Surgical treatment of displaced acetabular fractures. The exact surgical plan will be discussed with you before you are asked to consent agree to surgery. As techniques improve, imaging is being used more and more in the treatment of acetabular fractures. An acetabular fracture occurs when the socket of the hip joint is broken. This injury is caused by a blow to either the side or front of the knee and often occurs as a dashboard injury accompanied by a fracture of the femur the acetabulum is a cavity situated on the outer surface of the hip bone, also called the. Longitudinal ultrasound examination of the hip joint, showing intraarticular effusion. Successful outcomes depend on application of highly. In general, most acetabular fractures are operated on either through the buttock bottom muscles, or through the groin area between the legs. These kind of fractures are uncommon in elderly patients, but lately the number is increasing. We have developed a systematic approach that aids in the.
Pdf clinical and radiological assessment of acetabular fracture. Acetabular reconstruction fixation methods in simple. The socket part is lined with smooth cartilage and is called the acetabulum, which is part of the pelvis. Nov 28, 2018 fractures of the acetabulum occur as a result of the force exerted through the head of the femur to the acetabulum.
Role of acute negativepressure wound therapy over primarily. Both fractures can be simultaneously reduced through the approach to the os coxae see figure 1524, a. Fractures of the acetabulum occur when the head of the femur is driven into the pelvis. Anatomic reconstruction of the articular surface along with stable internal fixation of these fractures has been shown to produce less pain, better function. Acetabular fractures in the elderly population are marked by a high degree of variability in terms of patient and fracture characteristics. Immediate total hip replacement thr in patients with acetabular fractures is controversial because of concerns about high complication rates. Judet and letournel were pioneers in the surgical treatment of displaced acetabular fractures 6, 7. Pdf on sep 19, 2018, balaji zacharia and others published clinical and radiological.
Modified stoppa approach for surgical treatment of acetabular. Early mobilize the patient with displaced acetabular fractures with operative management. Acetabular fractures are usually caused by either highenergy trauma, most commonly from an automobile accident, or from what is called an insufficiency fracture. Total hip replacement may be considered a better option.
Anterior column acetabular fracture with associated left inferior pubic ramus fracture. The osteotomy line originated from the vertex of the greater sciatic notch a to the center of the quadrilateral surface o, the outside pelvis of the converging line went through the 2 oclock of the left posterior acetabulum and ran along the posterior brim of incisura acetabula c to separate the ramus ossis ischia. The incidence of acetabular fractures in the elderly population is increasing. The surgeon realigns or reduces the bones as precisely as possible to prevent the development of postinjury related problems, especially arthritis.
Management of highenergy acetabular fractures in the. Introduction generally caused by high energy trauma such high energy injuries usually have a high incidence of major associated injuries the fracture or fracture dislocation produced depends on the magnitude and the direction of the injuring force as well as on the strength of the bone. The use of an algorithm for classifying acetabular. Fractures of the pelvis and acetabulum by marvin tile 1. Sacroiliac joints and pubic symphysis are congruent. Fractures of the extremities, head injuries, chest, abdomen and pelvic ring injuries are the most commonly associated injuries 15. Predictors of poor outcome after both column acetabular. After careful preoperative evaluation and planning, the fixation methods usually employ some type of screw or plate fixation. However, for more complex fracture patterns involving both acetabular columns and those delayed past 2 to 3 weeks, an extensile or combined. An acetabular fracture can also be inferred from an arthritic hip figure 1210, although there are other causes of coxal arthritis, such as a proximal femoral fracture, chronic dislocation, osteochondritis, and. The judet brothers and, subsequently, emile letournel studied acetabular fractures extensively and were responsible for popularizing the surgical management of these challenging injuries. Small volume of associated extraperitoneal hematoma. Acetabular fracture overview, symptoms, and treatments.
Such fractures are far less common than fractures to the ball part of the joint. The femoral head acts like a hammer and is the last link in the chain of forces transmitted from the greater trochanter, knee, or foot to the acetabulum. It classifies acetabular fractures into ten major fracture patterns, which consist of five simple patterns and five complex patterns 1,2. According to a new study, classifying acetabular structures may require an updated system. The hss orthopedic trauma service has conducted many studies. Road traffic accidents account for majority of cases. We believe that the stoppa approach with an iliac window extension, previously described as a modified stoppa approach is adequate for the majority of acetabular fractures excluding those with predominant posterior wall involvement. Matta 1996 258 fractures anatomical reduction 71% with 76% excellent to good results. In the evaluation of the five most common acetabular fractures, assessment. Management of acetabular fractures in the geriatric patient.
Pdf acetabular fractures are uncommon other than in the. Outcome of acetabular fractures is dependent on the quality of surgical reduction and fixation, in turn. Acetabular fractures will be welcomed by orthopaedic and trauma surgeons, as well as by residents and fellows, in these fields. Judet and letournel 1980 417 fractures 73% perfect reduction with 84% very good results imperfect reduction 55% good results infection 5.
Acetabular fracture patterns and their associated injuries. Surgical management of fracture of acetabulum dilip kumar doltani, jugdesh kumar, ghulam mahboob abstract objective. The use of an algorithm for classifying acetabular fractures. The early management of pelvic and acetabular fractures. Fractures of the acetabulum are harder to treat because access to this bone is more difficult, and because of the acetabulums proximity to the major blood vessels to the legs, the sciatic nerve the major nerve that arises from the lower spine and provides sensation and movement to the leg and foot, the intestines.
The remaining seven acetabular fracture types were assumed to have resulted from a lateral or trochanteric load. Fractures extends to both the ilium and superior pubic ramus. For example, the bone can break straight across the socket or shatter into many pieces. The treatment of choice for displaced acetabular fractures in younger. Jun 04, 2011 the letournel and judet acetabular classification 46 is widely used and accepted for classifying acetabular fractures, communicating with others, selecting surgical approach, and reporting results 710, 12. While this may not cause a fracture in a young patient, in the elderly with osteoporotic bone, comminuted fractures, especially those involving the anterior column and quadrilateral plate, are common.
Such patients who present with acute hip pain must not be dismissed as. Acetabular bothcolumn fractures are challenging articular injuries. Outcome of surgical treatment for displaced acetabular fractures a anizarfaizi, md ukm, a hisam, ms orth, kp sudhagar, ms orth, m moganadass, ms orth, c suresh, ms orth department of orthopedics and traumatology, universiti kebangsaan malaysia medical centre, kuala lumpur, malaysia. Fractures in this population differ from those in younger patients, with more frequent involvement of the anterior column, more comminution, and more severe articular impaction in elderly patients. Complications are common and outcome is not uniform in all acetabular fractures. Mapping of both column acetabular fractures with threedimensional. Acetabular fracture an overview sciencedirect topics. Posterior column acetabular fracture fixation using a w. Incision comprises an oblique limb from the posterior superior iliac spine psis to the greater trochanter and a vertical limb that continues distally over the lateral aspect of the femur. Acetabular fractures were classified according to force vector at the time of injury. The majority of acetabular fractures are caused by some type of highenergy event, such as a car collision.
Please see our publications on acetabular fractures. A 34yearold male was a passenger in an automobile that collided with another vehicle at highspeed. Acetabulum fractures are less common and occur with an incidence of about three per 100. The few new epidemiological studies confirm that the elderly population with. Patients with acetabular fractures often require an open reduction with internal fixation orif, especially those patients who also have displacement of the joint. An insufficiency fracture is most common in older patients and is caused by the bone being weakened by osteoporosis. Surgical fixation of acetabular fracture is a major challenge before trauma surgeon.
The concept of primary thr following acetabular fractures is. This is the most common variety of acetabular fracture. The management of acetabular fractures has evolved in the last four decades. Although acetabular fractures in geriatric patients are more likely the result of lowenergy trauma, outcomes are. Fractures of the pelvis and acetabulum by marvin tile. Enclosed within the deep and complex structures of the hip joint and the surroundings, acetabular fractures confront the orthopaedic surgeon with great challenges. Acetabular fractures are more common in men with 3. Accurate characterization of acetabular fractures can be difficult because of the complex acetabular anatomy and the many fracture patterns. Any information contained in this pdf file is automatically generated from digital. In a smaller number of cases, a lowenergy incident, such as a fall from standing, may cause an acetabular fracture in an older person who has weaker bones. In the elderly patient defined as more than 60 years of age, the most common mechanism of injury is a fall mostly it is an isolated injury for a younger patient, in whom a motor vehicle accident is the most common.
Acetabular fractures in the elderly individuals are increasing in prevalence. The manual of fracture management wrist examines the management of traumatic and reconstructive problems of the distal radius, distal ulna, and the carpals, the key components of the human wrist. Bothcolumn acetabular fractures are complex lesions char acterised by lines. The most widely used acetabular fracture classification system among radiologists and orthopedic surgeons is the system of judet and letournel, which includes five elementary or elemental and five associated fractures. Pdf extensile triradiate approach in the management of. Although this classification scheme describes 10 types of acetabular fractures, we have focused on the most common fracture patterns, which represent 90% of acetabular fractures 2, 6 figs. An acetabular fracture is a fracture of the hip joint. Epileptic seizures can lead to acetabular fractures due to fall. During the operation, your doctor will reconstruct the normal anatomy of the hip jointaligning the bone fragments to restore the surface of the acetabulum, and fitting the femoral head into the hip socket. Acetabular fractures are often combined with associated injuries to the hip joint. The judet and letournel classification is the most widely used classification system for acetabular fractures. Plain radiography is the primary method for evaluation of these injuries, and computed tomography is now commonplace for the preoperative classification of patients with acetabular fractures. The most widely accepted classification scheme for acetabular fractures is that of judet and letournel 2, 4, 6.
The classification of acetabular fractures is important for preoperative planning. Pdf controversies in treatment of acetabular fracture. Pre op right and postop left radiograph of years old boy who was operated 68 days after polytrauma injury. Pdf acetabular fractures in the 21st century researchgate. Outcome of surgical treatment for displaced acetabular fractures. He was taken to the local trauma center for initial assessment where he was diagnosed with a rightsided anterior column posterior. Acetabular fractures before letournel conflicting recommendations on rx.
However, for orthopaedic surgeons with less experience with these fractures, correct classification can be more difficult. Because acetabular fractures damage the cartilage surface of the bone, an important goal of surgery is to restore a smooth, gliding hip surface. Acetabulum fracture an overview sciencedirect topics. Technical challenges however include infection, residual pelvic deformity, acetabular bone loss with ununited fractures, osteonecrosis of bone fragments, retained metalwork, heterotopic ossification, dealing with the sciatic nerve, and the difficulties of obtaining longterm acetabular component fixation. Essentials of operative management luca pierannunziia, florian fischera, lorenzo tagliabueb, giorgio maria calorib, marco dimporzanoa aiii division of orthopaedics and trauma gaetano pini orthopaedic institute, p. Fractures of the acetabulum were treated nonoperatively until the middle of the 20th century.
It is common among elderly and those with weaker bones. The simple acetabular fractures, while basic in their pattern, are not always the simplest fractures for treatment. The kocherlangenbeck approach is the most common approach used for treating acetabular fractures involving the posterior wall and column. An acetabular fracture is mostly caused by a traumatic accident, such as a motor vehicle or a bad fall, and affects often the younger population. Above all, i thought it was time to report the longterm results of the 940 acetabular fractures, 90070 of which were treated surgically a unique series. The concept of primary thr following acetabular fractures is an alternative to orif, especially in the elderly patient. Additionally, we can also combine anatomical parameters of the pelvis with the main fracture lines to design a novel internal fixation device. Acetabulum fractures acetabular fractures are uncommon, and generally occur from. Patient risk factors include, for example, age, comorbidities, and degree of osteoporosis. Acetabular fractures, harris hip score, judet views, road traffic accidents, outcome j ayub med coll abbottabad 20.
Acetabular fractures may result from highenergy trauma or lowenergy trauma in the elderly. Comminuted left acetabular fracture with medial and superior displacement of the femoral head. May 29, 2016 ubiquitous standard of care of acetabular fractures for the past 25 years. Bothcolumnfractures are t or yshaped fractures determined by two converging lines, the former originating from the greater sciatic notch, the latter from the superior or anterior border of the ilium. Ct is helpful in understanding the va rious fracture patterns.
A new classification for acetabular fractures, was published in the january 17, 2018 edition of the journal of bone and joint surgery. Letournel 4 has defined the pathoanatomy and radiology of these fractures and has classified acetabular injury. St georges hospital is the largest specialist centre for fractures of the acetabulum in the uk with several patients being referred from other hospitals each week. We present a patient with bilateral acetabular fractures after a seizure, with bilateral. This is much less common than most hip fractures, where the top of the thigh bone is damaged, not the socket. Injury risk factors mainly include the fracture pattern. Brown et al reported the use of computergenerated threedimensional 3d computed tomography ct moving images for preoperative planning and screwpin insertion, as well as the use of stereolithography wax or plastic 3d model of bony anatomy to. Jun 25, 2019 in one study, of 1273 patients with acetabular fractures, 193 15% were found to have ipsilateral knee symptoms within a period of 1 year from the date of injury, including 56 fractures 29%, 49 ligamentous lesions 25%, and 88 miscellaneous 46% injuries, including bone bruises, wounds, and swelling. Acetabular fractures treatment represents a great controversy, challenge and dilemma for an orthopedic surgeon. Multiple patterns of injury may combine in a given patient.
Modified stoppa approach for surgical treatment of. Modified stoppa approach for surgical treatment of acetabular fracture ha yong kim, md, dae suk yang, md, chang kyu park, md, won sik choy, md department of orthopedic surgery, eulji university hospital, eulji university college of medicine, daejeon, korea received march 27, 2014. The aim of our study was to analyze the outcome of both column acetabular fractures and the influence of osseous cofactors such. Acetabular fractures in older patients ted manson md associate professor joint replacement and orthopedic trauma r adams cowley shock trauma center disclosures consultant and royalties from stryker, aaos hip program committee, journal of arthroplasty editorial board, aahks scientific program committee disclosures. Fractures of the ilial body are the most common significant fractures to accompany acetabular fractures figure 1524, b. Acetabular bothcolumn fractures giorgio maria calori. Acute total hip replacement for acetabular fractures. Many times patients will have additional injuries that require immediate treatment. In elderly patients, acetabular fractures, like hip fractures, often result from simple falls. Figure 7 shows the age and gender distribution for operatively and nonoperatively treated acetabular fractures. This prospective study was carried out from april 1998 to december, 2000 in.
The aim of the paper was to present the results of treatment of 96 acetabular. Acetabular fractures are severe injuries, most frequently caused by a highenergy trauma. Outcome of surgical treatment for displaced acetabular. Acetabular fractures should be managed after the goal of achieving hemodynamic stability and. In a rapidly changing field of practice, orthopedic care of wrist fractures and disorders is becoming ever more complex as new technologies, plates, and methods merge and evolve with existing. Visser from university hospital, groningen we report aretrospective study of54acetabular fractures treated byopen reduction andinternal fixation, withanaverage followup of9. Acetabular fractures after seizures are uncommon, and fewer than 30 cases are described in the literature.
Acute isolated acetabular fracture following a game of. Literature in acetabular fracture surgery is lavish but truly meaningful studies that add something new are sparse. Acetabular fracture walking ability weightbearing a b s t r a c t introduction. Extensile triradiate approach in the management of combined acetabular fractures. Acetabular fractures pose a great surgical challenge for orthopedic trauma surgeons.
Those lines merge just above the roof supraacetabular groove, from where. Acetabular fractures are generally diagnosed in one of two ways. It is very rare for both sides of the hip joint to be damaged in an injury. Although there is evidence in the literature that acetabular fractures in elderly patients sustained as a result of lowenergy mechanisms can be well treated by nonoperative management, open reduction and internal fixation, or even acute arthroplasty, almost no literature exists that may appropriately guide the. When the acetabulum is fractured, the femoral head may no longer fit firmly into the socket, and the cartilage surface of both bones may be damaged. We present a case where an acetabular fracture was sustained in a relatively young female while playing squash without any history of fall or injury but was treated successfully nonoperatively. When the socket is fractured, it is called an acetabular fracture. Although hip injuries do not account a large amount of the sports physicians workload they can result in significant morbidity.
Elementary fracture description associated fractures description posterior wall. There was a lateral impact on the passenger side door. Surgery for acetabulum fractures if you require surgery, this can be done in several ways. Signs of an acetabular fracture consist of tingling or pain in the lower extremities. Predictors of postoperative outcome for acetabular fractures. Visser from university hospital, groningen we report aretrospective study of54acetabular fractures treated byopen reduction andinternal. On the diagnosis and treatment of acetabular fractures. Radiographic images at two years following surgery illustrate a healed acetabular fracture with excellent preservation of the hip joint space. Judet and letournel classification for acetabular fractures. Methods study participants a total of 55 patients were treated for acetabular fractures at our hospital from november 2007 to november 2010. Posterior wall, posterior column, and posterior columnposterior wall injuries were assumed to have been caused by an axial load. The letournel and judet classification system is commonly used for classifying acetabular fractures.
The position of the femur at the time of impact and the direction of the. Complete transformation of our understanding and treatment of fractures of the acetabulum two textbooks are the bibles of acetabular surgery 3. Some of these associated injuries seem to be responsible for poor longterm results and these injuries seem to affect the outcome independent of the quality of the acetabular reduction. Letournel e 1978 surgical repair of acetabular fractures more than three weeks after injury, apart from total hip replacement. The type of acetabular fractures is mainly depend on the position of. A line joining the lateral edge of sourcil to lateral edge of the inferior tear. Over many years this has led to the development of very specialised expertise and knowledge. Those lines merge just above the roof supraacetabular groove, from where a vertical tract descends and separates the.
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