Surgical Discussion

Patient positioning:  The patient was positioned prone on a radiolucent table, with appropriate padding and supports to facilitate posterior pelvic access and fluoroscopic imaging.

Anatomical surgical approach:  A standard Kocher-Langenbeck approach was performed, incising through the gluteal fascia and splitting the fibers of the gluteus maximus. The short external rotators were identified and protected, with subperiosteal dissection exposing the posterior column and wall of the acetabulum. The sciatic nerve was identified and mobilized laterally. The posterior capsule was found disrupted adjacent to the intact articular surface. The impacted osteochondral fragment was extracted from the joint space. The transverse fracture plane was debrided and reduced using clamps, with a greater trochanteric bone hook employed to manipulate the femoral head beneath the acetabular dome during reduction. Provisional fixation was achieved with a percutaneous lag screw across the transverse component. The peripheral posterior wall fragment was anatomically reduced and stabilized with a contoured plate. The medial wall defect provided access for reduction of the impacted articular segment, which was bone grafted prior to reduction and plating of the medial wall. Capsular tissues were repaired with nonabsorbable sutures prior to layered wound closure.

The posterior wall fragments exhibited an unusual caudal hinge morphology, necessitating careful mobilization to avoid propagation or comminution. Removal of the impacted intra-articular fragment was essential to achieve concentric reduction of the femoral head within the acetabular dome. Use of a greater trochanteric bone hook facilitated precise control of femoral head position during reduction maneuvers. The medial wall fragment, though non-articular, allowed direct visualization and accurate reduction of the impacted osteochondral segment, which was supported with bone graft prior to definitive fixation. Repair of disrupted capsular tissues was performed to restore soft tissue integrity and potentially reduce postoperative instability.

Postoperative protocol:   Postoperatively, toe-touch weight bearing was instituted for 8 weeks with active-assisted range of motion exercises initiated immediately. Hip flexion was limited to 90 degrees for 6 weeks to protect capsular repair. Abduction and external rotation were restricted during early rehabilitation. Progressive weight bearing commenced at 8 weeks based on radiographic evidence of healing.

Follow up:   Not specified

Orthopaedic implants used:   3.5mm pelvic reconstruction plate (posterior wall), 3.5mm pelvic reconstruction plate (medial wall), percutaneous cannulated lag screw, cancellous bone graft