Executive Editor: Richard Buckley

Authors: Tania Ferguson, Daren Forward

Acetabulum - Posterior wall

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Glossary

General considerations

Important factors for decision making are:

  • Stability of the hip
  • Size of the fragment
  • Degree of comminution
  • Age of the patient

The outcome is often surprisingly poor.

If surgery is indicated, variations of the Kocher-Langenbeck approach are used. These include the Gibson approach and the trochanter osteotomy extension.

The approach utilized is primarily dictated by the location of the major wall components. Most fractures can be addressed through a standard Kocher-Langenbeck approach. Patterns with significant superior extension may require a trochanter osteotomy.

Nonoperative treatment
Main indication Skill Equipment
Stable hip with a concentric reduction, no intraarticular fragments confirmed on CT with a small posterior wall fragment in elderly patients Highly experienced and skilled surgeon Basic equipment only

The gold standard for stability is an examination under anesthetic but an indication of stability will come from the percentage size of the wall fragment. If the fragment is less than 20% of the depth of the posterior wall then the hip is likely to be stable.

Contraindications

  • Progressive sciatic nerve deficit

Advantages

  • Avoidance of risks of surgery
  • Preservation of the soft tissue approach for later hip replacement

Disadvantages

  • Risk of late instability
ORIF through Kocher-Langenbeck
Main indication Skill Equipment
Approach of choice, most suited to smaller, more inferior fragment of the posterior wall Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Variations include the Gibson approach and the use of a trochanter osteotomy extension. As the fragment increases in size and extends superiorly, a trochanter osteotomy extension may become more favorable.

Advantages for approach

  • Smaller, simpler and less demanding surgery

Disadvantages

  • May not allow enough visualization and reduction of larger fragments
ORIF through trochanter osteotomy extension
Main indication Skill Equipment
Larger, more superiorly extending posterior wall fragment Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Advantages for approach

  • Much improved visualization of the superior column, wall and joint area
  • Allows surgical dislocation of the hip

Disadvantages

  • More demanding surgical technique
  • Increased blood loss
  • Potential of greater trochanter non-union
  • Increased heterotopic ossification formation
*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