Gabriel Hommel, MD

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Acetabular Fractures

• Gabriel Hommel, MD
• Louisiana State University Health Sciences
  Center, Shreveport, LA

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Goals

• To discuss the following 4 topics
• Pelvic Anatomy
• Radiographic Diagnosis
• Decision for surgery
• Decision for Approach

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Palpable Bony Landmarks

• Palpable Bony Landmarks
• Symphysis Pubis
• Anterior Superior Iliac Spine (ASIS)
• Iliac Wing
• Posterior Superior Iliac Spine (PSIS)

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Acetabular Columns

• Anterior (iliopubic) column
• Extends from anterior iliac crest ? symphysis
  pubis
• 3 segments
• Iliac segment
• Acetabular segment
• Pubic segment

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Acetabular Columns

• Posterior (ilioischial) column
• Extends from greater sciatic notch ? inferior
  ischium
• Acetabular dome forms keystone of arch

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Diagnosis

• 5 Views of the Pelvis
• 45 degree oblique pelvis views
• Obterator oblique
• Iliac oblique
• AP pelvis
• 35 degree cephalad and caudad projection views of
  pelvis
• Inlet view (caudad projection)
• Outlet view (cephalad projection)

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Iliac Oblique
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Obterator Oblique
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Teardrop

• Internal limb outer wall of obturator canal
• External limb middle 1/3 of cotyloid fossa
• Inferior border ischiopubic notch

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Diagnosis

• CT scan of the pelvis
• 5 mm Cuts, to include both hips, make copies with
  6 images printed on each sheet.
• Also, if possible, obtain 3-D reconstruction of
  the Pelvis.

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Diagnosis

• Classification of Acetabular Fractures
• Letournel and Judet
• Elementary or Simple Fractures
• Associated or Complex Fractures

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Diagnosis

• Simple Fracture Patterns
• Posterior Wall
• Posterior Column
• Anterior Wall
• Anterior Column
• Transverse

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Transverse

• Infratectal
• Juxtatectal
• Transtectal

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Diagnosis

• Associated Fracture Patterns
• Posterior wall associated Posterior Column
• T-Shape
• Both Column
• Anterior Column associated Posterior
  Hemi-Transverse
• Transverse associated posterior wall

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Both Column
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Anterior Column plus Posterior Hemitransverse
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Indication for Surgery

• Displaced acetabular fractures.
• Hip Dislocation with associated fracture of
  acetabulum.
• Traumatic Protrusio Acetabuli.

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What is a displaced fracture??

• When you look at the x-ray in any of the three
  views, there is a gap of greater than 1 or 2 mm
  from one of the fracture ends to the other.

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Roof Arc Angles

• Measurement of roof arc angles is appropriate for
  following fracture patterns
• Anterior Column
• Posterior Column
• Transverse
• T-shape
• Some associated patterns

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Roof Arc Angles

• There are three
• 1. Medial Roof Arc (AP pelvis)
• 2. Anterior Roof Arc (Obterator oblique)
• 3. Posterior Roof Arc (Iliac oblique)

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Non-Operative Candidate

• Displacement less than 2 to 5 mm in dome (Some
  say roof arc angles of 45 degrees or more on all
  3 views, Matta says 45, 25, 75).
• Distal anterior column fractures (low).
• Distal transverse fractures (infratectal).
• Both column fractures with secondary congruence
  and minimally displaced posterior column.

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When not to operate????

• Non-displaced acetabular fractures.
• Severe osteoporosis.
• Severe Neurological disease, uncontrolled seizure
  disorder.
• Multiply injured patient that is medically not
  stable for a big acetabular surgery.
• The patient with profound comorbid medical
  problems that will not tolerate surgery
  (cirrhosis, renal dialysis patients, CHF, etc).

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When to Operate???

• If you can measure at least 5 mm of displacement
  on any view of the pelvis or on the CT scan.
• If all of the fracture ends on all views and CT
  scan are 4 mm or less, then do not operate.

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Last Call

• If the hip joint is incongruous or if the hip is
  unstable, then operative treatment is indicated.
• Remember this point when taking exam.

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Risks

• 1. Injurying a major artery, nerve, vein.
• 2. Blood loss.
• 3. Heterotopic Ossification.
• 4. Arthritis.
• 5. Avascular necrosis.
• 6. Complications from anesthesia death,
  pneumonia, DVT, PE, MI, CVA, etc

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Timing of Surgery

• The sooner you can get to it, the easier it is to
  reduce.
• The sooner you operate on it, the more blood loss
  (within 2 days).
• Fractures operated on between 0 and 14 days have
  a higher rate of anatomical reduction (70)
  compared to those operated on between 15 and 21
  days (57).

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Surgical Approaches

• 1. Kocher Langenbach
• 2. Ilioinguinal
• 3. Extended Iliofemoral

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Use of fracture table

• Judet or fracture table can be used for
  approaches.
• The table will allow use of traction for
  reduction of fracture.
• Do not use if there is a concomitant pelvis
  fracture, especially pubic rami fractures.

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Indications for Kocher-Langenbeck

• Indications for Kocher-Langenbeck
• Posterior Wall Fractures
• Posterior Column Fractures
• Posterior Column / Posterior Wall Fractures
• Juxta-tectal / Infra-tectal Transverse or
  Transverse with Posterior Wall Fractures
• Some T-shaped Fractures

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Indications for EIF Approach

• Transtectal TrPW 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 which are operated greater than 21 days
  following injury.

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Operative Approach per fracture

• Transverse Post wall
• 77 Kocher Langenbach
• 22 Extended Iliofemoral
• 2 Combined (KL and II)

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Operative Approach per fracture

• T-shaped
• Kocher Langenbach 61
• Ilioinguinal 13
• Extended Iliofemoral 19
• Combined 6

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Operative Approach per fracture

• Both Column
• Kocher Langenbach 1
• Ilioinguinal 59
• Extended Iliofemoral 39
• Combined 1

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Controversy

• The transverse fracture can be fixed thru either
  K.L., I.I., or E.I. (when do you decide which
  approach?????)
• High anterior column fx. Then I.I.
• O.T.W. most others are Kocher Langenbach
  approach.
• Except for

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Transverse Exception

• 1. Trans Tectal
• 2. Extended Posterior Wall Fracture
• 3. Fracture of contralateral Pubic Ramus or a
  Symphesis Dislocation
• 4. Injury or fracture at a S.I. Joint
• If only 1 is present, K.L., If 2 are present,
  then K.L. vs. E.I.F., if 3 or 4 then E.I.F.

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Assessment of Reduction

• Post-op x-rays should be ordered and look at AP
  pelvis, 45 degrees obturator and iliac oblique
  pelvis views.
• Anatomical 0 to 1 mm of residual displacement
• Imperfect 2 to 3 mm
• Poor More than 3 mm
• Surgical Secondary Congruance

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Results

• Based on quality of reduction
• If there is an anatomical reduction
• You can expect 80 of patients to have excellent
  and good clinical results with low probability of
  developing arthritis.
• Around 20 may still develop problems such as
  arthritis, avascular necrosis, and heterotopic
  ossification that may require re-operation.

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Results

• If the reduction is poor, you can expect 40 to
  have poor clinical results and 12 to have fair
  clinical results.
• If the reduction is poor, you can expect that
  close to 100 will have poor radiographic results
  at 2 years.

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Post Operative Care

• Coumadin or Lovenox for 3 weeks.
• Ted hoses, knee high, for 3 weeks.
• 30 pounds weight bearing to surgery side for
  first 8 weeks. At 6 weeks obtain x-ray.
• Stool softeners, H2 blockers, I.V. antibiotics
  for 24hrs.
• Remove drains in 48 hours.
• If E.I.F. or K.L., then on POD 1, perform 600
  rads or indomethacin 25 mg po TID for 3 weeks.

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HO

• Common after extensile exposure of posterior
  aspect of acetabulum. (Risk greatest with
  EIFgtKLgtIlioinguinal)
• Necrotic or injured muscle should be removed to
  reduce risk of HO.
• Medical prophylaxis is controversial. Somes
  studies show indomethacin to equal radiation,
  some show no effect.
• Radiation (600cGY within 48hrs of surg) very
  effective however carries a risk of sarcoma
  formation, therefore some do not use on young
  patients. (No articles have reported this with
  acetabular fractures.)