import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ## Classification - Judet-Letournel System The Judet-Letournel classification is the foundation of acetabular fracture management. Your approach selection, reduction technique, and fixation strategy all depend on accurate classification. This is high-yield for FRCS viva. ### Elementary Patterns (5) ### Associated Patterns (5) ## Approach Selection Algorithm **Use Kocher-Langenbeck for:** | Pattern | Rationale | |---------|-----------| | Posterior Wall | Direct visualization of wall fragments | | Posterior Column | Access to posterior column and ischium | | Posterior Column + Wall | Both posterior elements accessible | | Transverse + Posterior Wall | Wall fragment requires direct reduction | | Transverse (most) | Posterior column reduces first, anterior follows | | T-Type (often) | May need combined if anterior displaced | **Kocher-Langenbeck accounts for 80% of acetabular approaches.** **Examiner Question**: "What determines whether a transverse fracture needs K-L alone or a combined approach?" **Model Answer**: "The key determinant is **anterior column displacement**. Most transverse fractures can be managed through K-L because: (1) The posterior column is the larger fragment and reduces first; (2) The anterior column typically follows as the columns are linked through the dome. However, if there is **significant anterior displacement that won't reduce indirectly** after posterior column fixation, I would consider staging an ilioinguinal approach 3-7 days later. I would NOT use extended iliofemoral due to its high morbidity (50%+ HO rate)." - **Using ilioinguinal for posterior wall** - cannot visualize wall fragments - **Extended iliofemoral for combined patterns** - stage instead (K-L + II) - **Missing sciatic nerve pre-op** - 5-15% palsy rate, document baseline - **Ignoring posterior wall size** - >40% = unstable, needs fixation **Use Ilioinguinal for:** | Pattern | Rationale | |---------|-----------| | Anterior Wall | Direct access to anterior lip | | Anterior Column | Access entire anterior column | | Anterior Column + PHT | Anterior column primary, posterior reduces indirectly | | Both Column | Anterior column first, posterior follows in 60-70% | **Key Features:** - Three windows provide complete anterior access - Cannot directly visualize posterior column - Posterior column often reduces indirectly through intact dome **Examiner Question**: "You've fixed the anterior column through ilioinguinal but the posterior column has 4mm residual displacement. What do you do?" **Model Answer**: "This is an important decision point. I would NOT convert to an extended iliofemoral approach due to its high morbidity (50%+ HO). Instead, I would: (1) **Close the ilioinguinal wound**; (2) **Stage a Kocher-Langenbeck approach 3-7 days later** when soft tissues have recovered; (3) Through K-L, I can then directly reduce and fix the posterior column. This staged approach provides equivalent access to extended iliofemoral with significantly lower complication rates. If the patient cannot tolerate a second surgery, I would accept the imperfect reduction but counsel regarding accelerated arthritis." - **Using K-L for anterior column** - cannot access anterior column through posterior approach - **Extended iliofemoral for residual displacement** - stage K-L instead (lower morbidity) - **Ignoring LFCN at ASIS** - 10-15% injury rate, identify 1cm medial to ASIS - **Forgetting corona mortis** - ligate prophylactically in middle window **Approach Options for Both Column:** **1. Ilioinguinal (Most Common)** - Fix anterior column first - Posterior column reduces indirectly in 60-70% - Stage K-L if posterior remains displaced **2. Modified Stoppa** - Better quadrilateral surface access - Direct visualization of medial displacement - Combine with lateral window if needed - Lower morbidity than extended iliofemoral **3. Extended Iliofemoral (Rarely Used)** - Very morbid (50%+ HO rate) - Reserved for delayed surgery with callus - Staged approach preferred in modern practice **Examiner Question**: "When would you choose Modified Stoppa over standard ilioinguinal for a both-column fracture?" **Model Answer**: "I would favor Modified Stoppa when there is significant **quadrilateral surface medialization** that requires direct buttress plating. The key advantages are: (1) **Direct intrapelvic visualization** of the quadrilateral surface through the Space of Retzius; (2) **Easier infrapectineal plate placement** for buttressing the medial wall; (3) Can combine with a **lateral window** for complete anterior column access. I would use standard ilioinguinal when the quadrilateral surface is minimally displaced or when I need superior access to the iliac crest and SI joint area." Extended iliofemoral has been largely abandoned due to high morbidity. Staged anterior + posterior approaches provide equivalent access with lower complication rates. **When to Consider Combined or Staged Approaches:** **Indications:** - T-type with significant displacement both columns - Both column where posterior won't reduce indirectly - Complex associated patterns - Delayed surgery with callus formation **Staged Approach (Preferred):** - Stage 1: Ilioinguinal (anterior column) - Assess posterior reduction on fluoroscopy - Stage 2: Kocher-Langenbeck 3-7 days later if needed **Same-Day Combined (Rare):** - Higher morbidity than staged - Consider if patient cannot tolerate second surgery - Position changes required (supine → lateral) **Examiner Question**: "A patient with a T-type fracture has significant displacement of both columns. How do you decide between same-day combined versus staged approaches?" **Model Answer**: "I would generally favor a **staged approach** unless there are specific factors making a second surgery risky. The decision factors are: (1) **Patient fitness** - if unable to tolerate second anesthetic, consider same-day combined; (2) **Soft tissue condition** - extensive bruising favors staging; (3) **Blood loss management** - combined approaches have more bleeding; (4) **Operative time** - staging keeps each procedure shorter (less HO). My typical approach: Ilioinguinal first, then assess posterior reduction on fluoroscopy. If residual >2mm, stage K-L at 3-7 days. Same-day combined requires position change (supine to lateral) adding complexity and time." - **Position change risks** - pressure injuries, nerve traction during repositioning - **Prolonged operative time** - increases HO and infection risk - **Excessive blood loss** - have cell saver running, crossmatch 4+ units - **Soft tissue compromise** - extended incisions through traumatized tissue ## Indications for Surgery **Mandatory Surgical Intervention:** 1. **Articular displacement >2mm** at weight-bearing dome 2. **Hip instability** or subluxation 3. **Incarcerated fragments** in joint 4. **Associated femoral head fracture** (Pipkin) 5. **Irreducible hip dislocation** 6. **Open fracture** 7. **Progressive sciatic nerve palsy** **Examiner Question**: "A patient has an acetabular fracture with 2.5mm dome displacement. Why would you operate?" **Model Answer**: "Displacement >2mm at the weight-bearing dome is an **absolute indication for surgery**. This threshold is based on biomechanical and outcome data showing: (1) **Increased contact pressure** - every mm of incongruity significantly increases articular stress; (2) **Matta's outcome data** - anatomic reduction (0-1mm) achieves 83% good outcomes versus 50% for poor reduction (>3mm); (3) **Weight-bearing dome** - this is where peak loads occur, making perfect reduction essential. At 2.5mm, the risk of accelerated osteoarthritis without surgery exceeds the risks of operative intervention." Irreducible dislocation, femoral head fracture, and incarcerated fragments require urgent surgery within 24 hours to prevent AVN and cartilage damage. **Surgery Generally Preferred:** 1. **Displacement 1-2mm** in young active patient 2. **Posterior wall >40% surface area** (unstable) 3. **Marginal impaction** requiring elevation 4. **High-demand occupation/athlete** 5. **Roof arc angles <45°** (insufficient dome coverage) **Examiner Question**: "How do you measure roof arc angles and what do they tell you?" **Model Answer**: "Roof arc angles assess dome integrity on **three views: AP, obturator oblique, and iliac oblique**. For each view: (1) Draw a vertical line through the center of the femoral head; (2) Draw a second line from the center to where the fracture exits the acetabulum; (3) Measure the angle between these lines. If the angle is **<45° on any single view**, there is insufficient weight-bearing dome coverage, and non-operative management will likely fail. This is because the dome is the primary load-bearing surface. All three views must have angles >45° to consider non-operative treatment." - **Missing posterior wall instability** - any wall fracture >40% needs fixation - **Ignoring marginal impaction** - requires elevation and bone grafting - **Measuring roof arcs incorrectly** - must use true AP and oblique views - **Underestimating young patient demands** - lower threshold for surgery **Consider Non-operative Management:** 1. **Displacement <2mm** at dome 2. **Roof arc >45°** on all three views 3. **Secondary congruence** in both-column fractures 4. **Stable hip** on examination 5. **Low-demand elderly patient** with acceptable alignment 6. **Severe comorbidities** precluding surgery **Secondary Congruence Criteria (Both Column):** - Roof arc >45° on AP, obturator, AND iliac obliques - Femoral head concentric on traction views - No posterior wall component - Patient can comply with protected weight-bearing **Examiner Question**: "What is secondary congruence and when can you rely on it?" **Model Answer**: "Secondary congruence is a phenomenon unique to **both-column fractures** where the femoral head remains congruent with the fractured acetabulum despite both columns being detached. The head 'medializes' with the medial column fragments, maintaining articular congruency. To rely on it: (1) **Roof arc >45°** on all three views (AP, obturator, iliac obliques); (2) **Concentric femoral head** on traction radiographs; (3) **No posterior wall component**; (4) Patient can comply with **6-12 weeks TTWB**. Even with true secondary congruence, I counsel that outcomes are slightly inferior to anatomic reduction, particularly in young active patients." - **Posterior wall component** - destabilizes hip, DO NOT manage non-operatively - **Loss of secondary congruence** - requires serial imaging to detect - **Patient non-compliance** - TTWB for 12 weeks is essential - **Young active patient** - may benefit from ORIF despite meeting criteria ## Timing of Surgery **Timing Pearls**: - 3-7 days is the "sweet spot" - soft tissue recovered, no callus yet - After 3 weeks, reduction becomes increasingly difficult - If forced to delay beyond 3 weeks, consider waiting until 6-8 weeks when fracture starts consolidating (less bleeding, more predictable) ## Approach Details ### Kocher-Langenbeck (Posterior) - Posterior wall fractures - Posterior column fractures - Posterior column + wall - Transverse + posterior wall - Most transverse fractures - T-type (often) - **Sciatic nerve** - 5-15% palsy rate - **Superior gluteal NV bundle** - above piriformis - **MFCA** - posterior capsular branches - **Short external rotators** - need repair **Options:** - **Lateral decubitus** (most common) - bean bag, affected side up - **Prone** - alternative, reduces bleeding **Setup:** - Radiolucent table with C-arm access - Affected limb draped free for manipulation - Hip in neutral or slight flexion **Examiner Question**: "What are the advantages and disadvantages of prone versus lateral positioning for K-L approach?" **Model Answer**: "**Lateral decubitus** is most common because: (1) Easier hip manipulation for reduction; (2) Familiar positioning for most surgeons; (3) Can dislocate hip for wall fixation. **Prone positioning** has advantages: (1) Reduced venous bleeding due to lower abdominal pressure; (2) Better access to posterior column superiorly; (3) Gravity assists exposure. However, prone makes hip dislocation difficult and limits manipulation. I would choose lateral for most cases, considering prone for posterior column fractures where dislocation is not required." - **Sciatic nerve protection** - hip in extension/neutral, NOT flexion (increases tension) - **Peroneal nerve padding** - ensure down leg fibular head is padded - **Axillary roll** - prevent brachial plexus compression - **Pelvic stability** - bean bag or pegs to prevent intra-op movement **Superficial Interval:** - Between gluteus maximus (inferior gluteal nerve) and gluteus medius (superior gluteal nerve) **Deep Interval:** - Between short external rotators and posterior hip capsule - Piriformis is key landmark - sciatic nerve exits below it **Examiner Question**: "Describe the internervous plane of the Kocher-Langenbeck approach." **Model Answer**: "The K-L approach utilizes **two internervous intervals**. **Superficially**: between gluteus maximus (inferior gluteal nerve) and gluteus medius (superior gluteal nerve) - we split maximus in line with its fibers rather than taking the interval. **Deeply**: between the short external rotators and the posterior hip capsule. The key landmark is the **piriformis muscle** - the sciatic nerve exits the pelvis below it. By releasing the short rotators from the greater trochanter (piriformis, superior gemellus, obturator internus, inferior gemellus), we can retract them posteriorly with the sciatic nerve, protecting it while exposing the posterior column." - **Exits ABOVE piriformis** - do not extend dissection proximal to greater trochanter - **3-5cm above piriformis** - safe zone is distal to this - **Supplies gluteus medius/minimus** - injury causes Trendelenburg gait - **If injured** - cannot be repaired, permanent abductor weakness **Incision:** - PSIS to greater trochanter to lateral femur (10-15cm) **Deep Dissection:** 1. Split gluteus maximus in line with fibers 2. Identify sciatic nerve (below piriformis) 3. Release short rotators from GT (tag for repair): - Piriformis - Superior gemellus - Obturator internus - Inferior gemellus - (Quadratus femoris - protect, usually preserve) 4. Capsulotomy for posterior column access 5. Hip dislocation (flex, adduct, IR) for posterior wall **Examiner Question**: "When do you need to dislocate the hip during a K-L approach, and how do you do it safely?" **Model Answer**: "Hip dislocation is required for **posterior wall fractures** to directly visualize and reduce the wall fragments. For isolated posterior column fractures, dislocation is usually NOT required. **Safe dislocation technique**: (1) Release short rotators completely; (2) Complete capsulotomy; (3) Flex hip to 90°, adduct, and internally rotate; (4) Lever femoral head posteriorly over acetabulum. **To protect femoral head blood supply**: minimize dislocation time, maintain reduction with provisional fixation, repair capsule at end. Prolonged dislocation increases AVN risk." - **Identify sciatic nerve BEFORE releasing rotators** - prevents inadvertent injury - **Tag rotators with suture** - enables anatomic repair at closure - **Protect quadratus femoris** - contains MFCA branches to femoral head - **Minimize capsular stripping** - MFCA runs in posterior capsule ### Ilioinguinal (Anterior) - Anterior wall fractures - Anterior column fractures - Anterior column + PHT - Both column fractures - T-type (if anterior predominant) - **Femoral nerve** - on iliopsoas - **LFCN** - 10-15% injury rate - **External iliac vessels** - **Corona mortis** - 30% incidence - **Spermatic cord/Round ligament** **Position:** - Supine on radiolucent table - Bolster under ipsilateral buttock (10-15° tilt) - Both limbs draped free - Foley catheter (mandatory) **Setup:** - C-arm for AP, inlet, outlet, Judet views - Cell saver recommended - Vascular instruments available **Examiner Question**: "Why do you tilt the pelvis during ilioinguinal approach?" **Model Answer**: "A **10-15° bolster under the ipsilateral buttock** serves multiple purposes: (1) **Improves access to the iliac wing** and SI joint area through the lateral window; (2) **Reduces venous congestion** compared to flat supine; (3) **Facilitates visualization** of the pelvic brim and quadrilateral surface. For both-column fractures or when Modified Stoppa is planned, I may position flat or with minimal tilt as this improves access to the true pelvis. The key is ensuring C-arm can still obtain all required views." - **Foley catheter MANDATORY** - decompresses bladder, reduces injury risk - **Cell saver running** - corona mortis bleeds profusely if injured - **Vascular tray in room** - external iliac injury requires immediate repair - **Femoral artery marked** - know location before incision **Lateral Window:** - Between iliacus (medial) and abductors (lateral) - Access: iliac wing, SI joint, superior pelvic brim - Femoral nerve safe on iliopsoas surface **Middle Window:** - Between external iliac vessels and iliopsoas - Access: quadrilateral surface, pelvic brim - **CORONA MORTIS** - identify and ligate **Medial Window:** - Between vessels and spermatic cord - Access: symphysis, superior ramus - Bladder immediately posterior **Examiner Question**: "Describe the middle window and how you protect the corona mortis." **Model Answer**: "The middle window lies between the **external iliac vessels medially** and the **iliopsoas muscle laterally**. This is the most dangerous window because of the **corona mortis** - an anastomosis between the obturator and external iliac vessels present in 30% of patients. To protect it: (1) **Identify systematically** - look on the posterior aspect of the superior pubic ramus; (2) **Ligate prophylactically** - clip or tie before dividing; (3) **If bleeding occurs** - direct pressure, then suture ligation on the ramus. The external iliac vessels are protected with vessel loops and retracted gently medially. I use malleable retractors padded with moist swabs." - **Corona mortis** (middle window) - present in 30%, ligate BEFORE it bleeds - **Femoral nerve** (lateral window) - lies on iliopsoas, retract muscle not nerve - **External iliac vessels** (middle) - vessel loop, gentle retraction only - **Bladder** (medial window) - immediately posterior, Foley essential **Standard Ilioinguinal:** - Start: Pubic symphysis - Course: Along inguinal ligament to ASIS - Extend: Posteriorly along iliac crest 8-10cm - Total length: 25-30cm **Key Steps:** 1. Identify and protect LFCN (1cm medial to ASIS) 2. Incise external oblique along inguinal ligament 3. Develop three windows sequentially 4. Protect spermatic cord/round ligament **Examiner Question**: "How do you develop the three windows of the ilioinguinal approach?" **Model Answer**: "After skin incision, I: (1) **Identify LFCN** 1cm medial to ASIS and protect; (2) **Incise external oblique aponeurosis** along inguinal ligament; (3) **Lateral window first** - elevate iliacus from iliac fossa, the femoral nerve is safe on the muscle surface; (4) **Identify spermatic cord/round ligament** and protect with vessel loop; (5) **Middle window** - identify external iliac vessels, place vessel loops, search for and ligate corona mortis on posterior pubic ramus; (6) **Medial window** - between vessels and spermatic cord, access symphysis. Sequential development prevents disorientation." - **LFCN injury** - permanent meralgia paresthetica, identify early - **Inguinal hernia** (5-10%) - meticulous fascial repair at closure - **Wound infection** - groin crease high bacterial load - **Lymphocele** - if lymphatics in groin disrupted ### Modified Stoppa (Intrapelvic) - Both column with quadrilateral medialization - Anterior column with medial displacement - Pelvic brim plating - Combined with lateral window for complex patterns - **Corona mortis** - must ligate - **External iliac vessels** - **Obturator nerve** - **Bladder** - 1-3% injury **Position:** Supine **Incision Options:** - Pfannenstiel (transverse) - Midline (longitudinal) **Dissection:** 1. Enter Space of Retzius (preperitoneal) 2. Retract bladder posteriorly 3. Identify and ligate corona mortis 4. Retract external iliac vessels laterally 5. Direct intrapelvic view of quadrilateral surface **Examiner Question**: "How do you safely enter the Space of Retzius?" **Model Answer**: "The Space of Retzius (retropubic space) is a **preperitoneal plane** between the bladder and pubic symphysis. To enter safely: (1) **Foley catheter** must be in place to decompress bladder; (2) Through Pfannenstiel or midline incision, identify rectus fascia; (3) **Incise fascia in midline** between rectus muscles; (4) **Blunt finger dissection** to develop the space - the peritoneum and bladder fall posteriorly; (5) Place a **Deaver retractor** to retract bladder posteriorly; (6) **Corona mortis** will be on the posterior pubic ramus - identify and ligate. The key is staying in the preperitoneal plane - if you see bowel, you've entered the peritoneum." - **Bladder injury** (1-3%) - ensure Foley in, know bladder position at all times - **Peritoneal entry** - if entered, close meticulously to prevent hernia - **Obturator nerve** - runs along lateral wall, retract carefully - **Corona mortis** - ligate before it retracts and bleeds from true pelvis **Benefits over Traditional Ilioinguinal:** - Better quadrilateral surface visualization - Direct view for buttress plating - Easier to place infrapectineal plate - Can combine with lateral window **Benefits over Extended Iliofemoral:** - Lower HO rate - Lower blood loss - Faster recovery - Less morbid overall **Examiner Question**: "How do you combine Modified Stoppa with a lateral window, and when would you do this?" **Model Answer**: "The **'Stoppa + lateral window'** approach provides complete anterior hemipelvis access. Indication: both-column fractures requiring both quadrilateral surface buttressing AND iliac wing/SI joint access. Technique: (1) Perform Stoppa through Pfannenstiel; (2) Add a **separate lateral incision** along the iliac crest; (3) Develop the lateral window between iliacus and abductors; (4) This avoids the extensive inguinal dissection of traditional ilioinguinal while accessing both areas. The advantage is avoiding inguinal canal dissection, reducing hernia risk while maintaining full access." - **Cannot access SI joint** - need lateral window or separate incision - **Cannot directly see posterior column** - relies on indirect reduction - **Limited iliac wing access** - combine with lateral window if needed - **Obese patients** - depth makes visualization challenging ## Danger Zones by Approach **Sciatic Nerve:** - 5-15% palsy rate - Below piriformis - Identify early, vessel loop - Release retractors q15-20min **Superior Gluteal Bundle:** - Above piriformis - Do not extend proximal to GT **MFCA:** - Posterior capsular branches - Minimize capsular stripping **Corona Mortis:** - Present in 30% - Obturator-external iliac anastomosis - Identify and ligate prophylactically **Femoral Nerve:** - Runs on iliopsoas - Protected in lateral window **LFCN:** - 10-15% injury rate - 1cm medial to ASIS **External Iliac Vessels:** - Middle window danger - Use vessel loops ## Reduction Principles **General Reduction Sequence:** 1. **Posterior column first** (if K-L approach) - Larger fragment, easier landmark - Clamps from outer table - Provisional K-wires 2. **Anterior column second** (if posterior fixed first) - Often reduces with posterior - May need manipulation through anterior window 3. **Wall fragments last** - Reduce to column first - Lag screws then buttress plate **For Ilioinguinal:** - Anterior column FIRST (foundation) - Posterior column reduces INDIRECTLY in 60-70% - If not → stage K-L approach **Examiner Question**: "Why do you reduce the posterior column before the anterior through K-L approach?" **Model Answer**: "Through the K-L approach, I reduce the **posterior column first** because: (1) It is the **larger, stronger fragment** - provides a stable foundation; (2) The **intact ilium** (sciatic buttress) serves as the reference point; (3) The anterior column is **indirectly linked through the acetabular dome** - when posterior reduces, anterior often follows; (4) If I tried to reduce anterior first through K-L, I have **no direct access** to manipulate it. For both-column via ilioinguinal, the sequence reverses - anterior first with posterior reducing indirectly in 60-70% of cases." - **Reducing wall before column** - wall has nothing to reduce to, must fix column first - **Forcing anterior through K-L** - limited access, consider staging ilioinguinal - **Accepting malreduction** - each mm increases arthritis risk, take time to optimize - **Inadequate provisional fixation** - columns slip during definitive plating **Clamps:** - Weber clamps (pointed reduction) - Farabeuf clamps - Jungbluth clamps - Bone tenaculum **Pushers:** - Ball-spike pusher - Cobb elevator - Periosteal elevator **Provisional Fixation:** - K-wires (2.0mm) - Small fragment screws **Examiner Question**: "What fluoroscopic views do you use to assess reduction and what does each show?" **Model Answer**: "I use **four views** intraoperatively: (1) **AP pelvis** - overall alignment, femoral head concentricity; (2) **Obturator oblique** (45° toward affected side) - shows **anterior column** as a profile and **posterior wall** en face; (3) **Iliac oblique** (45° away from affected side) - shows **posterior column** as a profile and **anterior wall** en face; (4) **Inlet/outlet** views if pelvic ring involvement. For reduction assessment, I look for: step-off <2mm, gap <2mm, concentric femoral head, and smooth articular contour. Any intra-articular hardware must be removed and redirected." - **Weber clamp deep penetration** - can enter joint, confirm position fluoroscopically - **K-wire in joint** - must check all wires for intra-articular placement - **Clamp on sciatic nerve** - check nerve before placing posterior clamps - **Vessel injury with retractors** - use blunt-tipped malleable retractors **Acceptable Reduction:** - **Less than 2mm** articular step-off at dome - **Less than 2mm** gap - **Concentric** femoral head position - **Stable** hip through ROM **Outcomes by Reduction Quality (Matta):** | Reduction | Good Outcome | |-----------|--------------| | Anatomic (0-1mm) | 83% | | Imperfect (2-3mm) | 68% | | Poor (>3mm) | 50% | **Examiner Question**: "You've achieved a 3mm step at the dome. What are your options?" **Model Answer**: "A 3mm step is **not acceptable** - Matta's data shows only 50% good outcomes versus 83% with anatomic reduction. My options: (1) **Reassess reduction technique** - am I pulling in the correct direction? Is there interposed soft tissue or marginal impaction blocking reduction? (2) **Change clamp position** - may need different reduction point; (3) **Address marginal impaction** - if impacted bone blocking reduction, must elevate and graft; (4) **Consider staging additional approach** - if this approach cannot achieve reduction; (5) **Accept only if absolutely no alternative** - after exhausting all options, document limitation and counsel patient. I would spend significant time optimizing reduction before accepting imperfection." Every millimeter of step-off increases contact stress and accelerates arthritis development. Anatomic reduction is the single most important prognostic factor. ## Fixation Principles EVERY screw must be checked for extraarticular position on fluoroscopy: - AP pelvis - Obturator oblique (anterior column screws) - Iliac oblique (posterior column screws) Intra-articular screw = guaranteed arthritis. If any doubt, remove and redirect. ## Post-operative Management ### Weight-bearing Protocol ### HO Prophylaxis **MANDATORY for K-L Approach:** **Indomethacin Protocol:** - Indomethacin 25mg TDS for 6 weeks - Start within 24-72 hours of surgery - Class 1 evidence for reducing Brooker grade HO **Radiation Alternative:** - Single dose 700cGy within 72 hours - Used if NSAID contraindicated **Without Prophylaxis:** - 20-30% significant HO - 5-10% Brooker grade III-IV **Examiner Question**: "What is your HO prophylaxis protocol after K-L approach, and what if the patient has renal impairment?" **Model Answer**: "For K-L approach, HO prophylaxis is **mandatory** given the 20-30% risk without it. My first-line is **indomethacin 25mg TDS for 6 weeks**, starting within 24-72 hours. If the patient has **renal impairment** (eGFR <30) or NSAID contraindication (PUD, aspirin-sensitive asthma, anticoagulation), I use **single-dose radiation 700cGy within 72 hours post-op**. Radiation is equally effective but more logistically complex. For patients on aspirin for cardiovascular protection, I discuss the risk-benefit - often the HO risk outweighs a brief NSAID course, but this requires MDT input." - **Starting after 72 hours** - significantly reduced effectiveness - **Stopping early** - full 6 weeks required for protection - **Missing contraindications** - check renal function, GI history, bleeding risk - **Omitting prophylaxis** - 20-30% HO rate is unacceptable **Recommended but Not Mandatory:** - Lower baseline HO risk than K-L - Consider for: - Complex fracture patterns - Extensive soft tissue stripping - Prior history of HO - Combined approaches **Protocol (if used):** - Indomethacin 25mg TDS for 6 weeks - OR radiation 700cGy **Examiner Question**: "Do you give HO prophylaxis after ilioinguinal approach?" **Model Answer**: "HO prophylaxis is **recommended but not mandatory** after ilioinguinal approach because the baseline risk is lower (5-15% vs 20-30% for K-L). I would give prophylaxis in specific situations: (1) **Complex patterns** with extensive dissection; (2) **Combined or staged approach** including K-L; (3) **Prior history of HO**; (4) **Prolonged operative time** with significant soft tissue trauma. When used, the protocol is the same: indomethacin 25mg TDS for 6 weeks or radiation 700cGy if NSAID contraindicated. For straightforward anterior column fractures with minimal dissection, I may omit prophylaxis." - **Combined approaches** - significantly increases risk, ALWAYS use prophylaxis - **Delayed surgery >2 weeks** - more soft tissue trauma required - **Male gender** - higher baseline HO risk - **TBI patients** - very high HO risk, mandatory prophylaxis ### Follow-up Schedule ## Complications **Sciatic Nerve (K-L Approach):** | Feature | Detail | |---------|--------| | Incidence | 5-15% | | Mechanism | Retraction, direct trauma, hematoma | | Recovery | 70-90% recover over 12-18 months | | Prevention | Identify early, vessel loop, release retractors | | Management | Document post-op, EMG at 3 weeks, observation | **LFCN (Ilioinguinal):** | Feature | Detail | |---------|--------| | Incidence | 10-15% | | Result | Meralgia paresthetica (lateral thigh numbness) | | Recovery | Usually permanent if divided | | Management | Reassurance, gabapentin if painful | **Examiner Question**: "A patient wakes up with a foot drop after K-L approach. How do you manage this?" **Model Answer**: "Post-operative sciatic nerve palsy after K-L occurs in 5-15% and is usually **neurapraxia from retraction**. My management: (1) **Immediate examination** - document motor/sensory function, distinguish peroneal (foot drop, dorsum numbness) from tibial division; (2) **Ankle splint** - prevent equinus contracture; (3) **Observation initially** - 70-90% recover over 12-18 months; (4) **EMG at 3-4 weeks** - baseline study to assess injury severity; (5) **Serial clinical exam** - monthly initially; (6) **Consider exploration** ONLY if: complete transection suspected (open injury), worsening despite time, no recovery signs by 4-6 months with EMG showing complete denervation. Most cases recover with observation." - **Identify before releasing rotators** - vessel loop for protection - **Hip in extension** - flexion increases nerve tension - **Release retractors every 15-20 minutes** - prevents traction injury - **If nerve looks injured intra-op** - note appearance, consider primary repair if transected **Corona Mortis:** - Present in 30% of patients - Severe bleeding if injured during middle window - Prevention: Identify and ligate prophylactically - Management: Direct pressure, suture ligation **External Iliac Vessels:** - Rare but catastrophic - Prevention: Vessel loops, gentle retraction - Management: Vascular surgery consultation, primary repair **Superior Gluteal Artery (K-L):** - Above piriformis - Prevention: Do not extend proximal to GT **Examiner Question**: "You encounter brisk arterial bleeding from the middle window during ilioinguinal approach. Talk me through your management." **Model Answer**: "Brisk arterial bleeding in the middle window is likely **corona mortis** (obturator-external iliac anastomosis) or external iliac vessel injury. My immediate management: (1) **Direct pressure** with finger or packing - maintain for 5 minutes; (2) **Call for help** - senior colleague, vascular surgery standby, blood bank; (3) **Improve exposure** - suction, lighting, additional retractors; (4) **Identify source** - if on superior pubic ramus, likely corona mortis; (5) **Corona mortis management** - clamp, ligate with 2-0 silk on the bone; (6) **If external iliac** - maintain pressure, DO NOT clamp blindly, await vascular surgery; (7) **Resuscitation** - cell saver, crossmatch blood products. Prevention is key - always look for and ligate corona mortis prophylactically." - **Cell saver running** before entering middle window - **4 units RBC crossmatched** before starting case - **Vascular surgery on call** - know how to contact rapidly - **Vessel loops on iliac vessels** - enables rapid proximal control if needed **Heterotopic Ossification:** - K-L: 20-30% without prophylaxis, 5-10% with - Ilioinguinal: 5-15% - Brooker Grade III-IV requires excision **Post-traumatic Arthritis:** - 20-40% long-term despite anatomic reduction - Correlates with reduction quality - May require THA conversion (10-30% at 10-20 years) **AVN Femoral Head:** - 5-10% overall - Higher with posterior dislocations - Higher with delayed reduction **Examiner Question**: "When would you excise heterotopic ossification after acetabular surgery?" **Model Answer**: "I would consider HO excision for **Brooker grade III-IV** causing functional limitation. Key principles: (1) **Wait for maturity** - typically 12-18 months post-surgery; (2) **Confirm maturity** with bone scan (cold scan = mature) or serial X-rays showing no change; (3) **Pre-operative planning** - CT to delineate HO extent and relationship to vessels/nerves; (4) **Approach** - usually through previous incision; (5) **Post-operative prophylaxis** - mandatory radiation (700cGy within 24-72 hours) AND indomethacin; (6) **CPM and aggressive physiotherapy** - maintain motion gains. Without maturity, recurrence rates approach 100%." - **20-40% develop arthritis** - even with anatomic reduction - **THA conversion rate** - 10-30% at 10-20 years - **Prior ORIF complicates THA** - higher dislocation, infection rates - **Document pre-op counselling** - patients must understand long-term prognosis **Infection:** - 2-5% overall - Higher with delay >14 days - Management: Debridement, IV antibiotics **DVT/PE:** - 2-5% with prophylaxis - Higher without prophylaxis - LMWH for 4-6 weeks **Loss of Reduction:** - Inadequate fixation - Early weight-bearing - Osteoporotic bone **Inguinal Hernia (Ilioinguinal):** - 5-10% - Prevention: Meticulous fascial repair **Examiner Question**: "A patient develops fever and wound erythema 10 days after acetabular ORIF. How do you manage this?" **Model Answer**: "This presentation suggests **surgical site infection**, a serious complication after acetabular surgery. My management: (1) **Clinical assessment** - wound inspection, systemic signs, neurological exam; (2) **Investigations** - FBC, CRP, blood cultures, wound swab for culture; (3) **Imaging** - X-ray to assess implant position, consider MRI if deep infection suspected; (4) **Early operative debridement** - within 24-48 hours of diagnosis, thorough washout, deep tissue cultures, consider implant retention if fixation stable; (5) **Antibiotics** - empirical IV (flucloxacillin + gentamicin), then culture-directed; (6) **Multidisciplinary input** - infectious diseases, consider suppressive antibiotics; (7) **Follow-up** - serial inflammatory markers, wound review. Early aggressive management preserves fixation and reduces long-term morbidity." - **Optimal timing** - surgery 3-7 days reduces infection vs delayed >14 days - **Prophylactic antibiotics** - within 60 minutes of incision, redose for long cases - **Meticulous soft tissue handling** - minimize dead space - **Wound closure** - ensure fascial integrity, consider drains for large dead space ## Viva Scenarios ## Key Exam Points Extended iliofemoral (lower morbidity)" ] }, { heading: "Critical Dangers", points: [ "K-L: Sciatic nerve (5-15%), superior gluteal (above piriformis)", "Ilioinguinal: Corona mortis (30%), LFCN (10-15%), femoral nerve", "Stoppa: Corona mortis, external iliac vessels, bladder" ] }, { heading: "Timing", points: [ "Emergent: Irreducible dislocation, femoral head fracture", "Optimal: 3-7 days (soft tissue settled, no callus)", "Delayed >3 weeks: Consider wait to 6-8 weeks" ] }, { heading: "Key Numbers", points: [ "Reduction goal: <2mm step, <2mm gap", "Roof arc: >45° on all views for non-op consideration", "K-L HO: 20-30% without prophylaxis, 5-10% with", "Long-term arthritis: 20-40% despite anatomic reduction" ] }, { heading: "Reduction Sequence", points: [ "K-L: Posterior column FIRST, then anterior follows, wall last", "Ilioinguinal: Anterior column FIRST, posterior reduces indirectly (60-70%)", "Matta outcomes: Anatomic (0-1mm) = 83% good, Poor (>3mm) = 50%" ] }, { heading: "Sciatic Nerve Protection", points: [ "Identify BELOW piriformis before releasing rotators", "Vessel loop and protect throughout", "Release retractors every 15-20 minutes", "Hip in extension (not flexion) reduces tension" ] }, { heading: "Examiner Favorites", points: [ "Three windows of ilioinguinal: LMM (Lateral, Middle, Medial)", "Spur sign = pathognomonic for both-column", "Secondary congruence criteria: roof arc >45° all views, concentric head, no PW", "HO prophylaxis: Indomethacin 25mg TDS x 6 weeks OR radiation 700cGy" ] } ]} /> ## References 1. **Judet R, Judet J, Letournel E.** Fractures of the acetabulum: classification and surgical approaches for open reduction. *J Bone Joint Surg Am.* 1964;46:1615-1646. 2. **Letournel E, Judet R.** Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993. 3. **Matta JM.** Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after injury. *J Bone Joint Surg Am.* 1996;78(11):1632-1645. 4. **Matta JM, Tornetta P 3rd.** Internal fixation of unstable pelvic ring injuries. *Clin Orthop Relat Res.* 1996;(329):129-140. 5. **Tile M, Helfet DL, Kellam JF.** Fractures of the Pelvis and Acetabulum. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2003. 6. **Cole JD, Bolhofner BR.** Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. *Clin Orthop Relat Res.* 1994;(305):112-123. 7. **Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr.** Ectopic ossification following total hip replacement: incidence and a method of classification. *J Bone Joint Surg Am.* 1973;55(8):1629-1632. 8. **Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H.** Operative treatment of displaced fractures of the acetabulum: a meta-analysis. *J Bone Joint Surg Br.* 2005;87(1):2-9. 9. **Sagi HC, Afsari A, Dziadosz D.** The anterior intra-pelvic (modified rives-stoppa) approach for fixation of acetabular fractures. *J Orthop Trauma.* 2010;24(5):263-270. 10. **Kaempffe FA, Bone LB, Border JR.** Open reduction and internal fixation of acetabular fractures: heterotopic ossification and other complications of treatment. *J Orthop Trauma.* 1991;5(4):439-445.

Acetabular Fracture ORIF - Comprehensive Approach Selection

Acetabular Fracture ORIF - Comprehensive Approach Selection