Surgical Approaches to the Acetabulum and Modifications in Technique

Comparative cadaveric study of the Kocher-Langenbeck approach with and without trochanteric osteotomy in extended posterior wall fractures of the acetabulum

INTRODUCTION

Standard exposure, such as the Kocher-Langenbeck (KL) approach, has a limited ability to access the cranial and anterior portions of the posterior wall with an extended fracture line into the acetabular dome. Augmentation of the KL approach with trochanteric osteotomy (TO) enhances the exposure in this area. We compared the area of surgical exposure in the KL approach with and without additional TO and identified the most anterior exit point of the posterior wall in each surgical approach.

MATERIALS AND METHODS

Ten fresh cadaveric hip specimens were used. The KL approach was initially used for each specimen, followed by additional TO. Surgical exposures were marked, and measurements were taken for anterior and cranial exposure distances, surface area of bony exposure, and posterior wall arc angle (PWAA).

RESULTS

TO significantly increased the anterior exposure distance (65.83 vs. 49.07 mm) and acetabular surface area (43.95 vs. 33.51 cm2) compared to the KL approach alone. PWAA was also significantly higher in the TO group (52.55° vs. 27.63°), indicating enhanced anterior exposure. However, the increase in cranial exposure distance was not statistically significant.

CONCLUSION

The KL approach with TO significantly improved surgical exposure for posterior wall acetabular fractures, especially in the anterior regions. For fractures with a PWAA of 0º-27º, the KL approach alone (in the prone or lateral decubitus positions) is sufficient. If the PWAA is between 27º and 52º, the KL approach in the lateral decubitus position is recommended, with TO planned, if necessary. For fractures with a PWAA greater than 52º, the KL approach with additional TO in the lateral decubitus position is recommended.

LEVEL OF EVIDENCE

IV, cadaveric study.

Iatrogenic Sciatic Nerve Injury in Posterior Acetabular Surgery: Surgeon More Predictive Than Position

OBJECTIVES

To identify factors that contribute to iatrogenic sciatic nerve palsy during acetabular surgery through a Kocher-Langenbeck approach and to evaluate if variation among individual surgeons exists.

METHODS

DESIGN

Retrospective cohort.

SETTING

Level I trauma center.

PATIENT SELECTION CRITERIA

Adults undergoing fixation of acetabular fractures (AO/OTA 62) through a posterior approach by 9 orthopaedic traumatologists between November 2010 and November 2022.

OUTCOME MEASURES AND COMPARISONS

The prevalence of iatrogenic sciatic nerve palsy and comparison of the prevalence and risk of palsy between prone and lateral positions before and after adjusting for individual surgeon and the presence of transverse fracture patterns in logistic regression. Comparison of the prevalence of palsy between high-volume (>1 patient/month) and low-volume surgeons.

RESULTS

A total of 644 acetabular fractures repaired through a posterior approach were included (median age 39 years, 72% male). Twenty of 644 surgeries (3.1%) resulted in iatrogenic sciatic nerve palsy with no significant difference between the prone (3.1%, 95% confidence interval [CI], 1.9%-4.9%) and lateral (3.3%, 95% CI, 1.3%-8.1%) positions (P = 0.64). Logistic regression adjusting for surgeon and transverse fracture pattern demonstrated no significant effect for positions (odds ratio 1.0, 95% CI, 0.3-3.9). Transverse fracture pattern was associated with increased palsy risk (odds ratio 3.0, 95% CI, 1.1-7.9). Individual surgeon was significantly associated with iatrogenic palsy (P < 0.02).

CONCLUSIONS

Surgeon and the presence of a transverse fracture line predicted iatrogenic nerve palsy after a posterior approach to the acetabulum in this single-center cohort. Surgeons should perform the Kocher-Langenbeck approach for acetabular fixation in the position they deem most appropriate, as the position was not associated with the rate of iatrogenic palsy in this series.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of Obturator Vessel Hemorrhage by Pubic Ramus Osteotomy During Acetabular Fixation-A Technical Trick

SUMMARY

It is known that hemorrhage from pelvic ring and acetabular fractures can cause hemodynamic instability. Methods to improve visualization and thus management of bleeding vessels are not commonly described. This report highlights techniques to manage hemorrhage from a retracted obturator vein during the definitive fixation of a complex acetabular fracture. After uncomplicated modified Stoppa anterior intrapelvic approach, abrupt and profuse bleeding was encountered from the distal end of a lacerated obturator vein, which had retracted into the obturator foramen. With unsuccessful attempts to achieve hemostasis, a superior pubic osteotomy was performed which allowed excellent visualization of the bleeding vein and ligation. It must be emphasized that the surgeon attempted all these other measures before performing an osteotomy. This technical trick contributes to the overall knowledge as a means of achieving emergent hemostasis associated with distal obturator vessel hemorrhage, a well described risk in complex acetabular fractures.

[Imaging examination procedures, navigation and minimally invasive procedures in acetabular surgery]

Acetabular fractures still pose a special challenge even today. Considering the increasing case numbers, especially in the geriatric patient group, modern imaging examination procedures represent an essential pillar of the diagnostics. Especially in this vulnerable patient group, minimally invasive methods are necessary, which can be guaranteed by intraoperative navigation; however, the choice of surgical access and implants is also made based on the existing morphological characteristics of fractures, which highlights the importance of an imaging modality that is as detailed as possible. Last but not least, new developments concerning the surgical treatment of these injuries are also based on this. This article summarizes the current state of the techniques and the available literature.

Treatment of Delayed Acetabular Fractures by Periacetabular Osteotomy through the Lateral-Rectus Approach

OBJECTIVE

There has been a controversy in the surgical approach for delayed acetabular fracture. The objective of the present study is to investigate the feasibility, surgical techniques, safety, and efficacy of periacetabular osteotomy using the single lateral-rectus approach (LRA) for the surgical treatment of delayed acetabular fracture.

METHODS

The retrospective study included 22 patients (16 males and six females, with an average age of 45 years) with delayed acetabular fractures from June 2012 to June 2019. For all cases, periacetabular osteotomy was performed through the single LRA. Fracture classification, mechanism of injury, associated injury, time to surgery, operation time, intraoperative blood loss, and complications were recorded and analyzed. The quality of the reduction was assessed based on Matta radiographic criteria. Potential impact factors affecting the quality of reduction were analyzed. Functional outcome was evaluated at the final follow-up according to a modified Mere D'Aubigne-Postel scoring system for each patient.

RESULTS

All patients were followed up for at least 12 months. The duration of surgery was 140 min on average (110-205 min) and the mean intraoperative blood loss was 1250 ml (500-2100 ml). According to Matta radiographic criteria, the accuracy of reduction was "anatomical" in seven patients, "imperfect" in 11 patients, and "poor" in four patients, with an excellent and good rate of 81.8%. The time to surgery in poor reduction group was significantly longer than anatomical or imperfect reduction group (p < 0.05). All the acetabular fractures united after 8-12 weeks. The average modified Merle D'Aubigne-Postel score evaluated at the final follow-up was 14.6 (6-18), and the clinical outcomes were rated as excellent in six patients, good in 10 patients, fair in four patients, and poor in two patients, with an excellent and good rate of 72.7%. There were two cases of osteonecrosis of the femoral head (9%). No other complication was found for all cases.

CONCLUSION

The LRA is an effective and minimally invasive approach in the treatment of delayed acetabular fractures excluding posterior wall fracture and posterior dislocation.

Posterior wall fractures of the acetabulum: treatment using an anatomical plate through direct posterior approach

OBJECTIVES

This study was aimed to measure the application of W-shaped acetabular angular plate (WAAP) through direct posterior approach (DPA) on the reconstruction of acetabular posterior wall fractures when compared with reconstruction plates.

PATIENTS AND METHODS

A retrospective study was performed on patients treated with the WAAP or reconstruction plates via the DPA. The intraoperative data of operative time, blood loss and radiation exposure times were recorded. Radiographs of the pelvis and CT scan were obtained within one week post-operation to assess the reduction quality. The clinical outcome was evaluated by the modified Merle d'Aubigne and Postel score.

RESULTS

From May 2016 to October 2019, a total of 41 patients with simple acetabular posterior wall fractures were included in this study, 22 from the WAAP group and 19 from the reconstruction plates group. There were no significant differences between the two group in age, gender, time from injury to operation, cause of injuries, length of incision and follow-up time (P > 0.05). In comparison with the reconstruction plates group, the average operation time of the WAAP group was significantly shorter (46.1 ± 12.7 min vs 59.2 ± 17.4 min, P < 0.05), the average radiation exposure times were significantly less (2.3 ± 0.6 vs 3.6 ± 1.0, P < 0.001), the average blood loss was significantly less (240 ± 98.9 ml vs 301.1 ± 66.6 ml, P < 0.05). According to Matta radiology criteria and the modified Merle d' Aubigne and Postel score, no significant difference was observed between the two group, as for the quality of reduction and function outcomes.

CONCLUSION

The application of WAAP through DPA showed satisfactory preliminary clinical outcomes, showing promise to be an alternative technique for the treatment of acetabular posterior wall fractures.

The Short- and Mid-term Follow-Up of Single-Column Fixation in Transverse and Posterior Wall Acetabular Fractures

OBJECTIVE

To evaluate the radiological and clinical outcomes of the surgical treatment for transverse and posterior wall fractures using single-column posterior fixation.

METHODS

From January 2009 to January 2018, a total of 24 patients with transverse and posterior wall acetabular fractures in our center were included in this retrospective study, including 17 males and seven females with a mean age of 47 years and a minimum follow-up of 1 year. All cases were closed fractures. All fractures were fixed with single-column fixation via the Kocher-Langenbeck approach. Primary outcome measures, including quality of reduction and clinical outcomes, were recorded by an independent observer, who also noted secondary outcome measures, including time to surgery, surgical time, intraoperative blood loss, and postoperative complications.

RESULTS

Twenty-four patients (range, 26-74 years) included 17 males and seven females. There were 14 cases on the left side and 10 cases on the right side. The mean time from injury to surgery was 7.1 days. Mean intraoperative blood loss and surgical time were 405.4 mL and 135.8 min, respectively. The mean follow-up time was 29.5 months (range 12-96 months). All the acetabular fractures united within 5 months after surgery. The quality of reduction was graded as anatomical in 17 cases (70.8%), imperfect in three cases (12.5%), and poor in four cases (16.7%). According to grading system of Merle d' Aubigne and Postel, clinical outcomes at the final follow-up were excellent in 10 cases (41.7%), good in six cases (25.0%), fair in five cases (20.5%), and poor in three cases (12.5%). The excellent and good rate was 66.7%. There was a significant relation between the quality of reduction and clinical outcomes (P < 0.05). At follow-up, there were one case of sciatic nerve injury, one case of wound infection, two cases of deep vein thrombosis, two cases of avascular necrosis, three cases of heterotopic ossification, and five cases of postoperative traumatic arthritis. Three of these patients underwent reoperation, including one with heterotopic ossification affecting hip movement and two with femoral head necrosis.

CONCLUSIONS

Our study shows that single-column posterior fixation of transverse and posterior wall acetabular fracture through the Kocher-Langenbeck approach can obtain satisfactory radiological and clinical outcomes if there is adequate indirect reduction of the anterior column.

Predicting the disaster - The role of CRP in acetabular surgery

OBJECTIVES

Acetabular fractures represent a complex surgical challenge. Given the heterogenous fracture pattern, the patient characteristics and spectrum of complications demand individual solutions. Surgical site infections (SSI) threaten osteosynthesis, and early detection of them and treatment remain crucial. What is the value of postoperative C-reactive protein (CRP) in this group of patients as well as its normal course?

DESIGN & METHODS

115 patients with isolated fractures of the acetabulum were retrospectively evaluated. CRP, white blood cell count (WBC) and fracture patterns as well as patient characteristics were assessed for 20 days following operative fixation of the acetabular fracture (n = 71) and in fractures that were managed conservatively (n = 44).

RESULTS

Twelve patients suffered an infectious complication. With a one-phase decay, 70.55% of the variance of postoperative CRP kinetics was predicted. To anticipate maximum CRP as well as an infection, the preoperative CRP represented the best prognostic parameter. To predict an infection, the single variable "peak CRP value above 100 mg/l" resulted in a sensitivity and specificity of 91.67% and 36.21%, respectively. Combining a second peak of CRP with maximum CRP and day 5 CRP value for receiver-operating characteristic (ROC) analysis resulted in 83.3% and 88.1%, respectively.

CONCLUSIONS

Predicting surgical site infections after an acetabular fracture is most predictive when analyzing the maximum overall CRP, the second peak and the CRP after day 5. With a combination of these parameters, a sensitivity and specificity of 83.3% and 88.1% to detect an infection was achieved.

Modified Stoppa Approach: Beyond Acetabular Fractures: A Report of 2 Cases

CASES

We used the modified Stoppa approach in a 17-year-old man with a retained bullet in his acetabular fossa. The acetabular hole was used to irrigate the hip joint. We also used this approach in a 29-year-old woman with right hip pain and limping to remove an isolated tenosynovial giant cell tumor ("localized pigmented villonodular synovitis") in the acetabular fossa expanding through the acetabulum.

DISCUSSION

We believe that this approach should become more familiar because it offers a simple alternative for treating acetabular pathologies mainly involving the acetabular fossa, sparing patients the hazards of capsulotomy, trochanteric osteotomy, dislocation, and traction and fluid pressure in hip arthroscopy.

Medium-Term Patient-Reported Quality of Life and Activities of Daily Living in Surgically Treated Trauma Patients With Pelvic, Acetabular or Combined Pelvic and Acetabular Fractures in a Retrospective Single-Center Study

OBJECTIVE

To gain more insights in the medium-term patient-reported quality of life (QoL), activities of daily living (ADL), and number of complications in trauma patients with an acetabular fracture (AF), a pelvic fracture (PF), and those with a surgically combined pelvic and AF (PAF).

DESIGN

Retrospective single-center study.

SETTING

Level I academic trauma center.

PATIENTS/PARTICIPANTS

51 trauma patients with PF, AF, or PAF who were surgically treated between 2014 and 2017.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures are patient-reported outcome questionnaire, which includes 2 items, the QoL, as measured with the Short Form-12, and the ADL, as measured with the Lower Extremity Functional Scale. The secondary outcome parameter was the occurrence of complications during a follow-up of at least 2 years.

RESULTS

The mean physical component score (PCS) of the QoL (P = 0.03) and the ADL (P = 0.03) were significantly higher in patients with AF compared with patients with PF. The incidence of the overall postoperative complications did not significantly differ between the PF, AF, and PAF groups (P = 0.28).

CONCLUSIONS

This study found that the PCS of the QoL and the ADL in surgically treated trauma patients with PF were significantly lower compared with patients with AF. No significant differences were found in overall complication rate between the PF, AF, and PAF groups.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Why Make the Cut? Trochanteric Slide Osteotomy Can Improve Exposure to the Anterosuperior Acetabulum

OBJECTIVE

To define relative increases in visual bony surface area and access to critical landmarks with the addition of a trochanteric slide osteotomy to a Kocher-Langenbeck approach.

METHODS

A Kocher-Langenbeck approach followed by a trochanteric slide osteotomy was sequentially performed on 10, fresh-frozen, hemipelvectomy cadaveric specimens. Visual and palpable access to relevant surgical landmarks was recorded. Calibrated digital photographs were taken of each approach and analyzed using Image J.

RESULTS

The acetabular surface area exposed was 27.66 (±6.67) cm2 for a Kocher-Langenbeck approach. This increased to and 41.82 (±7.97) cm2 with the addition of a trochanteric osteotomy. The exposed surface area was increased by 51.2% for the trochanteric osteotomy (P < 0.001). The superior margin of the acetabulum could be visualized and palpably accessed in both exposures. Access to the more anterosuperior portions of the acetabulum was consistently possible in the trochanteric osteotomy but not with the Kocher-Langenbeck approach.

CONCLUSIONS

A trochanteric osteotomy may visually improve access to the most anterosuperior acetabulum but does not significantly improve surgical access to relevant portions of the superior acetabulum when compared with a Kocher-Langenbeck approach.

Risk of Injury to the Neurovascular Structures in the Pararectus Approach Used in Acetabular Fractures: A Cadaver Study

OBJECTIVES

Complex acetabular fractures involving the quadrilateral plate may necessitate infrapectineal buttress plating, which can be performed through the pararectus approach. The aim of this cadaveric study was to identify the anatomical guide points to protect neurovascular structures at the risk of injury during the pararectus approach.

METHODS

Six fresh frozen cadavers (12 hemipelves) were dissected in this study. Location of the inferior epigastric artery (IEA), obturator nerve and corona mortis (CM) was measured using common anatomic landmarks, namely, anterior superior iliac spine, symphysis pubis (SP), and sacroiliac (SI) joint.

RESULTS

In the superficial dissection of the abdominal wall, the mean distance between the IEA and anterior superior iliac spine was 106.7 ± 5.2 (range, 99.2-116.4) mm, and the mean distance between IEA and SP was 77.9 ± 3.5 (range, 70.6-82.2) mm. In deep dissection, the mean distance between the SI joint and the SP was 133.1 ± 5.7 (range, 126.0-142.0) mm. The mean distance between the SI joint and ON was 37.3 ± 2.8 (range, 31.0-41.0) mm. The CM was unable to be detected in 2 cadavers, 1 on the right and 1 on the left hemipelves. The mean distance between the CM and SP was 47.7 ± 3.9 (range, 43.0-55.0) mm.

CONCLUSIONS

A pararectus approach is a useful approach which allows infrapectineal plating in the treatment of complex acetabular fractures; however, the preservation of critical neurovascular structures is essential during dissection. This study is helpful to identify the structures at risk according to commonly used anatomic landmarks. These data might be a necessary guideline for hip and trauma surgeons.

Fractures of the acetabulum: from yesterday to tomorrow

Purpose

The aim of this article is to present history, state of the art, and future trends in the treatment of acetabular fractures.

Methods

Review of recent and historical literature.

Results

Acetabular fractures are difficult to treat. The first descriptions of this injury already appeared in ancient Greek history, but intensive development started in the second half of the twentieth century after Judet and Letournel’s seminal work. Their classification is still the gold standard today. It is actually a pre-operative planning system and is used to determine the most appropriate surgical approach. The therapy of choice for dislocated fractures is open reduction and internal fixation. Recent modern techniques based on high-tech computerized planning systems and 3D printing have been successfully integrated into orthopaedic trauma practice.

Conclusion

There is no ideal surgical approach for acetabulum fracture treatment, so new approaches have been developed in recent decades. The best outcome series have shown good or excellent results, between 70 and 80%.

Combined Anterior Pelvic (CAP) approach for fracture acetabulum fixation - Functional outcome evaluation and predictors of outcome

OBJECTIVE

Ilio-inguinal approach has been considered standard anterior approach for acetabulum fracture fixation. Different modifications of this approach have been described. This study analysed the patients treated using a Combined Anterior Pelvic (CAP) approach - minimal AIP (anterior intra-pelvic) with modified ilio-femoral along with 'anterior superior iliac spine' osteotomy. This combined approach provides wide exposure of pelvis to direct visualise the entire anterior column from sacroiliac joint to pubic symphysis, medial side of quadrilateral plate and entire iliac wing with minimal retraction of soft tissues required.

METHODS

Data of patients treated from July 2014 to June 2018 for acetabulum fracture using CAP approach was retrieved from hospital record system. Inclusion criteria were - acetabulum fractures treated surgically using CAP approach. Exclusion criteria were - age less than 18 years, associated pelvis ring injury and incomplete peri-operative radiological record (pre-operative/post-operative antero-posterior, 45° obturator and 45° iliac oblique radiographs and pre-operative computed tomographic (CT) scans. 62 patients who met inclusion exclusion criteria were called in out-patient-department for final functional evaluation using Matta modified Merle d'aubigne score.

RESULTS

Out of 62 patients 47 patients who turned up for final functional evaluation were included in study. 19 patients had excellent, 15 had good, 2 had fair and 11 had poor results. Age less than 40 years, anterior column fracture pattern, Pre-operative fracture displacement >20 mm, fracture comminution and post-operative fracture reduction within 3 mm were the predictors of the functional outcome. When analysed using logistic regression model, post-operative fracture reduction was found to be the only significant predictor of functional outcome.

CONCLUSION

CAP approach is useful anterior approach to acetabulum. Fracture reduction is the independent predictor of functional outcome. Comparison of this approach with other anterior approaches to acetabulum can be area of further research.

Impact of closed suction drainage after surgical fixation of acetabular fractures

INTRODUCTION

The purpose of the present study was to evaluate the prevalence of closed suction drainage after a Kocher-Langenbeck (K-L) approach for surgical fixation of acetabular fractures and to determine the impact of closed suction drainage on patient outcomes.

METHODS

This retrospective study reports on 171 consecutive patients that presented to a single level I trauma center for surgical fixation of an acetabular fracture. Medical records were reviewed to evaluate the use of closed suction drains. The primary outcomes measures were rate of packed red blood cell (PRBC) transfusion and length of hospital stay (LOS). Secondary outcome measures were 30-day post-operative wound complication and 1-year deep infection rates.

RESULTS

Of the 171 patients included in this study, 140 (82%) patients were treated with drains. There was a significant association between the use of closed suction drainage and post-operative blood transfusion rate (p = 0.002). Thirty-five patients (25%) treated with drains required a post-operative blood transfusion compared to 0% in the no drain cohort. Regarding the total number of drains used, for every additional closed suction drain that was placed beyond a single drain, the odds of receiving a blood transfusion doubled (p = 0.002). Use of closed suction drainage was associated with a significantly longer LOS (p = 0.015), and no difference in wound complication or deep infection rates.

CONCLUSION

The use of closed suction drains for treatment of acetabular fractures using a K-L approach is associated with increased rates of blood transfusion and increased length of hospital stay, with no impact on surgical site infection rates. The results of this study suggest against routine drain usage in acetabular surgery.

Imaging Acetabular Fractures

Acetabular fractures are encountered by radiologists in a wide spectrum of practice settings. The radiologist's value in the acute and long-term management of acetabular fractures is augmented by familiarity with systematic computed tomography-based algorithms that streamline and simplify Judet-Letournel fracture typing, together with an appreciation of the role of imaging in initial triage, operative decision making, postoperative assessment, prognostication, and evaluation of complications. The steep increase in incidence of acetabular fractures in the elderly over the past several decades places special emphasis on familiarity with geriatric fracture patterns.

Treatment of intra-articular hip malignancy with extra-articular resection, preservation of the acetabular columns, and total hip arthroplasty

Intra-articular malignant lesions of the hip present significant challenges. Resection often requires large resection of the acetabular bone and pelvic columns. Concurrent reconstruction options after intra-articular hip tumors are challenging and may necessitate the use of techniques and implants with uncertain long-term survivorship. We present a case of an intra-articular hip malignancy with extra-articular resection and preservation of the acetabular columns with reconstruction using a cementless acetabular shell fixed with screws.

[Comparison of effectiveness between two combined anterior and posterior approaches for complicated acetabular fractures]

Objective

To compare the effectiveness between modified ilioinguinal approach combined with Kocher-Langenbeck (K-L) approach and Stoppa approach combined with K-L approach for the treatment of complicated acetabular fractures.

Methods

Between May 2011 and May 2016, Sixty-two patients with complicated acetabular fractures were treated with operation via combined anterior and posterior approaches. Thirty-four cases (group A) were treated with modified ilioinguinal approach combined with K-L approach, and 28 cases (group B) were treated with Stoppa approach combined with K-L approach. There was no significant difference in gender, age, injury causes, the type of fracture, time from injury to operation, and associated injury between 2 groups ( P>0.05). The operation time, intraoperative blood loss, and hospitalization time were recorded. X-ray film was performed to evaluate the fracture reduction according to the Matta reduction criteria and observe the fracture healing, osteoarthritis, and heterotopic ossification. Clinical results were evaluated according to the grading system of modified d'Aubigne and Postel.

Results

There was no significant difference in operation time, intraoperative blood loss, and hospitalization time between 2 groups ( P>0.05). Postoperative incision fat liquefaction occurred in 2 cases in group A and group B respectively, and deep vein thrombosis of lower extremity occurred in 1 case in group A. No iatrogenic injury was found in 2 groups. Fifty-six patients were followed up after operation. Thirty patients in group A were followed up 12-48 months (mean, 31.8 months). Twenty-six patients in group B were followed up 12-46 months (mean, 30.2 months). At 12 months after operation, according to the grading system of modified d'Aubigne and Postel, the hip function was rated as excellent in 9 cases, good in 16 cases, fair in 3 cases, and poor in 2 cases, with the excellent and good rate of 83.3% in group A; the hip function was rated as excellent in 7 cases, good in 14 cases, fair in 2 cases, and poor in 3 cases, with the excellent and good rate of 80.8% in group B. There was no significant difference in the hip function between 2 groups ( Z=0.353, P=0.724). The X-ray films showed that there were 23 cases of anatomical reduction, 6 cases of satisfactory reduction, and 1 case of unsatisfactory reduction in group A, and 20 cases, 5 cases, and 1 case in group B, respectively. There was no significant difference in the results of fracture reduction between 2 groups ( Z=0.011, P=0.991). Fracture healing was observed in both groups. There was no significant difference in fracture healing time between 2 groups ( t=0.775, P=0.106). During follow-up, 5 cases of osteoarthritis changes, 2 cases of heterotopic ossification, and 2 cases of avascular necrosis of femoral head occurred in group A, and 4 cases, 2 cases, and 1 case in group B, respectively. The difference between 2 groups was not significant ( P>0.05).

Conclusion

According to the location and type of fracture, making a choice between the modified anterior approach and Stoppa approach, and then combined with K-L approach for treatment of complicated acetabular fracture, can obtain satisfactory effectiveness.

The Ilioinguinal Approach: State of the Art

INTRODUCTION

The ilioinguinal approach is the standard approach for the open reduction and internal fixation of the majority of displaced, anteriorly based acetabular fractures as it offers wide access to the acetabulum, is extensile, and has been associated with enhanced recovery.

INDICATIONS & CONTRAINDICATIONS

STEP 1 PREOPERATIVE PLANNING

Review the patient's general condition and imaging studies and plan the sequence of reduction and fixation.

STEP 2 PREPARATION AND PATIENT POSITIONING

Position the patient supine on the fracture table, induce anesthesia, prepare the surgical field, administer intravenous antibiotics, and apply traction.

STEP 3 ILIOINGUINAL APPROACH

Make a long curvilinear incision over the affected lower flank, develop the 3 working windows, and reduce and stabilize the fracture while protecting the neurovascular structures and the bladder (Video 2).

STEP 4 FRACTURE REDUCTION AND FIXATION

For reduction of a both-column acetabular fracture, connect the mobile parts of the acetabulum to the iliac segment that is attached to the sacrum, noting that, in most cases, the usual sequence involves the reduction of the anterior column to the intact ilium followed by the reduction of the posterior column (Video 7).

STEP 5 WOUND CLOSURE AND POSTOPERATIVE AFTERCARE

Perform meticulous hemostasis, apply drains, and ensure watertight closure, which are the final steps of the operation (Video 8).

RESULTS

The ilioinguinal approach remains 1 of the standard approaches for the management of acetabular fractures10.

PITFALLS & CHALLENGES

The Kocher-Langenbeck Approach: State of the Art

Introduction

The Kocher-Langenbeck approach is the workhorse for the reduction and fixation of hip fractures that require fixation via a posterior approach^1,2.

Indications & Contraindications

Step 1 Preoperative Planning

Review the patient's general condition and imaging studies, plan the sequence of reduction and fixation, and make sure that all of the necessary equipment is available.

Step 2 Preparation and Patient Positioning

Induce anesthesia, administer intravenous antibiotics as per local hospital protocol, apply antiembolism stockings, and insert a Foley catheter to the bladder.

Step 3 Kocher-Langenbeck Approach

Make an incision that is 15 to 20 cm long and has 2 parts (proximal and distal), which are centered over the greater trochanter.

Step 4 Fracture Reduction and Fixation

The reconstruction of posteriorly based fractures depends on the specific fracture type, and the goal is to provide stable column fixation and anatomical reconstruction of the acetabular articular surface, with column fixation performed before the reconstruction of the posterior wall.

Step 5 Wound Closure and Postoperative Care

Meticulous hemostasis, application of drains, and watertight closure are the final steps of the operation.

Results

The Kocher-Langenbeck approach is the workhorse for the surgical management of acetabular fractures and provides sufficient access to the majority of posterior based acetabular fractures¹⁵.

Pitfalls & Challenges

Are Readmissions After THA Preventable?

BACKGROUND

Readmissions after total joint arthroplasty have become a key quality measure in elective surgery in the United States. The Affordable Care Act includes the Hospital Readmission Reduction Program, which calls for reduced payments to hospitals with excessive readmissions. This policy uses a method to determine excess readmission ratios and calculate readmission payment adjustments to hospitals, however, it is unclear whether readmission rates are an effective quality metric. The reasons or conditions associated with readmission after elective THA have been well established but the extent to which readmissions can be prevented after THA remains unclear.

QUESTIONS/PURPOSES

(1) Are unplanned readmissions after THA associated with orthopaedic or medical causes? (2) Are these readmissions preventable? (3) When during the course of aftercare are orthopaedic versus medical readmissions more likely to occur?

METHODS

We retrospectively evaluated all 1096 elective THAs for osteoarthritis performed between January 1, 2011 and June 30, 2014 at a major academic medical center. Of those, 69 patients (6%) who met inclusion criteria were readmitted in our healthcare system within 90 days of discharge after the index procedure during the study period. Fifty patients were readmitted within 30 days of discharge after the index procedure (5%). We defined a readmission as any unplanned inpatient or observation status admission to the hospital spanning at least one midnight. A panel of physicians not involved in the care of these patients used available criteria and existing consensus guidelines to evaluate the medical records, radiographs, and operative reports to identify whether the underlying reason for readmission was orthopaedic versus medical. They subsequently were classified as either nonpreventable or potentially preventable readmissions, based on any care that may have occurred during the index hospitalization. To make such determinations, consensus specialty society guidelines were used whenever possible for each readmission diagnosis.

RESULTS

A total of 50 of 1096 patients (5% of those who underwent THA during the period in question) were readmitted within 30 days and 69 of 1096 (6%) were readmitted within 90 days of their index procedures. Thirty-one patients were readmitted for orthopaedic reasons (31/69; 45%) and 38 of 69 were readmitted for medical reasons (55%). Three readmissions (three of 69; 4%) were identified as potentially preventable. Of these potentially preventable readmissions, one was orthopaedic (hip dislocation) and two were medical. Thirty-day readmissions were more likely to be orthopaedic than 90-day readmissions (odds ratio, 4.06; 95% CI, 1.18-13.96; p = 0.026).

CONCLUSIONS

Using a panel of expert reviewers, available existing criteria, and consensus methodology, it appears only a small percentage of readmissions after THA are potentially preventable. Orthopaedic readmissions occur earlier during the postoperative course. Currently, existing policies and readmission penalties may not serve as valuable external quality metrics. The readmission rates in our study may represent the threshold for expected readmission rates after THA. Future studies should enroll larger numbers of patients and have independent review panels in efforts to refine criteria for what constitutes preventable readmissions.

LEVEL OF EVIDENCE

Level III, therapeutic study.