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fractures of acetabulum- anatmy and orthopedic management
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Acetabular Fractures,imaging and management
Presented by : Harjot Singh GurudattaModerator : Dr. Gagan Khanna
• All three parts of the innominate bone contribute to form the acetabulum.
• o Pubis -------- anterosuperior part of the articular surface -------- 1/5th.
• o Ischium ----- posteroinferior part of nonarticular surface -------- 2/5th.
• o Ilium -------- rest of acetabulum -------- 2/5th
• corona mortis • At risk over superior pubic ramus
ANATOMY
Directed laterally, downwards and forwards. lateral inclination of 40 to 48 degrees , anteversion of 18 to 21 degrees
The margin is deficient inferiorly and this deficiency is called the acetabular notch , bridged by the transverse acetabular ligament. The nonarticular roughened floor is called the acetabular / COTYLOID fossa It contains a pad of fat lined by synovial membrane. A horse-shoe shaped articular surface or lunate surface is seen on the anterior, superior and posterior parts of the acetabulum.(ACETABULAR dome) It is lined by hyaline cartilage and articulates with the head of femur; the articular cartilage is thickest here.
Normal Anatomy: Letournel –Judet Columns and Walls
From the lateral aspect of the pelvis, the innominate osseous structural support of the acetabulum may be conceptualized as a two-
columned construct forming an inverted Y.
The anterior and posterior walls extend from each respective column and form the cup of the acetabulum.The anterior and posterior columns connect to the axial skeleton through a strut of bone called the sciatic buttress
Bony Anatomy
• Anterior Column• Anterior column
(iliopubic component): extends from iliac crest to symphysis pubis and includes the anterior wall of the acetabulum.
Bony Anatomy
• Posterior Column• Posterior column
(ilioischial component): extends from superior gluteal notch to ischial tuberosity and includes the posterior wall of the acetabulum
• When looking at the acetabulum en face, the anterior and posterior columns have the appearance of the Greek letter lambda (λ).
• The anterior column represents the longer, larger portion, which extends superiorly from the superior pubic ramus into the iliac wing. The posterior column extends superiorly from the ischiopubic ramus as the ischium toward the ilium.
• The anterior and posterior columns of bone unite to support the acetabulum.
• In turn, the sciatic buttress extends posteriorly from the anterior and posterior columns to become the articular surface of the sacroiliac joint, which attaches the columns to the axial skeleton.
• The anterior and posterior walls, which extend from the columns and support the hip joint, are well seen on an axial CT.
• The anterior and posterior walls, which extend from the columns and support the hip joint, are well seen on an axial CT.
Axial section through
acetabulum shows anterior
(arrowhead) and posterior (arrow) walls.
Acetabular dome: The superior weight-bearing portion of the acetabulum at the junction of the anterior and posterior columns, including contributions from each.
Like pelvis fractures, these injuries are mainly caused by high-energy trauma secondary to a motor vehicle, motorcycle accident, or fall from a height.
The fracture pattern depends on Position of femoral head at the time of injury, Magnitude of force, &
Age of patient.
Mechanism of injury
With indirect trauma, (e.g., a ‘dashboard’ injury to the flexed knee): As the degree of hip flexion increases, the
posterior wall is fractured in an increasingly inferior position.
Similarly, as the degree of hip flexion decreases, the superior portion of posterior wall is more likely to be involved.
Mechanism of injury•Direct impact to greater trochanter with: Hip in neutral: transverse acetabular fracture
An abducted hip: low transverse fracture, An adducted hip: high transverse fracture.
Hip externally rotated and abducted: anterior column injury. • Hip internally rotated: posterior column injury.
Clinical evaluation
• Trauma evaluation: with attention to ABCD, depending on the mechanism of injury.
• Patient factors (age, degree of trauma, presence of associated injuries, & general medical condition) affect treatment decisions as well as prognosis.
• Neurovascular assessment:• Sciatic nerve injury may be present in up to 40% of posterior
column disruptions.• Femoral nerve involvement with anterior column injury is
rare, although compromise of the femoral artery by a fractured anterior column has been described.
• Presence of associated ipsilateral injuries must be ruled out, with particular attention to the ipsilateral knee in which posterior instability and patellar fractures are common.
• Soft tissue injuries (e.g., abrasions, contusions, subcutaneous hemorrhage) may provide insight into the mechanism of injury.
IMAGING : Radiographic evaluation
• 5 Pelvic X-rays:• AP view• 2 Judet views (iliac & obturator oblique
views)• Inlet and Outlet Pelvis X-rays
• CT scan
Anatomic landmarks in AP view
• Iliopectineal line (limit of anterior column),
• Ilioischial line (limit of posterior column),
• Anterior lip, • Posterior lip,• Line depicting the
superior weight-bearing surface, terminating as the medial teardrop.
• Taken by rotating the patient into 45° of external rotation by elevating the uninjured side on a wedge.
• This best demonstrates: Posterior column (ilioischial line), *Iliac wing, border of sciatic notch * Anterior rim of
acetabulum.
Iliac oblique radiograph
(45-degree external rotation view)
• This is best for evaluating the anterior column and posterior wall of the acetabulum(iliac wing and spur sign(both colum # seen here)
• Taken by elevating the affected hip 45° to the horizontal by means of a wedge and directing the beam through the hip joint with a 15° upward tilt. beam is roughly perpendicular to the obturator foramen
Obturator oblique radiograph (45-degree internal rotation
view)
AP pelvis Iliac oblique Obturator oblique
AW—anterior wall;AC—anterior column; PC—posterior column; PW—posterior wall; OR—obturator ring.
Inlet Pelvis X-ray
• Best demonstrates ring configuration of pelvis• Evaluates for posterior displacement of pelvic ring or opening of pubic
symphysis• Patient lies supineThe central ray is directed 40° to 60° caudal and enters at
the level of the anterior superior iliac spine. This view will demonstrate the pelvic inlet in its entirety. A properly positioned inlet view of the pelvis should demonstrate the superior and inferior ramus of the pubic bones superimposed medially, near superimposition of the superior pubic ramus and ischial ramus, and symmetry of the ischial spines
Outlet Pelvis XR
The patient is placed supine on the radiographic table with the midsagittal plane aligned to the center of the grid. The central ray is directed 20° to 45° cephalic at the level 2 inches below the symphysis pubis. A properly positioned outlet view will demonstrate the superior and inferior rami of the pubis the superior and inferior rami of the pubis and the ischia, sacroiliac joint and vertical displacement
• Internal limb = outer wall of obturator canal
• External limb = middle 1/3 of cotyloid fossa
• Inferior border = ischiopubic notch
• Radiographic teardrop composed laterally of most inferior and anterior portion of acetabulum and medially of anterior flat part of quadrilateral surface of iliac bone
Teardrop
Radiographic evaluation
• CT scan• Provides additional
information regarding size & position of column fractures, impacted fractures of acetabular wall, retained bone fragments in the joint, degree of comminution, and sacroiliac joint disruption.
Three-dimensional reconstruction allows for digital subtraction of femoral head, with full delineation of the acetabular surface
Radiographic evaluation
• CT scan• Before a 3-dimensional
CT scan is ordered, the fracture patterns should be drawn on a 3-dimensional model of the pelvis to compare the 3-dimensional reconstructions and to aid Classification
• If sup glutel artery flap is planned, an angiogrphy should be done to ensure its continuity especially in post. Column #
Classification
• Accurate classification based on radiographs , CT, Associated injuries of acetabular fractures is important for determining the proper surgical treatment. Various classification system
• Judet-Letournel• Harris coupe• Comprehensive syetem of classification
Classification(Judet-Letournel)
• Because of the complex acetabular anatomy, various classification schemes have been suggested, but the Judet-Letournel classification system remains the most widely accepted.
• This classification system subdivides acetabular fractures into
• Elementary Fracture Types (posterior wall, posterior column, anterior wall, anterior column and transverse)
• Associated Fracture Types (T-shaped, posterior column and wall, anterior wall or column with posterior hemitransverse, and both column).
MC,Ischium+ischiopubic rami Ilioischial line#
additional break in the ischiopubic segment
Part of dome attached to ilium
Transverse FractureTypes (depending on the
orientation of the fracture line relative to the dome or tectum of the acetabulum):
1. Transtectal: through the acetabular dome.
2. Juxtatectal: through the junction of acetabular dome & fossa acetabuli.
3. Infratectal: through the fossa acetabuli.
Transtectal fractures are less forgiving and must be reduced anatomically.
Transverse fractures are sagittal plane fractures whereas both column fracturesare coronal plane fractures.
The femoral head follows the inferior ischiopubic fragment and may dislocate centrally.
Othopaedic Review Course January 2010
T-fracture Transverse/post.wall
Post.wall/post.column Ant.post.hemitrans.
Ass.both.column
Associated types
Transverse fracture of any type + Vertical fr through the isciopubic fragment
The vertical component is best seen on the obturator oblique view.
T-shaped fracture
The T-shaped fracture is similar to a both-column fracture in that it disrupts the obturator ring. Another similarity is disruption of both the iliopectineal and ilioischial lines. However, the superior extension of the fracture does not involve the iliac wing, which allows differentiation from the both-column fracture.
T-shaped fracture
In a pure transverse fracture, the anterior and posterior columns may be reduced through a single approach In a T-type fracture, the 2 columns must be reduced separate
Both columns are separated from each other and from the axial skeleton, resulting in a ‘floating’ acetabulum
This is the most complex type of acetabular fracture.
A both columns fracture can be considered a ‘high’ T-shaped fracture where both columns have been separated from the sciatic buttress.
Both-column fracture(formerly called ‘central acetabular
fracture’)
Both-column fracture(formerly called ‘central acetabular fracture’)
"Spur-sign" seen on the obturator oblique view
The "spur-sign," best seen on the obturator oblique view, is pathognomonic for the both-column fracture.
This sign represents posterior displacement of the sciatic buttress of the iliac wing fracture, which essentially disconnects the roof of the acetabulum from the axial skeleton.
When this occurs, weight from the torso and upper body can no longer be supported by the acetabulum.
Both-column fracture(formerly called ‘central acetabular fracture’)
On radiographs and CT, the spur sign appears as a shard of bone extending posteriorly at the level of the superior acetabulum.
Evaluation of sequential CT images shows the fracture, which separates the sciatic buttress from the acetabular roof.
3-D CT scan of a both-column acetabular fracture; obturator oblique view
Subsequent to the pioneering work of Judet and Letournel, their classification was then used as the basis for formulating an alphanumeric computerized format and the Comprehensive Classification of Fractures of the Acetabulum was developed by SICOT International and AO/ASIF.
Each fracture is classified according to morphological characteristics, and subdivided into types, groups, and subgroups.
The system is especially beneficial for research database applications.
Classification(The Comprehensive Classification of Fractures of the Acetabulum)
The Comprehensive Classification of Fractures of the Acetabulum
Roof Arc Angle(MATTA)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+ roof intersection to the geometric center.Roof arc angles are of limited utility for evaluation of both column fractures and posterior wall fractures. To find the amount of INTACT acetabular roof to decide treatment1. Medial Roof Arc (AP pelvis)2. Anterior Roof Arc (Obturator oblique)3. Posterior Roof Arc (Iliac oblique)
Question 1
Classify the following acetabular frx
Letournel Acetabular Frx Classification
Elementary 1. Anterior wall2. Anterior column3. Posterior wall 4. Posterior column 5. Transverse
Associated 6. T-shaped 7. Anterior wall/column plus posterior
hemitransverse 8. Transverse plus posterior wall 9. Posterior column plus posterior
wall 10. Both-column
Question 2
Classify the following acetabular frx
Letournel Acetabular Frx Classification
Elementary 1. Anterior wall2. Anterior column3. Posterior wall 4. Posterior column 5. Transverse
Associated 6. T-shaped 7. Anterior wall/column plus posterior
hemitransverse 8. Transverse plus posterior wall 9. Posterior column plus posterior
wall 10. Both-column
MCQ 3
• Which two quadrants of the acetabulum are most at risk for injury by screws during fixation of total hip arthroplasty (THA):1. Anterior-inferior and posterior-superior2. Anterior-superior and posterior-superior3. Anterior-superior and anterior-inferior4. Anterior-superior and posterior-inferior5. Posterior-superior and posterior inferior
Answer 3
• Which two quadrants of the acetabulum are most at risk for injury by screws during fixation of total hip arthroplasty (THA):1. Anterior-inferior and posterior-superior2. Anterior-superior and posterior-superior3. Anterior-superior and anterior-inferior4. Anterior-superior and posterior-inferior5. Posterior-superior and posterior inferior
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.
Acetabular Fractures,imaging and
MANAGEMENT 2
Presented by : Harjot Singh GurudattaModerator : Dr. Gagan Khanna
TILL NOW
PT CAME>>>>>>ABCD>>>>>STABILISATION>>>>>>>>>CLINICAL EXAMINATION
>>>>>>>NEUROVASCULAR ASSESSMENT>>>>>>XRAYS 5 VIEWS>>>>>>>CT HIP
>>>>>CLASSIFICATION OF ACETABULUM # >>>>>> Presence of associated ipsilateral injuries, with particular attention to the ipsilateral knee in which posterior instability and patellar fractures are common.Soft tissue injuries (e.g., abrasions, contusions, subcutaneous hemorrhage, MORELL LOVELLE LESION)ROOF ARC MEASUREMENTS DONE AS DESCRIBED>>>>>WAIT AND WATCH AND DECIDE FURTHER>>>>>
Goal of Treatment
• The goal of treatment is anatomic restoration of the articular surface , prevent posttraumatic arthritis, Mobilise patient, minimise asso. Compl.
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.
Non-operative treatment(MATTA-MERITT CRITERIA)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.
No # in CT Subchondral bone with in 10cm of joint.• # in non weight bearing dome: Low anterior column
fractures Distal anterior column or transverse (infratectal) fractures in which femoral head congruency is maintained by the remaining medial buttress.# Low transverse fractures Low T-shaped fractures. Even both column # with sec congruence
• Maintenance of medial, anterior and posterior roof arcs >45° (indicating fracture stability)
• Pt, is unfit for surgery
Operative treatment Indications
• Head unstable and/or incongruous joint
• Guidelines to be correlated to patient factors. 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)
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):
• 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
Operative treatment Timing
• Surgery should usually be performed within 2 weeks of injury and usually after 1 week.
• It requires• A well-resuscitated patient.• Appropriate radiologic workup.• Appropriate understanding of the fracture
pattern.• Appropriate operative team.
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
Assessment of reduction
Assessment of reduction includes:
• Restoration of pelvic lines.
• Concentric reduction on all 3 views.
• The goal of anatomic reduction.
Operative treatmentContraindications?/ Relative non operative
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
Morel–Lavallé lesion (Skin Degloving Injury• A closed degloving injury over the greater trochanter.The subcutaneous tissue is torn away from the underlying fascia, and a significant cavity containing hematoma and liquified fat forms• 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 with regular care.• Primary excision of the necrotic fat and closure over a drain has not
been routinely successful.
• Infection 6-10%• Nerve palsy
• 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.
Thromboembolic
Complications
Complications
• Heterotopic bone formation
• Extensile approaches• Young patient with muscle
split• Kocher-Langenbeck• Indocin 25mg TID• Low Dose Radiation• Excision after 15-18 mo:
80% of normal motion if no arthritis
Avascular necrosis, arthritis
Surgical Approaches• Kocher-Langenbeck (Posterior): best access to posterior column
(lateral/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 desirableNo single approach provides ideal exposure of all fracture types.Proper preoperative classification of the fracture configuration is
essential to selecting the best surgical approach.Intraoperatively, corkscrew, schanz pin, reduction forceps help to
achieve reduction
Surgical approaches:
FRACTURE TYPE APPROACHELIMENTARY FRACTURES
1 Posterior wall Kocher-Langenbeck2 Posterior column Kocher-Langenbeck3 Anterior wall Ilioinguinal4 Anterior column Ilioinguinal5 TransverseInfratectal/JuxtatectalTranstectal
Kocher-LangenbeckExtended iliofemoral or Kocher-Langenbeck
Surgical Approaches:
ASSOCIATED FRACTURES
1 Posterior column + wall Kocher-Langenbeck2 Anterior + posterior Hemitransverse
Ilioinguinal
3 Transverse + posterior wallInfratectal/JuxtatectalTranstectal
Kocher-LangenbeckExtended iliofemoral or Kocher-Langenbeck
4 T – shaped Infratectal/JuxtatectalTranstectal
Kocher-Langenbeck or combinedExtended iliofemoral or combined
5 Associated both column ABC
Ilioinguinal.
Kocher-Langenbeck Approach1 M. glutaeus maximus2 M. glutaeus medius3 M. glutaeus minimus4 M. piriformis5 M. gemellusSuperior6 M. obturatorius internus 7 M.
gemellus inferior8 M. quadratus femoris9 Lig. Sacrotuberale10, N.,A.,V., glutea inferior11 N.,A.,V., glutea superior
Kocher-Langenbeck ApproachIndications
• Posterior wall fractures• Posterior column fractures• Posterior column/posterior wall fractures• Juxtatectal/infratectal transverse or
transverse with posterior wall fractures• Some T-type fractures
• Trochantric osteotomy may be needed for good exposure in high T and posterior wall or post column # extending to supracetabular ilium, for exposing superior dome of acetabulum.
• acetabular fractures with cranial extension and dome involvement.
• Entire posterior column•Greater & lesser sciatic notches•Ischial spine•Retroacetabular surface•Ischial tuberosity•Ischiopubic ramus
Areas accessible by Kocher-Langenbeck approach
The room is set up such that the x-rays and CT scans areavailable for viewing during the procedure. The patient isprone on a radiolucent table.
The affected extremity is positioned with a distal femoralpin to allow for traction on the table with the hip in slightextension and the knee flexed to relax the sciatic nerve.
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
The skin incision is brought down to the level of the tensorfascia lata, which is divided in line with the incision. Thegluteus maximus fascia is then divided.
TENSORFASCIA
LATA
GLUTEUS FASCIA
The maximus muscle is gently separated digitally untilthe first traversing branches of the nerve are visible.
GLUTEAL NERVE BRANCH
Dividing the gluteus maximus too far proximally will denervate a significant portion of it.
TROCHANTERIC BURSA
The trochanteric bursa is divided.
GLUTEUS MAXIMUS
QUADRATUSFEMORIS
View of the deep musculature with the Charnley retractor in place.
VASTUS LATERALIS
GLUTEUSMEDIUS
SHORT EXTERNAL ROTATORS
With gentle retraction anteriorly of the gluteus medius, the piriformis tendon comes into view.
GLUTEUSMEDIUS
PIRIFORMIS
OBTURATOR INTERNIS PIRIFORMIS
After minimal dissection along the posterior aspect of the short external rotators the obturator internis tendon is identified between the gamelli.
TAG SUTURESBoth the piriformis and obturator internis are tagged and resectedapproximately 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.
The piriformis and obturator internis are being gently elevated using the sutures.
OBTURATORINTERNIS
PIRIFORMIS
With the piriformis being held back digitally, the sciatic nerveis visualized running posterior to the obturator internis tendon.
OBTURATORINTERNIS
SCIATIC NERVE
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 COBRARETRACTOR
OBTURATOR INTERNIS
SCIATICNERVE
Once in the lesser sciatic notch, posterior leverage on the retractorallows exposure of the posterior aspect of the acetabulum whileprotecting the nerve.
BLUNT COBRARETRACTOR
OBTURATOR INTERNIS
SCIATICNERVE
FEMORALHEAD
The femoral head and displaced portion of the posterior wall are easily identified.
DISPLACED POSTERIOR WALL
After the fracture and fracture bed are cleaned, the posterior wall is reduced and fixed in place with a buttress plate.
After the fracture and fracture bed are cleaned, the posterior wall is reduced and fixed in place with a buttress plate.
REDUCED FRACTURE
Ilioinguinal Approach
1 M. psoas major2 M. iliacus3 Pecten ossis pubis4 A. iliaca communis5 A. iliaca interna6 A. iliaca externa7 Aa. Vv. Testiculares8 V. iliaca communis9 V. iliaca externa10 N. ilioinguinalis11 N. genitofemoralis12 N. obturatorius13 N. femoralis14 N. cutaneus femoris lateralis15 Ductus spermaticus16 Ductus deferens
Ilioinguinal ApproachIndications
• Anterior wall• Anterior column• Transverse with significant anterior
displacement• Anterior column/posterior hemitransverse• Both-column
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.
ASIS
ASIS
AThe 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
SYMPHYSIS
Sharp retractors are used to identify the interval between the abductor and abdominal musculature.
The iliac crest is indicated by purple lines. The interval between theabdominal and abductor musculature occurs towards the posterioraspect of the iliac crest as the abdominal musculature hangs over the crest (dotted line)
The interval is taken with a Bovie down to the iliac crestand the abdominal musculature is reflected anteriorly.
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
After this dissection is complete, the posterior aspect of theiliac fossa is packed off with a lap and attention to brought to the anterior portion of the incision.
Gelpi retractors are used to retract the skin and softtissue after the external oblique fascia is identified.
EXTERNAL OBLIQUEFASCIA
The external oblique fascia is divided in line withthe incision and the fascia is reflected distally.
EXTERNALOBLIQUEFASCIA
VAS DEFERENS, SPERMATIC CORD, + ILIOINGUINAL NERVE
EXTERNALOBLIQUEFASCIA
INGUINAL LIGAMENT
EXTERNALOBLIQUE
FASCIA
After this is performed, the vas deferens, spermatic cord, and ilioinguinal nerve are identified and protected with a Penrose drain. Allis c lamps areused to retract the the external oblique fascia.
An incision is made in the inguinal ligament, allowing 1 to 2mm of the ligament to reflect medially with themusculature (dotted line).
ASIS
As the dissection extends toward the ASIS, one needs to identify the lateral femoral cutaneous nerve, which is immediately under the inguinal ligament. typically located
approximately 1cm medial to the ASIS
LATERAL FEMORALCUTANEOUS NERVE
ASIS
PSOAS FEMORALNERVE
ILIOPECTINEALFASCIA
EXTERNALILIAC
VESSELS
At this point, the identification of the iliopectineal fascia is performed,allowing for retraction of the exteral iliac vessels and lymphatics medially.
ILIOPSOASMUSCLE
FEMORAL NERVE
ILIOPECTINEALFASCIA
The psoas muscle and femoral nerve are retractedlaterally. The army-navy retractor protects the vasculature while the Allis clamp is holding the iliopectineal fascia.
TRUE PELVIS
PSOAS FEMORAL NERVE
Closeup of the iliopectineal fascia demonstrating the psoas and femoralnerve on the lateral side of the fascia in the false pelvis. The true pelvisis located medial to the iliopecineal fascia over the pelvic brim.
PSOAS FEMORAL NERVE
Once the iliopectineal fascia is excised, access to the true pelvis isobtained. The medial window of the approach is utilized when buttressplating to the symphyseal body or symphyseal fixation is necessary.
LATERAL FEMORALCUTANEOUS NERVE
View from the opposite side of the table demonstrating the lateral window and iliac wing fracture.
ILIAC FRACTURE
PSOASLATERAL FEMORALCUTANEOUS NERVE
VESSELS
PELVIC BRIM
View of the middle window demonstrating the pelvic brim.
SI JOINT
ILIOPSOAS
This figure demonstrates the lateral window and exposure of the anterior column from the iliac crest and S SI joint proximally to the psoas gutter and pelvic brim distally.
PELVICBRIM
PSOAS
This figure demonstrates the pelvic brim and displacementof the fracture as seen through the middle window.
VESSELS
SUPERIOR RAMUSFRAGMENT
DISPLACED ANTERIORCOLUMN
Closeup of the fracture.
Extended Iliofemoral Approach1 M. gemellus superior2 M. obturatorius internus3 M. gemellus inferior4 M. piriformis5 M. quadratus femoris6 Sehne des M. obturatorius
externus7 Tuber ischiadicum8 A. circumflexa femoris medialis,
tiefer Abzweig9 N. ischiadicus
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
Extended iliofemoral approach Indications
Extended iliofemoral approachExtended
iliofemoral approach has the highest incidence of ectopic bone formation (HO) and longest postoperative recovery
Other approaches
• Stoppa approach (supine): Allows access to the medial wall of acetabulum, quadrilateral surface, & sacroiliac joint.corona mortis at risk.
• 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
ImplantsScrews– 6.5-mm cancellous lag screws with buttress plate– 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.
ImplantsPlates
The 3.5-mm and 4.5 mm reconstruction plates for pelvic fixation
• 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 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.
Plates Sites of Application
Internal fixation with lag screw
• 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.
Closed reduction and percutaneous fixation – proposed for
elderly patients &
Simple fractures with minimal displacements.
No long term results available yet
Example Case
• 48 y/o female• Fx dislocation of L acetabulum -
displaced• Left SI joint injury• R non-displaced acetabular fx• L:ORIF and Perc SI - FFWB• R:Perc - WBAT
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).
