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First described by Ganz and Mast, the Bernese periacetabular osteotomy (PAO) was first developed for the treatment of hip dysplasia. The purpose of the surgical technique is to expose the innominate bone through a modified Smith-Petersen approach, thereby allowing osteotomies around the acetabulum to be performed while leaving the posterior column intact. Once the osteotomies have been completed, the acetabular fragment is freely mobile allowing reorientation based on the preoperative deformity. There are several anatomic structures at risk during the surgical procedure including the lateral femoral cutaneous nerve, femoral neurovascular structures, obturator neurovascular structures, sciatic nerve, and medial femoral circumflex vessels. The purpose of this chapter is to describe the modified technique we use to minimize the risk of injuries to these anatomic structures.

Posterior wall (PW) fractures represent one of the most common fractures of the acetabulum. Posterior column (PC) fractures are rarer, but the incidence of simultaneous presence of both PW and PC fracture is slightly higher. Both PW and PC acetabulum fractures are sustained following high-energy trauma. Routine initial radiographic workup includes an AP pelvic radiograph and Judet views. CT scan acquisition including 3-D reconstruction slices completes the radiological assessment of the joint. Combined PW and PC fractures require careful planning and the application of two plates. One plate has a role in buttressing the PW fragment whilst the other supports the PC element of the injury. Impaction injuries require the knowledge of special techniques in relation to reduction, management of the cancellous void created in the subchondral region (grafting options) and support of the impacted segment. This chapter focuses on the techniques of reduction and reconstruction of PW and PC acetabular fractures.

Acetabular fracture in older patients presents many challenges to even experienced pelvic surgeons. There remains a lack of clarity regarding many indications for nonoperative or operative management. Chronological age should not be considered in isolation when deciding upon a treatment plan; rather, the surgeon must individualize the plan to the patient’s activity level, physiological age, and risks for blood loss and general anesthesia. When an operative path is chosen, closed or limited open reduction techniques paired with percutaneous screw stabilization are an option for fracture patterns not associated with posterior instability of the hip joint. The goals of treatment should be restoration of the normal relationship of the cranial femoral head with the dome of the acetabulum and to provide fixation that is stable to allow for early mobilization. Fixation with screws alone provides less resistance to loss of reduction than do plates, but allows for implant placement without large open approaches. A secondary benefit of fixation with percutaneous screw is the ability to remove them at a later date with percutaneous incisions rather than open approaches. Common screw pathways used are familiar to pelvic surgeons and include anterior and posterior column screw and the LC-2 (pelvic brim) screw, but screw placement is only performed after an appropriate reduction has been achieved.

The intervertebral space offers a unique region of the lumbar spine to obtain alignment corrective goals as well as to achieve a solid arthrodesis. The vast majority of the body weight and compressive forces traverse the anteior column of the spine. Concomitantly, the intervertebral space offers a relatively short and vascularized gap across the motion segment, making this a prime environment for solid fusion. The Transforaminal interbody fusion technique uniquely allows the spine surgeon access to both anterior and posterior column pathologies for corrective measures and treatment using a single approach.

The ilio-inguinal approach is an anterior approach to the pelvis, introduced by Letournel in 1965. With its use, the results of surgical treatment of acetabular fractures with the main dislocation in the anterior column were greatly improved. The anatomical dissection leads to a low complication rate and fast recovery of the patient. Three anatomical windows are developed: The first exposes the anterior sacro-iliac joint and iliac fossa, the second exposes the anterior column, the anterior wall, and the quadrilateral surface, and the third exposes the superior pubic ramus. The main advantage of the ilio-inguinal approach is that by using all three windows, an extended direct view on the entire inner side of the pelvis can be achieved for fracture reduction and plate positioning. Main disadvantages are the lack of direct visualization of the acetabular surface, the impaired view on the posterior column, and the need to open the inguinal canal.

Smith-Petersen osteotomy (SPO) was first described in 1945 for patients with a kyphotic deformity secondary to rheumatic conditions (i.e. ankylosing spondylitis or rheumatoid arthritis). This technique uses the posterior half of the vertebral body and longitudinal ligament (PLL) as the fulcrum to obtain correction. This results in a shortening of the posterior column and a lengthening of the anterior column. This chapter describes a modified SPO technique for treatment of severe cervico-thoracic kyphotic deformities (CTKD). The osteotomy is performed at C7/T1 level. The technique consists in a complete resection of the C7 lamina, inferior portion of C6 and superior portion of T1 laminae. The cervical spine is instrumented from C3 to C6 and thoracic spine from T1 to T5. Malleable temporary rods are used to control coronal and sagittal plane movement during correction of the deformity while allowing extension at the cervico-thoracic junction. This technique is commonly applied in patients with ankylosing spondylitis but can be used in patients with other etiologies. Technical details are presented with advice on how to prevent common pitfalls with this technique.

A number of surgical approaches exist to allow surgeons the ability to access, reduce, and stabilize acetabular fractures from both the anterior and posterior aspects of the pelvis innominate bone. The anterior approaches in particular have evolved substantially since their inception to the extent that modern acetabular fracture surgery will frequently employ one or more approaches in isolation or in combination. Importantly, while separate camps may exist that favor one “philosophy” or “style,” surgeons should recognize the importance and value of each approach such that maximal access can be obtained to optimally expose reduce and stabilize the acetabulum. For example, many surgeons that would consider themselves “purists” in their use of the ilioinguinal approach have come to utilize some form of the “Modified Stoppa” or Anterior Intrapelvic Approach as a more functional medial window for access to the quadrilateral surface and posterior column. This does not represent any form of heresy or deviation; rather, the normal and necessary evolution of surgical techniques that continue to drive the progress and improve the outcomes of fracture surgery and the art of medicine. This chapter will focus on the historical and technical aspects of the “modern” and commonly used anterior surgical exposures for acetabular fracture surgery.

Scheuermann’s kyphosis (SK) presents as increased thoracic kyphosis or loss of lumbar lordosis with pathognomonic irregularities of the vertebral end plates. The majority of patients can be managed nonoperatively with bracing, short-term courses of NSAIDs, and physical therapy to address muscular discomfort. Surgical intervention should be considered for symptomatic patients with kyphosis exceeding 75°; however, smaller magnitude curves are also considered surgical if located in the thoracolumbar spine, if they are progressive, or if associated with significant pain or neurologic symptoms. A posterior approach with multilevel posterior column osteotomies at the apex of the deformity, segmental instrumentation, and fusion is the workhorse procedure. Junctional kyphosis is a complication that can often be avoided through careful selection of the upper (UIV) and lower instrumented vertebrae (LIV). In SK, the UIV should be the end vertebra; however, this is often difficult to visualize on lateral films, and therefore a line of best-fit technique may be used to aid selection. LIV is identified as the sagittal stable vertebra. Surgical correction of thoracic kyphosis and lumbar lordosis to values that are harmonious with the pelvic incidence (PI) is also important in preventing junctional kyphosis. In general terms, patients with high PI should be left with a larger thoracic kyphosis, while patients with relatively low PI should have a straighter sagittal profile. Asymptomatic, nonprogressive proximal junctional kyphosis (PJK) may be managed expectantly. The presence of progressive kyphosis, instability, or neurologic symptoms would mandate revision surgery with extension of the fusion proximally to a neutral or lordotic level.

Pelvic discontinuities consist of a lack of continuity between the superior hemipelvis and inferior hemipelvis. Radiographic indications of a pelvic discontinuity include a visible fracture line, obturator ring asymmetry, and medial migration of the inferior hemipelvis with disruption of Kohler’s line. The surgical treatment of pelvic discontinuities is demanding given the fact that both fracture and implant fixation must be addressed. The first goal is to restore a biomechanically continuous pelvic ring connecting the superior and inferior aspects of the pelvis (and thus acetabulum). The second is to obtain a stable reconstruction based on rigidly fixed implants.

Sagittal malalignment decreases patients’ quality of life and requires surgical correction to achieve realignment goals and spinopelvic balance. High-risk posterior-based osteotomy techniques ranging from posterior column osteotomies (PCO) to vertebral column resection (VCR) are the current standard treatment methods for addressing sagittal imbalance. More recently, minimally invasive surgeries (MIS) including lateral interbody fusion (LIF) have been developed in an effort to minimize the complication rate of more conventional posterior-based techniques while maintaining surgical goals. Anterior column realignment (ACR) utilizes hyperlordotic cages (20°–30°) filled with bone graft in the intervertebral disk space through an anterior lumbar interbody fusion (ALIF) retroperitoneal approach or lateral lumbar interbody fusion (LLIF) transpsoas approach. The anterior longitudinal ligament (ALL) along with the anterior annulus plays a major role in limiting the amount of distraction that can be achieved through the intervertebral disk. Hence, ALL release with careful consideration of anterior anatomic structures is required. Upon cage insertion, the construct can be secured in place with one or two screws into the adjacent vertebral bodies. It is highly recommended to perform this technique with triggered electromyogram (EMG), and somatosensory evoked potential (SSEP)/motor evoked potential (MEP) monitoring to avoid neurological complications. As a safeguard in case of vascular complications, it is prudent to have vascular surgeons available in the hospital at the time of surgery.

The objective of this chapter is to discuss the decision-making and surgical technique of lumbar osteotomies for treatment of malalignment. A comprehensive literature review was performed on the history, indications, preoperative evaluation, and decision-making in patients with sagittal and coronal plane malalignment, as well as surgical technique for lumbar osteotomies. There has been an evolution of many different types of osteotomies for correcting deformities; however, three general categories exist: (1) posterior column osteotomy (PCO), (2) pedicle subtraction osteotomy (PSO), and (3) vertebral column resection (VCR). More recently, the Schwab classification describes six anatomically defined osteotomies that are commonly accepted and used. Utilizing the best available evidence, we review the indications and patient selection as a first step and then discuss the decision-making and preoperative planning. Lastly, we detail the surgical technique with emphasis on complication avoidance.

Background Massive bone defects of the acetabulum with pelvic discontinuity are one of the major problems in revision total hip arthroplasty. Several techniques have been described for repair of acetabular defect; however, reconstruction of acetabulum with massive bone defect is still a major problem. We describe a patient who required four revision total hip arthroplasty during a 24-year period. Findings The acetabulum with pelvic discontinuity was successfully reconstructed by stabilization of the posterior column with a plate commonly used for fracture treatment, and stabilization of the anterior column by reinforcement device commonly used for acetabular reconstruction. Fixation of both acetabular columns provided significant improvement of component stability. Conclusions In the case of pelvic discontinuity with massive acetabular bone defect, reconstruction by stabilizing both acetabular columns using reconstruction plate and KT plate is one of the better surgical options.

Complex fractures of the proximal tibia are associated with soft tissue and neurovascular injuries. Appropriate clinical assessment, diagnostic imaging, and management of the soft tissue are the most important aspects. The sequential treatment algorithm with temporary external fixation allows the recovery of soft tissue and improvement of the results. Definitive treatment is aimed at reconstruction of the articular surfaces and restitution of normal mechanical axis. The use of the 2-incision approach decreases wound complications and deep sepsis. Minimally invasive techniques and anatomically contoured plates have afforded more biological approaches to these fractures. Bilateral dual plating is usually recommended as the definite fixation for this kind of fracture but may need an additional plate to fix the posterior column.