Seminar acetabulum fracture 4th semester

1. ACETABULUM FRACTURES
Presented by
Dr. Roshan Yadav
JR Orthopaedics
AIIMS , New Delhi

2. Anatomy
• Osseous cup at junction of ilium,
ischium and pubis (the Innominate
bone)
• Lateral surface: Anterior and posterior
wall, open inferiorly as the acetabular
notch
• Medial surface: Quadrilateral plate

3. Anterior Wall

4. Posterior Wall

5. Column concept
• Anterior column
• Posterior column
• Sciatic buttress - confluence
of the both columns
Iliac
crest
ASIS
AIIS
Ant Wall
SPR
G. Sciatic nth
L. Sciatic nth
Post Wall
Ischial
Tuberosity

6. Mechanism of Injury
• Impact of the femoral head with the acetabular articular
surface
• Greater trochanter(direct trauma along the axis of the
femoral neck)
• Anywhere along the long axis of the femoral
shaft(Indirect trauma-dashboard injury)

7. Type of # depends upon position of femoral head in acetabulum
and magnitude of force and quality of bone
Fracture location Position of femoral
head
Posterior column # IR
Anterior column
#
ER
Superior dome
#(high transverse
# )
Adduction
Inferior aspect of the
dome #(low
transverse #)
Abduction

8. Clinical evaluation
• Trauma evaluation: ATLS protocol
• 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.
• Presence of associated ipsilateral injuries must be ruled out, with
particular attention to the ipsilateral knee in which instability and
patellar fractures are common.
• Soft tissue injuries (e.g., abrasions, contusions, subcutaneous
hemorrhage) may provide insight into the mechanism of injury.

9. Morel Lavalle lesion
• Internal degloving injury, localized area of subcutaneous fat necrosis
over the lateral aspect of the hip
• Operating through it has been associated with a higher rate of
postoperative infection

10. Imaging
• X-Rays
• Standard AP view
• Judet Views
450 obturator oblique view
450 iliac oblique view
• Pelvic inlet and outlet view
• CT scan

11. Radiography
AP VIEW
• Three rings
• Joint spaces
• Sacral foramina
• Acetabulum

12. • Pelvic radiograph AP
view
 Iliopectineal line
 Ilioischial line
 Anterior rim
 Posterior rim

14. Judet views
Obturator oblique view
• Evaluation of anterior
column and posterior wall
• Obturator foramen in profile
Iliac oblique view
• Evaluation of posterior
column and anterior wall
• Iliac wing in profile
Obtained with the pelvis or tube turned 45 degrees in each direction

15. Pelvic inlet view
 Evaluation of the sacral
arcuate lines
 Internal rotation of fracture
fragments
 Pubic symphysis

16. Pelvic outlet view
 Evaluation of SI joints
 Cranial or caudal displacement
of fracture fragments

17. MDCT
• CT is more sensitive and accurate for depicting fractures than
radiography
• Depicts soft-tissue complications, presence of intra-articular
free fragments
• Orientation of fracture lines and marginal impaction,joint
congruency, femoral head defect
• Rotation of fracture fragments, pelvic hematoma, sacroiliac
joint integrity
AW
PW
AC
PC
Quadrilateral plate

18. Surface Rendered 3D
• Surface-rendered 3D images are helpful for visualizing, describing,
and communicating acetabular fracture geometry, subtract
unwanted structures and planning the operative approach.

19. Need for classification
• To communicate the type of # with surgeon.
• To categorize # for research purpose and compare the outcomes of
fractures.
3 systems of classification
Judet and Letournel system: Most widely used.
Orthopedic trauma Association (OTA): Research purpose.
Harris system: Developed in CT era, but did not replace Judet’s.

20. “Acetabular fractures, by
convention, are still described
and illustrated looking at the
acetabulum enface from the
lateral side, with the acetabular
notch pointing downward such
that the articular surface of the
acetabulum appears as an
inverted ‘U’ “.
Meir H. Scheinfeld et al. RadioGraphics 2015; 35:555–577

21. Judet and Letournel classification
• 5 Elementary #: Divide innominate and
acetabulum into 2 fragments
Posterior wall
Posterior column
Anterior wall
Anterior column
Transverse
• 5 Associated #: Divide innominate and
acetabulum into 3 or more major
fragments
Transverse with posterior wall
Posterior column with post wall
T-shaped
Ant column with post hemi
transverse (ACPHT)
Associated both column (ABC)

22. Elementary : Posterior wall #
• Involve posterior acetabular rim, which
includes the posterior articular surface
• Quadrilateral plate intact
• M/c fracture mechanism : Dash board
injury
• Gull sign

25. Posterior wall # Management
• Fracture involving < 20% width of
posterior wall – conservative
• > 50% width – Surgical
• 20% to 50% - Examination under
anesthesia
• Any Impaction is an indication of
surgery.

26. Examination under anesthesia(Dynamic stress fluoroscopy)
• Used to assess the posterior wall stability in isolated posterior wall #
• Hip is positioned in flexion, adduction and internal rotation
• Observe in AP and obturator oblique view-opening of medial clear
space(posterior subluxation on either view) suggests dynamic hip
instability.

27. Elementary : Posterior column #
• Posterior portion of acetabulum
• Disconnecting from sciatic buttress
• # line runs through greater sciatic notch and into
ischiopubic ramus
• Very unstable #
• Superior gluteal neurovascular bundles – trapped
in sciatic notch.

30. Elementary: Anterior column #
• Anterior column disconnected from
sciatic buttress
• Superior extent of # line can be
 High – through iliac crest
 Intermediate- b/w iliac spines
 Low- below AIIS
Very low- iliopectineal eminence
• # line crosses obturator foramen*

32. Elementary : Anterior wall #
• Least common type of acetabular #
• Do not involve obturator foramen
• Also contains portion of anterior column
(extension through quadrilateral plate)

33. Elementary : Transverse #
• Transverse # divides acetabulum into superior
(iliac) and inferior (ischiopubic) fragments
• Single # line involving both columns
• But portion of each column remains connected to
sciatic buttress

35. Associated #: Transverse with posterior wall
• M/c Associated #
• Worst prognosis of all acetabular #

38. Associated #: T-shaped
• Transverse # with inferior vertical stem running through IPR or through ischium
• Posterior column with anterior hemi transverse
• Transverse with anterior wall # T- shaped

41. Associated both column #
• Unique- wt bearing acetabulum disconnected from sciatic buttress –
Floating Acetabulum
• 2 columns are separated from each other
• Spur sign on obturator oblique view
• Secondary congruence

44. Anterior column/wall with posterior hemi-transverse #
• Anterior component can be Ant wall or column.
• Posterior component is posterior hemi-transverse.

45. Posterior column with posterior wall
• Column component undisplaced – hard to detect

47. Fracture pattern on outcome

48. Management
• The goal of the treatment is restoration of articular
surface, prevent post traumatic arthritis and to mobilise
the patient as early as possible.
• Factors to be considered are-
• Patient factors
• Fracture factors
• Expertise available

49. Patient factors Fracture factors
• Age . Instability
• Pre injury activity level . Incongruity
• Medical comorbidities
• Associated injuries
• Functional demands

50. Roof arc angle
• It is an estimation of amount of WBD involved
• Not applicable to isolated posterior wall # and ABC #
• Measured on all three radiograph views with the leg out of traction
• WBD is considered to be intact and hip joint congruous if measurement
> 45o (Matta) in all 3 views.

52. Criteria for non operative treatment
• CT subchondral arc is intact in the superior
10 mm of the acetabulum
• Femoral head remains congruent with the
superior acetabulum in AP and 45 degree oblique
views (out of traction)
• No evidence of posterior hip instability

53. Management
Imaging criteria for non-surgical
management:
• Roof arc angle > 45
• < 2mm displacement
• Posterior wall # inv < 20% width
Indication for surgery:
• Displacement > 2mm in
acetabular dome.
• Intraarticular fracture
fragment.
• Posterior wall # inv > 50%
width.
• Posterior wall impaction #

54. Non-operative Indications
• Hip stable and congruous/fractures with secondary congruence
(both-column)
• Patient factors-medical contraindications
• Undisplaced/Minimally displaced fractures
• Local soft tissue problems
• Morel Lavelle’ lesion
• Open wound
• Suprapubic catheter (C/I to Ilioinguinal and Stoppa)

55. When to do acetabular surgery??
• If hip is unstable and/or incongruous
• It is advisable to wait for 3 to 5 days, to allow patient’s
general condition to stabilize ,adequate blood should be
available.
• Indications for emergency ORIF
• Irreducible dislocation
• Large intraarticular bony fragments
• Soft tissue interposition
• Button holing of femoral head through capsule
• Unstable hip following reduction
• Increasing neurological deficit
• Associated vascular injury

56. Surgical approaches
The posterior Kocher-
Langenbeck exposure
Anterior ilioinguinal
approach
Newer approaches
Stoppa approach
Trochanter osteotomy
(digastric slide, flip)
Extended iliofemoral

57. Entire posterior column
• Greater & lesser sciatic notches
• Ischial spine
• Retroacetabular surface
• Ischial tuberosity
• Ischiopubic ramus
Areas accessible by Kocher-Langenbeck approach

58. The skin incision is brought down to the level of the tensor fascia lata,
which is divided in line with the incision.
TENSOR
FASCIA
LATA

59. The gluteus maximus muscle is identified and divided and trochanteric bursa is
divided.

60. With gentle retraction anteriorly of the gluteus medius, the piriformis tendon comes into
view. After minimal dissection along the posterior aspect of the short external
rotators the obturator internis tendon is identified between the gamelli.
GLUTEUS
MEDIUS
PIRIFORMIS

61. TAG SUTURES
Both the piriformis and obturator internis are tagged and resected
approximately 1-1.5cm away from their insertion in the femur.

62. The piriformis and obturator internis are being gently
elevated using the sutures.
OBTURATOR
INTERNIS
PIRIFORMIS

63. With the piriformis being held back digitally, the sciatic
nerve is visualized running posterior to the obturator
internis tendon.
OBTURATOR
INTERNIS
SCIATIC NERVE

64. 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
BLUNT COBRA
RETRACTOR
OBTURATOR INTERNIS
SCIATIC
NERVE

65. FEMORAL
HEAD
The femoral head and displaced portion
of the posterior wall are easily identified.
DISPLACED POSTERIOR WALL

66. After the fracture and fracture bed are cleaned, the posterior
wall is reduced and fixed in place with a buttress plate.

67. Precautions
Sciatic nerve:
• Release femoral insertion of Gluteus maximus to reduce tension
• Keep knee flexed(>90) , hip extended
Femoral head vascularity:
• Do not cut the quadratus from the femur
• Release the rotators >1cm from femoral neck
Superior gluteal artery and nerve:
• Care at the upper extent of dissection

68. Trochanteric flip osteotomy with surgical dislocation allows better intraarticular assessment, control
of intraarticular fragments, assists accurate reduction and the fixation of complex acetabular and femoral head
fractures, without compromising femoral head vascularity and abductor strength. This technique has provided
excellent midterm results in the management of complex injuries around the hip.

69. Surgical technique of Trochanteric Flip
G.Troch
Flip
screws
G.Med
G.Tr
V.lat

70. Which Fracture ?
Column or Wall?
• First column, then wall Transverse#
• Different plates for each fracture which part to fix first??
• Better exposure / view of the joint

71. Resources for acetabular fixation

72. Plate bending tool
Sciatic Nerve Retractor
Matta’s clamps
Ball Spike Pusher
Schantz pin
Farabeuf forceps

73. Ilioinguinal approach Advantages
•Excellent access is to the anterior
and internal aspects of the entire
pelvis and acetabulum.
•HO is minimal
Disadvantages
•Approach is extraarticular, reduction
achieved almost entirely by indirect
means
•Possible damage to the femoral
nerve, ext. iliac vessels, femoral lat.
cutaneous Nerve,inguinal canal
contents

74. Modified Stoppa Approach
• Position- Supine
• Provides improved exposure of the quadrilateral surface and posterior
column
• Advantage over the ilioinguinal is that dissection of the iliac vessels is
not required
• Risk of injury to Corona mortis and bladder

75. Extended Iliofemoral approach
• Indicated for selected complex acetabular fracture types and
for surgery delayed more than 2 weeks following injury
• Direct access to the iliac crest and the entire
internal iliac fossa
• Provides access to entire posterior column, ilium, SI joint, and
anterior column up to iliopectineal eminence

76. Extended Iliofemoral approach
Advantage
•Excellent access to entire
hemipelvis
Disadvantages
•High incidence of HO
•Possible damage to superior gluteal
and femoral NV bundles

77. Surgical approaches:
FRACTURE TYPE APPROACH
ELEMENTARY FRACTURES
1 Posterior wall Kocher-Langenbeck
2 Posterior column Kocher-Langenbeck
3 Anterior wall Ilioinguinal, Stoppa
4 Anterior column Ilioinguinal , Stoppa
5 Transverse Kocher-Langenbeck or Extended
iliofemoral

78. • ASSOCIATED FRACTURES
1.Posterior column + wall
2.Anterior + posterior
Hemitransverse
3.Transverse + posterior wall
4.T – shaped
5.Associated both
column(ABC)
Kocher-Langenbeck
Ilioinguinal
Kocher-Langenbeck
Extended iliofemoral
or Kocher-Langenbeck
Kocher-Langenbeck or
Ilioinguinal or
Extended iliofemoral
or combined

79. Post operative care
• Suction drain , antibiotic for 48 – 72 hours
• Thromboprophylaxis- Mechanical compressive device with
LMWH/ aspirin for 6 wks
• Indomethacin 25 mg tds beginning within 24 hours of surgery
and continued for 4 to 6 weeks to prevent HO
• Passive motion of the hip and toetouch mobilisation on 2nd
or 3rd day.
• Progression to FWB after 6 wks

80. Complications
• Early:
• Mortality (0-3-6%)
• Thromboembolism
• Infection
• Neurological injury
• Vascular injury
• Intraarticular hardware
• Malreduction
• Loss of reduction
• Late:
• Avascular necrosis
• Heterotopoic
ossification
• Pseudoarthrosis
• Post traumatic
arthritis

81. Heterotropic ossification
• Related to extensile surgical exposures, male gender,
associated head injury, significant delays to surgery, fracture
type, the severity of the injury
• Rare with ilioinguinal approach
• “Significant HO” -loss of active range of motion >20% of
normal.
• Indomethacin 25 mg tds for 6 weeks or 75 mg SR capsule OD
for 6 weeks
• Radiation therapy-7–8 Gy in a single dose or 10 Gy in five
doses

82. • 140 pts > 55 yrs
• 93 pts had FU of 5 yrs avg.
• Overall rate of THR was 30.95%
• 70% achieved functional outcomes without any need for secondary
surgeries
• Similar results by Letournel in 120 pts >60 yrs old
• 76% had good to excellent results
JOT 2010

83. • Older group of patients have far worse outcomes than of all ages
• Anatomical reduction with surgery ~ 45 %
• 2-3 mm step in 40% cases
• Rate of conversion to THR 20% in elderly
• conversion time: 30mths
• Higher incidence of peri-operative complications

84. Primary total hip arthroplasty in elderly patients having acetabular fractures is the mainstay of
treatment in order to provide a stable hip with early pain free mobilization. Open reduction and
internal fixation are the recognized treatment of displaced acetabular fractures in youngsters,
however, they are not successful in the elderly.

85. Revise

86. Practical approach to classify 5 common #
Obturator ring disruption
Yes No
Iliac wing #
Yes
T- ShapedBoth-Col #
Ilioischial, Iliopectineal
line disruption
Post wall # Isolated Post Wall#No
Yes No
Yes No
Transverse + Post Wall# Transverse #
yes

87. • 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-superior
2. Anterior-superior and posterior-superior
3. Anterior-superior and anterior-inferior
4. Anterior-superior and posterior-inferior
5. Posterior-superior and posterior inferior

88. the quadrant of death

89. Thank you