3.1.1 Preoperative planning

If a patient meets surgical indications, the next step is the preoperative planning phase. This is critical in the transverse fracture, as not all transverse patterns can be treated with a single approach. The decision of surgical approach should be dependent on the level (ie, the height) of the transverse fracture and its obliquity (ie, on which side it is highest or involving more of the weight-bearing portion of the acetabulum), displacement, and rotation ( Fig 2.10.3-3 ).

Surgeons must be familiar with all standard approaches and the associated reduction techniques and instrumentation to make the best decisions for the patient. Choosing the wrong position and approach can have disastrous effects on the surgical outcome.

Fractures highest anteriorly, with most displacement and involvement anteriorly should be approached anteriorly through an ilioinguinal incision ( Fig 2.10.3-3 ). In the reverse scenario when most displacement is posterior, the fracture should be approached through a Kocher-Langenbeck incision. The smaller the remaining intact articular surface of the dome, the greater the difficulty one faces in attempting to reduce through a standard single incision. In these scenarios, a dual or extensile approach has been advocated, which are especially useful in situations of surgical delay. A newer technique for approaching the high-transverse fracture situation is through a posterior approach with a trochanteric flip osteotomy and surgical dislocation, allowing exposure of the posterior column, dome, and articular surface ( Fig 2.10.3-4 ).

3.2.1 Approach

A standard Kocher-Langenbeck approach is indicated in most cases for the pure transverse pattern (see Chapters 2.7 and 2.8 for detailed descriptions of surgical approaches). Surgeons should pay close attention to the high, transtectal fracture pattern and to the fracture with significant anterior displacement/rotation. The standard Kocher-Langenbeck incision may not adequately expose the fracture to allow reduction and fixation. Exposure can be aided by an extensile approach, adding a lateral window of the ilioinguinal approach, or by performing a trochanteric flip osteotomy.

Patient position for the Kocher-Langenbeck approach is classically prone. Rather than the femoral head acting as a displacing force, traction and positioning can become a reduction aide for the inferior portion of the transverse component. The lateral position may be chosen if the surgeon wants to perform a trochanter osteotomy, as this is more technically challenging in a prone position. Also in a lateral position, a lateral window of the ilioinguinal approach can be added without breaking sterility. Ultimately, the surgeon must choose whether the freedom of the lateral position is worth the potential displacing force in a particular fracture. While the literature is limited, one study [3] failed to show a benefit of the prone position for fracture reduction in comparison to lateral.

The results from the University of Bern [4] highlight the potential benefits of the trochanteric flip osteotomy and surgical dislocation in addition to the Kocher-Langenbeck approach. Their indications for performing the dislocation were marginal impaction, highly comminuted posterior wall, involvement of the anteroposterior rim, anterior column displacement, and femoral head fractures. Anatomical reductions were observed in 93% of fractures, and no cases of osteonecrosis were observed. Again, the lateral decubitus position is needed for this technique.

A supine position should be chosen for the ilioinguinal approach (see Chapters 2.7 and 2.8 for a full description of this technique).

3.2.2 Reduction

Specific reduction techniques for pure transverse fractures depend largely on the approach needed for best exposure and control. Ultimately, the success of the procedure depends on a thorough understanding of the fracture on plain films and CT scans. Once the fracture is anatomically reduced, the ultimate stability of the joint fragments is gained through compression from lag screws and support from plates.

Most pure transverse patterns are treated with a Kocher-Langenbeck approach in a prone position (see Chapters 2.7 and 2.8). This approach is best suited for fractures where the greatest displacement, rotation, and articular involvement are posterior. The intraoperative view is of a displaced posterior column with the inferior fragment containing a portion of the anterior column and wall. As the anterior column reduction is essential to obtaining an anatomically correct acetabulum, the full Kocher-Langenbeck exposure should be used. This will ensure access from the greater sciatic notch to the ischium with digital access to the quadrilateral plate through both the greater and lesser notches. These are the best access points for insertion of a finger or clamp onto the inner aspect of the pelvis for reduction of displacement and rotation ( Figs 2.10.3-5 through 14). Fracture fragments should be meticulously cleaned so that minor displacement and rotatory mismatch can be appreciated.

Prior to beginning the reduction of the specific fragments, it is often helpful to place a Schanz pin into the femoral neck ( Fig 2.10.3-14 ). Traction through this pin uses the femoral head and intact capsule to supplement reduction forces through the fragments themselves. Femoral traction can be performed by an assistant, using a femoral distractor or on a traction table, depending on the surgeon’s preference.

The forces necessary to create reduction of the displaced transverse fragment of the acetabulum come from controlling and manipulating the inferior fragment. Often, the inferior fragment is displaced medially through shear along the obliquity of the fracture plane. A pelvic reduction clamp can be placed through the greater sciatic notch to reduce the fragment to the intact ilium ( Figs 2.10.3-5 through 13). Rotation of the fragment should be appreciated and controlled with a Schanz pin in the ischium.

A second reduction technique, particularly useful in the transverse fracture, is placement of a Jungbluth clamp on either side of the fracture on the posterior column via two screws ( Fig 2.10.3-5 through 13). These screws serve as attachment points for the clamp and should be placed so that when the Jungbluth clamp is closed and the clamp is tightened, the fracture keys in anatomically misplaced screws serve as a displacing force.

Small plates (3.5 or 2.7) can be placed along the posterior column to assist with reduction and temporary fixation. One should not forget the biomechanical principles when treating these fractures. Fracture line obliquity can cause shear during interfragmentary compression. Judicious use of antiglide plates can be beneficial in controlling shear when reduction clamp are closed or lag screws are tightened. Use of intraoperative x-rays is critical to ensure adequate reduction and fixation ( Figs 2.10.3-15–17 ).

Remember that in a classic Kocher-Langenbeck approach, visualization of the articular surface is not possible. If there are intraarticular fragments or marginal impaction that need direct assessment, surgeons should consider adding a trochanteric osteotomy and surgical dislocation of the hip.

3.2.3 Key instruments and implants

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  Femoral traction through 5 mm Schanz pin directed along the femoral neck

  
  
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  Schanz pin in the ischium for rotation control

  
  
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  Jungbluth forceps for posterior column reduction

  
  
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  Pelvic reduction clamp of multiple sizes

  
  
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  3.5 or 2.7 plates to help achieve and to maintain temporary fixation

  
  
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  Lag screws

  
  
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  Definitive posterior column plate 3.5 from the sciatic buttress to the ischium

3.2.4 Fixation

Once the reduction is judged successful, placement of the definitive plate can be performed. Small imperfections in the reduction can be corrected through well-placed plate screws pulling the displaced fragments into anatomical position. Minor corrections in rotation can also be corrected during this phase of surgery. This is best done when only one screw has been placed on each side of the fracture. A pelvic reduction clamp can be placed through the greater sciatic notch onto the quadrilateral plate to reduce and to derotate the inferior fragment.

Once aligned, lag screws should be placed from posterior to anterior after predrilling a gliding hole. The screws start lateral to the greater sciatic notch and run parallel to the quadrilateral plate as they travel into the anterior column. A finger placed along the quadrilateral plate will allow digital palpation of the oscillating drill bit as it passes parallel to the plate. Be careful to stay extraarticular and not to injure the neurovascular bundle anteriorly with the drill. This is best accomplished with 3.5 mm screws, preferably two for a standard transverse pattern ( Fig 2.10.3-18, Fig 2.10.3-19 ).

An alternative lag screw can be placed from the posterior ilium to the anterior column ( Figs 2.10.3-11 through 13). The increased length of this screw makes it more potentially dangerous secondary to the less digital control involved. The ideal starting point is just posterior to the gluteal ridge, three-finger breadths above the articular surface of the acetabulum. In the standard Kocher-Langenbeck approach, this would have to be done percutaneously through the abductor muscles with image intensification control. This screw has a small acceptable window in the anterior column for insertion, and be careful not to injure the neurovascular bundle if the drill exits near the iliopectineal eminence anteriorly ( Fig 2.10.3-20 ). The oscillating feature present on many drills can be used to minimize the risk. Our preference is to run a standard drill continuously so as to better feel the bone of the far cortex and minimize penetration. Image intensifier is essential to ensure safe screw positioning; inlet and obturator outlet views are the most helpful. Be sure to ensure that the fracture exits high enough anteriorly so that these screws are able to find purchase in the superior aspect of the inferior fragment.

Once lag screws and temporary fixation have been placed, the next step is to position a buttressing plate from the sciatic buttress to the ischium. A pelvic reconstruction plate 3.5 has the optimal amount of stiffness to support rigid fixation and some residual malleability to allow contouring as the screws are tightened. The posterior column plate in the setting of a transverse fracture should be slightly over contoured to create a small gap between the plate and the posterior surface of the acetabulum ( Fig 2.10.3-19 ). As the plate is tightened, it compresses the anterior aspect of the fracture and ensures minimal gapping. The buttress plate should not be used alone to hold the reduction; lag screws are fundamental to holding the reduction during the healing phase ( Fig 2.10.3-21 ).

3.2.5 Tips and tricks

With juxtatectal and lower transverse fractures posteriorly, it is sometimes difficult to control the posterior column, especially when there is a high shear angle to the fracture. A pelvic reconstruction plate 3.5 that has been contoured to the inferior fragment of the posterior column is applied with screws. Reduction and control are accomplished using a pointed reduction clamp and a unicortical drill hole in the iliac wing with one tine in the plate and one tine in the drill hole. Once reduction has been confirmed, the plate is fixed to the bone proximally with definitive screws. The pelvic reconstruction plate 3.5 is flexible enough to take on the contour of the bone as the screws are tightened. One must be careful during this step to ensure the plate screws do not displace the fracture.

Some transverse fractures begin in the infratectal and juxtatectal regions and extend superiorly into the inner pelvis producing a high spike of bone where the posterior and anterior columns meet. The application of an offset pelvic clamp through the greater sciatic notch with one tine on the spike and the other on the outer aspect of the iliac wing will often reduce this fracture. This is difficult, especially with comminution. It is sometimes possible to insert a pelvic reconstruction plate into the greater notch to spread the compressive forces of the offset pelvic clamp over a larger area and limit any propagation of fracture lines. Also in this setting, the simultaneous application of a Jungbluth clamp to the posterior column can aide in distributing the forces of reduction and controlling for rotation. If it is impossible to control the reduction of the fracture spike, the posterior column can be fixed anatomically, and the spike can be reduced and fixed with an antishear buttress plate from an ilioinguinal incision.

Transverse fractures may also be oblique in the opposite direction from that described above. The possibilities of fracture obliquity are numerous, and one should be prepared to “play” with the traction and rotation control through Schanz pins, pelvic clamp, Jungbluth clamp, plates, and screws. Moving a clamp in a different plane may be all that is required to overcome shear forces limiting a reduction. Carefully study the fracture lines to optimize placement of the reduction tools.

3.3.1 Postoperative care

At our institution, patients are kept toe-touch weight bearing (9 kg maximum). Out of bed ambulation with crutches is encouraged starting postoperative day 1. Drains are left in place until the patient is ambulatory. Physical therapy consultation is obtained during the postoperative hospital stay to teach weight-bearing restrictions and to demonstrate active and active-assist range of motion exercises in abduction, flexion, and extension. Hip precautions (no internal rotation, flexion past 90°, or adduction past midline) are stressed, especially in the case of a fracture/dislocation. Limitation of abduction is stressed if the patient had a trochanteric flip osteotomy.

Patients receive prophylaxis against heterotopic ossification (HO) in the setting of a posterior approach; HO prophylaxis after ilioinguinal approaches is not routinely performed. Typically indomethacin is given (75 mg sustained-release once daily for 6 weeks). This has been shown to be as effective as postoperative irradiation [5]. The best prophylaxis for HO is careful handling of the soft tissues during surgery. As there are risks with long-term nonsteroidal antiinflammatory drug dosing, surgeons must be diligent in following up patients during the postoperative course. Some [6] do not recommend nonsteroidal antiinflammatory drug prophylaxis at all, citing minimal improvements in HO rates compared to placebo.

Venous thrombus and pulmonary embolus can be devastating complications following pelvis surgery. With incidence of clots as high as 61% [7], most surgeons are aggressive about prescribing a preoperative prophylaxis regimen. However, literature is lacking on definitive recommendations for how to protect against clot/embolus, as well as how to screen for them [8]. Early dosing (within 24 hours of injury) of low-molecular-weight heparin has been shown to be effective in reducing rates of deep vein thrombosis [9]. In patients unable to receive low-molecular-weight heparin, we consider placement of an inferior vena cava filter in the preoperative setting.

Postoperative thrombus prophylaxis protocols also lack supporting evidence. At our institution, patients are treated with low-molecular-weight heparin, warfarin, or an inferior vena cava filter until they begin the gradual progression to full-weight bearing, typically at around 10 weeks postoperatively.