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Introduction
Acetabulum fractures can involve one or more of the two columns, two walls or roof
within the pelvis
Epidemiology
o demographics
fractures occur in a bimodal distribution
high energy trauma in younger patients (e.g., motor vehicle accidents)
low energy trauma in elderly patients (e.g., fall from standing height)
Pathoanatomy
o fracture pattern predominately determined by
force vector
position of femoral head at time of injury
bone quality (e.g., age)
Associated conditions
o orthopaedic manifestations
lower extremity injury (36%)
nerve palsy (13%)
spine injury (4%)
o systemic injuries
head injury (19%)
chest injury (18%)
abdominal injury (8%)
genitourinary injury (6%)
Prognosis
o poor outcomes are associated with:
multi-system trauma
increasing age
poor articular congruency
associated femoral head articular injury
post-traumatic arthritis
Anatomy
Osteology
o acetabular inclination & anteversion
mean lateral inclination of 40 to 48 degrees
anteversion of 18 to 21 degrees
o column theory
acetabulum is supported by two columns of bone
form an "inverted Y"
connected to sacrum through sciatic buttress
posterior column
comprised of
quadrilateral surface
posterior wall and dome
ischial tuberosity
greater/lesser sciatic notches
anterior column
comprised of
anterior ilium (gluteus medius tubercle)
anterior wall and dome
iliopectineal eminence
lateral superior pubic ramus
Vascular
o corona mortis
anastomosis of external iliac (epigastric) and internal iliac (obturator)
vessels
at risk with lateral dissection over superior pubic ramus
Letournel Classification
o Judet and Letournel
o most common referenced classification system
o classifed as 5 elementary and 5 associated fracture patterns
Treatment
Nonoperative
o protected weight bearing for 6-8 weeks
indications
patient factors
high operative risk (e.g., elderly patients, presence of
DVT)
morbid obesity
open contaminated wound
late presenting > 3weeks
fracture characteristics
minimally displaced fracture (< 2mm)
< 20% posterior wall fractures
treatment based on size of posterior wall is
controversial
recommend an exam under anesthesia (EUA)
using fluoroscopy best method to test stability
femoral head congruency with weight bearing roof (out of
traction)
both column fracture pattern with secondary
congruence (out of traction)
displaced fracture with roof arcs > 45 degrees in AP and
Judet views or >10 mm on axial CT cuts
technique
skeletal traction NOT required if stable fracture pattern, outside
the weight-bearing dome
activity as tolerated with crutches/walker
weight-bearing
lowest joint reactive forces seen with toe-touch weight
bearing and passive hip abduction
greatest joint contact force seen when rising from a
chair on the affected extremity
DVT prophylaxis if slow to mobilize
close radiographic follow-up
Operative treatment
o open reduction and internal fixation
indications
patient factors
<3 weeks from date of injury
physiologically stable
adequate soft-tissue envelope
no local infection
pregnancy is not contraindication to surgical
fixation
fracture factors
displacement of roof (>2mm)
unstable fracture pattern (e.g. posterior wall fracture
involving > 40-50%)
marginal impaction
intra-articular loose bodies
irreducible fracture-dislocation
approaches
anterior
ilioinguinal
iliofemoral
modified stoppa
posterior
Kocher-Langenbach
combined
extended ilifemoral
techniques
factors considered for fiaxtion methodology
location (column and/or wall) and level (high or low) of
the fracture pattern
amount of displacement
marginal impaction
assoicated injury
fixation modalities
column fixation strategies
reconstruction bridging plate and screws
percutaneous column screws
cable fixation
wall fixation strategies
bridge plate and screws
lag screw and neutralization plate
spring (butress) plate
outcomes
timing
associated hip dislocations should be reduced within 12
hours for improved outcomes
worse outcomes with fixation of fracture > 3 weeks from
time of injury
earlier operative treatment associated with
increased chance of anatomic reduction
peri-operative
clinical outcome correlates with quality of articular
reduction
postoperative CT scan is most accurate way to
determine posterior wall accuracy of reduction
which has greatest correlation with clinical
outcome
ideally articular reduction <2mm
post-operative
greatest stress on acetabular repair occurs when rising
from a seated position using the affected leg, and occurs
in the posterior superior portion of the acetabulum
functional outcomes most strongly correlate with hip
muscle strength and restoration of gait postoperatively
o total hip arthroplasty
indications
usually elderly patients with
significant osteopenia and/or significant comminution
pre-existing arthritis
post-traumatic arthritis in all ages
techniques
timing
immediate vs. delayed THA
immediate THA (with, or without, fracture fixation)
wall fractures
butress plate with multi-hole cup
column fracture
cage and cup constructs
delayed THA
outcomes
patients older than 60 years have approx. a 30% late
conversion rate to THA after acetabular fractures
10-year implant survival noted to be around 75-80%
Techniques
Percutaneous fixation with column screws
o approach
anterograde (from iliac wing to ramus)
retrograde (from ramus to iliac wing)
posterior column screws
o imaging
obturator oblique best view to rule out joint penetration
inlet iliac oblique view best to determine anteroposterior position of
screw within the pubic ramus
obturator oblique inlet view best to determine position of a
supraacetabular screw within tables of the ilium
ORIF
o approaches
approach depends on fracture pattern
two approaches can be combined
Complications
Post-traumatic DJD
o most common complication
o 80% survival noted at 20 years for patients s/p ORIF
o risk factors for DJD include
age >40
associated fracture patterns
concomitant femoral head injury
o treat with hip fusion or THA
Heterotopic Ossification
o highest incidence with extensile approach
treat with
indomethacin x 5 weeks post-op
low dose external radiation (no difference shown in direct
comparison)
o lowest incidence with anterior ilioinguinal approach
Osteonecrosis
o 6-7% of all acetabular fractures
o 18% of posterior fracture patterns
DVT and PE
Infection
Bleeding
Neurovascular injury
Intraarticular hardware placement
Abductor muscle weakness