Acetabular Fractures:

Surgical Management
Philip J. Kregor, MD

Created March 2004, Revised 2007 and 2011

 Objectives
 Goal of Operative Management
 Specific Approaches for Specific Fractures
 Indications for Kocher-Langenbeck Approach
 Indications for Ilioinguinal Approach
 Reduction Strategies
 Letournel School
 Thorough Understanding of Plain Films
 Optimize One Surgical Approach
 Goal of Perfect Concentric Reduction
Approaches to the Acetabulum
 Posterior: Kocher - Langenbeck
 Anterior: Ilioinguinal
 Extensile: Extended Iliofemoral
Kocher-Langenbeck Approach
 Langenbeck (1874): Superior Limb
 Kocher (1904): Inferior Limb
 Judet and Lagrange (1958)
 Letournel
Indications in Acute Acetabular Fxs
Posterior Wall Fractures
Posterior Column Fractures
Posterior Column / Posterior Wall Fractures
Juxta-tectal / Infra-tectal Transverse or Transverse
with Posterior Wall Fractures
Some “T-type” Fractures
Access: Kocher-Langenbeck
 Entire Posterior Column
 Greater and Lesser Sciatic Notches
 Ischial Spine
 Retro-Acetabular Surface
 Ischial Tuberosity
 Ischio-Pubic Ramus
 Prone Position
 Aids in Reduction of Ischiopubic Segment
 Facilitates Palpation of Quadrilateral Surface
 Allows Clamp Placement through Greater Sciatic
Notch
 Easier Prep and Drape
Judet Table
POSTERIOR WALL
FRACTURES
Posterior Wall Fxs: Surgical Keys
 Avoid Devascularization of Fragment/s
 Remove Intra-articular Fragments
 Address Marginal Impaction
 Provide adequate buttress
 Avoid Over-Contouring of Plate
CONTROLLED DISTRACTION
OF HIP JOINT
 FEMORAL DISTRACTOR
 TRACTION TABLE
POSTERIOR WALL FX
63 Y.O. MALE
L.W. 00.09.23
L.W. 00.09.23
L.W. 00.09.23
L.W. 00.09.23
L.W. 00.10.25
L.W. 00.10.25
L.W. 00.10.25
 SPECIAL CASE:
EXTENDED POSTERIOR WALL

??? GANZ TROCHANTERIC FLIP OSTEOTOMY TO

VISULIZE FRACTURE WITHOUT DEVITALIZING
ABDUCTORS
T.D. 00.02.01
T.D. 00.02.01
T.D. 00.02.01
T.D. 00.02.01
T.D. 00.02.08
T.D. 00.02.17
Reduction Aids: Kocher-Langenbeck
Approach
 Distal Femoral Traction
 Distraction of Hip Joint
 Ischial Tuberosity Schantz Pin
 Quadrangular Clamp through Greater Sciatic
Notch
 Farabeuf Clamp
FAERBEUF CLAMPS
M.M. 98.10.27
M.M 98.10.29
M.M. 98.11.04
M.M. 98.11.05
M.M. 98.11.05
TRANSTECTAL TRANVERSE
ACETABULAR FX
18 Y.O. MALE
ISOLATED INJURY
SKINNY PATIENT / TREATED EARLY
W.M. 99.11.27
W.M. 99.11.27
W.M. 99.11.27
W.M. 99.11.27
W.M. 00.01.12
W.M. 00.01.12
W.M. 00.01.12
16 YEAR OLD FEMALE
IRREDUCABLE HIP
DISLOCATION
 T-TYPE FRACTURE
 REDUCTION OF ANTERIOR COLUMN,
FOLLOWED BY POSTERIOR COLUMN
 REDUCTION OF POSTERIOR COLUMN,
FOLLOWED BY ANTERIOR COLUMN
 CREATION OF INTACT ISCHIOPUBIC
SEGMENT, FOLLOWED BY REDUCTION TO
THE INTACT ILIUM
Farless, Ron 02.07.29
 FACTORS COMPLICATING
TRANSVERSE FRACTURE
REDUCTION
 TRANSTECTAL FRACTURE PATTERN
 SEPARATE OSSEOCHONDRAL
ARTICULAR DOME FRAGMENT
 IPSILATERAL S.I. JOINT INJURY
 SYMPHYSIS INJURY OR
CONTRALATERAL ANTERIOR RING
INJURY
Ilioinguinal Approach: Indications
 Anterior Wall
 Anterior Column
 Transverse with significant Anterior
Displacement
 Anterior Column / Posterior Hemitransverse
 Both Column
Ilioinguinal Approach: Access
Ilioinguinal Approach
CASE 4: 63 YEAR OLD ROMAN
CATHOLIC PRIEST

FELL GOING DOWN STAIRS

WHAT IS THE DIAGNOSIS ??

WARNING: MAKE THE DX

WITHOUT C.T.
WHAT IS THE DIAGNOSIS ?
TREATMENT OPTIONS?

NON-OPERATIVE?
ORIF?
TOTAL HIP?
ORIF ANTERIOR COLUMN
ACETABULAR FRACTURE

SUPINE WITH FX TABLE

ILIOINGUINAL APPROACH
NORMAL HIP AT 3 YEAR
FOLLOW-UP
R.C. 00.03.09
R.C. 00.03.09
SPUR
SIGN

R.C. 00.03.09
R.C. 00.03.09
R.C. 00.03.09
 SYMPHYSIS

A.S.I.S.
 EXT. INGUINAL RING

EXT.
OBL.
A.S.I.S.
 CONJOINT TENDON
EXT.
OBL.
EXT.
PSOAS OBL.

A.S.I.S.

L.F.C.N.
INTACT ILIUM
R.C. 00.03.10
Limitations: Kocher-Langenbeck
 Superior Acetabular Region
 Anterior Column
 Fractures High in Greater Sciatic Notch
Extended Iliofemoral Approach
“T” Type Fractures
Trans-tectal Transverse Fractures
Delayed Reconstruction
Extended Iliofemoral Approach
R.H. 98.11.21
R.H. 98.11.21
R.H. 98.11.22
R.H. 98.11.22
Anterior Column / Posterior
Hemitransverse Acetabular
Fractures
 Anterior Column /
Posterior Hemitransverse

Anterior Wall or Column

Posterior Half of Transverse Fracture

ANTERIOR COLUMN FRACTURES
ANTERIOR WALL FRACTURE
Jeff Mast, M.D.
R.M. 98.08.15
R.M. 98.08.15
R.M. 98.08.15
R.M. 98.08.15
R.M. 98.08.15
R.M. 98.08.15
R.M. 98.08.15
R.M. 98.08.24
R.M. 99.02.17
R.M. 99.02.17
R.M. 99.02.17
H.S. 99.10.02
NO SPUR SIGN

H.S. 99.10.02
H.S. 00.04.12
H.S. 00.04.12
H.S. 00.04.12
 SPECIAL CASE:
Pipkin IV addressed through Ganz
Trochanteric Flip Osteotomy with
Surgical Dislocation
 CONCLUSIONS
 Good Understanding of the Fracture
 Know the Anatomy
 Optimize One Surgical Approach
THANK YOU
 Acknowledgment

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