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V06 orif acetabulum

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pelvis and hip

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V06 orif acetabulum

  1. 1. Acetabular Fractures: Surgical Management Philip J. Kregor, MD Orthopedic Traumatology University of Mississippi Med Center Jackson, Mississippi Created March 2004; Reviewed January 2007
  2. 2. Objectives • Goal of Operative Management • Specific Approaches for Specific Fractures • Indications for Kocher-Langenbeck Approach • Indications for Ilioinguinal Approach • Reduction Strategies
  3. 3. Letournel School • Thorough Understanding of Plain Films • Optimize One Surgical Approach • Goal of Perfect Concentric Reduction
  4. 4. GOAL: Anatomic Reduction
  5. 5. EXCELLENT GOOD FAIR POOR
  6. 6. Timing of Surgery: Criteria • Well - resuscitated patient • Appropriate radiological work-up • Appropriate understanding of fracture • Appropriate operative team
  7. 7. Matta 1996 Timing of Surgery and Anatomical Reductions • 0-7 Days 74% • 8-14 Days 71% • 15-21 Days 57%
  8. 8. Surgical Emergencies: Rare • Open Acetabular Fracture • New-Onset Sciatic Nerve Palsy after closed reduction of Hip dislocation
  9. 9. Surgical Urgencies: Infrequent • Irreducible Posterior Hip Dislocation • Medial Dislocation of Femoral Head against cancellous bone surface of intact Ilium
  10. 10. Matta 1996 NOT Predictive of CLINICAL OUTCOME • Type of fracture pattern • Posterior dislocation • Initial displacement • Presence of intra-articular fragments • Presence of acetabular impaction
  11. 11. Matta 1996 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
  12. 12. Approaches to the Acetabulum • Posterior: Kocher - Langenbeck • Anterior: Ilioinguinal • Extensile: Extended Iliofemoral
  13. 13. Letournel Classification • Anterior Wall • Anterior Column • Posterior Wall • Posterior Column • Transverse
  14. 14. Letournel Classification • Posterior Column / Posterior Wall • Transverse / Posterior Wall • “T-type” • Anterior Column / Posterior Hemitransverse • Both Column
  15. 15. Kocher-Langenbeck Approach • Langenbeck (1874): Superior Limb • Kocher (1904): Inferior Limb • Judet and Lagrange (1958) • Letournel
  16. 16. 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
  17. 17. Access: Kocher-Langenbeck • Entire Posterior Column • Greater and Lesser Sciatic Notches • Ischial Spine • Retro-Acetabular Surface • Ischial Tuberosity • Ischio-Pubic Ramus
  18. 18. Complications with KL • Sciatic Nerve Palsy 10% • Infection 3%
  19. 19. Limitations: Kocher-Langenbeck • Superior Acetabular Region • Anterior Column • Fractures High in Greater Sciatic Notch
  20. 20. Prone Position • Aids in Reduction of Ischiopubic Segment • Facilitates Palpation of Quadrilateral Surface • Allows Clamp Placement through Greater Sciatic Notch • Easier Prep and Drape
  21. 21. Judet Table
  22. 22. Posterior Wall Fractures
  23. 23. 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
  24. 24. Controlled Distraction of Hip Joint • Femoral Distractor • Traction Table
  25. 25. Posterior Wall Fx 63 Y.O. Male
  26. 26. L.W. 00.09.23
  27. 27. L.W. 00.09.23
  28. 28. L.W. 00.09.23
  29. 29. L.W. 00.09.23
  30. 30. L.W. 00.10.25
  31. 31. L.W. 00.10.25
  32. 32. L.W. 00.10.25
  33. 33. Special Case: Extended Posterior Wall ??? Ganz Trochanteric Flip Osteotomy to Visualize Fracture without Devitalizing Abductors
  34. 34. T.D. 00.02.01
  35. 35. T.D. 00.02.01
  36. 36. T.D. 00.02.01
  37. 37. T.D. 00.02.01
  38. 38. T.D. 00.02.17
  39. 39. T.D. 00.02.08
  40. 40. Reduction Aids: Kocher- Langenbeck Approach • Distal Femoral Traction • Distraction of Hip Joint • Ischial Tuberosity Schantz Pin • Quadrangular Clamp through Greater Sciatic Notch • Farabeuf Clamp
  41. 41. FAERBEUF CLAMPS
  42. 42. M.M. 98.10.27
  43. 43. M.M 98.10.29
  44. 44. M.M. 98.11.04
  45. 45. M.M. 98.11.05
  46. 46. M.M. 98.11.05
  47. 47. Letournel 1993 Optimal Screw Placement
  48. 48. Transtectal Tranverse Acetabular Fx 18 Y.O. Male Isolated Injury Skinny Patient / Treated Early
  49. 49. W.M. 99.11.27
  50. 50. W.M. 99.11.27
  51. 51. W.M. 99.11.27
  52. 52. W.M. 99.11.27
  53. 53. W.M. 00.01.12
  54. 54. W.M. 00.01.12
  55. 55. W.M. 00.01.12
  56. 56. Ilioinguinal Approach: Indications • Anterior Wall • Anterior Column • Transverse with significant Anterior Displacement • Anterior Column / Posterior Hemitransverse • Both Column
  57. 57. Ilioinguinal Approach: Access
  58. 58. II Complications • Direct Hernia 1% • Significant LFC nerve numbness 23% • External iliac artery thrombosis 1%
  59. 59. II Complications • Hematoma 5% • Infection 2%
  60. 60. Ilioinguinal Approach
  61. 61. Anterior Column Fx Isolated Injury 73 Y.O. Male
  62. 62. J.W. 00.10.14
  63. 63. J.W. 00.10.14
  64. 64. J.W. 00.10.14
  65. 65. Reduction of Anterior Column to Intact Ilium Clamp Placement Lag Screw Placement
  66. 66. J.W. 00.10.19
  67. 67. J.W. 00.11.02
  68. 68. J.W. 00.10.19
  69. 69. Anterior Column / Posterior Hemitransverse Anterior Wall or Column Posterior Half of Transverse Fracture
  70. 70. Anterior Column Fractures
  71. 71. Anterior Wall Fracture
  72. 72. Jeff Mast, M.D.
  73. 73. R.M. 98.08.15
  74. 74. R.M. 98.08.15
  75. 75. R.M. 98.08.15
  76. 76. R.M. 98.08.15
  77. 77. R.M. 98.08.15
  78. 78. R.M. 98.08.15
  79. 79. R.M. 98.08.15
  80. 80. R.M. 98.08.24
  81. 81. R.H. 98.11.22
  82. 82. R.M. 99.02.17
  83. 83. R.M. 99.02.17
  84. 84. R.M. 99.02.17
  85. 85. Both Column Acetabular Fracture 18 Y.O. Female Isolated Injury
  86. 86. R.C. 00.03.09
  87. 87. R.C. 00.03.09
  88. 88. R.C. 00.03.09 SPUR SIGN
  89. 89. R.C. 00.03.09
  90. 90. R.C. 00.03.09
  91. 91. A.S.I.S. SYMPHYSIS
  92. 92. EXT. OBL. A.S.I.S. EXT. INGUINAL RING
  93. 93. A.S.I.S. L.F.C.N. PSOAS EXT . OB L. EXT. OBL. CONJOINT TENDON
  94. 94. Completion of Iliac Fracture
  95. 95. Reduction of Anterior Column to Intact Ilium
  96. 96. Reduction of Posterior Column
  97. 97. INTACT ILIUM
  98. 98. R.C. 00.03.10
  99. 99. Extended Iliofemoral Approach • “T” Type Fractures • Trans-tectal Transverse Fractures • Delayed Reconstruction
  100. 100. EIF Complications • Sciatic nerve palsy 1% • Hematoma 8% • Infection 1%
  101. 101. Extended Iliofemoral Approach
  102. 102. R.H. 98.11.21
  103. 103. R.H. 98.11.21
  104. 104. R.H. 98.11.22
  105. 105. Special Case “T-Type” Acetabular Fracture Proximal Femur Fracture 14 y.o. Male Sequential K-L / Ilioinguinal Approaches
  106. 106. P.J. 00.12.16
  107. 107. P.J. 00.12.16
  108. 108. P.J. 00.12.16
  109. 109. P.J. 00.12.16
  110. 110. Initial Kocher-Langenbeck Approach
  111. 111. P.J. 00.12.18
  112. 112. P.J. 00.12.18
  113. 113. Subsequent Ilioinguinal Approach
  114. 114. P.J. 00.12.22
  115. 115. 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
  116. 116. Assessment of Reduction • Restoration of Pelvic Lines • Concentric Reduction on all 3 Views • Goal of Anatomic Reduction
  117. 117. 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
  118. 118. Letournel 1993 Complications: Long-term • 0.7 % Nonunion • 1% Cartilage Necrosis • 3.1% Avascular Necrosis • Osteoarthritis – 10.2 % after perfect reduction – 35.7 % after imperfect reduction
  119. 119. Letournel 1993 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.”
  120. 120. 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
  121. 121. 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.”
  122. 122. Significant HO (0 , 90° Hip Flexion) • KL 8% • II 2% • EIF 20%
  123. 123. Prophylaxis for HO • Indomethacin • 700 cGy radiation • Combination
  124. 124. DVT Prophylaxis • Controversial • Mechanical devices • Pharmacologic (I.e. LMWH)
  125. 125. Conclusions • Good Understanding of the Fracture • Know the Anatomy • Optimize One Surgical Approach • Goal of Perfect Reduction
  126. 126. THANK YOU 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

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