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Acetabular Fracture ORIF - Kocher-Langenbeck Approach

Complete surgical technique guide for the Kocher-Langenbeck posterior approach to acetabular fractures - the workhorse approach for posterior wall, posterior column, and transverse fracture patterns. FRCS exam preparation.

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High Yield Overview

KOCHER-LANGENBECK APPROACH TO THE ACETABULUM

Workhorse Posterior Approach | 80% of Acetabular Fractures | Advanced Trauma

Indications

Fracture Patterns Requiring Kocher-Langenbeck:

  • Posterior wall fracture - involving more than 40% of wall or causing hip instability
  • Posterior column fracture - displaced more than 2mm with articular incongruity
  • Transverse fracture - when posterior displacement predominates
  • T-type fracture - when posterior component is primary
  • Transverse + posterior wall - classic indication for this approach
  • Posterior column + posterior wall - associated pattern requiring posterior access

Radiographic Criteria:

  • Articular step-off more than 2mm on CT
  • Posterior wall involvement more than 40% (arc method)
  • Hip instability on stress fluoroscopy
  • Marginal impaction requiring elevation and grafting
  • Intra-articular fragments requiring removal

Pre-operative Planning

History:

  • Mechanism: Dashboard injury (posterior wall), fall from height, high-energy MVA
  • Time since injury (dislocation more than 6 hours increases AVN risk)
  • Associated injuries (head, chest, abdomen - polytrauma common)
  • Pre-injury mobility and occupation

Examination:

  • Sciatic nerve function - CRITICAL baseline documentation
    • Common peroneal: ankle dorsiflexion, EHL, sensation dorsal foot
    • Tibial: ankle plantarflexion, FHL, sensation sole
  • Hip position (flexed, internally rotated = posterior dislocation)
  • Posterior gluteal skin - bruising, Morel-Lavallee lesion, abrasions
  • Peripheral pulses

EXAM KEY: "I document detailed sciatic nerve examination BEFORE surgery. The approach places the nerve at risk, and I need baseline for comparison. Nerve injury occurs in 10-15% of cases."

Equipment

Implants

  • 3.5mm pelvic reconstruction plates (8-14 hole)
  • Pre-contoured posterior wall plates
  • 3.5mm cortical screws (16-50mm)
  • Spring plates for comminution
  • 4.0mm cannulated screws
  • Buttress plates for wall support

Instruments

  • Large pelvic reduction set
  • Pointed reduction forceps (Weber, Farabeuf)
  • Ball spike pushers
  • Blunt Hohmann retractors (essential)
  • Schanz pins (5.0mm)
  • Bone graft harvesting instruments
  • Heavy sutures for rotator tagging

Adjuncts

  • Fluoroscopy (C-arm)
  • Cell saver (blood loss 500-1500ml)
  • Beanbag positioner
  • Radiolucent table
  • 4 units PRBC crossmatched
  • TXA 1g IV at induction
  • Nerve stimulator (optional)

Anaesthesia and Positioning

Type: General anaesthesia (mandatory)

  • Muscle relaxation essential for reduction
  • Lateral decubitus precludes spinal alone
  • Consider arterial line for polytrauma

Adjuncts:

  • Tranexamic acid 1g IV at induction, repeat at 3 hours
  • Cell saver for blood conservation
  • Warming blanket (forced air)

Considerations:

  • Antibiotic prophylaxis: Cefazolin 2g IV within 60 minutes of incision
  • Repeat antibiotics every 4 hours or 1.5L blood loss
  • Avoid prolonged hypotension (increases AVN risk if dislocation present)

Surface Anatomy and Landmarks

Critical Surface Landmarks

Imaging

Bilateral posterior hip dislocation with acetabular fracture - CT and intraoperative view
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Multi-panel demonstrating bilateral posterior hip dislocation (top left radiographs), 3D CT reconstruction showing posterior wall fractures (bottom left panels), and intraoperative photos of posterior acetabular exposure via Kocher-Langenbeck approach (right panels) showing fracture reduction and fixationCredit: Keel MJ et al. via Eur J Trauma Emerg Surg via Open-i (NIH) (Open Access (CC BY))
Intraoperative photos of posterior acetabular exposure with radiographs
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Intraoperative photos showing posterior acetabular exposure (top panels) with pre-reduction radiographs (bottom left) and post-reduction radiographs (bottom right) demonstrating restoration of hip joint congruityCredit: Keel MJ et al. via Eur J Trauma Emerg Surg via Open-i (NIH) (Open Access (CC BY))
Acetabular fracture imaging and surgical approach demonstration
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Multi-panel showing AP pelvic radiograph with acetabular fracture (top left), axial CT demonstrating fracture pattern (top center), 3D CT reconstruction (top right), patient positioning in lateral decubitus for Kocher-Langenbeck approach (bottom left), and intraoperative photos of posterior exposure (bottom panels)Credit: Magu NK et al. via Indian J Orthop via Open-i (NIH) (Open Access (CC BY))
Pelvic radiographs showing acetabular fracture with posterior wall fragment
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Three-panel pelvic radiographs: AP view showing posterior wall fragment seated over femoral head like a cap with congruous joint (left), obturator oblique view demonstrating posterior column and anterior wall (center), and iliac oblique view showing posterior wall fragment (right)Credit: Magu NK et al. via Indian J Orthop via Open-i (NIH) (Open Access (CC BY))

Surgical Approach

Internervous Plane

The Kocher-Langenbeck approach uses the interval between:

  • Superior gluteal nerve (L4, L5, S1) - supplies gluteus medius and minimus
  • Inferior gluteal nerve (L5, S1, S2) - supplies gluteus maximus

The gluteus maximus is split in line with its fibres, NOT detached from its insertion.

Incision

Configuration: Curvilinear, hockey-stick shaped

  • Begin 10cm distal to PSIS, curve over posterior greater trochanter
  • Continue along lateral femoral shaft for 8-10cm distal to trochanter
  • Total length: 15-20cm

Layers:

  1. Skin and subcutaneous tissue
  2. Fascia lata (thick layer over trochanter)
  3. Gluteus maximus (split in line with fibres)

Superficial Dissection

  1. Incise skin and subcutaneous fat
  2. Identify fascia lata over greater trochanter - incise in line with skin
  3. Identify gluteus maximus fibres running obliquely (superomedial to inferolateral)
  4. Split gluteus maximus in line with its fibres using blunt finger dissection
  5. Control bleeding from superior and inferior gluteal vessels at proximal extent

Superior Gluteal Nerve

The superior gluteal neurovascular bundle exits above piriformis, 3-4cm from the acetabular rim. Do NOT extend the split of gluteus maximus more than 4-5cm proximal to the greater trochanter.

Deep Dissection and Sciatic Nerve Identification

Sciatic Nerve - Critical Step

Finding the Sciatic Nerve

Landmark: Fat pad overlying quadratus femoris muscle

The sciatic nerve lies 1-2cm medial to the lateral border of quadratus femoris at the level of the ischium. It exits the pelvis through the greater sciatic notch, BELOW the piriformis muscle in 90% of cases.

Identification Steps:

  1. After splitting gluteus maximus, identify the fat pad over quadratus femoris
  2. Gently palpate for a cord-like structure medial to the muscle
  3. The nerve should feel mobile and soft (not tethered)
  4. Place a blunt Hohmann retractor MEDIAL to the nerve to protect it throughout

EXAM KEY: "I always identify the sciatic nerve before any deep dissection. It lies in the fat pad medial to quadratus femoris. I protect it with a blunt retractor positioned medially."

Release of Short External Rotators

Mnemonic

Piriformis, Gemellus superior, Obturator internus, Gemellus inferior, Obturator externus, Quadratus femorisPGOGOQ - Short External Rotators

Technique:

  1. Identify piriformis at superior border of greater trochanter
  2. Place tagging suture (2-0 Ethibond) in tendon before release
  3. Release piriformis 1-2cm from insertion with diathermy
  4. Repeat for gemellus superior, obturator internus, gemellus inferior
  5. Preserve quadratus femoris when possible (protects medial femoral circumflex artery)
  6. Preserve obturator externus (deep, protects MFCA)

Vascular Anatomy

Medial femoral circumflex artery (MFCA) provides the blood supply to the femoral head. It runs between obturator externus and quadratus femoris. Dividing these muscles increases AVN risk. Preserve both if possible.

Capsulotomy and Joint Inspection

  1. Perform posterior capsulotomy parallel to acetabular rim
  2. Place stay sutures for later repair
  3. Flex hip gently and apply traction to visualize joint
  4. Remove loose osteochondral fragments and haematoma
  5. Assess articular surface for:
    • Marginal impaction (present in 50%)
    • Cartilage damage
    • Femoral head injury (Pipkin)

Critical Danger Structures

Structures at Risk in Kocher-Langenbeck

Operative Technique

Step-by-Step Procedure

Step 1: Positioning and Preparation

  1. Position lateral decubitus with affected hip up
  2. Pelvis perpendicular to table (confirm on AP fluoro)
  3. Hip flexed 30-40 degrees, knee flexed 90 degrees (relaxes sciatic nerve)
  4. Beanbag or pelvic supports for stability
  5. Prep from iliac crest to mid-thigh, include knee in field
  6. Mark incision before prep

Exam Pearl

Technical Pearl: "Hip and knee flexion is NOT optional - it relaxes the sciatic nerve and significantly reduces the risk of traction injury during the procedure."

Step 2: Incision and Approach to Gluteus Maximus

  1. Make 15-20cm curvilinear incision
  2. Begin 10cm distal to PSIS, curve over greater trochanter
  3. Continue along lateral femoral shaft 8-10cm
  4. Divide subcutaneous fat and fascia lata
  5. Identify gluteus maximus fibres (oblique orientation)

Step 3: Split Gluteus Maximus and Identify Sciatic Nerve

  1. Split gluteus maximus in line with fibres using blunt dissection
  2. Do NOT extend split more than 4-5cm proximal to trochanter
  3. Control bleeding from gluteal vessels
  4. Identify fat pad over quadratus femoris
  5. Identify sciatic nerve 1-2cm medial to QF
  6. Place blunt Hohmann retractor MEDIAL to nerve for protection

Sciatic Nerve Protection Protocol

Throughout the procedure:

  • Maintain hip and knee flexion
  • Use ONLY blunt retractors near nerve
  • Release retractors every 15 minutes
  • Avoid extending hip with retractors in place
  • Check nerve position before placing any screws

Step 4: Release and Tag Short External Rotators

  1. Identify piriformis at superior trochanter
  2. Tag with heavy suture (2-0 Ethibond) before release
  3. Release 1-2cm from insertion using diathermy
  4. Repeat for gemellus superior, obturator internus, gemellus inferior
  5. Preserve quadratus femoris and obturator externus (MFCA protection)
  6. Reflect rotator cuff posteriorly (protects nerve)

Exam Pearl

Technical Pearl: "I release the rotators close to their insertion and TAG them with suture. This allows anatomic repair at closure which reduces dislocation risk from 10% to less than 2%."

Step 5: Capsulotomy and Joint Inspection

  1. Perform posterior capsulotomy parallel to rim
  2. Place stay sutures for later repair
  3. Flex hip and apply gentle traction
  4. Remove all loose bodies (chondral fragments, bone, haematoma)
  5. Assess articular surface systematically
  6. Look for marginal impaction (present in 50% of posterior wall fractures)

Step 6: Expose Posterior Column and Wall

  1. Place three Hohmann retractors for exposure:
    • Greater sciatic notch (PROTECT SCIATIC NERVE)
    • Ischium inferiorly
    • Ilium/posterior column superiorly
  2. Use periosteal elevator to clear fracture surfaces
  3. Identify all fracture fragments
  4. Clear haematoma and fibrous tissue
  5. Map out fracture pattern before reduction

Step 7: Reduce Posterior Column

Principle: Reduce column FIRST - it is the stable reference

  1. Place Schanz pin or ball spike in ischial fragment
  2. Manipulate to reduce column to intact ilium
  3. Apply pointed reduction forceps or Farabeuf clamps
  4. Confirm reduction on obturator oblique (best view for posterior column)
  5. Hold with 2.0mm K-wires

Exam Pearl

Technical Pearl: "The obturator oblique view shows the posterior column in profile. This is my go-to view for assessing posterior column reduction. I aim for less than 1mm step."

Step 8: Address Marginal Impaction and Reduce Posterior Wall

Marginal Impaction (if present):

  1. Identify impacted fragment through joint
  2. Elevate using Freer elevator or curette from within the joint
  3. Fill metaphyseal void with cancellous autograft:
    • Femoral head (if damaged from dislocation)
    • Greater trochanter
    • Iliac crest
  4. Support elevated fragment with graft before wall reduction

Wall Reduction:

  1. Reduce wall fragments to column using pointed forceps
  2. Maintain reduction with K-wires
  3. Assess reduction on iliac oblique (best view for posterior wall)

Step 9: Apply Posterior Column Plate

  1. Contour 3.5mm pelvic reconstruction plate to posterior column
  2. Plate from ischium to ilium along posterior column
  3. Position on posterior column surface
  4. Minimum 3 bicortical screws each side of fracture
  5. Check screw lengths - avoid joint penetration

Screw Safety

  • Ischial screws: maximum 20mm (pudendal vessels/rectum medially)
  • Screws toward joint: confirm on iliac oblique (shows posterior wall/joint)
  • If in doubt, use shorter screw - safety over purchase

Step 10: Apply Posterior Wall Fixation

Technique: Buttress plating perpendicular to column

  1. Position 3.5mm plate perpendicular to column plate (L or T configuration)
  2. Plate BUTTRESSES wall fragments - prevents displacement into joint
  3. For small/comminuted fragments: use spring plates
  4. Alternative: 3.5-4.0mm lag screws if geometry allows
  5. Check all screw positions on iliac oblique

Exam Pearl

Technical Pearl: "The wall plate is a BUTTRESS - it prevents the wall from displacing into the joint. I position it perpendicular to the column plate. Spring plates are excellent for comminuted fragments."

Step 11: Assess Stability and Range of Motion

  1. Remove all retractors
  2. Reduce hip and test stability
  3. Apply axial load with hip flexed - assess for subluxation
  4. Range hip through flexion, internal rotation
  5. Check for smooth motion without crepitus
  6. If unstable: reassess fixation, consider additional plates

Step 12: Final Fluoroscopic Assessment

Required Views:

  1. AP pelvis - overall reduction, joint space
  2. Inlet (25-degree caudal) - anterior/posterior displacement
  3. Outlet (45-degree cranial) - vertical displacement
  4. Obturator oblique - posterior column, anterior wall
  5. Iliac oblique - anterior column, POSTERIOR WALL (key for joint penetration)

Confirm:

  • Anatomic reduction (less than 2mm step)
  • No intra-articular hardware
  • No loose bodies
  • Adequate fixation of all fragments

Step 13: Repair Short External Rotators and Capsule

  1. Repair posterior capsule with 0-Vicryl
  2. Repair short external rotators using tagged sutures
  3. Reattach to posterior capsule/trochanter insertion
  4. Ensure appropriate tension (not too tight - limits ROM)

Exam Pearl

Technical Pearl: "Anatomic repair of the short external rotators reduces posterior dislocation risk from 10% to less than 2%. This is NOT optional."

Step 14: Closure and Drain Placement

  1. Close gluteus maximus fascia with 1-0 Vicryl
  2. Place deep drain (19Fr Blake) under gluteus maximus
  3. Close fascia lata with 0-Vicryl
  4. Subcutaneous closure 2-0 Vicryl
  5. Skin: staples or 3-0 Monocryl subcuticular

Intra-operative Complications

Rate: 10-15% (higher with associated posterior dislocation - up to 25%)

Recognition:

  • Usually not apparent intraoperatively
  • Post-operative: foot drop (common peroneal), weakness of ankle plantar/dorsiflexion
  • Pre-operative documentation essential for comparison

Prevention:

  • Identify nerve EARLY via fat pad over quadratus femoris
  • Maintain hip and knee FLEXION throughout
  • Use ONLY blunt retractors near nerve
  • Release retractors every 15 minutes
  • Never extend hip with retractors in place
  • Flex hip when reducing posterior wall fragments

Management:

  • Most are neuropraxias from traction - expect recovery over 6-18 months
  • Document findings and compare with pre-operative baseline
  • EMG at 6 weeks if no recovery - assess for axonotmesis
  • AFO for foot drop during recovery
  • Neurosurgical referral if no recovery by 6 months

Post-operative Care

Monitoring:

  • ICU/HDU if polytrauma or significant blood loss
  • Sciatic nerve checks every 2 hours for 24 hours
  • Compare with documented pre-operative function
  • Monitor drain output

Medications:

  • DVT prophylaxis: LMWH (Enoxaparin 40mg daily) from Day 1
  • HO prophylaxis within 24 hours:
    • Indomethacin 25mg TDS for 6 weeks OR
    • Single-fraction radiation 700cGy within 72 hours
  • PCA then oral analgesia

Drains:

  • Remove when output less than 30ml per 8-hour shift
  • Typically Day 2-3
  • Prolonged drainage increases HO risk

Viva Scenarios

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 35-year-old man sustains a posterior wall acetabular fracture with associated posterior hip dislocation. He presents to your emergency department 4 hours after the injury. Describe your management."

EXCEPTIONAL ANSWER
This patient has a posterior wall fracture with posterior hip dislocation. My priorities are urgent closed reduction of the dislocation followed by definitive assessment and surgical planning. **Immediate Management:** 1. ATLS assessment - this is a high-energy injury and I need to exclude other injuries 2. Analgesia and sedation 3. Clinical documentation: I document detailed sciatic nerve examination BEFORE any manipulation, as the nerve is at risk from the dislocation and any subsequent surgery. I check ankle dorsiflexion (common peroneal), plantarflexion (tibial), and sensation in both distributions. 4. Urgent closed reduction under sedation or general anaesthesia. The goal is to reduce the hip within 6 hours of injury to minimise AVN risk. I use the Allis or Stimson manoeuvre - the Allis technique involves flexing the hip and knee to 90 degrees and applying axial traction along the femur while an assistant stabilises the pelvis. 5. Post-reduction AP pelvis X-ray to confirm concentric reduction 6. Post-reduction sciatic nerve check and documentation **Definitive Assessment:** Once reduced, I obtain a CT scan with 3D reconstruction to assess: - Posterior wall percentage using the arc method on sagittal cuts - Marginal impaction (present in 50% of cases) - Free intra-articular fragments - Femoral head injury (Pipkin fracture) - Posterior column involvement **Surgical Decision:** The posterior wall 40% rule states that fractures involving more than 40% of the posterior wall cause hip instability and require fixation. Even with smaller fragments, I would perform dynamic stress testing under fluoroscopy - if the hip subluxates with axial load in flexion, it requires fixation. For this patient, assuming significant wall involvement and instability, I would plan Kocher-Langenbeck approach and ORIF within 5-7 days once soft tissues allow, but ideally within 2 weeks for optimal reduction. **Key Points:** - Closed reduction within 6 hours minimises AVN risk - Document sciatic nerve function before and after reduction - CT essential for surgical planning - Posterior wall more than 40% or dynamic instability = surgery
VIVA SCENARIOStandard

EXAMINER

"During a Kocher-Langenbeck approach for posterior wall ORIF, you notice the patient has post-operative foot drop. The pre-operative sciatic nerve examination was normal. How do you assess and manage this?"

EXCEPTIONAL ANSWER
Post-operative sciatic nerve palsy after Kocher-Langenbeck approach occurs in 10-15% of cases. In this scenario where pre-operative function was normal and post-operative deficit is present, the injury occurred during surgery. Most are traction neuropraxias from retractor pressure or positioning. **Immediate Assessment:** 1. Confirm the clinical findings: I examine ankle dorsiflexion and eversion (common peroneal), toe extension (deep peroneal), ankle plantarflexion and toe flexion (tibial), and sensation in both distributions. I document findings using the MRC power grading scale. 2. Review the operative note for any concerning events: prolonged retractor time, difficult reduction requiring manipulation, or direct nerve visualisation. 3. Foot drop suggests common peroneal division involvement (more superficial and vulnerable), though mixed injuries are common. **Investigations:** - Nerve conduction studies and EMG at 6 weeks - this is the earliest time that denervation potentials become apparent - The EMG helps differentiate: - Neuropraxia: conduction block only, best prognosis - Axonotmesis: axonal damage with intact nerve sheath, recovery expected but slower - Neurotmesis: complete nerve transection, poor prognosis without repair **Management:** 1. **Reassurance:** The majority (90%) are neuropraxias from retraction and will recover over 6-18 months. I explain this to the patient and family. 2. **AFO (Ankle-Foot Orthosis):** An AFO prevents foot drop during gait, reduces falls risk, and maintains the ankle in neutral position to prevent equinus contracture. 3. **Physiotherapy:** Passive ROM exercises to prevent contractures, gentle strengthening as recovery occurs, gait training with AFO. 4. **Serial clinical assessment:** Monthly examination documenting any signs of recovery - earliest sign is usually return of sensation in web space (superficial peroneal), followed by motor recovery. 5. **Repeat EMG at 3-6 months:** If no clinical improvement, repeat EMG to assess for reinnervation potentials which indicate recovery. **Indications for Surgical Exploration:** If there is no clinical or EMG evidence of recovery by 6 months, I would consider: - MRI of the sciatic nerve to assess continuity - Neurosurgical referral for possible exploration - However, direct repair is rarely possible and outcomes are guarded - Nerve transfer or tendon transfer may be considered for permanent deficits **Prevention for Future Cases:** - Maintain hip and knee flexion throughout to relax the nerve - Identify the nerve early via the fat pad over quadratus femoris - Use only blunt Hohmann retractors near the nerve - Release retractors every 15 minutes - Never extend the hip with retractors in place
VIVA SCENARIOStandard

EXAMINER

"What is marginal impaction in posterior wall fractures and how do you manage it?"

EXCEPTIONAL ANSWER
Marginal impaction is a crucial concept in posterior wall fractures that directly impacts outcomes. It is present in approximately 50% of posterior wall fractures and, if unaddressed, leads to persistent joint incongruity and post-traumatic arthritis. **Definition:** Marginal impaction refers to the depression or impaction of the articular cartilage and subchondral bone at the rim of the acetabulum, typically at the posterior margin where the wall fragment was attached. When the femoral head dislocates posteriorly and then spontaneously reduces (or is reduced), the impact of the femoral head drives the osteochondral rim fragment into the metaphyseal bone of the acetabulum. **Identification:** On CT Scan: - Look at axial and sagittal cuts through the posterior acetabulum - The impacted fragment appears as a depressed area of subchondral bone just peripheral to the weight-bearing dome - There is often a corresponding metaphyseal defect or void beneath the impacted fragment - The cortical rim (posterior wall) may appear intact, masking the impaction Intra-operatively: - Through the posterior capsulotomy, I palpate the posterior acetabular rim - The impacted area feels depressed compared to the adjacent normal articular surface - Direct visualization after fracture fragment reduction confirms the defect **Surgical Management:** 1. **Identification:** After capsulotomy, I systematically palpate the entire posterior acetabular rim feeling for any depression or step-off. 2. **Elevation:** Using a Freer elevator or curette, I work from WITHIN the joint to elevate the impacted osteochondral fragment. I insert the instrument beneath the depressed segment and lever it up to restore articular congruity. The key is to restore the normal spherical contour of the acetabulum. 3. **Bone Grafting:** Once elevated, there is a metaphyseal void beneath the elevated fragment. This void MUST be filled to support the elevated cartilage and prevent re-collapse. I use cancellous autograft from: - Femoral head (if there is a divot from impact during dislocation - this is my first choice as it's already exposed) - Greater trochanter - Iliac crest (if larger volume needed) I pack the graft firmly but not excessively - overpacking increases pressure and can damage the elevated cartilage. 4. **Wall Reduction:** Only AFTER addressing the impaction do I reduce the posterior wall fragments to the column. The wall fragments are then held with a buttress plate. **Outcomes:** Studies by Matta and others have shown that failure to address marginal impaction is associated with: - Persistent articular incongruity - Higher rates of post-traumatic arthritis - Worse functional outcomes When properly addressed with elevation and grafting, outcomes are comparable to posterior wall fractures without impaction.

Key Exam Points

Kocher-Langenbeck Approach - FRCS Quick Reference

High-Yield Exam Summary

References

Key Literature

Original Description:

  • Kocher T. Textbook of Operative Surgery. 3rd ed. London: Adam and Charles Black; 1911. Original description of the approach
  • Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993. Definitive textbook on acetabular fracture surgery

Outcomes:

  • Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632-45. Landmark outcomes study - 80% good/excellent results with anatomic reduction

Sciatic Nerve Injury:

  • Helfet DL, Schmeling GJ. Somatosensory evoked potential monitoring in the surgical treatment of acute, displaced acetabular fractures. Clin Orthop Relat Res. 1994;(301):213-20.
  • Middlebrooks ES, Sims SH, Grisoni BE, et al. Incidence of sciatic nerve injury in operatively treated acetabular fractures. J Orthop Trauma. 1997;11(5):323-6. 10-15% injury rate

Heterotopic Ossification:

  • Moed BR, Letournel E. Low-dose irradiation and indomethacin prevent heterotopic ossification after acetabular fracture surgery. J Bone Joint Surg Br. 1994;76(6):895-900. Prophylaxis reduces HO by 50%
  • Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am. 1973;55(8):1629-32. Brooker classification

Marginal Impaction:

  • Moed BR, WillsonCarr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am. 2002;84(5):752-8.

AVN:

  • Hougaard K, Thomsen PB. Traumatic posterior dislocation of the hip - prognostic factors influencing the incidence of avascular necrosis of the femoral head. Arch Orthop Trauma Surg. 1986;106(1):32-5. Time to reduction and AVN risk