surgical treatment of Associated patterns fracture acetabulum

Thesis submitted By
Sherif Mohammed Mostafa El-Aidy
Assistant Lecturer of Orthopedic Surgery
Faculty Of Medicine, Zagazig University
2015

Prof. Dr.
Abd El-Salam Mohammad Hefney
Professor of Orthopedic Surgery
Faculty of Medicine - Zagazig University
Prof. Dr.
Omar Mohammad Abd-elwahab Kilany
Dr.
Yousuf Mohammad khera
Assistant professor of Orthopedic Surgery

Prof. Dr.
Abd El-Salam Mohammad Hefney
Prof. Dr.
Osama Ahmed Farouk
Faculty of Medicine - Assiut University
Prof. Dr.
Khalid Idris Abd El-Rahman

The associated patterns of fracture acetabulum according to Judet
and Letournel classification 1961 include: Posterior column and posterior
wall fracture, Transverse and posterior wall fracture , T-shaped fracture,
Anterior column and posterior hemitransverse fracture and Associated
both-column fracture. Surgical intervention with (ORIF) is the treatment of
choice for indicated cases . These fractures tend to be more severe in nature
and require very careful planning to ensure appropriate access and obtain
an anatomic reduction with lowest incidence of complications .

The aim of this work is to evaluate the results of surgical treatment
of associated patterns of fracture acetabulum (Letournel and Judet
classification) and new trends in surgical treatment.

ANATOMY
The acetabulum is a complex
geometric structure .The pubis forms
the anterosuperior fifth of the
articular surface, the ischium forms
the floor of the fossa and the
posteroinferior two-fifths of the
articular surface, and the ilium forms
the remainder
It has six principal components:
• Anterior column
• Posterior column
• Anterior wall
• Posterior wall
• Acetabular dome or tectum
• Medial wall

Anteriorly:
•The femoral vessels are extremely
close . The iliopectineal fascia
separates the femoral vessels from
the femoral nerve within the
iliopsoas muscle.
•The corona mortise connecting
inferior epigastric vessels and
obturator vessels may be present up
to 30% in some studies.
Important anatomical
realtionships

Posteriorly:
• It is important to understand the
relationship between the piriformis
muscle ( which is oriented 45° into
piriformis fossa) and the peroneal
component of sciatic nerve.
•The obturator internus and the 2
gemilli (oriented transversely)
protect the sciatic nerve when
retracted.
•The Superior gluteal bundle crosses
the greater sciatic notch.
•The medial femoral circumflex
artery ascends close to lateral
rotators insertion.

Mechanism of injury
•Fractures of the acetabulum are caused by forces that drive the femoral head into the pelvis.
•The type of acetabular fracture depends on the position of the femoral head at the
moment of impact.
•The injurious force may be applied to the flexed knee (as in the dashboard injury) to the
greater trochanter, foot, or lumbosacral area .

Classification of Fracture Acetabulum
ANATOMIC CLASSIFICATION:
•The most widely used classification is
that of Judet and Letournel 1961.
•This system divides fractures of the
acetabulum into
1. five simple (elementary) patterns :
- the anterior wall,
- anterior column,
- posterior wall,
-posterior column,
-transverse fractures
2. five complex (associated) patterns:
-Posterior column and posterior wall
fracture,
-Transverse and posterior wall
fracture. ,
-T-shaped fracture,
-Anterior column and posterior
hemitransverse fracture,
-Associated both-column fracture

Assessment of Acetabular Fractures
(A)Clinical assessment:
•History: the mechanism of injury , the patient's post trauma status ,general medical profile
and age of the patient .
• Physical Examination:
1. General examination: searching for bleeding source, associated pelvic disruption or
associated fractures.
2. Local examination:
pain in groin area.
The injured hip may be dislocated (shortened and externally or internally rotated).
Inspection of the skin for open wounds or (Morel–Lavalle lesion).
3. Careful neurologic examination for nerve palsy.
4. Genitourinary and rectal examination.

On the AP pelvis x-ray, six lines (Judet lines)
are identified:
1-iliopectineal line.
2-ilioischial line.
3-teardrop.
4- roof.
5-anterior rim (acetabuloobturator line).
6- posterior rim (ischioacetabular line).
(B)Radiographic assessment:
(1) plain radiography:
• The three standard pelvic views
anteroposterior, inlet, and outlet.
•The iliac oblique, and the
obturator oblique (Judet views).

(2)Computed tomography:
(plain , multiplaner and 3dimention)CT
vital in assessment of :
- The fracture site and extent.
- Degree of comminution .
- Marginal impaction.
- Intraarticular fragment.
- Femoral head injury.
- pelvic haematoma.
(3)Dynamic floroscopic stress examination:

Management of Associated Patterns of
Fracture Acetabulum
Initial Management:
1. Polytrama patient management follows the Advanced Trauma Life Support (ATLS)
guidelines .
2. Any hemodynamically unstable patient must be investigated and treated aggressively .
3. Extraskeletal and Skeletal injuries are managed according to their priorities.
4. Reduction of a dislocated femoral head when patient is stabilized and application of traction
if needed .
5. Subcutaneous degloving injury (Morel–Lavalle lesion) debridment.

Citeria for Conservative Management:
(1)Comorbities limiting physiological reserve.
(2)Insufficient bone stock to allow adequate
fixation.
(3)Displacement of less than 2mm.
(4) Roof arcs of more than 45°, a intact subchondral
CT arc(superior 10 mm).
(5) Congruence on all veiws ,or 2ndry Congruent
both column fractures.
(6) Displacement of less than 50% of the posterior
wall.

Indications for Operative treatment:
(1)Displacement of fractures(≥5mm is
absolute indication).
(2)Roof-arc angle less than 45 degrees on
(AP) and oblique radiographs.
(3) Irreducible fracture-dislocation hip .
(4) loss of congruence on any of the three
plain radiographic views.
(5)posterior wall fracture with associated
hip instability(size of posterior wall
fragment >50%).
(6)An incarcerated osteochondral fragment .
(7) polytrauma patient with an acetabular
fracture that needs to be mobilized.

SURGICALAPPROACHES
Choice depends on:
(1)The fracture pattern.
(2)The local soft tissue
conditions.
(3)The presence of associated
major systemic injuries.
(4) The interval from injury to
surgery.
Type of Fracture Approach
Posterior column
posterior wall
Posterior approach
Transverse plus
posterior wall
Posterior approach
Anterior column
posterior
hemitransverse
Anterior approach
T-type All approaches applicable
:anterior,posterior,or combined
approaches ;depending on
major displacement
Both-column Anterior approach±posterior
approach, combined and
Rarely extensile

POSTERIOR KOCHER-LANGENBECK
APPROACH
Position:the lateral decubitus position or prone.
Access:direct access to the retroacetabular
surface of the innominate bone Indirect
access to the quadrilateral surface.
Surgical Technique:
-The skin incision from PSIS to the posterior
one third proximal femur.
-The gluteus maximus is divided .
-Identify the piriformis and short lateral
rotators insertions which are divided 1.5 cm
from their insertion on the femur (avoiding
MFCA injury) .

Advantages:
- Adequate for posterior pathology, well-
known to most surgeons and Muscle
dissection is minimal, as is blood loss.
Structures at Dangers and
disadvantages:
Superior Gluteal Neurovascular Bundle,
Sciatic Nerve , pudendal nerve, medial
femoral circumflex artery , Heterotopic
Ossification and Hip Abductor Weakness.
Modification:
Greater trochantric osteotomy either classic or
flip .
Surgical Technique:
-Dissection extends from the ischial
tuberosity to the iliac wing.

THE ILIOINGUINALAPPROACH
Position :Supine on a fluoroscopic table.
Access: Direct visualization of iliac fossa ,sacroiliac
joint, entire anterior column, and symphysis pubis.
Surgical Technique:
-The skin incision extends from the lateral
iliac crest down to two fingerbreadths above
the syphysis.
-Division of aponeurosis of external oblique
abdomenus muscle .
-Subperiosteal exposure of internal iliac fossa.

Surgical Technique:
-Snaring of spermatic cord with Penrose drain, cutting
the iliopectineal arch between vascular and muscular
compartments.
-Snaring of femoral artery and vein. Snaring of
iliopsoas muscle and femoral nerves over
iliopubic eminence.
-Exposure of 3 windows of the approach.
Advantages:
Excellent access to the anterior and internal
aspects of the entire pelvis and acetabulum.
heterotopic ossification is minimal.
Structures at Dangers and disadvantages:
-The femoral vessels, the corona mortis , The femoral nerve and The lateral femoral
cutaneous nerve .
-It is extraarticular with the reduction by indirect means .
-Postoperative hernia can occur.

THE ANTERIOR INTRA-PELVIC (AIP) (MODIFIED
STOPPA) APPROACH
Positioning: The patient is placed supine
on a radiolucent table. The surgeon stands
opposite the fractured acetabulum. .
Access: Excellent visualization of the pelvic
ring, including the medial wall, dome, and
quadrilateral plate to ala of sacrum.
Surgical Technique :
-Incision begins 2 cm superior to the symphysis
pubis in a transverse fashion with the length
extending approximately from the ipsilateral
external inguinal ring to the contralateral
external ring.
-The rectus abdominus muscle is split
vertically.
-The corona mortise exposed to be ligated.

Surgical Technique :
-The rectus and iliofemoral vessels next are
retracted laterally and anteriorly.
-The lateral window use is optional when necessary.
Advantages:
-direct access to the pelvic brim, posterior column,
and the quadrilateral surface.
-less invasive .
Disadvantages and Dangers:
-Extraarticular , requires indirect reduction maneuvers.
-The same structures are at risk as during the ilioinguinal approach( except LFCN of Thigh)
specially obturator vessels and lumbosacral trunk.

EXTENSILE APPROACHES:
-Useful in delayed cases and specific fractures
e.g. T-type , AC+PHT and ABC with posterior
wall.
-These approaches have high complication rate
e.g.infection, stiffness and flap necrosis.
(B)Triradiate approach:
-composed of posterolateral incision with
trochantric osteotomy and anterior incision to
ASIS in triradiate fashion.
(A)Extended Iliofemoral Approach:
-It allows access to both columns by elevating
gluteal muscle flap posteriorly.
COMBINED APPROACHES:
The combination of an anterior and posterior approach
either simultaneous or staged .

Techniques of Reduction and Fixation
Required human and material
resources:
•Assistants: two and occasionally
three assistants are necessary.
•Special instruments: like fracture
pushers, Farabeuf clamps, The pelvic
reduction clamp and other standard
fracture clamps .
•Traction:
-Traction table: is controversial.
-Manual Traction: manual pull
, sharp hook, a corkscrew, Schantz
pin and femoral distractor.

Implants:
Plates:
-3.5-mm reconstruction plate.
- 4.5-mm reconstruction plate
-1/3 tubular plate as spring plate.
Screws: Varity of cancellous lag screws and
3.5 mm and 4.5 mm cortical screws or
cannulated screws.
Marginal impaction:
-Depressed rotated fragment of the
posteromedial part of the acetabulum.
-marginal fragment is reduced into position and
buttressed by bone graft from greater
trochanter.

COLUMN SCREWS:
(A)Anterior Column Screw(ACS):
1-Retrograde used in low anterior
column fracture line.
2-Antegrade used in high anterior
column fracture line.
(B)Posterior Column Screw(PCS)
1-Retrograde .
2-Antegrade:

COMPLICATIONS:
Early complications:
1-Venous Thromboembolism.
2-Neurovascular injury: Sciatic nerve, the lateral femoral cutaneous nerve, Femoral nerve,
Superior gluteal bundle and the iliofemoral vessels.
3-Intraarticular hardware.
4-Malreducton.
5-Failure of fixation.
6-Infection.
Late complications:
1-Avascular necrosis: femoral or acetabular.
2-Posttraumatic Arthritis.
3-Heterotopic Ossification.
4-Nonunion.

•During period between January 2011 and January 2014, this study was conducted
prospectively .
•Fifty patients of associated patterns fracture acetabulum ( according to Letournel and
Judet classification) underwent surgery in Zagazig university hospitals.
•Follow up was at least for 1 year . Evaluation of the patients was done clinically and
radiologically.
•We adopted in this study in addition to standard methods of surgical treatment of open
reduction and internal fixation :
1-(modified Stoppa approach) as new trend in the surgical exposures in some patients
2-(antegrade posterior column screw) as new trend in the methods of fixation in other
patients.

•Inclusion Criteria:
1-Patients with associated patterns (Letournel & Judet classification) of fracture acetabulum.
2- Age group from 20 to 60 years old .
3-Surgical treatment within 3 weeks from time of fracture.
•Exclusion Criteria:
1-Septic focus
2-Soft tissue loss at site of incision

Patients:
1-Age and Sex distribution:
The age of the patients ranged from
(21-58)
2-Mechanism of injury:
3-Associated injuries
3-Side of injury:
The side of injury was left in (17) patient, right in (33) patients
representing and no bilateral cases.

4-Associated injuries:
Isolated acetabular injury patients were 19 , and associated injuries were present in 31
patients.
5-Time of operation:
Ranged from 3 days to 20 days from time of injury.
6-Types of fractures:

Preoperative management:
•Clinical assessment.
•Radiological assessment.
•Ten cases presented with posterior fracture dislocation (6 of them had preoperative
sciatic nerve palsy) acetabulum were reduced under general anaethesia.
• All patients received DVT prophylaxis by 40I.U. of Clexane to be stopped 12 hours
before surgery, Prophylactic broad spectrum antibiotic and urethral catheter.
•Anaesthesia: spinal anesthesia and epidural anesthesia were used for (34) patients and
general anesthesia was used for (16) patients.

Methods of surgical treatment:
Approaches:
Four types including
- KocherLangenbeck approach in 37 patients.
- The Ilio-inguinal approach in 7 patients.
- The (modified Stoppa) approach in 4
patients.
- Combined staged approaches ( Kocher
langenbeck with ilioinguinal approach) in 2
patients.

Fixation:
•The most commonly used implant was the 4.5 mm reconstruction plates (standard
and low profile) and 4.5 mm cortical screws .
•The 3.5 mm reconstruction plates with 3.5 screws
•1/3 tubular plate was used as spring plate
•Antegrade posterior column screw (>90mm long 4.5 cortical screw)
• Interfragmentry screws mostly 3.5 mm screws
•Reduction:
By Specialized instruments using methods of manual traction on radiotranslucent
table with the assistance of intraoperative flouroscopy.

Postoperative management:
•Closed suction surgical drains were used routinely for 24-48 hours.
•Prophylactic parentral broad spectrum antibiotics were used for 1 week , then oral
antibiotics for 2 weeks.
•Indomethacin (25 mg three times daily for six weeks postoperatively) .
• Subcutaneous single daily injection of (Clexane 40 IU) .
•Postoperative x-rays were done in addition to postoperative CT in some cases .
•The patients were allowed to move in bed as soon as pain tolerated. They subsequently
began physical therapy . Axillary crutches were allowed to move without weight bearing for
3 months.

Data Collection:
•The telephone numbers and addresses of the patients were recorded
•follow up evaluation was scheduled at two weeks, six weeks, three months, six months,
ninth months and one year
•At the last follow-up examination , radiographic , clinical grades and complications were
assigned.
•Radiological evaluation:
-The plain radiographs made after surgery were reviewed to assess fracture
reduction(degrees of displacement), according to Matta et al. (1986) criteria
-The followup radiographs were examined for complications e.g. avascular necrosis of the
femoral head and arthritic changes .
Displacement Grade of reduction
Zero or 1mm Anatomical
2-3mm Satisfactory
>3mm Unsatisfactory

Clinical Evaluation:
The clinical grade was
based on a modification of
the system of Merle
d'Aubigné and Postel
(Matta.1996).
Modified Merle d'Aubigné and Postel Clinical
Grading system
Points
Pain
None 6
Slight or intermittent 5
After walking but resolves 4
Moderately severe but patient is able
to walk
3
Severe, prevents walking 2
Walking
Normal 6
No cane but slight limp 5
Long distance with cane or crutch 4
Limited even with support 3
Very limited 2
Unable to walk 1
Range of
motion
95–100% 6
80–94% 5
70–79% 4
60–69% 3
50–59% 2
<50% 1
-Excellent(18points).
-Good (15, 16, or17).
-Fair (13 or 14).
-Poor (< 13).

The descriptive statistics:
Range Mean ± SD
Operation time /minute 120 min -- 300 min 180 min ± 60
Blood loss/ml 500ml -- 2800 ml 916 ml ± 482
Blood transfusion/ml 500ml -- 1500 ml 780 ml ± 350
Radiological results in this study:
Achieved reductions were anatomical
in 15 cases , 26 were satisfactory and
9 were unsatisfactory.

Clinical results:
Score N %
Excellent(18) 9 18.0
Good(15, 16, or 17) 27 54.0
Fair(13, or 14) 5 10.0
Poor( <13) 9 18.0

Relationship between clinical results and radiological results:
•Statistically ,there was significant association between clinical result and radiological
reductions.
•In 15 cases radiologically anatomic reductions ,there were 7cases excellent and 8 cases
good.
•In 26 cases with satisfactory reductions , there were 2 cases excellent , 18 cases good , 3
cases fair and 3 cases poor .
• In 9 unsatisfactory reductions , there were 1 case good , 2 cases fair and 6 cases poor.

Relationship between clinical results and Fracture type:
•Best clinical results occurred in (Transverse and posterior wall fracture ) with 12
satisfactory clinical results(5excellent+7good) out of 13 patients.
•The worst clinical results occurred in both column fractures with 7 unsatisfactory
clinical results ( 4 fair+ 3 poor) out of 17 patients.
•Statistically, there was no significant association between type of fracture and clinical
results.

Relationship between radiological results and Fracture type:
•Significant Statistical association was found between radiological results and type of
fracture as about half of anatomical results were in Transverse and posterior wall fracture
group while unsatisfactory results (9) were (4) in Both column fracture group and (5) in T
fracture.

COMPLICATION:
Some patients had more than one postoperative complication.
•Intraoperative complications:
One case iliofemoral vessels injury.
•Early Post-operative complications:
-13 cases had infection all subsided
after treatment or debridement but one
required implant removal and later
arthrodesis hip (case N 29).
-4 cases of postoperative sciatic nerve
palsy.
-2 cases had lateral cutaneus nerve
palsy .
-1 case with wound complication (angle
necrosis) (case N 16)

Late Post-operative complications:
- One patient had late infection.
-Two cases with avascular necrosis posterior wall acetabulum and 3 cases with avascular
necrosis femoral head.
-Two OA hip without AVN ,Two Heterotopic ossification cases and two cases with gluteal
muscle weakness.
-Statistical significant association was found between clinical results and late
complication as poor results associated more with complications.

Antegrade posterior column screw(APCS):
-(APCS) was performed in 3 patients ( 6% of study size) All of them were both column
fractures (17.6 % of both column fractures).
-It was applied by modified Stoppa approach in 2 cases and the ilio-inguinal approach in 1
case.
-There were no intraoperative or late postoperative complications , Early postoperative
complications were superficial infection in 1 cases and one postoperative sciatic palsy .
-All had satisfactory reduction with 1 excellent and 2 good clinical results .
-Within both column fracture group , comparison between cases with (APCS) used and
cases without showed no significance except clinical results score means , as(APCS) group
has higher scores.

Modified Stoppa approach Results:
-Modified Stoppa approach was performed in 4 patients( 8% of study size). All of
them were both column fractures (23.5% of both column fractures).
-All reductions achieved in modified Stoppa approach were satisfactory with 1 case had
excellent clinical result and 3 cases had good .
-There were no intraoperative or late postoperative complications , Early postoperative
complications were superficial infection in 2 cases and one postoperative sciatic palsy .
-Within both column fracture group , comparison between cases done by modified Stoppa
approach and those done by the ilio-inguinal approach did not show significance except in
clinical results score means favoring modified Stoppa approach.

Case (N 50):
-35 years old male driver
Preoperative Xrays and CT:
- Left Posterior column and posterior
wall fracture dislocation (reduced on
urgent basis) with marginal impaction
(not associated with any other
skeletal or extra skeletal injuries).
-Posterior (Kocher-Langenbeck)
approach ,bone graft from greater
trochanter fixation was done by low
profile 4.5 mm reconstruction plate
after fixing posterior wall by 1
interfragmentry screw.
- Reduction achieved was anatomical
,and clinical scoring was (17)good
-No complications were encountred.
-Followup period was 12 months

Case (N 50):
•postoperative Xrays :
•postoperative Xrays 1 year followup:

Case(N 3):
-21 years old , female ,college student
-Both column fracture acetabulum ,
left side(associated with left fracture
distal radius and supracondylar
fracture humerus operated and fixed
before fracture acetabulum was done)
-Operative management was through
anterior ilioinguinal approach ,
fixation was done by low profile 4.5
mm reconstruction plate and 1
interfragmentry screw .
-Reduction was satisfactory( 2 mm
displacement) and clinical scoring was
excellent
-No complications
-Follow up was 17 months

Case (N 3):
•postoperative Xrays 17 months followup:

Case (N 43)
-Female patient , 26 years old , housewife
-Right both column fracture acetabulum
(associated with ipsilateral fracture both
bone leg fixed by interlocking nail tibia
first )
-Using the modified Stoppa approach
anterior column fracture fixed by
(4.5mm) reconstruction plate while
posterior column was fixed by one long
antegrade posterior column screw.
-The reduction achieved was satisfactory
(2mm step)
-She had early superficial infection with
no other complications
-Clinical scoring was good (17)
-Folloup was 12 months.

Case (N 43):
•postoperative Xrays 12 months followup:

•Surgical treatment of associated patterns of acetabular fractures is effective but
often difficult and technically demanding .
•Early surgical intervention within 3 weeks makes reduction easier with larger
chances of anatomic reduction.
•Clinical and radiological results correlate closely as anatomic reductions
yeild best clinical results.
•Type of the fracture has significant prognostic value , as shown in this study
best results occurred in Transverse and posterior wall fractures and the worst
were among associated both column and T fractures.
•Use of Antegrade posterior column screw was necessary to fix posterior column
from anterior approach. Together with single anterior approach , they obviate
the need to combined or extenile approaches .
•Use of the modified Stoppa approach permits satisfactory reduction in the majority
of cases allowing visualization of the corona mortis, quadrilateral surface, and
posterior column . It is viable alternative to the classic ilioinguinal approach in
indicated the cases.

surgical treatment of Associated patterns fracture acetabulum

surgical treatment of Associated patterns fracture acetabulum

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