Download Acetabular Fractures in the Elderly

Acetabular Fractures
in the Elderly
Dr. Mustafa Nawaz
F.C.P.S ORTH
Registrar Orthopedics
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“I cannot teach any body anything ,
I can only make them think”.
-Socrates
Anatomy
Incomplete
hemispherical
socket with an
inverted
horseshoe-shaped
articular cartilage
surface
surrounding the
non-articular
cotyloid fossa.
Two column concept
Radiographic evaluation
Judet views
Matta Angle
TILES CASSIFICATION
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Tile's classification of acetabular
fracture:
I - Simple fracture, anterior or
posterior wall column
II – Transeverse fracture
III - T - Type fracture involving two
columns
IV - Both columns fractures, floating
acetabulum
J/L Classification
Patterns in elderly
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Increased involvement of the
anterior column,
quadrilateral plate comminution,
medialization of the femoral head,
marginal impaction
Preoperative anteroposterior pelvic radiograph demonstrating the
fracture with a so-called gull sign, representing superomedial dome
impaction (large black arrow) and quadrilateral plate
displacement (thin white arrow),
Epidemiology
In patients over the age of sixty,
there has been a 2.4-fold increase in
the incidence of ace tabular fractures
over the past quarter of a century.
Mechanism of injury
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Low-energy falls from a standing
height accounted for 50% (117) of
235 acetabular fractures in patients
over sixty years of age.
Only 30% (seventy) of 235 older
patients with an acetabular fracture
had associated injuries likely because
of decreased involvement in motor
vehicle collisions
Common #
The anterior column-posterior hemitransverse fracture pattern is the
classic osteopenic acetabular
fracture.
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Impact through the greater
trochanter results in an anteromedial force fracturing and displacing
the anterior column and quadrilateral
plate.
Femoral head medializes with the
anterior column and impacts the
postero-medial portion of the roof
Radiological evaluation
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X ray AP & Judet views
C T scan & 3 D reconstruction
MRI
Percentage of fractures
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Both column fracture 23-26 %
Anterior column with post
hemitranseverse # 15% to 19%.
Isolated anterior column 11-19 %.
Isolated posterior wall fractures 8% -13%
(marginal impaction 38% and fracture
comminution 44%).
Isolated posterior column fractures (0.4%
to 2%)
.
MANAGEMENT
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ER:ABC
Patient’s associated injuries, medical
history, ambulatory status, functional
demands, living situation, and
history of arthritic hip pain.
Vitamin D level.
Dexa scan
Future need of hip arthroplasty
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Age >45
Anterior dislocation
Posterior wall involvement
Femoral head cartilage impaction
fractures
Marginal impaction
Acetabular impaction
Initial articular displacement of >2
cm.
Non operative treatment
Historically poor result.
 Indicated in both column fracture
Criteria
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<2mm of displacement
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an intact roof arc angle of 45
 superior 10 mm of the subchondral ring intact on
CT
 posterior wall fractures involving <20% of the
posterior wall
 hip joint stability and congruity
 Medically unfit for surgery or functionally
incapacitated
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PROTOCOL
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Short period of bed rest for pain
control
Early mobilization with toe-touch
weight-bearing -6 weeks
Follow up 2,6,12 weeks
Poor prognostic factors
Open reduction and internal fixation
are
 Posterior wall comminution,
 Marginal impaction of the
acetabulum,
 Femoral head impaction fracture,
 Gull sign
 Hip dislocation.
Operative treatment
Anterior column:ilioinguinal approach
or the intrapelvic Stoppa approach.
 Posterior wall or isolated posterior
column:Kocher-Langenbeck approach
 Geriatric fractures: stoppa .
 Fracture fixation with arthroplasty
 Anterior approach.
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ORIF
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Disimpaction of medialized femoral head
Lateral window of ilioinguinal approach,
reduction and lag screw and/or plate
fixation of high anterior column fractures
Deformity correction: internal rotation of
the anterior column, and anti-glide plate
techniques
Without blocking the reduction of the
medial articular fragments or quadrilateral
plate.
ORIF
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Stoppa approach: hinge open the
quadrilateral plate and directly
reduce the impacted articular
fragments.
Quadrilateral plate can be reduced
using offset pelvic clamps or ballspike pushers with a spiked disc
attachment
Percutaneous fixation
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Needs expertise
Flouroscopic anatomy of pelvis
Helps in early mobilization
Contraindication
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Posterior wall fractures with hip joint
instability
Lack of expertise with percutaneous
column fixation.
Post op management
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DVT prophylaxis
Protected weight bearing 3 months
ORIF Out come
Conversion to THR
 22 % in ORIF
 25 % in Percutaneous
Acceptable reduction 86 %{ORIF}
Anatomic reduction 45 %{ORIF}
Acute THR
Poor prognostic factors
 Severe non-reconstructible comminution
 Femoral head lesions,
 Impaction fracture of >40% of the dome
 Femoral head and/or neck fractures
 Preexisting severe degenerative arthritis.
{Ref:Mears DC, Velyvis JH. Acute total hip
arthroplasty for selected displaced
acetabular fractures: two to twelve-year
results. J Bone Joint Surg Am. 2002
Jan;84(1):1-9.}
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Delayed THR
Osteoarthritis following ORIF /non-operative
treatment.
obstacles
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scarring
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heterotrophic bone
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retained hardware
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ace tabular deformity
 ace tabular nonunion
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potential quiescent infection
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osteonecrosis of the femoral head
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{ Sierra RJ, Mabry TM, Sems SA, Berry DJ. Acetabular
fractures: the role of total hip replacement. Bone Joint J.
2013 Nov;95-B(11)(Suppl A):11-6}
Summary
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Acetabulum fractures in elderly becomes
increasingly common
Advanced surgical skills
ORIF have acceptable outcomes
22 % conversion to THR
Poor prognostic factors :acute THR
Delayed THR : COMPLEX
{REF:THE JOURNAL OF BONE & JOINT SURGERY d JBJ S .ORG
VOLUME 97-A d NUMBER 9 d MAY 6, 2015}
Future research
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Low-energy, osteopenic fracture
patterns rather than chronologic age
to remove the existing heterogeneity
of fracture patterns in the literature.
THANK YOU
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Food Street, Lahore, Pakistan.