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Surgical Treatment of Acetabular Fractures
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Joel M. Matta, M.D.
BASIC CONSIDERATIONS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Fractures of the acetabulum occur primarily in young adult patients as the result of high-energy trauma.20 The displacement of fracture fragments of the acetabulum creates an incongruity between the cartilage of the femoral head and acetabulum. In effect, the contact area between the femoral head and acetabulum is markedly decreased. If the acetabular fracture is allowed to heal in the displaced position, weight-bearing forces applied to the small remaining area of contact can lead to rapid breakdown of the articulator cartilage and result in post-traumatic arthritis. Severe incongruity can cause wear of the femoral head, which is often misdiagnosed as avascular necrosis. Surgical treatment of the acetabular fracture should accurately restore the normal shape of the acetabulum, normal topography of the contact area, and normal pressure distribution within the joint.2, 3, 6, 10, 12, 16, 28, 50
Radiographic Diagnosis
The initial diagnosis of an acetabular fracture is made from an anteroposterior (AP) view of the pelvis.44 After this, 45 oblique views of the pelvis should be obtained for all patients with an acetabular fracture.5 After examination of the plain lms, a computed tomography (CT) scan should be obtained to provide additional information about the fracture conguration and answer any questions that might remain after examining the plain lms. Three-dimensional reconstruction of the CT scan (3-D CT) can also be useful for understanding the fracture conguration and displacement.1, 16 Interpretation of the plain lms is based on understanding the normal radiographic lines of the acetabulum and what each line represents. Disruption of any of the normal lines of the acetabulum represents a fracture involving that portion of the bone.24, 43 On the AP view, the iliopectineal line roughly follows the pelvic brim and represents involvement of the anterior column. The ilioischial line is formed by the tangency of the x-ray beam to the posterior portion of the quadrilateral surface and is therefore a radiographic landmark of the posterior column (Fig. 372). The 45 obturator oblique view is taken with the fractured acetabulum rotated toward the x-ray tube. It shows the obturator foramen in its largest dimension and proles the anterior column and posterior rim of the acetabulum. The iliac oblique view is taken with the fractured acetabulum rotated away from the x-ray tube. It shows the iliac wing in its largest dimension and proles the greater and lesser sciatic notches and the anterior rim of the acetabulum. Most fractures can be properly classied from plain radiographs alone. They are usually best for assessing the congruence between the femoral head and roof of the acetabulum. The CT scan is advantageous for assessing fracture lines
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Bony Anatomy
The acetabulum is formed as a portion of the innominate bone. It ties at the point where the ilium, ischium, and pubis are joined by the triradiate cartilage, which later fuses to form the innominate bone. It is useful for the surgeon to divide the acetabulum and innominate bone into anterior and posterior columns. The anterior column comprises the anterior border of the iliac wing, the entire pelvic brim, the anterior wall of the acetabulum, and the superior pubic ramus. The posterior column comprises the ischial portion of the bone, including the greater and lesser sciatic notch, the posterior wall of the acetabulum, and the ischial tuberosity (Fig. 371). The surgeon must be familiar with the anatomy and various bony landmarks and contours of the innominate bone.
Copyright 2003 Elsevier Science (USA). All rights reserved.
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Print Graphic Anterior column Presentation Posterior column Anterior column
FIGURE 371. The extent of the anterior and posterior columns on the inner and outer aspects of the bone.
in several areas.15 It provides an excellent picture of sacral fractures. It shows minimally displaced fractures of the iliac wing that are often missed on plain lms and shows fractures through the quadrilateral surface that may be invisible on plain lms. It often best demonstrates the degree of gap in a fracture through the roof of the acetabulum, although it does not reveal a vertical step at the fracture line through the roof or demonstrate congruity between the femoral head and roof. The CT scan can miss fracture lines that lie in a transverse plane and therefore most surgeons rely primarily on plane lms to visualize those fractures.
Free fragments of bone that are lodged between the femoral head and walls of the acetabulum are often best seen on the CT scan, but the CT scan may not adequately demonstrate an incarcerated fragment of bone located between the top of the femoral head and the roof of the acetabulum. A 3-D CT scan can provide a good overall picture of the fracture conguration, particularly in widely displaced fractures.4 The 3-D scan, however, lacks ne detail, and fracture lines displaced less than 3 mm may not be represented. Assessment is aided by the computer removing the femoral head from the picture.
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FIGURE 372. A, The normal radiographic lines of the acetabulum as they appear in the anteroposterior (AP) radiographic view. 1, The iliopectineal line; 2, ilioischial line; 3, roentgenographic U, or teardrop; 4, roof; 5, anterior rim; 6; posterior rim. B, The normal radiographic landmarks of the obturator oblique view. 1, The iliopectineal line; 2, posterior rim; 3, obturator ring; 4, anterior superior iliac spine. C, The normal radiographic landmarks of the iliac oblique view. 1, Posterior border of innominate bone; 2, anterior rim; 3, anterior border of iliac wing; 4, posterior rim. (AC, Redrawn from Judet, R.; et al. J Bone Joint Surg Am 46:16151646, 1964.)
CHAPTER 37 Surgical Treatment of Acetabular Fractures
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FIGURE 373. Classication of acetabulum fractures according to Letournel. A, Posterior wall fracture. B, Posterior column fracture. C, Anterior wall fracture. D, Anterior column fracture. E, Transverse fracture. Illustration continued on following page
Classication
An anatomic classication of acetabular fractures was published by Judet and colleagues in 1964 and has been altered slightly by Letournel since then.21, 54 Letournels classication is the most useful for surgeons.26, 54 A thorough knowledge of all fracture types is essential to decision making in surgical management and for understanding the technical aspects of the surgery. Fractures of the acetabulum are divided into ve simple fracture types and ve associated fracture types, which are formed by combinations of the simple fracture types.48, 49, 55 The simple fracture types are posterior wall, posterior column, anterior wall, anterior column, and transverse fractures. The ve associated fracture types are associated posterior and posterior wall, associated transverse and posterior wall, T-shaped, associated anterior column and posterior hemitransverse, and both-column fractures (Fig. 373).
Fractures of the posterior wall typically involve the posterior rim of the acetabulum, a portion of the retroacetabular surface, and a variable segment of the articular cartilage. A common nding is impaction of the articular cartilage, which should be diagnosed preoperatively on the basis of plain lms or a CT scan. Extended posterior wall fractures can involve the entire retroacetabular surface and include a portion of the greater or lesser sciatic notch, the ischial tuberosity, or both areas. The ilioischial line remains intact on the AP view. Posterior column fractures include only the ischial portion of the bone. The entire retroacetabular surface is displaced with the posterior column. As the vertical line separating the anterior from the posterior column traverses inferiorly, it most commonly enters the obturator foramen. There is an associated fracture of the inferior pubic ramus. Sometimes, the fracture line traverses just posterior to the obturator foramen, splitting the ischial tuberosity. On the AP view, the ilioischial line is displaced.
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FIGURE 373 Continued. F, Associated posterior column and posterior wall fractures. G, Associated transverse and posterior wall fractures. H, T-shaped fracture. I, Associated anterior and posterior hemitransverse fractures. J, Both-column fracture.
Fractures of the anterior wall involve the central portion of the anterior column. The inferior pubic ramus is not fractured. The pelvic brim is displaced in its midportion, and the AP radiograph shows a displacement of the iliopectineal line. Anterior column fractures can occur anywhere from a very low to a very high level. Low fractures involve only the superior ramus and pubic portion of the acetabulum. High fractures can involve the entire anterior border of the innominate bone. The pelvic brim and iliopectineal line are displaced. Transverse fractures divide the innominate bone into two portions. A horizontally oriented fracture line can cross the acetabulum at various levels. The innominate bone is then divided into a superior part composed of the iliac wing and a portion of the roof of the acetabulum. The lower part of the bone, the ischiopubic segment, is composed of an intact obturator foramen with the anterior and posterior walls of the acetabulum.5
The association of a posterior column and posterior wall fracture divides the posterior column into a larger posterior column segment and an associated smaller posterior wall segment. The association of the transverse plus posterior wall fracture combines a normal transverse conguration with one or more separate posterior wall fragments. The T fracture is similar to the transverse fracture, except for the addition of a vertical split along the quadrilateral surface and acetabular fossa, which divides the anterior from the posterior column. An associated fracture of the inferior pubic ramus exists. The anterior plus posterior hemitransverse fracture combines an anterior wall or anterior column fracture with a horizontal transverse component, which traverses the posterior column at a low level and crosses the posterior border of the bone near the ischial spine. The anterior component is typically at a higher level and is more displaced than the posterior component. Both-column fractures form a distinct category because all articular segments are detached from the intact portion
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of the ilium, which remains attached to the sacrum. The area of intact ilium depends on the course of the anterior column fracture. The least iliac involvement is present when the anterior column fracture reaches the anterior border of the bone at the interspinous notch (between the anterior superior and anterior inferior iliac spines). In most cases, the anterior column fracture reaches the iliac crest. The greatest iliac involvement occurs when fracture lines of the anterior or posterior column cross the sacroiliac joint. The surgeon should realize that transverse, associated transverse plus posterior wall, T-shaped, and anterior plus posterior hemi-transverse fractures show involvement of the anterior plus the posterior column of the acetabulum but are not both-column fractures. In these four fracture types, a portion of the articular surface remains in its normal position, attached to the intact portion of the ilium. The both-column fracture is therefore unique, with its division of all segments of articular cartilage from the ilium.
Indications for Operative Treatment

Operative treatment is indicated for most displaced acetabular fractures to allow early ambulatory function and to decrease the chance of post-traumatic arthritis. Nonoperative treatment, however, can still be successful for a minority of displaced acetabular fractures. Indications for nonoperative treatment are based on the analysis of the fracture conguration. The decision about whether to operate is based on the initial series of plane lms and CT scans. Attempts at closed reduction by manipulation under anesthesia or skeletal traction are not applicable for assessing the indication for surgical treatment. If the surgeon concludes from the initial radiographs that an accurate reduction of the articular surface is necessary to ensure a good prognosis, operation is indicated. Nonoperative treatment is reserved for patients in whom a tolerable incongruity is present and also for those with contraindications to surgery. Contraindications include local or systemic infection and severe osteoporosis, although many elderly patients, even with some degree of osteoporosis, can benet from surgery. Satisfactory bone stock can be found for xation, particularly along the pelvic brim and greater sciatic notch. Relative contraindications include age, associated medical conditions, and associated soft tissue and visceral injuries. Displaced fractures that should be considered for nonoperative treatment are usually in one of two categories: 1. A large portion of the acetabulum remains intact, and the femoral head remains congruous with this portion of the acetabulum. 2. A secondary congruence exists after only moderate displacement of a both-column fracture. The rst situation, in which a large portion of the acetabulum remains intact, can occur with any of several different fracture types. In the case of posterior wall fractures, only a small portion of the posterior wall may be displaced. If the CT scan shows less than 50% of the width of the posterior articular cartilage displaced on
the CT cut that shows maximal involvement, nonoperative treatment may be considered. The cranial-caudad location of the fracture also should be considered. A small fragment displaced at the level of the roof may be more important to reduce than a larger one near the inferior portion of the posterior articular surface. Some authorities have advocated a test for stability of the hip against posterior dislocation with the patient under anesthesia. I, however, have never based my indication on the results of manipulation and am not aware of follow-up data to support its use. In practice, therefore, surgery is appropriate for most posterior wall fractures. Many low anterior column fractures that involve only the pubic portion of the acetabulum can be treated by nonoperative means. A minority of low, T-shaped or transverse fractures can be treated nonoperatively. In assessing the size of the intact portion of acetabulum, it is useful to perform roof arc measurements.30, 31, 33 These are made on the AP, obturator, and iliac oblique radiographic views. A vertical line is drawn to the geometric center of the acetabulum. Another line is drawn through the point where the fracture line intersects the acetabulum and again to the geometric center of the acetabulum. The angle drawn in this way represents the medial, anterior, or posterior roof arc as seen on the AP, obturator oblique, or iliac oblique view, respectively. If nonoperative treatment is to be considered, all roof arc measurements should be more than 45, and the head should remain congruous with the roof of the acetabulum with the patient out of traction. The CT subchondral arc technique of Olson and colleagues48 appears to be most effective for evaluating the superior acetabulum. Demonstration of no involvement of the upper 10 mm of the acetabulum by CT corresponds to an intact 45 roof arc on the three plain lm views. The roof arc and CT subchondral arc were initially devised as study techniques. Rowe and Lowell31 described the intact weight-bearing dome as an indication for nonoperative treatment but did not precisely describe the portion of the acetabulum they were referring to or how to evaluate it radiographically. This area is still incompletely studied, although an intact 45 anterior roof arc or CT subchondral arc is reliable for predicting a good outcome for displaced, low anterior column fractures. This knowledge is useful for assessing when an operation is not needed or for planning the extent of surgery that must be performed. For some operations, reduction and xation of the lower portion (i.e., below the 10-mm CT cut) of the anterior column can be deferred if it would require increased operative exposure or prolonged time. For an intact medial or posterior 45 arc or CT arc, nonoperative treatment may not be indicated. The second category of fractures (i.e., both-column fractures with secondary congruence) presents a unique situation. Because both-column fractures detach all articular segments from the intact ilium, even though displacement of the fracture has occurred, the fracture fragments can remain congruously grouped around the femoral head despite medial and proximal displacement of the femoral head and some rotational displacement of the fragments.6, 26, 30, 34, 50 This congruence can be assessed on the three plain lm views and the CT scan. Perfect
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secondary congruence may be theoretical, and most actual situations may show some lack of congruence between the head and the walls of the acetabulum, although instances of long-term good function and freedom from arthritis have been observed. Predicting a good outcome, however, is less reliable than a perfect reduction, and surgery is recommended in most cases. The goal of nonoperative treatment is prevention of the displacement from worsening. Skeletal traction through a proximal tibia pin is often used. Neufeld roller traction is a useful form of treatment that allows motion of the hip and knee while the patient is in traction.38 The amount of traction should not be so great that it distracts the femoral head from the acetabulum. Lateral skeletal traction through the greater trochanter is not benecial in achieving a reduction and can even cause severe problems, such as infection of the greater trochanter or soft tissues lateral to the hip joint. Traction through the greater trochanter must not be used if surgical treatment is being considered. Surgery is usually undertaken 2 to 3 days after the injury, when the initial bleeding from the fracture and intrapelvic vessels has subsided. Ideally, the operation should be performed before 10 days so that the fracture fragments remain mobile. Three weeks after injury, a bony callus is usually present, which makes reduction of the fracture more difcult. A nal and important consideration regarding the indication for surgery is the capability of the surgeon and the environment in which he or she operates. As with other forms of fracture surgery, the best and worst results follow surgery. If the surgeon is not condent that he or she can achieve and maintain an anatomic or near anatomic reduction with a low chance of complication, the value of surgery is questionable, and it may actually do harm.
columns. The surgical approach should be chosen with the expectation that the entire reduction and xation can be done through that single approach. Combined approaches performed concurrently or successively are less desirable than the single approach. The patient is generally positioned appropriately for the single approach: prone for the Kocher-Langenbeck, supine for the ilioinguinal, or lateral for the extended iliofemoral. Although the extended iliofemoral provides the most commanding access to the bone, it has the longest period of postoperative recovery and the highest incidence of ectopic bone formation. It is therefore preferable to choose the ilioinguinal or KocherLangenbeck approach if the reduction is judged to be feasible through either of these approaches.
Types of Surgical Approaches

KOCHER-LANGENBECK APPROACH The patient is usually positioned in a prone position on the fracture table. The incision starts lateral to the posterior superior iliac spine, proceeds to the greater trochanter, and then continues along the axis of the femur to almost the midpoint of the thigh (Fig. 374A). The gluteal fascia is split in line with the bers of the gluteus maximus. The fascia lata is split in line with the axis of the femur. After posterior reection of the gluteus maximus, the sciatic nerve is identied on the posterior surface of the quadratus femoris and followed proximally until it disappears beneath the piriformis (see Fig. 374B). The tendons of the piriformis and obturator internus are transected at their trochanteric insertion and retracted posteriorly, exposing the greater and lesser sciatic notch. Subperiosteal elevation exposes the inferior aspect of the iliac wing. The capsule can be opened along its rim and the femoral head distracted to expose the internal aspect of the joint (see Fig. 374C). A trochanteric osteotomy can help in further visualization of the inferior iliac wing and the interior of the joint. Alternatively, the tendon of the gluteus medius can be partially transected. The gluteus maximus tendon is transected at its femoral insertion. At completion of the procedure, the detached tendons are reattached to the femur at their normal points of insertion. Hemovac drains are usually placed, with one in the greater sciatic notch and the other in the external iliac fossa. An important access with this approach is to the quadrilateral surface through the greater sciatic notch. Fracture lines traversing the quadrilateral surface and pelvic brim can be palpated through the sciatic notch and the reduction thereby assessed. ILIOINGUINAL APPROACH The patient is normally placed in the supine position on a fracture table. It is useful to have lateral traction through the greater trochanter available, if needed, intraoperatively. The incision starts at the midline 2 ngerbreadths above the symphysis pubis, proceeds to the anterior superior spine, and then continues posteriorly along the line of the iliac crest about two thirds of the way around the iliac crest (Fig. 375A). The periosteum is sharply
Choice of Surgical Approach

No one surgical incision is ideal for all fractures of the acetabulum. After radiographic analysis and classication of the fracture, the surgeon should be able to draw the fracture conguration on a model or a drawing of the innominate bone. Preoperative considerations should include an understanding of the fracture conguration on the outside and inside of the bone and of the orientation of the fracture planes as they traverse the inner aspect of the bone. From this information and from knowledge of the benets and limitations of each surgical approach, the appropriate surgical procedure can be chosen. The Kocher-Langenbeck, ilioinguinal, and extended iliofemoral approaches are the most commonly used. Alternatively, the triradiate approach gives an exposure roughly comparable to that of the extended iliofemoral but has a few limitations. All surgical approaches provide some access to the anterior and posterior columns, but each has advantages and disadvantages. The Kocher-Langenbeck approach provides the best access to the posterior column. The ilioinguinal approach gives the best access to the anterior column and the inner aspect of the innominate bone. The extended iliofemoral approach gives the best simultaneous access to the two
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FIGURE 374. The Kocher-Langenbeck approach. A, The skin incision. B, Splitting of the gluteus maximus muscle and transection of its tendon. The sciatic nerve is visible on the posterior aspect of the quadratus femoris. C, The completed exposure of the retroacetabular surface. Transection and reection of the obturator internus tendon give access to the ischial tuberosity on the lesser sciatic notch. A capsulotomy can be made at the acetabular rim. (AC, Redrawn from Matta, J.M. Surgical Approaches to Fractures of the Acetabulum and Pelvis. Los Angeles, J.M. Matta Publisher, 1986.)
incised along the iliac crest. The attachment of the abdominals and iliacus is mobilized from the crest and internal iliac fossa. Elevation of the iliacus from the internal iliac fossa exposes the anterior sacroiliac joint and pelvic brim. The aponeurosis of the external obliquus is incised in line with the skin incision. This layer is reected distally, unroong the inguinal canal. The spermatic cord is isolated with a nger, and a rubber drain is placed around the spermatic cord for retraction (see Fig. 375B). An incision is carefully made along the inguinal
ligament from its medial attachment to the pubis to the anterior superior spine. Approximately 1 mm of the ligament is split away from its main portion, releasing the transversalis fascia from the ligament medially and freeing the common origin of the internal oblique and transversus abdominis from the lateral portion of the ligament. The conjoined tendon and tendon of the rectus abdominis are often transected in the medial portion of the incision. This incision along the inguinal ligament provides access to the retropubic space of Retzius medi-
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FIGURE 375. The ilioinguinal approach. A, The skin incision. B, The internal iliac fossa has been exposed and the inguinal canal has been unroofed by distal reection of the external oblique aponeurosis. C, An incision along the inguinal ligament detaches the abdominal muscles and transversalis fascia, giving access to the psoas sheath, the iliopectineal fascia, the external aspect of the femoral vessels, and the retropubic space of Retzius. D, An oblique section through the lacuna musculorum and lacuna vascularum at the level of the inguinal ligament.
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FIGURE 375 Continued. E, Division of the iliopectineal fascia to the pectineal eminence. F, An oblique section demonstrates division of the iliopectineal fascia. G, Proximal division of the iliopectineal fascia from the pelvic brim allows access to the true pelvis. H, The rst window of the ilioinguinal approach gives access to the internal iliac fossa, the anterior sacroiliac joint, and the upper portion of the anterior column. Illustration continued on following page
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FIGURE 375 Continued. I, The second window of the ilioinguinal approach gives access to the pelvic brim from the anterior sacroiliac joint to the lateral extremity of the superior pubic ramus. The quadrilateral surface and posterior column are accessible beyond the pelvic brim. J, Access to the symphysis pubis and retropubic space of Retzius, medial to the spermatic cord and femoral vessels. (IJ, Redrawn from Matta, J.M. Surgical Approaches to Fractures of the Acetabulum and Pelvis. Los Angeles, J.M. Matta Publisher, 1986.)
ally, the external aspect of the iliac vessels, and the psoas sheath. The lateral cutaneous nerve of the thigh and the femoral nerve are found within the psoas sheath (see Fig. 375C). A periosteal elevator is used along the pelvic brim, superior ramus, and quadrilateral surface to obtain a better view of the bone. The obturator nerve and artery are visualized medial or lateral to the vessels as they enter the obturator foramen. The surgeon should check for an anomalous origin of the obturator artery from the external iliac system. If present, it should be clamped, transected, and ligated so that it does not tear during the procedure and cause bleeding, which is difcult to control. The interior of the joint can be approached and visualized by distraction of the fracture lines, but the interior of the joint is not visible after reduction of the fracture. The entire anterior column is exposed through the ilioinguinal approach (see Fig.375H). Limited but useful access to the posterior column can be obtained by manipulating the quadrilateral surface through the second window of the ilioinguinal approach (see Fig. 375I). Rubber drains are also placed around the iliopsoas and femoral nerves and around the external iliac vessels with their lymphatics to manipulate and retract them for the reduction and internal xation (see Fig. 375J). It is often necessary to release the inguinal ligament and sartorius origin from the anterosuperior spine and to elevate the tensor fascia lata origin from the outer aspect of the bone to place reduction forceps across the anterior border of the bone. At the completion of the procedure, Hemovac drains are placed in the retropubic space along the quadrilateral
surface and in the internal iliac fossa. The iliopectineal fascia is not repaired, but all other structures are repaired anatomically. MODIFIED STOPPA ANTERIOR APPROACH Cole and Bolhofner7 described the use of the modied Stoppa anterior approach to access the medial wall of the acetabulum, quadrilateral surface, and sacroiliac joint. The patient is positioned supine on the table, and a horizontal incision is made 2 cm above the symphysis pubis, extending from external ring to external ring. The rectus abdominis muscle is then split vertically and incised sharply from its insertion on the pubic surface bilaterally. The bladder is protected. Anastomotic vascular connections between the inferior epigastric and obturator vessels and between the external iliac and bladder, as well as nutrient vessels to the pelvis, must be identied and clipped. The surgical approach passes under the external iliac vessels and femoral nerve. Full access to the inner pelvic surface is achieved by sharply dividing and elevating the iliopectineal fascia along the pelvic rim. While exing the ipsilateral hip to relax the iliopsoas muscle, it can be elevated from the internal iliac fossa to enhance the superior exposure. Multiple retractors, including Hohmann and malleable devices and abdominal retractors such as those designed by Deaver and Harrington, are held by an assistant standing on the side of the pelvic injury. The operating surgeon stands on the side opposite the injury to gain the best view of the fracture. Reduction is achieved with direct pressure on the pelvic surface with the ball-spike pusher, a bone
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hook through the sciatic notch, Schantz screws in the pelvic rim and greater trochanter, and reduction forceps. Fixation is achieved with reconstruction plates and 3.5-mm screws inserted just below the pelvic brim on the medial surface. By avoiding dissection of the gluteal muscles, the modied Stoppa approach achieves a low incidence of heterotopic bone formation, similar to the ilioinguinal approach. Wound closure, which includes reattachment of the rectus abdominis, is simplied because of the size and location of the incision. EXTENDED ILIOFEMORAL APPROACH The extended iliofemoral approach was developed by Emile Letournel as a simultaneous approach to the two columns of the acetabulum.23, 25, 26, 54 It can be regarded as the lateral approach to the innominate bone that primarily exposes the external aspect of the bone. The internal iliac fossa, however, can also be exposed, and circumferential access to the bone can be obtained by palpating the quadrilateral surface from the pelvic brim to the greater sciatic notch. The patient is usually placed in the lateral position on the fracture table. The knee is kept in at least 60 of exion to relax the sciatic nerve. The incision starts at the posterosuperior iliac spine, follows the iliac crest to the anterosuperior spine, and then turns slightly laterally to parallel the femur on the anterolateral aspect of the thigh (Fig. 376A). The periosteum is sharply incised along the iliac crest, and the gluteal muscles are reected from the lateral aspect of the iliac wing. The fascia lata is incised over the tensor fascia lata muscle. The incision is usually carried distally enough so that the distal extent of the tensor fascia lata muscle can be located. The tensor fascia lata muscle is retracted posteriorly, exposing a fascia layer that separates it from the rectus femoris. This fascial layer is opened. Another fascial layer separating the rectus femoris from the vastus lateralis is split longitudinally, and the lateral femoral circumex vessels are found immediately beneath this fascial layer. The lateral femoral circumex vessels are clamped, transected, and ligated. The strong aponeurotic bers that traverse the anterior aspect of the femur must also be transected to provide access to the trochanter. The tendon of the gluteus minimus is identied at its anterior insertion on the trochanter. It is transected in its midportion and tagged with suture. The tendon is then also released from its attachment to the anterior and superior hip capsule. The gluteus medius tendon is identied as a broad band over the external aspect of the greater trochanter. It is transected in its midsubstance and tagged with multiple sutures (see Fig. 376C). Although the medius tenotomy has been used for most of my cases, I now prefer to osteotomize the greater trochanter with a thin oscillating saw after sectioning the minimus tendon to mobilize the medius. An osteotomy should not go medial to the posterior ridge of the greater trochanter, or it may damage the femoral head vascularity. The piriformis and obturator internus tendons are identied at their insertion on the proximal femur. These are transected and tagged with suture. As they are retracted
posteriorly, the greater and lesser sciatic notches are exposed, as are the ischial spine and ischial tuberosity. The reected tendon of the rectus femoris is identied and is usually excised. An incision along the rim of the acetabulum provides access to the interior of the joint as the femoral head is distracted from the joint (see Fig. 376D). Access to the internal iliac fossa and anterior column is made possible by detachment of the sartorius and rectus femoris origins from the anterior border of the bone and by elevation of the iliacus from the distal portion of the internal iliac fossa. If the iliac crest is not involved by the fracture (e.g., transverse or T shaped), the surgeon can alternatively osteotomize the anterior superior iliac spine for muscle detachment and exposure. The upper portion of the anterior column is accessible, but the anterior column is not accessible distal to the pectineal eminence (see Fig. 376E). In the case of a both-column fracture with an anterior column fracture traversing the anterior portion of the iliac wing to the iliac crest, it is possible to devascularize the anterior column by removing all muscle attachments from the outer and inner aspects of this bone segment. As with other types of fracture surgery, soft tissue pedicles should be left attached to all bony fragments to prevent loss of vascularity. At completion of the procedure, Hemovac drains are usually placed along the external aspect of the bone and into the greater sciatic notch. The internal iliac fossa should also be drained if it has been exposed. The origins of the sartorius and rectus femoris are reattached to the anterior border of the bone with suture placed through drill holes (or an osteotomy repaired with 3.5-mm screws). The tendons of the piriformis, obturator internus, gluteus medius, and gluteus minimus are reattached to their anatomic positions on the femur with multiple sutures (or the trochanter and medius origin xed with 3.5-mm screws). The fascia lata is reattached to the abdominal fascia along the iliac crest, and the fascia lata is closed over the thigh. During the suture of the fascia lata to the abdominals, the hip should be placed in abduction to facilitate the repair, which necessitates removal of the leg from its Judet table attachment. In addition to the interrupted sutures, a second continuous suture reinforces the repair from posterior to the gluteus medius tubercle to distal to the anterior superior spine. Before surgery, the femur has often been displaced to an intrapelvic position, and returning it to its normal, more lateral position creates initial tension on the abductor repair, which is lessened when the limb is abducted. This abducted position should be maintained as patients are returned to their beds from the table, and an abductor pillow is secured between the legs for the rst 5 days. Care must be taken throughout the procedure to avoid undue injury to the large muscle ap or to the superior gluteal vessels that vascularize it. The muscle should also be prevented from becoming desiccated by applying irrigant and irrigant-soaked sponges. TRIRADIATE APPROACH The triradiate approach offers an alternative exposure to the external aspect of the innominate bone.40 It provides
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FIGURE 376. The extended iliofemoral approach. A, The skin incision. B, The gluteal muscle has been elevated from the wing. The lateral femoral circumex vessels will be transected and ligated. C, The tendons of the gluteus minimus and medius are transected in midsubstance at their trochanteric insertions. D, The completed exposure of the external aspect of the bone with a capsulotomy along the acetabular rim. E, The completed exposure of the internal aspect of the bone. (CE, Redrawn from Matta, J.M. Surgical Approaches to Fractures of the Acetabulum and Pelvis. Los Angeles, J.M. Matta Publisher, 1986.)
almost the same exposure to the bone as the extended iliofemoral approach, but the exposure to the posterior part of the ilium is not as good. The incision starts as with the Kocher-Langenbeck approach, dissecting between the bers of the gluteus maximus and splitting the fascia lata. An anterior limb of the incision is then incised from the
anterosuperior greater spine to the trochanter (Fig. 377A). The fascia lata is reected off the external aspect of the tensor fascia lata muscle. The greater trochanter is osteotomized, and the abductor insertion, along with the tensor fascia lata muscle, is retracted proximally. Further exposure to the iliac wing can be obtained by release of the fascia lata
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from the iliac crest, as with the extended iliofemoral approach (see Fig. 377B). A medial limb of the incision can also be extended across the lower abdomen to obtain some exposure to the inner aspect of the bone.
COMBINED APPROACHES The high incidence of heterotopic bone formation and other complications that have been associated with the use of extensile approaches by some surgeons has led them to adopt combined approaches. Simultaneous anterior and posterior approaches are performed to afford adequate access to the external and internal surfaces of the pelvis. Anteriorly, the approaches used include the SmithPetersen iliofemoral, ilioinguinal, and Stoppa. Posteriorly,
the Kocher-Langenbeck is generally chosen. The combined approach is used in lieu of an extensile approach to access both columns. The patient is positioned in a so-called oppy lateral position so that access can be increased at will to the anterior and posterior approaches. With the combined approaches of a signicant operation, it is thought that complications are reduced by limiting the dramatic muscle stripping that is employed in the extensile approaches.
Table and Positioning

One of the main differences in technique between surgeons is to operate with or without the Judet (or other) fracture
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B
FIGURE 377. The triradiate approach. A, The skin incision. B, The completed exposure of the external aspect of the bone.
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table. The Judet table maximizes the capabilities of each surgical approach. This is particularly important with the Kocher-Langenbeck and ilioinguinal approaches to avoid the extended iliofemoral or two approaches when possible. Using the Judet table, the patient is positioned specically for the approach to be performed: prone for KocherLangenbeck, supine for ilioinguinal, or lateral for an extended iliofemoral approach. When the extended iliofemoral approach is chosen, the Judet table aids reduction and visualization of the articular surface. Other surgeons use a standard table and place the patient in a oppy lateral position. The advantage of this is the ability to go to a second approach if desired. From this position, they most often begin with the KocherLangenbeck approach and drape the patient to allow a subsequent ilioinguinal procedure to be performed simultaneously if the need arises. This position also allows extension of the Kocher-Langenbeck to the triradiate approach. The disadvantage of the oppy lateral position on a standard table is that the surgeon impairs his or her capabilities to reduce the fracture through the initial Kocher-Langenbeck approach. If a subsequent ilioinguinal approach is performed, the surgeon also works at a disadvantage. In effect, choosing the oppy lateral position for the purpose of allowing two approaches makes the possibility of requiring two approaches more likely. If care is taken in the choice of approach and the patient is positioned appropriately on the Judet table, the frequency of an unexpected second approach is about 2%.
and adhesive vinyl skin covering applied subsequently should maintain the drapes attached to the skin to lessen the chance of contamination from the anus and perineum. Before applying the nal adhesive Betadine-impregnated vinyl skin covering, the skin should be wiped with alcohol and then dried to enhance adhesion. The skin surface is usually folded and convoluted, and it is best to not apply the vinyl skin drape under tension, because a skin drape under tension usually becomes detached from concave areas of the skin surface. The nal appearance of the skin drape therefore includes wrinkles and folds, but it is less likely to detach. Air pockets are punctured and pressed down. Attempting to walk air bubbles to the side is not done because it damages drape adhesion. Increased skin area is exposed by a fracture table because the pelvis is supported by a narrow sacral support rather than the broad at top of a standard table. This larger area of exposed skin makes it easier to maintain an adequate margin between border drapes and the wound and lessens the chance of looking at the table during surgery. A stable pelvis position in relation to the table rather than a oppy one also enhances drape security.
Techniques of Reduction and Internal Fixation

After the preoperative radiographic evaluation and decision-making process have been completed, reduction of the fracture remains the primary problem facing the surgeon. The goal of surgery is an anatomic reduction of the innominate bone and acetabulum. Displacements greater than 1 mm correlate with an impaired prognosis. Even after determining the precise fracture conguration and performing the appropriate surgical approach, reduction of an acetabular fracture can be an extremely challenging problem, even with appropriate instrumentation. The technique of reduction is always individualized to the fracture type. It often varies, even for a specic fracture type, and frequently depends on the exact conguration of the individual fracture.32 A fracture table, particularly the Judet fracture table, aids in the reduction of the fracture and helps to maximize the possibilities of what can be done through each surgical approach. The fracture table does not complete the fracture reduction but does distract the femoral head from its usual centrally displaced position to allow reduction of the acetabulum and, with the Kocher-Langenbeck or extended iliofemoral approach, allows visualization of the interior of the joint. With the Judet fracture table, the patient and extremity can be tilted for better visualization. Its use also facilitates easy repositioning of the limb during surgery as the limb remains in traction. An alternative to the fracture table is the ASIF femoral distractor, which can be placed between the ilium and proximal femur to apply distraction across the hip joint. Although it can be effective, the direction of pull is sometimes not ideal, and the femoral distractor is another instrument that can impede access to the wound. Various reduction forceps are useful for reducing acetabular fractures. Several types can grasp heads of screws.
Preparing and Draping for Surgery

Preparing and draping the patient for surgery may seem an elementary and mundane subject to the accomplished fracture surgeon, but a signicant portion of the success in controlling and decreasing the infection rate can be attributed to this discipline. Because infection can almost be as devastating as death or amputation in importance as a complication, the surgeon must carefully supervise this routine. Before positioning the patient, the physician begins with an examination of all areas of the skin. Because of pain and difculty in dealing with other injuries, the trauma patient may have skin areas that have been incompletely cleaned and evaluated. If the skin has not been properly cleaned before surgery, it should be done in the operating room before positioning, preparing, and draping, paying particular attention to the gluteal crease and perineum. Draping out dirty areas is not sufcient. Examination in the operating room may also disclose skin damage or subcutaneous hematoma sufcient to require debridement and postponement of surgery. After patient positioning, adhesive plastic drapes are applied to the borders of the area to be prepared, and their adhesive is enhanced with tincture of benzoin applied to the skin. When possible, these border drapes should be placed a minimum of 8 to 10 cm from the planned incision. Subsequent drapes are attached to the skin with staples along their edges and should not narrow this 8- to 10-cm margin of exposed skin. The border drapes, staples,
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FIGURE 378. Instruments for open reduction of acetabulum fractures. AD and H, Variously shaped pointed reduction forceps to accommodate the different contours of the innominate bone. E, The ball-spike instrument for pushing fragments. F and G, Farabeuf reduction forceps for direct application to the bone and for grasping the heads of 4.5- and 3.5-mm screws. I, Pelvic reduction forceps for application to 4.5-mm screws. J and K, Six-millimeter Schanz screw and T-handled chuck for insertion and manipulation. L, Sciatic nerve retractor.
These include Farabeuf clamps, adapted to grasp 3.5- or 4.5-mm diameter screws, and pelvic reduction forceps available from several manufacturers. Pointed reduction forceps are helpful, as is a ball-spiked instrument that can be used for pushing fracture fragments. A femoral head corkscrew or 6-mm Schanz screw can be inserted into the bone to control rotational displacement (Fig. 378). The reduction and xation usually proceed in a stepwise fashion, with reduction followed by xation of individual fragments and then building on the assembled parts59 (Figs. 379 to 3726). Initial lag screw xation47, 51 usually allows removal of the reduction forceps, followed by more denitive plate xation (Fig. 3727). K-wires do not always provide adequate stability for temporarily securing a reduction. The reduction is assessed by visualization of the fracture lines and by palpation of fracture lines that cannot be observed directly. It is usually preferable to visualize the nal reduction on the articular surface, although the surgical approach sometimes may not allow this. The nal articular reduction is often inferred to be correct by reduction of the fracture lines on the extraarticular cortex of the innominate bone. It is usually helpful to include extra-articular fragments in the reduction and xation; they are commonly found along the pelvic brim, sciatic notch, or iliac crest. These small fragments are often essential for the reduction of the
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FIGURE 379. Model showing an anterior column fracture. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3710. Anterior-posterior radiograph of a 32-year-old woman with a both-column fracture. The femoral head is medialized because of the muscle forces across the hip. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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larger articular fragments and aid in providing nal stability. In reducing the initial fragments, it is important to obtain accurate reduction of even the extra-articular fragments, because any errors in reduction are compounded as additional fracture fragments are added. Reduction and xation are carried out most effectively when the surgeon plans several steps ahead. Clamps must be placed so they are effective in reduction and allow access to the bone for screw and, sometimes, for plate xation before clamp removal. Screws must be placed in an effective position and placed so their heads do not interfere with a subsequent plate. Sometimes, reduction of the wrong fragment rst blocks reduction of a subsequent fragment. The surgeon should have a fairly good picture of the entire process and the desired nal construct before starting the rst step. A few tips are valuable. Although great force sometimes is needed for reduction, it is usually best carried out with a nesse that avoids damage to the bone and increasing difculties. What seems initially to be an uncorrectable displacement sometimes can be corrected easily when the
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FIGURE 3712. A, Model viewed from behind shows the typical medial displacement of the posterior column after anterior xation. B, Computed tomography shows the internal rotation of the posterior column (arrow). (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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proper instrument and direction of force are used. Fixation needs to be stable, but the surgeon should not overdo it. Precise placement of xation is more important and effective than quantity. Many plates are applied with one or more screw holes left empty. The nal stability of the construct depends on both reduction and xation. An imperfect reduction is less stable and its xation more likely to fail. When possible, the surgeon should strive for a perfect reduction. This process may take an extra hour, but it can affect the rest of the patients life.
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Percutaneous Fixation
FIGURE 3711. Computed tomographic scan of an anterior column fracture shows the external rotation of the displaced fragment. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
There has been increased discussion in the literature about percutaneous xation of acetabular fractures.29 This method has been proposed and used for several Text continued on page 1133
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FIGURE 3713. A, View of an anterior column fracture with the typical external rotation deformity. A Farabauf clamp is placed on the iliac wing. B and C, By pulling the clamp laterally and internally rotating (arrows) it, most of the reduction is possible. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3714. A, Model shows overlap of the displaced anterior column on the intact ilium. B and C, A mini-Hohmann or curved osteotome can be used as a pry bar to reduce this displacement. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3715. A, A model of an anterior column fracture viewed from the inside of the pelvis reveals only slight displacement at the lateral edge of the iliac wing (arrowhead). B, This small amount of rotational deformity found at the wing may translate into a large displacement at the articular surface. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3716. A, A ball spike placed through the middle window may be used to push down the cephalomedial corner of the anterior column (arrow). B, This action reduces the fracture. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3717. Model shows bone tenaculum holding the iliac wing reduction. With a Farabauf clamp on the wing, a ball-spike instrument can be used to push the inferior aspect of the fracture into its anatomic position. The use of multiple clamps is often required for the reduction of the anterior column. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
FIGURE 3718. View of a both-column fracture after xation of the anterior column. The posterior column is displaced medially and posteriorly and is internally rotated. The quadrilateral surface (arrow) is used for placement of clamps. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
FIGURE 3719. A, B, A Matta clamp placed from the anterior inferior iliac spine to the quadrilateral surface effects a lateral reduction force on the posterior column, pictured here with a spiked disc to disperse the force of the clamp. C, A Mayo offset clamp can be used in the same fashion to reduce the posterior column. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3721. A bone hook placed in the sciatic notch can pull the posterior column anteriorly (arrow). (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3720. A, Lateral view of the pelvis shows the position of the Mayo clamp on the outside of the innominate bone. B, A view of the pelvis from below shows the location of the psoas and femoral nerve (between the arms of the clamp) and the external iliac vessels (medial to the clamp). Clamps in these positions place tension on the vessels by displacing them medially. A pulse should always be closely observed when these reduction clamps are used. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
FIGURE 3722. A one-third tubular or reconstruction plate can be used to reduce and hold the quadrilateral surface when it is comminuted. This is usually placed under the anterior column plate. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3723. A push plate placed through the medial window or a modied Stoppa approach can be used to reduce and support the medial displacement of the posterior column (arrow). (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
FIGURE 3725. Postoperative anteroposterior radiograph of the patient shown in Figure 3710. An arrow identies the percutaneously placed lag screw from the retroacetabular surface to the quadrilateral surface. The sacroiliac joint was also xed because of posterior instability. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3724. The long 2.5-mm oscillating drill bit is pictured going through the anterior column plate into the posterior column to maintain the reduction gained using the Mayo clamp. This screw is placed parallel to the quadrilateral surface. (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3726. Preoperative anteroposterior (A), obturator oblique (B), and iliac oblique (C) views of a 23-year-old man with a both-column fracture. Illustration continued on following page
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FIGURE 3726 Continued. Postoperative views (D and E ) show reduction of the joint with the use of an iliac wing lag screw and plate, an anterior column plate, posterior column lag screws placed from the pelvic brim through the plate and percutaneously from the retroacetabular surface, and a posterior column push plate, which is seen best on the iliac oblique view (F). (From Tornetta, P., III; Riina, J. Oper Tech Orthop 7:184195, 1997.)
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FIGURE 3727. Plates and screws for internal xation of acetabulum fractures include curved and straight plates accepting screws 3.5, 4.5, and 6.5 mm in diameter.
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indications: nondisplaced fractures, fractures in elderly patients, and when the chosen surgical approach does not allow access for a desired screw. Although it is possible to place xation percutaneously, the indications remain controversial. Would nondisplaced fractures have a different prognosis if they were not xed? Most authorities would say no. Does this benet elderly patients? This outcome has not been demonstrated. The question for most elderly patients is not whether they can undergo an open procedure, but whether an adequate reduction and xation can be obtained. Percutaneous xation cannot enhance reduction and can be expected to impair it. Fixation is less effective when reduction is not obtained and xation is achieved with screws alone. Percutaneous xation may be considered when the surgical approach does not allow access for a desired screw. The most common situation encountered is soft tissue restriction of the drill and screw direction. In these cases, the point for screw insertion usually is seen in the wound, whereas the drill and screw enter through a small, separate insertion wound. This is useful sometimes when a screw is placed to the anterior column while operating through the Kocher-Langenbeck approach. Percutaneous techniques do not address the most important problems of reduction and xation that remain to be solved in acetabular fracture surgery.
SURGICAL TREATMENT OF INDIVIDUAL FRACTURE TYPES Posterior Wall Fracture
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The posterior wall fracture is the most common acetabular fracture. It is usually the most straightforward to treat surgically. The surgeon should be aware, however, that
these fractures can be demanding in their reduction and xation and that treatment can be unsuccessful if errors are made during surgery.8, 18 Most posterior wall fractures that leave a portion of the retroacetabular surface intact can be effectively operated on with the patient in the lateral position on the standard operating table. A Kocher-Langenbeck approach is used. The hip is usually dislocated posteriorly during surgery to remove incarcerated fragments and to excise the torn ligamentum teres. After congruous reduction of the hip, the posterior wall fragments are repositioned using the femoral head as a mold for the reduction. Impaction of the articular surface must be recognized preoperatively and always corrected during surgery. If there is a bone defect after elevation of the impaction, it should be buttressed using an autogenous cancellous graft. Free fragments that include only cartilage and a segment of underlying cancellous bone are commonly found. The fragments should be reduced into their anatomic position and, if not directly xed, should be held in place by the overlying posterior wall fragments that include a portion of the retroacetabular surface. Small fragments are eventually discarded, but an effort should be made to save and reduce all fragments, because discarding fragments can lead to defects in the posterior wall that may lead to an instability of the hip and redislocation. After reduction, the fragments are xed with one or two lag screws, followed by xation with a plate placed from the superior pole of the ischium to the inferior iliac wing. The plate should be curved so that it roughly parallels the rim of the acetabulum (Fig. 3728). It is easy for screws inserted into the retroacetabular surface to enter the joint. The screws are normally directed away from the joint, oblique to the retroacetabular surface. Extended posterior wall fractures that displace the entire retroacetabular surface and involve the greater or lesser sciatic notch (or both) are usually best operated on with prone positioning of the patient on the Judet table. This arrangement provides for better control of the femoral
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FIGURE 3728. Application of a posterior wall buttress plate. A, The posterior wall fragment is reduced and held with provisional interfragmentary screws. A posterior buttress plate is applied. The plate should be slightly undercontoured so that the plate produces a buttress effect, applying a force to the posterior wall perpendicular to the undersurface of the plate. B, The inferior screw of the posterior plate can often be placed into the ischium. This provides excellent xation to the inferior aspect of the plate. The posterior plate should be curved around the acetabular rim, avoiding excessive dissection along the superior iliac wing. Ideally, two screws should be used above and below the fracture. Interfragmentary screws can also be applied through the plate.
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FIGURE 3729. A, Anteroposterior (AP) view of the right hip and innominate bone of a 42-year-old man with a fracture of the posterior wall of the acetabulum. Seen are the displaced posterior wall fragment, the defect in the line of the posterior rim, an incarcerated fragment medial to the head, and slight lateral displacement of the head. B, Obturator oblique view. C, Iliac oblique view. D, Computed tomographic (CT) scan just distal to the roof, demonstrating the posterior wall fracture fragment. E, CT scan through the midportion of the joint, demonstrating the posterior wall defect and incarcerated segments of the posterior wall medial to the femoral head.
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FIGURE 3729 Continued. AP (F), iliac oblique (G), and obturator oblique (H) views of the innominate bone and hip following open reduction and internal xation of the fracture performed through the Kocher-Langenbeck approach with the patient in the prone position on the Judet table. The incarcerated fragments have been removed from the joint and incorporated into the posterior wall reduction and xation. A curved pelvic plate of 88-mm radius is used for xation, as well as one 3.5-mm diameter screw outside the plate and four through the plate. Note that the curved plate parallels the posterior rim of the acetabulum and does not diverge from the acetabular rim proximally. I, AP radiograph of innominate bone and hip 2 years following the injury demonstrates no arthritic changes. The patients hip function was rated excellent.
head reduction and easier access to the greater and lesser sciatic notches. In this case, the hip is not re-dislocated posteriorly, but distraction of the femoral head from the acetabulum provides for removal of free fragments (Fig. 3729).
Posterior Column Fractures

Posterior column fractures are normally operated on with the patient in the prone position on the Judet table. Using the Kocher-Langenbeck approach, the fracture lines are
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distracted initially using a lamina spreader or the AO/ASIF femoral distractor. Blood clot and granulation tissue are thoroughly removed from the fracture lines, as are any free bone fragments that may impede reduction. The displacement is usually corrected by the two-screw technique. The position each screw is placed in before attempting reduction greatly inuences the success of this procedure. The posterior column usually rotates along its longitudinal axis as it displaces. This rotation must always be corrected, usually by a rotational lever placed into the ischial tuberosity. This device can be a femoral head corkscrew or a Schanz screw. The reduction is assessed by visualizing the retroacetabular surface and the cartilage of the joint by distraction of the femur and by palpating the quadrilateral surface through the greater sciatic notch. Palpation of the quadrilateral surface is particularly useful for assessing rotational deformities of the posterior column. Initial xation is usually achieved with a lag screw that is placed from posterior to anterior and followed by placement of a curved plate on the retroacetabular surface.
toward the anterior column. The lag screw crosses the transverse fracture from a proximal to distal direction, and a plate is then placed along the retroacetabular surface to complete the xation.14 A few transverse fractures are best treated through the ilioinguinal approach, with the patient in the supine position on the Judet table. The ilioinguinal approach can be used for relatively high anterior and low posterior transverse fractures and for those that are more displaced along the anterior articular surface. The reduction is usually obtained by a Farabeuf clamp applied to two screws along the pelvic brim or with pointed reduction forceps applied along the internal aspect of the bone. Fixation is attained with a curved plate along the pelvic brim.
Associated Transverse and Posterior Wall Fractures

Most associated transverse and posterior wall fractures can be operated on through the Kocher-Langenbeck approach, with prone positioning of the patient on the Judet table. The femoral head is initially distracted, and incarcerated fragments are removed. Reduction of the transverse fracture is carried out rst, using the standard technique and xation with a lag screw. Sometimes, it is not possible to obtain initial xation with a lag screw, and the rst xation should then be done with a plate along the greater sciatic notch. After xation of the transverse fracture, the reduction clamps are removed from the wound, and the posterior wall fracture is reduced and initially xed with lag screws. A curved plate, applied from the ischial tuberosity to the inferior ilium, bridges the transverse and the posterior wall fracture (Fig. 3730). Some associated transverse plus posterior wall fractures offer unusual difculties, such as a transverse fracture associated with an extended posterior wall fracture. In this
Transverse Fractures
For reduction of transverse fractures, the patient usually is positioned prone on the Judet table, and the KocherLangenbeck approach is used. The reduction technique is similar to that used for the posterior column fracture. Typically, the two-screw technique is used to control displacement, and a rotational lever is placed into the ischial tuberosity. As the rotational lever is being applied, the entire ischiopubic segment is rotated rather than the posterior column alone. Reduction of the anterior portion of the transverse fracture is assessed by palpation of the quadrilateral surface and pelvic brim through the greater sciatic notch. Initial xation is achieved with a lag screw inserted into the retroacetabular surface and directed
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FIGURE 3730. Internal xation of a transverse plus a posterior wall fracture as performed through the KocherLangenbeck approach.
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FIGURE 3731. Internal xation of a T-shaped fracture performed through the extended iliofemoral approach.
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case, the extended iliofemoral or triradiate approach would be the best choice.
T-Shaped Fractures
Many T fractures can be operated on through the KocherLangenbeck approach, with prone positioning of the patient on the Judet table.55 The fracture of the anterior column can be visualized on the acetabular articular surface after distraction of the posterior column fracture line. The anterior column can be reduced with a bone hook or pointed reduction forceps, followed by xation with lag screws placed from a posterior to anterior direction. The posterior column is reduced and xed in the usual fashion. If the surgeon nds it impossible to reduce the anterior column through the Kocher-Langenbeck approach, the posterior column is xed, and the patient is turned supine for a subsequent ilioinguinal approach. If staged approaches are to be used, great care must be taken not to place screws into the posterior column, which would block subsequent reduction of the anterior column. If there is doubt about whether the reduction can be performed through the Kocher-Langenbeck approach, the extended iliofemoral approach can be chosen initially (Fig. 3731). Another satisfactory option is the triradiate approach. The surgeon can start with the Kocher-Langenbeck approach and proceed to the anterior limb of the triradiate approach, as indicated.
with the pointed reduction forceps. Fixation is accomplished with a curved plate placed along the pelvic brim from the superior pubic ramus to the internal iliac fossa. Because screws are placed along the brim, the acetabulum can be entered easily. The screws should be placed close to the pelvic brim and parallel to the quadrilateral surface. In the area of the pectineal eminence, usually only a short screw (approximately 12 or 14 mm long) is placed to avoid entering the joint (Fig. 3732). After xation, the reduction can be checked using an image intensier, which additionally conrms that screws are clear of the joint.
Anterior Column Fractures

Anterior column fractures are operated on through the ilioinguinal approach, with supine positioning of the patient on the Judet table. The anterior wall or column is reduced and xed in the normal manner, but care is taken to prevent screws from crossing the posterior column fracture line.9 The posterior column is reduced through the second window of the ilioinguinal approach by pressure applied to the quadrilateral surface or by pointed reduction forceps applied to the quadrilateral surface. The posterior column is then internally xed with long lag screws placed from the pelvic brim and directed parallel to the quadrilateral surface, roughly in the direction of the ischial spine and lesser sciatic notch.
Anterior Wall Fractures

Anterior wall fractures are operated on through the ilioinguinal approach, with supine positioning of the patient on the Judet table. Traction removes the femoral head from the centrally displaced position. Reduction is performed with pressure applied by means of the ball-spike instrument and
Both-Column Fractures
Most both-column fractures can be reduced and xed through the ilioinguinal approach, but approximately one third require the extended iliofemoral approach. The ilioinguinal approach is preferable, when possible, because it leaves a more cosmetically pleasing scar; involves minimal stripping of the outer aspect of the bone, which
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FIGURE 3732. Internal xation of an anterior wall fracture performed through the ilioinguinal approach.
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leads to a quick postoperative recovery, and results in almost no ectopic bone formation. Fractures requiring the extended iliofemoral approach are those that have displaced fracture lines crossing the sacroiliac joint and those with complex involvement of the posterior column. When the ilioinguinal approach is chosen, the anterior column is reduced and internally xed rst. An anterior column fracture usually extends to the crest of the ilium and is reduced and xed as is normally done for a high anterior column fracture (Fig. 3733). If a plate is used along the pelvic brim, many screw holes are initially left open so that the screws do not enter the posterior column fracture site. The posterior column segment is then reduced through the second window of the ilioinguinal approach by pressure on the quadrilateral surface and with pointed reduction forceps placed from the pelvic brim or from the outer aspect of the anterior column to the quadrilateral surface (Fig. 3734). The reduction is assessed by visualizing and palpating the quadrilateral surface and by palpating the greater sciatic notch. Fixation is performed with lag screws from the pelvic brim placed into the posterior column (Fig. 3735). The image intensier is useful at the completion of surgery to conrm the reduction and to ensure that all screws are clear of the joint. When the extended iliofemoral approach is chosen, the patient is positioned in the lateral position on the Judet table. The anterior column is usually reduced and xed to the intact portion of the ilium before the posterior column. If the posterior column segment is large and especially if the displaced posterior column segments involve a portion of the sacroiliac joint, it may be best to proceed with reduction and xation of the posterior column rst, followed by the anterior column reduction and xation. Reduction techniques include the two-screw technique, the use of pointed reduction forceps, and careful control of rotation of the two columns of the acetabulum using
standard techniques (Figs. 3736 to 3738). Generally, the extended iliofemoral approach provides the most commanding access to both-column fractures and provides the easiest assessment of reduction through wide visualization of the bone and by visualization of the articular surface (Fig. 3739). As surgeons gain experience with the ilioinguinal approach, they realize that it is effective and provides signicant advantages for the patient (Fig. 3740).
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FIGURE 3733. Technique of reduction of the anterior column component of a both-column fracture through the ilioinguinal approach. The Farabeuf clamp is applied along the anterior border of the bone to control rotation of the anterior column. The ball spike is applied for pressure along the pelvic brim. The same technique can be used for reduction with an isolated anterior column fracture or an anterior column and posterior hemitransverse fracture.
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FIGURE 3734. Technique of reduction of the posterior column through the ilioinguinal approach. An angled-jaw, pointed reduction forceps is applied from the anterior to the posterior column, across the pelvic brim.
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FIGURE 3735. Internal xation of a fracture of both columns performed through the ilioinguinal approach.
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FIGURE 3736. Technique of reduction of the anterior column performed through the extended iliofemoral approach. A Farabeuf clamp grasps two screw heads just above the level of the greater sciatic notch. A second Farabeuf clamp grasps the anterior border of the bone and controls anterior column rotation. A pointed reduction forceps is applied to the iliac crest.
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FIGURE 3737. Assessment of rotation of the anterior column at the iliac crest. A, Residual rotation is evidenced by medial gaping of the fracture line. B, The reduction is correct.
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FIGURE 3738. Reduction technique for the posterior column segment of a fracture of both columns performed through the extended iliofemoral approach. A Farabeuf clamp grasps screw heads on either side of the fracture. A screw has been inserted into the ischium for rotational control.
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FIGURE 3739. Internal xation of a fracture of both columns performed through the extended iliofemoral approach.
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Avoiding Intra-articular Screws

A screw placed and left protruding into the joint typically destroys the articular surface. The surgeons knowledge of the anatomy of the innominate bone and his perception of screw length and direction are the primary factors in preventing this complication. Intra-articular visualization and radiographs are also useful. The surgeon must be satised before the patient leaves the operating room, and certainly before the patient leaves the hospital, that all screws are outside the joint. Screws that traverse the acetabular fossa medial to and not in contact with the head may sometimes be safe, but generally these screws should not be left in place. When a screw is in doubt and beyond vision, radiographs are necessary. In almost all cases, uoroscopy and, sometimes, plain lms are the most useful modalities. The CT scan is often confusing and useful only in exceptional cases of other implants blocking a plain lm or uoroscopy view. The uoroscope is most useful because it can be manipulated into an innite number of obliquities in an attempt to nd one view that shows the screw to be outside the joint. If this view cannot be found, the screw must be removed.
is allowed. The patient is encouraged to ambulate with a step-through gait and a heel-toe walking motion, using crutches or a walker. The patient is instructed in active exion, abduction, and extension exercises to be performed at the hip while standing. For the extended iliofemoral approach, however, active abduction and passive adduction are not allowed during the rst 3 weeks. Limitation of weight bearing is continued for 8 weeks postoperatively, at which time the patient is allowed to bear weight to tolerance and to use external support only as needed. If the fracture has been reduced accurately and ectopic bone does not develop, the range of motion can be expected to return to 90% of normal without difculty. Physical therapy is therefore directed primarily toward regaining muscle strength at the hip, particularly abductor muscle strength. An AP radiograph of the pelvis is usually obtained at the completion of the operation for preliminary conrmation of the reduction.57, 58 When patients are more comfortable, they are sent to the radiology department for AP and 45 oblique views of the pelvis. After gait training and before discharge, another AP pelvic radiograph is generally obtained to conrm that loss of reduction has not occurred during ambulation. A single AP pelvic radiograph is obtained at each follow-up examination.
POSTOPERATIVE CARE
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The patient is placed on bedrest initially, although allowed to ambulate with external support when symptoms allow. However, for the extended iliofemoral approach, 5 days of absolute bedrest after surgery is preferable to allow for edema to subside and initial wound healing to occur before starting ambulation. Passive motion of the hip and extremity can be instituted by a physical therapist or by the continuous passive motion machine. By 2 days postoperatively, pain has usually subsided enough so that the patient can start gait training. Fifteen kilograms of weight bearing
COMPLICATIONS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz The most common serious complications after operative treatment of an acetabular fracture include operative wound infection, iatrogenic nerve palsy, periarticular ectopic bone formation, and thromboembolic complications.45, 53, 56 Post-traumatic arthritis is the most common late complication.37 If the patients general condition is good and no associated injuries exist, the risk of infection should not be
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FIGURE 3740. Anteroposterior (AP) (A), iliac oblique (IO) (B), and obturator oblique (OO) (C) views of the left innominate bone and hip in a 38-year-old man, demonstrating an acute both-column fracture of the left acetabulum. All of the normal radiographic landmarks of the acetabulum are disrupted, and the roof is not in its normal position. C, The OO view demonstrates a separate segment of the posterior wall. D, A computed tomographic (CT) cut just distal to the roof demonstrates all of the major fracture segments: the anterior column, the posterior column seen only as a segment of the quadrilateral surface, the intact ileum seen only as a small triangular posterior segment, and the posterior wall with its articulator surface.
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FIGURE 3740 Continued. E, F, Two three-dimensional reconstructions of the CT scan show the outer aspect of the innominate bone and the interior of the joint. The displacement along the rim of the acetabulum is not great, and this indicates that the acetabular labrum and capsule probably remain attached to all of the articular segments along the acetabular rim. These soft tissue attachments are an essential aid to reduction of the acetabulum if the ilioinguinal approach is chosen. G, AP view following open reduction and internal xation of the fracture through the ilioinguinal approach performed with the patient supine on the Judet table. Following reduction, the posterior column is xed with two screws. One is seen to be relatively horizontal and traverses from the outer aspect of the anterior column near the pelvic brim and parallels the quadrilateral surface just posterior and medial to the joint and exits the posterior border of the bone distal to the ischial spine. I prefer this type of posterior column xation to a quadrilateral surface plate. H, The OO view demonstrates the reduction of the posterior wall, as well as the screw from the inner aspect of the anterior column to the retroacetabular surface that xes it. The reduction of the posterior column was performed by limiting exposure to the outer aspect of the bone and placing a pointed clamp around the anterior border of the bone. Illustration continued on following page
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FIGURE 3740 Continued. I, The IO view demonstrates the reduction and also the position of the long screw that xes the posterior column and exits the bone distal to the ischial spine. J, AP radiograph 2 years after the injury demonstrates no arthritic changes and some heterotopic bone distant from the joint. The clinical result was rated excellent.
higher than for other types of hip surgery. Unfortunately, most patients with acetabular fractures have associated injuries. These can include injuries of the abdominal or pelvic viscera or of the extremities. A bladder rupture or a bowel, rectal, or vaginal injury can increase the chance of operative wound infection and can inuence the indications for operation. Open fractures of the ipsilateral lower extremity can also increase the risk for wound infection in the acetabular fracture. A relatively common problem associated with acetabular fracture is local soft tissue injury, including local wounds, abrasions, and a closed, degloving injury. With the closed, degloving injury, the subcutaneous tissue is torn away from the underlying fascia, and a signicant cavity results that contains hematoma and liqueed fat between the subcutaneous tissue and deep fascia. This condition results from the blunt trauma that caused the acetabular fracture. When this lesion exists over the greater trochanter, it is known as a Morel-Lavale lesion.13 These areas must be drained and debrided before or during surgery to decrease the chance of infection. After drainage and debridement, it is advisable to leave this area open through the surgical incision or a separate incision. Dressing changes and wound packing are sometimes necessary over a prolonged period, until the wound has closed secondarily. Primary excision of the necrotic fat and closure over drainage tubes has not been routinely successful. Wound infection remains a danger, even without associated injuries. There is an increased risk of postoperative
hematoma formation in the large wounds that are necessary for acetabular surgery. Liberal use of suction drains is advised. Hemostasis at the time of wound closure is always desirable. During the procedure, the large areas of exposed soft tissue should be kept moist and be irrigated frequently with antibiotic solution. Moist sponges placed over exposed soft tissue help to prevent desiccation. The surgeon should always strive to preserve soft tissue pedicles to all bone fragments to maintain vascularity of the bone. If a fragment is devascularized, it usually revascularizes rapidly if no infection develops. In the presence of infection, however, bacteria rapidly colonize an avascular fragment, and it usually needs to be debrided and excised. Some bloody drainage can seep from the wound for the rst 1 to 2 days after surgery, although the seepage should subside rapidly. It is not uncommon for a clear, yellow, serous drainage to continue for as long as 10 days after surgery without infection being present. If the wound has been benign for a number of days, however, and bloody or cloudy yellowish drainage then occurs, the patient should be returned to the operating room immediately for irrigation and debridement of the wound. If a wound hematoma exists, the amount of hematoma is usually much greater than initially suspected by inspecting the wound, and surgical drainage is indicated. If infection is suspected, the surgeon should not wait for denitive results of the wound culture but should proceed with reopening the wound on the clinical basis alone. If it is later found that no infection existed, little harm has been done, and an infection possibly has been
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prevented. If an infection existed at the time of the earliest clinical suspicion, the surgeon has acted properly by treating the infection expeditiously. After evacuation of a wound hematoma, the wound is usually closed over suction drainage. In the case of debridement for infection, all implants that are stable and aid in the xation are left in place. Avascular and infected bone fragments must be removed. If the diagnosis of infection is made early, before abscess formation, the wound can be closed over suction drainage tubes and appropriate antibiotic therapy instituted. If infection is not diagnosed quickly and a signicant abscess has developed, it may be necessary to leave a portion of the wound open, with later debridement and closure over drainage tubes. In severe cases, it may be necessary to allow the wound to granulate secondarily. If the infection is extra-articular, it can probably be controlled successfully, and the functional result will not be impaired. In the case of an intra-articular infection, the cartilage of the joint is almost invariably destroyed, and hip function is signicantly impaired. Iatrogenic nerve palsy is caused almost exclusively by vigorous or prolonged retraction of the sciatic nerve. This occurs primarily with the Kocher-Langenbeck approach and mainly involves the peroneal branch of the sciatic nerve. There is also a small chance of a stretch injury to the sciatic nerve with the extended iliofemoral approach and a slight possibility of injuring the femoral nerve by stretch injury during the ilioinguinal approach, but this result is unusual. The surgeon must constantly monitor the force and duration of pull that the surgical assistants place on the sciatic nerve.17, 42 It is helpful to keep the patients knee exed at least 60 and the hip extended when the Kocher-Langenbeck or extended iliofemoral approach is used. If a nerve palsy develops, it is best treated with an ankle-foot orthosis. There is some chance for recovery of the sciatic nerve for up to 3 years after injury. Tendon transfer procedures to correct a footdrop should not be performed during these initial 3 years. Ectopic bone formation occurs almost exclusively with the lateral exposure of the innominate bone.35 The incidence of signicant ectopic bone formation is highest with the extended iliofemoral approach, followed by the Kocher-Langenbeck approach; it is almost nonexistent with the ilioinguinal or modied Stoppa approach. Part of the prevention of ectopic bone formation should be directed toward choosing the ilioinguinal or modied Stoppa approach when possible and limiting muscle trauma during surgery by careful handling of soft tissue. Indomethacin, given in a dose of 25 mg three times daily perioperatively and for several weeks after surgery, has been reported to decrease the incidence of ectopic bone, but at least in one series this was not conrmed. Postoperative irradiation has been shown to be effective in decreasing the incidence of ectopic bone formation, but the long-term carcinogenic effects are unknown.1, 19, 46 A prospective, randomized study comparing indomethacin with localized irradiation after surgical treatment of acetabular fractures found that both provided equally effective prophylaxis for heterotopic bone formation.3 The sample size may not have been large enough, however, to reach a denitive conclusion on this issue. Ectopic bone formation is inuenced by the surgical
approach and probably by the initial muscle trauma suffered by the patient and other associated injuries. The combination of the two creates an inammatory response that triggers the formation of bone. Many patients show a signicant amount of ectopic bone on radiography, but muscle function and range of motion are satisfactory. In other patients, rotation and abduction are limited, but if patients can fully extend the hip to the neutral position and have satisfactory exion of at least 90, they may be happy with the result and have no desire for further surgery to excise the bone. When possible, surgery for excision of ectopic bone should be delayed for 15 to 18 months after injury. If it is performed at this time, there is usually no problem with recurrence, and motion can be expected to return to more than 80% of normal, assuming no arthritis exists. A few patients show a spontaneous regression of ectopic bone over several years. If the indications for excision of the bone are equivocal, it may be best to wait, with the hope of some spontaneous regression of the ectopic bone and improvement of motion. There is signicant potential for deep venous thrombosis and pulmonary embolism with fractures of the acetabulum.45, 53, 56 Routine use of Doppler ultrasound evaluation of the lower extremity veins before surgery plus prophylaxis will reduce the incidence of embolisminduced deaths. If a thrombosis is found and thought to be recently formed, it may resolve over a 5-day trial of therapeutic-level heparin (assuming surgery is not urgent). If the clot does not resolve or heparin therapy is deferred, an inferior vena cava lter should be placed before surgery. Contrast-enhanced magnetic resonance imaging (MRI) has been reported to be more sensitive in detecting lower extremity and particularly pelvic thrombi. However, it adds expense and difculty to the evaluation, and the current protocol has not been associated with death from pulmonary embolus. Use of MRI has resulted in up to 30% of patients receiving inferior vena cava lters, compared with less than 5% in my own series. Below-knee pneumatic compression boots on both lower extremities from the time of admission are also applied until the patient is fully ambulatory. Warfarin is started at 48 hours after surgery, and the patient is discharged to his or her home with warfarin anticoagulation for 6 weeks after surgery. The level of anticoagulation with warfarin is maintained at about 1.5 times normal. Although the potential for thromboembolic complications is always present, the surgeon must be cautious about too much anticoagulation, because a large wound hematoma can have a devastating effect on the patient if a deep infection occurs in the hip.45, 56 An adjunct team of medical specialists for managing this protocol is very benecial for the patient.
TREATMENT OF COMPLEX RECONSTRUCTIVE PROBLEMS
zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz Three weeks after injury, bony callus is present in the fracture lines, making operation more difcult and possibly
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changing the operative indications. In a young adult patient with a clearly bad prognosis, the surgeon should usually proceed with surgery as long as the femoral head is in good condition and has not been damaged by wear. For the older patient, particularly if the prognosis for nonoperative treatment is not obviously bad, the surgeon can consider nonoperative therapy. For a posterior wall or posterior column fracture, the old fracture can be approached as usual through the Kocher-Langenbeck approach. For an anterior wall or anterior column fracture, the approach remains the ilioinguinal. For all other fracture types, the extended iliofemoral approach is necessary, with the possibility for circumferential access to the bone. Maximum access to the bone is necessary for excision of callus or osteotomy and for intra-articular visualization of the reduction. It may also be necessary to osteotomize the superior or inferior pubic ramus to gain mobility of the acetabular fracture. Operation of old acetabular fractures is technically demanding and should probably be undertaken only by surgeons with extensive experience in the operation of acute fractures.
a THR in the presence of such a deformity. This step is particularly important in young people undergoing THR who may have one or more revision surgeries during their lifetimes. Depending on the severity of the problem, this may be performed as a two-stage or one-stage procedure. Many patients have an increased tendency for postoperative dislocation because of partially compromised soft tissues and, in some cases, a recurrent dislocation. THR components more resistant to dislocation (i.e., increased offset neck, large head, and hooded acetabular liner) should often be considered. Hip arthrodesis is also a consideration for treatment of a poor result after acetabular fracture. Possible indications are very young age, associated bone loss, and infection. The Smith-Peterson exposure, with the patient supine and an anterior plate from the pelvis to the femur, is a preferable approach.
Primary Total Hip Replacement for Acute Fracture

The indication for a primary THR as a treatment for an acute acetabular fracture, is unusual but sometimes necessary in elderly patients.2, 39, 41 For cases of impaction of the acetabulum or femoral head (or both) in the elderly with impaired bone stock, THR may be combined with open reduction and internal xation (ORIF) of the fracture. Placing a THR requires a stable and reduced acetabulum. A porous-coated acetabular shell with screws placed through the holes cannot be considered adequate xation of an acetabular fracture. Because of comminution, osteoporosis, or both conditions in elderly patients, the fracture sometimes may be judged to be impossible to reconstruct. The judgment that the surgeon will probably not have success by ORIF alone does not necessarily mean that the fracture can be treated successfully by THR. A successful ORIF is necessary before acetabular shell placement. The most common indication for primary THR is an anterior column or associated anterior plus posterior hemi-transverse fracture in an elderly patient, although most of these elderly patients are treated by ORIF alone. These are common fracture types for a slip and fall injury in the elderly population. When the prognosis is doubtful for return of hip function by ORIF alone or conservative care, THR plus ORIF can be considered. In these cases, the patient should be placed in the supine position on the Judet table and the site exposed through the SmithPeterson approach. Exposure of the internal iliac fossa and pelvic brim is used to reduce and x the anterior column fracture.12 The quadrilateral surface often is reached by palpation or by clamps. The femoral neck is osteotomized and the head removed before nal fracture xation. The acetabular shell is placed into the xed acetabulum, often over bone from the head used as morselized graft.20 Treatment of acetabular fractures has been enhanced by ORIF techniques that can restore the anatomy of the innominate bone and the congruency of the articular surfaces.52 These procedures, however, remain technically demanding and are potentially dangerous to the patient.36
Total Hip Replacement after Acetabular Fracture

A total hip replacement (THR) may be indicated after acetabular fracture following a bad result caused by arthritic wear or osteonecrosis of the femoral head.20 For patients with a gradual onset of arthritis, the indication for surgery is typically pain. If the patient, however, shows ongoing wear of the femoral head or acetabulum, THR surgery should not be delayed, because acetabular bone stock is being lost, as is the available femoral head graft2 (Fig. 3741). The surgical approach used for an initial xation may inuence the choice of approach for THR but typically does not determine it. Most surgeons use the KocherLangenbeck approach for THR, and it can be used after a previous Kocher-Langenbeck, ilioinguinal, or extended iliofemoral approach for fracture xation. However, previous plates and screws can sometimes be removed through a separate approach. Although the THR may be straightforward, the greatest problems involve cases with bony defects or deformities. The most common bony defect involves the posterior wall. On rst exposing the joint, the extent of the defect may not be apparent, but thorough debridement of all nonhealed or necrotic posterior wall fragments must be carried out. The femoral head and neck are used as a graft against the intact viable bone to substitute for the posterior wall. The block graft is contoured and xed with a plate, as is done in treating a posterior wall fracture. Nonunions of a transverse fracture or one or both columns of the acetabulum must be internally xed, and it is often best to consider a two-stage procedure, with implantation of the femoral portion of the THR carried out only after the bone and graft have healed around the prosthetic acetabulum (about 3 months).12 Severe malunions of the innominate bone should be corrected at the time of surgery, rather than attempting
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FIGURE 3741. A, Anteroposterior (AP) hip radiograph of a 32-year-old man 1 year after nonoperative treatment of a T-shaped fracture of the left acetabulum. The patient had a painful hip and impaired ambulatory capabilities. The radiograph demonstrates a malunion of the acetabulum and wear of the femoral head. B, Computed tomographic scan at the level of the superior femoral head demonstrates union of the transverse component of the fracture. C, Postoperative AP hip radiograph shows the results following osteotomy and reduction of the malunion and total hip arthroplasty performed during the same procedure through the extended iliofemoral approach. Osteotomy of the femoral neck and removal of the head and neck from the wound allows access to the posterior column without the normal tenotomy of the gluteus medius and minimus. Although an acetabular prosthesis could have been placed in a medial position without altering the malunion, I prefer to correct such a severe malunion in a young adult. A young person can expect future revision surgery and progressively decreasing bone stock. The bone stock problem would be increased if the malunion were left uncorrected. D, AP hip radiograph 2 years after the surgery demonstrates a healed osteotomy, stable components, and an area of heterotopic bone. Functional recovery was satisfactory, and motion was not impaired.
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SECTION III Pelvis 25. Letournel, E. The results of acetabular fractures treated surgically. Twenty-one years experience. In: The Hip: Proceedings of the Seventh Open Scientic Meeting of The Hip Society. St. Louis, C.V. Mosby, 1979, pp. 4285. 26. Letournel, E. Fractures of the Acetabulum. New York, SpringerVerlag, 1981. 27. Levine, M.A. A treatment of central fractures of the acetabulum. J Bone Joint Surg Am 25:902906, 1943. 28. Matta JM. Fractures of the acetabulum: Accuracy of the reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am 78:16321645, 1996. 29. Matta, J.M. Percutaneous xation of acetabular fractures. J Orthop Trauma 12:370, 1998. 30. Matta, J. Operative indications and choice of surgical approach for fractures of the acetabulum. Tech Orthop 1:1322, 1986. 31. Matta, J.; Anderson, L.; Epstein, H.; Hendrick, P. Fractures of the acetabulum: A retrospective analysis. Clin Orthop 205:230240, 1986. 32. Matta, J.; Letournel, E.; Browner, B. Surgical management of acetabular fractures. Instr Course Lect 35:382397, 1986. 33. Matta, J.; Mehne, D.; Rof, R. Fractures of the acetabulum: Early results of a prospective study. Clin Orthop 205:241250, 1986. 34. Matta, J.M.; Merritt, P.O. Displaced acetabular fractures. Clin Orthop 230:8397, 1988. 35. Matta, J.M.; Siebenrock, K.A. Does indomethacin reduce heterotopic bone formation after operations for acetabular fractures? A prospective randomized study. J Bone Joint Surg Br 79:959963, 1997. 36. Malkani, A.L.; Voor, M.J.; Rennirt, G.; et al. Increased peak contact stress after incongruent reduction of transverse acetabular fractures: A cadaveric model. 51:704709, 2001. 37. Marti, R.K.; Chaldecott, L.R.; Kloen, P. Intertrochanteric osteotomy for posttraumatic arthritis after acetabular fractures. J Orthop Trauma 15:384393, 2001. 38. Mays, J.; Neufeld, A.J. Skeletal traction methods. Clin Orthop 102:144151, 1974. 39. Mears, D.C. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surgeons 7:128141, 1999. 40. Mears, D.C.; Rubash, H. Pelvic and Acetabular Fractures. Thorofare, NJ, Slack, 1986. 41. Mears, D.C.; Shirhama, M. Stabilization of an acetabular fracture with cables for acute total hip arthroplasty. J Arthroplasty 13:104 107, 1998. 42. Middlebrooks, E.S.; Sims, S.H.; Kellam, J.F Bosse, M.J. Incidence of .; sciatic nerve injury in operatively treated acetabular fractures without somatosensory evoked potential monitoring. J Orthop Trauma 11:327329, 1997. 43. Moed, B.R.; Smith, S.T. Three-view radiographic assessment of heterotopic ossication after acetabular fracture surgery. J Orthop Trauma 10:9398, 1996. 44. Montgomery, K.D.; Potter, H.G.; Helfet, D.L. Magnetic Resonance venography to evaluate the deep venous system of the pelvis in patients who have an acetabular fracture. J Bone Joint Surg Am 77:16391649, 1995. 45. Montgomery, K.D.; Potter, H.G.; Helfet, D.L. The detection and management of proximal deep venous thrombosis in patients with acute acetabular fractures: A follow-up report. J Orthop Trauma 11:330336, 1997. 46. Moore, K.D.; Goss, K.; Anglen, J.O. Indomethacin versus radiation therapy for prophylaxis against heterotropic ossication in acetabular fractures: A randomized, prospective study. J Bone Joint Surg Br 80:259263, 1998. 47. Muller, M.E.; Allgoer, M. Manual of Internal Fixation. New York, Springer-Verlag, 1979. 48. Olson, S.A.; Bay, B.K.; Chapman, M.W.; Sharkey, N.A. Biomechanical consequences of fracture and repair of the posterior wall of the acetabulum. J Bone Joint Surg Am 77:11841192, 1995. 49. Olson, S.A.; Bay, B.K.; Pollak, A.N.; et al. The effect of variable size posterior wall acetabular fractures on contact characteristics of the hip joint. J Orthop Trauma 10:395402, 1996. 50. Oransky, M.; Sanguinetti, C. Surgical treatment of displaced acetabular fractures: Results of 50 consecutive cases. J Orthop Trauma 7:2832, 1993. 51. Parker, P.J.; Copeland, C. Percutaneous uoroscopic screw xation of acetabular fractures. Injury 28:597600, 1997.
Although the results of treatment have undoubtedly been improved by newer techniques, surgeons must always keep their own experience and abilities in mind and consider the potential risks to the patient.
REFERENCES 1. Anglen, J.O.; Moore, K.D. Prevention of heterotopic bone formation after acetabular fracture xation by single-dose radiation therapy: A preliminary report. J Orthop Trauma 10:258263, 1996. 2. Berry, D.J. Total hip arthroplasty following acetabular fracture. Orthopedics 22:837839, 1999. 3. Burd, T.A.; Lowry, K.J.; Anglen, J.O. Indomethacin compared with localized irradiation for the prevention of heterotopic ossication following surgical treatment of acetabular fractures. J Bone Joint Surg Am 83:17831788, 2001. 4. Burk, D.L, Jr.; Mears, D.C.; Kennedy, W.H.; et al. Three-dimensional computed tomography of acetabular fractures. Radiology 155:183 185, 1985. 5. Chang, J.K.; Gill, S.S.; Zura, R.D.; et al. Comparative strength of three methods of xation of transverse acetabular fractures. Clin Orthop 392:433441, 2001. 6. Chen, C.M.; Chiu, F .Y.; Chuang, T.Y.; Lo, W.H. Treatment of acetabular fractures: 10-year experience. Chung Hua I Hseuh Tsa Chih 63:384390, 2000. 7. Cole, J.D.; Bolhofner, B.R. Acetabular fracture xation via a modied Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Rel Res 305:112123, 1994. 8. Deo, S.D.; Tavares, S.P.; Pandey, R.K.; et al. Operative management of acetabular fractures in Oxford. Injury 32:581586, 2001. 9. Ebraheim, N.A.; Xu, R.; Biyani, A.; Benedetti, J.A. Anatomic basis of lag screw placement in the anterior column of the acetabulum. Clin Orthop Rel Res 339:200205, 1997. 10. Epstein, H.C. Open management of fractures of the acetabulum. In: The Hip: Proceedings of the Seventh Open Scientic Meeting of the Hip Society. St. Louis, C.V. Mosby, 1979, pp. 1741. 11. Epstein, H.C. Traumatic Dislocations of the Hip. Baltimore, Williams & Wilkins, 1980. 12. Hak, D.J.; Hamel, A.J.; Bay, B.K.; et al. Consequences of transverse acetabular fracture malreduction on load transmission across the hip joint. J Orthop Trauma 12:90100, 1998. 13. Hak, D.J.; Olson, S.A.; Matta, J.M. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: The Morel-Lavale lesion. J Trauma 42:1046 1051, 1997. 14. Hardy, S.L. Femoral nerve palsy associated with an associated posterior wall transverse acetabular fracture. J Orthop Trauma 11:4042, 1997. 15. Harley, J.; Mack, L; Winquist, R. CT of acetabular fractures. AJR Am J Roentgenol 138:413417, 1982. 16. Haveri, M.; Junila, J.; Suramo, I.; Lahde, S. Multiplanar and 3D CT of acetabular fractures. Acta Radiol 39:257264, 1998. 17. Helfet, D.L.; Malkani, A.L.; Heise, C.; et al. Intraoperative monitoring of motor pathways during operative xation of acute acetabular fractures. J Orthop Trauma 11:26, 1997. 18. Hull, J.B.; Raza, S.A.; Stockley, I.; Elson, R.A. Surgical management of fractures of the acetabulum: The Shefeld experience 19761994. Injury 28:3540, 1997. 19. Johnson, E.E.; Kay, R.M.; Dorey, F Heterotropic ossication .J. prophylaxis following operative treatment of acetabular fractures. Clin Orthop 305:8895, 1994. 20. Jimenez, M.L.; Tile, M.; Schenk, R.S. Total hip replacement after acetabular fracture. Orthop Clin North Am 28:435446, 1997. 21. Judet, R.; Judet, J.; Letournel, E. Fractures of the acetabulum. Classication and surgical approaches for open reduction. J Bone Joint Surg Am 46:16151638, 1964. 22. Knight, R.A.; Smith, H. Central fractures of the acetabulum. J Bone Joint Surg Am 40:116, 1958. 23. Letournel, E. Les fractures du cotyle. Etude dune serie de 75 cas. Medical thesis. Paris, Arnette, 1961. 24. Letournel, E. Les fractures du cotyle. Etude dune serie de 75 cas. J Chir 82:4787, 1961.
CHAPTER 37 Surgical Treatment of Acetabular Fractures 52. Plaiser, B.R.; Meldon, S.W.; Super, D.M.; Malangoni, M.A. Improved outcome after early xation of acetabular fractures. Injury 31:8184, 2000. 53. Russell, G.V., Jr.; Norsk, S.E.; Chip Routt, M.L., Jr. Perioperative complications associated with operative treatment of acetabular fractures. J Trauma 51:10981103, 2001. 54. Saterbak, A.M.; Marsh, J.L.; Turbett, T.; Brandser, E. Acetabular fractures classication of Letournel and JudetA systematic approach. Iowa Orthop J 15:184196, 1995. 55. Simonian, P.T.; Routt ML; Harrington, R.M.; Tencer, A.F The . acetabular T-type fracture. A biomechanical evaluation of internal xation. Clin Orthop Rel Res 314:234240, 1995.
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Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Print Graphic Anterior column Presentation Posterior column Anterior column

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Indications for Operative Treatment

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Types of Surgical Approaches

Choice of Surgical Approach

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Table and Positioning

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Techniques of Reduction and Internal Fixation

Preparing and Draping for Surgery

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

Copyright 2003 Elsevier Science (USA). All rights reserved.

Print Graphic Print Graphic

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Print Graphic Print Graphic

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Copyright 2003 Elsevier Science (USA). All rights reserved.

SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

SURGICAL TREATMENT OF INDIVIDUAL FRACTURE TYPES Posterior Wall Fracture

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SECTION III Pelvis

Copyright 2003 Elsevier Science (USA). All rights reserved.

CHAPTER 37 Surgical Treatment of Acetabular Fractures

Posterior Column Fractures