26. acetabular fractures treatment - muhammad abdelghani

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Part 2 of a lecture about acetabular fractures by Muhammad Abdelghani

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26. acetabular fractures treatment - muhammad abdelghani

  1. 1. Acetabular FracturesAcetabular Fractures TreatmentTreatment Muhammad Abdelghani
  2. 2. Goal of Treatment  The goal of treatment is anatomic restoration of the articular surface to prevent posttraumatic arthritis.
  3. 3. Initial Management The patient is usually placed in skeletal traction to 1. allow for initial soft tissue healing, 2. allow associated injuries to be addressed, 3. maintain limb length, & 4. maintain femoral head reduction within the acetabulum.
  4. 4. Non-operative treatment Indications:  Displacement <5mm in the dome, or articular step-off of <2mm (with maintanance of femoral head congruency out of traction, & absence of intraarticular osseous fragments). N.B. If a fracture is displaced <2mm, no matter what the anatomical type, nonoperative treatment should yield good results.  Distal anterior column or transverse (infratectal) fractures in which femoral head congruency is maintained by the remaining medial buttress.  Maintenance of medial, anterior and posterior roof arcs >45° (indicating fracture stability).
  5. 5. Roof arcs  The medial, anterior, & posterior roof arcs are measured on AP, obturator oblique, and iliac oblique views, respectively.  The roof arc is formed by the angle between two lines, one drawn vertically through the geometric center of the acetabulum, the other from the fracture line to the geometric center.  Roof arc angles are of limited utility for evaluation of both column fractures and posterior wall fractures.
  6. 6. Roof Arc Angles  1. Medial Roof Arc (AP pelvis)  2. Anterior Roof Arc (Obturator oblique)  3. Posterior Roof Arc (Iliac oblique)
  7. 7. Roof arc measurement
  8. 8. Operative treatment Indications  Head unstable and/or incongruous  Guidelines to be correlated to patient factors.
  9. 9. Instability  Hip dislocation associated with:  Posterior wall or column fractures (posterior instability)  Major anterior wall fractures (anterior instability)  Any fracture with significant size quadrilateral plate fracture (Central instability)
  10. 10. Incongruity  Alteration or inconsistency in relationship between femoral head & acetabulum.  Incongruity of the hip may result in early degenerative changes & posttraumatic osteoarthritis.  Evaluation:  Roof arc angle of Matta  Roof arc measurement by CT.
  11. 11.
  12. 12. Incongruity  Displaced dome fractures:  surgery is usually necessary to restore the weight-bearing surface.  High transverse or T-type fractures  These are shearing injuries that are grossly unstable when they involve the superior, weight-bearing dome.  Displaced both-column fractures (floating acetabulum): Surgery is indicated for restoration of congruence if the roof fragment is displaced and secondary congruence cannot be obtained or if the posterior column is grossly displaced.  Retained osseous fragments may result in incongruity or an inability to maintain concentric reduction of the femoral head..  Femoral head fractures generally require ORIF to maintain sphericity and congruity.  Soft tissue interposition may necessitate operative removal of the interposed tissues.  Fractures through the roof or dome
  13. 13. Assessment of reduction Assessment of reduction includes:  Restoration of pelvic lines.  Concentric reduction on all 3 views.  The goal of anatomic reduction.
  14. 14. Operative treatment Contraindications Operative contraindications  local or systemic infection,  severe osteoporosis Relative contraindications  advanced age,  associated medical conditions  associated soft tissue and visceral injuries,  multiply injured patient not stable for a big acetabular surgery
  15. 15. Operative treatment Timing  Surgery should be performed within 2 weeks of injury.  It requires  A well-resuscitated patient.  Appropriate radiologic workup.  Appropriate understanding of the fracture pattern.  Appropriate operative team.
  16. 16. Operative treatment Timing  Surgical emergencies include:  Open acetabular fracture.  New-onset sciatic nerve palsy after closed reduction of hip dislocation.  Irreducible posterior hip dislocation.  Medial dislocation of femoral head against cancellous bone surface of intact ilium.
  17. 17. Morel–Lavallé lesion (Skin Degloving Injury(  A closed degloving injury over the greater trochanter.  Results from the blunt trauma that caused the fracture.  The subcutaneous tissue is torn away from the underlying fascia, and a significant cavity results  Cavity contains hematoma and liquified fat.  These areas must be drained and debrided before or during definitive fracture surgery to decrease the chance of infection.  Advisable to leave this area open through the surgical incision or a separate incision.  Dressing changes and wound packing are sometimes needed for a prolonged period of time.  Primary excision of the necrotic fat and closure over a drain has not been routinely successful.
  18. 18. Surgical Approaches  Kocher-Langenbeck (Posterior): best access to posterior column (prone)  ilioinguinal (Anterior): best access to anterior column and inner aspect of innominate bone (supine)  Extended iliofemoral (Lateral): best simultaneous access to the two columns (lateral) Combined approaches performed concurrently or successively is less desirable No single approach provides ideal exposure of all fracture types. Proper preoperative classification of the fracture configuration is essential to selecting the best surgical approach.
  19. 19. Kocher-Langenbeck Approach
  20. 20. Kocher-Langenbeck Approach Anatomische Skizze der Weichteilstrukturen bei Kocher-Langenbeck- Zugang 1 M. glutaeus maximus 2 M. glutaeus medius 3 M. glutaeus minimus 4 M. piriformis 5 M. gemellus Superior 6 M. obturatorius internus 7 M. gemellus inferior 8 M. quadratus femoris 9 Lig. Sacrotuberale 10, N.,A.,V., glutea inferior 11 N.,A.,V., glutea superior
  21. 21. Kocher-Langenbeck Approach Indications  Posterior wall fractures  Posterior column fractures  Posterior column/posterior wall fractures  Juxtatectal/infratectal transverse or transverse with posterior wall fractures  Some T-type fractures
  22. 22. Areas accessible by Kocher- Langenbeck approach • Entire posterior column •Greater & lesser sciatic notches •Ischial spine •Retroacetabular surface •Ischial tuberosity •Ischiopubic ramus
  23. 23. The room is set up such that the x-rays and CT scans are available for viewing during the procedure. The patient is prone on a radiolucent table with SCD’s in place.
  24. 24. The affected extremity is positioned with a distal femoral pin to allow for traction on the table with the hip in slight extension and the knee flexed to relax the sciatic nerve.
  25. 25. The incision is midline over the femur, and angles posteriorly at the posterior aspect of the greater trochanter to end slightly superior to the posterior iliac spine.
  26. 26. The incision is midline over the femur, and angles posteriorly at the posterior aspect of the greater trochanter to end slightly superior to the posterior iliac spine. GREATER TROCHANTER
  27. 27. The skin incision is brought down to the level of the tensor fascia lata, which is divided in line with the incision. The gluteus maximus fascia is then divided. GLUTEUS FASCIA TENSOR FASCIA LATA
  28. 28. The gluteus maximus muscle is identified. GLUTEUS MAXIMUS
  29. 29. The maximus muscle is gently separated digitally until the first traversing branches of the nerve are visible.
  30. 30. GLUTEAL NERVE BRANCH Dividing the gluteus maximus too far proximally will denervate a significant portion of it.
  31. 31. GLUTEUS MAXIMUS TROCHANTERIC BURSA The trochanteric bursa is divided.
  32. 32. QUADRATUS FEMORIS View of the deep musculature with the Charnley retractor in place. VASTUS LATERALIS GLUTEUS MEDIUS SHORT EXTERNAL ROTATORS
  33. 33. With gentle retraction anteriorly of the gluteus medius, the piriformis tendon comes into view. PIRIFORMIS GLUTEUS MEDIUS
  34. 34. OBTURATOR INTERNIS PIRIFORMIS After minimal dissection along the posterior aspect of the short external rotators the obturator internis tendon is identified between the gamelli.
  35. 35. TAG SUTURES Both the piriformis and obturator internis are tagged and resected approximately 1cm away from their insertion in the femur. It is helpful before this is performed to identify the sciatic nerve in an area of healthy tissue, usually at the level of the quadratus femorus.
  36. 36. The piriformis and obturator internis are being gently elevated using the sutures. OBTURATOR INTERNIS PIRIFORMIS
  37. 37. With the piriformis being held back digitally, the sciatic nerve is visualized running posterior to the obturator internis tendon. OBTURATOR INTERNIS SCIATIC NERVE
  38. 38. Knowing that the nerve is safe and can be protected by the obturator internis muscle, a Letournel retractor, or blunt cobra, is placed anteriorly to the obturator internus tendon into the lesser sciatic notch.
  39. 39. Knowing that the nerve is safe and can be protected by the obturator internis muscle, a Letournel retractor, or blunt cobra, is placed anteriorly to the obturator internus tendon into the lesser sciatic notch. BLUNT COBRA RETRACTOR OBTURATOR INTERNIS SCIATIC NERVE
  40. 40. Once in the lesser sciatic notch, posterior leverage on the retractor allows exposure of the posterior aspect of the acetabulum while protecting the nerve. BLUNT COBRA RETRACTOR OBTURATOR INTERNIS SCIATIC NERVE
  41. 41. POSTERIOR ACETABULUM
  42. 42. FEMORAL HEAD DISPLACED POSTERIOR WALL The femoral head and displaced portion of the posterior wall are easily identified.
  43. 43. After the fracture and fracture bed are cleaned, the posterior wall is reduced and fixed in place with a buttress plate.
  44. 44. After the fracture and fracture bed are cleaned, the posterior wall is reduced and fixed in place with a buttress plate. REDUCED FRACTURE
  45. 45. Ilioinguinal approach
  46. 46. Ilioinguinal Approach Weichteilstrukturen bei ilioinguinalem Zugang 1 M. psoas major 2 M. iliacus 3 Pecten ossis pubis 4 A. iliaca communis 5 A. iliaca interna 6 A. iliaca externa 7 Aa. Vv. Testiculares 8 V. iliaca communis 9 V. iliaca externa 10 N. ilioinguinalis 11 N. genitofemoralis 12 N. obturatorius 13 N. femoralis 14 N. cutaneus femoris lateralis 15 Ductus spermaticus 16 Ductus deferens
  47. 47. Ilioinguinal Approach Indications  Anterior wall  Anterior column  Transverse with significant anterior displacement  Anterior column/posterior hemitransverse  Both-column
  48. 48. Setup: The patient is supine on a radiolucent table with skeletal traction holding the affected extremity in slight flexion. A perineal post is used to allow for traction if needed.
  49. 49. Figure 6 Figure 7
  50. 50. ASIS SYMPHYSIS ASIS A The incision is drawn out. Figure A shows the location of the incision with respect to the symphysis and ASIS. Figure B shows the patient from the side as one would observe during surgery. The incision is curvilinear towards the posterior aspect of the ilium. The surgery begins by approaching the iliac crest along the area shown in figure B. B
  51. 51. ASIS SYMPHYSIS ASIS Figure 6 Figure 7 The incision is drawn out. Figure A shows the location of the incision with respect to the symphysis and ASIS. Figure B shows the patient from the side as one would observe during surgery. The incision is curvilinear towards the posterior aspect of the ilium. The surgery begins by approaching the iliac crest along the area shown in figure B.
  52. 52. Sharp retractors are used to identify the interval between the abductor and abdominal musculature.
  53. 53. The iliac crest is indicated by purple lines. The interval between the abdominal and abductor musculature occurs towards the posterior aspect of the iliac crest as the abdominal musculature hangs over the crest (dotted line)
  54. 54. The interval is taken with a Bovie down to the iliac crest and the abdominal musculature is reflected anteriorly.
  55. 55. Closeup of previous image.
  56. 56. After the iliacus is released from the inside of the ilium a large key elevator is used to elevate subperiosteally to the SI joint. ILIUM ILIACUS
  57. 57. After this dissection is complete, the posterior aspect of the iliac fossa is packed off with a lap and attention to brought to the anterior portion of the incision.
  58. 58. Gelpi retractors are used to retract the skin and soft tissue after the external oblique fascia is identified. EXTERNAL OBLIQUE FASCIA
  59. 59. The external oblique fascia is divided in line with the incision and the fascia is reflected distally. EXTERNAL OBLIQUE FASCIA
  60. 60. VAS DEFERENS, SPERMATIC CORD, + ILIOINGUINAL NERVE EXTERNAL OBLIQUE FASCIA INGUINAL LIGAMENT EXTERNAL OBLIQUE FASCIA After this is performed, the vas deferens, spermatic cord, and ilioinguinal nerve are identified and protected with a Penrose drain. Allis clamps are used to retract the the external oblique fascia.
  61. 61. VAS DEFERENS SPERMATIC CORD ILIOINGUINAL NERVE EXTERNAL OBLIQUE FASCIA INGUINAL LIGAMENT EXTERNAL OBLIQUE FASCIA It is helpful to include some subcutaneous tissue in the clamps to protect the external oblique fascia from tearing. This exposes the inguinal ligament, which is a reflection of the external oblique fascia.
  62. 62. An incision is made in the inguinal ligament, allowing 1 to 2mm of the ligament to reflect medially with the musculature (dotted line).
  63. 63. Incision through the inguinal ligament.
  64. 64. ASIS LATERAL FEMORAL CUTANEOUS NERVE
  65. 65. ASIS LATERAL FEMORAL CUTANEOUS NERVE As the dissection extends toward the ASIS, one needs to identify the lateral femoral cutaneous nerve, which is immediately under the inguinal ligament.
  66. 66. ASIS LATERAL FEMORAL CUTANEOUS NERVE The nerve is typically located approximately 1cm medial to the ASIS but is variable and may be more than one branch.
  67. 67. ASIS PSOAS FEMORAL NERVE ILIOPECTINEAL FASCIA EXTERNAL ILIAC VESSELS
  68. 68. ASIS PSOAS FEMORAL NERVE ILIOPECTINEAL FASCIA EXTERNAL ILIAC VESSELS At this point, the identification of the iliopectineal fascia is performed, allowing for retraction of the exteral iliac vessels and lymphatics medially.
  69. 69. ASIS PSOAS FEMORAL NERVE ILIOPECTINEAL FASCIA EXTERNAL ILIAC VESSELS The psoas muscle and femoral nerve are retractedlaterally. The army- navy retractor protects the vasculature while the Allis clamp is holding the iliopectineal fascia.
  70. 70. TRUE PELVIS ILIOPSOAS MUSCLE FEMORAL NERVE ILIOPECTINEAL FASCIA Closeup of previous image.
  71. 71. PSOAS FEMORAL NERVE Closeup of the iliopectineal fascia demonstrating the psoas and femoral nerve on the lateral side of the fascia in the false pelvis. The true pelvis is located medial to the iliopecineal fascia over the pelvic brim.
  72. 72. PSOAS FEMORAL NERVE Once the iliopectineal fascia is excised, access to the true pelvis is obtained. The medial window of the approach is utilized when buttress plating to the symphyseal body or symphyseal fixation is necessary.
  73. 73. PSOAS FEMORAL NERVE In this case, the reduction and fixation was performed through only the lateral and middle windows.
  74. 74. LATERAL FEMORAL CUTANEOUS NERVE ILIAC FRACTURE View from the opposite side of the table demonstrating the lateral window and iliac wing fracture.
  75. 75. PSOAS LATERAL FEMORAL CUTANEOUS NERVE VESSELS PELVIC BRIM View of the middle window demonstrating the pelvic brim.
  76. 76. PSOAS LATERAL FEMORAL CUTANEOUS NERVE VESSELS PELVIC BRIM View of the middle window demonstrating the pelvic brim.
  77. 77. The following sequence will demonstrate the view from the surgeon’s side of the table.
  78. 78. SI JOINT ILIOPSOAS This figure demonstrates the lateral window and exposure of the anterior column from the iliac crest and SI joint proximally to the psoas gutter and pelvic brim distally.
  79. 79. PELVIC BRIM PSOAS VESSELS This figure demonstrates the pelvic brim and displacement of the fracture as seen through the middle window.
  80. 80. PELVIC BRIM PSOAS VESSELS This figure demonstrates the pelvic brim and displacement of the fracture as seen through the middle window.
  81. 81. SUPERIOR RAMUS FRAGMENT DISPLACED ANTERIOR COLUMN Closeup of the fracture.
  82. 82. SUPERIOR RAMUS FRAGMENT DISPLACED ANTERIOR COLUMN Closeup of the fracture.
  83. 83. Extended iliofemoral approach
  84. 84. Extended Iliofemoral Approach Operationssitus bei erweitertem iliofemoralen Zugang 1 M. gemellus superior 2 M. obturatorius internus 3 M. gemellus inferior 4 M. piriformis 5 M. quadratus femoris 6 Sehne des M. obturatorius externus 7 Tuber ischiadicum 8 A. circumflexa femoris medialis, tiefer Abzweig 9 N. ischiadicus
  85. 85. Extended iliofemoral approach Indications  Transtectal transverse + posterior wall or T- shaped fractures  Transverse fractures with extended posterior wall  T-shaped fractures with wide separations of the vertical stem of the ‘T’ or those with‌ associated pubic symphysis dislocations  Certain associated both column fractures  Associated fracture patterns or transverse fractures operated on >21 days following injury
  86. 86. Extended iliofemoral approach Extended iliofemoral approach has the highest incidence of ectopic bone formation (HO) and longest postoperative recovery
  87. 87. Other approaches  Stoppa approach (supine): Allows access to the medial wall of acetabulum, quadrilateral surface, & sacroiliac joint  Triradiate approach (prone): Alternate exposure to the external aspect of innominate bone, with almost same exposure as iliofemoral but visualization of the posterior part of ilium is not as good
  88. 88. Reduction Techniques Special instruments.  Essential instruments include pointed fracture forceps, reduction clamps, fracture pushers, and other standard fracture clamps.  Special pelvic reduction clamps are extremely helpful. The pelvic reduction clamp is screwed directly to the bone using two 4.5-mm cortical screws or 6.5-mm cancellous screws. This clamp can be extremely helpful by applying direct forces to the fracture.
  89. 89. Reduction Techniques Traction.  Traction on the femoral head is essential in obtaining a reduction.  Traction may be obtained by the use of a traction table, which must be adaptable, allowing the prone as well as the supine position.  An unscrubbed surgeon or technician is needed to control the leg rotation.
  90. 90. Helpful Hints for Reduction  The articular surface of the joint must be adequately visualized by a wide capsulorrhaphy in most cases.
  91. 91. Helpful Hints for Reduction  Most patients can be managed without a traction table, but direct traction on the femoral head is essential. This can be obtained by:  a corkscrew in the femoral neck to allow better retraction of the femoral head and visualization of the articular surface.  A sharp hook over the greater tuberosity can give the same effect.
  92. 92. Helpful Hints for Reduction  A 5- or 6-mm Schantz pin with a T-handle should be inserted into the ischial tuberosity in high transverse or T-type fractures to allow rotation of the posterior column, which in some instances cannot be reduced by any other method.
  93. 93. Helpful Hints for Reduction  Holes should be drilled to accept the pointed forceps.
  94. 94. Helpful Hints for Reduction  Washers with extensions have been developed for use with the pointed forceps.
  95. 95. Helpful Hints for Reduction  Work within the fracture.  In visualizing impacted fragments from either an anterior or posterior approach, it is important to move the major fracture out of the way so that the impacted fragment can be visualized.  This is akin to the tibial plateau fracture where the lateral fragment is retracted like a book to allow reduction of the impacted fragment.  Therefore, work within the fracture where possible.  Marginally impacted fractures must be reduced in this way.
  96. 96. Cerclage wires  Cerclage wires inserted through the greater sciatic notch and around the anterior inferior iliac spine may greatly facilitate derotation & reduction of the columns, esp. if either the posterior or anterior column is “high” on the greater sciatic notch
  97. 97. Implants Screws – 6.5-mm cancellous lag screws – 4.0-mm cancellous lag screws and 3.5 mm cortical screws (lengths up to 120 mm) – 6.5-mm fully threaded cancellous screws  For fixation of the plate to bone, fully threaded cancellous screws are desirable, the 6.5-mm screw for the large reconstruction plate (4.5-mm) and the 3.5-screw for the 3.5-mm reconstruction plate.  Cannulated screws may also be helpful.
  98. 98. Implants Plates  A 3.5-mm reconstruction plate is the implant of choice for acetabular reconstruction.  These plates can be molded in two planes and around the difficult areas such as the ischial tuberosity.  Also, precurved 3.5-mm plates are available for anterior column fixation.  These plates are fixed with the 3.5-mm cancellous screws.  In large individuals, and in pelvic fixation, the 4.5-mm reconstruction plates are also useful, with fixation by the 6.5-mm fully threaded cancellous screws; however, they are rarely used at this time. The 3.5-mm and 4.5 mm reconstruction plates for pelvic fixation
  99. 99. Plates Sites of Application  The plates may be applied to the anterior column from the inner table of the ilium to the symphysis pubis.  Plates may also be applied to the posterior column and the superior aspect of the acetabulum.  The distal screw should be anchored in the ischial tuberosity.  Great care should be taken to ensure that screws in the central portion of the plate do not penetrate the articular cartilage of the acetabulum.  In most instances, no screws should be put into that danger area, but if screws are necessary for stable fixation, they should be directed away from the joint. Screws within the joint are a not uncommon cause of chondrolysis.  Plates may be nested to buttress small fragments.
  100. 100. Internal fixation  Stable fixation is best achieved by interfragmental compression using lag screws.  After provisional fixation of all fractures with K-wires, or cerclage wires, screw fixation of the fractures is essential. The joint must be visualized at all times to ensure that anatomical reduction has been achieved and that no screw penetrates the articular cartilage.  After fixation by interfragmental lag screws, plates may be used to neutralize the fracture.  Plates may be placed either on the anterior or posterior column, depending on the approach.
  101. 101. Internal fixation  Adequate contouring of the plates is essential. Otherwise, displacement of the opposite column may occur.
  102. 102. Postoperative Care  Indomethacin or irradiation: for heterotopic ossification prophylaxis.  A variety of treatments has been proposed to decrease the amount of heterotopic bone including the use of diphosphonates, radiation and indomethacin.  Diphosphonates prevent the mineralisation of osteoid, but this begins again after withdrawal of the drug, and their use has been questioned.  There have been several reports of the use of indomethacin after operation for acetabular fractures.  Local radiation therapy has also been used after reports of successful results in hip arthroplasty.  Chemical prophylaxis, sequential compression devices, and compressive stockings for thromboembolic prophylaxis.  Mobilization out of bed is indicated as associated injuries allow.  Full weight bearing on the affected extremity should be withheld until radiographic signs of union are present (generally by 8-12 weeks postoperatively).
  103. 103. Complications  Surgical wound infection: Risk is increased secondary to the presence of associated abdominal and pelvic visceral injuries.  Nerve injury  Sciatic nerve: Kocher-Langenbach approach with prolonged or forceful traction.  Femoral nerve: Ilioinguinal approach may result in traction injury to femoral nerve. Rarely, the nerve may be lacerated by an anterior column fracture.  Superior gluteal nerve: most vulnerable in the greater sciatic notch. Injury during trauma or surgery may result in paralysis of hip abductors with severe disability.  Heterotopic ossification: Incidence is highest with extended iliofemoral approach and second highest with Kocher-Langenbach. The highest risk is a young male patient undergoing a posterolateral extensile approach in which muscle is removed.  Avascular necrosis: This devastating complication occurs mostly with posterior types associated with high-energy injuries.  Chondrolysis: This may occur with or without surgical intervention, resulting in posttraumatic osteoarthritis. Concentric reduction with restoration of articular congruity may minimize this complication.  Thromboembolic complications
  104. 104. Case Study
  105. 105. Case Study  An 18-year-old woman was inadvertently struck on the lateral aspect of the hip by a police officer while marching in a homecoming parade.
  106. 106. Case Study Obturator oblique view Iliac oblique view AP, obturator oblique, and iliac oblique views show a both-column acetabular fracture The obturator oblique view shows the pathognomonic "spur-sign." Note that the spur represents the iliac wing fragment, or the constant fragment, and the entire acetabulum has been medialized. None of the dome of the acetabulum remains attached to the iliac wing.
  107. 107. Case Study Two- and three-dimensional CT scans show an ipsilateral disruption of sacroiliac joint and extreme comminution through the dome of the acetabulum.
  108. 108. Case Study Two- and three-dimensional CT scans show an ipsilateral disruption of sacroiliac joint and extreme comminution through the dome of the acetabulum. This patient also had disruption of the pubic symphysis, creating an ipsilateral unstable hemipelvis with a both-column acetabular fracture.
  109. 109. Case Study Final Reconstruction
  110. 110. Case Study  Postoperative radiographs showing anatomic reduction of the hemipelvis along with anatomic reduction of the acetabular fracture.  In high-energy trauma injuries such as this, stability of the hemipelvis must be obtained first, by stabilizing the anterior and posterior aspects of the pelvis, after which the acetabular fracture is addressed.  Anatomic alignment of the pelvic inlet and outlet should also be regained before the articular component of the injury (acetabular fracture) is addressed.
  111. 111. MCQ 1  Which two quadrants of the acetabulum are most at risk for injury by screws during fixation of total hip arthroplasty (THA): a) Anterior-inferior and posterior-superior b) Anterior-superior and posterior-superior c) Anterior-superior and anterior-inferior d) Anterior-superior and posterior-inferior e) Posterior-superior and posterior inferior
  112. 112. Answer 1  Which two quadrants of the acetabulum are most at risk for injury by screws during fixation of total hip arthroplasty (THA): a) Anterior-inferior and posterior-superior b) Anterior-superior and posterior-superior c) Anterior-superior and anterior-inferior d) Anterior-superior and posterior-inferior e) Posterior-superior and posterior inferior
  113. 113. Explanation  The acetabular quadrant system described by Wasielewski and colleagues is useful for determining the location of planned acetabular screw fixation in THA to avoid neurovascular complications. The quadrants are formed by drawing a line from the anterior-superior iliac spine through the center of the acetabulum and bisecting that line at the center of the acetabulum to form four equal quadrants. The line from the anterior-superior iliac spine to the center of the acetabulum serves as the dividing line between anterior and posterior, and the bisecting line as the division between superior and inferior. In cadaver studies, the posterior-superior and posterior-inferior quadrants were shown to have the thickest bone and best potential for obtaining secure fixation with the least risk for injury to vessels. The anterior-superior quadrant (the quadrant of death) and the anterior-inferior quadrant were shown to be the most dangerous quadrants for fixation due to the thin bone and close proximity of the vessels to bone in that region.
  114. 114. MCQ 2  Criteria for nonoperative management of an acetabular fracture includes all of the following except: a) Stability demonstrated by dynamic stress radiographs b) Femoral head subluxation of 3 mm c) Congruence of the femoral head with the unaffected acetabular roof on the anteroposterior and Judet views d) Roof arc measurement of greater than or equal to 45° e) Unbroken computerized tomography arc at 10 mm from subchondral bone
  115. 115. Answer 2  Criteria for nonoperative management of an acetabular fracture includes all of the following except: a) Stability demonstrated by dynamic stress radiographs b) Femoral head subluxation of 3 mm c) Congruence of the femoral head with the unaffected acetabular roof on the anteroposterior and Judet views d) Roof arc measurement of greater than or equal to 45° e) Unbroken computerized tomography arc at 10 mm from subchondral bone
  116. 116. Explanation  The outcome of nonoperative treatment of acetabular fractures depends on the stability of the hip, the concentricity of the head of the femur under the roof of the acetabulum, and the condition of the roof itself.  Nonoperative criteria include roof arc measurement of at least 45°, unbroken subchondral computerized tomography arc of 10 mm, stability of the joint on stress radiographs, and congruence off the femoral head with the unaffected acetabular roof on all three views, anteroposterior and both Judet radiographs.  Any subluxation reduces the likelihood of a good result.
  117. 117. References  Jimenez ML: Classification of Acetabular Fractures. Medscape.com  Moore KD, Goss K, Anglen JO: Indomethacin versus radiation therapy for prophylaxis against heterotopic ossification in acetabular fractures. J Bone Joint Surg [Br] 1998;80-B:259-63.  Rommens PM, Hessmann MH: Azetabulumfrakturen. Unfallchirurg 1999; 102: 591-610

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