Clinical Orthopaedics and Related Research®

, Volume 471, Issue 12, pp 4056–4064

Surgical Dislocation Technique for the Treatment of Acetabular Fractures

  • Alessandro Masse
  • Alessandro Aprato
  • Luca Rollero
  • Andrea Bersano
  • Reinhold Ganz
Multimedia Article

Abstract

Background

Surgical hip dislocation allows for a 360° view of the acetabulum and may facilitate a reduction in selected acetabular fractures. To our knowledge there is no description in the literature of the different techniques used to reduce acetabular fractures through this approach. The aims of this study are to describe a technique of hip surgical dislocation to treat a variety of acetabular fracture patterns and to ascertain the early results with this technique, including the quality of fracture reductions achieved, clinical results, operative time, and complications such as avascular necrosis and heterotopic ossification.

Description of Technique

The procedure involves digastric trochanteric flip osteotomy and safe dislocation of the femoral head, preserving its vessels. T-type, transverse fractures alone or associated with posterior wall could be reduced with specific clamps and reduction adequacy can be judged by direct view. Anterior column fixation could be performed with one or two screws; the posterior column could be fixed with a single posterior plate or with two plates if a transverse fracture is associated with a posterior wall fracture.

Methods

Between 2005 and 2011, we used this approach selectively to manage those types of fractures; during the period in question, we treated 312 acetabular fractures surgically, of which 31 (10%) were treated using this approach. Patient demographic, injury, and surgical variables as well as complications were recorded. Outcomes were evaluated with the Merle d’Aubigné and Postel system. Radiographic outcome was scored according to Matta’s criteria on postoperative radiographs (AP and Judet views). Minimum followup was 24 months (mean, 43 months; range, 24–87 months).

Results

Fracture reduction was defined as anatomic in 65% cases, imperfect in 16%, and poor in 19%. Mean Merle d’Aubigné score was 15 points (out of 18, with higher scores being better). Two patients developed symptomatic femoral head avascular necrosis.

Conclusions

In complex cases, surgical dislocation presents several advantages; a single approach may reduce surgical time, permit direct intraarticular assessment, and facilitate screw placement closer to the articular surface. It also presents several limitations; some difficulties with bone-reduction clamp positioning, limited fixation of the anterior column, and a small risk of greater trochanter malunion.

Supplementary material

11999_2013_3228_MOESM1_ESM.doc (22 kb)
Supplementary material (DOC 22 kb)

Video 1 The different techniques for the reduction of fractures through the surgical dislocation technique are shown. (WMV 339487 kb)

Video 2 Reduction of a transverse fracture is commonly performed by pushing the inferior part of the pelvic brim outward and downward. (AVI 39548 kb)

References

  1. 1.
    Alonso JE, Davila R, Bradley E. Extended iliofemoral versus triradiate approaches in management of associated acetabular fractures. Clin Orthop Relat Res. 1994;305:81–87.PubMedCrossRefGoogle Scholar
  2. 2.
    Brooker A, Bowerman J, Robinson R, Riley LH. Ectopic ossification following total hip replacement: incidence and a method of classification. J Bone Joint Surg Am. 1955;55:1629–1632.Google Scholar
  3. 3.
    Chiu FY, Chen CM, Lo WH. Surgical treatment of displaced acetabular fractures in 72 cases followed for 10 (6 ± 14) years. Injury. 2000;31:181–185.PubMedCrossRefGoogle Scholar
  4. 4.
    Cohen JA. A coefficient of agreement of nominal scales. Educ Psychol Measure. 1960;20:37–46.CrossRefGoogle Scholar
  5. 5.
    Collinge C, Archdeacon M, Sagi HC. Quality of radiographic reduction and perioperative complications for transverse acetabular fractures treated by the Kocher-Langenbeck approach: prone versus lateral position. J Orthop Trauma. 2011;25:538–542.PubMedCrossRefGoogle Scholar
  6. 6.
    d’Aubigné RM, Postel M. The Classic: Functional results of hip arthroplasty with acrylic prosthesis. 1954. Clin Orthop Relat Res. 2009;467:7–27.PubMedCrossRefGoogle Scholar
  7. 7.
    Daum WJ, Scarborough MT, Gordon W Jr, Uchida T. Heterotopic ossification and other perioperative complications of acetabular fractures. J Orthop Trauma. 1992;6:427–432.PubMedCrossRefGoogle Scholar
  8. 8.
    Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119–1124.PubMedCrossRefGoogle Scholar
  9. 9.
    Gardner MJ, Suk, Pearle A, Buly RL, Helfet DL, Lorich DG. Surgical dislocation of the hip for fractures of the femoral head. J Orthop Trauma. 2005;19:334–342.PubMedGoogle Scholar
  10. 10.
    Gautier E, Ganz K, Krügel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br. 2000;82:679–683.PubMedCrossRefGoogle Scholar
  11. 11.
    Ghalambor N, Matta JM, Bernstein L. Heterotopic ossification following operative treatment of acetabular fracture. An analysis of risk factors. Clin Orthop Relat Res. 1994;305:96–105.PubMedCrossRefGoogle Scholar
  12. 12.
    Giannoudis PV, Grotz MRW, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. J Bone Joint Surg Br. 2005;87:2–9.PubMedGoogle Scholar
  13. 13.
    Griffin DB, Beaulé PE, Matta JM. Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the acetabulum. J Bone Joint Surg Br. 2005;87:1391–1396.PubMedGoogle Scholar
  14. 14.
    Harris AM, Althausen P, Kellam JF, Bosse MJ. Simultaneous anterior and posterior approaches for complex acetabular fractures. J Orthop Trauma. 2008;22:494–497.PubMedCrossRefGoogle Scholar
  15. 15.
    Heeg M, Klasen HJ, Visser JD. Operative treatment for acetabular fractures. J Bone Joint Surg Br. 1990;72:383–386.PubMedGoogle Scholar
  16. 16.
    Heeg M, Oostvogel HJ, Klasen HJ. Conservative treatment of acetabular fractures: the role of the weight-bearing dome and anatomic reduction in the ultimate results. J Trauma. 1987;27:555–559. PubMedCrossRefGoogle Scholar
  17. 17.
    Iselin LD, Wahl P, Studer P, Munro JT, Gautier E. Associated lesions in posterior wall acetabular fractures: not a valid predictor of failure. J Orthop Traumatol. 2013 June 4 [Epub ahead of print]. DOI: 10.1007/s10195-013-0247-x.
  18. 18.
    Johnson EE, Matta JM, Mast JW, Letournel E. Delayed reconstruction of acetabular fractures 21–120 days following injury. Clin Orthop Relat Res. 1994;305:20–30.PubMedGoogle Scholar
  19. 19.
    Kaempffe FA, Bone LB, Border JR. Open reduction and internal fixation of acetabular fractures: heterotopic ossification and other complications of treatment. J Orthop Trauma. 1991;5:439–445.PubMedCrossRefGoogle Scholar
  20. 20.
    Kinik H, Armangil M. Extensile triradiate approach in the management of combined acetabular fractures. Arch Orthop Trauma Surg. 2004;124:476–482.PubMedCrossRefGoogle Scholar
  21. 21.
    Kumar A, Shah NA, Kershaw SA, Clayson AD. Operative management of acetabular fractures. A review of 73 fractures. Injury. 2005;36:605–612. PubMedCrossRefGoogle Scholar
  22. 22.
    Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin, Germany: Springer-Verlag; 1993:521–588.CrossRefGoogle Scholar
  23. 23.
    Li XG, Tang TS, Sun JY. Results after surgical treatment of transtectal transverse acetabular fractures. Orthop Surg. 2010;2:7–13.PubMedCrossRefGoogle Scholar
  24. 24.
    Liu Q, Wu D, Li P, Han SF. Surgical treatment for complex acetabular fractures. Chin J Traumatol. 2006;9:325–328.PubMedGoogle Scholar
  25. 25.
    Massè A, Aprato A, Grappiolo G, Turchetto L, Campacci A, Ganz R. Surgical hip dislocation for anatomic reorientation of slipped capital femoral epiphysis: preliminary results. Hip Int. 2012;22:137–144.PubMedCrossRefGoogle Scholar
  26. 26.
    Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78:1632–1645.PubMedGoogle Scholar
  27. 27.
    Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of the acetabulum. A retrospective analysis. Clin Orthop Relat Res. 1986;205:230–240.PubMedGoogle Scholar
  28. 28.
    Mears DC, Velyvis JH, Chang CP. Displaced acetabular fractures managed operatively: indicators of outcome. Clin Orthop Relat Res. 2003;407:173–186.PubMedCrossRefGoogle Scholar
  29. 29.
    Moed BR, Carr SE, Gruson KI, Watson JT, Craig JG. Computed tomographic assessment of fractures of the posterior wall of the acetabulum after operative treatment. J Bone Joint Surg Am. 2003;85:512–522.PubMedGoogle Scholar
  30. 30.
    Naranje S, Shamshery P, Yadav CS, Gupta V, Nag HL. Digastric trochanteric flip osteotomy and surgical dislocation of hip in the management of acetabular fractures. Arch Orthop Trauma Surg. 2010;130:93–101.PubMedCrossRefGoogle Scholar
  31. 31.
    Negrin LL, Benson CD, Seligson D. Prone or lateral? Use of the Kocher-Langenbeck approach to treat acetabular fractures. J Trauma. 2010;69:137–141.PubMedCrossRefGoogle Scholar
  32. 32.
    Nötzli HP, Siebenrock KA, Hempfing A, Ramseier LE, Ganz R. Perfusion of the femoral head during surgical dislocation of the hip. Monitoring by laser Doppler flowmetry. J Bone Joint Surg Br. 2002;84:300–304.PubMedCrossRefGoogle Scholar
  33. 33.
    Oh CW, Kim PT, Park BC, Kim SY, Kyung HS, Jeon IH, Cheon SH, Min WK. Results after operative treatment of transverse acetabular fractures. J Orthop Sci. 2006;11:478–484. PubMedCrossRefGoogle Scholar
  34. 34.
    Onche II, Obiano SK, Udoh MK. A prospective evaluation of the management and outcome of traumatic posterior dislocation of the hip: a preliminary report. Niger J Med. 2008;17:163–167.PubMedGoogle Scholar
  35. 35.
    Peters CL, Erickson JA. Treatment of femoro-acetabular impingement with surgical dislocation and débridement in young adults. J Bone Joint Surg Am. 2006;88:1735–1741.PubMedCrossRefGoogle Scholar
  36. 36.
    Porter SE, Graves ML, Allan Maples R, Woodall JJ, Wallace JG, Russell GV. Acetabular fracture reductions in the obese patient. J Orthop Trauma. 2011;25:371–377.PubMedCrossRefGoogle Scholar
  37. 37.
    Reinert CM, Bosse MJ, Poka A, Schacherer T, Brumback RJ, Burgess AR. A modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg Am. 1988;70:329–337.PubMedGoogle Scholar
  38. 38.
    Siebenrock KA, Gautier E, Woo AK, Ganz R. Surgical dislocation of the femoral head for joint débridement and accurate reduction of fractures of the acetabulum. J Orthop Trauma. 2002;16:543–552.PubMedCrossRefGoogle Scholar
  39. 39.
    Siebenrock KA, Gautier E, Ziran BH, Ganz R. Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using a Kocher-Langenbeck approach. J Orthop Trauma. 1998;12:387–391.PubMedCrossRefGoogle Scholar
  40. 40.
    Sink EL, Beaulé PE, Sucato D, Kim YJ, Millis MB, Dayton M, Trousdale RT, Sierra RJ, Zaltz I, Schoenecker P, Monreal A, Clohisy J. Multicentre study of complications following surgical dislocation of the hip. J Bone Joint Surg Am. 2011;93:1132–1136.PubMedCrossRefGoogle Scholar
  41. 41.
    Spencer S, Millis MB, Kim YJ. Early results of treatment for hip impingement syndrome in slipped capital femoral epiphysis and pistol grip deformity of femoral head-neck junction using the surgical dislocation technique. J Pediatr Orthop. 2006;26:281–285.PubMedCrossRefGoogle Scholar
  42. 42.
    Stannard JP, Harris HW, Volgas DA, Alonso JE. Functional outcome of patients with femoral head fractures associated with hip dislocations. Clin Orthop Relat Res. 2000;377:44–56.PubMedCrossRefGoogle Scholar
  43. 43.
    Starr AJ, Watson JT, Reinert CM, Jones AL, Whitlock S, Griffin DR, Borer DS. Complications following the ‘T extensile’ approach: a modified extensile approach for acetabular fracture surgery—report of forty-three patients. J Orthop Trauma. 2002;16:535–542.PubMedCrossRefGoogle Scholar
  44. 44.
    Stöckle U, Hoffmann R, Südkamp NP, Reindl R, Haas NP. Treatment of complex acetabular fractures through a modified extended iliofemoral approach. J Orthop Trauma. 2002;16:220–230.PubMedCrossRefGoogle Scholar
  45. 45.
    Tannast M, Krüger A, Mack PW, Powell JN, Hosalkar HS, Siebenrock KA. Surgical dislocation of the hip for the fixation of acetabular fractures. J Bone Joint Surg Br. 2010;92:842–852.PubMedGoogle Scholar
  46. 46.
    Triantaphillopoulos PG, Panagiotopoulos EC, Mousafiris C, Tyllianakis M, Dimacopoulos P, Lambiris EE. Long-term results in surgically treated acetabular fractures through the posterior approaches. J Trauma. 2007;62:378–382.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2013

Authors and Affiliations

  • Alessandro Masse
    • 1
  • Alessandro Aprato
    • 1
    • 2
  • Luca Rollero
    • 1
  • Andrea Bersano
    • 1
  • Reinhold Ganz
    • 3
  1. 1.Department of Orthopaedic Surgery, San Luigi Hospital of OrbassanoUniversity of TurinTurinItaly
  2. 2.TurinItaly
  3. 3.University of BernBernSwitzerland

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