Suresh Pandey

Consultant Orthopedic Surgeon

COMS
Plan? 28 M RTA with associated
femur and tibia ipsilateral
shaft fracture
Combined approach; KL and
Modified Iliofemoral
KL + Modified Iliofemoral approach
Background
 Complex area of Orthopedics
 Learning curve steep
 Low energy in elderly and high in young
 Good reduction is the most important determinant of
outcome (Matta, Leutornell, Judet)
Weight bearing area: Roof
Associated Injury
Neurovascular structure to be taken care of

 Ext iliac vessels

 Sciatic, femoral and
LCN
 Superior gluteal n and
vessels
 Corona Mortis
classification
Most Common
 Posterior wall, transverse and both column constitute
2/3rd
Imaging package
Roof arc measurement
 Tells fracture line exits (whether inside the dome or
outside)
 Stable if >45 deg
 Not applicable in post wall or both column fracture
Wall vs column vs transverse
Conservative
Operative
Timing of Surgery
 Ideal 5-7 days
 >3 weeks too late
 Before 2 weeks reasonable
Approach
Anterior
 Ilioinguinal
 Modified Stoppa
 Combined
 Iliofemoral extended
 Modification of Iliofemoral
Posterior
 Kocher Langenbeck
 Trochanteric osteotomy
KL Approach
Prone Vs lateral
 Reduction easy
 Maintain knee flexion and hip extension
 Traction table or trochanteric traction
 Trochanteric osteotomy: Anterior extension of fracture
in wall or column or muscular or obese patient.
 Better visualization due to lifting up of abductors
Modification of Iliofemoral
In out In technique for anterior
column

AIIS
ASIS
Anterior Ilioinguinal Approach
Division of Iliopectineal fascia and access area
Modified Stoppa approach
Access area in Modified Stoppa
approach
Ilioinguinal vs Modified Stoppa
 Blood loss more
 More operative time
 Increased risk of NV injury
 Less accurate reduction
 Visualization and fixation of quadrilateral plate
difficult
Reduction instruments
Reduction techniques
Post wall KL approach
 Avoid devascularization of
the fragment
 Remove I/A fragment if any
 Fragments with screws and
supplement with buttress
plate
 Avoid overcountering
Post Column KL approach
Access increased with
Troch Osteotomy
Plate or lag screw with
plate
Anterior wall and column
 Isolated Ant wall
uncommon
 Ant Ilioing/Iliofemoral
approach/ Modified
Stoppa or combination
 Contoured plate along
pelvic brim
Transverse fracture with or without
posterior wall
 Presents spectrum of
difficulty
 Transtectal have worst
prognosis
 Infratectal can be treated
conservatively
 Approach: posterior,
anterior or combined
 Screw, plates and
combinations
Both column fracture
 Most difficult
 T type fracture with
transv component above
the dome
 Reduction begins at
most proximal and then
towards joint
 Apporach combined
Combined approach with both
column fixation
Posterior wall fracture with
incarcerated fragment
KL approach
Bilateral transverse Fracture
Prognostic factors for acetabulum
 Accuracy of redn
 Age
 Soft tissue
 Injury to femoral head
 Fracture location, severity and morphology
Complications
 Neurovascular injury: 6%
 Infection: 4%
 DVT
 AVN: 7.5%
 Post traumatic OA: 10-35%
 HO: 14-50% without prophylaxis
 Mortality: 2.5%
Take home…
 Approach decided by fracture location, geometry, soft
tissue status and experience
 Prognosis depends on patient and surgeon factors

Accurate reduction (<2 mm of step) is key to success