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.
|Minimally displaced fractures, poor quality bone, elderly less fit patients, comminuted joint fragments, early hip replacement|
- Congruently reduced hip joint
- Stable hip joint through range of motion
- No evidence of progressive displacement
- Avoidance of risk of surgery
- 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 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|
- Displaced anterior column fracture with minimally displaced posterior hemitransverse fracture
- Difficulty with visualization and controlling hemorrhage from the corona mortis
- Difficulty with instrumentation of the quadrilateral surface
|ORIF through sequential approaches|
|Displaced anterior element of the anterior column and posterior hemitransverse fracture following anterior approach and fixation|
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.
- Direct reduction and stabilization of segment not easily reached from an anterior approach alone
- Risks of surgery
- Long procedure time and blood loss
|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|