import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ### Absolute Indications - Posterior wall fracture >40% of acetabulum (instability) - Posterior column or wall fracture with >2mm displacement - Incongruous hip joint on imaging - Incarcerated intra-articular fragments - Associated femoral head fracture (Pipkin) - Hip instability despite closed reduction ### Relative Indications - Posterior wall fracture 20-40% with marginal impaction - Non-concentric hip reduction - Young, active patient with any displacement - Associated posterior column fracture ### Absolute Contraindications - Medically unfit for major surgery - Active infection overlying surgical site - Moribund patient with limited life expectancy ### Relative Contraindications - Severe osteoporosis (consider buttress plating) - Delayed presentation >21 days (consider primary THA) - Low-demand elderly patient with small wall fragment - Extensive Morel-Lavallée lesion (delay for soft tissue recovery) - Coagulopathy (correct before surgery) ### Essential Imaging - **AP pelvis**: Overall assessment, both columns visible - **Obturator oblique (45°)**: Best view for posterior WALL - **Iliac oblique (45°)**: Best view for posterior COLUMN - **CT with 3D reconstruction**: Essential for surgical planning ### Posterior Wall Assessment | Feature | Significance | |---------|--------------| | Wall involvement >40% | Biomechanically unstable | | Marginal impaction | 30-50% of cases - must address | | Comminution | Affects fixation strategy | | Femoral head damage | Prognosis indicator | ### Stability Assessment - Examine under fluoroscopy if uncertain - Hip flexion 90° + internal rotation stresses posterior wall - >40% wall loss typically unstable - <20% may be stable and managed conservatively ### Timing - Optimal: 3-7 days (soft tissue recovery, swelling reduction) - Urgent: Open fracture, vascular injury, progressive neurological deficit - Delayed >21 days: Consider primary THA vs ORIF ### Implants - 3.5mm reconstruction plates (posterior column) - Acetabular spring plates (posterior wall) - 3.5mm and 4.5mm cortical screws - Lag screws for large wall fragments ### Instruments - Pelvic reduction clamps (Farabeuf, Jungbluth, Matta) - Ball spike pusher - Schanz pins for joystick manipulation - Cobb elevators for marginal impaction - Bone curettes ### Bone Graft - Iliac crest autograft (preferred for marginal impaction) - Calcium phosphate bone substitute - Allograft chips ### Other - Radiolucent table - Beanbag for lateral positioning - Vessel loops for nerve protection - Cell saver - Intraoperative fluoroscopy **Location**: Exits greater sciatic notch 20-30mm medial to posterior acetabular rim. Runs on deep surface of gluteus maximus. **Protection**: Identify BEFORE releasing rotators. Hip/knee flexion 45°/90°. Vessel loop. Limit retraction <2hr. **Location**: ONLY structure exiting ABOVE piriformis at greater sciatic notch. **At risk**: Extended approaches, excessive superior retraction. Contains superior gluteal artery, vein, and nerve. **Location**: Exits BELOW piriformis. Supplies gluteus maximus. **At risk**: Splitting gluteus maximus, deep dissection near greater sciatic notch. **Location**: Courses posteriorly at base of femoral neck, deep branch supplies femoral head. **Protection**: Careful capsulotomy, avoid damage to femoral head blood supply (AVN risk). ### Posterior Column and Wall Anatomy **Posterior Column**: - Extends from posterior ilium to ischial tuberosity - Forms posterior support of hip joint - Visualized on ILIAC oblique view (Judet) **Posterior Wall**: - Posterior lip of acetabulum - Critical for hip stability - prevents posterior dislocation - Visualized on OBTURATOR oblique view (Judet) ### 40% Rule Biomechanical studies demonstrate: - Posterior wall involvement <20%: Usually stable - Posterior wall involvement 20-40%: May be stable - stress test - Posterior wall involvement >40%: UNSTABLE - requires surgery Assessment: CT 3D reconstruction with arc measurement ### Marginal Impaction - Present in 30-50% of posterior wall fractures - Depressed articular segment at weight-bearing dome - Caused by femoral head impacting wall during dislocation - MUST be addressed - elevation + bone graft - Failure to recognize causes residual incongruity → arthritis ### Sciatic Nerve Anatomy - Largest nerve in body (L4-S3) - Exits pelvis through greater sciatic foramen BELOW piriformis - Lies 20-30mm medial to posterior acetabular rim - Hip flexion + knee flexion relaxes nerve by 20-30% - At highest risk during external rotator release **Patient Position**: Lateral decubitus (most common - 95% of surgeons), affected hip up. Secured with beanbag or pelvic posts. Hip must be free to flex/extend/rotate for reduction maneuvers. **Nerve Protection Setup**: Plan for hip flexion 45°/knee flexion 90° throughout case. **Surgical Approach**: Kocher-Langenbeck posterior approach. **Incision**: From PSIS curving over greater trochanter to lateral thigh (15-20cm). **Key Setup**: - Radiolucent table for fluoroscopy - Test AP, obturator oblique, iliac oblique views BEFORE draping - Cell saver available - Neuromonitoring optional but useful for complex cases ### Step 1: Position Patient in Lateral Decubitus - Secure with beanbag or posts (anterior chest, posterior sacrum) - Affected hip UP - Adequate padding all pressure points - Hip must be free to flex, extend, and rotate - Test fluoroscopy before draping (AP, obturator oblique, iliac oblique) **EXAM KEY**: Lateral decubitus allows gravity-assisted reduction and easier fluoroscopy than prone. Hip/knee flexion 45°/90° relaxes sciatic nerve - maintain throughout case. ### Step 2: Make Kocher-Langenbeck Incision - Mark incision from PSIS curving over greater trochanter to lateral thigh - Total length 15-20cm - Incise skin and subcutaneous tissue - Identify and protect posterior cutaneous nerve of thigh - Develop plane to gluteal fascia **EXAM KEY**: Adequate length essential - short incision causes excessive retraction → nerve injury. Extensile approach can extend for complex fractures or THA if needed. ### Step 3: Split Gluteus Maximus in Line with Fibers - Identify fiber direction (superolateral to inferomedial) - Blunt dissection with fingers or scissors along fibers - Fiber-splitting is internervous plane (inferior gluteal nerve enters deep) - Place self-retaining retractor - Expose underlying short external rotators **EXAM KEY**: Fiber-SPLITTING (not cutting) preserves innervation and blood supply. Gluteus maximus reflection (trochanteric slide) is alternative for extensile approach. ### Step 4: Identify and Protect Sciatic Nerve **CRITICAL STEP**: - Sciatic nerve runs along deep surface of gluteus maximus - Crosses short external rotators - PALPATE nerve BEFORE releasing any structures - Place vessel loop for gentle retraction - Maintain hip flexion 45°/knee flexion 90° throughout Identification is MANDATORY before proceeding. Flexing hip/knee relaxes nerve by 20-30%. Palsy rate 2-8% but permanent <1% with meticulous protection. Avoid traction and limit retraction time. ### Step 5: Release External Rotators (PGOQG) - Identify each muscle: Piriformis → Gemellus superior → Obturator internus → Gemellus inferior → Quadratus femoris - Release tendons 5-10mm from greater trochanter insertion - TAG each tendon with heavy non-absorbable suture (#2 Ethibond) - Sciatic nerve lies on deep surface - PROTECT during release **EXAM KEY**: Tag for repair - unrepaired external rotators cause instability. Some preserve piriformis and superior gemellus to protect superior gluteal nerve. ### Step 6: Perform Posterior Capsulotomy - T-shaped or cruciate capsulotomy - Longitudinal limb along posterior femoral neck - Transverse limbs at acetabular rim - Visualize femoral head and acetabular surfaces - Remove hematoma and loose fragments from joint **EXAM KEY**: Capsulotomy allows DIRECT articular visualization for reduction assessment. Remove all loose fragments - they cause mechanical block and chondral damage. ### Step 7: Expose and Assess Fracture Pattern - Clear fracture site of hematoma - Assess posterior COLUMN (greater sciatic notch to ischial tuberosity) - Assess posterior WALL fragments (simple vs comminuted) - Identify MARGINAL IMPACTION (depressed articular segment) - Note any anterior column involvement (transverse pattern) **EXAM KEY**: Marginal impaction present in 30-50% - appears as depressed articular segment at weight-bearing dome. Requires elevation and bone graft to restore congruity. ### Step 8: Reduce Posterior Column If posterior column displaced: - Ball spike pusher in ischium and greater sciatic notch - Schanz pin in ischial tuberosity for joystick control - Farabeuf clamps or pointed reduction forceps across fracture - Reduce INFERIOR fragment (ischium) to SUPERIOR stable reference (ilium) **EXAM KEY**: Column reduction restores pelvic ring stability. Always reduce UNSTABLE fragment to STABLE reference. Confirm reduction on fluoroscopy before definitive fixation. ### Step 9: Address Marginal Impaction If marginal impaction present: - Use curved osteotome or curette to elevate depressed segment - Support with bone graft (iliac crest autograft preferred) - Pack subchondral void completely to prevent re-depression - Hold elevated segment with K-wire temporarily MUST be addressed - failure to elevate causes residual articular incongruity and accelerated arthritis. Bone graft prevents collapse. This is frequently tested in exams. ### Step 10: Reduce Posterior Wall Fragments - Reduce large fragments anatomically with reduction clamps - Small fragments may need to be captured with plate only - K-wire provisional fixation - Ensure articular surface is congruent (<1mm step) ### Step 11: Provisional Fixation and Confirmation - Hold reduction with 2.0mm K-wires or provisional screws - Visually confirm articular reduction through capsulotomy (<1mm step) - Obtain fluoroscopy: AP, obturator oblique, iliac oblique - Do NOT proceed to plating until confirming ANATOMIC reduction **EXAM KEY**: Obturator oblique shows posterior WALL best. Iliac oblique shows posterior COLUMN best. Both views mandatory - fracture involves both structures. ### Step 12: Apply Posterior Column Plate If column fracture present: - 3.5mm or 4.5mm reconstruction plate along posterior column - Pre-contour to match anatomy - Minimum 3 screws above fracture (ilium), 3 below (ischium) - Bicortical screws for maximum purchase - Screws directed anteriorly - must NOT penetrate joint **EXAM KEY**: Plate position critical - too anterior risks joint penetration, too posterior loses bone contact. Pre-contouring essential or plate will displace reduction when tightened. ### Step 13: Apply Buttress Plate for Posterior Wall - Large fragments: lag screws first if geometry allows - Then apply BUTTRESS plate (reconstruction or spring plate) - Position to prevent posterior displacement - Multiple screws into stable posterior column - Plate spans from stable column across ALL wall fragments **EXAM KEY**: Buttress plate prevents re-displacement but doesn't compress. Spring plate contours to posterior wall anatomy. Ensure ALL marginal fragments captured. ### Step 14: Check Hip Stability and Final Imaging - Remove provisional K-wires - Gently rotate and translate hip - should be stable through full ROM - Final fluoroscopy: AP and both Judet views - Arc image intensifier through joint to check for screw penetration - Posterior wall coverage should be >60% for stability **EXAM KEY**: Stability test confirms adequate fixation. If unstable, need revision or augmentation. Posterior wall coverage <60% may need constrained liner or THA. ### Step 15: Repair External Rotators and Close **External Rotator Repair**: - Heavy non-absorbable suture (#2 or #5 Ethibond) - Repair PGOQG to posterior capsule and greater trochanter - Create bone tunnels if needed - Robust repair critical for stability **Closure**: - Meticulous hemostasis (gluteal muscles bleed significantly) - Irrigate 3-6L saline - 14Fr drain deep to gluteus maximus - Close gluteal fascia (0-Vicryl), subcutaneous (2-0 Vicryl), skin (staples) **Postoperative Protocol**: - Touch weight-bearing × 6 weeks, progressive to full by 12 weeks - Posterior precautions if stability concern (no flexion >90°, no IR, no adduction) × 6-12 weeks - DVT prophylaxis: LMWH or DOAC × 35 days - HO prophylaxis: Indomethacin 75mg daily × 6 weeks - X-rays: 6 weeks, 12 weeks, 6 months, 12 months 1. Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Springer-Verlag; 1993. The definitive text on acetabular fracture classification and management. 2. 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):1632-1645. 3. Moed BR, Carr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg Am. 2002;84(5):752-758. 4. Vailas JC, Hurwitz S, Wiesel SW. Posterior acetabular fracture-dislocations: fragment size, joint capsule, and stability. J Trauma. 1989;29(11):1494-1496. 5. Calkins MS, Zych G, Latta L, et al. Computed tomography evaluation of stability in posterior fracture dislocations of the hip. Clin Orthop Relat Res. 1988;227:152-163. 6. 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. 7. 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. 8. Briffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture fixation with ten years' follow-up. J Bone Joint Surg Br. 2011;93(2):229-236. 9. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion. J Trauma. 1997;42(6):1046-1051. 10. Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am. 2012;94(17):1559-1567.

Posterior Column and Wall Acetabular Fracture ORIF

Posterior Column and Wall Acetabular Fracture ORIF