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Acetabulum Posterior Wall Fracture ORIF

Planning

B

Preoperative Plan

1

Radiographic templating of fracture

  • check the amount of marginal impaction and fracture displacement with CT scan, AP pelvis and Judet views

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • Recon plates

2

Room setup and equipment

  • fracture table
  • hip positioners or bean bag

3

Patient positioning

  • prone position
  • affected side is suspended using distal femoral traction pin
  • peroneal post padded to prevent pudendal nerve palsy
  • place the affected leg in traction with the hip in extension and the knee flexed to at least 80 degrees
  • pad the foot and secure the foot to the fracture table in the resting position
  • place SCDs on both legs
  • bovie pad on contralateral thigh or abdomen

Technique

D

Kocher Langenbock Approach

1

Mark out the incision over the greater trochanter

  • make a longitudinal incision centered over greater trochanter
  • start just below iliac crest, lateral to PSIS
  • extend to 10 cm below tip of greater trochanter

2

Deepen the incision starting at the lower half of the incision

  • incise fascia lata in lower half of incision
  • extend proximally along anterior border of gluteus maximus

3

Split the gluteus maximus

  • split gluteus maximus muscle along avascular plane

4

Release portion of gluteal sling to aide in anterior retraction of muscle belly

5

Identify and release the short external rotators

  • detach short external rotators after tagging
  • the piriformis should be tagged and released approximately 1.5cm from the tip of the greater trochanter to avoid damaging the blood supply to the femoral head

6

Identify the greater sciatic notch

  • the piriformis will provide a landmark leading to the greater sciatic notch

7

Tag structures

  • the obturator internus should be tagged 1.5 cm from the greater trochanter and blunt dissection should be used to follow its origin to the lesser sciatic notch
  • posterior retraction will protect the sciatic nerve

8

Expose the posterior wall

  • clear abductors and soft tissue to visualize posterior capsule and posterior wall region
E

Fracture Site Exposure and Debridement

1

Debride the fracture site

  • debride the fracture site and the joint
  • remove any residual hematoma from the field
  • this will make the posterior wall fragment and the posterior column easily visible

2

Inspect the posterior column carefully

  • look for any non displaced transverse fracture lines

3

Book open the fracture site

  • flip the wall piece out into the wound
  • the posterior wall typically remains attached by the wall capsule and some periosteum

4

Debride the fracture site

  • strip away from the wall any periosteum that prevents the mobilization
  • be aware not to injure any of the labral attachments
  • peel all the periosteum off the fracture edges
  • direct visualization of interdigitation at the fracture site is vital in judging anatomic reduction
  • often times it is necessary to sharply dissect the overlying gluteus minimus from the posterior wall to allow mobilization

5

Visualize the femoral head

6

Inspect the interior of the hip joint

  • look for any damage to the femoral head

7

Remove any intra-articular fragments

  • irrigate the joint to remove any other debris

8

Create space in the joint

  • use the fracture table/femoral distractor to pull traction and distract the joint
  • this will help with joint debridement

9

Prepare the intact segment in a similar fashion

  • strip any additional periosteum and soft tissue that remains attached to the intact retroacetabular surface at the fracture edge
  • elevate the soft tissue from the top of the ischium
  • this prepares the ischium to receive the reconstruction plate
  • elevate the soft tissues that are superolateral to the acetabulum on the outer table of the ilium
  • this prepares this area to receive the proximal aspect of the place
  • in this area it is often needed to elevate the overlying gluteus minimus
F

Reduction of Marginal Wall Impaction

1

Reduce areas of marginal impaction

  • check the preoperative imaging for areas of marginal impaction
  • when the femoral head is sitting in the acetabulum reduce the areas of impaction to the head
  • place an osteotome deep to the depressed areas of the subchondral bone
  • this can be done with gentle malleting
  • this technique reduces the articular surface with intact cartilage

2

Replace the defect

  • pack the area of original bone collapse with osteoconductive bone void filler
  • this provides structure and prevents recollapse
G

Reduction of the Posterior Wall Fragment

1

Flip the wall fragment into its bed

  • use a ball spike pusher to manipulate the piece until a smooth convex retroacetabular surface with no external stepoff is obtained
  • if this cannot be accomplished flip the wall piece out of the bed and look for causes of malreduction
  • if the fragment doesn’t reduce perfectly at the retroacetabular surface, it will not reduce perfectly at the joint
H

Provisional Fixation

1

Place interfragmentary lag screws or K wires

  • place a ball spike pusher to stabilize the fracture fragment and place a K wire or Lag screws to hold the reduction
  • the advantage of using 2.7 mm lag screws is that the heads sit flush with the bony cortex and do not interfere with the subsequent placement of definitive fixation

2

Place a spring plate

  • cut the end hole of a one third tubular plate into a V thus creating tines
  • bend the plate so that the tines can effect the reduction
  • this plate can be used as provisional fixation to hold a small wall fragment in place or as a small spring plate to prevent the medial aspect of a large wall fragment from kicking up
  • place the tines and a portion of the plate over the wall fragment
  • position the plate so it is possible to drill outside of the joint
I

Reconstruction Plate Stabilization

1

Place reconstruction plate

  • place a slightly underbent contoured eight hole plate that is fashioned to sit at the edge of the wall and the labrum
  • ensure that there is no portion of the plate that is sitting on the labrum
  • placing the plate in this location offers the greatest biomechanical advantage in buttressing the wall

2

Perform initial fixation

  • place the initial fixation of the plate to the pelvis at the level of the ischial tuberosity
  • drill into screw hole number 2 from the distal aspect of the plate
  • this should be resting within the recess at the top of the ischial tuberosity
  • aim distally and medially into the proximal portion of the ischium
  • this area has good bone stock

3

Check position of the plate

  • check that the plate position is at the edge of the wall but not impinging on the labrum

4

Place a ball spiker

  • place a ball spike pusher into screw hole number 8

5

Place the proximal screw

  • use a ball spike pusher and place the first proximal screw in hole number 7
  • this will compress the plate to the posterior wall

6

Remove any Kwires

7

Place additional screws

  • place at least one additional screw proximally and one distally

8

Check imaging

  • take C arm images to evaluate the reduction and ensure that the screws are place extra-articularly
  • check that the joint is reduced
  • check the proximal screws using the obturator oblique view
  • check the distal screws with the iliac oblique view
J

Wound Closure

1

Irrigation, hemostasis, and drain

  • pulsatile irrigate acetabulum and deep tissues
  • cauterize peripheral bleeding vessels
  • check the integrity of the sciatic nerve
  • place a hemovac drain on the bone along the posterior aspect of the posterior wall
  • remove any devitalized muscle to decrease the risk of heterotopic ossification

2

Deep closure

  • repair short external rotators and capsular layer with #5 Ethibond figure of 8 sutures
  • tie to either glut medius anteriorly or through bone on posterior aspect of GT
  • close TFL with #1 Ethibond figure of 8 sutures

3

Superficial closure

  • need use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin

4

Dressing and immediate immobilization

  • soft incision dressings over hip

Patient Care

K

Preoperative H & P

1

Obtain history and perform physical exam

  • document distal neurovascular status
  • identify patient comorbidities and ASA status (predictor of mortality)
  • make sure patient has Foley urinary catheter in place

2

Order basic imaging studies

  • Judet Views

3

Perform operative consent and lists potential complications

  • describe complications of surgery including
  • postoperative arthritis
  • superficial / deep infection
  • heterotopic ossification
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • use antibiotics for 24 hours
  • heterotopic ossification prevention (controversial)
  • indomethacin 25 mg orally three times daily
  • Radiation
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • foley out when ambulating
  • check appropriate labs
  • wound care
  • change dressings POD2

2

Appropriate medical management and medical consultation

3

Initiate physical therapy POD1

4

out of bed the next day

  • no active range of motion of the hip
  • passive range of motion only
  • footflat weightbeaing for 3 months

5

Discharges patient appropriately

  • pain meds
  • DVT prophylaxis
  • schedule follow up appointment in 2weeks
  • outpatient PT
M

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • determine the mechanism of injury
  • check neurovascular status
  • document presence of underlying osteoarthritis
  • concomitant and associated orthopaedic injuries

2

Interpret basic imaging studies

  • AP pelvis and Judet views

3

Interact with consultants regarding optimal patient management

  • timing of surgery
  • medical management
  • assess risk for thromboembolic disease

4

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • staples/sutures removed
  • continue physical therapy and range of motion exercises
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • check for evidence of callus on the radiographs
  • advance weightbearing to partial weightbearing
  • start strengthening and gait training with special concentration on the hip abductors
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Comprehensive assessment of fracture patterns on imaging studies

2

Modifies and adjusts post-operative treatment plan as needed

3

Provides prohylaxis and manages thromboemblotic disease

O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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