Executive Editor: Richard Buckley

Authors: Tania Ferguson, Daren Forward

Acetabulum - Anterior column and posterior hemitransverse

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Glossary

General considerations

This category often behaves like an isolated anterior column fracture and represents a large range in anatomical location, fracture comminution and complexity.

Thorough preoperative evaluation of the fracture will allow the majority of acetabular fractures to be managed through a single surgical approach.

The important consideration is whether the posterior element is displaced.

Many posterior fractures are not greatly displaced and can be treated by anterior approaches only, with either the modified Stoppa or ilioinguinal approach.

Displaced posterior fractures can be extremely challenging even for experienced surgeons and may require a sequential approach.

Nonoperative treatment
Main indication Skill Equipment
Minimally displaced fractures, poor quality bone, elderly less fit patients, comminuted joint fragments, early hip replacement Highly experienced and skilled surgeon Basic equipment only

Indications

  • Congruently reduced hip joint
  • Stable hip joint through range of motion
  • No evidence of progressive displacement

Advantage

  • Avoidance of risk of surgery

Disadvantages

  • Residual displacement may compromise hip replacement
ORIF through modified Stoppa approach
Main indication Skill Equipment
Approach of choice when surgery is required Highly experienced and skilled surgeon Full specialized surgical and imaging resources

This approach may be also combined with a Kocher-Langenbeck.

Indications

  • Displaced anterior element of the anterior column and posterior hemitransverse fracture

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

It is likely that use of the modified Stoppa approach will make the need for a sequential approach unnecessary in comparison to using the ilioinguinal for the anterior approach.

ORIF through ilioinguinal approach
Main indication Skill Equipment
Surgeon’s preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Displaced anterior column fracture with minimally displaced posterior hemitransverse fracture

Disadvantages

  • Difficulty with visualization and controlling hemorrhage from the corona mortis
  • Difficulty with instrumentation of the quadrilateral surface
ORIF through sequential approaches
Main indication Skill Equipment
Displaced anterior element of the anterior column and posterior hemitransverse fracture following anterior approach and fixation Highly experienced and skilled surgeon Full specialized surgical and imaging resources

A sequential approach, an anterior approach plus a Kocher-Langenbeck for the posterior-inferior segment, is sometimes necessary. The anterior approach may be either the modified Stoppa or the ilioinguinal approach.

Advantage

  • Direct reduction and stabilization of segment not easily reached from an anterior approach alone

Disadvantages

  • Risks of surgery
  • Long procedure time and blood loss
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2017-11-27