import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable, MedicalImage } from '@/components/mdx' ## Indications **Fracture Patterns Requiring Kocher-Langenbeck:** - **Posterior wall fracture** - involving more than 40% of wall or causing hip instability - **Posterior column fracture** - displaced more than 2mm with articular incongruity - **Transverse fracture** - when posterior displacement predominates - **T-type fracture** - when posterior component is primary - **Transverse + posterior wall** - classic indication for this approach - **Posterior column + posterior wall** - associated pattern requiring posterior access **Radiographic Criteria:** - Articular step-off more than 2mm on CT - Posterior wall involvement more than 40% (arc method) - Hip instability on stress fluoroscopy - Marginal impaction requiring elevation and grafting - Intra-articular fragments requiring removal **Patient-Related:** - Associated posterior hip dislocation (closed reduction first, then staged ORIF) - Femoral head injury (Pipkin fracture) requiring posterior access - Failed closed reduction of posterior dislocation - Delayed presentation (up to 3 weeks) with acceptable soft tissues **Technical:** - Combined approach when posterior fixation required first - Revision for failed percutaneous fixation - Removal of incarcerated posterior wall fragments **Absolute:** - Active posterior wound infection - Morel-Lavallee lesion (degloving injury) - delay until resolved - Severe gluteal muscle necrosis from ischaemia - Medical unfitness for prolonged lateral decubitus positioning **Relative:** - Anterior column/wall as primary injury (use ilioinguinal or Stoppa) - Morbid obesity (BMI more than 45) - extreme positioning difficulty - Previous hip surgery with posterior scarring - Pre-existing complete sciatic nerve palsy (no protective function to preserve) - Both-column fractures (usually require anterior approach) ## Pre-operative Planning **History:** - Mechanism: Dashboard injury (posterior wall), fall from height, high-energy MVA - Time since injury (dislocation more than 6 hours increases AVN risk) - Associated injuries (head, chest, abdomen - polytrauma common) - Pre-injury mobility and occupation **Examination:** - **Sciatic nerve function** - CRITICAL baseline documentation - Common peroneal: ankle dorsiflexion, EHL, sensation dorsal foot - Tibial: ankle plantarflexion, FHL, sensation sole - Hip position (flexed, internally rotated = posterior dislocation) - Posterior gluteal skin - bruising, Morel-Lavallee lesion, abrasions - Peripheral pulses **EXAM KEY:** "I document detailed sciatic nerve examination BEFORE surgery. The approach places the nerve at risk, and I need baseline for comparison. Nerve injury occurs in 10-15% of cases." **Plain Radiographs (Judet Series):** - AP Pelvis - overall alignment, roof arc measurement - Inlet view (25-degree caudal) - anterior/posterior displacement - Outlet view (45-degree cranial) - vertical displacement - **Obturator oblique** (45-degree toward affected side) - **POSTERIOR COLUMN**, anterior wall - **Iliac oblique** (45-degree away from affected side) - anterior column, **POSTERIOR WALL** **CT Scan with 3D Reconstruction:** - Axial 2mm slices through acetabulum - Sagittal and coronal reformats - 3D surface rendering (subtract femoral head) - **Key Assessment:** - Posterior wall percentage (arc method on sagittal) - Marginal impaction (present in 50%) - Free intra-articular fragments - Associated femoral head injury (Pipkin) - Posterior column comminution **Posterior Wall Arc Measurement:** - Draw line from centre of femoral head to posterior wall margin - Normal arc = 104 degrees - Calculate percentage: (Remaining arc / 104) x 100 - More than 40% loss = unstable **Expected Outcomes:** - Anatomic reduction in 75-85% of cases - Good/excellent clinical outcome in 70-80% at 10 years - Post-traumatic arthritis in 20-30% requiring THA **Specific Risks:** | Complication | Rate | Details | |--------------|------|---------| | Sciatic nerve injury | 10-15% | Higher with dislocation, most neuropraxia | | AVN | 2-10% | Higher if dislocation more than 6 hours | | Heterotopic ossification | 15-40% | Highest of any approach | | Infection | 2-5% | Higher with open injuries | | Post-traumatic arthritis | 20-30% | Correlates with reduction quality | | DVT/PE | 2-5% | Despite prophylaxis | | Dislocation | less than 2% | If rotators repaired | **Alternatives:** - Non-operative: Bed rest 6-8 weeks (if stable, less than 2mm displaced) - Percutaneous fixation: Selected posterior column patterns - THA: Elderly, severe comminution, pre-existing arthritis ## Equipment - 3.5mm pelvic reconstruction plates (8-14 hole) - Pre-contoured posterior wall plates - 3.5mm cortical screws (16-50mm) - Spring plates for comminution - 4.0mm cannulated screws - Buttress plates for wall support - Large pelvic reduction set - Pointed reduction forceps (Weber, Farabeuf) - Ball spike pushers - Blunt Hohmann retractors (essential) - Schanz pins (5.0mm) - Bone graft harvesting instruments - Heavy sutures for rotator tagging - Fluoroscopy (C-arm) - Cell saver (blood loss 500-1500ml) - Beanbag positioner - Radiolucent table - 4 units PRBC crossmatched - TXA 1g IV at induction - Nerve stimulator (optional) ## Anaesthesia and Positioning **Type:** General anaesthesia (mandatory) - Muscle relaxation essential for reduction - Lateral decubitus precludes spinal alone - Consider arterial line for polytrauma **Adjuncts:** - Tranexamic acid 1g IV at induction, repeat at 3 hours - Cell saver for blood conservation - Warming blanket (forced air) **Considerations:** - Antibiotic prophylaxis: Cefazolin 2g IV within 60 minutes of incision - Repeat antibiotics every 4 hours or 1.5L blood loss - Avoid prolonged hypotension (increases AVN risk if dislocation present) **Position:** Lateral decubitus with affected hip UP **Setup:** - Beanbag or pelvic positioners anteriorly and posteriorly - Pelvis PERPENDICULAR to table (confirm on AP fluoro before prep) - **Hip flexed 30-40 degrees** - relaxes sciatic nerve - **Knee flexed 90 degrees** - further relaxes sciatic nerve - Lower leg supported on Mayo stand or pillow **Pressure Points:** - Axillary roll under dependent axilla - Lateral malleolus padded (peroneal nerve) - Dependent knee padded - Head neutral on head ring **Preparation:** - Prepare from iliac crest to mid-thigh - Include posterior gluteal region - Drape knee into field (allows flexion adjustment) - Mark incision before prep **EXAM KEY:** "I position with hip and knee flexed to relax the sciatic nerve. This is critical - the nerve is under tension when the hip is extended." ## Surface Anatomy and Landmarks ### Imaging ## Surgical Approach The Kocher-Langenbeck approach uses the interval between: - **Superior gluteal nerve** (L4, L5, S1) - supplies gluteus medius and minimus - **Inferior gluteal nerve** (L5, S1, S2) - supplies gluteus maximus The gluteus maximus is split in line with its fibres, NOT detached from its insertion. ### Incision **Configuration:** Curvilinear, hockey-stick shaped - Begin 10cm distal to PSIS, curve over posterior greater trochanter - Continue along lateral femoral shaft for 8-10cm distal to trochanter - Total length: 15-20cm **Layers:** 1. Skin and subcutaneous tissue 2. Fascia lata (thick layer over trochanter) 3. Gluteus maximus (split in line with fibres) ### Superficial Dissection 1. Incise skin and subcutaneous fat 2. Identify fascia lata over greater trochanter - incise in line with skin 3. Identify gluteus maximus fibres running obliquely (superomedial to inferolateral) 4. **Split gluteus maximus** in line with its fibres using blunt finger dissection 5. Control bleeding from superior and inferior gluteal vessels at proximal extent The superior gluteal neurovascular bundle exits above piriformis, 3-4cm from the acetabular rim. Do NOT extend the split of gluteus maximus more than 4-5cm proximal to the greater trochanter. ### Deep Dissection and Sciatic Nerve Identification **Landmark:** Fat pad overlying quadratus femoris muscle The sciatic nerve lies **1-2cm medial to the lateral border of quadratus femoris** at the level of the ischium. It exits the pelvis through the greater sciatic notch, BELOW the piriformis muscle in 90% of cases. **Identification Steps:** 1. After splitting gluteus maximus, identify the fat pad over quadratus femoris 2. Gently palpate for a cord-like structure medial to the muscle 3. The nerve should feel mobile and soft (not tethered) 4. Place a blunt Hohmann retractor MEDIAL to the nerve to protect it throughout **EXAM KEY:** "I always identify the sciatic nerve before any deep dissection. It lies in the fat pad medial to quadratus femoris. I protect it with a blunt retractor positioned medially." ### Release of Short External Rotators **Technique:** 1. Identify **piriformis** at superior border of greater trochanter 2. Place tagging suture (2-0 Ethibond) in tendon before release 3. Release piriformis 1-2cm from insertion with diathermy 4. Repeat for **gemellus superior, obturator internus, gemellus inferior** 5. **Preserve quadratus femoris** when possible (protects medial femoral circumflex artery) 6. **Preserve obturator externus** (deep, protects MFCA) **Medial femoral circumflex artery** (MFCA) provides the blood supply to the femoral head. It runs between obturator externus and quadratus femoris. Dividing these muscles increases AVN risk. Preserve both if possible. ### Capsulotomy and Joint Inspection 1. Perform posterior capsulotomy parallel to acetabular rim 2. Place stay sutures for later repair 3. Flex hip gently and apply traction to visualize joint 4. Remove loose osteochondral fragments and haematoma 5. Assess articular surface for: - Marginal impaction (present in 50%) - Cartilage damage - Femoral head injury (Pipkin) ## Critical Danger Structures ## Operative Technique ### Step 1: Positioning and Preparation 1. Position lateral decubitus with affected hip up 2. Pelvis perpendicular to table (confirm on AP fluoro) 3. Hip flexed 30-40 degrees, knee flexed 90 degrees (relaxes sciatic nerve) 4. Beanbag or pelvic supports for stability 5. Prep from iliac crest to mid-thigh, include knee in field 6. Mark incision before prep **Technical Pearl:** "Hip and knee flexion is NOT optional - it relaxes the sciatic nerve and significantly reduces the risk of traction injury during the procedure." ### Step 2: Incision and Approach to Gluteus Maximus 1. Make 15-20cm curvilinear incision 2. Begin 10cm distal to PSIS, curve over greater trochanter 3. Continue along lateral femoral shaft 8-10cm 4. Divide subcutaneous fat and fascia lata 5. Identify gluteus maximus fibres (oblique orientation) ### Step 3: Split Gluteus Maximus and Identify Sciatic Nerve 1. **Split gluteus maximus in line with fibres** using blunt dissection 2. Do NOT extend split more than 4-5cm proximal to trochanter 3. Control bleeding from gluteal vessels 4. **Identify fat pad over quadratus femoris** 5. **Identify sciatic nerve 1-2cm medial to QF** 6. Place blunt Hohmann retractor MEDIAL to nerve for protection Throughout the procedure: - Maintain hip and knee flexion - Use ONLY blunt retractors near nerve - Release retractors every 15 minutes - Avoid extending hip with retractors in place - Check nerve position before placing any screws ### Step 4: Release and Tag Short External Rotators 1. Identify piriformis at superior trochanter 2. Tag with heavy suture (2-0 Ethibond) before release 3. Release 1-2cm from insertion using diathermy 4. Repeat for gemellus superior, obturator internus, gemellus inferior 5. Preserve quadratus femoris and obturator externus (MFCA protection) 6. Reflect rotator cuff posteriorly (protects nerve) **Technical Pearl:** "I release the rotators close to their insertion and TAG them with suture. This allows anatomic repair at closure which reduces dislocation risk from 10% to less than 2%." ### Step 5: Capsulotomy and Joint Inspection 1. Perform posterior capsulotomy parallel to rim 2. Place stay sutures for later repair 3. Flex hip and apply gentle traction 4. **Remove all loose bodies** (chondral fragments, bone, haematoma) 5. Assess articular surface systematically 6. **Look for marginal impaction** (present in 50% of posterior wall fractures) ### Step 6: Expose Posterior Column and Wall 1. Place three Hohmann retractors for exposure: - Greater sciatic notch (PROTECT SCIATIC NERVE) - Ischium inferiorly - Ilium/posterior column superiorly 2. Use periosteal elevator to clear fracture surfaces 3. Identify all fracture fragments 4. Clear haematoma and fibrous tissue 5. Map out fracture pattern before reduction ### Step 7: Reduce Posterior Column **Principle:** Reduce column FIRST - it is the stable reference 1. Place Schanz pin or ball spike in ischial fragment 2. Manipulate to reduce column to intact ilium 3. Apply pointed reduction forceps or Farabeuf clamps 4. Confirm reduction on **obturator oblique** (best view for posterior column) 5. Hold with 2.0mm K-wires **Technical Pearl:** "The obturator oblique view shows the posterior column in profile. This is my go-to view for assessing posterior column reduction. I aim for less than 1mm step." ### Step 8: Address Marginal Impaction and Reduce Posterior Wall **Marginal Impaction (if present):** 1. Identify impacted fragment through joint 2. Elevate using Freer elevator or curette from within the joint 3. Fill metaphyseal void with cancellous autograft: - Femoral head (if damaged from dislocation) - Greater trochanter - Iliac crest 4. Support elevated fragment with graft before wall reduction **Wall Reduction:** 1. Reduce wall fragments to column using pointed forceps 2. Maintain reduction with K-wires 3. Assess reduction on iliac oblique (best view for posterior wall) ### Step 9: Apply Posterior Column Plate 1. Contour 3.5mm pelvic reconstruction plate to posterior column 2. Plate from ischium to ilium along posterior column 3. Position on posterior column surface 4. **Minimum 3 bicortical screws each side of fracture** 5. Check screw lengths - avoid joint penetration - Ischial screws: maximum 20mm (pudendal vessels/rectum medially) - Screws toward joint: confirm on iliac oblique (shows posterior wall/joint) - If in doubt, use shorter screw - safety over purchase ### Step 10: Apply Posterior Wall Fixation **Technique:** Buttress plating perpendicular to column 1. Position 3.5mm plate perpendicular to column plate (L or T configuration) 2. Plate BUTTRESSES wall fragments - prevents displacement into joint 3. For small/comminuted fragments: use spring plates 4. Alternative: 3.5-4.0mm lag screws if geometry allows 5. **Check all screw positions on iliac oblique** **Technical Pearl:** "The wall plate is a BUTTRESS - it prevents the wall from displacing into the joint. I position it perpendicular to the column plate. Spring plates are excellent for comminuted fragments." ### Step 11: Assess Stability and Range of Motion 1. Remove all retractors 2. Reduce hip and test stability 3. Apply axial load with hip flexed - assess for subluxation 4. Range hip through flexion, internal rotation 5. Check for smooth motion without crepitus 6. If unstable: reassess fixation, consider additional plates ### Step 12: Final Fluoroscopic Assessment **Required Views:** 1. AP pelvis - overall reduction, joint space 2. Inlet (25-degree caudal) - anterior/posterior displacement 3. Outlet (45-degree cranial) - vertical displacement 4. **Obturator oblique** - posterior column, anterior wall 5. **Iliac oblique** - anterior column, **POSTERIOR WALL** (key for joint penetration) **Confirm:** - Anatomic reduction (less than 2mm step) - No intra-articular hardware - No loose bodies - Adequate fixation of all fragments ### Step 13: Repair Short External Rotators and Capsule 1. Repair posterior capsule with 0-Vicryl 2. **Repair short external rotators** using tagged sutures 3. Reattach to posterior capsule/trochanter insertion 4. Ensure appropriate tension (not too tight - limits ROM) **Technical Pearl:** "Anatomic repair of the short external rotators reduces posterior dislocation risk from 10% to less than 2%. This is NOT optional." ### Step 14: Closure and Drain Placement 1. Close gluteus maximus fascia with 1-0 Vicryl 2. **Place deep drain** (19Fr Blake) under gluteus maximus 3. Close fascia lata with 0-Vicryl 4. Subcutaneous closure 2-0 Vicryl 5. Skin: staples or 3-0 Monocryl subcuticular ## Intra-operative Complications **Rate:** 10-15% (higher with associated posterior dislocation - up to 25%) **Recognition:** - Usually not apparent intraoperatively - Post-operative: foot drop (common peroneal), weakness of ankle plantar/dorsiflexion - Pre-operative documentation essential for comparison **Prevention:** - Identify nerve EARLY via fat pad over quadratus femoris - Maintain hip and knee FLEXION throughout - Use ONLY blunt retractors near nerve - Release retractors every 15 minutes - Never extend hip with retractors in place - Flex hip when reducing posterior wall fragments **Management:** - Most are neuropraxias from traction - expect recovery over 6-18 months - Document findings and compare with pre-operative baseline - EMG at 6 weeks if no recovery - assess for axonotmesis - AFO for foot drop during recovery - Neurosurgical referral if no recovery by 6 months **Rate:** 15-40% (highest of any acetabular approach) **Clinically significant (Brooker III-IV):** 5-10% **Recognition:** - Hip stiffness developing 6-12 weeks post-operatively - Pain with passive motion - X-ray shows ossification in surgical field **Prevention (MANDATORY):** - Minimise soft tissue stripping - Meticulous haemostasis - **Deep drain** for 48-72 hours - **HO prophylaxis within 24 hours:** - Indomethacin 25mg TDS for 6 weeks (reduces risk by 50%) - OR Single-fraction radiation 700-800cGy within 72 hours - Radiation preferred if NSAID contraindicated **Management:** - Physiotherapy to maintain ROM - Surgical excision if severe (Brooker III-IV with functional limitation) - Wait until HO matures (12-18 months) before excision - Re-prophylaxis at excision **Rate:** 2-10% (higher with associated posterior dislocation) **Risk Factors:** - Posterior dislocation more than 6 hours before reduction - Multiple closed reduction attempts - Disruption of medial femoral circumflex artery - Severe initial displacement **Recognition:** - Progressive hip pain 6-24 months post-operatively - MRI: signal changes in femoral head - Late: femoral head collapse on X-ray **Prevention:** - URGENT reduction of posterior dislocation (less than 6 hours ideal) - Single gentle closed reduction attempt only - Preserve obturator externus and quadratus femoris (MFCA protection) - Avoid excessive traction on hip during surgery **Management:** - Non-weight bearing if early - Core decompression (pre-collapse) - THA if femoral head collapse **Rate:** 2-5% superficial, 1-2% deep **Risk Factors:** - Open fracture - Morel-Lavallee lesion - Prolonged operative time (more than 4 hours) - Associated bowel/bladder injury - Diabetes, immunosuppression **Prevention:** - Prophylactic antibiotics within 60 minutes - Repeat antibiotics every 4 hours or 1.5L blood loss - Meticulous haemostasis - Deep drain to prevent haematoma - Delayed surgery if Morel-Lavallee present **Management:** - Superficial: oral antibiotics, wound care - Deep: surgical debridement, hardware retention if stable, IV antibiotics 6 weeks - Consider hardware removal once healed if persistent infection ## Post-operative Care **Monitoring:** - ICU/HDU if polytrauma or significant blood loss - **Sciatic nerve checks every 2 hours for 24 hours** - Compare with documented pre-operative function - Monitor drain output **Medications:** - DVT prophylaxis: LMWH (Enoxaparin 40mg daily) from Day 1 - **HO prophylaxis within 24 hours:** - Indomethacin 25mg TDS for 6 weeks OR - Single-fraction radiation 700cGy within 72 hours - PCA then oral analgesia **Drains:** - Remove when output less than 30ml per 8-hour shift - Typically Day 2-3 - Prolonged drainage increases HO risk **Mobilisation:** - **Toe-touch weight bearing only** for 6-12 weeks - Walker or crutches - Hip precautions (no combined flexion/adduction/internal rotation) - Physiotherapy for ROM and strengthening **Wound Care:** - Inspect at 48 hours for haematoma - Remove staples/sutures at 14-21 days - Monitor for signs of HO (stiffness at 6 weeks) **Imaging:** - Post-operative CT within 48 hours (confirm reduction, hardware position) - 6-week X-ray series (AP pelvis, Judet views) **Weight Bearing Progression:** - 6 weeks: Continue toe-touch if healing - 8-10 weeks: Progress to partial weight bearing - 12 weeks: Full weight bearing as tolerated if radiographic healing **Function:** - 6-week review: X-ray, ROM assessment - Check for HO development - Continue physiotherapy **Work/Activities:** - Sedentary work: 3-6 months - Manual work: 6-12 months - Impact activities: 9-12 months if fully healed **Follow-up Schedule:** - 6 weeks: Clinical and radiographic - 3 months: Assess healing, ROM - 6 months: Functional outcome - 1 year: Final radiographs - Long-term: Monitor for post-traumatic arthritis **Complications to Monitor:** - Post-traumatic arthritis (20-30% at 10 years) - AVN (may present 6-24 months post-injury) - HO limiting ROM **Hardware Removal:** - Rarely indicated - Consider if symptomatic and healed - Wait minimum 12-18 months ## Viva Scenarios ## Key Exam Points ## References **Original Description:** - Kocher T. Textbook of Operative Surgery. 3rd ed. London: Adam and Charles Black; 1911. *Original description of the approach* - Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993. *Definitive textbook on acetabular fracture surgery* **Outcomes:** - Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632-45. *Landmark outcomes study - 80% good/excellent results with anatomic reduction* **Sciatic Nerve Injury:** - Helfet DL, Schmeling GJ. Somatosensory evoked potential monitoring in the surgical treatment of acute, displaced acetabular fractures. Clin Orthop Relat Res. 1994;(301):213-20. - Middlebrooks ES, Sims SH, Grisoni BE, et al. Incidence of sciatic nerve injury in operatively treated acetabular fractures. J Orthop Trauma. 1997;11(5):323-6. *10-15% injury rate* **Heterotopic Ossification:** - Moed BR, Letournel E. Low-dose irradiation and indomethacin prevent heterotopic ossification after acetabular fracture surgery. J Bone Joint Surg Br. 1994;76(6):895-900. *Prophylaxis reduces HO by 50%* - 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):1629-32. *Brooker classification* **Marginal Impaction:** - Moed BR, WillsonCarr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am. 2002;84(5):752-8. **AVN:** - Hougaard K, Thomsen PB. Traumatic posterior dislocation of the hip - prognostic factors influencing the incidence of avascular necrosis of the femoral head. Arch Orthop Trauma Surg. 1986;106(1):32-5. *Time to reduction and AVN risk*

Acetabular Fracture ORIF - Kocher-Langenbeck Approach

Acetabular Fracture ORIF - Kocher-Langenbeck Approach