Executive Editor: Richard Buckley

Authors: Tania Ferguson, Daren Forward

Acetabulum - Transverse and posterior wall

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Glossary

General considerations

Important factors for decision making will be the stability of the hip, size of the fragment and the degree of comminution. The outcome is often poor.

The higher the fracture, the more likely surgery will be required.

Unlike in the isolated transverse fracture, the presence of the posterior wall fragment requires a posterior approach.

The wall fragment may make it impossible for the main fracture to be stabilized without the wall already being reduced.

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

Some surgeons favor a sequential approach combining posterior and anterior approaches.

Surgery is urgent for:

  • Irreducible dislocation
  • Hip joint incongruence with risk of femoral head damage

ORIF is the optimal operative treatment for most fractures. For severe arthrosis or osteoporosis, total joint replacement should be considered.

Nonoperative treatment
Main indication Skill Equipment
Stable hip with a concentric reduction, no intraarticular fragments identified on CT with a small posterior wall fragment or low infratectal fractures in an elderly patient Highly experienced and skilled surgeon Basic equipment only

The greater the roof arc angle, the more suitable the fracture for nonoperative treatment.

Caution
Transtectal transverse fractures significantly involve the weight bearing articular surface, so that any displacement or gap may compromise outcome. Thus, surgical repair is more strongly indicated.

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 of this approach include the Gibson approach and the use of a trochanter osteotomy extension. As the posterior wall fragment increases in size and extends superiorly, enlargement with a trochanter osteotomy extension may be more favorable.

Advantages of Kocher-Langenbeck

  • Smaller, simpler and less demanding surgery

Disadvantages of Kocher-Langenbeck

  • May not allow enough visualization and reduction of larger fragments

Advantages of the trochanter osteotomy extension

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

Disadvantages of the trochanter osteotomy extension

  • More demanding surgical technique
  • Increased blood loss
  • Potential of greater trochanter non-union
  • Increased heterotopic ossification formation
ORIF through extended iliofemoral approach
Main indication Skill Equipment
Significant anterior displacement of the transverse element of the fracture Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Indications

  • Displaced transverse fracture, especially transtectal or juxtatectal types

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