Although considered to be the most challenging acetabular fracture type, the associated both column fracture often behaves and can be treated like a simpler fracture pattern, typically the anterior column fracture or anterior column/posterior hemitransverse fracture.
Usually a single anterior approach, modified Stoppa or ilioinguinal approach, is sufficient.
|Undisplaced fractures, highly comminuted fractures planned for a delayed total hip replacement which may include fractures with secondary congruence|
- Residual displacement may compromise hip replacement
|ORIF through modified Stoppa approach|
|Approach of choice when surgery is required|
This approach may be also combined with a Kocher-Langenbeck.
- Displaced associated both column fractures
- Incongruent hip joint
Advantages for approach
- Much improved visualization of the column
- Direct instrumentation of the quadrilateral surface
- Easy control of the corona mortis
- Easy access to the pubic symphysis
- Reduced dissection of the inguinal canal
- Difficulty with reducing small peripheral anterior wall fragments associated with the anterior column fracture
|ORIF through ilioinguinal approach|
- Large anterior wall fragment associated with the anterior column fracture
- Difficulty with visualization and controlling hemorrhage from the corona mortis
- Difficulty with instrumentation of the quadrilateral surface
|ORIF through sequential approaches|
|Displaced posterior elements following anterior approach and fixation|
A sequential approach, an anterior approach plus a Kocher-Langenbeck for the posterior-inferior segment if this cannot be reduced from the anterior approach. The anterior approach may be either the modified Stoppa or the ilioinguinal approach.
- Direct reduction and stabilization of segment not easily reached from an anterior approach alone
- Risks of surgery
- Long procedure time and blood loss
|ORIF through extended iliofemoral approach|
|Displaced anterior and posterior elements|
- Physiologic instability
- Poor wound healing following this extended approach (higher risk with traumatic skin injury)
- Great visualization of the acetabulum
- Direct control of both anterior and posterior fracture segments simultaneously
- Risks of surgery
For some surgeons, the risk of wound breakdown is sufficiently great that they would choose two approaches over this single, combined approach.
|Basic surgical experience, no specialized skills|
|Some specialized surgical experience|
|Highly experienced and skilled surgeon|
|Basic equipment only|
|Simple surgical and imaging resources|
|Full specialized surgical and imaging resources|