Treatment of Transverse with or without Posterior Wall Fractures of Acetabulum Using a Modified Smith-Petersen Combined with Kocher-Langenbeck Approach

Abstract

BACKGROUND The aim of this study was to explore the surgical treatment of transverse with or without posterior wall fractures of the acetabulum. MATERIAL AND METHODS We surgically treated 21 consecutive cases of pure transverse (7 cases) and with posterior wall (14 cases) fractures of the acetabulum. The anterior column fractures were firstly reduced, temporarily fixed through a modified Smith-Petersen small incision, and finally fixed after the fixation of the posterior column and wall fractures, which were reduced and fixed through a Kocher-Langenbeck approach. The operative time, intra-operative blood loss, quality of reduction (Matta criteria), perioperative complications, osseous union, subsequent complications, and hip function evaluation were recorded. RESULTS The mean operative time was 198.1 min and the mean intra-operative blood loss was 938.1 ml. Anatomic reduction of the anterior column was obtained in 20 cases and was imperfect in 1 case. All posterior column and wall fractures were anatomically reduced. We followed up 18 cases for a mean duration of 16.3 (8-30) months. All the fractures achieved osseous union. The mean Harris score was 85.1 points, with an excellent result in 7 cases, good in 8, fair in 2, and poor in 1. According to modified Merle d' Aubigne and Postel score system, the results were excellent in 2 cases, good in 15, and poor in 1. Avascular necrosis of the femoral head occurred in 1 case, heterotopic ossification in 3 cases, and numbness of the anterolateral thigh in 6 cases. CONCLUSIONS For transverse with or without posterior wall fractures of the acetabulum, reduction and fixation of anterior and posterior column should be done in sequence, and a modified Smith-Petersen small incision might be a good choice in reduction and fixation of the anterior column because it possesses advantages of direct visualization and minimal invasion.

Figure 1

The displacement of the main fragment of the anterior column was measured on the coronal view of a 3D CT scan.

Figure 2

The patient was placed in a floating position and a modified Smith-Peterson incision was marked on the skin.

Figure 3

A pointed reduction clamp was used to reduce anterior column fractures.

Figure 4

The anterior column fracture was first reduced and temporarily fixed with 2 K-wires, and then the posterior column and wall fractures were reduced and fixed with 2 plates. Before application of final fixation of the anterior column fracture, its position was checked again on the C-arm.

Figure 5

The reductions and screws and plates on both columns were finally checked. In this patient, the anterior and posterior column were anatomically reduced and are shown on obturator oblique view.

Figure 6

A short, contoured reconstruction plate was also used to isolate and fix this anterior column fracture (A, B).

Figure 7

A 54-year-old patient with anterior column of the transverse and associated posterior wall fractures, fixed with a cannulated screw.(A) postoperative X-ray examination. (B) A 3-mm gap was identified on a postoperative CT scan; hip function was excellent.

Figure 8

A 56-year-old patient (case 3) had a left transverse acetabular fracture, surgically treated by using a modified Smith-Peterson incision combined with K-L approach. (A) X-ray showed obvious displacement at the fracture site. (B, C) 3D reconstruction of the fracture.

Figure 9

A postoperative X-ray (A) and CT scan (B, C) demonstrated an anatomic reduction of the fracture was obtained in case 3.

Figure 10

Complete union of the fracture was obtained 3 years after surgery in case 3.