acetabular fractures surgical management kregor 2011
DESCRIPTION
manajemen bedah fraktur acetabularTRANSCRIPT
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
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SPECIAL CASE:EXTENDED POSTERIOR WALL
??? GANZ TROCHANTERIC FLIP OSTEOTOMY TO VISULIZE FRACTURE WITHOUT DEVITALIZING
ABDUCTORS
T.D. 00.02.01
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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
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TRANSTECTAL TRANVERSE ACETABULAR FX
18 Y.O. MALE
ISOLATED INJURY
SKINNY PATIENT / TREATED EARLY
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W.M. 00.01.12
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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 STAIRSWHAT 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 TABLEILIOINGUINAL APPROACH
NORMAL HIP AT 3 YEAR FOLLOW-UP
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SPURSIGN
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A.S.I.S.
SYMPHYSIS
EXT.OBL.
A.S.I.S.
EXT. INGUINAL RING
A.S.I.S.
L.F.C.N.
PSOAS
EXT.OBL.
EXT.OBL.
CONJOINT TENDON
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
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R.M. 98.08.24
R.M. 99.02.17
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H.S. 99.10.02
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NO SPUR SIGN
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
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