A combination of the K-L and S-P approaches for treating acetabular posterior wall factures accompanied by femoral head fractures with open reduction and internal fixation

Abstract

Background: In clinical practice, acetabular posterior wall fracture combined with femoral head fracture is rare. However, with the increasing number of engineering and traffic accidents, such fractures, have increased significantly in recent years. This paper aims to explore the clinical efficiency of the Kocher-Langenbeck (K-L) and Smith-Petersen (S-P) combined approaches for open reduction and internal fixation (ORIF) of acetabular posterior wall fractures accompanied by femoral head fractures (Pipkin type IV fractures).

Methods: A retrospective study was conducted on 8 patients who underwent open reduction and internal fixation (ORIF) of Pipkin type IV fractures through the K-L combined with S-P approach in our hospital from January 2015 to January 2020. All 8 patients were successfully operated on without serious complications, such as important blood vessel and nerve damage, with an operation time of 143.8 ± 44.38 min and intraoperative blood loss of 225 ± 70.71 ml. Perioperative data were recorded. The Harris score was used to evaluate the clinical effect. Fracture reduction quality was evaluated according to the Matta radiological standard. The grade of ectopic ossification was evaluated by the Brooker grading method, and the stage of femoral head necrosis was evaluated by Ficat-Arlet staging.

Results: The Harris score increased significantly from 57.38 ± 4.779 at 3 months, to 76.13 ± 3.682 at 6 months, 88.25 ± 3.495 at 12 months, and 92.13 ± 2.232 at 36 months postoperatively. After statistical analysis, compared with the previous observation time point, the data comparison differences between the groups were statistically significant. P < 0.001, P < 0.001, P < 0.05). By the time of the latest follow-up, 6 of the 8 patients had recovered to the level of pre-injury sports capacity. In contrast, the other 2 patients remained below the level of pre-injury sports capacity. In terms of imaging evaluation, the quality of fracture reduction on radiographs was graded as excellent in 6 patients and good in 2 patients according to Matta's criteria. At the last follow-up, no heterotopic ossification or femoral head necrosis was found in of all the images. In addition, the hip joint space was normal in 6 cases, mildly narrowed in 1 case, and clearly narrowed in 1 case.

Conclusions: The K-L combined with S-P approach provides effective exposure for the reduction and fixation of Pipkin type IV fractures and achieves satisfactory clinical outcomes.

Keywords: Acetabular posterior wall fracture; Femoral head fracture; K-L approach combined with S-P approach; Pipkin type IV fracture; Surgical approach.

Fig. 1

Typical case images. A, B, E, F Preoperative CT showed an acetabular posterior wall fracture and posterior dislocation of the hip. The fracture line of the left femoral head was located below the fovea. C, G X-ray examination immediately after the operation showed that the fracture was anatomically reduced, and the position of internal fixation was good. D, H X-ray examination at follow-up 1 year after operation showed that the fracture healed, no femoral head necrosis occurred, and the hip joint space was normal

Fig. 2

Main surgical steps of the K-L approach combined with the S-P approach for ORIF. A Posterior K-L approach. B Reduction and fixation of acetabular posterior wall fracture through the K-L approach. C Reduction and fixation of femoral head fracture through the S-P approach; K-L Kocher-Langenbeck approach, S-P Smith-Petersen approach, ORIF open reduction and internal fixation

Fig. 3

Pairwise comparison of Harris scores during 12 to 36 months of follow-up. P(α) < 0.001, 6 months versus 3 months, Harris scores improved significantly. P(β) < 0.001, 12 months versus 6 months, Harris scores improved significantly. P(γ) < 0.05, 36 months versus 12 months, the improvement in Harris scores was still statistically significant