Executive Editor: Richard Buckley

Authors: Tania Ferguson, Daren Forward

Acetabulum - Both columns

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Glossary

General considerations

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.

Nonoperative treatment
Main indication Skill Equipment
Undisplaced fractures, highly comminuted fractures planned for a delayed total hip replacement which may include fractures with secondary congruence Highly experienced and skilled surgeon Basic equipment only

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 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

Disadvantage

  • Difficulty with reducing small peripheral anterior wall fragments associated with the anterior column fracture
ORIF through ilioinguinal approach
Main indication Skill Equipment
Surgeon’s preference Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indication

  • Large anterior wall fragment associated with the anterior column 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 posterior elements 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 if this cannot be reduced from the anterior approach. 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
ORIF through extended iliofemoral approach
Main indication Skill Equipment
Displaced anterior and posterior elements Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Possible contraindications

  • Physiologic instability
  • Poor wound healing following this extended approach (higher risk with traumatic skin injury)

Advantages

  • Great visualization of the acetabulum
  • Direct control of both anterior and posterior fracture segments simultaneously

Disadvantages

  • 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.

*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