acetabular fractures in older patients · acetabular fractures in older patients ted manson md...
TRANSCRIPT
11/18/2015
1
Acetabular Fractures in Older Patients
Ted Manson MD
Associate Professor
Joint Replacement and Orthopedic Trauma
R Adams Cowley Shock Trauma Center
Disclosures
• Consultant and Royalties from Stryker, AAOS Hip Program Committee, Journal of Arthroplasty Editorial Board, AAHKS Scientific Program Committee
Disclosures
• There will be a strong bias towards ORIF alone
• At STC THA used sparingly in specific patients
– Part of a randomized trial ORIF vs ORIF +THA
– Dome Impaction or
– Posterior wall or
– Femoral head impaction
• Percutaneous fixation also works well
– Less used at our center, but use growing
11/18/2015
2
• Dome Impaction
• Dome Impaction
• Quadrilateral Surface comminution
11/18/2015
3
• Dome Impaction
• Quadrilateral Surface comminution
• Anterior Fracture patterns predominate
• Dome Impaction
• Quadrilateral Surface comminution
• Anterior Fracture patterns predominate
• Osteopenia
Treatment Options-Displaced Fractures
• Non-operative
• Percutaneous
• Limited ORIF
• Standard ORIF
• ORIF+ THA
Increasing Invasiveness
11/18/2015
4
Non-Operative Treatment of Displaced Fractures
• Acceptable option for:
– Patients who are not community ambulators
– Patients with dementia
– Patients with severe medical co-morbities
• Caveats:
– Usually requires 2-3 months of non-weight bearing
– Difficult to manage unstable posterior wall fractures non-operatively
11/18/2015
5
Problems with Non-operative Treatment
• Patient is non-weight bearing for several months
• They probably have more pain
• This lack of mobility causes the standard problems with stasis
– UTI
– Pressure Sores
– Deconditioning
What if they develop arthritis?
• They have been immobile and deconditioned for months
• Now they need a THA and the whole process starts over again
• Ends up being a long convalescence
11/18/2015
6
Open Reduction and Internal Fixation
11/18/2015
7
ORIF
• Good reduction shows the best chance of avoiding a later THA
• Can be sometimes accomplished with percutaneous fixation or less invasive approaches
• Long history of ORIF for acetabular fracture
Challenges in this Population
• Femoral Head medialization
– Quadrilateral surface comminution
• Dome Impaction
• Increased EBL can be a problem
11/18/2015
8
11/18/2015
9
11/18/2015
10
11/18/2015
11
11/18/2015
12
View from Stoppa
View from lateral window
Surgeons positioned on patient’s left to repair right
acetabular fracture
Rectus fascia
Malleable protecting bladder
Right
Left
11/18/2015
13
Patient Right
Foot
Patient Left
Malleable retracting bladder
Iliac Vein
Corona Mortis
11/18/2015
14
Fascia over
obturator
internus
Pelvic brim
Cobb
elevating
Iliopectineal
fascia
Pelvic Brim
Pelvic Brim
Quadrilateral Surface
Malleable
retracting
obturator
internus
11/18/2015
15
Quadrilateral
SurfaceMalleable retracting obturator
internus muscle
Iliac Fossa
Greater Sciatic Notch
Quadrilateral Surface
11/18/2015
16
Quadrilateral Surface
Retractor in
Greater Sciatic
Notch
Iliac Fossa
11/18/2015
17
11/18/2015
18
11/18/2015
19
11/18/2015
20
11/18/2015
21
11/18/2015
22
11/18/2015
23
11/18/2015
24
11/18/2015
25
Problems with ORIF
• Failure rate fairly high for ORIF of geriatric fractures—25-30%
– Helfet
– O’Toole
– Matta
• And this 25-30% failure rate was just the patients who actually came to THA
– Did not include patients doing poorly who did not get further surgery
Posterior Wall Component
Dome Impaction
11/18/2015
26
Dome Impaction
Dome Impaction
Femoral Head Fracture
11/18/2015
27
Femoral Head Fracture
Geriatric Acetabulum
• In active elderly patients with fracture patterns at high risk for failure
– What about acute ORIF +THA in the same surgery
– Is this a reasonable strategy?
Combined ORIF + THA
Posterior (Kocher) Approach
11/18/2015
28
Restore Posterior Column and Wall
Restore Posterior Column and Wall
11/18/2015
29
Head Foot
Troch
Cobra in
Lesser
Notch
Hip
Capsule
Head Foot
Troch
11/18/2015
30
THA Alone in Posterior Wall Fractures
• Isolated posterior wall fracture
• AIIS and Ischium Intact
• No transverse fracture line present
• Wedge cup between AIIS and Ischium
11/18/2015
31
Wedge cup between AIIS and Ischium
AIIS
Ischium
THA Alone in Posterior Wall Fractures
• Ignore and impaction graft Anterior and posterior wall defect
• Less surgical time
• Can be done through a Hardinge or Direct Anterior approach
– Exploit the stability present with these approaches
Hoppenfeld, Surgical Exposures in Orthopaedics
11/18/2015
32
11/18/2015
33
11/18/2015
34
11/18/2015
35
11/18/2015
36
11/18/2015
37
Anterior Fracture Patterns
Combined ORIF + THA
Levine (Extended Smith-Petersen)
Approach
Beaule, Matta et al, JOT 2004
11/18/2015
38
Beaule, Matta et al, JOT 2004
View from lateral window
11/18/2015
39
ASIS
Foot
Head
TFL
Foot ASIS
11/18/2015
40
11/18/2015
41
HEAD
11/18/2015
42
HEAD
TFL
FASCIAASIS
HEAD
TFLASIS
Iliac
Crest
HEAD
TFLASIS
11/18/2015
43
HEAD
Inguinal
Ligament
ASIS
HEAD
Rectus
Muscle
TFL
ASIS
HEAD
ASIS
Iliac
Fossa
11/18/2015
44
Patient’s
Head
Femoal
Head
Iliac
Fossa
ASIS
11/18/2015
45
11/18/2015
46
11/18/2015
47
11/18/2015
48
11/18/2015
49
Head
ASIS
Head
Iliac
Fossa
ASIS
Acetabulum
Iliac Fossa
11/18/2015
50
Patient’s
Head
Femoal
Head
Iliac
Fossa
ASIS
Acetabulum
Iliac Fossa
11/18/2015
51
11/18/2015
52
11/18/2015
53
11/18/2015
54
11/18/2015
55
11/18/2015
56
AIIS
Ischium
Thanks To
• Chris Lebrun MD
• Jason Nascone MD
• Robert O’Toole MD
• Andy Pollak MD
• Marcus Sciadini MD
• Cliff Turen MD
• Andy Eglseder MD
• Chris Boulton MD
• Ray Pensy MD
• Jide Tinubu MD
• Gerard Slobogean MD
11/18/2015
57
Thank You