Abstract
Objective
Safe posterior column screw fixation via an anterior approach under two-dimensional fluoroscopic control.
Indications
Anterior column with posterior hemitransverse fractures (ACPHF); transverse fractures; two-column fractures and T‑type fractures without relevant residual displacement of the posterior column after reduction of the anterior column and the quadrilateral plate.
Contraindication
Acetabular fractures requiring direct open reduction via a posterior approach; very narrow osseous corridor in preoperative planning; insufficient intraoperative fluoroscopic visualization of the anatomical landmarks.
Surgical technique
Preoperative planning of the starting point and screw trajectory using a standard pelvic CT scan and a multiplanar reconstruction tool. Intraoperative fluoroscopically controlled identification of the starting point using the anterior–posterior (ap) view. Advancing the guidewire under fluoroscopic control using the lateral–oblique view. Lag screw fixation of the posterior column with cannulated screws.
Postoperative management
Partial weight bearing as advised by the surgeon. Postoperative CT scan for the assessment of screw position and quality of reduction of the posterior column. Generally no implant removal.
Results
In a series of 100 pelvic CT scans, the mean posterior angle of the ideal posterior column screw trajectory was 28.0° (range 11.1–46.2°) to the coronal plane and the mean medial angle was 21.6° (range 8.0–35.0°) to the sagittal plane. The maximum screw length was 106.3 mm (range 82.1–135.0 mm). Twelve patients were included in this study: 10 ACPHF and 2 transverse fractures. The residual maximum displacement of the posterior column fracture component in the postoperative CT scan was 1.4 mm (0–4 mm). There was one intraarticular screw penetration and one perforation of the cortical bone in the transition zone between the posterior column and the sciatic tuber without neurological impairment.
Zusammenfassung
Operationsziel
Sichere Zugschraubenosteosynthese des hinteren Azetabulumpfeilers über einen vorderen Zugang unter zweidimensionaler Bildwandlerkontrolle.
Indikationen
Vordere Pfeilerfrakturen mit hinterer Hemiquerfraktur (ACPHF); Querfrakturen; Zweipfeilerfrakturen und T‑Frakturen ohne relevante Dislokation des hinteren Pfeilers nach Reposition des vorderen Pfeilers und der quadrilateralen Fläche.
Kontraindikationen
Azetabulumfrakturen, die einer direkten offenen Reposition von dorsal bedürfen; sehr enger knöcherner Korridor in der präoperativen Planung; unzureichende intraoperative Darstellung der relevanten Strukturen im Röntgenbildverstärker (BV).
Operationstechnik
Präoperative Planung des Eintrittspunkts und des Schraubenkorridors mithilfe des nativen axialen CT-Datensatzes und eines multiplanaren Rekonstruktionstools. Intraoperative BV-kontrollierte Identifikation des Startpunkts in der a.-p.-Projektion. Vorbringen des Führungsdrahts unter BV-Kontrolle in schräg-seitlicher Projektion. Zugschraubenosteosynthese des hinteren Pfeilers mit kanülierten Schrauben.
Weiterbehandlung
Teilbelastung gemäß den Vorgaben des Chirurgen. Postoperative CT-Kontrolle zur Überprüfung der Schraubenlage und Reposition des hinteren Pfeilers. Keine Implantatentfernung.
Ergebnisse
Der in 100 Patienten bestimmte optimale Schraubenkorridor war durchschnittlich 28,0° (Spanne 11,1–46,2°) nach dorsal (bezogen auf die Koronarebene) und 21,6° (Spanne 8,0–35,0°) nach medial (bezogen auf die Sagittalebene) anguliert. Die maximale Schraubenlänge betrug 106,3 mm (Spanne 82,1–135,0 mm). In diese Studie wurden 12 Patienten eingeschlossen: 10 mit ACPHF und 2 mit Querfraktur. Die durchschnittlich verbliebene Dislokation im Bereich des hinteren Pfeilers betrug 1,4 mm (Spanne 0–4 mm). In einem Fall wurde eine intraartikuläre Schraubenlage und in einem weiteren Fall eine kortikale Perforation im Übergangsbereich zwischen hinterem Pfeiler und Tuber ischiadicum ohne neurologisches Defizit beobachtet.
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Introductory remarks
In acetabular fractures involving one column only, either a single anterior or a single posterior approach is required for internal fixation. However, in acetabular fractures involving both columns, such as transverse fractures, T‑type fractures, anterior column with posterior hemitransverse fractures and two-column fractures, various strategies for surgical stabilization may be considered. Some of these fractures may be treated via a single approach without plate fixation of the other column, while others may require an extended or a combined anterior and posterior approach. The latter increases surgical time, blood loss and morbidity due to the need for a second approach [1,2,3,4].
An alternative option for selected acetabular fractures involving both columns is open reduction and plate fixation of the anterior column via an anterior approach combined with a fluoroscopically controlled lag screw fixation of the posterior column via the same single approach [5,6,7]. One prerequisite of this technique, however, is that the posterior column fracture is either nondisplaced or adequately reduced after reduction of the anterior column and the quadrilateral plate. As a consequence, T‑type fractures or two-column fractures, in general, are less often amenable to this technique, whereas transverse fractures and anterior column with posterior hemitransverse fractures (ACPHF; Fig. 1) appear to be a favorable indication for this fixation strategy. ACPHF and transverse fractures constitute up to 31% of acetabular fractures in patients aged 55 years and older and about 12% of fractures in younger patients, while T‑type and two-column fractures represent more than one third of fractures in both older and younger patients [8, 9].
Although surgical techniques such as CT-controlled and navigated screw fixation may be capable of reducing the rate of screw malpositioning in pelvic and acetabular surgery [10,11,12], these techniques are not widely available due to their high costs and skills required. The aim of this article therefore is to present a simple preoperative planning technique for the estimation of the starting point and screw trajectory of acetabular posterior column screw fixation via an anterior approach and to delineate its intraoperative application under fluoroscopic control.
Surgical principles and objective
Safe posterior column screw fixation via an anterior approach under two-dimensional fluoroscopic control in the following two steps:
First step.
Preoperative planning of the starting point and screw trajectory for posterior column screw placement via an anterior approach using a standard pelvic CT scan and a commonly available multiplanar reconstruction tool.
Second step.
Intraoperative fluoroscopically controlled identification of the starting point in the pelvic anterior–posterior (ap) view and advancing the guidewire/screw under fluoroscopic control using a lateral–oblique view in order to prevent intraarticular screw penetration and lesions of the sciatic nerve.
Advantages
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No expensive planning software required
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No intraoperative CT or navigation system required
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Reduced risk of screw malpositioning
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Posterior column screw placement via an anterior approach (Olerud approach or ilioinguinal approach)
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No additional posterior approach required
Disadvantages
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Relatively high intraoperative radiation exposure
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Fluoroscopic identification of the anatomic landmarks is mandatory
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Time required for preoperative planning
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More challenging technique compared to navigated techniques
Indications
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Anterior column with posterior hemitransverse fractures
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Transverse fractures
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Two-column fractures and T‑type fractures without relevant residual displacement of the posterior column after open reduction and fixation of the anterior column and the quadrilateral plate
Contraindications
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Relevant residual displacement of the posterior column after open reduction and fixation of the anterior column and the quadrilateral plate
-
Very narrow osseous corridor according to the preoperative planning
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Insufficient fluoroscopic visualization of the anatomical landmarks, i.e., the hip joint and the sciatic tuber
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Patients with severe obesity
Patient information
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General surgical risks
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Residual risk of screw malpositioning with intraarticular screw penetration or iatrogenic sciatic nerve injury
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Generally no implant removal
Preoperative work up
The preoperative planning is the major step for safe fluoroscopically controlled posterior column screw placement and is therefore described in detail (Fig. 2 and 3). Pelvic CT scans with a slice depth of 0.6 mm are recommended for preoperative planning. CT scans with slice depths >0.6 mm are also applicable, but may result in inferior image quality during the reformation process. Any imaging software, which supports two-dimensional multiplanar reformation (MPR), is suitable for preoperative assessment.
Instruments and implants
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Guide wire (2.8 mm diameter)
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Partially threaded cannulated large fragment screws (16 mm or 32 mm thread) for the application as lag screws
Anesthesia and positioning
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General anesthesia
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Supine positioning
Surgical technique
Postoperative management
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Partial weight bearing as advised by the surgeon
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Postoperative CT imaging for the assessment of screw position and quality of reduction of the posterior column is recommended
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Generally no implant removal
Errors, hazards and complications
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Inadequate reduction of the posterior hemitransverse fracture via an anterior approach: open reduction via a posterior approach
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Poor fluoroscopic visualization of the anatomical landmarks
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Narrow osseous corridor
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Screw misplacement: revision surgery in the case of neurological impairment or intraarticular screw penetration (Fig. 7)
Results
Osseous corridors and resulting ideal screw trajectories for posterior column screws were assessed in a series of 100 pelvic CT scans. These CT scans were performed during clinical routine with the indications for imaging not related to this study. Accordingly, the patients were not exposed to additional radiation. There were 50 female and 50 male patients with a mean age of 57.0 years (range 18–90 years). The mean posterior angle of the ideal posterior column screw trajectory was 28.0° (range 11.1–46.2°) to the coronal plane and the mean medial angle was 21.6° (range 8.0–35.0°) to the sagittal plane. The maximum screw length was 106.3 mm (range 82.1–135.0 mm). There were no significant differences between the right and the left side (t-test for paired samples, p > 0.05). There were also no significant differences between male and female patients regarding the posterior and medial angles of the ideal posterior column screw trajectories (t-test for independent samples, p > 0.05). The average maximum screw length, however, was significantly greater in male patients (111.9 ± 9.3 mm vs. 99.7 ± 8.5 mm, p < 0.01).
Twelve patients were included in this study. The small number of patients is attributable to the fact that only a subset of acetabular fractures involving both columns is amenable to posterior column fixation via an anterior approach. Additionally, only patients with postoperative CT scans available for review were included. There were 10 ACPHF and 2 transverse fractures. The residual maximum displacement of the posterior column fracture components was 1.4 mm (range 0–4 mm). Beside the case shown in Fig. 7, there was one case with a perforation of the cortical bone in the transition zone between posterior column and sciatic tuber (maximum screw protrusion of 5 mm) without neurological impairment.
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Open access funding provided by University of Innsbruck and Medical University of Innsbruck.
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D. Krappinger, P. Schwendinger and R.A. Lindtner declare that they have no competing interests.
For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case. This retrospective study was performed after consultation with the institutional ethics committee and in accordance with national legal requirements. The Ethics Committee of the Medical University of Innsbruck confirmed in a general statement that for retrospective observational studies no ethics committee approval is required by Austrian law.
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Krappinger, D., Schwendinger, P. & Lindtner, R.A. Fluoroscopically guided acetabular posterior column screw fixation via an anterior approach. Oper Orthop Traumatol 31, 503–512 (2019). https://doi.org/10.1007/s00064-019-00631-0
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DOI: https://doi.org/10.1007/s00064-019-00631-0
Keywords
- Acetabular fracture
- Fracture fixation, internal
- Posterior hemitransverse fracture
- Osseous corridor
- Multiplanar reformation
- Fluoroscopy