Acetabula fractures
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Acetabula fractures

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Acetabula fractures Acetabula fractures Presentation Transcript

  • Acetabular Fractures Joshua Landau, MD David Seidman, MD 11/23/04
  • Overview  Radiographs  Classification  Treatment Options  Surgical Approaches
  • Radiographic Evaluation  From the lateral, acetabulum is inverted Y  Anterior column  Posterior column  Sciatic notch through obturator and inferior pubic ramus View slide
  • AP  6 Lines  Iliopectineal  Ilioischial  Posterior wall  Anterior wall  Dome  Teardrop View slide
  • Radiographs AP  6 Lines  Iliopectineal  Ilioischial  Posterior wall  Anterior wall  Dome  Teardrop
  • Oblique
  • Iliac Oblique  Posterior column  Anterior wall
  • Iliac Oblique  Posterior column  Anterior wall
  • Iliac Oblique  Posterior column  Anterior wall
  • Oblique
  • Obturator  Anterior column  Posterior Wall
  • Obturator Oblique
  • The Dome
  • The Dome
  • Weight Bearing Dome:Roof arc angle  Vertical line through the rotational center of acetabulum  Angled line through the fracture  Mata: <45 deg on any view  Recently:  anterior <25  Medial <45  Posterior <70  Top of the dome distally for 1 cm on CT
  • Classification: Letournel and Judet
  • Classification: Special Notes  Both column  essentially a T type occurring proximal to the joint  No portion of the articular surface is attached to axial skeleton  SPUR SIGN  Division of both columns ABOVE the acetabulum  Secondary congruence
  • AP view
  • Obturator oblique view
  • Iliac oblique view
  • Representative CT cuts of the fracture, demonstrating that approximately 50 percent of the posterior wall is affected.
  • Posterior Wall  Beware posterior hip dislocation  Sometimes completely unstable  Traction to maintain reduction until fixation  Osteochondral fx common: require fixation/reduction if in weight bearing portion
  • Biomechanics  Weight bearing portion:  Primarily posterior and superior  Hip stable  <20% of posterior wall  Hip unstable  >40% of posterior wall
  • Posterior Wall Fracture  Blood supply is from capsule: do not detach  Flip over leaving capsule if possible
  • Anterior column + posterior hemitransverse vs. T type  Reducing anterior column usually reduces posterior column, post capsule is not usually disrupted  In contrast, in the T type, reducing the anterior does not reduce the posterior and the post capsule is disrupted
  • T type
  • T type
  • T type  Must involve obturator foramen
  • Both Column
  • Both Column
  • Treatment options  Nonoperative  Traction  NWB  Indicated if displacement < 2mm  Operative  ORIF  ORIF w/ THA  Absolute indication is hip instability / subluxation out of traction
  • Operative vs. Non-op  Classic Articles  Rowe and Lowell: non-op is preferred  Judet et. al: 90% good result if anatomic reduction, 74% good result overall  Current Literature  Rowe and Lowell  2 groups of fractures  High energy forces, incongruous joint  Operative management is better  Low energy, minimal displacement  Non-op management is satisfactory
  • Surgical Considerations  Timing  Surgery should be completed within 7 d  results deteriorate after 3 weeks  Approaches  Iliofemoral  Ilioinguinal  Kocher-Langenbach  Triradiate  Extended Iliofemoral  Combined
  • Iliofemoral  Anterior column or anterior wall fractures w/ displacement cephalad to hip joint  Lag screws into anterior column  Plate only fits on crest of ilium, not on pelvic brim
  • Ilioinguinal  For anterior fractures where access to entire anterior column  Can be used for both column fx only if posterior piece is large and intact  Don’t see articular surface, only fx lines in pelvis  Commonly sacrifice lateral cutaneous nerve of the thigh  Divide external oblique from inguinal ring to asis, expose spermatic cord/round ligament  Ligate inferior epigastric vessels
  • Ilioinguinal  Complications:  Femoral nerve injury  LFCN  Thrombosis in femoral vessels
  • Ilioinguinal  Sling 1: iliopsoas  Sling 2: external iliac artery and vein (aka femoral sheath)  Sling 3: spermatic cord
  • Kocher-Langenbach  Isolated posterior wall or posterior column injuries only  Exposure limited superiorly by superior gluteal vessels and greater trochanter  High incidence of HO and sciatic injury  May consider troch osteotomy  Complications:  Sciatic nerve 2-10%  Damage to femoral head blood supply via medial femoral circumflex a.
  • Triradiate  Both column fractures  ASIS to top of sciatic notch is exposed  Expose TFL, divide TFL and G. max  Remove greater troch  Capsulorrhaphy and joint exposure
  • Extended iliofemoral  Exposes  Outer table of ilium  Superior dome  Posterior column  Anterior column to iliopubic eminence  Provides exposure to bone above sciatic notch  Highest risk for HO  Also risk for superior gluteal artery injury leading to muscle necrosis
  • Approach by fracture type  Kocher-Langenbach  Posterior column  Prone is best  Weight of leg in lateral position causes rotation of posterior column  Posterior wall  Lateral is OK  Posterior column + posterior wall  Prone is best  Anterior column + posterior hemitransverse  Ilioinguinal approach usually adequate  Transverse fxs  Depends on location of displacement  T type is most difficult
  • Approach by fracture type  Both Column  If posterior column is a single large fragment, then ilioinguinal approach is preferred  If posterior column is not reduced, then add Kocher- Langenbach  If significant posterior wall fracture, choose extensile or combined approach
  • Reduction  Traction  Fracture table  Direct pull on femoral neck  Corkscrew into femoral neck  T handled bone hook on greater troch  External distractors  5 or 6 mm Schanz threaded pin through the ischial tuberosity as joystick for T type or posterior column fxs  Farabeuf clamps on screws inserted on either side of fx
  • Reduction  Cerclage wires may help through the greater or lesser sciatic notch
  • Fixation  Interfrag lag screws  3.5 mm cortical screws, even in cancellous bone  No tap necessary except in dense bone of sciatic butress  3.5 mm recon plate contoured
  • Outcomes  THA after ORIF of acetabulum does better than THA after unreduced acetabulum fx
  • Complications  Thromboembolism: 60% of cases  HO  Use XRT or indomethacin peri/post op for prophylaxis w/ Kocher-Langenbach approach  Neurologic injury  AVN  18% of posterior fracture patterns  Post-traumatic DJD  Abductor weakness  Intra-articular hardware