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