A 46 year-old gentleman presented to our institution after a motor vehicle collision
. He sustained multiple injuries including a left transverse-posterior wall [AO/OTA 62-B1.3, a4] acetabular fracture with associated posterior dislocation of the femoral head (Figure 1). Other injuries included a sternal body fracture with retrosternal hematoma, omental hematoma, traumatic left elbow arthrotomy, and closed right perilunate dislocation. Physical exam of the left lower extremity demonstrated decreased sensation and weakness in the peroneal distribution of the sciatic nerve with intact posterior tibial nerve function. There were palpable pulses in the left foot equal to the contralateral limb. The patient reported no complaints with his left hip prior to this injury. A closed reduction of the left hip joint was performed and the patient was placed in distal femoral skeletal traction to maintain reduction of the joint and to lateralize displacement of the transverse fracture line. The left foot drop persisted after closed reduction of the left hip. Cystogram demonstrated displacement of the bladder toward the contralateral hemipelvis without evidence of bladder rupture (Figure 2). Computed tomography of the pelvis was obtained after reduction of the hip joint which revealed a transtectal transverse fracture line with a large posterior wall fragment with marginal impaction (Figures 3 a-b).
The patient underwent debridement and irrigation with closure of the left elbow traumatic arthrotomy and open reduction percutaneous
pinning of his right perilunate dislocation on the day of presentation after evaluation and clearance by the general surgery trauma service. He remained in distal femoral skeletal traction for his left acetabulum fracture for five days prior to definitive fixation. Deep venous thrombosis prophylaxis was administered with sequential compression device and lovenox 30 mg twice daily.
Due to the significant displacement and the transtectal nature of the transverse component of the acetabular fracture
, combined ilioinguinal and Kocher-Langenbeck approaches were chosen.
An ilioinguinal approach was performed in a supine position with intraoperative distal femoral traction on an OSI flat top table with traction arc [Mizuho OSI, Union City, CA, USA]. Upon dissection of the middle window, a large cystic
, soft tissue mass approximately 5 x 6 cm was encountered just lateral to the iliopectineal fascia and anterior to the superior pubic ramus (Figure 4). The femoral vessels were dissected and did not communicate with the mass. Blunt dissection around the mass was carried out and the mass originated from the anterior portion of the hip joint. The mass was excised and the stalk near the anterior hip joint was ligated. Fluid within the mass was consistent with a ganglion cyst. The mass was sent to pathology for examination. A labral tear was noted associated with the anterior portion of the transverse fracture. No formal repair was performed. The transverse portion of the acetabular fracture was then reduced and fixed with an anterior column screw prior to closure of the ilioinguinal approach. A Kocher-Langenbeck approach was subsequently performed under the same anesthetic for fixation of the posterior components of the fracture. Neurolysis
of the sciatic nerve was performed and the nerve was found to be in continuity. Traumatic disruption of the superior gluteal system at the greater sciatic notch was found intraoperatively. Internal fixation for the posterior wall component consisted of two lag screws and a buttress plate.
Soft tissue windows of the original CT scan of the pelvis were reviewed postoperatively and a soft tissue mass (Figures 5) was noted just lateral to the femoral
vessels consistent with our intraoperative findings.
Postoperative management included posterior hip dislocation precautions for 4 weeks and touchdown weight bearing to the left lower extremity for a total of 12 weeks. An ankle-foot
orthosis was ordered for the left foot drop. Surgical pathology of the mass was read as “consistent with ganglion cyst”.
The patient had an uneventful postoperative course. He was advanced to weight bearing as tolerated 12 weeks after fixation and his sciatic nerve
function gradually returned to normal over six months. At six months follow-up, the patient’s hip is asymptomatic without evidence of posttraumatic arthritis or avascular necrosis.