Acetabular Fractures:Surgical Management

Philip J. Kregor, MD

Created March 2004, Revised 2007 and 2011

Objectives Goal of Operative Management

Specific Approaches for Specific Fractures Indications for Kocher-Langenbeck Approach

Indications for Ilioinguinal Approach Reduction Strategies

Letournel School

Thorough Understanding of Plain Films Optimize One Surgical Approach

Goal of Perfect Concentric Reduction

Approaches to the Acetabulum

Posterior: Kocher - Langenbeck Anterior: Ilioinguinal

Extensile: Extended Iliofemoral

Kocher-Langenbeck Approach

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

Letournel

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

Access: Kocher-Langenbeck

Entire Posterior Column Greater and Lesser Sciatic Notches

Ischial Spine Retro-Acetabular Surface

Ischial Tuberosity Ischio-Pubic Ramus

Prone Position

Aids in Reduction of Ischiopubic Segment Facilitates Palpation of Quadrilateral Surface

Allows Clamp Placement through Greater Sciatic Notch

Easier Prep and Drape

Judet Table

POSTERIOR WALL FRACTURES

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

CONTROLLED DISTRACTION OF HIP JOINT

FEMORAL DISTRACTOR TRACTION TABLE

POSTERIOR WALL FX

63 Y.O. MALE

L.W. 00.09.23

L.W. 00.09.23

L.W. 00.09.23

L.W. 00.09.23

L.W. 00.10.25

L.W. 00.10.25

L.W. 00.10.25

SPECIAL CASE:EXTENDED POSTERIOR WALL

??? GANZ TROCHANTERIC FLIP OSTEOTOMY TO VISULIZE FRACTURE WITHOUT DEVITALIZING

ABDUCTORS

T.D. 00.02.01

T.D. 00.02.01

T.D. 00.02.01

T.D. 00.02.01

T.D. 00.02.08

T.D. 00.02.17

Reduction Aids: Kocher-Langenbeck Approach

Distal Femoral Traction Distraction of Hip Joint

Ischial Tuberosity Schantz Pin Quadrangular Clamp through Greater Sciatic

Notch Farabeuf Clamp

FAERBEUF CLAMPS

M.M. 98.10.27

M.M 98.10.29

M.M. 98.11.04

M.M. 98.11.05

M.M. 98.11.05

TRANSTECTAL TRANVERSE ACETABULAR FX

18 Y.O. MALE

ISOLATED INJURY

SKINNY PATIENT / TREATED EARLY

W.M. 99.11.27

W.M. 99.11.27

W.M. 99.11.27

W.M. 99.11.27

W.M. 00.01.12

W.M. 00.01.12

W.M. 00.01.12

16 YEAR OLD FEMALE

IRREDUCABLE HIP DISLOCATION

T-TYPE FRACTURE REDUCTION OF ANTERIOR COLUMN,

FOLLOWED BY POSTERIOR COLUMN REDUCTION OF POSTERIOR COLUMN,

FOLLOWED BY ANTERIOR COLUMN CREATION OF INTACT ISCHIOPUBIC

SEGMENT, FOLLOWED BY REDUCTION TO THE INTACT ILIUM

Farless, Ron 02.07.29

FACTORS COMPLICATING TRANSVERSE FRACTURE

REDUCTION TRANSTECTAL FRACTURE PATTERN

SEPARATE OSSEOCHONDRAL ARTICULAR DOME FRAGMENT

IPSILATERAL S.I. JOINT INJURY

SYMPHYSIS INJURY OR CONTRALATERAL ANTERIOR RING

INJURY

Ilioinguinal Approach: Indications

Anterior Wall Anterior Column

Transverse with significant Anterior Displacement

Anterior Column / Posterior Hemitransverse Both Column

Ilioinguinal Approach: Access

Ilioinguinal Approach

CASE 4: 63 YEAR OLD ROMAN CATHOLIC PRIEST

FELL GOING DOWN STAIRSWHAT IS THE DIAGNOSIS ??

WARNING: MAKE THE DX WITHOUT C.T.

WHAT IS THE DIAGNOSIS ?

TREATMENT OPTIONS?

NON-OPERATIVE?ORIF?

TOTAL HIP?

ORIF ANTERIOR COLUMN ACETABULAR FRACTURE

SUPINE WITH FX TABLEILIOINGUINAL APPROACH

NORMAL HIP AT 3 YEAR FOLLOW-UP

R.C. 00.03.09

R.C. 00.03.09

R.C. 00.03.09

SPURSIGN

R.C. 00.03.09

R.C. 00.03.09

A.S.I.S.

SYMPHYSIS

EXT.OBL.

A.S.I.S.

EXT. INGUINAL RING

A.S.I.S.

L.F.C.N.

PSOAS

EXT.OBL.

EXT.OBL.

CONJOINT TENDON

INTACT ILIUM

R.C. 00.03.10

Limitations: Kocher-Langenbeck

Superior Acetabular Region Anterior Column

Fractures High in Greater Sciatic Notch

Extended Iliofemoral Approach

“T” Type Fractures

Trans-tectal Transverse Fractures

Delayed Reconstruction

Extended Iliofemoral Approach

R.H. 98.11.21

R.H. 98.11.21

R.H. 98.11.22

R.H. 98.11.22

Anterior Column / Posterior Hemitransverse Acetabular

Fractures

Anterior Column / Posterior Hemitransverse

Anterior Wall or Column

Posterior Half of Transverse Fracture

ANTERIOR COLUMN FRACTURES

ANTERIOR WALL FRACTURE

Jeff Mast, M.D.

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.24

R.M. 99.02.17

R.M. 99.02.17

R.M. 99.02.17

H.S. 99.10.02

H.S. 99.10.02

NO SPUR SIGN

H.S. 00.04.12

H.S. 00.04.12

H.S. 00.04.12

SPECIAL CASE:Pipkin IV addressed through Ganz Trochanteric Flip Osteotomy with

Surgical Dislocation

CONCLUSIONS

Good Understanding of the Fracture Know the Anatomy

Optimize One Surgical Approach

THANK YOU

Acknowledgment

Return to Pelvis Index

E-mail OTA about Questions/Comments

If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org