import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ### Absolute Indications - Displaced transverse fracture with >2mm articular step or gap - Incongruous hip joint on CT (roof arc angles violated) - Associated posterior wall fracture causing instability - Open fracture - Sciatic nerve palsy with fracture displacement ### Relative Indications - 2mm displacement in young, active patient - Quadrilateral plate medialization causing hip incongruity - Associated T-type component - Failed conservative management ### Absolute Contraindications - Severe medical comorbidities precluding 2-3 hour surgery - Active sepsis or local skin infection - Moribund patient ### Relative Contraindications - Severe osteoporosis (relative - may need buttress plating) - Low-demand elderly patient with infratectal fracture - Non-ambulatory patient - Delayed presentation >21 days (consider THA) - Marginal soft tissues (Morel-Lavallée lesion - delay) ### Essential Imaging - **AP pelvis**: Assess overall alignment, both columns visible - **Obturator oblique (45°)**: Shows anterior column + posterior wall - **Iliac oblique (45°)**: Shows posterior column + anterior wall - **CT with 3D reconstruction**: Gold standard for surgical planning ### Roof Arc Measurement | View | Critical Angle | Interpretation | |------|----------------|----------------| | AP | >45° | Dome NOT involved | | Obturator oblique | >25° | Dome NOT involved | | Iliac oblique | >25° | Dome NOT involved | ### Fracture Level Classification - **Transtectal**: Through weight-bearing dome - worst prognosis - **Juxtatectal**: At dome edge - intermediate - **Infratectal**: Below dome - best prognosis, may be non-operative ### Surgical Timing - Optimal: 3-7 days post-injury (soft tissue recovery) - Delayed >21 days: Consider primary THA if reduction unlikely ### Implants - 3.5mm reconstruction plates (pre-contoured pelvic) - 4.5mm cortical screws for column fixation - 3.5mm cortical screws for wall fixation - Spring plate for posterior wall fragments ### Instruments - Pelvic reduction clamps (Farabeuf, Jungbluth, Matta) - Ball spike pusher - Schanz pins for joystick manipulation - Cobb elevators - Large Weber clamps ### Other - Radiolucent table - Beanbag/pelvic posts for lateral positioning - Vessel loops for nerve protection - Cell saver - Intraoperative fluoroscopy **Location**: Exits greater sciatic notch 20-30mm medial to posterior acetabular rim. **Protection**: Hip flexion 45°/knee flexion 90° reduces tension. Vessel loop protection. Limit retraction to 2 hours. **Location**: Exits ABOVE piriformis at greater sciatic notch (only structure above piriformis). **At risk**: Extended iliofemoral approach, retraction through greater sciatic notch. **Location**: 30-40mm medial to pelvic brim in middle window. **At risk**: If anterior/combined approach needed for T-type or quadrilateral plate fixation. **Location**: Lateral to external iliac artery in iliopsoas groove. **At risk**: Anterior approach retraction. Protected by iliopsoas during surgery. ### Letournel's Column Concept The acetabulum is formed by two columns: - **Anterior column**: Anterior ilium → anterior wall → superior pubic ramus (forms "inverted Y") - **Posterior column**: Posterior ilium → posterior wall → ischium **Transverse fracture** divides the acetabulum horizontally into: - **Superior segment**: Iliac wing + superior dome (attached to sacrum - STABLE) - **Inferior segment**: Ischiopubic segment (UNSTABLE - displaces) ### Roof Arc Concept The weight-bearing dome is the critical articular surface: - **Arc of Matta**: Describes superior 10mm of cartilage bearing 70-90% of load - Fractures involving dome have higher rates of post-traumatic arthritis - Roof arc angles determine dome involvement from plain radiographs ### Sciatic Nerve Anatomy - Exits pelvis through greater sciatic foramen BELOW piriformis - Lies 20-30mm medial to posterior acetabular rim - Most commonly injured nerve in acetabular surgery (3-10%) - Hip flexion + knee flexion relaxes nerve, reduces stretch injury ### Quadrilateral Plate - Thin medial wall of acetabulum - Separates hip joint from pelvis - Commonly displaces medially in transverse fractures - Medialization causes hip joint incongruity even with column reduction **Patient Position**: Lateral decubitus (most common for transverse fractures), affected side up, secured with beanbag or pelvic posts. Hip flexion 45°/knee flexion 90° relaxes sciatic nerve. **Surgical Approach**: Kocher-Langenbeck posterior approach (70% of transverse fractures). Extended iliofemoral only for complex T-types or when better anterior column visualization needed. **Incision**: Curved incision from PSIS to greater trochanter to lateral thigh (15-20cm). Adequate length prevents excessive retraction. **Key Setup Points**: - Ensure hip can flex/extend/rotate for reduction maneuvers - Test all fluoroscopy views BEFORE draping (AP, obturator oblique, iliac oblique) - Confirm radiolucent table positioning - Cell saver available for blood conservation ### Step 1: Preoperative Planning and CT Analysis Study CT with 3D reconstruction systematically: - **Fracture classification**: Pure transverse vs transverse + posterior wall (30-40%) vs T-type - **Fracture level**: Transtectal, juxtatectal, or infratectal - **Roof arc angles**: Measure on AP and both obliques - **Quadrilateral plate displacement**: Assess medialization - **Marginal impaction**: Identify areas requiring elevation **Letournel Principle**: Most transverse fractures CAN be fixed from posterior Kocher-Langenbeck approach alone using anterior column screws directed from posterior. This avoids combined approach morbidity. ### Step 2: Position and Prepare for Kocher-Langenbeck Approach - Lateral decubitus, affected side up, secured with beanbag - Hip flexion 45°/knee flexion 90° - CRITICAL to relax sciatic nerve - Radiolucent table allowing AP, obturator oblique, iliac oblique views - Test ALL views before draping **EXAM KEY**: Hip/knee flexion reduces sciatic nerve traction injury from 10% to 3-5%. Lateral decubitus allows gravity-assisted reduction and easier imaging than prone. ### Step 3: Make Kocher-Langenbeck Incision - Incision from PSIS to greater trochanter to lateral thigh (15-20cm curved) - Divide subcutaneous tissue - Split gluteus maximus in fiber direction (internervous plane) - Identify and protect sciatic nerve with vessel loop EARLY - Short incision → excessive retraction → nerve injury Identify sciatic nerve BEFORE releasing external rotators. Place vessel loop. Maintain hip/knee flexion throughout case. Limit retraction to <2 hours continuous. ### Step 4: Release External Rotators (PGOQG) - Release short external rotators 5-10mm from greater trochanter insertion - Order: **P**iriformis, **G**emellus superior, **O**bturator internus, **G**emellus inferior, **Q**uadratus femoris - Tag with heavy non-absorbable suture (#2 Ethibond) for later repair - Posterior capsulotomy for joint visualization **EXAM KEY**: Meticulous tagging allows anatomic repair. External rotator repair reduces dislocation risk from 10-15% to 1-2%. ### Step 5: Assess Fracture Pattern Through Posterior Exposure - Clear hematoma from fracture site and joint - Identify posterior column fracture line (greater sciatic notch to ischial tuberosity) - Visualize transverse fracture line across dome - Check for associated posterior wall fragments (30-40% of transverse) - Assess anterior column indirectly through greater sciatic notch - Identify any marginal impaction requiring elevation **Column Anatomy**: Superior segment = ilium + dome (STABLE). Inferior segment = ischium + pubis (UNSTABLE - displaces). Always reduce unstable to stable. ### Step 6: Reduce Inferior Fragment to Superior Stable Reference **Reduction Sequence** (critical principle): 1. Superior iliac segment is stable (attached to sacrum) - this is the REFERENCE 2. Inferior ischiopubic segment displaces - this must be REDUCED 3. Insert ball spike pusher through greater sciatic notch to control superior fragment 4. Place Schanz pin in ischial tuberosity for joystick manipulation of inferior fragment 5. Apply pelvic reduction clamps (Farabeuf, Jungbluth) to compress fracture 6. Reduce inferior TO superior, NOT vice versa **EXAM KEY**: Always reduce UNSTABLE fragment to STABLE reference. Working from stable to unstable is fundamental. Confirm reduction on fluoroscopy before clamping. ### Step 7: Assess Articular Reduction **Direct Visualization**: - Through posterior capsulotomy, directly visualize articular surface - Gentle hip rotation allows visualization of anterior and superior dome - Accept only <1mm articular step **Fluoroscopic Confirmation** (ALL views mandatory): - AP pelvis: Overall alignment - Obturator oblique: Anterior column + posterior wall - Iliac oblique: Posterior column + anterior wall **Judet Views**: Obturator oblique shows what you CAN'T directly see from posterior (anterior column, posterior wall profile). Iliac oblique shows posterior column clearly. ### Step 8: Provisional Fixation - Hold reduction with 2.0mm K-wires or provisional lag screws - Ensure reduction maintained on repeat fluoroscopy - If reduction lost with provisional fixation → reassess reduction technique - Do NOT proceed to plating without confirmed anatomic reduction ### Step 9: Apply Posterior Column Plate - 3.5mm reconstruction plate contoured to posterior column - Position from greater sciatic notch posteriorly to ischial tuberosity inferiorly - Minimum 3 screws in superior segment (ilium) - Minimum 3 screws in inferior segment (ischium) - All screws bicortical for maximum purchase - Screws directed anteriorly, away from joint **Plate Contouring**: Pre-contour BEFORE final reduction or plate will displace fracture when tightened. Plate too anterior risks joint penetration. ### Step 10: Place Anterior Column Lag Screws from Posterior **Letournel's Key Technique**: - Insert lag screws from posterior column directed anteriorly into anterior column - Use 3.5mm or 4.5mm cortical screws - Entry point on posterior column - Trajectory toward pelvic brim/anterior column - Provides fixation of BOTH columns from single posterior approach - Check length on fluoroscopy - must NOT penetrate anterior cortex **EXAM KEY**: Anterior column screws from posterior is Letournel's major contribution. This allows single approach for most transverse fractures, avoiding combined approach morbidity. Use fluoroscopy on ALL views to confirm screw trajectory. Screws directed too medially risk iliac vessel injury. Too anteriorly risks penetration into soft tissues. ### Step 11: Address Associated Posterior Wall (if present) - 30-40% of transverse fractures have associated posterior wall - Reduce wall fragments separately AFTER column fixation - Apply buttress plate (reconstruction or spring plate) for posterior wall - Multiple screws into stable posterior column - Assess hip stability - should be stable through ROM **Fixation Sequence**: Column MUST be fixed before wall. Wall fixation buttresses against stable column construct. Check posterior wall coverage >60% for stability. ### Step 12: Address Quadrilateral Plate Medialization If significant medialization visible on obturator oblique: - May need limited ilioinguinal medial window OR separate Stoppa approach - Infrapectineal buttress plating from medial prevents continued medialization - This is additional morbidity but prevents hip incongruity **Clinical Significance**: Quadrilateral plate medialization causes hip joint incongruity and accelerates arthritis EVEN IF columns are anatomically reduced. Address if significant. ### Step 13: Final Fluoroscopic Confirmation Obtain all views: - AP pelvis - Obturator oblique (anterior column, posterior wall) - Iliac oblique (posterior column, anterior wall) - Lateral **Checklist**: 1. Articular reduction <1mm step 2. Column alignment anatomic 3. NO intra-articular screws (arc intensifier through joint) 4. Adequate screw purchase and length 5. Quadrilateral plate position acceptable **EXAM KEY**: Screw malposition occurs in 3-8% despite careful technique. Judet views mandatory - fracture crosses both columns so both must be assessed. ### Step 14: Repair External Rotators and Capsule - Heavy non-absorbable suture (#2 or #5 Ethibond) - Repair PGOQG to posterior capsule and greater trochanter - Create bone tunnels in trochanter if needed - Capsule repair important for stability - Assess hip stability after repair ### Step 15: Close and Postoperative Protocol **Closure**: - Meticulous hemostasis (gluteal muscles bleed significantly) - Copious irrigation 3-6L saline - Place 14Fr drain deep to gluteus maximus - Close gluteal fascia (0-Vicryl), Scarpa's (2-0 Vicryl), skin (staples) **Postoperative Protocol**: - Touch weight-bearing (10-20kg) × 6 weeks, progressive to full by 12 weeks - ROM exercises begin day 1-2 - Posterior precautions if stability concern × 6-12 weeks - VTE prophylaxis: LMWH or DOAC × 35 days - HO prophylaxis: Indomethacin 75mg daily × 6 weeks - X-rays: 6 weeks, 12 weeks, 6 months, 12 months 1. Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Springer-Verlag; 1993. The definitive text on acetabular fracture classification and surgical treatment. 2. 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):1632-1645. 3. Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. J Bone Joint Surg Br. 2005;87(1):2-9. 4. 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):1629-1632. 5. Briffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture fixation with ten years' follow-up. J Bone Joint Surg Br. 2011;93(2):229-236. 6. Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am. 2012;94(17):1559-1567. 7. Kaempffe FA, Bone LB, Border JR. Open reduction and internal fixation of acetabular fractures: heterotopic ossification and other complications of treatment. J Orthop Trauma. 1991;5(4):439-445. 8. Moed BR, Carr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am. 2002;84(5):752-758. 9. Routt ML Jr, Swiontkowski MF. Operative treatment of complex acetabular fractures: combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am. 1990;72(6):897-904. 10. Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. 3rd ed. Lippincott Williams & Wilkins; 2003.

Transverse Acetabular Fracture ORIF

Transverse Acetabular Fracture ORIF