Abstract
Anatomical reduction and rigid fixation of acetabular posterior wall fractures extending to the acetabular roof proves challenging because of the big bony fragment and muscular obstruction to accessing this region. This report describes a novel reconstructive technique in a patient with an acetabular posterior wall fracture involving the acetabular roof. Both the standard Kocher-Langenbeck approach and a greater trochanter osteotomy technique were used. Following anatomical reduction, a dual arc-shaped reconstruction plate technique was employed to achieve rigid fixation. The patient recovered with satisfactory function at the injured hip. We recommend this dual arc-shaped reconstruction plate technique for the treatment of acetabular posterior wall fractures extending to the acetabular roof in clinical practice.
Introduction
Acetabular posterior wall fractures are the most common type of acetabular fractures, which comprise approximately 35–47% of acetabular fractures, with 3.76% of these involving the acetabular roof [1, 2, 3]. Surgical correction is the optimal treatment for displaced posterior wall acetabular fractures [4]. The standard approach (Kocher-Langenbeck) for posterior wall fracture proves difficult when the fracture involves the acetabular roof; therefore, a greater trochanter osteotomy will need to be employed. Anatomical reduction and rigid fixation of the fracture fragments are crucial for achieving good outcome.
This report describes a posterior wall fracture involving the acetabular roof. We used a greater trochanter osteotomy combined with two arc-shaped reconstruction plates for therapeutic management and were successful in achieving a good outcome.
Case report
The patient provided informed consent for the publication of this study and the use of his photographs.
A 43-year-old man was admitted to our hospital complaining of right hip pain and restricted mobility at the joint following a motor vehicle accident (MVA). Radiographs at admission revealed an acetabular posterior wall fracture (Fig. 1A and B). Neurovascular examination showed no abnormalities or deficits in the right lower extremity, and a 3D CT demonstrated that the fracture extended to the acetabular roof together with a hip dislocation (Fig. 1C and D). The patient underwent interim management with closed reduction of the hip dislocation followed by skin traction for 5 days. Operative stabilization was done on the sixth day following the traumatic injury, after the peri-fracture swelling had alleviated.
Preoperative plain radiographs and CT scans. A and B: x-rays revealed an acetabular posterior wall fracture. C and D: 3D CT demonstrating the fracture extension to the acetabular roof with hip dislocation.
Postoperative x-rays and intraoperative photograph. A: Postoperative x-ray showing anatomical reduction of the fractures. B: Postoperative x-rays at 5 months revealed that fracture lines were blurred and calluses had formed. C: Intraoperative photograph showing the position of plates.
Under general anesthesia, the patient was placed in lateral decubitus on a radiolucent operating table. A standard Kocher-Langenbeck approach was used. The fascia lata was incised and the gluteus maximus muscle split with blunt dissection. The piriformis and obturator internus muscles were released from their distal attachments. After retraction of these muscles, both the posterior wall of the acetabulum and the gluteus medius muscle could be seen [2]. To enhance visibility of the acetabular roof, a greater trochanter osteotomy was employed. The displaced bony fragments of the posterior wall and roof was reduced anatomically under direct visualization using lower extremity traction, and then held temporarily using K-wires with 3.5-mm screws to fix the fragments. Thereafter, stable fixation of the fracture was achieved by using two arc-shaped reconstruction plates (Synthes, Solothurn, Switzerland), which were sufficiently long to cover the entire posterior wall and acetabular roof, and then fixed with a single screw onto the ischial tuberosity. Moreover, the plates were slightly underbent to enable compression into and buttressing of the fragments to aid stabilization of the reduction. One of the plates was situated near the border of the acetabulum after leaving a 5-mm margin, whereas the other plate was placed close to the fracture line, to enable rigid fixation of the reduced fragments (Fig. 2C). Finally, the greater trochanter was fixed with two 3.5 mm screws. Intraoperative fluoroscopic imaging was used to evaluate the accuracy of the reduction and the position of implants. Closed suction drainage was used for 1 day.
Intravenous antibiotic prophylaxis was routinely initiated 30 min before surgery and continued for 24 h postoperatively. Routine dressing changes and symptomatic therapy were administered postoperatively, and the patient was started on muscle strengthening and range-of-motion exercises. The incision healed and stitches were removed postoperatively at 2 weeks, and the patient was discharged. Partial weight-bearing was started postoperatively at 6 weeks, and gradually increased to full weight-bearing at 3 months. Postoperative x-rays revealed good reduction of the fractures (Fig. 2A). At 5 months postoperatively, an x-ray showed that fracture lines were blurred and calluses had formed (Fig 2B). The patient was satisfied with the function of the injured hip.
Discussion
Operative treatment of acetabular fractures is technically demanding. Anatomical reduction and rigid fixation are necessary to excellent or good outcomes. Fractures involving the posterior wall and acetabular roof prove considerably challenging to treat because of the big bony fragment and muscular obstruction to accessing this region, and achieving anatomical reduction and rigid fixation proves difficult. Several techniques have been employed to expose the acetabular roof and posterior wall [5]. However, a greater trochanter osteotomy is the most common technique [6], and we employed this in our case. Numerous studies report a high failure rate after open reduction and internal fixation for these fractures [7, 8]. Li et al. used 2 parallel reconstruction plates for fracture fixation, with good outcome [9]. However, the space along the posterior wall may not always be sufficient for 2 parallel reconstruction plates. In the present case, we used 2 arc-shaped reconstruction plates long enough to cover the entire posterior wall and acetabular roof that were fixed with a single screw onto the ischial tuberosity as they required a smaller area than 2 parallel reconstruction plates. Rigid fixation was achieved by this method, and the patient recovered without complications and with satisfactory function at the injured hip. Therefore, the 2 arc-shaped reconstruction plate technique for acetabular posterior wall fractures extending to the acetabular roof can be recommended for use in clinical practice.
Conflict of interest
The authors declare that they have no conflict of interest.