What is the step-by-step procedure for treating a right acetabulum fracture with plating?

Step-by-Step Procedure for Right Acetabular Fracture Plating

The surgical management of right acetabular fractures through plating requires meticulous preoperative planning, proper patient positioning, careful surgical approach, and precise reduction and fixation techniques to ensure optimal outcomes for morbidity, mortality, and quality of life.

Preoperative Assessment and Planning

• Evaluate fracture pattern and stability using CT scans and radiographs (AP, Judet views)
• Assess patient's functional status, mobility, and pain level
• Check metabolic status, skin condition, and nutritional status
• Differentiate between pathologic and traumatic fractures
• Consider bone scan if metastatic disease is suspected

Surgical Approach Selection

Based on fracture pattern:

• Anterior fractures: Ilioinguinal approach
• Posterior fractures: Kocher-Langenbeck approach
• Complex fractures: Extended iliofemoral or combined approaches
• Consider minimally invasive techniques like APACHE (Anterior Plating of the Acetabulum in Hemi-Endoscopic Technique) for suitable cases 1

Patient Positioning

For Kocher-Langenbeck Approach (Posterior Wall/Column Fractures):

• Position patient in lateral decubitus position
• Secure with anterior and posterior posts
• Pad all bony prominences
• Ensure ipsilateral leg is draped free for intraoperative manipulation

For Ilioinguinal Approach (Anterior Wall/Column Fractures):

• Position patient supine on radiolucent table
• Place bump under ipsilateral hip for better exposure
• Ensure fluoroscopic access is unobstructed

Step-by-Step Surgical Procedure

1. Surgical Approach and Exposure

• Make appropriate incision based on selected approach
• Carefully identify and protect neurovascular structures
• For posterior approach: identify and protect sciatic nerve
• For anterior approach: identify and protect femoral vessels, femoral nerve, and lateral femoral cutaneous nerve
• Expose fracture site with careful soft tissue dissection

2. Fracture Reduction

• Remove hematoma and debris from fracture site
• Use bone reduction clamps and specialized reduction tools
• Reduce articular fragments first, working from inside to outside
• Verify reduction with direct visualization and fluoroscopy
• Use temporary K-wires to maintain reduction

3. Fixation with Plates and Screws

• Select appropriate reconstruction plates (3.5mm)
• For posterior wall fractures: contour plate along posterior column
• For anterior column fractures: place plate along pelvic brim
• For transverse fractures: consider orthogonal double plating
• For quadrilateral surface involvement: consider anatomically preformed suprapectineal quadrilateral surface (QLS) plates 2
• Secure plates with appropriate screws (avoid joint penetration)
• Verify screw placement with fluoroscopy or intraoperative CT if available

4. Final Assessment

• Confirm anatomic reduction of articular surface
• Ensure stable fixation through range of motion testing
• Verify no intra-articular hardware with fluoroscopy
• Irrigate wound thoroughly

5. Wound Closure

• Place drain if necessary
• Close wound in layers with attention to soft tissue planes
• Ensure watertight fascial closure
• Close skin with appropriate sutures or staples

Postoperative Care

• Administer prophylactic antibiotics
• Implement appropriate DVT prophylaxis
• Initiate early mobilization based on reconstruction stability
• Restrict weight-bearing according to fracture pattern and fixation stability
• Monitor for complications including infection, hardware failure, and non-union
• Perform radiographic evaluation at 6 weeks, 3 months, 6 months, and 1 year

Potential Complications and Management

• Infection (5-7%): Aggressive antibiotic treatment, possible debridement 3
• Sciatic nerve injury (10%): Monitor for recovery, consider neurolysis if no improvement
• Deep vein thrombosis (3-4%): Therapeutic anticoagulation 3
• Heterotopic ossification (3-5%): Prophylaxis with NSAIDs or radiation in high-risk cases
• Avascular necrosis: May require total hip arthroplasty
• Post-traumatic arthritis: Monitor and manage symptomatically

Technical Pearls

• Anatomic reduction is critical for good outcomes 4
• Avoid over-resection at fracture edges to maintain stability
• Use lag screws for large posterior wall fragments before plate application
• Consider buttress plating for quadrilateral surface fractures
• Surgical timing affects quality of reduction - earlier surgery (within 5-7 days) yields better results 3
• QLS plates may reduce operating time compared to orthogonal double plating (163 vs. 187 minutes) 2

The success of acetabular fracture fixation depends on achieving anatomic reduction, stable fixation, and early mobilization while minimizing complications. The surgical approach and fixation technique must be tailored to the specific fracture pattern to optimize outcomes.