Operative treatment of transverse acetabular fractures: is it really necessary to fix both columns?

Abstract

Objective: we prospectively evaluated clinical and radiographic outcomes in patients with displaced combined transverse-posterior wall acetabular fractures managed at our Institution over a period of seven years by posterolateral single approach, direct posterior wall and posterior column reduction and plating, and indirect reduction of anterior column controlled by fluoroscopic images with or without lag-screw fixation. The aim was to identify if the obtained immediate postoperative Matta radiographic roof-arc angles after fracture reduction and fixation alters in the postoperative period when comparing posterior plating alone versus posterior plate and anterior column lag-screw fixation.

Patients and methods: 35 skeletally mature patients (31 male and four female, with mean age of 39.9 years old [range, 23.3 to 66.7 y/o]) with combined transverse-posterior wall acetabular fractures surgically treated by a posterolateral single approach were enrolled in this prospective investigation. Nineteen patients had associated orthopaedic injuries. The first part of the acetabular fracture management was similar to all patients and consisted in anatomical reduction and fixation of the transverse posterior component followed by anatomical reduction and fixation of the posterior wall component. The transverse anterior component reduction was controlled by fluoroscopic images (anteroposterior (AP), iliac oblique, and obturator oblique views) and digital palpation through the greater sciatic notch. Fifteen of the 35 patients had an additional lag-screw fixation from the posterior to the anterior columns with an extra-long small-fragment cortical screw. AP and Judet oblique radiographic views were taken at the end of the procedure and roof-arc angles were measured. Clinical results were assigned according to the grading system of Merle D'Aubigne and Postel as modified by Matta et al. Radiographic roof-arc angles were checked and compared between the two groups of patients to the same data collected both at the time of the surgical procedure and at three months postoperatively. Statistical analysis was done by either using chi-square (clinical outcome) and Mann-Whitney (roentgenographic outcome) tests, with a level of significance of alpha = 5%.

Results: at final follow-up examination 18 to 84 months postoperatively (mean, 46.8 months), the clinical results were considered satisfactory in 31 (88.6%) patients (excellent in nine (25.7%) and good in 22 (62.9%) patients). There was no difference between patients with (n = 15) and without (n = 20) fixation of the transverse anterior component of the acetabular fracture (p = 0.67). Radiographic roof-arc angles measured at discharge, at three months postoperatively and at the last follow-up consultation didn't changed significantly (p > 0.05). There was no statistically significant difference between patients treated with (n = 15) and without (n = 20) fixation of the anterior component of the transverse acetabular fracture in terms of medial displacement of the femoral head.

Conclusion: the authors suggest that associated transverse-posterior wall acetabular fractures can be managed by a single posterior approach. Direct reduction and fixation of the posterior wall and column components is an adequate option for these injuries. If there is adequate indirect reduction of the anterior column, as checked by digital palpation and fluoroscopy, we feel that it is not necessary to fix the anterior column component of the transverse acetabular fracture.

Keywords: acetabulum; fracture; posterior wall; roof-arc angle.; transverse.

Conflict of interest statement

CONFLICT OF INTEREST: The authors have declared that no conflict of interest exists.

Figures

Figure 1

Pre-operative radiographs and CT scan, and postoperative radiographs of a patient (31 y/o female, road-traffic accident, unrestrained) who had fixation of the anterior component of the transverse acetabular fracture with an extra-long small fragment cortical screw ('home-run screw'). Note that the long screw bends as a result of the intimate contact with the pelvic brim. Follow-up duration of 18 months.

Figure 2

Pre-operative radiographs and CT scan, and postoperative radiographs of a patient (57 y/o male, road-traffic accident, unrestrained) without fixation of the anterior component of the transverse acetabular fracture with. Observe the anatomic reduction of both column of the acetabulum and the perfect congruency between the femoral head and the roof. Follow-up duration of 26 months.

Figure 3

Immediate postoperative and last outclinic consultation radiographs of a patient (66.7 y/o female, road-traffic accident, unrestrained) without fixation of the anterior component of the transverse acetabular fracture. Roof-arc measurements didn't alter and the fracture healed uneventfully. After 56 months from the surgery, there are no signs of arthritis.