Acetabular Fractures in Older Patients Assessment and Management Theodore T Manson  Editor 123 Acetabular Fractures in Older Patients Theodore T Manson Editor Acetabular Fractures in Older Patients Assessment and Management Editor Theodore T Manson Department of Orthopaedic Surgery R Adams Cowley Shock Trauma Center University of Maryland Baltimore, MD USA ISBN 978-3-030-25104-8    ISBN 978-3-030-25105-5 (eBook) https://doi.org/10.1007/978-3-030-25105-5 © Springer Nature Switzerland AG 2020 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface The number of older adults with acetabular fractures is increasing; not only from lower energy falls but also from higher energy injuries in a more active older population Our exploration of the care of these patients will start with a description of the scope of the problem and special techniques to evaluate activity level and frailty of older adults The optimal treatment for older adults with acetabular fractures is controversial with advocates for non-operative treatment, limited percutaneous or minimally invasive techniques, standard formal reduction and fixation and even fixation plus concomitant total hip arthroplasty in the same surgery Rather than advocating for one technique, all these techniques are reviewed and detailed surgical descriptions and illustrations are included Finally, the known outcomes for each of these techniques are reviewed and summarized We hope that you will find this helpful in managing these difficult fractures Baltimore, MD, USA Theodore T. Manson v Contents 1 Introduction and Scope of the Problem ������������������������������������������������    1 Andrew H Schmidt 2 Life Expectancy and Assessment of Functional Status in Older Adults ����������������������������������������������������������������������������������������    5 Lisa Reider 3 Nonoperative Treatment of the Geriatric Acetabular Fracture����������   21 Mariano E Menendez and Scott P Ryan 4 Open Reduction and Internal Fixation of Posterior Wall and Column Fractures in Older Patients����������������������������������������������   29 Marcus Sciadini and David Potter 5 Open Reduction and Internal Fixation of Anterior Fracture Patterns through a Limited Ilioinguinal Approach������������������������������   39 David L Helfet and Gele B Moloney 6 Dealing with Dome Impaction and Quadrilateral Plate Comminution in Older Patients Treated with Open Reduction and Internal Fixation������������������������������������������������������������   49 Brendan R Southam and Michael T Archdeacon 7 Percutaneous Treatment of Acetabular Fractures in Older Patients��������������������������������������������������������������������������������������   65 Joshua L Gary 8 Total Hip Arthroplasty Alone for Treatment of Selected Acetabular Fractures in Older Patients������������������������������������������������   97 John M Whatley, Andrew H Schmidt, and Theodore T Manson vii viii Contents 9 Open Reduction and Internal Fixation with Concomitant Total Hip Arthroplasty����������������������������������������������������������������������������  113 Theodore T Manson 10 Outcomes of Treatment Options for Acetabular Fractures in Older Patients��������������������������������������������������������������������������������������  133 Robert V O’Toole 11 Conversion Total Hip Arthroplasty��������������������������������������������������������  143 Theodore T Manson and Aaron J Johnson Index������������������������������������������������������������������������������������������������������������������  165 Contributors Michael  T.  Archdeacon, MD, MSE  University of Cincinnati Academic Health Center, Department of Orthopaedic Surgery, Cincinnati, OH, USA Joshua  L.  Gary, MD  Department of Orthopaedic Surgery, McGovern Medical School at UTHealth, Houston, TX, USA David L. Helfet, MD  Orthopaedic Trauma Service and Center for Hip Preservation Hospital for Special Surgery and New  York Presbyterian Hospital Weill Cornell Medicine, New York, NY, USA Aaron  J.  Johnson, MD  Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA Theodore T. Manson, MD  Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA Mariano E. Menendez, MD  Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA Gele B. Moloney, MD  Division of Orthopaedic Trauma, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Robert V. O’Toole, MD  Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA David  Potter, MD  R.  Adams Crowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA Lisa Reider, PhD  Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Scott  P.  Ryan, MD  Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA Andrew H. Schmidt, MD  Hennepin Healthcare, Minneapolis, MN, USA University of Minnesota, Minneapolis, MN, USA ix x Contributors Marcus Sciadini, MD  Department of Orthopaedic Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD, USA Brendan  R.  Southam, MD  University of Cincinnati Academic Health Center, Department of Orthopaedic Surgery, Cincinnati, OH, USA John M. Whatley, MD  Baton Rouge Orthopaedic Clinic, Baton Rouge, LA, USA Chapter Introduction and Scope of the Problem Andrew H. Schmidt Acetabular fractures in the elderly population are increasing in frequency, with the incidence of such fractures in patients over age 60 more than doubling in the past 25 years [1] In younger patients, such fractures result from high-energy trauma In older patients, acetabular fractures are just as likely to occur from low energy as a high-energy mechanism [1, 2] Acetabular fractures that result from low-energy trauma (typically a fall from standing height) are associated with osteopenia and are considered a marker of significant frailty, and such patients tend to be older, have a lower body mass index, and have more comorbidities than patients with acetabular fractures from higher-energy trauma [2] As might be expected given the differences in patient’s bone density and mechanisms of injury, acetabular fractures in the elderly have different fracture patterns than are seen in younger population, with a greater incidence of anterior column impaction, involvement of the quadrilateral plate, and articular impaction (Fig. 1.1) [3] Like patients with fractures of the proximal femur, elderly patients who suffer an acetabular fracture have significant mortality, reported to be as high as 25% [4] However, unlike proximal femur fractures, surgical repair of acetabular fractures in the elderly has not been shown to reduce mortality [5] Management of elderly patients with acetabular fracture is challenging As with all elderly patients with “hip” fractures, these patients demand and benefit from expert multidisciplinary co-management including input from geriatrics, internal medicine, orthopedic surgery, anesthesiology, and occasionally other medical and surgical subspecialties Nonoperative management of these injuries results in unacceptable outcomes in 30% or more of patients [6] Internal fixation of these complex fractures in patients with reduced bone quality and inability to “protect” the hip from loading following surgery make open reduction and internal fixation (ORIF) A H Schmidt (*) Hennepin Healthcare, Minneapolis, MN, USA University of Minnesota, Minneapolis, MN, USA e-mail: schmi115@umn.edu © Springer Nature Switzerland AG 2020 T T Manson (ed.), Acetabular Fractures in Older Patients, https://doi.org/10.1007/978-3-030-25105-5_1 154 T T Manson and A J Johnson Fig 11.15  Another patient who had an intra-articular 8.0 mm cannulated screw We were concerned that this would interfere with acetabular component placement so it was removed through exposure of the pelvic brim A direct anterior approach to the hip was used In this case release of the inguinal ligament was not necessary and a 4 cm incision over the iliac crest with subperiosteal dissection underneath the iliacus was all that was required to remove the long cannulated screw (and a portion of the pelvic brim plate) prior to total hip arthroplasty (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) and screws can be easily removed in the case of acetabular component impingement or suspicion of infection This is particularly true if the plates and screws are more laterally positioned on the acetabulum (Figs. 11.15, 11.16, and 11.17) Posterior Approach for Conversion to a Total Hip Replacement The patient is positioned in a lateral decubitus position taking care to position the pelvis as orthogonal to the table as possible and to have the lumbar spine parallel to the back edge of the operating room table The leg is prepped free, but in our center no neural monitoring is used during the procedure A standard posterior approach to the hip is used with a couple of important caveats (Fig. 11.18) First on approach and exposure, five sets of deep tissue cultures are taken and frozen section specimens are taken on each case Although the literature guiding the interpretation of frozen sections in these cases is inconclusive, if we see more than 5–10 white blood cells in multiple high-powered fields present in the frozen section analysis, we would proceed with fracture implant removal, Prostalac spacer implantation, and later staged hip replacement Another difference from a standard posterior approach to the hip is that in each case we release the gluteus maximus sling tagging it for later repair (Figs. 11.19 and 11.20) This is to take pressure off the sciatic nerve when the hip is internally rotated We not formally dissect the tissues around the sciatic nerve unless there is a preoperative sciatic nerve palsy If there is a preoperative sciatic nerve palsy, then we 11  Conversion Total Hip Arthroplasty 155 Fig 11.16  This patient has posttraumatic osteoarthritis with two spring plates in place Even if these plates and screws would end up impinging on the acetabular component, they can be easily bent away from the final acetabular component with an osteotome It is perfectly acceptable to use a direct anterior or Hardinge approach to the hip for these patients (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) will free up a lateral scar tissue on the sciatic nerve and trace the nerve up to the sciatic notch However, we will not perform circumferential dissection of the nerve in most cases The external rotators and capsule are released from the posterior greater trochanter as one unit, as they are often indistinguishable based on the scarring present Heterotopic bone that is present is removed at this time period with 0.75 inch curved osteotome Preparation of the Acetabulum: The “Inside-Out” Technique If the implants from the posterior wall and column need to be removed, then we use a specific technique for removal We start inside the acetabulum and we use a Bovie to elevate the capsule off the posterior wall and column We this with a hip extended, with the knee flexed, and with a hand on the foot, so that if the Bovie gets to close the sciatic nerve, the anterior tibialis or extensor hallucis longus will fire The capsule is then elevated “inside-out” technique staying strictly subperiosteal as 156 T T Manson and A J Johnson Fig 11.17  In this patient with posttraumatic osteoarthritis, marked heterotopic ossification, and more laterally based 3.5 mm reconstruction plates, the potential for these implants to interfere with acetabular component placement is much higher In this case, we would recommend using a Kocher-Langenbeck approach to the hip so that these implants could be removed if necessary (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.18  The previous Kocher-Langenbeck approach to the hip is used However it is usually not necessary to utilize the entire incision that was used for acetabular fixation (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) 11  Conversion Total Hip Arthroplasty 157 Fig 11.19  The gluteus maximus sling is exposed and released by placing a tonsil clamp medial to the sling and then releasing the sling using Bovie electrocautery In this image the patients head is to the left of the image (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.20  Care must be used as there are often times large blood vessels directly applied to the medial aspect of the gluteus maximus sling and sometimes this sciatic nerve can be scarred up against the medial aspect of the sling as well The majority of the sling is released and then marked for repair at the conclusion of the procedure (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) far medially and posteriorly as is needed to access the implants in question Many times the implants are grown over with bone and this bone is most easily removed using three-quarter inch curved osteotome The “inside-out” technique proceeds from known anatomy to unknown scarred anatomy in a stepwise fashion to avoid sciatic nerve injury A 0.75 inch osteotome is used to peel away scar tissue and heterotopic bone starting inside the acetabulum and then proceeding along the superior rim of the acetabulum (Figs.  11.21 and 11.22] Then with the superior aspect of the acetabulum and fixation plate exposed, the osteotome is directed inferiorly and medially to dissect along the posterior wall toward the sciatic notch and ischium (Figs.  11.22 and 11.23) This is clinically shown in (Figs. 11.24, 11.25, 11.26, and 11.27) It is extremely important that the hip is kept extended and the knee bent during exposure to minimize pressure on the sciatic nerve as has been described by Dr Letournel [7] Then after the plate is exposed, the screw heads are freed of heterotopic bone and fibrous tissue and removed under direct vision (Figs. 11.28, 11.29, 11.30, and 11.31) 158 T T Manson and A J Johnson Fig 11.21 Shows progression of the exposure of the posterior acetabulum We start with a three-quarter inch curved sharp osteotome inside the acetabulum (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.22  We then extend the osteotome dissection up over this superior lateral aspect of the acetabulum first so that we get a subperiosteal dissection of the posterior acetabulum (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Usually, only the implants that are going to directly interfere with acetabular component placement are removed Many times posterior wall fixation implants may interfere with acetabular placement but the more medial posterior column fixation can be retained (Fig. 11.32) The basis of all acetabular preparation is to a wedge acetabular component in between the ischium and the anterior inferior iliac spine as detailed in (Fig. 8.6) Many times there will be large posterior wall defects that not affect component fixation unless the ischium or AIIS is compromised For acetabular preparation, we start reaming to the base of the cotyloid fossa and then use sequentially larger reamers to ream for a 1  mm press-fit in the acetabulum 11  Conversion Total Hip Arthroplasty 159 Fig 11.23  shows further dissection using a three-quarter inch curved osteotome along the posterior acetabulum heading toward greater sciatic notch It is critical during this portion of the procedure that the hip is extended and the knee is flexed to take pressure off of the sciatic nerve In addition Bovie electrocautery rather than a knife will allow recognition of proximity to the sciatic nerve as the foot will jump if the Bovie gets near to the nerve (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.24  shows the most difficult part of the exposure where the posterior lateral aspect of the acetabulum stretching down to the hamstring insertion is exposed to remove the most distal screws present in an acetabular reconstruction plate Careful dissection making sure to stay subperiosteal and noting any twitches of the foot will help protect the sciatic nerve (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) 160 T T Manson and A J Johnson Fig 11.25  Shows a intraoperative photos of the retained reconstruction plate that we want to remove The patients head is to the left of the picture and the foot is to the right A retractor holds the femur anteriorly while we expose the posterior plate and screws (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.26  shows the three-quarter inch osteotome clearing heterotopic bone which incarcerates the plate heading directly superiorly in the 11 o’clock position on the acetabulum (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Screws and plates that impinge on the acetabular reamers are removed Through this approach, the screws were usually removed in their entirety using a screwdriver However, a high-speed burr could be used for removal of screw segments if the surgeon felt this is necessary We usually prefer to remove the screws entirely and not use the burr to minimize metal fragment generation A standard multihole acetabular high porous coated revision component is used We use the transverse acetabular ligament as well as fluoroscopic imaging to guide 11  Conversion Total Hip Arthroplasty 161 Fig 11.27  shows the three-quarter inch curved osteotome being used to free the posterior capsule and heterotopic bone from the plate and screws Care is taken at this point to again flex the knee and extend the hip to protect the sciatic nerve (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.28  shows gentle exposure of the most distal aspect of the posterior reconstruction plate and ischium Often times gentle taps on the osteotome will allow for a subperiosteal dissection with minimal soft tissue disruption (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) component placement However, the surgeon should be cautioned that the transverse acetabular ligament will not be in the normal location to the acetabular deformity If the acetabular bone defects are large, then multiple screws superior and inferior to the equator of the acetabular component should be used to optimize initial fixation and allow early weight-bearing (Figs. 11.33 and 11.34) 162 T T Manson and A J Johnson Fig 11.29  shows screws being removed from the proximal aspect of the reconstruction plate (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.30  show screws being removed from the distal aspect of the reconstruction plate These distal screws can often have stripped heads due to their angle of insertion and so care is taken to visualize the screwdriver entering the head of the screw prior to screw extraction (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) A careful repair of the external rotators and capsule to the trailing edge of the gluteus medius tendon or through drill holes in the posterior greater trochanter is utilized to limit postoperative dislocation [8, 9] Postoperative Care In many cases the acetabular stability obtained by this technique is excellent and patients can begin full weight-bearing immediately after surgery If there are concerns, the surgeon can keep the patient 50% weight-bearing for four to six weeks 11  Conversion Total Hip Arthroplasty 163 Figs 11.31 and 11.32  to show removal of the reconstruction plate after it has been freed from its screws (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) Fig 11.33  shows a typical patient with posttraumatic left hip osteoarthritis that was treated with conversion through a Kocher approach The posterior column plate did not impinge with implant placement and so was left in place The posterior wall reconstruction plate was removed as it was found to impinge on the acetabular reamer during preparation for an acetabular component (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) after surgery, but usually is the maximum amount of time that the patient would need to be protected weight-bearing and gradual languishment of assistive devices is encouraged Patients are followed very closely for graft consolidation and usually this is reliable given the autograft femoral head that is utilized 164 T T Manson and A J Johnson Fig 11.34  shows a patient who had difficulty with wound healing around the time of her initial fracture fixation A preoperative aspiration, CRP, and ESR were all negative However in these cases an abundance of caution is prudent At the time of conversion hip replacement, we removed all of her implants and treated her with a one-stage exchange to a primary hip replacement As noted, we did use a multihole acetabular component with screws both superior and inferior to the equator of the cup to optimize her acetabular component stability and allow early weight-bearing (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center Used with Permission) References Ibrahim MS, Raja S, Haddad FS. Acetabular impaction bone grafting in total hip replacement J Bone Joint Surgery Br 2013;95B:98–102 Sloof TJ, Huiskes R, Van Horn J, Lemmens AJ.  Bone grafting in total hip replacement for acetabular protrusion Acta Orthop Scand 1984;55:593–6 George DA, Haddad FS.  One-stage exchange arthroplasty: a surgical technique update J Arthroplast 2017;32(9S):S59–62 Levine MA A treatment of central fractures of the acetabulum A case report J Bone Joint Surg 1943;25:902–6 Beaule PE, Griffin DB, Matta JM. The Levine anterior approach for total hip replacement as the treatment for an acute acetabular fracture J Orthop Trauma 2004;18(9):623–9 Leunig M, Siebenrock KA, Ganz R. Rationale of periacetabular osteotomy and background work J Bone Joint Surg Am 2001;83A:438–48 Letournel E, Judet R. Fractures of the acetabulum New York: Springer; 1981 Browne JA, Pagnano MW. Surgical technique: a simple soft tissue only repair of the capsule and external rotators in posterior approach THA. Clin Orthop Relat Res 2012;470(2):511–5 Pellicci PM, Bostrom M, Poss R. Posterior approach to total hip replacement using enhanced posterior soft tissue repair Clin Orthop Relat Res 1998;355:224–8 Index A Acetabular fractures anesthesiology, geriatrics, internal medicine, low-energy trauma, nonoperative treatment method, 2, ORIF, orthopaedic surgery, proximal femur fractures, THA, treatment options, Acetabular injuries, 67 Activities of daily living (ADLs), Acute arthroplasty, 138, 139 Anesthesiologist Physical Status Score (ASA PS), 10 Antegrade anterior column, 70 Antegrade screws, 68 Anterior column posterior hemitransverse fracture, 54 Anterior column screw, 68, 78 Anterior inferior iliac spine (AIIS), 72, 107, 114 Anterior intra-pelvic (Stoppa) approach (AIP), 45, 52, 151 Anterior pins, 79 Anterior superior iliac spine (ASIS), 40 AP pelvis radiograph, 23 B Behavioral Risk Factor Surveillance System survey (BRFSS), Bureau of Labor Statistics, Buttress screw, 57, 58 C Calcium phosphate void filler, 58 Clamps, 81–83 Clinical frailty scale (CFS), 8, Cobb elevator, 40, 80, 84 Conversion total hip arthroplasty hip replacement, 150, 151 initially treated non-operatively, 144 inside-out technique, 155, 157, 158, 160–163 post-traumatic acetabular deformity, 144–147 posttraumatic arthritis, 143 previous ORIF, 149, 150 standard posterior approach, 154, 155 Coumadin, 25 Cox proportional hazards modeling, 26 Cup-cage technique, 99 D Dome impaction anterior column disruption, 49 anterior column fracture, 55 balanced skeletal traction, 50 buttress screw, 57, 58 fracture fragments and hematoma, 53 gull sign, 50 Hohman-type retractor, 52 intact bone stock forcing, 55–56 ipsilateral knee, 50 Kirschner wires, 57 multiple small fragments, 56 obturator neurovascular bundle, 52 particular fracture variants, 50 posterior subchondral impaction, 53 © Springer Nature Switzerland AG 2020 T T Manson (ed.), Acetabular Fractures in Older Patients, https://doi.org/10.1007/978-3-030-25105-5 165 166 Dome impaction (cont.) quadrilateral plate, 49, 53 radiographic signs, 49 sagittal and coronal CT reconstructions, 50 sharp osteotome, 55 small anterior column fracture, 50 standard anterior–posterior radiograph, 50 vascular clips, 52 E External oblique fascia, 40 F Femoral nerve, 41 H Hardinge approach, 106 Helfet, 65 Hemitransverse fracture, 98 I Ilioinguinal approach, 71, 151 contraindications, 39 external oblique fascia, 40 femoral nerve and vessels, 39 lateral to iliacus, psoas, and femoral nerve, 39 medial to femoral vessels, 39 penrose drain, 41 reduction and fixation, 41, 44, 45, 47 retropubic vascular connection, 41 setup, 40 subperiosteal dissection, 41 Iliopsoas muscle, 41 Instrumental activities (IADLs), Internal fixation, 36, 37 Ipsilateral knee, 50 J Joker elevator, 86 K Kirschner wires, 57 Kocher-Langenbeck approach, 33, 126 L Lacuna musculorum, 40 Lacuna vasorum, 40 Index Lag screws, 77 LC-2 screw, 72 Levine approach, 115 Life expectancy and function fourth age, frailty ASA score, clinical scale, cognitive evaluation adds, 11 comprehensive geriatric assessment, 11 deficit accumulation model, distinct clinical syndrome, frailty index score, 10–11 Fried and Rockwood approaches, 10 index variables, low energy femoral neck fractures, 10 medical record-based model, 10 modified frailty index, 10, 11 multiple options, multiple physiologic system, orthopedic injury, 11 phenotype, postsurgical morbidity, 10 risk stratification, 12 screening tools, 11 frailty measures, moderate-intensity physical activity, older U.S population, physical function evaluation, 12–16 preexisting comorbidity and disability, third age, vigorous aerobic activity, M Magic screw, 73, 74 Major Extremity Trauma Research Consortium (METRC), 22 Modified frailty index (mFI), 10 Musculoskeletal Function Assessment scores, 26 N National Health Interview Survey (NHS), National Surgical Quality Improvement Program (NSQIP), 10 Non operative treatment AP pelvis radiograph, 24 chemoprophylaxis, 25 contraindications for, 22 femoral head impaction, 24 indications for, 22 operative fixation, 22 operative options, 22 Index outcomes, 134, 135 partial weight bearing and advancement, 24 patient-reported outcomes, 25, 26 percutaneous fixation, 22 plain radiographs, 24 poor bone quality and comminuted fractures, 22 poor outcomes, 21 prolonged traction or external fixation, 21 radiographic workup of, 23 skeletal traction, 24 stable and unstable, 21 symptomatic postoperative arthritis, 22 toe-touch weight bearing, 24 O Open reduction and internal fixation (ORIF), anterior approach acetabular preparation, 123–124 bone-to-bone fixation, 117 Ethibond suture, 117 femoral neck and head, 116 femoral preparation, 124 Hanna table, 114 indications, 114 intrapelvic approach, 114 posterior column injuries, 117 Stoppa approach, 120 Kocher-Langenbeck approach acetabular liner, 129 cotyloid fossa, 128 femoral head, 126, 127 Hemovac drain, 130 indications, 125 labrum and pulvina, 128 morselized femoral head fragments, 128 sequentical capsulotomy, 126 total hip arthroplasty, 125 weightbearing, 130 outcomes, 137, 138 Orthopaedic Trauma Association (OTA), 139 P Pelvic corridors, 67 Percutaneous treatment acetabular fracture, 90 acetabulum and compression, 90 anatomic reduction, 65 bilateral superior and inferior rami fractures, 90 bony corridors 167 anterior column screw, 68 LC-2 screw, 72 magic screw, 73, 74 percutaneous fixation, 68 posterior column screw, 68, 70 traditional open approaches, 67 indications, 66, 67 joker elevator, 85 open reduction and internal fixation, 85 outcomes, 135, 136 postoperative management, 85 reduction techniques clamps, 81–83 collinear clamp, 75 external fixation, 80, 81 invasive open approach, 75 lag by design/lag by technique, 77, 78 ligamentataxis/traction, 76–77 manipulative reduction aids, 78–80 osteochondral impaction, 75, 83 Reinert clamp, 90 retrograde posterior column screw, 90 right T-type acetabular fracture, 90 sagittal reconstruction, 90 transsacral-transiliac screw, 90 Posterior column fracture, 30, 31 Posterior inferior iliac spine (PIIS), 72 Posterior wall and column acetabular fractures indications and contraindications, 32, 33 Kocher-Langenbeck approach, 33, 34 loss of joint congruence, 29 positioning/draping/C-arm, 33 post-operative management, 36, 37 pubic symphysis, 29 radiographic evaluation, 30, 31 reduction and fixation, 34–36 Posterior wall fragment, 30, 32 Post-traumatic acetabular deformity, 144–147 Prostalac, 150 Q Quadrilateral surface comminution, 59–62 R Reinert paddle clamp, 82, 86 Retrograde screws, 68, 70 S Schanz pins, 53, 77, 79 Schanz screw, 41 Short physical performance battery (SPPB), 13, 14 168 6-meter walk test (6MW), 13 Spermatic cord, 40 Steinman pin, 76 “Stoppa” anterior intrapelvic approach, 123 T Total hip arthroplasty (THA), 2, 113 anterior approaches indications, 106, 107 postoperative care, 111 surgical technique, 107–110 Index formal open reduction, 97 internal fixation, 97 posterior approaches, 98, 99 post-operative care, 105, 106 surgical technique, 99, 101, 104, 105 Traction tables, 77 W Watson-Jones or direct anterior approach, 144 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 25 ... but the patient cannot tolerate substantial anesthetic time or blood loss, nonoperative treatment may be the best treatment option  uthors’ Preferred Treatment Method for Treating Patients A.. .Acetabular Fractures in Older Patients Theodore T Manson Editor Acetabular Fractures in Older Patients Assessment and Management Editor Theodore T Manson Department of Orthopaedic Surgery... others [ 1, 4, 5, 1 1, 18] Operative options include percutaneous fixation [ 7, 9, 20 ], open reduction and internal fixation [ 4, 5, 1 0, 1 1, 18 ], and acute total hip arthroplasty (THA) with or without