Acetabulum Fracture Dr Suresh Pandey

1. Suresh Pandey
Consultant Orthopedic Surgeon
COMS

2. Plan? 28 M RTA with associated
femur and tibia ipsilateral
shaft fracture

4. Combined approach; KL and
Modified Iliofemoral

5. KL + Modified Iliofemoral approach

6. Background
 Complex area of Orthopedics
 Learning curve steep
 Low energy in elderly and high in young
 Good reduction is the most important determinant of
outcome (Matta, Leutornell, Judet)

7. Weight bearing area: Roof

9. Associated Injury

10. Neurovascular structure to be taken care of
 Ext iliac vessels
 Sciatic, femoral and
LCN
 Superior gluteal n and
vessels
 Corona Mortis

11. classification

12. Most Common
 Posterior wall, transverse and both column constitute
2/3rd

13. Imaging package

15. Roof arc measurement
 Tells fracture line exits (whether inside the dome or
outside)
 Stable if >45 deg
 Not applicable in post wall or both column fracture

16. Wall vs column vs transverse

18. Conservative

21. Operative

22. Timing of Surgery
 Ideal 5-7 days
 >3 weeks too late
 Before 2 weeks reasonable

23. Approach
Anterior
 Ilioinguinal
 Modified Stoppa
 Combined
 Iliofemoral extended
 Modification of Iliofemoral
Posterior
 Kocher Langenbeck
 Trochanteric osteotomy

24. KL Approach

25. Prone Vs lateral
 Reduction easy
 Maintain knee flexion and hip extension
 Traction table or trochanteric traction

26.  Trochanteric osteotomy: Anterior extension of fracture
in wall or column or muscular or obese patient.
 Better visualization due to lifting up of abductors

28. Modification of Iliofemoral

29. In out In technique for anterior
column
ASIS
AIIS

30. Anterior Ilioinguinal Approach

32. Division of Iliopectineal fascia and access area

34. Modified Stoppa approach

35. Access area in Modified Stoppa
approach

37. Ilioinguinal vs Modified Stoppa
 Blood loss more
 More operative time
 Increased risk of NV injury
 Less accurate reduction
 Visualization and fixation of quadrilateral plate
difficult

38. Reduction instruments

39. Reduction techniques

40. Post wall KL approach
 Avoid devascularization of
the fragment
 Remove I/A fragment if any
 Fragments with screws and
supplement with buttress
plate
 Avoid overcountering

41. Post Column KL approach
Access increased with
Troch Osteotomy
Plate or lag screw with
plate

42. Anterior wall and column
 Isolated Ant wall
uncommon
 Ant Ilioing/Iliofemoral
approach/ Modified
Stoppa or combination
 Contoured plate along
pelvic brim

43. Transverse fracture with or without
posterior wall
 Presents spectrum of
difficulty
 Transtectal have worst
prognosis
 Infratectal can be treated
conservatively
 Approach: posterior,
anterior or combined
 Screw, plates and
combinations

44. Both column fracture
 Most difficult
 T type fracture with
transv component above
the dome
 Reduction begins at
most proximal and then
towards joint
 Apporach combined

46. Combined approach with both
column fixation

47. Posterior wall fracture with
incarcerated fragment

49. KL approach

51. Bilateral transverse Fracture

52. Prognostic factors for acetabulum
 Accuracy of redn
 Age
 Soft tissue
 Injury to femoral head
 Fracture location, severity and morphology

53. Complications
 Neurovascular injury: 6%
 Infection: 4%
 DVT
 AVN: 7.5%
 Post traumatic OA: 10-35%
 HO: 14-50% without prophylaxis
 Mortality: 2.5%

54. Take home…
 Approach decided by fracture location, geometry, soft
tissue status and experience
 Prognosis depends on patient and surgeon factors
Accurate reduction (<2 mm of step) is key to success