2. Objectives
• Goal of Operative Management
• Specific Approaches for Specific Fractures
• Indications for Kocher-Langenbeck Approach
• Indications for Ilioinguinal Approach
• Reduction Strategies
3. Letournel School
• Thorough Understanding of Plain Films
• Optimize One Surgical Approach
• Goal of Perfect Concentric Reduction
6. Timing of Surgery: Criteria
• Well - resuscitated patient
• Appropriate radiological work-up
• Appropriate understanding of fracture
• Appropriate operative team
7. Matta 1996
Timing of Surgery and
Anatomical Reductions
• 0-7 Days 74%
• 8-14 Days 71%
• 15-21 Days 57%
8. Surgical Emergencies: Rare
• Open Acetabular Fracture
• New-Onset Sciatic Nerve Palsy after closed
reduction of Hip dislocation
9. Surgical Urgencies: Infrequent
• Irreducible Posterior Hip Dislocation
• Medial Dislocation of Femoral Head
against cancellous bone surface of intact
Ilium
10. Matta 1996
NOT Predictive of
CLINICAL OUTCOME
• Type of fracture pattern
• Posterior dislocation
• Initial displacement
• Presence of intra-articular fragments
• Presence of acetabular impaction
11. Matta 1996
Predictive of
CLINICAL OUTCOME
• Injury to Cartilage or Bone of Femoral
Head
– Damage: 60% Good / Excellent Result
– No Damage: 80% Good / Excellent Result
• Anatomic Reduction
• Age of Patient …….. But only in that it
predicts the ability to achieve an anatomic
reduction
12. Approaches to the Acetabulum
• Posterior: Kocher - Langenbeck
• Anterior: Ilioinguinal
• Extensile: Extended Iliofemoral
21. Prone Position
• Aids in Reduction of Ischiopubic Segment
• Facilitates Palpation of Quadrilateral
Surface
• Allows Clamp Placement through Greater
Sciatic Notch
• Easier Prep and Drape
140. Intra-Operative Assessment of
Reduction
• Visual Assessment of Fracture Reduction
• Palpation of Fracture
– Quadrilateral surface through Greater Sciatic
Notch
– Anterior Column
• C-Arm assessment
• Plain A.P. Radiograph
• Assurance that all Screws are out of Joint
141. Assessment of Reduction
• Restoration of Pelvic Lines
• Concentric Reduction on all 3 Views
• Goal of Anatomic Reduction
144. Letournel 1993
Avascular Necrosis
“In our opinion avascular necrosis is a diagnosis much too often
put forward to explain a post-operative complication. Since it is
known that there is nothing we can do about it, as the trauma is
considered solely responsible for it, there is much too great a
tendency to blame necrosis for what is really a wearing of the
femoral head against a malreduced fracture line. If wear takes
place there is disappearance of a segment of the head but no
sequestrum formation, and the shape of the loss of substance is
the negative imprint of the shape responsible for the wear: the
step in the acetabular reconstruction. For instance, wearing
against a transverse fracture line appears on the antero-posterior
view as an orange-slice-shaped missing part of the head without
any sequestrum.”
145. Heterotopic Ossification:
Brooker Classification
• I: Islands of bone less than 1 cm in diameter
• II: Larger islands of bone, leaving at least 1 cm
free space between the two bones of the hip
• III: Free space between the ossification and the
pelvis or the femur is less than 1 cm
• IV: Apparent ankylosis of the joint by a bony
bridge uniting the pelvis and the femur
146. Heterotopic Ossification
• Classification does not predict mobility
• Approach:
– 34% Grade III / IV Extended Iliofemoral
– 11% Grade III / IV Kocher-Langenbeck
– 1 % Grade III / IV Ilioinguinal
• “Ectopic bone formation appears early on
radiography, and maturity is reached 6
months to 1 year after operation.”
150. Conclusions
• Good Understanding of the Fracture
• Know the Anatomy
• Optimize One Surgical Approach
• Goal of Perfect Reduction
151. THANK YOU
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