Acetabular Fractures:

Surgical Management
Philip J. Kregor, MD

Created March 2004, Revised 2007 and 2011

Objectives
Goal of Operative Management
Specific Approaches for Specific Fractures
Indications for Kocher-Langenbeck Approach
Indications for Ilioinguinal Approach
Reduction Strategies

Letournel School
Thorough Understanding of Plain Films
Optimize One Surgical Approach
Goal of Perfect Concentric Reduction

Approaches to the Acetabulum

Posterior: Kocher - Langenbeck
Anterior: Ilioinguinal
Extensile: Extended Iliofemoral

Kocher-Langenbeck Approach
Langenbeck (1874): Superior Limb
Kocher (1904): Inferior Limb
Judet and Lagrange (1958)
Letournel

Indications in Acute Acetabular Fxs

Posterior Wall Fractures
Posterior Column Fractures
Posterior Column / Posterior Wall Fractures
Juxta-tectal / Infra-tectal Transverse or Transverse
with Posterior Wall Fractures
Some T-type Fractures

Access: Kocher-Langenbeck
Entire Posterior Column
Greater and Lesser Sciatic Notches
Ischial Spine
Retro-Acetabular Surface
Ischial Tuberosity
Ischio-Pubic Ramus

Prone Position
Aids in Reduction of Ischiopubic Segment
Facilitates Palpation of Quadrilateral Surface
Allows Clamp Placement through Greater Sciatic
Notch
Easier Prep and Drape

Judet Table

POSTERIOR WALL
FRACTURES

Posterior Wall Fxs: Surgical Keys

Avoid Devascularization of Fragment/s
Remove Intra-articular Fragments
Address Marginal Impaction
Provide adequate buttress
Avoid Over-Contouring of Plate

CONTROLLED DISTRACTION
OF HIP JOINT
FEMORAL DISTRACTOR
TRACTION TABLE

POSTERIOR WALL FX
63 Y.O. MALE

L.W. 00.09.23

L.W. 00.09.23

L.W. 00.09.23

L.W. 00.09.23

L.W. 00.10.25

L.W. 00.10.25

L.W. 00.10.25

SPECIAL CASE:
EXTENDED POSTERIOR WALL
??? GANZ TROCHANTERIC FLIP OSTEOTOMY TO
VISULIZE FRACTURE WITHOUT DEVITALIZING
ABDUCTORS

T.D. 00.02.01

T.D. 00.02.01

T.D. 00.02.01

T.D. 00.02.01

T.D. 00.02.08

T.D. 00.02.17

Reduction Aids: Kocher-Langenbeck

Approach
Distal Femoral Traction
Distraction of Hip Joint
Ischial Tuberosity Schantz Pin
Quadrangular Clamp through Greater Sciatic
Notch
Farabeuf Clamp

FAERBEUF CLAMPS

M.M. 98.10.27

M.M 98.10.29

M.M. 98.11.04

M.M. 98.11.05

M.M. 98.11.05

TRANSTECTAL TRANVERSE
ACETABULAR FX
18 Y.O. MALE
ISOLATED INJURY
SKINNY PATIENT / TREATED EARLY

W.M. 99.11.27

W.M. 99.11.27

W.M. 99.11.27

W.M. 99.11.27

W.M. 00.01.12

W.M. 00.01.12

W.M. 00.01.12

16 YEAR OLD FEMALE

IRREDUCABLE HIP
DISLOCATION

T-TYPE FRACTURE
REDUCTION OF ANTERIOR COLUMN,
FOLLOWED BY POSTERIOR COLUMN
REDUCTION OF POSTERIOR COLUMN,
FOLLOWED BY ANTERIOR COLUMN
CREATION OF INTACT ISCHIOPUBIC
SEGMENT, FOLLOWED BY REDUCTION TO
THE INTACT ILIUM

Farless, Ron 02.07.29

FACTORS COMPLICATING
TRANSVERSE FRACTURE
REDUCTION

TRANSTECTAL FRACTURE PATTERN

SEPARATE OSSEOCHONDRAL
ARTICULAR DOME FRAGMENT
IPSILATERAL S.I. JOINT INJURY
SYMPHYSIS INJURY OR
CONTRALATERAL ANTERIOR RING
INJURY

Ilioinguinal Approach: Indications

Anterior Wall
Anterior Column
Transverse with significant Anterior
Displacement
Anterior Column / Posterior Hemitransverse
Both Column

Ilioinguinal Approach: Access

Ilioinguinal Approach

CASE 4: 63 YEAR OLD ROMAN

CATHOLIC PRIEST
FELL GOING DOWN STAIRS
WHAT IS THE DIAGNOSIS ??
WARNING: MAKE THE DX
WITHOUT C.T.

WHAT IS THE DIAGNOSIS ?

TREATMENT OPTIONS?
NON-OPERATIVE?
ORIF?
TOTAL HIP?

ORIF ANTERIOR COLUMN

ACETABULAR FRACTURE
SUPINE WITH FX TABLE
ILIOINGUINAL APPROACH

NORMAL HIP AT 3 YEAR

FOLLOW-UP

R.C. 00.03.09

R.C. 00.03.09

SPUR
SIGN

R.C. 00.03.09

R.C. 00.03.09

R.C. 00.03.09

SYMPHYSIS

A.S.I.S.

EXT. INGUINAL RING

EXT.
OBL.
A.S.I.S.

EXT.
OBL.

CONJOINT TENDON

PSOAS

A.S.I.S.
L.F.C.N.

EXT.
OBL.

INTACT ILIUM

R.C. 00.03.10

Limitations: Kocher-Langenbeck
Superior Acetabular Region
Anterior Column
Fractures High in Greater Sciatic Notch

Extended Iliofemoral Approach

T Type Fractures
Trans-tectal Transverse Fractures
Delayed Reconstruction

Extended Iliofemoral Approach

R.H. 98.11.21

R.H. 98.11.21

R.H. 98.11.22

R.H. 98.11.22

Anterior Column / Posterior

Hemitransverse Acetabular
Fractures

Anterior Column /
Posterior Hemitransverse
Anterior Wall or Column
Posterior Half of Transverse Fracture

ANTERIOR COLUMN FRACTURES

ANTERIOR WALL FRACTURE

Jeff Mast, M.D.

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.15

R.M. 98.08.24

R.M. 99.02.17

R.M. 99.02.17

R.M. 99.02.17

H.S. 99.10.02

NO SPUR SIGN

H.S. 99.10.02

H.S. 00.04.12

H.S. 00.04.12

H.S. 00.04.12

SPECIAL CASE:
Pipkin IV addressed through Ganz
Trochanteric Flip Osteotomy with
Surgical Dislocation

CONCLUSIONS
Good Understanding of the Fracture
Know the Anatomy
Optimize One Surgical Approach

THANK YOU

Acknowledgment

If you would like to volunteer as an author for the

Resident Slide Project or recommend updates to any of
the following slides, please send an e-mail to
ota@aaos.org

E-mail OTA
about
Questions/Comments

Returnto
Pelvis
Index