Acetabular Fractures: Surgical Management

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Acetabular FracturesSurgical Management

• Philip J. Kregor, MD
• Orthopedic Traumatology
• University of Mississippi Med Center
• Jackson, Mississippi
• Created March 2004 Reviewed January 2007

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Objectives

• Goal of Operative Management
• Specific Approaches for Specific Fractures
• Indications for Kocher-Langenbeck Approach
• Indications for Ilioinguinal Approach
• Reduction Strategies

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Letournel School

• Thorough Understanding of Plain Films
• Optimize One Surgical Approach
• Goal of Perfect Concentric Reduction

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GOAL Anatomic Reduction
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EXCELLENT
GOOD
FAIR
POOR
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Timing of Surgery Criteria

• Well - resuscitated patient
• Appropriate radiological work-up
• Appropriate understanding of fracture
• Appropriate operative team

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Timing of Surgery and Anatomical Reductions

• 0-7 Days 74
• 8-14 Days 71
• 15-21 Days 57

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Surgical Emergencies Rare

• Open Acetabular Fracture
• New-Onset Sciatic Nerve Palsy after closed
  reduction of Hip dislocation

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Surgical Urgencies Infrequent

• Irreducible Posterior Hip Dislocation
• Medial Dislocation of Femoral Head against
  cancellous bone surface of intact Ilium

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NOT Predictive of CLINICAL OUTCOME

• Type of fracture pattern
• Posterior dislocation
• Initial displacement
• Presence of intra-articular fragments
• Presence of acetabular impaction

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Predictive of CLINICAL OUTCOME

• Injury to Cartilage or Bone of Femoral Head
• Damage 60 Good / Excellent Result
• No Damage 80 Good / Excellent Result
• Anatomic Reduction
• Age of Patient .. But only in that it predicts
  the ability to achieve an anatomic reduction

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Approaches to the Acetabulum

• Posterior Kocher - Langenbeck
• Anterior Ilioinguinal
• Extensile Extended Iliofemoral

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Letournel Classification

• Anterior Wall
• Anterior Column
• Posterior Wall
• Posterior Column
• Transverse

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Letournel Classification

• Posterior Column / Posterior Wall
• Transverse / Posterior Wall
• T-type
• Anterior Column / Posterior Hemitransverse
• Both Column

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Kocher-Langenbeck Approach

• Langenbeck (1874) Superior Limb
• Kocher (1904) Inferior Limb
• Judet and Lagrange (1958)
• Letournel

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Indications in Acute Acetabular Fxs

• Posterior Wall Fractures
• Posterior Column Fractures
• Posterior Column / Posterior Wall Fractures
• Juxta-tectal / Infra-tectal Transverse or
  Transverse with Posterior Wall Fractures
• Some T-type Fractures

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Access Kocher-Langenbeck

• Entire Posterior Column
• Greater and Lesser Sciatic Notches
• Ischial Spine
• Retro-Acetabular Surface
• Ischial Tuberosity
• Ischio-Pubic Ramus

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Complications with KL

• Sciatic Nerve Palsy 10
• Infection 3

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Limitations Kocher-Langenbeck

• Superior Acetabular Region
• Anterior Column
• Fractures High in Greater Sciatic Notch

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Prone Position

• Aids in Reduction of Ischiopubic Segment
• Facilitates Palpation of Quadrilateral Surface
• Allows Clamp Placement through Greater Sciatic
  Notch
• Easier Prep and Drape

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Posterior Wall Fractures
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Posterior Wall Fxs Surgical Keys

• Avoid Devascularization of Fragment/s
• Remove Intra-articular Fragments
• Address Marginal Impaction
• Provide adequate buttress
• Avoid Over-Contouring of Plate

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Controlled Distraction of Hip Joint

• Femoral Distractor
• Traction Table

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Posterior Wall Fx

• 63 Y.O. Male

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Special CaseExtended Posterior Wall

• ??? Ganz Trochanteric Flip Osteotomy
• to Visualize Fracture
• without Devitalizing Abductors

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Reduction Aids Kocher-Langenbeck Approach

• Distal Femoral Traction
• Distraction of Hip Joint
• Ischial Tuberosity Schantz Pin
• Quadrangular Clamp through Greater Sciatic Notch
• Farabeuf Clamp

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Optimal Screw Placement
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Transtectal Tranverse Acetabular Fx

• 18 Y.O. Male
• Isolated Injury
• Skinny Patient / Treated Early

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Ilioinguinal Approach Indications

• Anterior Wall
• Anterior Column
• Transverse with significant Anterior Displacement
• Anterior Column / Posterior Hemitransverse
• Both Column

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Ilioinguinal Approach Access
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II Complications

• Direct Hernia 1
• Significant LFC nerve numbness 23
• External iliac artery thrombosis 1

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II Complications

• Hematoma 5
• Infection 2

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Ilioinguinal Approach
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Anterior Column Fx

• Isolated Injury
• 73 Y.O. Male

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Reduction of Anterior Column to Intact Ilium

• Clamp Placement
• Lag Screw Placement

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Anterior Column / Posterior Hemitransverse

• Anterior Wall or Column
• Posterior Half of Transverse Fracture

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Anterior Column Fractures
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Anterior Wall Fracture
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Both Column Acetabular Fracture

• 18 Y.O. Female
• Isolated Injury

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SPUR SIGN
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SYMPHYSIS
A.S.I.S.
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EXT. INGUINAL RING
EXT. OBL.
A.S.I.S.
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CONJOINT TENDON
EXT. OBL.
EXT. OBL.
PSOAS
A.S.I.S.
L.F.C.N.
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Completion of Iliac Fracture
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Reduction of Anterior Column to Intact Ilium
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Reduction of Posterior Column
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INTACT ILIUM
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Extended Iliofemoral Approach

• T Type Fractures
• Trans-tectal Transverse Fractures
• Delayed Reconstruction

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EIF Complications

• Sciatic nerve palsy 1
• Hematoma 8
• Infection 1

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Extended Iliofemoral Approach
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Special Case

• T-Type Acetabular Fracture
• Proximal Femur Fracture
• 14 y.o. Male
• Sequential K-L / Ilioinguinal Approaches

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Initial Kocher-Langenbeck Approach
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Subsequent Ilioinguinal Approach
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Intra-Operative Assessment of Reduction

• Visual Assessment of Fracture Reduction
• Palpation of Fracture
• Quadrilateral surface through Greater Sciatic
  Notch
• Anterior Column
• C-Arm assessment
• Plain A.P. Radiograph
• Assurance that all Screws are out of Joint

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Assessment of Reduction

• Restoration of Pelvic Lines
• Concentric Reduction on all 3 Views
• Goal of Anatomic Reduction

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Complications Early

• 9 / 262 Nerve Palsies
• 2 Sciatic Nerves
• 1 Femoral Nerve
• 6 Peroneal Nerves
• 13 / 262 Wound Infections
• 5 Extra-articular
• 8 Intra-articular
• 13 / 262 Wear of femoral head

Letournel 1993 12.2 Pre-Op Deficits
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Complications Long-term

• 0.7 Nonunion
• 1 Cartilage Necrosis
• 3.1 Avascular Necrosis
• Osteoarthritis
• 10.2 after perfect reduction
• 35.7 after imperfect reduction

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Avascular Necrosis
In our opinion avascular necrosis is a diagnosis
much too often put forward to explain a
post-operative complication. Since it is known
that there is nothing we can do about it, as the
trauma is considered solely responsible for it,
there is much too great a tendency to blame
necrosis for what is really a wearing of the
femoral head against a malreduced fracture line.
If wear takes place there is disappearance of a
segment of the head but no sequestrum formation,
and the shape of the loss of substance is the
negative imprint of the shape responsible for the
wear the step in the acetabular reconstruction.
For instance, wearing against a transverse
fracture line appears on the antero-posterior
view as an orange-slice-shaped missing part of
the head without any sequestrum.
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Heterotopic Ossification
Brooker Classification

• I Islands of bone less than 1 cm in diameter
• II Larger islands of bone, leaving at least 1
  cm free space between the two bones of the hip
• III Free space between the ossification and the
  pelvis or the femur is less than 1 cm
• IV Apparent ankylosis of the joint by a bony
  bridge uniting the pelvis and the femur

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Heterotopic Ossification

• Classification does not predict mobility
• Approach
• 34 Grade III / IV Extended Iliofemoral
• 11 Grade III / IV Kocher-Langenbeck
• 1 Grade III / IV Ilioinguinal
• Ectopic bone formation appears early on
  radiography, and maturity is reached 6 months to
  1 year after operation.

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Significant HO (0 , 90 Hip Flexion)

• KL 8
• II 2
• EIF 20

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Prophylaxis for HO

• Indomethacin
• 700 cGy radiation
• Combination

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DVT Prophylaxis

• Controversial
• Mechanical devices
• Pharmacologic (I.e. LMWH)

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Conclusions

• Good Understanding of the Fracture
• Know the Anatomy
• Optimize One Surgical Approach
• Goal of Perfect Reduction

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