Courtesy: Prof Nabil Ebraheim, University of Toledo, Ohio, USA

Overview

Selection of the surgical approach in acetabular fractures depends on multiple factors:

Key Determinants

• Location of the fracture within the acetabulum
• Fracture pattern and classification
• Degree of displacement
• Complexity of fracture fragments

Principle

An appropriate approach should:

• Provide adequate exposure for reduction and fixation
• Minimize soft tissue damage and complications

---

Posterior Approach

---

Indications

The posterior approach is preferred for fractures involving posterior acetabular structures:

• Posterior wall fractures
• Posterior column fractures
• Combined posterior wall + posterior column fractures
• Posterior wall fractures with transverse patterns
• Selected low transverse fractures

---

Surgical Considerations

• Provides excellent visualization of posterior structures
• Can be extended with:
  • Anterior approach
  • Trochanteric osteotomy

---

Sliding Trochanteric Osteotomy

• Enhances exposure of:
  • Acetabular dome
  • Superior joint surface

---

Complications

1. Sciatic Nerve Injury

• Requires meticulous protection during dissection

2. Limited Anterior Exposure

• Anteriorly displaced fractures may not be adequately visualized

3. Femoral Head Vascular Compromise

• Avoid excessive capsular damage
• Preserve ~1 cm capsular cuff

---

Sciatic Nerve Protection

• Keep the knee flexed to reduce tension
• Especially important during traction

---

Retractor Placement

• Retractor may be placed in the greater sciatic notch
• Obturator internus muscle acts as a protective buffer

---

Anatomical Relationships

• Sciatic nerve lies:
  • Posterior to obturator internus
  • Anterior to piriformis

---

Anterior Approach

---

Indications

Used for fractures involving anterior acetabular structures:

• Anterior wall fractures
• Anterior column fractures
• Both column fractures
• High transverse fractures
• Associated anterior column + posterior hemi-transverse fractures

---

Surgical Windows

The anterior approach typically involves three windows:

---

1. Medial Window

Contents

• Spermatic cord (male) / round ligament (female)
• Ilioinguinal nerve

Risk

• Inadequate closure ? postoperative hernia

---

2. Middle Window

Contents

• External iliac vessels
• Corona mortis (variable vascular connection)

---

3. Lateral Window

Contents

• Iliopsoas muscle
• Femoral nerve
• Lateral femoral cutaneous nerve

Important

• All structures must be carefully protected

---

Iliopectineal Fascia

Anatomy

• Lies between middle and lateral windows

Surgical Step

• Incision along the pelvic brim

Benefit

• Improves communication between:
  • True pelvis
  • False pelvis
• Enhances visualization and reduction

---

Important Risks

1. Lateral Femoral Cutaneous Nerve Injury

• Leads to sensory disturbance over lateral thigh

---

2. Abdominal Wall Hernia

• Due to improper muscle closure

---

3. Corona Mortis Injury

Characteristics

• Vascular connection between:
  • Internal iliac system
  • External iliac / inferior epigastric vessels
• Located on superior pubic ramus
• Typically 3–7 cm from pubic symphysis

Clinical Significance

• Injury can cause severe, difficult-to-control bleeding

---

Management of Transverse Fractures

• High transverse fractures ? Usually anterior approach
• Low transverse fractures ? May be treated via posterior approach

---

Combined Surgical Approaches

---

Indications

Used for complex fracture patterns involving both columns:

• T-shaped fractures
• Combined anterior and posterior injuries

---

Rationale

• Allows complete visualization and reduction of both components

---

Extended Surgical Approaches

---

Types

• Extended iliofemoral approach
• Triradiate trans-trochanteric approach

---

Indications

• Severe or highly complex fractures
• Need for extensive visualization of:
  • Both columns
  • Acetabular dome

---

Complications

1. Gluteal Muscle Necrosis

• Due to compromised blood supply

2. Heterotopic Ossification (HO)

• Increased risk with extensive dissection

---

Muscle Consideration

• Gluteus medius and minimus remain attached mainly via:
  • Superior gluteal vessel pedicle

---

Heterotopic Ossification (HO)

---

Risk

• Higher in extended approaches

---

Prevention Strategies

• Low-dose radiation therapy (within 72 hours post-op)
• Indomethacin therapy (~6 weeks)

 Complete prevention is not always possible

---

Preference for Dual Approaches

Many surgeons prefer separate anterior and posterior approaches over extended approaches.

---

Advantages

• Reduced soft tissue damage
• Lower risk of heterotopic ossification
• Better control of individual fracture fragments

---

Safe Screw Placement

---

Concern

• Certain regions of acetabulum are danger zones

Risk

• Intra-articular screw penetration

---

Precautions

• Use multiple fluoroscopic views
• Consider direct visualization

---

Fixation of Posterior Wall Fractures

---

Techniques

• Buttress plates
• Hook plates

---

Special Situation: Marginal Impaction

• Elevate impacted fragment
• Fill defect with bone graft

---

Soft Tissue Injuries in Acetabular Trauma

---

Morel-Lavallée Lesion

Definition

• Closed degloving injury
• Separation of:
  • Skin and subcutaneous tissue
  • From underlying fascia

---

Common Locations

• Pelvis
• Greater trochanter region

---

Clinical Importance

• Frequently associated with high-energy trauma

---

Surgical Concern

• Increased risk of infection
• Up to 30% of operative sites may be colonized

---

Key Takeaways

• Approach selection is fracture-specific
• Posterior– posterior structures
• Anterior– anterior structures
• Complex fractures — may require combined or extended approaches
• Careful handling of:
  • Neurovascular structures
  • Soft tissues
  • Screw placement