Reduction and Internal Fixation with Concomitant Total Hip Arthroplasty

Fig. 9.1

A standard flat top radiolucent table can be used for either anterior or posteriorly based approaches to the hip. If attempting concomitant open reduction internal fixation and total hip arthroplasty through the Levine approach to the acetabulum, folded blankets may be used to raise the patient’s torso up off the surface of the radiolucent table. This will make hyperextension of the hip possible during femoral preparation. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig2_HTML.jpg — Fig. 9.2

In this photograph the patient is being prepared for concomitant ORIF plus THA through an anteriorly based approach. The patient’s torso has been raised up off the operative table using folded blankets. This allows hyperextension of the hip. Further in the surgeon’s learning curve for direct anterior hip replacement, hyperextension of the hip is not necessary. The author’s current practice is to place the patient directly on a flat top radiolucent table and to prepare the femur without femoral hyperextension during the surgery. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

Both legs are draped into the field and the hip as well as the area above the pubic symphysis are draped into the operative fields so that if the surgeon finds it necessary to make a Stoppa anterior intrapelvic approach, this is possible without re-prepping and redraping (Fig. 9.3).

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig3_HTML.jpg — Fig. 9.3

In this image, the patient is positioned supine for concomitant ORIF plus THA through an anterior approach. The patient’s head is to the right of the image and the foot is to the left of the image. An incision 2–3 fingerbreadths lateral to the anterior superior iliac spine is continued proximally and then curves posteriorly along the course of the iliac crest. It may be necessary to place the incision more lateral if the patient has a more protuberant abdomen. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

An incision is made much like a standard direct anterior approach 2–3 cm lateral to the ASIS. The incision then curves posteriorly proximal to the ASIS to access the iliac Crest (Fig. 9.3). We usually perform the direct anterior approach to the hip first. The tensor fascia lata sheath is split in its midline so as to protect the lateral femoral cutaneous nerve (Fig. 9.4). The branches of the ascending branch of the lateral femoral circumflex artery are coagulated and an anterior capsulotomy is made exposing the femoral neck and head. At this point in time, the femoral neck and head may be left in place or they can be resected to facilitate reduction of the acetabular fracture. To equalize leg lengths postoperatively as much as possible, the neck resection is based on a templated marker ball radiographs of the contralateral intact hip.

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig4_HTML.jpg — Fig. 9.4

In this image of a cadaver dissection of the right-sided hip, the cadaver’s head is to the left of the image. A standard incision is made in the midportion of the tensor fascia lata sheath and this continues up to an incision over the iliac crest in between the external oblique fascia and the fascia lata. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

With the hip exposed, the dissection is carried further up to the anterior superior iliac spine. We usually release the inguinal ligament subperiosteally from its insertion on the anterior superior iliac spine and tag the ligament insertion with Ethibond suture for later repair (Fig. 9.5). Alternatively, an osteotomy of the edge of superior iliac spine can be made for bony repair at the conclusion of the procedure.

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig5_HTML.jpg — Fig. 9.5

The intrapelvic dissection and the dissection for the anterior hip replacement are connected by taking down the inguinal ligament from the anterior superior iliac spine. This is released in a subperiosteal fashion and tagged using a nonabsorbable suture. At the conclusion of the procedure the inguinal ligament is usually repaired back down to the anterior superior iliac spine using Ethibond sutures through a drill hole. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

The iliacus muscle is elevated subperiosteally from the internal surface of the iliac fossa and with the hip flexed to release tension on the neurovascular structures. Retractors are placed over the pelvic brim into the true pelvis (Fig. 9.6).

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig6_HTML.jpg — Fig. 9.6

The iliac fossa is exposed by subperiosteal dissection of the iliacus muscle from the bone. Care must be taken as large nutrient vessels enter the ileum in this area and may need to be coagulated. Blunt retractors were placed medially over the pelvic brim. A spiked retractor can also be placed lateral to the iliopectineal eminence as is typically done with the approach for a Ganz acetabular osteotomy [3]. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

Further visualization of the low anterior column and wall could be accomplished by release of the rectus femoris from its direct insertion into the pelvis. The majority of the time this is not necessary. However, if rectus takedown is necessary, we perform an osteotomy of the anterior inferior iliac spine to be attached later with bone-to-bone fixation (Figs. 9.7 and 9.8).

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig7_HTML.jpg — Fig. 9.7

In most cases the direct head of the rectus muscle can be left attached to the anterior inferior iliac spine. The rectus muscle is retracted medially and the reflected head of the rectus femoris is released as a surgeon would typically accomplish for a standard direct anterior hip replacement. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig8_HTML.jpg — Fig. 9.8

If more exposure is needed, the rectus femoris direct insertion can be released from the anterior inferior iliac spine either subperiosteally, as a tenotomy or as an anterior inferior iliac spine osteotomy. The author’s preference in these situations is an anterior inferior iliac spine osteotomy. Release of the rectus femoris insertion dramatically improves the exposure but again is rarely necessary. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

The goal of pelvic stabilization is not anatomic reduction, but to stabilize the subchondral bone of the acetabulum attached to the anterior inferior iliac spine. Often times, a 3.5 mm reconstruction plate can be used to definitively fix these fragments. To “lock in” the quadrilateral surface component of the fracture, long screws parallel to the quadrilateral surface traversing directly medial to the fossa are very powerful for fixation of these fractures (Figs. 9.9, 9.10, and 9.11).

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig9_HTML.jpg — Fig. 9.9

Postoperative AP pelvis x-ray shows fixation of the fracture with long screws parallel to the quadrilateral surface stabilizing the relationship between the anterior and posterior columns of the acetabulum. We use a multihole acetabular component with screws both superior and inferior to the equator of the acetabular component a. A standard uncemented femoral stem is used. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig10_HTML.jpg — Fig. 9.10

Postoperative iliac oblique view shows the long screws parallel to the quadrilateral plate and medial to the acetabular component stabilizing the columns of the acetabulum. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

../images/395168_1_En_9_Chapter/395168_1_En_9_Fig11_HTML.jpg — Fig. 9.11

Postoperative obturator oblique view again shows the plate and long screws stabilizing the relationship between the anterior inferior iliac spine and the ischium. This is the relationship that is critical to stabilize in order to gain stability for the acetabular component which is wedged in between the anterior inferior iliac spine and ischium. (Property of Theodore Manson and the R Adams Cowley Shock Trauma Center. Used with Permission)

Posterior column injuries can be reduced well through this approach as long as they are not significantly displaced. The posterior column component of the fracture can be stabilized with long 3.5 or 7.3 mm screws traversing from the iliac fossa into the posterior column (Figs. 9.11, 9.12, and 9.14).