Downloaded 144 times
More Related Content
Similar to V06 orif acetabulum
![Acetabularfracture hip fractue[1]_11[1].pptx](https://cdn.slidesharecdn.com/ss_thumbnails/acetabularfracture1111-250322022902-1fed1d8a-thumbnail.jpg?width=640&height=640&fit=bounds)
![Apporach to lung biopsy [Auto-saved].pptx latest](https://cdn.slidesharecdn.com/ss_thumbnails/apporachtolungbiopsyauto-saved-251211225655-93258539-thumbnail.jpg?width=640&height=640&fit=bounds)
V06 orif acetabulum
- 1. Acetabular Fractures: Surgical Management PhilipJ. Kregor, MD Orthopedic Traumatology University of Mississippi Med Center Jackson, Mississippi Created March 2004; Reviewed January 2007
- 2. Objectives • Goal ofOperative Management • Specific Approaches for Specific Fractures • Indications for Kocher-Langenbeck Approach • Indications for Ilioinguinal Approach • Reduction Strategies
- 3. Letournel School • ThoroughUnderstanding of Plain Films • Optimize One Surgical Approach • Goal of Perfect Concentric Reduction
- 4.
- 5.
- 6. Timing of Surgery:Criteria • Well - resuscitated patient • Appropriate radiological work-up • Appropriate understanding of fracture • Appropriate operative team
- 7. Matta 1996 Timing ofSurgery and Anatomical Reductions • 0-7 Days 74% • 8-14 Days 71% • 15-21 Days 57%
- 8. Surgical Emergencies: Rare •Open Acetabular Fracture • New-Onset Sciatic Nerve Palsy after closed reduction of Hip dislocation
- 9. Surgical Urgencies: Infrequent •Irreducible Posterior Hip Dislocation • Medial Dislocation of Femoral Head against cancellous bone surface of intact Ilium
- 10. Matta 1996 NOT Predictiveof CLINICAL OUTCOME • Type of fracture pattern • Posterior dislocation • Initial displacement • Presence of intra-articular fragments • Presence of acetabular impaction
- 11. Matta 1996 Predictive of CLINICALOUTCOME • 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. Approaches to theAcetabulum • Posterior: Kocher - Langenbeck • Anterior: Ilioinguinal • Extensile: Extended Iliofemoral
- 13. Letournel Classification • AnteriorWall • Anterior Column • Posterior Wall • Posterior Column • Transverse
- 14. Letournel Classification • PosteriorColumn / Posterior Wall • Transverse / Posterior Wall • “T-type” • Anterior Column / Posterior Hemitransverse • Both Column
- 15. Kocher-Langenbeck Approach • Langenbeck(1874): Superior Limb • Kocher (1904): Inferior Limb • Judet and Lagrange (1958) • Letournel
- 16. Indications in Acute AcetabularFxs • 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. Access: Kocher-Langenbeck • EntirePosterior Column • Greater and Lesser Sciatic Notches • Ischial Spine • Retro-Acetabular Surface • Ischial Tuberosity • Ischio-Pubic Ramus
- 19. Complications with KL •Sciatic Nerve Palsy 10% • Infection 3%
- 20. Limitations: Kocher-Langenbeck • SuperiorAcetabular Region • Anterior Column • Fractures High in Greater Sciatic Notch
- 21. Prone Position • Aidsin Reduction of Ischiopubic Segment • Facilitates Palpation of Quadrilateral Surface • Allows Clamp Placement through Greater Sciatic Notch • Easier Prep and Drape
- 22.
- 23.
- 24. Posterior Wall Fxs: SurgicalKeys • Avoid Devascularization of Fragment/s • Remove Intra-articular Fragments • Address Marginal Impaction • Provide adequate buttress • Avoid Over-Contouring of Plate
- 25. Controlled Distraction of HipJoint • Femoral Distractor • Traction Table
- 30. Posterior Wall Fx 63Y.O. Male
- 31.
- 32.
- 33.
- 34.
- 35.
- 36.
- 37.
- 38. Special Case: Extended PosteriorWall ??? Ganz Trochanteric Flip Osteotomy to Visualize Fracture without Devitalizing Abductors
- 39.
- 40.
- 41.
- 42.
- 43.
- 44.
- 45. Reduction Aids: Kocher- LangenbeckApproach • Distal Femoral Traction • Distraction of Hip Joint • Ischial Tuberosity Schantz Pin • Quadrangular Clamp through Greater Sciatic Notch • Farabeuf Clamp
- 47.
- 48.
- 49.
- 50.
- 51.
- 52.
- 53. Letournel 1993 Optimal ScrewPlacement
- 56. Transtectal Tranverse Acetabular Fx 18Y.O. Male Isolated Injury Skinny Patient / Treated Early
- 57.
- 58.
- 59.
- 60.
- 61.
- 62.
- 63.
- 64. Ilioinguinal Approach: Indications • AnteriorWall • Anterior Column • Transverse with significant Anterior Displacement • Anterior Column / Posterior Hemitransverse • Both Column
- 65.
- 66. II Complications • DirectHernia 1% • Significant LFC nerve numbness 23% • External iliac artery thrombosis 1%
- 67. II Complications • Hematoma5% • Infection 2%
- 68.
- 69. Anterior Column Fx IsolatedInjury 73 Y.O. Male
- 70.
- 71.
- 72.
- 73. Reduction of AnteriorColumn to Intact Ilium Clamp Placement Lag Screw Placement
- 74.
- 75.
- 76.
- 77. Anterior Column / PosteriorHemitransverse Anterior Wall or Column Posterior Half of Transverse Fracture
- 78.
- 79.
- 80.
- 81.
- 82.
- 83.
- 84.
- 85.
- 86.
- 87.
- 88.
- 89.
- 90.
- 91.
- 92.
- 93. Both Column Acetabular Fracture 18Y.O. Female Isolated Injury
- 94.
- 95.
- 96.
- 97.
- 98.
- 100.
- 101.
- 102.
- 108. Completion of IliacFracture
- 111. Reduction of AnteriorColumn to Intact Ilium
- 117. Reduction of PosteriorColumn
- 118.
- 123.
- 124. Extended Iliofemoral Approach •“T” Type Fractures • Trans-tectal Transverse Fractures • Delayed Reconstruction
- 125. EIF Complications • Sciaticnerve palsy 1% • Hematoma 8% • Infection 1%
- 126.
- 127.
- 128.
- 129.
- 130. Special Case “T-Type” AcetabularFracture Proximal Femur Fracture 14 y.o. Male Sequential K-L / Ilioinguinal Approaches
- 131.
- 132.
- 133.
- 134.
- 135.
- 136.
- 137.
- 138.
- 139.
- 140. 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
- 141. Assessment of Reduction •Restoration of Pelvic Lines • Concentric Reduction on all 3 Views • Goal of Anatomic Reduction
- 142. 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
- 143. 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
- 144. Letournel 1993 Avascular Necrosis “Inour 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.”
- 145. 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
- 146. Heterotopic Ossification • Classificationdoes 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.”
- 147. Significant HO (0 ,90° Hip Flexion) • KL 8% • II 2% • EIF 20%
- 148. Prophylaxis for HO •Indomethacin • 700 cGy radiation • Combination
- 149. DVT Prophylaxis • Controversial •Mechanical devices • Pharmacologic (I.e. LMWH)
- 150. Conclusions • Good Understandingof the Fracture • Know the Anatomy • Optimize One Surgical Approach • Goal of Perfect Reduction
- 151. THANK YOU Return to Pelvis Index E-mailOTA 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