LONG-TERM OUTCOME AFTER SURGICAL-TREATMEN T OF COMPLICATED ACETABULARFRACTURES VIA EXTENDED APPROACHES

Extended approaches are indicated for complex acetabular fractures. Th e advantage of extended approaches is the simultaneous exposure of bot h columns of the acetabulum; disadvantages are the wide exposure of th e soft tissue and a high rate of heterotopic ossification. Muscle weak ness and necrosis of the muscle have been described. Although there is good exposure with an extended approach, the indication for it is res tricted. Between 1972 and 1993, 688 patients with acetabular fractures were treated at the Trauma Department of the Hannover Medical School; 322 had open reduction and internal fixation. Thirty-five patients (1 0%) were treated with an extended approach. In a retrospective study o f 24 patients treated with an extended approach between 1985 and 1993, perioperative data, long-term clinical outcome and radiological outco me were investigated. The aim of the study was to compare the outcome of two groups treated using either the classical extended iliofemoral approach or the Maryland modification. Eleven patients were treated wi th the extended iliofemoral approach, 13 with the Maryland approach. T here were no significant differences in age, type of accident, fractur e classification, time to operation, time of operation and blood loss. The postoperative X-ray was anatomic or nearly anatomic in 22 cases; 2 patients had a dislocation of more than 2 mm. The main complications were hematomas and seromas. In both groups we found one thrombosis an d one nerve injury with partial recovery. Twenty patients were followe d up at least 2 years after trauma, 8 after extended iliofemoral appro ach and 12 after Maryland approach. There was no correlation between c linical and radiological outcome. In the clinical outcome (Merle d'Aub igne-Score) there were no excellent results. Six patients with Marylan d approach had an excellent radiological result versus one after exten ded iliofemoral approach. Six patients had poor clinical results, thre e after each approach; one patient developed acetabular head necrosis, subsequently treated with THR, after the Maryland approach, two had s evere coxarthrosis after the extended iliofemoral approach and the oth ers had severe pain or functional impairments. Significant heterotopic ossification (Brooker type III) developed in three cases, one after t he Maryland and two after the classic approach. There were no signific ant differences between these two approaches. The indication for an ex tended approach should be restricted in the case of complicated fractu res. Where it is indicated at all, the Maryland modification seems to be technically advantageous.