Publication: Utilidad de la ecografía en la colocación de las fichas supra-acetabulares de los osteotaxos pélvicos
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2017-02-23
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Universidad Complutense de Madrid
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Abstract
La fractura de pelvis es una causa potencial de inestabilidad hemodinámica en los pacientes politraumatizados. La fijación externa es un tratamiento capaz de estabilizar estas lesiones en la cirugía de control de daños. La colocación de fichas supra-acetabulares es la opción que aporta mayor estabilidad biomecánica, pero requiere la utilización de radioscopia intraoperatoria. El objetivo de este estudio es analizar la utilidad de la ecografía en la colocación de las fichas supra-acetabulares de los osteotaxos pélvicos. Material y Método Estudio transversal en dos etapas. Etapa 1: Estudio ecográfico de la anatomía de la región supra-acetabular en sujetos sanos, dividido en dos subetapas. Etapa 1.1: Estudio ecográfico de la anatomía de la región supraacetabular en sujetos sanos, reproducibilidad inter-observador y variabilidad intra-observador; y Etapa 1.2 Estudio ecográfico de la anatomía de la región supra-acetabular en pacientes sin patología pélvica. Se realizó un análisis de datos demográficos (edad, sexo, IMC), estudio de la región supra-acetabular (EAIS, escotadura innominada, EIAI, reborde acetabular y cabeza femoral), y medición ecográfica de espina iliaca anteroinferior (EIAI) en plano sagital y coronal. Se analizó la reproducibilidad inter-observador (coeficiente Kappa, k) y la variabilidad intra-observador (correlación intraclase, CCI). Etapa 2: Precisión de la implantación de fichas guiado por ecografía. Análisis de la colocación en pelvis de cadáver, realizando comprobación indirecta, con control radiológico, y comprobación directa mediante disección y estudio anatómico. Resultados Etapa 1.1: Se analizaron 28 caderas en 14 voluntarios sanos, con una altura media de 1,71m (+/- 0,09; 1,55-1,84) e IMC medio de 21,43 kg/m2 (+/- 2,22; 17,78-24,69). En todos los casos se realizó visualización completa de la región supra-acetabular (k=+ 1; concordancia absoluta). El valor medio de la EIAI en plano sagital fue de 1,42cm (+/- 0,39; 0,8-2,43) y de 0,94cm (+/- 0,25; 0,57-1,76) en el plano coronal, con una correlación positiva entre el tamaño en plano coronal y la talla (r=0,40). Se obtuvo una baja variabilidad intraobservador, con un CCI de 0,95 (0,89-0,98 al 95%; p < 0,001). Etapa 1.2: Se analizaron 148 caderas en 74 pacientes, con una edad media de 62 años, altura media de 1,70cm (+/- 0,1; 1,48-1,91) e IMC medio 25,95 Kg/m2 (+/- 4,81; 15,62-39,71). Etapa 2: Se implantaron 14 fichas supra-acetabulares en 7 pelvis de cadáver guiadas por ecografía. En la valoración indirecta mediante control radiológico se obtuvo una colocación excelente en todos los casos. En la valoración directa se observó una colocación excelente en el 100% de los casos. Tras la disección anatómica se observó lesión del nervio femorocutáneo en un caso. Conclusión La colocación de fichas supra-acetabulares guiadas por ecografía es una técnica posible y eficaz. Los estudios realizados hasta la fecha indican que su colocación sin necesidad de radiología intra-operatoria es viable, sin comprometer la fiabilidad de su colocación. Es necesario corroborar los resultados con un mayor número de casos, aunque la aplicación de esta nueva técnica en la práctica clínica de nuestro centro aporta resultados esperanzadores.
Pelvic fracture in trauma patients can lead to hemodynamic instability. External fixation is a treatment capable of stabilizing these injuries in damage control surgery. Supra-acetabular half-pin offer the greater biomechanical stability but requires the use of intraoperative fluoroscopy. The aim of this study is to analyse our results with surgical procedure of supra-acetabular pin placing guided by ultrasonography. Material and Methods Cross-sectional study in two stages. Stage 1: Anatomic ultrasoundguided study of the supra-acetabular region divided into two sub-stages. Stage 1.1 an anatomic ultrasound-guided study of the supra-acetabular region in healthy volunteers, interobserver reproducibility and intraobserver variability, and Stage 1.2 an anatomic ultrasound-guided study of the supra-acetabular region in patients without pelvic pathology. Analysis of demographic data (age, sex, BMI), supra-acetabular region study (ASIS, innominate line, AIIS, acetabular rim and femoral head) was performed. Ultrasound measurement of anterior superior iliac spine (AIIS) was performed in sagittal and coronal plane. The interobserver reproducibility (Kappa coefficient, k) and intraobserver variability (intraclass correlation coeficcient, ICC) were analysed. Stage 2: Ultrasound-guided half-pin placement precision study in cadaveric specimens. Double evaluation was performed: indirect evaluation with radiological control, and direct evaluation by anatomical dissection study. Results Stage 1.1: Analysis of 28 hips in 14 volunteers. Average height 1.71m (+/- 0.09; 1.55-1.84) and mean BMI 21.43 kg/m2 (+/- 2.22; 17.78-24.69). In all cases a complete supra-acetabular display was conducted. k = + 1 (complete agreement). Mean ASIS in sagittal plane 1.42cm (+/- 0.39; 0.8-2,43) and 0.94cm (+/- 0.25; 0.57-1.76) in the coronal; positive correlation between coronal plane size and height (r=0.40) and ICC=0.95 (95% from 0.89 to 0.98; p <0.001). Stage 1.2: Analysis of 148 hips in 74 patients, with a mean age of 62 years. Mean height of 1.70cm (+/- 0.1, 1.48 to 1.91) and mean BMI 25.95 kg/m2 (+/- 4.81; 15.62 to 39.71). Stage 2: 14 ultrasound-guided supra-acetabular half-pins were placed in 7 cadaveric specimen pelvises. Excellent placement in all cases, evaluated with radiological control. Good qualitative bone fixing after dissection. There was one femoral cutaneous nerve injury. Conclusion Ultrasound-guided supra-acetabular half-pin placement is a feasible and effective technique. Studies to date indicate that placement without intraoperative radiology is feasible without compromising the reliability of its placement. Future studies are needed, although the application of this new technique in clinical practice of our centre brings encouraging results.
Pelvic fracture in trauma patients can lead to hemodynamic instability. External fixation is a treatment capable of stabilizing these injuries in damage control surgery. Supra-acetabular half-pin offer the greater biomechanical stability but requires the use of intraoperative fluoroscopy. The aim of this study is to analyse our results with surgical procedure of supra-acetabular pin placing guided by ultrasonography. Material and Methods Cross-sectional study in two stages. Stage 1: Anatomic ultrasoundguided study of the supra-acetabular region divided into two sub-stages. Stage 1.1 an anatomic ultrasound-guided study of the supra-acetabular region in healthy volunteers, interobserver reproducibility and intraobserver variability, and Stage 1.2 an anatomic ultrasound-guided study of the supra-acetabular region in patients without pelvic pathology. Analysis of demographic data (age, sex, BMI), supra-acetabular region study (ASIS, innominate line, AIIS, acetabular rim and femoral head) was performed. Ultrasound measurement of anterior superior iliac spine (AIIS) was performed in sagittal and coronal plane. The interobserver reproducibility (Kappa coefficient, k) and intraobserver variability (intraclass correlation coeficcient, ICC) were analysed. Stage 2: Ultrasound-guided half-pin placement precision study in cadaveric specimens. Double evaluation was performed: indirect evaluation with radiological control, and direct evaluation by anatomical dissection study. Results Stage 1.1: Analysis of 28 hips in 14 volunteers. Average height 1.71m (+/- 0.09; 1.55-1.84) and mean BMI 21.43 kg/m2 (+/- 2.22; 17.78-24.69). In all cases a complete supra-acetabular display was conducted. k = + 1 (complete agreement). Mean ASIS in sagittal plane 1.42cm (+/- 0.39; 0.8-2,43) and 0.94cm (+/- 0.25; 0.57-1.76) in the coronal; positive correlation between coronal plane size and height (r=0.40) and ICC=0.95 (95% from 0.89 to 0.98; p <0.001). Stage 1.2: Analysis of 148 hips in 74 patients, with a mean age of 62 years. Mean height of 1.70cm (+/- 0.1, 1.48 to 1.91) and mean BMI 25.95 kg/m2 (+/- 4.81; 15.62 to 39.71). Stage 2: 14 ultrasound-guided supra-acetabular half-pins were placed in 7 cadaveric specimen pelvises. Excellent placement in all cases, evaluated with radiological control. Good qualitative bone fixing after dissection. There was one femoral cutaneous nerve injury. Conclusion Ultrasound-guided supra-acetabular half-pin placement is a feasible and effective technique. Studies to date indicate that placement without intraoperative radiology is feasible without compromising the reliability of its placement. Future studies are needed, although the application of this new technique in clinical practice of our centre brings encouraging results.
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Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, Departamento de Cirugía, leída el 10-03-2016