2. Introduction
⢠Contemporary icon of pelvic
and acetabular surgery .
⢠Ubiquitous standard of care
of acetabular fractures for
the past 25 years.
⢠Complete transformation of
our understanding and
treatment of fractures of the
acetabulum
⢠Two textbooks are the
âBiblesâ of acetabular
surgery
3. Acetabular fractures
Before Letournel
⢠Conflicting recommendations
on Rx.
⢠No classification
⢠No consensus on
conservative or operative
⢠Only AP view Pelvis obtained
⢠Invariably poor results â
JOINT INSTABILITY/ AVN.
After Letournel
⢠First systematic classification
⢠Phenominal concepts
⢠AP, 45 deg oblique views ; CT
⢠Concept of accurate reduction
⢠Surgical approaches and
management protocols
⢠Standard plate and screw
fixation
⢠Aim is congruent and stable
hip.
4.
5. Principles of acetabular fracture Rx
⢠Thorough understanding of 3-D anatomy of
innominate bone
⢠Diagnosis, Classification and operative repair
⢠Stable congruent hip esp. weight bearing
dome.
⢠Surgery is complex and done by experienced
surgeon.
⢠Anatomic reduction ( < 2mm ) is key to
functional outcome.
6. Mechanism of injury
⢠Impact of femoral head with the acetabular
surface
⢠Force is via GT or Axis of femur
⢠Fracture pattern decided by position of hip at
the time of impact
⢠Also force of impact and bone quality
9. Assessment â ATLS protocol
History
⢠Mechanism of injury
⢠Ask for position of hip
⢠Ask of axial loading or
direct injury
⢠Low energy trauma
⢠Underlying illness
Examination
⢠Open wounds
⢠Morel- Lavallee lesions
⢠Shortening
⢠Attitude of limb
⢠Neurological examination
⢠Document sciatic nerve
palsy
23. CT Scan- 2D/3D
⢠Extent & location
⢠intra- articular free
fragment / head
fragment
⢠orientation of # lines
⢠rotation of fragments
⢠status of posterior
pelvic ring
⢠Marginal Impaction
Donât decide hip joint instability based on CT Scan.
PELVIC PLASTIC MODEL
30. Go for non operative here
⢠Polytrauma with sick condition
⢠Severe head injury
⢠Open wound in the planned incision site
⢠Morel â Lavale lesions
⢠Suprapubic catheter â No ilioinguinal
approach. Wait till track seals.
⢠Elderly with osteoporotic bone
Gull sign â poor prognosis
31. Non operative protocol
⢠Bed rest
⢠Mobilise as soon as symptoms allow
⢠Begin with partial weight bearing
⢠Assess displacement weekly for first 4 weeks
⢠By 6 to 12 weeks patient returns to full weight
bearing
⢠Joint mobilisation throughout
⢠Prolonged traction only for patients who needs
surgery but contraindicated due to other reasons
32. Fix if
⢠Displaced # in dome.
⢠Posterior wall # > 50 % displacement
⢠Positive fluoroscopy stress test
⢠Both column fractures with loss of parallelism
⢠Incarcerated fragments in the acetabulum
after closed reduction.
Ideal time â 5 to 7 days
35. Anterior Ilioinguinal
⢠Anterior wall, anterior column, anterior
column + posterior hemitransverse, transverse
with major displacement in anterior region
⢠Careful of corona mortis
⢠Lowest rate of heterotrophic ossification
⢠Risk of damage to lat.cut.N, femoral.N,
external iliac vessels and inguinal canal
62. Indications for emergency fixation
⢠Recurrent dislocation following reduction
despite traction
⢠Irreducible hip dislocation
⢠Progressive sciatic nerve palsy
⢠Associated vascular injury
⢠Open fractures
⢠Ipsilateral neck fractures
63. Posterior wall fractures
⢠25 % of all acetabular fractures
⢠Kocher â Langenbeck approach
⢠Limit periosteal elevation to fracture site, donât
release any fragment from capsule
⢠Distract head and remove osteochondral
fragments. May need hip subluxation
⢠Large fragment removal needs Modified Gibsonâs
approach and troch flip osteotomy ( lateral)
⢠Bone grafting
⢠Two level reconstruction
90. Posterior column
⢠3 â 5 %
⢠Reduced by using Schanz screw into ischium
⢠Reduction clamps used
⢠Interfragmentary screws + butress plate.
91. Transverse #
⢠5 â 19 %
⢠medial and superior displacement of head
⢠Transtectal, juxtatectal and infratectal
⢠Reduction â Schanz screws, sciatic notch
clamp, clamp between two screws
⢠Anterior column screws can be placed only at
acertain angle
⢠ilioinguinal approach
145. THR in acetabular #
⢠Elderly patient
⢠Post traumatic
⢠Patients with poor prognosis
⢠Cementless cup in fractured acetabulum is a
concern
146. Associated injuries
⢠Acetabulum + Posterior hip dislocation
⢠Acetabulum + Pelvic ring
⢠Acetabulum + Femoral head
⢠Acetabulum + Femoral neck in young
⢠Acetabulum + Shaft femur/ IT