WEBVTT 00:00:00.000 --> 00:00:02.060 Did you know that even with the most advanced 00:00:02.060 --> 00:00:04.919 surgery, a really significant number of hip socket 00:00:04.919 --> 00:00:06.879 fractures, particularly in our older patients, 00:00:07.059 --> 00:00:09.419 might still end up needing a total hip replacement? 00:00:10.060 --> 00:00:12.019 We're talking about injuries that don't just 00:00:12.019 --> 00:00:14.960 break a bone. They fundamentally change a patient's 00:00:14.960 --> 00:00:17.879 mobility, their quality of life. It's this impact 00:00:17.879 --> 00:00:20.399 and the often quite counterintuitive complexities 00:00:20.399 --> 00:00:22.960 that we're here to unravel today. Welcome to 00:00:22.960 --> 00:00:25.280 the Depth Dive, the show where we aim to extract 00:00:25.280 --> 00:00:27.320 essential knowledge and hopefully some surprising 00:00:27.320 --> 00:00:30.160 insights from complex medical topics. Today, 00:00:30.179 --> 00:00:32.859 we're taking a deep dive into acetabular fractures, 00:00:32.899 --> 00:00:35.399 those critical breaks right in the hip's vital 00:00:35.399 --> 00:00:38.020 socket. These aren't just any fractures. They 00:00:38.020 --> 00:00:40.100 demand, well, a really nuanced understanding, 00:00:40.359 --> 00:00:42.880 meticulous decision making, and often highly 00:00:42.880 --> 00:00:45.539 specialized care. And joining us to unpack this 00:00:45.539 --> 00:00:48.420 intricate area, drawing from vast clinical experience 00:00:48.420 --> 00:00:51.020 and the latest research, is a true luminary in 00:00:51.020 --> 00:00:53.219 the field. He's a consultant orthopedic surgeon 00:00:53.219 --> 00:00:55.619 at the Royal London Hospital, specializing in 00:00:55.619 --> 00:00:58.140 pelvis, acetabular, and revision arthroplasty. 00:00:58.380 --> 00:01:00.979 He's also the founder of OrthoGlobe, an international 00:01:00.979 --> 00:01:03.920 collaborative dedicated to advancing musculoskeletal 00:01:03.920 --> 00:01:06.799 practice through global research. A very warm 00:01:06.799 --> 00:01:08.560 welcome. Thank you very much for having me. It's 00:01:08.560 --> 00:01:10.060 a real pleasure to be here to talk about this. 00:01:10.239 --> 00:01:12.920 It's our absolute privilege. So let's kick things 00:01:12.920 --> 00:01:15.420 off with a bit of a rapid fire segment just to 00:01:15.420 --> 00:01:18.219 set the stage for our deep dive. For those in 00:01:18.219 --> 00:01:20.359 our audience who might perhaps sometimes lump 00:01:20.359 --> 00:01:23.280 all hip or pelvic injuries together, what's the 00:01:23.280 --> 00:01:25.560 fundamental difference that really defines an 00:01:25.560 --> 00:01:28.340 acetabular fracture and why is spotting that 00:01:28.340 --> 00:01:30.879 distinction so critical for outcomes? That's 00:01:30.879 --> 00:01:32.579 a great question to start with. The fundamental 00:01:32.579 --> 00:01:35.359 distinction and it really dictates everything 00:01:35.359 --> 00:01:38.359 that follows is that an acetabular fracture inherently 00:01:38.359 --> 00:01:41.140 involves the articular surface of the hip joint, 00:01:41.599 --> 00:01:44.239 the cartilage. The joint surface itself. Exactly. 00:01:44.519 --> 00:01:46.739 Unlike many pelvic ring fractures, which might 00:01:46.739 --> 00:01:49.680 affect the structural integrity of the pelvis, 00:01:49.739 --> 00:01:52.519 but often spare the joint itself, an acetabular 00:01:52.519 --> 00:01:56.019 fracture directly impacts that smooth cartilage 00:01:56.019 --> 00:01:58.700 line socket where the femoral head moves. And 00:01:58.700 --> 00:02:00.879 this direct involvement of the joint surface 00:02:00.879 --> 00:02:04.150 is absolutely paramount. because it's the primary 00:02:04.150 --> 00:02:06.069 determinant of post -traumatic osteoarthritis 00:02:06.069 --> 00:02:09.090 down the line. If that articular surface isn't 00:02:09.090 --> 00:02:12.250 restored almost perfectly, the joint mechanics 00:02:12.250 --> 00:02:14.710 are disrupted. That leads to progressive wear 00:02:14.710 --> 00:02:18.090 and tear. pain, stiffness, and ultimately what 00:02:18.090 --> 00:02:20.550 we sometimes call the death of the hip, meaning 00:02:20.550 --> 00:02:22.810 it needs replacing. So it really is all about 00:02:22.810 --> 00:02:25.289 that critical joint integrity, that surface smoothness, 00:02:25.449 --> 00:02:27.849 knowing that if we look at the bigger picture, 00:02:28.169 --> 00:02:31.629 epidemiologically speaking, who is most vulnerable 00:02:31.629 --> 00:02:33.750 to these injuries and what sort of forces are 00:02:33.750 --> 00:02:35.889 typically causing them? Well, acetabular fractures 00:02:35.889 --> 00:02:38.189 show quite a fascinating bimodal distribution. 00:02:38.569 --> 00:02:41.490 So we see peaks in two very distinct age groups. 00:02:41.509 --> 00:02:44.280 Right. In younger patients, typically those between, 00:02:44.280 --> 00:02:47.479 say, 20 and 39 years old, and this group actually 00:02:47.479 --> 00:02:49.740 made up over half the patients in one large study, 00:02:50.360 --> 00:02:52.419 these are overwhelmingly high energy injuries. 00:02:52.659 --> 00:02:54.900 Road traffic accidents are a major cause, accounting 00:02:54.900 --> 00:02:57.460 for nearly 57 % in that same study. You have 00:02:57.460 --> 00:02:59.639 to think of that classic dashboard injury, where 00:02:59.639 --> 00:03:02.039 the knee hits the dashboard, driving the femoral 00:03:02.039 --> 00:03:04.400 head backwards forcefully into the acetabular 00:03:04.400 --> 00:03:07.699 socket. Then, in stark contrast, the other peak 00:03:07.699 --> 00:03:11.310 occurs in our elderly patients. Here, it's typically 00:03:11.310 --> 00:03:13.870 low energy falls, often just from a standing 00:03:13.870 --> 00:03:16.210 height that caused the fracture. And this is 00:03:16.210 --> 00:03:19.289 primarily due to weakened bone quality from osteoporosis. 00:03:19.889 --> 00:03:22.150 The precise force vector, you know, the direction 00:03:22.150 --> 00:03:24.050 of the impact and the position of the femoral 00:03:24.050 --> 00:03:26.689 head at that exact moment, abduction, adduction 00:03:26.689 --> 00:03:30.310 rotation, they're absolutely key in determining 00:03:30.310 --> 00:03:32.550 the specific fracture pattern we see. It's quite 00:03:32.550 --> 00:03:34.969 remarkable how the mechanism shifts so dramatically 00:03:34.969 --> 00:03:38.090 with age. So finally, just to frame our discussion 00:03:38.090 --> 00:03:40.870 today, in a single sentence, what would you say 00:03:40.870 --> 00:03:42.729 is the biggest challenge you personally face 00:03:42.729 --> 00:03:44.650 when you're approaching the management of an 00:03:44.650 --> 00:03:46.870 acetabular fracture, particularly in our more 00:03:46.870 --> 00:03:50.830 senior patients? Hmm, in senior patients? I'd 00:03:50.830 --> 00:03:53.389 say the single biggest challenge is reliably 00:03:53.389 --> 00:03:57.090 achieving and crucially maintaining stable fixation 00:03:57.090 --> 00:03:59.990 in bone that's often highly comminuted, shattered 00:03:59.990 --> 00:04:03.069 into many pieces, and osteoporotic. And that 00:04:03.069 --> 00:04:05.750 task is compounded by their significant medical 00:04:05.750 --> 00:04:08.349 comorbidities, which ultimately impacts their 00:04:08.349 --> 00:04:10.729 ability to mobilize afterwards and recover effectively. 00:04:11.169 --> 00:04:13.530 It's a complex interplay. That sets the stage 00:04:13.530 --> 00:04:15.490 perfectly for the complexity we're diving into. 00:04:15.750 --> 00:04:18.029 Let's really unpack the hip joint itself then. 00:04:18.110 --> 00:04:20.829 To genuinely grasp these fractures, we need to 00:04:20.829 --> 00:04:23.230 understand the, well, the architectural marvel 00:04:23.230 --> 00:04:25.430 that is the acetabulum. When you visualize the 00:04:25.430 --> 00:04:27.730 hip, what's the architectural blueprint that 00:04:27.730 --> 00:04:29.870 immediately comes to mind when considering these 00:04:29.870 --> 00:04:32.430 fractures? What are those critical anatomical 00:04:32.430 --> 00:04:34.709 elements a surgeon just has to understand? Well, 00:04:34.709 --> 00:04:36.350 when I think of the hip joint, I immediately 00:04:36.350 --> 00:04:39.180 picture this beautifully engineered ball and 00:04:39.180 --> 00:04:41.439 socket system. Yeah. It's quite elegant, really. 00:04:41.459 --> 00:04:44.480 Yes. The ball is the femoral head, the top end 00:04:44.480 --> 00:04:47.019 of the thigh bone, and the socket is the acetabulum, 00:04:47.120 --> 00:04:49.079 which is an integral part of the pelvis itself. 00:04:49.660 --> 00:04:52.300 What makes the acetabulum so intricate and why 00:04:52.300 --> 00:04:55.439 injuring it is so challenging is its highly specific 00:04:55.439 --> 00:04:57.819 structural complexity. Both the femoral head 00:04:57.819 --> 00:05:00.120 and the acetabulum are covered with articular 00:05:00.120 --> 00:05:03.240 cartilage. That smooth surface. Exactly. This 00:05:03.240 --> 00:05:06.240 incredibly smooth, almost frictionless substance 00:05:06.240 --> 00:05:09.329 is absolutely critical. It allows the bones to 00:05:09.329 --> 00:05:11.769 glide effortlessly, facilitating movement without 00:05:11.769 --> 00:05:14.329 friction or pain. And surrounding this, you have 00:05:14.329 --> 00:05:16.790 strong ligaments, tough bands of tissue that 00:05:16.790 --> 00:05:19.129 provide stability, whilst allowing an extensive 00:05:19.129 --> 00:05:21.589 range of motion without dislocation. But perhaps 00:05:21.589 --> 00:05:23.589 the most fundamental concept, particularly for 00:05:23.589 --> 00:05:26.310 surgical planning, is the Judet and Lateral Column 00:05:26.310 --> 00:05:28.589 Theory. It's the bedrock of how we think about 00:05:28.589 --> 00:05:31.350 these fractures. Right, the two columns. Precisely. 00:05:31.529 --> 00:05:34.930 They conceptualize the acetabulum as being supported 00:05:34.930 --> 00:05:38.069 by two main columns, forming an invented Y shape, 00:05:38.470 --> 00:05:40.750 almost like structural scaffolding holding the 00:05:40.750 --> 00:05:44.069 socket up. The anterior column is the more extensive 00:05:44.069 --> 00:05:46.930 one. It traces from the anterior iliac spines 00:05:46.930 --> 00:05:49.589 along the iliac wing and connects down to the 00:05:49.589 --> 00:05:53.209 pubic rami. The posterior column, in contrast, 00:05:53.449 --> 00:05:55.589 is a bit more limited structurally. It extends 00:05:55.589 --> 00:05:57.529 from the sciatic notch and runs down through 00:05:57.529 --> 00:06:00.310 the ischium. Understanding these columns is absolutely 00:06:00.310 --> 00:06:02.889 vital because fracture patterns aren't just random 00:06:02.889 --> 00:06:06.050 cracks. They typically involve breaks along or 00:06:06.050 --> 00:06:08.329 between these fundamental structural supports. 00:06:08.610 --> 00:06:10.490 So the fractures follow these lines of force, 00:06:10.490 --> 00:06:13.110 essentially? In a way, yes. And when we look 00:06:13.110 --> 00:06:15.910 at x -rays, we're not just glancing. We're meticulously 00:06:15.910 --> 00:06:18.389 searching for specific radiographic landmarks 00:06:18.389 --> 00:06:20.290 that help us delineate these columns and assess 00:06:20.290 --> 00:06:22.790 the fracture. Key among these are the ileopectinale 00:06:22.790 --> 00:06:25.290 line, which essentially represents the integrity 00:06:25.290 --> 00:06:27.819 of that anterior column. and the ilioeschial 00:06:27.819 --> 00:06:31.319 line, which signifies the posterior column. You 00:06:31.319 --> 00:06:33.779 also look for the radiographic teardrop, indicating 00:06:33.779 --> 00:06:36.699 the medial wall, and the radiographic roof that's 00:06:36.699 --> 00:06:39.259 the crucial weight -bearing dome. It's important 00:06:39.259 --> 00:06:41.259 to remember these lines aren't literal cracks 00:06:41.259 --> 00:06:43.779 themselves. They're overlapping condensations 00:06:43.779 --> 00:06:46.839 of cortical bones seen on the 2D image. But they 00:06:46.839 --> 00:06:49.259 offer critical clues about the underlying 3D 00:06:49.259 --> 00:06:51.839 structural integrity. I see. And what about the 00:06:51.839 --> 00:06:54.029 surrounding structures, nerves? blood vessels. 00:06:54.550 --> 00:06:56.990 Yes. From a surgeon's perspective, perhaps nothing 00:06:56.990 --> 00:06:59.629 is more critical than the vascular and neurovascular 00:06:59.629 --> 00:07:02.129 considerations. There's a particularly precarious 00:07:02.129 --> 00:07:04.810 anastomosis, a connection between blood vessels 00:07:04.810 --> 00:07:07.689 often rather dramatically dubbed the coronamortis, 00:07:07.790 --> 00:07:10.329 the crown of death. This involves vessels from 00:07:10.329 --> 00:07:12.949 the external iliac system. like the inferior 00:07:12.949 --> 00:07:15.829 epigastric artery, and the internal iliac system, 00:07:15.930 --> 00:07:19.189 like the obturator vessels. This area is highly 00:07:19.189 --> 00:07:21.430 susceptible to injury during certain surgical 00:07:21.430 --> 00:07:24.949 approaches, particularly anterior ones. Significant 00:07:24.949 --> 00:07:27.029 bleeding can occur very quickly if it's damaged. 00:07:27.670 --> 00:07:30.209 And perhaps even more importantly, major nerves, 00:07:30.589 --> 00:07:33.750 most notably the sciatic nerve, pass perilously 00:07:33.750 --> 00:07:36.009 close to the posterior aspect of the hip socket. 00:07:37.029 --> 00:07:39.689 Extremely close. Damage to this nerve? either 00:07:39.689 --> 00:07:41.870 from the initial injury itself or unfortunately 00:07:41.870 --> 00:07:44.449 sometimes during surgery can lead to significant 00:07:44.449 --> 00:07:47.410 long -term problems like foot drop. That's why 00:07:47.410 --> 00:07:49.850 we approach this region with such extreme caution 00:07:49.850 --> 00:07:52.069 and respect. That paints such a clear picture 00:07:52.069 --> 00:07:55.329 of just how wonderfully complex but also quite 00:07:55.329 --> 00:07:58.139 vulnerable this structure is. If the femoral 00:07:58.139 --> 00:08:00.399 head acts like a hammer, as you described earlier, 00:08:00.800 --> 00:08:02.459 how do these intricate architectural elements 00:08:02.459 --> 00:08:04.620 then dictate the distinct injury patterns we 00:08:04.620 --> 00:08:07.279 actually see? It sounds like even a small shift 00:08:07.279 --> 00:08:09.579 in force or femur position could lead to a vastly 00:08:09.579 --> 00:08:11.740 different fracture. You've hit on a crucial point 00:08:11.740 --> 00:08:14.959 there. The path of physiology is precisely that 00:08:14.959 --> 00:08:17.259 forces are transmitted through the femoral head, 00:08:17.620 --> 00:08:19.660 which really does act like a hammer striking 00:08:19.660 --> 00:08:22.680 the acetabulum. And the exact position of the 00:08:22.680 --> 00:08:26.579 femur at the moment of impact, whether it's adducted 00:08:26.579 --> 00:08:28.920 closer to the midline, abducted away from the 00:08:28.920 --> 00:08:32.299 midline, or rotated and the precise direction 00:08:32.299 --> 00:08:35.600 of the force are absolutely critical in determining 00:08:35.600 --> 00:08:37.799 the specific fracture pattern and the amount 00:08:37.799 --> 00:08:40.240 of displacement. It's not random at all. Can 00:08:40.240 --> 00:08:42.200 you give some examples? Sure. Let's take that 00:08:42.200 --> 00:08:44.519 common dashboard injury again. If the knee strikes 00:08:44.519 --> 00:08:46.639 the dashboard, it drives the femoral head directly 00:08:46.639 --> 00:08:49.399 backwards against the acetabulum. This frequently 00:08:49.399 --> 00:08:51.379 results in a posterior wall fracture. That's 00:08:51.379 --> 00:08:53.299 actually the most common pattern overall. Right. 00:08:53.480 --> 00:08:55.970 Falls directly onto the side of the hip. transmitting 00:08:55.970 --> 00:08:58.970 force from the side can also cause these. And 00:08:58.970 --> 00:09:01.649 we differentiate fundamentally between high -energy 00:09:01.649 --> 00:09:04.909 trauma, typically seen in younger adults, the 00:09:04.909 --> 00:09:08.389 road accidents, the major falls. Exactly. Which 00:09:08.389 --> 00:09:10.769 not only causes significant bone fragmentation, 00:09:11.029 --> 00:09:13.669 but also extensive soft tissue damage, internal 00:09:13.669 --> 00:09:16.129 bleeding, and potential lacerations of major 00:09:16.129 --> 00:09:18.750 blood vessels or nerves. These patients often 00:09:18.750 --> 00:09:21.440 present with multiple associated injuries. That 00:09:21.440 --> 00:09:24.799 Jordan's study again noted over half of 53 .9 00:09:24.799 --> 00:09:27.279 percent had other serious injuries needing attention 00:09:27.279 --> 00:09:31.620 head chest abdomen a major trauma scenario Absolutely 00:09:31.620 --> 00:09:34.539 in contrast you have low energy trauma more common 00:09:34.539 --> 00:09:37.580 in our elderly patients This causes fractures 00:09:37.580 --> 00:09:39.460 because the bone quality is severely weakened 00:09:39.460 --> 00:09:42.610 primarily due to osteoporosis Whilst the energy 00:09:42.610 --> 00:09:45.350 is lower, the compromised bone makes stable surgical 00:09:45.350 --> 00:09:47.549 fixation exponentially more challenging. It's 00:09:47.549 --> 00:09:49.970 fascinating how the energy level ties into age 00:09:49.970 --> 00:09:52.649 and bone health. Given this wide spectrum, how 00:09:52.649 --> 00:09:55.289 do orthopedic professionals actually categorize 00:09:55.289 --> 00:09:57.769 these fractures? How do you standardize communication 00:09:57.769 --> 00:10:00.570 and, importantly, guide treatment decisions? 00:10:00.750 --> 00:10:03.350 Is there a sort of universal language? Yes, there 00:10:03.350 --> 00:10:06.009 is, thankfully. To bring order and a common language 00:10:06.009 --> 00:10:09.049 to this complexity, the Judet -Laternal classification 00:10:09.049 --> 00:10:11.509 is without doubt the most widely accepted and 00:10:11.509 --> 00:10:13.789 foundational system. It's really the framework 00:10:13.789 --> 00:10:15.950 we all use when discussing acetabular fractures. 00:10:16.350 --> 00:10:18.370 It systematically divides fractures into two 00:10:18.370 --> 00:10:21.549 main types, five elementary patterns and five 00:10:21.549 --> 00:10:23.870 associated patterns. I'd say five of each. Exactly. 00:10:24.230 --> 00:10:26.210 The five elementary patterns involve essentially 00:10:26.210 --> 00:10:29.570 a single main fracture line dividing the acetabulum. 00:10:30.149 --> 00:10:33.009 First, the posterior wall fracture. As we said, 00:10:33.070 --> 00:10:35.509 the most common overall, making up almost 38 00:10:35.509 --> 00:10:37.950 % of cases in the Jordan study often linked to 00:10:37.950 --> 00:10:40.470 those dashboard injuries. Second, the posterior 00:10:40.470 --> 00:10:42.870 column fracture involving that larger posterior 00:10:42.870 --> 00:10:46.070 structural support. Third, the anterior wall 00:10:46.070 --> 00:10:48.669 fracture. This is quite rare on its own. It often 00:10:48.669 --> 00:10:50.850 presents more as part of a complex pelvic ring 00:10:50.850 --> 00:10:53.090 injury or is associated with an anterior hip 00:10:53.090 --> 00:10:56.009 dislocation. Fourth, the anterior column fracture 00:10:56.009 --> 00:10:58.909 involving the anterior support. And fifth, the 00:10:58.909 --> 00:11:01.250 transverse fracture. This is defined as a single 00:11:01.250 --> 00:11:03.350 fracture line that crosses both the anterior 00:11:03.350 --> 00:11:05.590 and posterior columns, essentially cutting the 00:11:05.590 --> 00:11:07.350 acetabulum in half horizontally. Right, those 00:11:07.350 --> 00:11:09.490 are the elementary ones. What about the associated 00:11:09.490 --> 00:11:11.750 patterns? The five associated patterns are combinations 00:11:11.750 --> 00:11:14.549 of these elementary types. They indicate more 00:11:14.549 --> 00:11:16.629 complex and generally more severe injuries. You 00:11:16.629 --> 00:11:19.610 have anterior column with posterior hematransverse, 00:11:20.210 --> 00:11:23.029 posterior column with posterior wall, transverse 00:11:23.029 --> 00:11:25.929 with posterior wall, Now, this one is actually 00:11:25.929 --> 00:11:28.389 the most common associated pattern, and importantly, 00:11:28.629 --> 00:11:31.529 it's linked to the highest incidence of sciatic 00:11:31.529 --> 00:11:34.269 nerve injury. That's a critical point for prognosis 00:11:34.269 --> 00:11:36.590 and patient counseling. Definitely. Then there's 00:11:36.590 --> 00:11:39.610 the T -shaped fracture. This is basically a transverse 00:11:39.610 --> 00:11:41.529 fracture combined with a vertical split that 00:11:41.529 --> 00:11:43.549 goes down through the quadrilateral surface in 00:11:43.549 --> 00:11:46.350 the acetabular fossa, creating that T shape on 00:11:46.350 --> 00:11:49.230 imaging. And finally, the both -column fracture. 00:11:49.419 --> 00:11:51.799 This is where both the anterior and posterior 00:11:51.799 --> 00:11:54.320 columns are completely separated from the intact 00:11:54.320 --> 00:11:57.019 posterior part of the ilium. All the articular 00:11:57.019 --> 00:11:59.340 segments, the joint surface pieces, are detached. 00:11:59.779 --> 00:12:02.600 It's a truly severe injury pattern. And are there 00:12:02.600 --> 00:12:05.139 specific signs you look for on imaging to help 00:12:05.139 --> 00:12:07.919 identify these patterns? Absolutely. When we're 00:12:07.919 --> 00:12:10.220 diagnosing these, we're meticulously looking 00:12:10.220 --> 00:12:13.460 for specific diagnostic features or signs on 00:12:13.460 --> 00:12:16.879 the x -rays and CT scans that are almost pathognomonic, 00:12:17.120 --> 00:12:18.700 meaning if you see them, you know what you're 00:12:18.700 --> 00:12:21.679 dealing with. For instance, the goal sign. This 00:12:21.679 --> 00:12:24.600 is seen on the iliac oblique x -ray view and 00:12:24.600 --> 00:12:27.440 it represents impaction, a crushing injury of 00:12:27.440 --> 00:12:30.259 the supermedial roof. the top part of the socket. 00:12:30.620 --> 00:12:33.259 Okay. It's a telltale sign often seen with posterior 00:12:33.259 --> 00:12:35.980 wall fractures, but critically, it's often a 00:12:35.980 --> 00:12:39.419 strong, poor, prognostic indicator. It frequently 00:12:39.419 --> 00:12:41.899 suggests the need for an acute total hip replacement, 00:12:42.379 --> 00:12:44.639 rather than just fixation, because it signifies 00:12:44.639 --> 00:12:47.240 significant articular cartilage damage. I see. 00:12:47.360 --> 00:12:49.419 So that sign carries a lot of weight. It does. 00:12:49.600 --> 00:12:51.720 Another crucial sign is the spur sign, which 00:12:51.720 --> 00:12:54.159 is visible on the obturator oblique x -ray view. 00:12:54.759 --> 00:12:57.019 This looks like a sharp spike of intact ilium 00:12:57.019 --> 00:12:59.720 sticking out laterally, while the entire acetabulum 00:12:59.720 --> 00:13:02.600 is shifted medially. It's pythognomonic for both 00:13:02.600 --> 00:13:04.919 colon fractures. It's also vital to understand 00:13:04.919 --> 00:13:07.379 the concept of secondary congruence, particularly 00:13:07.379 --> 00:13:09.620 in both colon fractures. You mentioned that earlier. 00:13:10.000 --> 00:13:12.799 Yes. Despite the acetabulum being completely 00:13:12.799 --> 00:13:15.379 separated from the axial skeleton, The displaced 00:13:15.379 --> 00:13:18.679 fragments might deceptively appear to align reasonably 00:13:18.679 --> 00:13:20.899 well around the femoral head on initial x -rays. 00:13:21.740 --> 00:13:24.340 It can look falsely reassuring. So it looks okay, 00:13:24.399 --> 00:13:26.779 but it's actually completely detached. Precisely. 00:13:27.220 --> 00:13:29.700 It can be profoundly misleading and really underscores 00:13:29.700 --> 00:13:31.840 the absolute necessity for more advanced imaging, 00:13:32.220 --> 00:13:35.019 like CT, to truly appreciate the extent of the 00:13:35.019 --> 00:13:37.809 injury and the instability. And whilst Judelet 00:13:37.809 --> 00:13:40.169 -Dornel remains the bedrock, we do sometimes 00:13:40.169 --> 00:13:42.809 briefly consider other systems, like the tile 00:13:42.809 --> 00:13:45.429 classification, which focuses on overall pelvic 00:13:45.429 --> 00:13:48.289 stability type C being complex, unstable injuries, 00:13:48.830 --> 00:13:51.210 or the Young -Burgess classification, which looks 00:13:51.210 --> 00:13:54.009 at the mechanism of injury. But for the acetabulum 00:13:54.009 --> 00:13:56.409 specifically, Judelet -Dornel is really our guiding 00:13:56.409 --> 00:13:59.190 light. That level of detail in classification 00:13:59.190 --> 00:14:02.110 truly highlights the precision needed. So after 00:14:02.110 --> 00:14:04.850 identifying the likely pattern, accurate diagnosis 00:14:04.850 --> 00:14:07.230 is paramount for planning treatment. What are 00:14:07.230 --> 00:14:09.450 the essential imaging tools you rely on and what 00:14:09.450 --> 00:14:11.169 are those non -negotiable key findings you're 00:14:11.169 --> 00:14:13.389 looking for, especially given pitfalls like that 00:14:13.389 --> 00:14:15.730 secondary concurrence? For accurate diagnosis, 00:14:16.009 --> 00:14:18.490 we use a very specific sort of stepwise approach 00:14:18.490 --> 00:14:20.929 to imaging. X -rays are always the initial step. 00:14:21.019 --> 00:14:24.580 While standard anteroposterior, or AP, views 00:14:24.580 --> 00:14:27.059 are useful baseline images, the critical views 00:14:27.059 --> 00:14:29.879 are the specific judit views. We always get these. 00:14:30.039 --> 00:14:32.399 A two oblique view. Exactly. The obturator oblique 00:14:32.399 --> 00:14:34.919 view, which profiles the obturator foramen and 00:14:34.919 --> 00:14:37.179 gives a clear picture of the anterior column 00:14:37.179 --> 00:14:39.850 and the posterior wall. and the iliac oblique 00:14:39.850 --> 00:14:42.009 view, which profiles the iliac wing and clearly 00:14:42.009 --> 00:14:44.289 shows the posterior column and the anterior wall. 00:14:44.909 --> 00:14:46.909 These specialized views are absolutely essential 00:14:46.909 --> 00:14:48.929 for visualizing the fracture pattern properly 00:14:48.929 --> 00:14:51.409 and assessing the degree of displacement, which, 00:14:51.649 --> 00:14:53.509 as I said, is often not fully appreciated on 00:14:53.509 --> 00:14:57.009 a standard AP view alone. However, for truly 00:14:57.009 --> 00:14:59.009 precise management and preoperative planning, 00:14:59.549 --> 00:15:02.980 computed tomography or CT scams, are unequivocally 00:15:02.980 --> 00:15:05.059 considered the gold standard. You really can't 00:15:05.059 --> 00:15:07.500 plan surgery properly without one. Why is CT 00:15:07.500 --> 00:15:10.659 so crucial? Well, a CT provides exquisitely detailed 00:15:10.659 --> 00:15:13.500 cross -sectional views of the hip. This is crucial 00:15:13.500 --> 00:15:15.600 for visualizing subtle injuries that might not 00:15:15.600 --> 00:15:18.340 be apparent on x -rays, particularly complex 00:15:18.340 --> 00:15:21.620 posterior injuries or impaction. It defines the 00:15:21.620 --> 00:15:24.620 fragment size. their exact orientation in 3D 00:15:24.620 --> 00:15:27.840 space, identifies any subtle marginal impaction, 00:15:28.000 --> 00:15:30.200 the crushing of the cancellous bone just beneath 00:15:30.200 --> 00:15:32.879 the articular surface, which affects prognosis, 00:15:33.419 --> 00:15:35.879 and it detects any intra -articular loose bodies, 00:15:36.419 --> 00:15:38.080 little bits of bone or cartilage floating in 00:15:38.080 --> 00:15:40.200 the joint, or articular gaps and step -offs. 00:15:40.980 --> 00:15:42.879 All of these are critical details for surgical 00:15:42.879 --> 00:15:45.259 decision -making. You'll simply miss these nuances 00:15:45.259 --> 00:15:47.529 without a CT. And are there specific measurements 00:15:47.529 --> 00:15:49.929 you take on these scans? Yes. We look at various 00:15:49.929 --> 00:15:51.809 things. For instance, we sometimes use measurements 00:15:51.809 --> 00:15:54.490 like the roof arc angle to try and assess stability. 00:15:55.090 --> 00:15:56.690 A fracture is generally considered stable if 00:15:56.690 --> 00:15:58.970 the main fracture line exits outside the primary 00:15:58.970 --> 00:16:01.250 weight -bearing dome of the acetabulum. This 00:16:01.250 --> 00:16:03.029 is typically defined as having an angle greater 00:16:03.029 --> 00:16:06.149 than 45 degrees on the AP and Judith fuse, or 00:16:06.149 --> 00:16:08.509 it's indicated by seeing an intact subchondral 00:16:08.509 --> 00:16:11.610 bone ring in the superior 10 millimeters on the 00:16:11.610 --> 00:16:14.590 axial CT cuts. But you mentioned limitations. 00:16:14.990 --> 00:16:17.830 Yes. It's crucial to note its limitation in certain 00:16:17.830 --> 00:16:20.389 fracture patterns, like both column fractures 00:16:20.389 --> 00:16:22.990 where the whole thing is detached, or some posterior 00:16:22.990 --> 00:16:26.429 wall fractures. In these cases, there isn't necessarily 00:16:26.429 --> 00:16:29.250 an intact portion of the acetabulum available 00:16:29.250 --> 00:16:31.649 for this type of measurement, so you rely on 00:16:31.649 --> 00:16:34.850 other signs of instability. Beyond static imaging, 00:16:35.149 --> 00:16:37.570 sometimes we need to dynamically assess stability, 00:16:38.230 --> 00:16:40.820 particularly for posterior wall fractures. This 00:16:40.820 --> 00:16:43.279 might involve an examination under anesthesia, 00:16:43.600 --> 00:16:46.799 or EUA, using fluoroscopy live x -ray. To see 00:16:46.799 --> 00:16:50.059 how it moves under stress. Exactly. During this, 00:16:50.200 --> 00:16:52.179 if the medial clear space, the gap between the 00:16:52.179 --> 00:16:54.080 femoral head and the socket medially opens up 00:16:54.080 --> 00:16:56.779 under stress, that can be a definitive sign of 00:16:56.779 --> 00:16:59.059 instability in the posterior wall, which might 00:16:59.059 --> 00:17:00.639 not have been obvious from the static images 00:17:00.639 --> 00:17:03.879 alone. And finally, tying back to the urgency, 00:17:04.380 --> 00:17:07.230 if there's an associated hip dislocation, Early 00:17:07.230 --> 00:17:09.049 imaging and diagnosis are absolutely critical 00:17:09.049 --> 00:17:11.829 because as we'll discuss these are surgical emergencies 00:17:11.829 --> 00:17:14.890 Reduction should ideally occur within 12 hours 00:17:14.890 --> 00:17:17.529 for improved outcomes Primarily to mitigate the 00:17:17.529 --> 00:17:19.809 risk of a vascular necrosis death of the bone 00:17:19.809 --> 00:17:22.109 of the femoral head due to compromised blood 00:17:22.109 --> 00:17:25.630 supply It's also vital to exclude an associated 00:17:25.630 --> 00:17:28.369 femoral neck fracture in cases of hip dislocation 00:17:28.599 --> 00:17:31.160 If there's any doubt whatsoever on the initial 00:17:31.160 --> 00:17:33.940 x -rays, a CT scan is strongly recommended to 00:17:33.940 --> 00:17:36.440 rule this out, as finding one would significantly 00:17:36.440 --> 00:17:39.420 alter the immediate treatment plan, perhaps necessitating 00:17:39.420 --> 00:17:41.819 a different acute surgical approach altogether. 00:17:42.359 --> 00:17:44.779 It's clear these injuries demand a rapid, thorough, 00:17:45.039 --> 00:17:48.940 and incredibly precise diagnostic cascade. Beyond 00:17:48.940 --> 00:17:51.359 the fracture itself, you've mentioned an associated 00:17:51.359 --> 00:17:54.279 hip dislocation can be a true orthopedic emergency. 00:17:54.940 --> 00:17:57.200 What's the immediate priority for a patient presenting 00:17:57.200 --> 00:17:59.200 like that, and what are the steps you take to 00:17:59.200 --> 00:18:02.480 manage it acutely? The immediate priority, unequivocally, 00:18:02.640 --> 00:18:04.920 is to recognize that a fractured acetabulum with 00:18:04.920 --> 00:18:07.779 a hip dislocation is a surgical emergency. It 00:18:07.779 --> 00:18:09.900 requires urgent reduction of the dislocated hip. 00:18:10.099 --> 00:18:12.380 This is not something that can wait. The clock 00:18:12.380 --> 00:18:14.460 starts ticking immediately to minimize the risk 00:18:14.460 --> 00:18:16.819 of complications, particularly that of vascular 00:18:16.819 --> 00:18:19.539 necrosis of the femoral head. Okay, so time is 00:18:19.539 --> 00:18:22.539 critical. Absolutely. Our initial patient assessment, 00:18:22.539 --> 00:18:24.740 of course, is always based on Advanced Trauma 00:18:24.740 --> 00:18:27.980 Life Support or ATLS principles. That means we 00:18:27.980 --> 00:18:31.220 first prioritize airway, breathing, and circulation 00:18:31.220 --> 00:18:34.220 of the ABCs to ensure the patient is physiologically 00:18:34.220 --> 00:18:38.039 stable. Once that's secured, a thorough neurological 00:18:38.039 --> 00:18:40.259 and vascular assessment of the affected limb 00:18:40.259 --> 00:18:43.500 is crucial. We must meticulously check for any 00:18:43.500 --> 00:18:46.220 signs of nerve damage, particularly sciatic nerve 00:18:46.220 --> 00:18:49.680 injury, which can manifest as foot drop and inability 00:18:49.680 --> 00:18:52.920 to lift the foot even after the reduction. This 00:18:52.920 --> 00:18:55.220 assessment guides our immediate next steps and 00:18:55.220 --> 00:18:57.480 helps us anticipate potential long -term deficits. 00:18:57.660 --> 00:19:00.240 And the reduction itself. The process of urgent 00:19:00.240 --> 00:19:02.559 reduction is ideally performed immediately in 00:19:02.559 --> 00:19:05.240 the emergency department, or RISIS. It requires 00:19:05.240 --> 00:19:07.779 appropriate sedation, good muscle relaxation, 00:19:08.039 --> 00:19:10.000 which is key, and often a two -person technique 00:19:10.000 --> 00:19:12.359 to apply traction and counter -traction safely 00:19:12.359 --> 00:19:15.019 and effectively. We commonly differentiate between 00:19:15.019 --> 00:19:17.599 the types of dislocation. Posterior dislocations 00:19:17.599 --> 00:19:19.599 are the most frequent, often seen with those 00:19:19.599 --> 00:19:22.019 dashboard injuries. The limb typically presents 00:19:22.019 --> 00:19:24.480 as shortened, abducted, and internally rotated. 00:19:24.900 --> 00:19:27.039 And anterior. Anterior dislocations are less 00:19:27.039 --> 00:19:30.119 common. The limb is typically externally rotated, 00:19:30.579 --> 00:19:33.700 abducted, and may be slightly flexed. The reduction 00:19:33.700 --> 00:19:36.579 maneuver is often considered slightly more straightforward 00:19:36.579 --> 00:19:40.339 due to the shallower anterior wall of the acetabulum, 00:19:40.680 --> 00:19:42.640 but they can still be challenging. What if you 00:19:42.640 --> 00:19:45.720 can't reduce it closed? If closed reduction fails 00:19:45.720 --> 00:19:47.779 in the emergency department, the implications 00:19:47.779 --> 00:19:50.279 are serious. The patient must be transferred 00:19:50.279 --> 00:19:52.900 immediately to the operating theater for an open 00:19:52.900 --> 00:19:56.269 reduction. This should ideally be performed by 00:19:56.269 --> 00:19:59.069 a hip surgeon, familiar with the necessary approaches, 00:19:59.329 --> 00:20:01.690 often a posterior approach, and someone who is 00:20:01.690 --> 00:20:03.869 able to explore the sciatic nerve if there's 00:20:03.869 --> 00:20:07.490 any concern about entrapment or injury. So specialist 00:20:07.490 --> 00:20:10.309 input is needed quickly. Yes. It highlights the 00:20:10.309 --> 00:20:12.410 critical importance of having the right expertise 00:20:12.410 --> 00:20:15.630 available immediately, day or night. We also 00:20:15.630 --> 00:20:17.589 have to remember, as we noted from the Jordan 00:20:17.589 --> 00:20:21.309 study, that more than half 53 .9 % of these patients 00:20:21.309 --> 00:20:23.390 have other significant body injuries. Right, 00:20:23.509 --> 00:20:26.609 the polytrauma aspect. Exactly. These can be 00:20:26.609 --> 00:20:28.869 life -threatening head injuries, chest trauma, 00:20:29.309 --> 00:20:32.609 abdominal bleeding, other fractures. They require 00:20:32.609 --> 00:20:36.130 urgent simultaneous attention within a multidisciplinary 00:20:36.130 --> 00:20:39.930 trauma team setting. It's a comprehensive, coordinated 00:20:39.930 --> 00:20:42.630 approach that's vital for survival and optimal 00:20:42.630 --> 00:20:45.500 outcomes. That immediate coordinated response 00:20:45.500 --> 00:20:48.740 is absolutely critical. But Professor, it's equally 00:20:48.740 --> 00:20:50.700 important to clarify, as you hinted earlier, 00:20:50.759 --> 00:20:53.599 that not all acetabular fractures require immediate 00:20:53.599 --> 00:20:56.500 surgery. When is non -operative management a 00:20:56.500 --> 00:20:59.140 viable and perhaps even preferable option for 00:20:59.140 --> 00:21:02.839 these complex injuries? And what does true functional, 00:21:03.119 --> 00:21:05.400 consumptive care actually look like in practice? 00:21:05.480 --> 00:21:07.599 It's not just bed rest, is it? No, absolutely 00:21:07.599 --> 00:21:09.059 not. That's a crucial distinction at a point 00:21:09.059 --> 00:21:11.400 I often emphasize, particularly when discussing 00:21:11.400 --> 00:21:13.740 elderly patients. Non -surgical treatment is 00:21:13.740 --> 00:21:16.039 a viable and often very appropriate option in 00:21:16.039 --> 00:21:18.700 specific scenarios. We consider it based on both 00:21:18.700 --> 00:21:20.400 the fracture characteristics and the broader 00:21:20.400 --> 00:21:22.400 patient factors. Okay, so what fracture types 00:21:22.400 --> 00:21:24.779 might be suitable? For fracture characteristics, 00:21:25.039 --> 00:21:27.920 we look for minimally displaced fractures, generally 00:21:27.920 --> 00:21:30.400 meaning the displacement is less than two millimeters 00:21:30.400 --> 00:21:33.880 on all views. Certain stable fractures, perhaps 00:21:33.880 --> 00:21:36.819 some isolated anterior column or anterior wall 00:21:36.819 --> 00:21:39.220 fractures, can also be managed non -operatively 00:21:39.220 --> 00:21:42.019 if the joint remains congruent. And crucially, 00:21:42.430 --> 00:21:45.710 Some associated both column fractures can exhibit 00:21:45.710 --> 00:21:48.670 what we call secondary congruency. Remember that? 00:21:48.809 --> 00:21:51.650 Yes, where it looks aligned despite being detached. 00:21:51.849 --> 00:21:54.869 Exactly. Where, despite the fragments being significantly 00:21:54.869 --> 00:21:56.970 displaced relative to the rest of the pelvis, 00:21:57.329 --> 00:21:59.549 they maintain a relatively stable articulation 00:21:59.549 --> 00:22:02.309 around the femoral head itself. In these select 00:22:02.309 --> 00:22:04.650 cases, even with significant displacement from 00:22:04.650 --> 00:22:07.069 the pelvic ring, the hip joint might still function 00:22:07.069 --> 00:22:09.890 acceptably without surgery, avoiding major operation. 00:22:10.769 --> 00:22:13.849 Lastly, highly combinated fractures, very shattered 00:22:13.849 --> 00:22:16.509 and severely osculoporotic bone might also be 00:22:16.509 --> 00:22:19.089 better suited for conservative management. This 00:22:19.089 --> 00:22:21.329 is because attempting surgical fixation in such 00:22:21.329 --> 00:22:24.150 poor quality bone can be technically very difficult, 00:22:24.410 --> 00:22:26.549 unreliable, and prone to failure, potentially 00:22:26.549 --> 00:22:28.809 causing more harm than good. And what about patient 00:22:28.809 --> 00:22:32.150 factors? Patient factors are equally, if not 00:22:32.150 --> 00:22:34.950 more important, especially in the geriatric population. 00:22:35.079 --> 00:22:38.279 We strongly consider non -operative management 00:22:38.279 --> 00:22:40.660 for patients who are at a very high risk for 00:22:40.660 --> 00:22:44.299 surgical complications due to significant comorbidities. 00:22:44.569 --> 00:22:46.789 things like severe uncontrolled heart disease, 00:22:47.289 --> 00:22:49.630 advanced lung disease, poorly controlled diabetes, 00:22:50.190 --> 00:22:52.690 perhaps advanced dementia, or those with severely 00:22:52.690 --> 00:22:55.490 limited pre -injury mobility who simply may not 00:22:55.490 --> 00:22:57.849 tolerate extensive surgery and the demanding 00:22:57.849 --> 00:23:00.450 rehabilitation afterwards. Makes sense. Also, 00:23:00.609 --> 00:23:03.609 patients presenting late, say, more than three 00:23:03.609 --> 00:23:05.490 weeks after the injury where the fracture has 00:23:05.490 --> 00:23:07.690 already started to stick or partially healed 00:23:07.690 --> 00:23:10.950 with fibrous tissue may also be candidates. Delayed 00:23:10.950 --> 00:23:13.109 surgery in these cases can be exponentially more 00:23:13.109 --> 00:23:14.970 challenging and fra - with complications like 00:23:14.970 --> 00:23:17.789 infection or nerve injury. And finally, sometimes 00:23:17.789 --> 00:23:20.289 surgical factors play a role. If there's a lack 00:23:20.289 --> 00:23:22.670 of available multidisciplinary expertise locally 00:23:22.670 --> 00:23:25.089 to offer complex reconstructive surgery safely 00:23:25.089 --> 00:23:27.289 and effectively, then conservative management 00:23:27.289 --> 00:23:29.089 might indeed be the more prudent and ethical 00:23:29.089 --> 00:23:31.789 choice for that patient in that setting. So if 00:23:31.789 --> 00:23:34.049 non -operative is chosen, what does that involve? 00:23:34.430 --> 00:23:36.420 Definitely not just lying in bed. Absolutely 00:23:36.420 --> 00:23:39.079 not. Modern functional conservative treatment 00:23:39.079 --> 00:23:42.539 is far from passive bed rest. It demands a comprehensive, 00:23:42.680 --> 00:23:46.039 proactive, multidisciplinary team approach. This 00:23:46.039 --> 00:23:48.799 absolutely has to include specialist physiotherapists 00:23:48.799 --> 00:23:52.039 guiding early, safe movement, excellent nursing 00:23:52.039 --> 00:23:54.319 care focusing on skin integrity, nutrition, and 00:23:54.319 --> 00:23:57.000 comfort, dedicated pain management teams using 00:23:57.000 --> 00:23:59.740 multimodal analgesia, occupational therapists 00:23:59.740 --> 00:24:01.799 assisting with adaptations for daily living, 00:24:02.339 --> 00:24:04.460 or for geriatricians who are utterly vital for 00:24:04.460 --> 00:24:06.680 managing comorbidities. and optimizing the patient's 00:24:06.680 --> 00:24:09.079 overall medical health. Nutritionists and robust 00:24:09.079 --> 00:24:11.680 community rehabilitation support teams for ongoing 00:24:11.680 --> 00:24:14.200 recovery after discharge. It takes a village. 00:24:14.640 --> 00:24:16.380 It really does sound like a team effort. What 00:24:16.380 --> 00:24:18.779 are the key components? Key components include 00:24:18.779 --> 00:24:21.160 meticulous pain management. Getting that right 00:24:21.160 --> 00:24:24.000 is fundamental. Correcting any fluid and electrolyte 00:24:24.000 --> 00:24:27.269 imbalances. Proactive pressure area care to prevent 00:24:27.269 --> 00:24:30.289 devastating pressure sores. Early chest physiotherapy 00:24:30.289 --> 00:24:32.549 to prevent pneumonia and limb physiotherapy to 00:24:32.549 --> 00:24:35.089 maintain muscle strength and joint range. Early 00:24:35.089 --> 00:24:37.190 progression to sitting out of bed is crucial. 00:24:37.769 --> 00:24:40.809 And of course, venous thromboembolism or VTE 00:24:40.809 --> 00:24:43.210 prophylaxis blood thinners is critical throughout 00:24:43.210 --> 00:24:46.009 to prevent clots. But the cornerstone is early 00:24:46.009 --> 00:24:48.809 mobilization. Patients are actively encouraged 00:24:48.809 --> 00:24:51.769 to move as pain allows, often self -regulating 00:24:51.769 --> 00:24:54.539 their weight -bearing. We often find that elderly 00:24:54.539 --> 00:24:56.940 patients in particular frequently struggle with 00:24:56.940 --> 00:24:58.619 strict non -weight -bearing instructions due 00:24:58.619 --> 00:25:01.160 to other medical issues, perhaps upper limb weakness 00:25:01.160 --> 00:25:04.019 from arthritis or balance problems. So you adapt? 00:25:04.339 --> 00:25:06.880 We have to be pragmatic. Supervised ambulation 00:25:06.880 --> 00:25:09.160 with appropriate walking aids, like a Zimmer 00:25:09.160 --> 00:25:11.819 frame, is common and actively encouraged as soon 00:25:11.819 --> 00:25:14.579 as it's safe. All the while we maintain constant 00:25:14.579 --> 00:25:16.859 clinical and radiological surveillance, usually 00:25:16.859 --> 00:25:19.440 with weekly x -rays initially, to watch for any 00:25:19.440 --> 00:25:21.299 late displacement that might change the plan. 00:25:21.440 --> 00:25:23.279 And what about traction? Does that still have 00:25:23.279 --> 00:25:25.839 a role? The role of prolonged skeletal traction 00:25:25.839 --> 00:25:28.279 has diminished significantly in modern management, 00:25:28.720 --> 00:25:31.859 especially for frail elderly patients. It has 00:25:31.859 --> 00:25:35.140 major disadvantages. Pressure sores, muscle wasting, 00:25:35.680 --> 00:25:38.359 joint stiffness, risk of pin site infection, 00:25:38.799 --> 00:25:42.319 and the pins can easily disengage in porous osteoporotic 00:25:42.319 --> 00:25:45.680 bone. It might be used very short -term preoperatively, 00:25:45.960 --> 00:25:48.500 but not generally as a definitive long -term 00:25:48.500 --> 00:25:51.079 treatment anymore. What does the evidence say 00:25:51.079 --> 00:25:53.740 about outcomes for this non -operative approach? 00:25:54.119 --> 00:25:56.720 Well, perhaps surprisingly to some, studies have 00:25:56.720 --> 00:25:58.980 shown reasonably good functional outcomes in 00:25:58.980 --> 00:26:01.460 select elderly patients treated non -operatively, 00:26:01.980 --> 00:26:04.200 even for some fracture patterns that would typically 00:26:04.200 --> 00:26:06.940 meet operative criteria in younger, fitter individuals. 00:26:07.259 --> 00:26:09.900 What's truly interesting is that there's no convincing 00:26:09.900 --> 00:26:12.279 evidence when you adjust for comorbidities that 00:26:12.279 --> 00:26:14.779 conservative management inherently leads to higher 00:26:14.779 --> 00:26:17.400 mortality or higher re -operation rates compared 00:26:17.400 --> 00:26:21.039 to surgery in this specific elderly cohort. Yes, 00:26:21.559 --> 00:26:24.140 and secondary conversion rates to total hip arthroplasty, 00:26:24.579 --> 00:26:27.299 or THA, down the line are often quite similar 00:26:27.299 --> 00:26:29.740 for both conservatively and operatively treated 00:26:29.740 --> 00:26:32.420 patients in this age group. They might end up 00:26:32.420 --> 00:26:35.079 needing a hip replacement either way. Another 00:26:35.079 --> 00:26:37.299 fascinating point from a technical perspective 00:26:37.299 --> 00:26:39.920 is that performing a delayed primary arthroplasty, 00:26:40.119 --> 00:26:41.859 a planned hip replacement later on following 00:26:41.859 --> 00:26:44.160 a period of conservatively managed fracture healing, 00:26:44.799 --> 00:26:46.980 is often technically more straightforward than 00:26:46.980 --> 00:26:49.500 doing a secondary THA after a failed surgical 00:26:49.500 --> 00:26:52.400 fixation. This is primarily due to less scar 00:26:52.400 --> 00:26:54.480 tissue formation and no hardware interference 00:26:54.480 --> 00:26:57.380 from plates and screws that need removing. So 00:26:57.380 --> 00:26:59.019 this functional conservative approach really 00:26:59.019 --> 00:27:01.500 highlights a pragmatic, patient -centered philosophy 00:27:01.500 --> 00:27:03.740 when facing these complex challenges in our older 00:27:03.740 --> 00:27:06.180 population. That's a truly crucial distinction 00:27:06.180 --> 00:27:08.759 from perhaps older, more restrictive ideas of 00:27:08.759 --> 00:27:12.180 conservative care. Now, shifting gears for fractures 00:27:12.180 --> 00:27:14.759 that are significantly displaced, unstable, and 00:27:14.759 --> 00:27:17.400 deemed suitable for surgery, open reduction internal 00:27:17.400 --> 00:27:20.440 fixation, or ORFF, remains a primary approach. 00:27:21.089 --> 00:27:23.690 Professor, what are the core goals when you undertake 00:27:23.690 --> 00:27:26.289 ORFF? What surgical techniques are involved? 00:27:26.490 --> 00:27:28.349 And crucially, what persistent challenges do 00:27:28.349 --> 00:27:30.470 you still face, especially in older patients? 00:27:30.769 --> 00:27:33.809 When ORFS is the chosen path, our primary goals 00:27:33.809 --> 00:27:36.329 are threefold, and each is absolutely critical 00:27:36.329 --> 00:27:38.250 for the long -term survival and function of the 00:27:38.250 --> 00:27:40.880 patient's hip. First, we aim to meticulously 00:27:40.880 --> 00:27:44.000 restore a smooth, gliding hip surface. The joint 00:27:44.000 --> 00:27:46.539 needs to move without friction or catching to 00:27:46.539 --> 00:27:49.380 prevent premature wear and pain. Second, we strive 00:27:49.380 --> 00:27:51.940 to achieve an anatomical reduction. That means 00:27:51.940 --> 00:27:53.859 the bone fragments are pieced back together as 00:27:53.859 --> 00:27:56.119 perfectly as possible, with the goal being post 00:27:56.119 --> 00:27:58.099 -operative displacement ideally less than two 00:27:58.099 --> 00:28:00.529 millimeters on follow -up imaging. That Jordan 00:28:00.529 --> 00:28:02.609 study reported achieving this level of reduction 00:28:02.609 --> 00:28:05.250 in about 84 % of their surgically treated cases, 00:28:05.430 --> 00:28:07.569 which is good, but still leaves a significant 00:28:07.569 --> 00:28:11.069 minority with less than perfect reduction. The 00:28:11.069 --> 00:28:14.269 third goal is to provide robust, stable fixation 00:28:14.269 --> 00:28:17.500 with plates and screws. This is essential to 00:28:17.500 --> 00:28:20.099 hold the reduction while the bone heals, and 00:28:20.099 --> 00:28:23.279 importantly to try and prevent or delay the onset 00:28:23.279 --> 00:28:25.720 of post -traumatic osteoarthritis, which unfortunately 00:28:25.720 --> 00:28:28.099 remains a significant long -term complication 00:28:28.099 --> 00:28:30.900 even after technically successful surgery. Is 00:28:30.900 --> 00:28:33.680 there an ideal time to do the surgery? Yes. The 00:28:33.680 --> 00:28:35.859 optimal timing for ORFF is generally considered 00:28:35.859 --> 00:28:38.480 to be in the window between about 3 and 10 days 00:28:38.480 --> 00:28:41.630 post -injury. Why that specific window? Well, 00:28:41.789 --> 00:28:43.829 this allows some of the initial soft tissue swelling 00:28:43.829 --> 00:28:46.410 to subside, making the surgery technically easier 00:28:46.410 --> 00:28:48.829 and potentially reducing room complications. 00:28:49.509 --> 00:28:51.829 But it's before significant bone resorption or 00:28:51.829 --> 00:28:53.910 fibrous tissue formation occurs at the fracture 00:28:53.910 --> 00:28:56.349 site, which can make achieving an anatomical 00:28:56.349 --> 00:28:58.829 reduction much more difficult. The fragments 00:28:58.829 --> 00:29:01.630 sort of get sticky and resistant to moving back 00:29:01.630 --> 00:29:04.579 into place. Delays beyond 10 days can certainly 00:29:04.579 --> 00:29:07.039 complicate reductions significantly, and delays 00:29:07.039 --> 00:29:09.440 exceeding 3 weeks can lead to substantial problems 00:29:09.440 --> 00:29:11.619 with both achieving reduction and maintaining 00:29:11.619 --> 00:29:14.140 stable fixation due to that progressive bone 00:29:14.140 --> 00:29:16.480 resorption and early callus formation. How do 00:29:16.480 --> 00:29:19.319 you decide which surgical approach to use? The 00:29:19.319 --> 00:29:21.900 surgical approach is chosen very carefully, based 00:29:21.900 --> 00:29:24.299 almost entirely on the specific fracture pattern 00:29:24.299 --> 00:29:27.579 identified on the CT scan. You tailor the approach 00:29:27.579 --> 00:29:29.599 to get the best access to the fractured columns 00:29:29.599 --> 00:29:32.680 that need fixing. For anterior approaches, we 00:29:32.680 --> 00:29:34.960 commonly use either the classic ilioinguinal 00:29:34.960 --> 00:29:38.140 approach or, increasingly, the modified stoppa 00:29:38.140 --> 00:29:40.579 approach, sometimes combined with a lateral window. 00:29:40.779 --> 00:29:43.440 The modified STAPA in particular is highlighted 00:29:43.440 --> 00:29:45.700 for giving excellent visualization of the anterior 00:29:45.700 --> 00:29:48.720 column in the medial wall or quadrilateral plate, 00:29:49.099 --> 00:29:51.519 and it can even allow some access to the anterior 00:29:51.519 --> 00:29:54.259 aspect of the posterior column. It's particularly 00:29:54.259 --> 00:29:56.940 beneficial for buttressing comminuted medial 00:29:56.940 --> 00:29:59.119 wall fractures. And for posterior fractures? 00:29:59.400 --> 00:30:01.759 For posterior approaches, the workhorse is the 00:30:01.759 --> 00:30:04.059 Kocher -Langenbeck approach. This is commonly 00:30:04.059 --> 00:30:06.160 used for posterior wall and posterior column 00:30:06.160 --> 00:30:08.880 fractures. Occasionally for very complex patterns, 00:30:09.119 --> 00:30:11.140 like some both column fractures, a combination 00:30:11.140 --> 00:30:13.440 of approaches, perhaps anterior and posterior, 00:30:13.599 --> 00:30:16.299 might be necessary. But this significantly increases 00:30:16.299 --> 00:30:19.359 the operative time, blood loss, and overall morbidity 00:30:19.359 --> 00:30:21.539 for the patient. So we try to avoid it if possible. 00:30:21.839 --> 00:30:24.119 Can you walk us through the basic surgical technique? 00:30:24.319 --> 00:30:27.000 Sure. In terms of surgical techniques, the displaced 00:30:27.000 --> 00:30:29.440 bone fragments are first carefully repositioned, 00:30:29.440 --> 00:30:32.359 or reduced, back into their normal anatomical 00:30:32.359 --> 00:30:35.160 alignment, often using specialized clamps and 00:30:35.160 --> 00:30:37.619 instruments, all under fluoroscopic guidance 00:30:37.619 --> 00:30:41.579 live X -ray checks. Then metal plates contour 00:30:41.579 --> 00:30:44.079 to the bone shape and screws are meticulously 00:30:44.079 --> 00:30:46.119 attached to the outer surfaces of the bone to 00:30:46.119 --> 00:30:48.480 hold the fragments securely while the fracture 00:30:48.480 --> 00:30:51.809 heals. In osteoporotic bone, there's a growing 00:30:51.809 --> 00:30:54.509 use of locking implants plates, where the screws 00:30:54.509 --> 00:30:56.750 lock into the plate itself at a fixed angle. 00:30:57.390 --> 00:30:59.690 This theoretically provides better fixation stability 00:30:59.690 --> 00:31:02.069 in weak bone, though comprehensive comparative 00:31:02.069 --> 00:31:04.369 evidence showing superior outcomes versus conventional 00:31:04.369 --> 00:31:07.430 plates is still somewhat limited but emerging. 00:31:07.690 --> 00:31:10.150 What about bone grafting? Yes, that's often crucial. 00:31:10.410 --> 00:31:12.490 It's very important to consider bone grafting, 00:31:12.750 --> 00:31:14.730 using either autograft taken from the patient's 00:31:14.730 --> 00:31:17.690 own pelvis or perhaps cancerless bone substitutes 00:31:17.690 --> 00:31:20.369 to fill any underlying metaphysical defects, 00:31:20.789 --> 00:31:23.529 particularly after elevating impacted articular 00:31:23.529 --> 00:31:26.630 fragments. If you lift up a depressed piece of 00:31:26.630 --> 00:31:29.170 joint surface, there's often a void underneath. 00:31:29.849 --> 00:31:32.170 Filling this void is critical for supporting 00:31:32.170 --> 00:31:34.690 the elevated fragments and preventing them from 00:31:34.690 --> 00:31:36.710 collapsing again under load during weight bearing. 00:31:36.829 --> 00:31:39.170 Despite the best techniques, complications can 00:31:39.170 --> 00:31:41.809 still happen. Oh, absolutely. Despite meticulous 00:31:41.809 --> 00:31:44.490 technique, potential intraoperative and early 00:31:44.490 --> 00:31:46.609 post -operative complications are significant 00:31:46.609 --> 00:31:49.069 and must always be anticipated and discussed 00:31:49.069 --> 00:31:51.990 with the patient. Sciatic nerve injury is a major 00:31:51.990 --> 00:31:54.190 risk, particularly with the Cochlear -Langenbeck 00:31:54.190 --> 00:31:56.799 posterior approach. Reported rates are around 00:31:56.799 --> 00:32:00.339 210%, and the Jordan study reported a 3 .5 % 00:32:00.339 --> 00:32:02.400 rate of iatrogenic injury, meaning caused by 00:32:02.400 --> 00:32:05.019 the surgery itself. This can lead to the functionally 00:32:05.019 --> 00:32:07.960 debilitating foot drop. Heterotopic ossification, 00:32:08.240 --> 00:32:11.259 or HO, that abnormal growth of bone and the soft 00:32:11.259 --> 00:32:13.480 tissues around the hip is another significant 00:32:13.480 --> 00:32:16.200 concern. The highest incidence is seen with the 00:32:16.200 --> 00:32:18.700 older, more extensive approaches, though it seems 00:32:18.700 --> 00:32:21.940 to be lower with the ilioinguinal approach. We 00:32:21.940 --> 00:32:24.240 sometimes use prophylaxis, like radiation or 00:32:24.240 --> 00:32:26.440 medication, to try and prevent it in high -risk 00:32:26.440 --> 00:32:29.700 cases. There is also always a risk, albeit small, 00:32:30.180 --> 00:32:32.039 of damage to the blood supply of the femoral 00:32:32.039 --> 00:32:34.440 head during the surgery or from the initial injury, 00:32:34.559 --> 00:32:36.960 which could lead to that dreaded irascular necrosis 00:32:36.960 --> 00:32:39.700 later on. Looking at the longer term, what are 00:32:39.700 --> 00:32:42.599 the outcomes and challenges of ORIF? Well, looking 00:32:42.599 --> 00:32:45.440 at the outcomes and challenges. Whilst the clinical 00:32:45.440 --> 00:32:47.460 outcome strongly correlates with the quality 00:32:47.460 --> 00:32:49.619 of the articular reduction, the closer you get 00:32:49.619 --> 00:32:52.329 it to anatomical. Generally, the better the result. 00:32:52.950 --> 00:32:54.809 A really significant proportion of patients, 00:32:54.930 --> 00:32:57.309 maybe up to 30 % in some studies, and perhaps 00:32:57.309 --> 00:33:00.609 around 31 % overall in others, still go on to 00:33:00.609 --> 00:33:02.609 develop post -traumatic arthritis, even with 00:33:02.609 --> 00:33:05.009 a good -looking x -ray initially. So a good reduction 00:33:05.009 --> 00:33:07.369 doesn't guarantee success. Unfortunately, not 00:33:07.369 --> 00:33:10.250 always. And this frequently leads to a high rate 00:33:10.250 --> 00:33:12.630 of late conversion to total hip arthroplasty, 00:33:13.009 --> 00:33:16.660 or THA. Some studies suggest 20 -25 % of elderly 00:33:16.660 --> 00:33:19.440 patients might need a revision surgery or conversion 00:33:19.440 --> 00:33:21.660 to a hip replacement within the first one to 00:33:21.660 --> 00:33:25.099 two years after their initial ORF. We also know 00:33:25.099 --> 00:33:27.500 that the presence of that goal sign on the initial 00:33:27.500 --> 00:33:31.000 imaging indicating severe dome impaction is considered 00:33:31.000 --> 00:33:33.740 a very strong predictor of orioth failure in 00:33:33.740 --> 00:33:36.940 geriatric acetabular fractures. Seeing that often 00:33:36.940 --> 00:33:39.279 prompts serious consideration for an acute THA 00:33:39.279 --> 00:33:43.670 from the outset rather than attempting ORF. It's 00:33:43.670 --> 00:33:45.250 also important to note that while the operative 00:33:45.250 --> 00:33:47.289 treatment itself doesn't necessarily increase 00:33:47.289 --> 00:33:49.230 or decrease mortality when you carefully account 00:33:49.230 --> 00:33:51.990 for comorbidities, high one -year mortality rates 00:33:51.990 --> 00:33:55.109 up to 25 % in one study are reported in this 00:33:55.109 --> 00:33:57.930 elderly population undergoing surgery. This is 00:33:57.930 --> 00:34:00.230 often influenced by factors like age over 70 00:34:00.230 --> 00:34:02.920 and their overall medical frailty. often measured 00:34:02.920 --> 00:34:04.980 by things like the Charleston Comorbidity Index. 00:34:05.619 --> 00:34:07.599 It truly underscores the vital importance of 00:34:07.599 --> 00:34:09.860 comprehensive medical optimization before, during, 00:34:09.920 --> 00:34:12.320 and after any major surgery in these vulnerable 00:34:12.320 --> 00:34:15.480 patients. That's a truly comprehensive and frankly 00:34:15.480 --> 00:34:18.059 quite sobering look at the outcomes sometimes 00:34:18.059 --> 00:34:20.840 seen with traditional ORIF. Given these persistent 00:34:20.840 --> 00:34:23.000 challenges, particularly in patients with poor 00:34:23.000 --> 00:34:25.980 bone quality, you mentioned an alternative strategy 00:34:25.980 --> 00:34:28.820 has emerged, the fix and replace approach or 00:34:28.820 --> 00:34:31.340 acute total hip arthroplasty. Professor, could 00:34:31.340 --> 00:34:33.500 you explain this concept and its specific role? 00:34:33.679 --> 00:34:35.679 When might you choose this? Yes, the fix and 00:34:35.679 --> 00:34:39.539 replace strategy or acute THA combined with fixation 00:34:39.539 --> 00:34:42.179 represents a significant evolution in our thinking, 00:34:42.739 --> 00:34:44.780 particularly for managing these fractures in 00:34:44.780 --> 00:34:47.679 elderly or osteoporotic patients. The rationale 00:34:47.679 --> 00:34:49.679 is really to directly address those challenges 00:34:49.679 --> 00:34:52.119 we just discussed. The difficulty of achieving 00:34:52.119 --> 00:34:55.079 stable fixation in poor bone and the relatively 00:34:55.079 --> 00:34:57.659 high failure rates seen with ORIF alone in this 00:34:57.659 --> 00:35:00.139 group. At the same time, it aims to facilitate 00:35:00.139 --> 00:35:02.179 earlier weight bearing and functional recovery, 00:35:02.639 --> 00:35:04.860 which is so crucial for older patients to avoid 00:35:04.860 --> 00:35:07.260 deconditioning. So fixing and replacing in one 00:35:07.260 --> 00:35:10.659 go. Exactly. Instead of solely attempting to 00:35:10.659 --> 00:35:13.159 reconstruct the native joint, this approach combines 00:35:13.159 --> 00:35:16.000 fracture fixation stabilizing the columns with 00:35:16.000 --> 00:35:18.679 an immediate total hip arthroplasty during the 00:35:18.679 --> 00:35:21.639 same operation. There's some compelling data 00:35:21.639 --> 00:35:24.179 emerging. One study, for instance, highlighted 00:35:24.179 --> 00:35:27.079 its potential effectiveness, showing 100 % hip 00:35:27.079 --> 00:35:29.440 joint survival, meaning no further surgery needed 00:35:29.440 --> 00:35:32.019 on the hip replacement with this combined approach, 00:35:32.400 --> 00:35:34.860 compared to just about 29 % survival of the native 00:35:34.860 --> 00:35:37.480 hip after fixation alone in a comparable group. 00:35:37.610 --> 00:35:40.449 That's a stark difference. So when is it indicated? 00:35:40.570 --> 00:35:42.389 What are the triggers? Well, the indications 00:35:42.389 --> 00:35:44.349 for fix and replace are still evolving and there 00:35:44.349 --> 00:35:46.969 isn't universal consensus. But common factors 00:35:46.969 --> 00:35:49.809 that push us towards it include very complex 00:35:49.809 --> 00:35:51.829 judit laturnal fracture patterns, especially 00:35:51.829 --> 00:35:54.929 those involving both columns or significant combination 00:35:54.929 --> 00:35:57.550 of the weight bearing dome. The presence of significant 00:35:57.550 --> 00:35:59.969 pre -existing hip osteoarthritis is a strong 00:35:59.969 --> 00:36:03.409 indicator. Associated femoral head or neck fractures 00:36:03.409 --> 00:36:06.550 often make reconstruction impossible. Any pathological 00:36:06.550 --> 00:36:08.969 fracture through tumor. Significant cartilage 00:36:08.969 --> 00:36:11.050 damage seen either on imaging or at the time 00:36:11.050 --> 00:36:13.190 of surgery to either the femoral head or the 00:36:13.190 --> 00:36:16.010 incetabulum. And patient factors. Yes, poor bone 00:36:16.010 --> 00:36:18.929 quality, significant osteopenia or osteoporosis 00:36:18.929 --> 00:36:21.769 where you anticipate fixation will be unreliable 00:36:21.769 --> 00:36:24.809 is a major factor. Fractures deemed unreconstructable. 00:36:24.989 --> 00:36:27.849 patients presenting after a prolonged hip dislocation 00:36:27.849 --> 00:36:30.429 where the femoral head might be damaged, or delayed 00:36:30.429 --> 00:36:32.710 presentations where the window for optimal ORIF 00:36:32.710 --> 00:36:35.409 has closed. Furthermore, several negative prognostic 00:36:35.409 --> 00:36:37.829 factors we discussed earlier, like age over 40 00:36:37.829 --> 00:36:40.929 or certainly over 60, an anticipated poor reduction 00:36:40.929 --> 00:36:42.769 with more than three millimeters of residual 00:36:42.769 --> 00:36:46.050 displacement, multifragmentary fractures, very 00:36:46.050 --> 00:36:48.429 significant initial displacement of over 20 millimeters, 00:36:48.929 --> 00:36:50.949 or delayed surgery, particularly more than five 00:36:50.949 --> 00:36:53.949 days for associated patterns, or 15 days for 00:36:53.949 --> 00:36:56.699 elementary all might steer the decision towards 00:36:56.699 --> 00:36:59.199 this combined procedure. How is it done technically? 00:36:59.420 --> 00:37:01.960 Is it just like a standard hip replacement? Not 00:37:01.960 --> 00:37:05.550 quite. It's significantly more complex. The primary 00:37:05.550 --> 00:37:07.869 principle technically is still to achieve stable 00:37:07.869 --> 00:37:11.110 osteosynthesis, stable fixation of the acetabular 00:37:11.110 --> 00:37:13.610 columns first, typically using plates and screws. 00:37:14.170 --> 00:37:17.150 For example, we might meticulously use two posterior 00:37:17.150 --> 00:37:20.070 column plates to achieve optimal rotational stability 00:37:20.070 --> 00:37:23.090 of the hemipelvis. This creates a robust, bony 00:37:23.090 --> 00:37:25.530 foundation onto which the acetabular prosthetic 00:37:25.530 --> 00:37:28.050 component, the cup, can be securely implanted. 00:37:28.329 --> 00:37:30.309 So you fix the pelvis first, then put the cup 00:37:30.309 --> 00:37:33.769 in? Essentially. Yes, modern practice often involves 00:37:33.769 --> 00:37:36.650 using highly porous acetabular components like 00:37:36.650 --> 00:37:39.210 trabecular metal or similar materials, which 00:37:39.210 --> 00:37:41.590 offer excellent biological fixation potential. 00:37:41.849 --> 00:37:44.550 These cups often have multiple screw options, 00:37:44.989 --> 00:37:46.969 allowing fixation into intact bone away from 00:37:46.969 --> 00:37:49.170 the fracture lines. Sometimes these cups can 00:37:49.170 --> 00:37:51.269 even be drilled through in strategic locations 00:37:51.269 --> 00:37:54.030 to place additional screws, for instance, placing 00:37:54.030 --> 00:37:56.010 an anterior colon screw through the metal shell 00:37:56.010 --> 00:37:58.489 from a posterior approach to achieve a really 00:37:58.489 --> 00:38:00.730 strong triangular purchase that significantly 00:38:00.730 --> 00:38:02.989 enhances the fixation stability. That sounds 00:38:02.989 --> 00:38:04.730 technically demanding. What about the surgical 00:38:04.730 --> 00:38:07.130 approach? There's also been an evolution in surgical 00:38:07.130 --> 00:38:09.929 approaches for this. While older techniques might 00:38:09.929 --> 00:38:12.610 have involved complex constructs with intra -pelvic 00:38:12.610 --> 00:38:16.190 wires and bulky anti - protrusion cages, modern 00:38:16.190 --> 00:38:18.869 strategies often favor using a single posterior 00:38:18.869 --> 00:38:21.989 approach, like the Kocher -Langenbeck. This allows 00:38:21.989 --> 00:38:24.329 the surgeon to both fix the crucial posterior 00:38:24.329 --> 00:38:27.289 column and wall fragments and then implant the 00:38:27.289 --> 00:38:29.349 arthroplasty components through the same incision. 00:38:29.519 --> 00:38:32.420 This potentially avoids the extensive soft tissue 00:38:32.420 --> 00:38:35.380 disruption and increased complication risks associated 00:38:35.380 --> 00:38:38.380 with needing dual anterior and posterior approaches. 00:38:39.320 --> 00:38:41.420 We might also use the patient's own femoral head 00:38:41.420 --> 00:38:43.800 bone graft after it's removed for the arthroplasty 00:38:43.800 --> 00:38:46.519 to pack and support posterior wall defects, helping 00:38:46.519 --> 00:38:48.360 to reconstruct the bone stock behind the cup. 00:38:48.639 --> 00:38:51.099 It sounds effective, but complex. What about 00:38:51.099 --> 00:38:53.159 the downsides, the outcomes, and complications? 00:38:53.699 --> 00:38:56.239 You're right to ask. While fix and replace can 00:38:56.239 --> 00:38:58.139 be highly effective in preserving hip function 00:38:58.139 --> 00:39:00.960 and allowing early mobilization, it is undeniably 00:39:00.960 --> 00:39:03.760 a major surgical insult, particularly for frail 00:39:03.760 --> 00:39:06.400 elderly patients. It's a bigger operation than 00:39:06.400 --> 00:39:09.360 either ORIF or a standard primary hip replacement 00:39:09.360 --> 00:39:12.360 alone. It typically involves significantly longer 00:39:12.360 --> 00:39:14.639 operative times, averaging around three hours, 00:39:14.960 --> 00:39:17.900 174 minutes in one review, and substantially 00:39:17.900 --> 00:39:20.360 greater blood loss. averaging close to a liter, 00:39:20.559 --> 00:39:23.900 maybe 964 milliliters, compared to traditional 00:39:23.900 --> 00:39:26.960 ORIF. And complication rates. Reported complication 00:39:26.960 --> 00:39:29.760 rates are significant. They hover around 20 % 00:39:29.760 --> 00:39:32.360 in some meta -analyses, but individual studies 00:39:32.360 --> 00:39:35.539 report rates ranging up to nearly 60%. These 00:39:35.539 --> 00:39:37.320 include infections, which are always a major 00:39:37.320 --> 00:39:39.219 concern with implants and extensive surgery, 00:39:39.800 --> 00:39:41.880 heterotopic ossification, although some studies 00:39:41.880 --> 00:39:44.000 surprisingly suggest lower rates of clinically 00:39:44.000 --> 00:39:47.139 significant HO with acute THA compared to delayed 00:39:47.139 --> 00:39:50.119 THA after ORIF, and aseptic loosening of the 00:39:50.119 --> 00:39:52.800 acetabular component over time requiring revision 00:39:52.800 --> 00:39:55.599 surgery. The revision rate was about 2 .3 % in 00:39:55.599 --> 00:39:57.800 one systematic review over a medium -term follow 00:39:57.800 --> 00:40:00.739 -up of about 4 .5 years. Dislocation rates can 00:40:00.739 --> 00:40:03.079 also be higher than standard THA. What about 00:40:03.079 --> 00:40:06.119 mortality with this bigger operation? Mortality 00:40:06.119 --> 00:40:08.699 rates are also a serious consideration. The mean 00:40:08.699 --> 00:40:11.500 reported rate is around 9%, but studies have 00:40:11.500 --> 00:40:14.639 shown rates up to 58 % at three years in some 00:40:14.639 --> 00:40:17.900 very frail cohorts, with perhaps 26 % mortality 00:40:17.900 --> 00:40:20.440 in the first year alone being reported in one 00:40:20.440 --> 00:40:22.940 challenging group. It's crucial to acknowledge 00:40:22.940 --> 00:40:25.179 that the high -level evidence base for acute 00:40:25.179 --> 00:40:28.500 THA, specifically for acetabular fractures, is 00:40:28.500 --> 00:40:31.170 still developing. This means that the surgeon's 00:40:31.170 --> 00:40:33.550 experience, judgment, and the specific capabilities 00:40:33.550 --> 00:40:35.730 of the treating center remain absolutely crucial 00:40:35.730 --> 00:40:37.969 in guiding these complex high -stakes decisions. 00:40:38.469 --> 00:40:40.269 So it really requires a balanced perspective. 00:40:40.519 --> 00:40:42.920 While it may lead to better intermediate hip 00:40:42.920 --> 00:40:45.099 survival and function compared to Oriaf alone 00:40:45.099 --> 00:40:47.619 in selected elderly patients, the decision for 00:40:47.619 --> 00:40:49.420 fix and replace must be very carefully weighed 00:40:49.420 --> 00:40:51.699 against these significant upfront risks and the 00:40:51.699 --> 00:40:54.119 potential alternative of a simpler delayed THA 00:40:54.119 --> 00:40:56.539 after a period of functional conservative management, 00:40:56.940 --> 00:40:59.179 especially for the most committed difficult fractures 00:40:59.179 --> 00:41:02.360 in the frailest patients. That's a truly comprehensive 00:41:02.360 --> 00:41:05.780 and again quite a nuanced look at the fix and 00:41:05.780 --> 00:41:08.340 replace strategy and the critical decision making 00:41:08.340 --> 00:41:11.289 involved. In the immediate treatment strategy, 00:41:11.449 --> 00:41:13.809 Professor, what truly dictates a patient's long 00:41:13.809 --> 00:41:16.690 -term journey? What factors determine the ultimate 00:41:16.690 --> 00:41:19.869 survival of their native hip after an acetabular 00:41:19.869 --> 00:41:22.230 fracture? You use that phrase, death of the hip. 00:41:22.250 --> 00:41:24.820 What predicts that? This really gets to the heart 00:41:24.820 --> 00:41:27.159 of the long -term impact of these injuries. We 00:41:27.159 --> 00:41:29.139 use that concept of death of the hip essentially 00:41:29.139 --> 00:41:31.900 as the ultimate need for a total hip replacement, 00:41:32.300 --> 00:41:34.579 sometimes many years after the initial injury 00:41:34.579 --> 00:41:37.460 and fixation. Several key prognostic indicators 00:41:37.460 --> 00:41:40.099 truly dictate this long -term journey and determine 00:41:40.099 --> 00:41:42.440 if that native hip can be preserved or if it's 00:41:42.440 --> 00:41:44.340 destined for replacement. What's the most significant 00:41:44.340 --> 00:41:47.320 factor? The strongest predictor of poor outcos, 00:41:47.519 --> 00:41:51.500 unequivocally, is age. Older patients, especially 00:41:51.500 --> 00:41:54.380 those over 60, or perhaps even over 40, according 00:41:54.380 --> 00:41:57.139 to some research, are significantly more likely 00:41:57.139 --> 00:42:00.079 to have fragile osteoporotic bone, experience 00:42:00.079 --> 00:42:02.320 higher rates of surgical and medical complications, 00:42:02.699 --> 00:42:04.900 and ultimately have a greater chance of requiring 00:42:04.900 --> 00:42:08.420 a THA. Their physiological reserve is simply 00:42:08.420 --> 00:42:11.400 lower, making recovery more arduous, and achieving 00:42:11.400 --> 00:42:14.260 lasting stable fixation is inherently more difficult. 00:42:14.619 --> 00:42:17.219 And after age. Another paramount factor is the 00:42:17.219 --> 00:42:19.219 quality of the articular reduction achieved at 00:42:19.219 --> 00:42:21.280 the time of surgery, if surgery is performed. 00:42:21.550 --> 00:42:24.269 An imperfect reduction, clinically defined as 00:42:24.269 --> 00:42:26.429 post -operative displacement persisting at greater 00:42:26.429 --> 00:42:29.190 than 2 millimeters, significantly increases the 00:42:29.190 --> 00:42:31.130 risk of developing post -traumatic arthritis. 00:42:31.730 --> 00:42:33.829 If that smooth joint surface isn't perfectly 00:42:33.829 --> 00:42:37.010 realigned, even by a millimeter or two, it inevitably 00:42:37.010 --> 00:42:39.309 sets the stage for accelerated wear and tear, 00:42:39.610 --> 00:42:41.849 leading to progressive pain, stiffness, and joint 00:42:41.849 --> 00:42:43.829 destruction. Does the fracture pattern itself 00:42:43.829 --> 00:42:46.909 matter long term? Yes. Specific fracture patterns 00:42:46.909 --> 00:42:49.090 and their initial severity also play a major 00:42:49.090 --> 00:42:52.269 role. For example, Posterior wall fractures, 00:42:52.530 --> 00:42:54.650 despite sometimes appearing relatively simple 00:42:54.650 --> 00:42:57.510 on initial assessment, often carry a surprisingly 00:42:57.510 --> 00:43:01.050 poor long -term prognosis. This is often due 00:43:01.050 --> 00:43:03.670 to associated complications like subtle marginal 00:43:03.670 --> 00:43:06.409 impaction, higher risk of sciatic nerve injury, 00:43:06.909 --> 00:43:09.409 heterotopic ossification, and a propensity for 00:43:09.409 --> 00:43:12.059 secondary osteoarthritis development. Similarly, 00:43:12.420 --> 00:43:14.280 the more complex patterns like transverse and 00:43:14.280 --> 00:43:16.699 T -type fractures and the associated both -column 00:43:16.699 --> 00:43:19.079 fractures often present higher risks just given 00:43:19.079 --> 00:43:21.219 their inherent instability and the sheer extent 00:43:21.219 --> 00:43:23.400 of disruption to the joint architecture. What 00:43:23.400 --> 00:43:25.920 about damage to other structures? Absolutely. 00:43:26.480 --> 00:43:29.219 Associated injuries are critical prognostic indicators. 00:43:29.820 --> 00:43:31.960 This includes any direct damage to the femoral 00:43:31.960 --> 00:43:34.659 head cartilage itself sustained during the initial 00:43:34.659 --> 00:43:38.019 injury or dislocation, significant marginal impaction, 00:43:38.190 --> 00:43:40.190 That crushing of the cancellous bone under the 00:43:40.190 --> 00:43:42.590 articular surface, especially in the weight -bearing 00:43:42.590 --> 00:43:46.210 dome, is a bad sign. Any pre -existing arthritis 00:43:46.210 --> 00:43:48.750 in the hip joint obviously worsens the prognosis. 00:43:49.510 --> 00:43:51.670 And other major systemic injuries, like head 00:43:51.670 --> 00:43:54.130 or chest trauma, can significantly complicate 00:43:54.130 --> 00:43:56.590 the overall recovery trajectory and impact the 00:43:56.590 --> 00:43:59.210 functional outcome. And that seagull sign we 00:43:59.210 --> 00:44:01.809 discussed earlier, visible on imaging and indicative 00:44:01.809 --> 00:44:04.869 of severe dome impaction, is a particularly strong 00:44:04.869 --> 00:44:08.050 poor prognostic sign. Seeing that often immediately 00:44:08.050 --> 00:44:10.289 suggests that attempting to save the native joint 00:44:10.289 --> 00:44:13.230 with ORIVE is likely futile, and total hip replacement, 00:44:13.449 --> 00:44:15.210 either acutely or delayed, might be the more 00:44:15.210 --> 00:44:17.409 realistic option. Does delaying surgery affect 00:44:17.409 --> 00:44:20.650 the long -term outcome? Yes. The delay to surgery 00:44:20.650 --> 00:44:23.349 significantly impacts outcomes, particularly 00:44:23.349 --> 00:44:26.739 for ORIF. Prolonged delays beyond that optimal 00:44:26.739 --> 00:44:30.179 window say more than five days for complex associated 00:44:30.179 --> 00:44:32.960 fractures or perhaps more than 15 days for elementary 00:44:32.960 --> 00:44:35.519 fractures have been consistently shown to negatively 00:44:35.519 --> 00:44:37.860 impact a surgeon's ability to achieve and maintain 00:44:37.860 --> 00:44:40.480 an anatomical reduction. This directly affects 00:44:40.480 --> 00:44:42.900 the long -term prognosis and increases the risk 00:44:42.900 --> 00:44:44.719 of secondary osteoarthritis developing later. 00:44:44.960 --> 00:44:46.860 What are the most common long -term problems 00:44:46.860 --> 00:44:49.860 people face? In terms of common long -term complications, 00:44:50.360 --> 00:44:52.380 post -traumatic arthritis is by far the most 00:44:52.380 --> 00:44:55.159 frequent issue, leading to chronic pain, stiffness, 00:44:55.559 --> 00:44:57.820 and functional limitation, often necessitating 00:44:57.820 --> 00:45:01.340 that late THA. Heterotopic ossification is also 00:45:01.340 --> 00:45:03.760 common, where that abnormal bone grows around 00:45:03.760 --> 00:45:06.480 the joint, physically restricting movement. A 00:45:06.480 --> 00:45:09.019 vascular necrosis, or AVN, of the femoral head 00:45:09.019 --> 00:45:12.059 occurs in roughly 6 to 7 percent of all acetabular 00:45:12.059 --> 00:45:14.610 fractures, but the risk is higher. perhaps up 00:45:14.610 --> 00:45:17.530 to 18 % in posterior fracture patterns or after 00:45:17.530 --> 00:45:19.849 dislocation, where the blood supply to the femoral 00:45:19.849 --> 00:45:22.989 head is most vulnerable. Other significant long 00:45:22.989 --> 00:45:24.750 -term issues include chronic pain, which can 00:45:24.750 --> 00:45:26.869 be multifactorial, and persistent nerve injury, 00:45:27.230 --> 00:45:29.210 such as that debilitating foot drop from sciatic 00:45:29.210 --> 00:45:31.670 nerve damage, which can require long -term bracing 00:45:31.670 --> 00:45:34.090 and significantly impact quality of life. How 00:45:34.090 --> 00:45:36.409 long does recovery typically take? The recovery 00:45:36.409 --> 00:45:38.409 timeline for these major injuries is extensive 00:45:38.409 --> 00:45:40.570 and requires considerable patience from both 00:45:40.570 --> 00:45:43.730 the patient and the clinical team. While it typically 00:45:43.730 --> 00:45:46.309 takes around 9 -12 months for the acetabular 00:45:46.309 --> 00:45:49.429 fracture itself to completely heal radiologically, 00:45:50.230 --> 00:45:51.949 achieving the full restoration of mobility and 00:45:51.949 --> 00:45:54.269 function generally occurs somewhere within the 00:45:54.269 --> 00:45:57.969 6 -12 month window, post -injury, sometimes longer. 00:45:58.730 --> 00:46:01.150 It's really important to set realistic expectations 00:46:01.150 --> 00:46:03.900 for patients from the outset. Due to the complex 00:46:03.900 --> 00:46:05.860 nature of these injuries and the potential for 00:46:05.860 --> 00:46:08.480 these long -term complications, many patients, 00:46:08.900 --> 00:46:11.239 particularly those with more severe initial injuries 00:46:11.239 --> 00:46:14.099 or those who develop complications, may not fully 00:46:14.099 --> 00:46:16.340 return to their pre -injury activity levels or 00:46:16.340 --> 00:46:18.780 occupations. The ultimate goal then is always 00:46:18.780 --> 00:46:21.159 to maximize their functional outcome and quality 00:46:21.159 --> 00:46:23.619 of life within the limitations imposed by the 00:46:23.619 --> 00:46:27.039 injury itself. So summing that up. Yes. In conclusion, 00:46:27.210 --> 00:46:29.670 Whilst complications can certainly be anticipated 00:46:29.670 --> 00:46:32.590 with these severe injuries, timely intervention, 00:46:33.110 --> 00:46:34.989 meticulous surgical technique when indicated, 00:46:35.389 --> 00:46:38.010 and truly comprehensive post -operative care, 00:46:38.369 --> 00:46:41.590 including rigorous DVT prophylaxis, early but 00:46:41.590 --> 00:46:44.489 safe mobilization protocols, and vigilant pain 00:46:44.489 --> 00:46:47.190 management are absolutely crucial for mitigating 00:46:47.190 --> 00:46:49.469 adverse outcomes and improving the long -term 00:46:49.469 --> 00:46:52.170 prognosis. It's all about aiming for the best 00:46:52.170 --> 00:46:54.889 possible quality of life we can achieve for every 00:46:54.889 --> 00:46:57.210 individual patient facing this challenge. injury. 00:46:57.909 --> 00:46:59.989 Professor, that was an incredibly thorough and 00:46:59.989 --> 00:47:02.389 insightful review. You've distilled years of 00:47:02.389 --> 00:47:05.070 complex experience into truly digestible knowledge 00:47:05.070 --> 00:47:07.289 for us. Let's move into a quick lightning round 00:47:07.289 --> 00:47:09.389 now just to crystallize some key insights for 00:47:09.389 --> 00:47:12.630 our listeners. First up, one essential piece 00:47:12.630 --> 00:47:15.889 of imaging you simply cannot go without for accurate 00:47:15.889 --> 00:47:18.150 acetabular fracture assessment. Oh, definitely 00:47:18.150 --> 00:47:20.889 a high quality CT scan with meticulous multi 00:47:20.889 --> 00:47:22.929 -planar reconstructions. It's non -negotiable 00:47:22.929 --> 00:47:25.000 for planning. For managing our older patients 00:47:25.000 --> 00:47:27.300 with these fractures, what's a single core principle 00:47:27.300 --> 00:47:29.880 that really underpins your entire approach? I'd 00:47:29.880 --> 00:47:32.699 say proactive, multidisciplinary medical optimization 00:47:32.699 --> 00:47:35.539 combined with a tailored focus on early functional 00:47:35.539 --> 00:47:38.019 mobilization. Get them assessed, get them optimized, 00:47:38.119 --> 00:47:40.900 get them moving safely. What's one common diagnostic 00:47:40.900 --> 00:47:43.460 or management pitfall that orthopedic professionals 00:47:43.460 --> 00:47:45.679 should always be wary of with these intricate 00:47:45.679 --> 00:47:49.440 injuries? A common pitfall. perhaps failing to 00:47:49.440 --> 00:47:52.480 thoroughly assess for and address marginal impaction 00:47:52.480 --> 00:47:56.679 of the articular surface, or, relatedly, misinterpreting 00:47:56.679 --> 00:47:59.000 complex pelvic ring injuries that involve the 00:47:59.000 --> 00:48:02.519 acetabulum as solely acetabular fractures. Understanding 00:48:02.519 --> 00:48:04.619 the full extent of pelvic instability is key. 00:48:04.780 --> 00:48:07.619 Finally, what's one quick win if such a thing 00:48:07.619 --> 00:48:09.699 exists for significantly reducing long -term 00:48:09.699 --> 00:48:12.159 complications after an acetabular fracture? A 00:48:12.159 --> 00:48:14.320 quick win? Well, it's not always quick or easy, 00:48:14.840 --> 00:48:17.500 but achieving and rigorously maintaining an anatomical 00:48:17.500 --> 00:48:20.360 articular reduction and keeping that post -operative 00:48:20.360 --> 00:48:22.900 displacement under two millimeters is undoubtedly 00:48:22.900 --> 00:48:25.139 the cornerstone of preventing or delaying post 00:48:25.139 --> 00:48:28.260 -traumatic arthritis. That's the goal. This deep 00:48:28.260 --> 00:48:30.679 dive has truly illuminated the intricate world 00:48:30.679 --> 00:48:33.519 of acetabular fractures, offering critical insights 00:48:33.519 --> 00:48:35.780 for our medical professional audience. Let's 00:48:35.780 --> 00:48:37.820 just quickly recap some key takeaways to enhance 00:48:37.820 --> 00:48:40.599 your understanding and clinical practice. Firstly, 00:48:40.900 --> 00:48:43.360 a crucial understanding. Acetabular fractures 00:48:43.360 --> 00:48:46.300 are distinct, complex intraarticular injuries. 00:48:46.760 --> 00:48:49.340 Remember, even seemingly simple patterns like 00:48:49.340 --> 00:48:51.739 posterior wall fractures, often linked to dashboard 00:48:51.739 --> 00:48:54.619 injuries, can carry a surprisingly poor long 00:48:54.619 --> 00:48:57.059 -term prognosis due to associated issues like 00:48:57.059 --> 00:49:00.099 impaction or nerve injury. Precise early diagnosis 00:49:00.099 --> 00:49:02.800 is vital. Secondly, accurate diagnosis hinges 00:49:02.800 --> 00:49:05.099 not just on standard x -rays, but specifically 00:49:05.099 --> 00:49:07.840 on judit views and critically detailed CT scans. 00:49:08.400 --> 00:49:10.760 These advanced images reveal subtle yet vital 00:49:10.760 --> 00:49:13.699 signs like the GUL sign or SPUR sign, which can 00:49:13.699 --> 00:49:15.800 entirely alter your treatment approach and the 00:49:15.800 --> 00:49:18.679 patient's prognosis. Thirdly, remember management 00:49:18.679 --> 00:49:21.179 is highly individualized. It spans from meticulous 00:49:21.179 --> 00:49:23.380 functional conservative care, emphasizing early 00:49:23.380 --> 00:49:25.159 mobilization, especially in the frail elderly, 00:49:25.619 --> 00:49:28.980 to comp surgery like RAF or acute THA. The choice 00:49:28.980 --> 00:49:31.360 depends heavily on the patient's health, bone 00:49:31.360 --> 00:49:34.440 quality, fracture pattern, and importantly, available 00:49:34.440 --> 00:49:38.000 surgical expertise. Fourthly, the long -term 00:49:38.000 --> 00:49:40.119 outlook and the ultimate survival of the native 00:49:40.119 --> 00:49:42.360 hip hinge significantly on factors like age, 00:49:42.900 --> 00:49:45.460 initial injury severity, and pattern, but most 00:49:45.460 --> 00:49:47.400 critically, the quality of articular reduction 00:49:47.400 --> 00:49:50.019 achieved. Diligent prevention and management 00:49:50.019 --> 00:49:52.940 of long -term complications like arthritis, HO, 00:49:53.460 --> 00:49:56.590 and AVN are paramount. And finally, never forget, 00:49:57.090 --> 00:50:00.190 an associated hip dislocation is a true surgical 00:50:00.190 --> 00:50:03.349 emergency. It demands urgent reduction, ideally 00:50:03.349 --> 00:50:05.750 within hours, to mitigate both immediate risks 00:50:05.750 --> 00:50:08.369 like AVN and long -term consequences for the 00:50:08.369 --> 00:50:11.449 patient. Our deep dive into acetabular fractures 00:50:11.449 --> 00:50:14.130 has been incredibly insightful today, really 00:50:14.130 --> 00:50:16.090 shedding light on the complexities and advancements 00:50:16.090 --> 00:50:18.289 in managing these challenging injuries. We truly 00:50:18.289 --> 00:50:20.150 trust this discussion provides you with valuable 00:50:20.150 --> 00:50:21.989 perspectives to inform your clinical practice 00:50:21.989 --> 00:50:24.969 and ultimately improve patient outcomes. If you 00:50:24.969 --> 00:50:27.070 found this conversation valuable, please do consider 00:50:27.070 --> 00:50:28.809 sharing this deep dive with your professional 00:50:28.809 --> 00:50:31.429 network on LinkedIn or perhaps on X. Your support 00:50:31.429 --> 00:50:33.170 helps us reach more colleagues who can benefit 00:50:33.170 --> 00:50:35.710 from these discussions. And if you haven't yet, 00:50:35.809 --> 00:50:37.750 please take just a moment to rate and review 00:50:37.750 --> 00:50:40.699 our show. wherever you listen. It genuinely makes 00:50:40.699 --> 00:50:44.059 a difference in helping others find us. A profound 00:50:44.059 --> 00:50:46.619 thank you again for graciously sharing your expensive 00:50:46.619 --> 00:50:48.559 knowledge and experience with us today. It's 00:50:48.559 --> 00:50:50.840 been an absolute privilege. Thank you again for 00:50:50.840 --> 00:50:53.320 having me with my pleasure. Until our next deep 00:50:53.320 --> 00:50:56.360 dive, continue to explore, question, and expand 00:50:56.360 --> 00:50:57.880 your expertise. Goodbye for now.