Executive Editor: Richard Buckley

Authors: Tania Ferguson, Daren Forward

Acetabulum - Transverse

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Glossary

General considerations

Transverse fractures are often displaced, requiring surgery. The higher the fracture, the more likely surgery will be required.

The approach used is dictated by the location of the maximum displacement, whether anterior or posterior. Typically, a posterior approach will be used. The Kocher-Langenbeck approach is satisfactory for most transverse fractures.

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

Fracture reduction can be difficult and it is possible to reduce for example the posterior fracture apparently perfectly, but with significant anterior displacement remaining.

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

Surgery is urgent for:

  • Irreducible dislocation
  • Hip joint incongruity with risk of femoral head damage
Nonoperative treatment
Main indication Skill Equipment
Undisplaced fractures with a congruent hip joint, low infratectal fractures Highly experienced and skilled surgeon Basic equipment only

The greater the roof arc angle, the more suitable the fracture for nonoperative treatment (roof arc angle >30° anteriorly, >45° in the mid zone, and >60° posteriorly).

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.

Advantages

  • Avoidance of risk of surgery
ORIF through Kocher-Langenbeck
Main indication Skill Equipment
Displacement of mainly the posterior portion Highly experienced and skilled surgeon Full specialized surgical and imaging resources

This approach can be enlarged with the trochanter osteotomy extension.

Advantages for approach

  • Easy manipulation of fracture fragments
  • Easy control of low fractures

Disadvantages

  • Heterotopic bone formation
  • Interference with subsequent hip replacement
ORIF through modified Stoppa approach
Main indication Skill Equipment
Transtectal or juxtatectal fracture with more anterior displacement Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Advantages for approach

  • No compromise of any subsequent hip replacement
  • Easier to control the anterior element of the fracture than with Kocher-Langenbeck
  • Much better soft tissue healing than with the extended iliofemoral approach

Disadvantages

  • More demanding approach and fixation than with Kocher-Langenbeck
  • Difficulties to stabilize low fractures
  • Joint not directly visualized
ORIF through extended iliofemoral approach
Main indication Skill Equipment
Comminuted, transtectal or juxtatectal fracture, displaced fracture with delayed presentation 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