Did you know that even with the most advanced
surgery, a really significant number of hip socket
fractures, particularly in our older patients,
might still end up needing a total hip replacement?
We're talking about injuries that don't just
break a bone. They fundamentally change a patient's
mobility, their quality of life. It's this impact
and the often quite counterintuitive complexities
that we're here to unravel today. Welcome to
the Depth Dive, the show where we aim to extract
essential knowledge and hopefully some surprising
insights from complex medical topics. Today,
we're taking a deep dive into acetabular fractures,
those critical breaks right in the hip's vital
socket. These aren't just any fractures. They
demand, well, a really nuanced understanding,
meticulous decision making, and often highly
specialized care. And joining us to unpack this
intricate area, drawing from vast clinical experience
and the latest research, is a true luminary in
the field. He's a consultant orthopedic surgeon
at the Royal London Hospital, specializing in
pelvis, acetabular, and revision arthroplasty.
He's also the founder of OrthoGlobe, an international
collaborative dedicated to advancing musculoskeletal
practice through global research. A very warm
welcome. Thank you very much for having me. It's
a real pleasure to be here to talk about this.
It's our absolute privilege. So let's kick things
off with a bit of a rapid fire segment just to
set the stage for our deep dive. For those in
our audience who might perhaps sometimes lump
all hip or pelvic injuries together, what's the
fundamental difference that really defines an
acetabular fracture and why is spotting that
distinction so critical for outcomes? That's
a great question to start with. The fundamental
distinction and it really dictates everything
that follows is that an acetabular fracture inherently
involves the articular surface of the hip joint,
the cartilage. The joint surface itself. Exactly.
Unlike many pelvic ring fractures, which might
affect the structural integrity of the pelvis,
but often spare the joint itself, an acetabular
fracture directly impacts that smooth cartilage
line socket where the femoral head moves. And
this direct involvement of the joint surface
is absolutely paramount. because it's the primary
determinant of post -traumatic osteoarthritis
down the line. If that articular surface isn't
restored almost perfectly, the joint mechanics
are disrupted. That leads to progressive wear
and tear. pain, stiffness, and ultimately what
we sometimes call the death of the hip, meaning
it needs replacing. So it really is all about
that critical joint integrity, that surface smoothness,
knowing that if we look at the bigger picture,
epidemiologically speaking, who is most vulnerable
to these injuries and what sort of forces are
typically causing them? Well, acetabular fractures
show quite a fascinating bimodal distribution.
So we see peaks in two very distinct age groups.
Right. In younger patients, typically those between,
say, 20 and 39 years old, and this group actually
made up over half the patients in one large study,
these are overwhelmingly high energy injuries.
Road traffic accidents are a major cause, accounting
for nearly 57 % in that same study. You have
to think of that classic dashboard injury, where
the knee hits the dashboard, driving the femoral
head backwards forcefully into the acetabular
socket. Then, in stark contrast, the other peak
occurs in our elderly patients. Here, it's typically
low energy falls, often just from a standing
height that caused the fracture. And this is
primarily due to weakened bone quality from osteoporosis.
The precise force vector, you know, the direction
of the impact and the position of the femoral
head at that exact moment, abduction, adduction
rotation, they're absolutely key in determining
the specific fracture pattern we see. It's quite
remarkable how the mechanism shifts so dramatically
with age. So finally, just to frame our discussion
today, in a single sentence, what would you say
is the biggest challenge you personally face
when you're approaching the management of an
acetabular fracture, particularly in our more
senior patients? Hmm, in senior patients? I'd
say the single biggest challenge is reliably
achieving and crucially maintaining stable fixation
in bone that's often highly comminuted, shattered
into many pieces, and osteoporotic. And that
task is compounded by their significant medical
comorbidities, which ultimately impacts their
ability to mobilize afterwards and recover effectively.
It's a complex interplay. That sets the stage
perfectly for the complexity we're diving into.
Let's really unpack the hip joint itself then.
To genuinely grasp these fractures, we need to
understand the, well, the architectural marvel
that is the acetabulum. When you visualize the
hip, what's the architectural blueprint that
immediately comes to mind when considering these
fractures? What are those critical anatomical
elements a surgeon just has to understand? Well,
when I think of the hip joint, I immediately
picture this beautifully engineered ball and
socket system. Yeah. It's quite elegant, really.
Yes. The ball is the femoral head, the top end
of the thigh bone, and the socket is the acetabulum,
which is an integral part of the pelvis itself.
What makes the acetabulum so intricate and why
injuring it is so challenging is its highly specific
structural complexity. Both the femoral head
and the acetabulum are covered with articular
cartilage. That smooth surface. Exactly. This
incredibly smooth, almost frictionless substance
is absolutely critical. It allows the bones to
glide effortlessly, facilitating movement without
friction or pain. And surrounding this, you have
strong ligaments, tough bands of tissue that
provide stability, whilst allowing an extensive
range of motion without dislocation. But perhaps
the most fundamental concept, particularly for
surgical planning, is the Judet and Lateral Column
Theory. It's the bedrock of how we think about
these fractures. Right, the two columns. Precisely.
They conceptualize the acetabulum as being supported
by two main columns, forming an invented Y shape,
almost like structural scaffolding holding the
socket up. The anterior column is the more extensive
one. It traces from the anterior iliac spines
along the iliac wing and connects down to the
pubic rami. The posterior column, in contrast,
is a bit more limited structurally. It extends
from the sciatic notch and runs down through
the ischium. Understanding these columns is absolutely
vital because fracture patterns aren't just random
cracks. They typically involve breaks along or
between these fundamental structural supports.
So the fractures follow these lines of force,
essentially? In a way, yes. And when we look
at x -rays, we're not just glancing. We're meticulously
searching for specific radiographic landmarks
that help us delineate these columns and assess
the fracture. Key among these are the ileopectinale
line, which essentially represents the integrity
of that anterior column. and the ilioeschial
line, which signifies the posterior column. You
also look for the radiographic teardrop, indicating
the medial wall, and the radiographic roof that's
the crucial weight -bearing dome. It's important
to remember these lines aren't literal cracks
themselves. They're overlapping condensations
of cortical bones seen on the 2D image. But they
offer critical clues about the underlying 3D
structural integrity. I see. And what about the
surrounding structures, nerves? blood vessels.
Yes. From a surgeon's perspective, perhaps nothing
is more critical than the vascular and neurovascular
considerations. There's a particularly precarious
anastomosis, a connection between blood vessels
often rather dramatically dubbed the coronamortis,
the crown of death. This involves vessels from
the external iliac system. like the inferior
epigastric artery, and the internal iliac system,
like the obturator vessels. This area is highly
susceptible to injury during certain surgical
approaches, particularly anterior ones. Significant
bleeding can occur very quickly if it's damaged.
And perhaps even more importantly, major nerves,
most notably the sciatic nerve, pass perilously
close to the posterior aspect of the hip socket.
Extremely close. Damage to this nerve? either
from the initial injury itself or unfortunately
sometimes during surgery can lead to significant
long -term problems like foot drop. That's why
we approach this region with such extreme caution
and respect. That paints such a clear picture
of just how wonderfully complex but also quite
vulnerable this structure is. If the femoral
head acts like a hammer, as you described earlier,
how do these intricate architectural elements
then dictate the distinct injury patterns we
actually see? It sounds like even a small shift
in force or femur position could lead to a vastly
different fracture. You've hit on a crucial point
there. The path of physiology is precisely that
forces are transmitted through the femoral head,
which really does act like a hammer striking
the acetabulum. And the exact position of the
femur at the moment of impact, whether it's adducted
closer to the midline, abducted away from the
midline, or rotated and the precise direction
of the force are absolutely critical in determining
the specific fracture pattern and the amount
of displacement. It's not random at all. Can
you give some examples? Sure. Let's take that
common dashboard injury again. If the knee strikes
the dashboard, it drives the femoral head directly
backwards against the acetabulum. This frequently
results in a posterior wall fracture. That's
actually the most common pattern overall. Right.
Falls directly onto the side of the hip. transmitting
force from the side can also cause these. And
we differentiate fundamentally between high -energy
trauma, typically seen in younger adults, the
road accidents, the major falls. Exactly. Which
not only causes significant bone fragmentation,
but also extensive soft tissue damage, internal
bleeding, and potential lacerations of major
blood vessels or nerves. These patients often
present with multiple associated injuries. That
Jordan's study again noted over half of 53 .9
percent had other serious injuries needing attention
head chest abdomen a major trauma scenario Absolutely
in contrast you have low energy trauma more common
in our elderly patients This causes fractures
because the bone quality is severely weakened
primarily due to osteoporosis Whilst the energy
is lower, the compromised bone makes stable surgical
fixation exponentially more challenging. It's
fascinating how the energy level ties into age
and bone health. Given this wide spectrum, how
do orthopedic professionals actually categorize
these fractures? How do you standardize communication
and, importantly, guide treatment decisions?
Is there a sort of universal language? Yes, there
is, thankfully. To bring order and a common language
to this complexity, the Judet -Laternal classification
is without doubt the most widely accepted and
foundational system. It's really the framework
we all use when discussing acetabular fractures.
It systematically divides fractures into two
main types, five elementary patterns and five
associated patterns. I'd say five of each. Exactly.
The five elementary patterns involve essentially
a single main fracture line dividing the acetabulum.
First, the posterior wall fracture. As we said,
the most common overall, making up almost 38
% of cases in the Jordan study often linked to
those dashboard injuries. Second, the posterior
column fracture involving that larger posterior
structural support. Third, the anterior wall
fracture. This is quite rare on its own. It often
presents more as part of a complex pelvic ring
injury or is associated with an anterior hip
dislocation. Fourth, the anterior column fracture
involving the anterior support. And fifth, the
transverse fracture. This is defined as a single
fracture line that crosses both the anterior
and posterior columns, essentially cutting the
acetabulum in half horizontally. Right, those
are the elementary ones. What about the associated
patterns? The five associated patterns are combinations
of these elementary types. They indicate more
complex and generally more severe injuries. You
have anterior column with posterior hematransverse,
posterior column with posterior wall, transverse
with posterior wall, Now, this one is actually
the most common associated pattern, and importantly,
it's linked to the highest incidence of sciatic
nerve injury. That's a critical point for prognosis
and patient counseling. Definitely. Then there's
the T -shaped fracture. This is basically a transverse
fracture combined with a vertical split that
goes down through the quadrilateral surface in
the acetabular fossa, creating that T shape on
imaging. And finally, the both -column fracture.
This is where both the anterior and posterior
columns are completely separated from the intact
posterior part of the ilium. All the articular
segments, the joint surface pieces, are detached.
It's a truly severe injury pattern. And are there
specific signs you look for on imaging to help
identify these patterns? Absolutely. When we're
diagnosing these, we're meticulously looking
for specific diagnostic features or signs on
the x -rays and CT scans that are almost pathognomonic,
meaning if you see them, you know what you're
dealing with. For instance, the goal sign. This
is seen on the iliac oblique x -ray view and
it represents impaction, a crushing injury of
the supermedial roof. the top part of the socket.
Okay. It's a telltale sign often seen with posterior
wall fractures, but critically, it's often a
strong, poor, prognostic indicator. It frequently
suggests the need for an acute total hip replacement,
rather than just fixation, because it signifies
significant articular cartilage damage. I see.
So that sign carries a lot of weight. It does.
Another crucial sign is the spur sign, which
is visible on the obturator oblique x -ray view.
This looks like a sharp spike of intact ilium
sticking out laterally, while the entire acetabulum
is shifted medially. It's pythognomonic for both
colon fractures. It's also vital to understand
the concept of secondary congruence, particularly
in both colon fractures. You mentioned that earlier.
Yes. Despite the acetabulum being completely
separated from the axial skeleton, The displaced
fragments might deceptively appear to align reasonably
well around the femoral head on initial x -rays.
It can look falsely reassuring. So it looks okay,
but it's actually completely detached. Precisely.
It can be profoundly misleading and really underscores
the absolute necessity for more advanced imaging,
like CT, to truly appreciate the extent of the
injury and the instability. And whilst Judelet
-Dornel remains the bedrock, we do sometimes
briefly consider other systems, like the tile
classification, which focuses on overall pelvic
stability type C being complex, unstable injuries,
or the Young -Burgess classification, which looks
at the mechanism of injury. But for the acetabulum
specifically, Judelet -Dornel is really our guiding
light. That level of detail in classification
truly highlights the precision needed. So after
identifying the likely pattern, accurate diagnosis
is paramount for planning treatment. What are
the essential imaging tools you rely on and what
are those non -negotiable key findings you're
looking for, especially given pitfalls like that
secondary concurrence? For accurate diagnosis,
we use a very specific sort of stepwise approach
to imaging. X -rays are always the initial step.
While standard anteroposterior, or AP, views
are useful baseline images, the critical views
are the specific judit views. We always get these.
A two oblique view. Exactly. The obturator oblique
view, which profiles the obturator foramen and
gives a clear picture of the anterior column
and the posterior wall. and the iliac oblique
view, which profiles the iliac wing and clearly
shows the posterior column and the anterior wall.
These specialized views are absolutely essential
for visualizing the fracture pattern properly
and assessing the degree of displacement, which,
as I said, is often not fully appreciated on
a standard AP view alone. However, for truly
precise management and preoperative planning,
computed tomography or CT scams, are unequivocally
considered the gold standard. You really can't
plan surgery properly without one. Why is CT
so crucial? Well, a CT provides exquisitely detailed
cross -sectional views of the hip. This is crucial
for visualizing subtle injuries that might not
be apparent on x -rays, particularly complex
posterior injuries or impaction. It defines the
fragment size. their exact orientation in 3D
space, identifies any subtle marginal impaction,
the crushing of the cancellous bone just beneath
the articular surface, which affects prognosis,
and it detects any intra -articular loose bodies,
little bits of bone or cartilage floating in
the joint, or articular gaps and step -offs.
All of these are critical details for surgical
decision -making. You'll simply miss these nuances
without a CT. And are there specific measurements
you take on these scans? Yes. We look at various
things. For instance, we sometimes use measurements
like the roof arc angle to try and assess stability.
A fracture is generally considered stable if
the main fracture line exits outside the primary
weight -bearing dome of the acetabulum. This
is typically defined as having an angle greater
than 45 degrees on the AP and Judith fuse, or
it's indicated by seeing an intact subchondral
bone ring in the superior 10 millimeters on the
axial CT cuts. But you mentioned limitations.
Yes. It's crucial to note its limitation in certain
fracture patterns, like both column fractures
where the whole thing is detached, or some posterior
wall fractures. In these cases, there isn't necessarily
an intact portion of the acetabulum available
for this type of measurement, so you rely on
other signs of instability. Beyond static imaging,
sometimes we need to dynamically assess stability,
particularly for posterior wall fractures. This
might involve an examination under anesthesia,
or EUA, using fluoroscopy live x -ray. To see
how it moves under stress. Exactly. During this,
if the medial clear space, the gap between the
femoral head and the socket medially opens up
under stress, that can be a definitive sign of
instability in the posterior wall, which might
not have been obvious from the static images
alone. And finally, tying back to the urgency,
if there's an associated hip dislocation, Early
imaging and diagnosis are absolutely critical
because as we'll discuss these are surgical emergencies
Reduction should ideally occur within 12 hours
for improved outcomes Primarily to mitigate the
risk of a vascular necrosis death of the bone
of the femoral head due to compromised blood
supply It's also vital to exclude an associated
femoral neck fracture in cases of hip dislocation
If there's any doubt whatsoever on the initial
x -rays, a CT scan is strongly recommended to
rule this out, as finding one would significantly
alter the immediate treatment plan, perhaps necessitating
a different acute surgical approach altogether.
It's clear these injuries demand a rapid, thorough,
and incredibly precise diagnostic cascade. Beyond
the fracture itself, you've mentioned an associated
hip dislocation can be a true orthopedic emergency.
What's the immediate priority for a patient presenting
like that, and what are the steps you take to
manage it acutely? The immediate priority, unequivocally,
is to recognize that a fractured acetabulum with
a hip dislocation is a surgical emergency. It
requires urgent reduction of the dislocated hip.
This is not something that can wait. The clock
starts ticking immediately to minimize the risk
of complications, particularly that of vascular
necrosis of the femoral head. Okay, so time is
critical. Absolutely. Our initial patient assessment,
of course, is always based on Advanced Trauma
Life Support or ATLS principles. That means we
first prioritize airway, breathing, and circulation
of the ABCs to ensure the patient is physiologically
stable. Once that's secured, a thorough neurological
and vascular assessment of the affected limb
is crucial. We must meticulously check for any
signs of nerve damage, particularly sciatic nerve
injury, which can manifest as foot drop and inability
to lift the foot even after the reduction. This
assessment guides our immediate next steps and
helps us anticipate potential long -term deficits.
And the reduction itself. The process of urgent
reduction is ideally performed immediately in
the emergency department, or RISIS. It requires
appropriate sedation, good muscle relaxation,
which is key, and often a two -person technique
to apply traction and counter -traction safely
and effectively. We commonly differentiate between
the types of dislocation. Posterior dislocations
are the most frequent, often seen with those
dashboard injuries. The limb typically presents
as shortened, abducted, and internally rotated.
And anterior. Anterior dislocations are less
common. The limb is typically externally rotated,
abducted, and may be slightly flexed. The reduction
maneuver is often considered slightly more straightforward
due to the shallower anterior wall of the acetabulum,
but they can still be challenging. What if you
can't reduce it closed? If closed reduction fails
in the emergency department, the implications
are serious. The patient must be transferred
immediately to the operating theater for an open
reduction. This should ideally be performed by
a hip surgeon, familiar with the necessary approaches,
often a posterior approach, and someone who is
able to explore the sciatic nerve if there's
any concern about entrapment or injury. So specialist
input is needed quickly. Yes. It highlights the
critical importance of having the right expertise
available immediately, day or night. We also
have to remember, as we noted from the Jordan
study, that more than half 53 .9 % of these patients
have other significant body injuries. Right,
the polytrauma aspect. Exactly. These can be
life -threatening head injuries, chest trauma,
abdominal bleeding, other fractures. They require
urgent simultaneous attention within a multidisciplinary
trauma team setting. It's a comprehensive, coordinated
approach that's vital for survival and optimal
outcomes. That immediate coordinated response
is absolutely critical. But Professor, it's equally
important to clarify, as you hinted earlier,
that not all acetabular fractures require immediate
surgery. When is non -operative management a
viable and perhaps even preferable option for
these complex injuries? And what does true functional,
consumptive care actually look like in practice?
It's not just bed rest, is it? No, absolutely
not. That's a crucial distinction at a point
I often emphasize, particularly when discussing
elderly patients. Non -surgical treatment is
a viable and often very appropriate option in
specific scenarios. We consider it based on both
the fracture characteristics and the broader
patient factors. Okay, so what fracture types
might be suitable? For fracture characteristics,
we look for minimally displaced fractures, generally
meaning the displacement is less than two millimeters
on all views. Certain stable fractures, perhaps
some isolated anterior column or anterior wall
fractures, can also be managed non -operatively
if the joint remains congruent. And crucially,
Some associated both column fractures can exhibit
what we call secondary congruency. Remember that?
Yes, where it looks aligned despite being detached.
Exactly. Where, despite the fragments being significantly
displaced relative to the rest of the pelvis,
they maintain a relatively stable articulation
around the femoral head itself. In these select
cases, even with significant displacement from
the pelvic ring, the hip joint might still function
acceptably without surgery, avoiding major operation.
Lastly, highly combinated fractures, very shattered
and severely osculoporotic bone might also be
better suited for conservative management. This
is because attempting surgical fixation in such
poor quality bone can be technically very difficult,
unreliable, and prone to failure, potentially
causing more harm than good. And what about patient
factors? Patient factors are equally, if not
more important, especially in the geriatric population.
We strongly consider non -operative management
for patients who are at a very high risk for
surgical complications due to significant comorbidities.
things like severe uncontrolled heart disease,
advanced lung disease, poorly controlled diabetes,
perhaps advanced dementia, or those with severely
limited pre -injury mobility who simply may not
tolerate extensive surgery and the demanding
rehabilitation afterwards. Makes sense. Also,
patients presenting late, say, more than three
weeks after the injury where the fracture has
already started to stick or partially healed
with fibrous tissue may also be candidates. Delayed
surgery in these cases can be exponentially more
challenging and fra - with complications like
infection or nerve injury. And finally, sometimes
surgical factors play a role. If there's a lack
of available multidisciplinary expertise locally
to offer complex reconstructive surgery safely
and effectively, then conservative management
might indeed be the more prudent and ethical
choice for that patient in that setting. So if
non -operative is chosen, what does that involve?
Definitely not just lying in bed. Absolutely
not. Modern functional conservative treatment
is far from passive bed rest. It demands a comprehensive,
proactive, multidisciplinary team approach. This
absolutely has to include specialist physiotherapists
guiding early, safe movement, excellent nursing
care focusing on skin integrity, nutrition, and
comfort, dedicated pain management teams using
multimodal analgesia, occupational therapists
assisting with adaptations for daily living,
or for geriatricians who are utterly vital for
managing comorbidities. and optimizing the patient's
overall medical health. Nutritionists and robust
community rehabilitation support teams for ongoing
recovery after discharge. It takes a village.
It really does sound like a team effort. What
are the key components? Key components include
meticulous pain management. Getting that right
is fundamental. Correcting any fluid and electrolyte
imbalances. Proactive pressure area care to prevent
devastating pressure sores. Early chest physiotherapy
to prevent pneumonia and limb physiotherapy to
maintain muscle strength and joint range. Early
progression to sitting out of bed is crucial.
And of course, venous thromboembolism or VTE
prophylaxis blood thinners is critical throughout
to prevent clots. But the cornerstone is early
mobilization. Patients are actively encouraged
to move as pain allows, often self -regulating
their weight -bearing. We often find that elderly
patients in particular frequently struggle with
strict non -weight -bearing instructions due
to other medical issues, perhaps upper limb weakness
from arthritis or balance problems. So you adapt?
We have to be pragmatic. Supervised ambulation
with appropriate walking aids, like a Zimmer
frame, is common and actively encouraged as soon
as it's safe. All the while we maintain constant
clinical and radiological surveillance, usually
with weekly x -rays initially, to watch for any
late displacement that might change the plan.
And what about traction? Does that still have
a role? The role of prolonged skeletal traction
has diminished significantly in modern management,
especially for frail elderly patients. It has
major disadvantages. Pressure sores, muscle wasting,
joint stiffness, risk of pin site infection,
and the pins can easily disengage in porous osteoporotic
bone. It might be used very short -term preoperatively,
but not generally as a definitive long -term
treatment anymore. What does the evidence say
about outcomes for this non -operative approach?
Well, perhaps surprisingly to some, studies have
shown reasonably good functional outcomes in
select elderly patients treated non -operatively,
even for some fracture patterns that would typically
meet operative criteria in younger, fitter individuals.
What's truly interesting is that there's no convincing
evidence when you adjust for comorbidities that
conservative management inherently leads to higher
mortality or higher re -operation rates compared
to surgery in this specific elderly cohort. Yes,
and secondary conversion rates to total hip arthroplasty,
or THA, down the line are often quite similar
for both conservatively and operatively treated
patients in this age group. They might end up
needing a hip replacement either way. Another
fascinating point from a technical perspective
is that performing a delayed primary arthroplasty,
a planned hip replacement later on following
a period of conservatively managed fracture healing,
is often technically more straightforward than
doing a secondary THA after a failed surgical
fixation. This is primarily due to less scar
tissue formation and no hardware interference
from plates and screws that need removing. So
this functional conservative approach really
highlights a pragmatic, patient -centered philosophy
when facing these complex challenges in our older
population. That's a truly crucial distinction
from perhaps older, more restrictive ideas of
conservative care. Now, shifting gears for fractures
that are significantly displaced, unstable, and
deemed suitable for surgery, open reduction internal
fixation, or ORFF, remains a primary approach.
Professor, what are the core goals when you undertake
ORFF? What surgical techniques are involved?
And crucially, what persistent challenges do
you still face, especially in older patients?
When ORFS is the chosen path, our primary goals
are threefold, and each is absolutely critical
for the long -term survival and function of the
patient's hip. First, we aim to meticulously
restore a smooth, gliding hip surface. The joint
needs to move without friction or catching to
prevent premature wear and pain. Second, we strive
to achieve an anatomical reduction. That means
the bone fragments are pieced back together as
perfectly as possible, with the goal being post
-operative displacement ideally less than two
millimeters on follow -up imaging. That Jordan
study reported achieving this level of reduction
in about 84 % of their surgically treated cases,
which is good, but still leaves a significant
minority with less than perfect reduction. The
third goal is to provide robust, stable fixation
with plates and screws. This is essential to
hold the reduction while the bone heals, and
importantly to try and prevent or delay the onset
of post -traumatic osteoarthritis, which unfortunately
remains a significant long -term complication
even after technically successful surgery. Is
there an ideal time to do the surgery? Yes. The
optimal timing for ORFF is generally considered
to be in the window between about 3 and 10 days
post -injury. Why that specific window? Well,
this allows some of the initial soft tissue swelling
to subside, making the surgery technically easier
and potentially reducing room complications.
But it's before significant bone resorption or
fibrous tissue formation occurs at the fracture
site, which can make achieving an anatomical
reduction much more difficult. The fragments
sort of get sticky and resistant to moving back
into place. Delays beyond 10 days can certainly
complicate reductions significantly, and delays
exceeding 3 weeks can lead to substantial problems
with both achieving reduction and maintaining
stable fixation due to that progressive bone
resorption and early callus formation. How do
you decide which surgical approach to use? The
surgical approach is chosen very carefully, based
almost entirely on the specific fracture pattern
identified on the CT scan. You tailor the approach
to get the best access to the fractured columns
that need fixing. For anterior approaches, we
commonly use either the classic ilioinguinal
approach or, increasingly, the modified stoppa
approach, sometimes combined with a lateral window.
The modified STAPA in particular is highlighted
for giving excellent visualization of the anterior
column in the medial wall or quadrilateral plate,
and it can even allow some access to the anterior
aspect of the posterior column. It's particularly
beneficial for buttressing comminuted medial
wall fractures. And for posterior fractures?
For posterior approaches, the workhorse is the
Kocher -Langenbeck approach. This is commonly
used for posterior wall and posterior column
fractures. Occasionally for very complex patterns,
like some both column fractures, a combination
of approaches, perhaps anterior and posterior,
might be necessary. But this significantly increases
the operative time, blood loss, and overall morbidity
for the patient. So we try to avoid it if possible.
Can you walk us through the basic surgical technique?
Sure. In terms of surgical techniques, the displaced
bone fragments are first carefully repositioned,
or reduced, back into their normal anatomical
alignment, often using specialized clamps and
instruments, all under fluoroscopic guidance
live X -ray checks. Then metal plates contour
to the bone shape and screws are meticulously
attached to the outer surfaces of the bone to
hold the fragments securely while the fracture
heals. In osteoporotic bone, there's a growing
use of locking implants plates, where the screws
lock into the plate itself at a fixed angle.
This theoretically provides better fixation stability
in weak bone, though comprehensive comparative
evidence showing superior outcomes versus conventional
plates is still somewhat limited but emerging.
What about bone grafting? Yes, that's often crucial.
It's very important to consider bone grafting,
using either autograft taken from the patient's
own pelvis or perhaps cancerless bone substitutes
to fill any underlying metaphysical defects,
particularly after elevating impacted articular
fragments. If you lift up a depressed piece of
joint surface, there's often a void underneath.
Filling this void is critical for supporting
the elevated fragments and preventing them from
collapsing again under load during weight bearing.
Despite the best techniques, complications can
still happen. Oh, absolutely. Despite meticulous
technique, potential intraoperative and early
post -operative complications are significant
and must always be anticipated and discussed
with the patient. Sciatic nerve injury is a major
risk, particularly with the Cochlear -Langenbeck
posterior approach. Reported rates are around
210%, and the Jordan study reported a 3 .5 %
rate of iatrogenic injury, meaning caused by
the surgery itself. This can lead to the functionally
debilitating foot drop. Heterotopic ossification,
or HO, that abnormal growth of bone and the soft
tissues around the hip is another significant
concern. The highest incidence is seen with the
older, more extensive approaches, though it seems
to be lower with the ilioinguinal approach. We
sometimes use prophylaxis, like radiation or
medication, to try and prevent it in high -risk
cases. There is also always a risk, albeit small,
of damage to the blood supply of the femoral
head during the surgery or from the initial injury,
which could lead to that dreaded irascular necrosis
later on. Looking at the longer term, what are
the outcomes and challenges of ORIF? Well, looking
at the outcomes and challenges. Whilst the clinical
outcome strongly correlates with the quality
of the articular reduction, the closer you get
it to anatomical. Generally, the better the result.
A really significant proportion of patients,
maybe up to 30 % in some studies, and perhaps
around 31 % overall in others, still go on to
develop post -traumatic arthritis, even with
a good -looking x -ray initially. So a good reduction
doesn't guarantee success. Unfortunately, not
always. And this frequently leads to a high rate
of late conversion to total hip arthroplasty,
or THA. Some studies suggest 20 -25 % of elderly
patients might need a revision surgery or conversion
to a hip replacement within the first one to
two years after their initial ORF. We also know
that the presence of that goal sign on the initial
imaging indicating severe dome impaction is considered
a very strong predictor of orioth failure in
geriatric acetabular fractures. Seeing that often
prompts serious consideration for an acute THA
from the outset rather than attempting ORF. It's
also important to note that while the operative
treatment itself doesn't necessarily increase
or decrease mortality when you carefully account
for comorbidities, high one -year mortality rates
up to 25 % in one study are reported in this
elderly population undergoing surgery. This is
often influenced by factors like age over 70
and their overall medical frailty. often measured
by things like the Charleston Comorbidity Index.
It truly underscores the vital importance of
comprehensive medical optimization before, during,
and after any major surgery in these vulnerable
patients. That's a truly comprehensive and frankly
quite sobering look at the outcomes sometimes
seen with traditional ORIF. Given these persistent
challenges, particularly in patients with poor
bone quality, you mentioned an alternative strategy
has emerged, the fix and replace approach or
acute total hip arthroplasty. Professor, could
you explain this concept and its specific role?
When might you choose this? Yes, the fix and
replace strategy or acute THA combined with fixation
represents a significant evolution in our thinking,
particularly for managing these fractures in
elderly or osteoporotic patients. The rationale
is really to directly address those challenges
we just discussed. The difficulty of achieving
stable fixation in poor bone and the relatively
high failure rates seen with ORIF alone in this
group. At the same time, it aims to facilitate
earlier weight bearing and functional recovery,
which is so crucial for older patients to avoid
deconditioning. So fixing and replacing in one
go. Exactly. Instead of solely attempting to
reconstruct the native joint, this approach combines
fracture fixation stabilizing the columns with
an immediate total hip arthroplasty during the
same operation. There's some compelling data
emerging. One study, for instance, highlighted
its potential effectiveness, showing 100 % hip
joint survival, meaning no further surgery needed
on the hip replacement with this combined approach,
compared to just about 29 % survival of the native
hip after fixation alone in a comparable group.
That's a stark difference. So when is it indicated?
What are the triggers? Well, the indications
for fix and replace are still evolving and there
isn't universal consensus. But common factors
that push us towards it include very complex
judit laturnal fracture patterns, especially
those involving both columns or significant combination
of the weight bearing dome. The presence of significant
pre -existing hip osteoarthritis is a strong
indicator. Associated femoral head or neck fractures
often make reconstruction impossible. Any pathological
fracture through tumor. Significant cartilage
damage seen either on imaging or at the time
of surgery to either the femoral head or the
incetabulum. And patient factors. Yes, poor bone
quality, significant osteopenia or osteoporosis
where you anticipate fixation will be unreliable
is a major factor. Fractures deemed unreconstructable.
patients presenting after a prolonged hip dislocation
where the femoral head might be damaged, or delayed
presentations where the window for optimal ORIF
has closed. Furthermore, several negative prognostic
factors we discussed earlier, like age over 40
or certainly over 60, an anticipated poor reduction
with more than three millimeters of residual
displacement, multifragmentary fractures, very
significant initial displacement of over 20 millimeters,
or delayed surgery, particularly more than five
days for associated patterns, or 15 days for
elementary all might steer the decision towards
this combined procedure. How is it done technically?
Is it just like a standard hip replacement? Not
quite. It's significantly more complex. The primary
principle technically is still to achieve stable
osteosynthesis, stable fixation of the acetabular
columns first, typically using plates and screws.
For example, we might meticulously use two posterior
column plates to achieve optimal rotational stability
of the hemipelvis. This creates a robust, bony
foundation onto which the acetabular prosthetic
component, the cup, can be securely implanted.
So you fix the pelvis first, then put the cup
in? Essentially. Yes, modern practice often involves
using highly porous acetabular components like
trabecular metal or similar materials, which
offer excellent biological fixation potential.
These cups often have multiple screw options,
allowing fixation into intact bone away from
the fracture lines. Sometimes these cups can
even be drilled through in strategic locations
to place additional screws, for instance, placing
an anterior colon screw through the metal shell
from a posterior approach to achieve a really
strong triangular purchase that significantly
enhances the fixation stability. That sounds
technically demanding. What about the surgical
approach? There's also been an evolution in surgical
approaches for this. While older techniques might
have involved complex constructs with intra -pelvic
wires and bulky anti - protrusion cages, modern
strategies often favor using a single posterior
approach, like the Kocher -Langenbeck. This allows
the surgeon to both fix the crucial posterior
column and wall fragments and then implant the
arthroplasty components through the same incision.
This potentially avoids the extensive soft tissue
disruption and increased complication risks associated
with needing dual anterior and posterior approaches.
We might also use the patient's own femoral head
bone graft after it's removed for the arthroplasty
to pack and support posterior wall defects, helping
to reconstruct the bone stock behind the cup.
It sounds effective, but complex. What about
the downsides, the outcomes, and complications?
You're right to ask. While fix and replace can
be highly effective in preserving hip function
and allowing early mobilization, it is undeniably
a major surgical insult, particularly for frail
elderly patients. It's a bigger operation than
either ORIF or a standard primary hip replacement
alone. It typically involves significantly longer
operative times, averaging around three hours,
174 minutes in one review, and substantially
greater blood loss. averaging close to a liter,
maybe 964 milliliters, compared to traditional
ORIF. And complication rates. Reported complication
rates are significant. They hover around 20 %
in some meta -analyses, but individual studies
report rates ranging up to nearly 60%. These
include infections, which are always a major
concern with implants and extensive surgery,
heterotopic ossification, although some studies
surprisingly suggest lower rates of clinically
significant HO with acute THA compared to delayed
THA after ORIF, and aseptic loosening of the
acetabular component over time requiring revision
surgery. The revision rate was about 2 .3 % in
one systematic review over a medium -term follow
-up of about 4 .5 years. Dislocation rates can
also be higher than standard THA. What about
mortality with this bigger operation? Mortality
rates are also a serious consideration. The mean
reported rate is around 9%, but studies have
shown rates up to 58 % at three years in some
very frail cohorts, with perhaps 26 % mortality
in the first year alone being reported in one
challenging group. It's crucial to acknowledge
that the high -level evidence base for acute
THA, specifically for acetabular fractures, is
still developing. This means that the surgeon's
experience, judgment, and the specific capabilities
of the treating center remain absolutely crucial
in guiding these complex high -stakes decisions.
So it really requires a balanced perspective.
While it may lead to better intermediate hip
survival and function compared to Oriaf alone
in selected elderly patients, the decision for
fix and replace must be very carefully weighed
against these significant upfront risks and the
potential alternative of a simpler delayed THA
after a period of functional conservative management,
especially for the most committed difficult fractures
in the frailest patients. That's a truly comprehensive
and again quite a nuanced look at the fix and
replace strategy and the critical decision making
involved. In the immediate treatment strategy,
Professor, what truly dictates a patient's long
-term journey? What factors determine the ultimate
survival of their native hip after an acetabular
fracture? You use that phrase, death of the hip.
What predicts that? This really gets to the heart
of the long -term impact of these injuries. We
use that concept of death of the hip essentially
as the ultimate need for a total hip replacement,
sometimes many years after the initial injury
and fixation. Several key prognostic indicators
truly dictate this long -term journey and determine
if that native hip can be preserved or if it's
destined for replacement. What's the most significant
factor? The strongest predictor of poor outcos,
unequivocally, is age. Older patients, especially
those over 60, or perhaps even over 40, according
to some research, are significantly more likely
to have fragile osteoporotic bone, experience
higher rates of surgical and medical complications,
and ultimately have a greater chance of requiring
a THA. Their physiological reserve is simply
lower, making recovery more arduous, and achieving
lasting stable fixation is inherently more difficult.
And after age. Another paramount factor is the
quality of the articular reduction achieved at
the time of surgery, if surgery is performed.
An imperfect reduction, clinically defined as
post -operative displacement persisting at greater
than 2 millimeters, significantly increases the
risk of developing post -traumatic arthritis.
If that smooth joint surface isn't perfectly
realigned, even by a millimeter or two, it inevitably
sets the stage for accelerated wear and tear,
leading to progressive pain, stiffness, and joint
destruction. Does the fracture pattern itself
matter long term? Yes. Specific fracture patterns
and their initial severity also play a major
role. For example, Posterior wall fractures,
despite sometimes appearing relatively simple
on initial assessment, often carry a surprisingly
poor long -term prognosis. This is often due
to associated complications like subtle marginal
impaction, higher risk of sciatic nerve injury,
heterotopic ossification, and a propensity for
secondary osteoarthritis development. Similarly,
the more complex patterns like transverse and
T -type fractures and the associated both -column
fractures often present higher risks just given
their inherent instability and the sheer extent
of disruption to the joint architecture. What
about damage to other structures? Absolutely.
Associated injuries are critical prognostic indicators.
This includes any direct damage to the femoral
head cartilage itself sustained during the initial
injury or dislocation, significant marginal impaction,
That crushing of the cancellous bone under the
articular surface, especially in the weight -bearing
dome, is a bad sign. Any pre -existing arthritis
in the hip joint obviously worsens the prognosis.
And other major systemic injuries, like head
or chest trauma, can significantly complicate
the overall recovery trajectory and impact the
functional outcome. And that seagull sign we
discussed earlier, visible on imaging and indicative
of severe dome impaction, is a particularly strong
poor prognostic sign. Seeing that often immediately
suggests that attempting to save the native joint
with ORIVE is likely futile, and total hip replacement,
either acutely or delayed, might be the more
realistic option. Does delaying surgery affect
the long -term outcome? Yes. The delay to surgery
significantly impacts outcomes, particularly
for ORIF. Prolonged delays beyond that optimal
window say more than five days for complex associated
fractures or perhaps more than 15 days for elementary
fractures have been consistently shown to negatively
impact a surgeon's ability to achieve and maintain
an anatomical reduction. This directly affects
the long -term prognosis and increases the risk
of secondary osteoarthritis developing later.
What are the most common long -term problems
people face? In terms of common long -term complications,
post -traumatic arthritis is by far the most
frequent issue, leading to chronic pain, stiffness,
and functional limitation, often necessitating
that late THA. Heterotopic ossification is also
common, where that abnormal bone grows around
the joint, physically restricting movement. A
vascular necrosis, or AVN, of the femoral head
occurs in roughly 6 to 7 percent of all acetabular
fractures, but the risk is higher. perhaps up
to 18 % in posterior fracture patterns or after
dislocation, where the blood supply to the femoral
head is most vulnerable. Other significant long
-term issues include chronic pain, which can
be multifactorial, and persistent nerve injury,
such as that debilitating foot drop from sciatic
nerve damage, which can require long -term bracing
and significantly impact quality of life. How
long does recovery typically take? The recovery
timeline for these major injuries is extensive
and requires considerable patience from both
the patient and the clinical team. While it typically
takes around 9 -12 months for the acetabular
fracture itself to completely heal radiologically,
achieving the full restoration of mobility and
function generally occurs somewhere within the
6 -12 month window, post -injury, sometimes longer.
It's really important to set realistic expectations
for patients from the outset. Due to the complex
nature of these injuries and the potential for
these long -term complications, many patients,
particularly those with more severe initial injuries
or those who develop complications, may not fully
return to their pre -injury activity levels or
occupations. The ultimate goal then is always
to maximize their functional outcome and quality
of life within the limitations imposed by the
injury itself. So summing that up. Yes. In conclusion,
Whilst complications can certainly be anticipated
with these severe injuries, timely intervention,
meticulous surgical technique when indicated,
and truly comprehensive post -operative care,
including rigorous DVT prophylaxis, early but
safe mobilization protocols, and vigilant pain
management are absolutely crucial for mitigating
adverse outcomes and improving the long -term
prognosis. It's all about aiming for the best
possible quality of life we can achieve for every
individual patient facing this challenge. injury.
Professor, that was an incredibly thorough and
insightful review. You've distilled years of
complex experience into truly digestible knowledge
for us. Let's move into a quick lightning round
now just to crystallize some key insights for
our listeners. First up, one essential piece
of imaging you simply cannot go without for accurate
acetabular fracture assessment. Oh, definitely
a high quality CT scan with meticulous multi
-planar reconstructions. It's non -negotiable
for planning. For managing our older patients
with these fractures, what's a single core principle
that really underpins your entire approach? I'd
say proactive, multidisciplinary medical optimization
combined with a tailored focus on early functional
mobilization. Get them assessed, get them optimized,
get them moving safely. What's one common diagnostic
or management pitfall that orthopedic professionals
should always be wary of with these intricate
injuries? A common pitfall. perhaps failing to
thoroughly assess for and address marginal impaction
of the articular surface, or, relatedly, misinterpreting
complex pelvic ring injuries that involve the
acetabulum as solely acetabular fractures. Understanding
the full extent of pelvic instability is key.
Finally, what's one quick win if such a thing
exists for significantly reducing long -term
complications after an acetabular fracture? A
quick win? Well, it's not always quick or easy,
but achieving and rigorously maintaining an anatomical
articular reduction and keeping that post -operative
displacement under two millimeters is undoubtedly
the cornerstone of preventing or delaying post
-traumatic arthritis. That's the goal. This deep
dive has truly illuminated the intricate world
of acetabular fractures, offering critical insights
for our medical professional audience. Let's
just quickly recap some key takeaways to enhance
your understanding and clinical practice. Firstly,
a crucial understanding. Acetabular fractures
are distinct, complex intraarticular injuries.
Remember, even seemingly simple patterns like
posterior wall fractures, often linked to dashboard
injuries, can carry a surprisingly poor long
-term prognosis due to associated issues like
impaction or nerve injury. Precise early diagnosis
is vital. Secondly, accurate diagnosis hinges
not just on standard x -rays, but specifically
on judit views and critically detailed CT scans.
These advanced images reveal subtle yet vital
signs like the GUL sign or SPUR sign, which can
entirely alter your treatment approach and the
patient's prognosis. Thirdly, remember management
is highly individualized. It spans from meticulous
functional conservative care, emphasizing early
mobilization, especially in the frail elderly,
to comp surgery like RAF or acute THA. The choice
depends heavily on the patient's health, bone
quality, fracture pattern, and importantly, available
surgical expertise. Fourthly, the long -term
outlook and the ultimate survival of the native
hip hinge significantly on factors like age,
initial injury severity, and pattern, but most
critically, the quality of articular reduction
achieved. Diligent prevention and management
of long -term complications like arthritis, HO,
and AVN are paramount. And finally, never forget,
an associated hip dislocation is a true surgical
emergency. It demands urgent reduction, ideally
within hours, to mitigate both immediate risks
like AVN and long -term consequences for the
patient. Our deep dive into acetabular fractures
has been incredibly insightful today, really
shedding light on the complexities and advancements
in managing these challenging injuries. We truly
trust this discussion provides you with valuable
perspectives to inform your clinical practice
and ultimately improve patient outcomes. If you
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a difference in helping others find us. A profound
thank you again for graciously sharing your expensive
knowledge and experience with us today. It's
been an absolute privilege. Thank you again for
having me with my pleasure. Until our next deep
dive, continue to explore, question, and expand
your expertise. Goodbye for now.