Executive Editor: Richard Buckley

Authors: Tania Ferguson, Daren Forward

Acetabulum - T-type

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Glossary

General considerations

ORIF is the optimal operative treatment for most fractures.

The fracture anatomy must be carefully understood in planning surgical tactic. The anterior element is usually displaced.

The posterior, inferior segment of the fracture will dictate the approach used. If this part is undisplaced, then the fracture will behave in a similar fashion to a transverse fracture and may be approached anteriorly or posteriorly, but usually anteriorly through a modified Stoppa or ilioinguinal approach.

If both the anterior element and the posterior, inferior fragments are displaced, then likely a sequential approach, anteriorly and posteriorly, is required, or alternatively and less frequently an extended iliofemoral approach.

For severe arthrosis or osteoporosis, total joint replacement should be considered.

Nonoperative treatment
Main indication Skill Equipment
Undisplaced fractures, elderly or unfit patients Highly experienced and skilled surgeon Basic equipment only

Consideration can be given to initial nonoperative treatment followed by planned total 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 in a sequential approach.

Indications

  • Displaced anterior column fracture
  • 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, anterior wall fragments associated with anterior column fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

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-inferior quadrant of T-type 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.

Advantages

  • 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-inferior 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 for approach

  • 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