Session VII Pelvis and Acetabulum

Planned Simultaneous Anterior and Posterior Approaches for the Treatment of Complex and Malunited Acetabular Fractures

Stephen H. Sims, MD, James F. Kellam, MD, Michael J. Bosse, MD

Dept. of Orthopaedic Surgery, Carolinas Medical Center, Charlotte NC

Extensile exposures of the pelvis are often required for the treatment of complex acetabular fractures and malunions. The extended iliofemoral, the triradiate and the modified extensile exposures are the approaches commonly recommended for these cases. Complete mobilization of the abductor muscle mass is required. The use of a combined exposure, employing a posterior Kocher-Langenbeck (K-L) and an anterior ilioinguinal (II) or an iliofemoral (IF) exposure has been reported, but in a stage fashion, moving to the second exposure when the first failed to provide adequate reduction/fixation exposure. The use of planned simultaneous anterior and posterior approaches has facilitated the treatment of complex or malunited acetabular fractures at our center for selected cases.

From January 1990 to June 1994, 184 patients required acetabular fracture surgery. Thirty patients (16%) with 30 complex or late-presenting acetabular fractures (15 both column, 6 T-type, 6 transverse with posterior wall, 2 ACPHT, and one transverse) were treated by a planned simultaneous approach via a K-L and an IF exposure in lieu of a traditional extensile approach. The patients were selected for the procedure based on the expectation that both the anterior and posterior columns would require exposure for fracture reduction and fixation. Surgery was performed with the patient in a floppy lateral position. Two surgical teams worked simultaneously, exposing both columns.

Anatomic or satisfactory reduction was obtained in 93% of the cases. The average surgical time was 4 hours and 19 minutes with a blood loss of 1546 cc. No patient developed a postoperative infection or wound problem. Two patients developed Brooker III-IV H.O.

The planned simultaneous approach to the anterior and posterior column for acetabular fracture surgery affords excellent visualization of the fractures, facilitates fragment mobilization and reduction and allows for stabilization of both columns. The abductor muscles do not require extensive mobilization, and the origins and insertions of the abductors are preserved.