was performed in 5 and arthrodesis of the talonavicular joint in 1 patient. According to the Hawkins score, 35/80 feet achieved good/very good function versus 43 with the Mazur score. Radiographs showed ankle or subtalar arthrosis in two thirds of the patients. A normal range of motion was achieved in 18 ankle and 19 subtalar joints. The overall rate of talar necrosis was 9/80 fractures.

The Hawkins Sign proved to be a relatively reliable sign for vitality of the talus after fracture. Risk for avascular necrosis increases according to the degree of fracture dislocation.