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The objective of surgery for acetabular fractures is to achieve precise reduction to restore joint congruence, fix internal bone fragments, avoid displacement of the fracture and allow rapid rehabilitation.
Open reduction and internal fixation is the benchmark method for displaced acetabular fractures, but open reductions can increase morbidity, ca...
Context in source publication
Context 1
... We have not found publi- cations that describe using this corridor to stabilize the posterior column or fractures compromising the iliac crest, posterior supra acetabular and posterior column fractures. CT scans show the narrow area of this corridor to be approximately 6.1 mm × 140 mm long. Therefore 4.5-mm screws can be used in this corridor (Fig. ...
Citations
... Minimally invasive percutaneous screw fixation represents a critical advancement in orthopedic surgery for managing pelvic ring and acetabular fractures, offering significant advantages over traditional approaches [1]. This method, gaining prominence since its introduction by Routt et al. [2], provides several advantages over traditional open reduction and internal fixation, such as less soft-tissue trauma, reduced intraoperative blood loss, lower infection risks, early pain relief, and the possibility of early weight-bearing ambulation [3,4]. ...
... Despite its benefits, including lessened soft-tissue damage and expedited postoperative recovery, the technique demands high precision due to the complex anatomy of the pelvis and proximity to critical neurovascular structures [5]. Achieving success with percutaneous interventions requires not only an intimate knowledge of pelvic anatomy and skill in radiographic imaging but also the ability to execute screw placement with extreme accuracy [4,6,7]. Elmhiregh et al. [8] demonstrated the critical role of careful radiographic assessment in avoiding intra-articular screw placement during acetabular surgery, a recognized complication with significant clinical repercussions. ...
... While these are fundamentally Fig. 4 Anteroposterior, obturator and iliac radiographs of the pelvis illustrating the correct alignment of cannulated screws six months after surgery in a patient with a transverse-type right acetabulum fracture. In the radiographs, both columns of the acetabulum are fixed in proper alignment effective, they occasionally encounter difficulties in unique fracture patterns and anatomical contexts [4]. Our technique, which employs a guidewire with a bent tip, skillfully addresses such misdirections. ...
Background
Minimally invasive percutaneous screw fixation for pelvic ring and acetabular fractures has become increasingly popular due to its numerous benefits. However, the precise placement of the screw remains a critical challenge, necessitating a modification of the current techniques. This paper introduces a refined technique employing a modified guidewire to enhance the precision and efficiency of percutaneous fixation in pelvic and acetabular fractures.
Methods
This study details the surgical techniques implemented for correcting guidewire misdirection in percutaneous screw fixation and includes a retrospective analysis of patients treated with this modified approach over a three-year period.
Results
In this study, 25 patients with pelvic ring and acetabular fractures underwent percutaneous screw fixation. The cohort, predominantly male (23 out of 25), had an average age of 38 years. The majority of injuries were due to traffic accidents (18 out of 25). Types of injuries included pelvic ring (6 cases), acetabular fractures (8 cases), and combined injuries (11 cases). Various screw types, including antegrade and retrograde anterior column screws, retrograde posterior column screws, and lateral compression screws, were used, tailored to each case. Over an average follow-up of 18 months, there were no additional procedures or complications, such as neurovascular injury or hardware failure, indicating successful outcomes in all cases.
Conclusions
This study introduces a simple yet effective method to address guidewire misdirection during percutaneous fixation for pelvic and acetabular fractures, offering enhanced precision and potentially better patient outcomes. Further research with a larger patient cohort is required for a more comprehensive understanding of its efficacy compared to traditional methods.
Level of evidence
IV. Therapeutic Study (Surgical technique and Cases-series).
... 16,18,19 The objective of surgery for acetabular fractures is to reconstruct the joint congruency, fixate the bone fragments, prevent further fracture displacement and allow rapid mobilisation and rehabilitation. 20 Percutaneous fixation of fractures involving the anterior and posterior acetabular columns, although still a relatively new concept in South Africa, has been described previously. 1,9 Percutaneous fixation of the sacroiliac joint has long been considered the gold standard of treatment for posterior element instability of the pelvis and is well-established treatment. ...
... Wound healing, infection and blood loss are all complications that are more attributable to open procedures rather than the actual fractures. 3,20 Where fractures are amenable and/or patients have contraindications for major procedures, percutaneous procedures should ideally be used. Giannoudis et al. found in the early results of many studies that patients had a shorter hospital stay and decreased morbidity when treated with percutaneous techniques. ...
... The percutaneous technique is, however, more technically challenging than open reduction and fixation due to acetabular geometry. 20 The technique is recommended with the use of cannulated intramedullary screws to treat non-displaced to slightly displaced fractures, especially in the elderly who cannot receive total joint arthroplasty, and in osteoporotic and/or obese patients. 20 This study demonstrates how preoperative CT scans can be used to determine 'functional' bone corridors to help guide fluoroscopic screw choice and placement. ...
Citation: Strydom S, Ryan Booyse R, Chacko A, Mostert P, Snyckers CH. Measurement of functional acetabular column sizes using a 3D CT model, for guiding percutaneous screw fixation of acetabular fractures using fluoroscopy. SA Orthop J. 2024;23(1):37-42. http:// dx. Abstract Background
... In pelvic and acetabular surgery, numerous osseous fixation corridors suitable for screw placement have been described, including the transiliac, transsacral, sacroiliac, anterior column, and posterior column [13]. These fixation corridors are frequently used in both percutaneous surgery [14,15] and open surgery [7][8][9]. ...
The use of pelvic osseous fixation corridors and lag screw fixation in acetabular and pelvic surgery has gained popularity, especially with the recent development of intraoperative imaging and navigation techniques. However, advanced intraoperative imaging and navigation techniques require technical equipment and are costly. Therefore, traditional fluoroscopic techniques still maintain their importance. In this article, we describe a novel pelvic osseous fixation corridor that traverses both columns of the acetabulum, along with the detailed methodology of its fluoroscopic imaging and the techniques for fluoroscopy-assisted screw placement. The technique of placing screws in this current fixation corridor is only under fluoroscopy assistance, without using any specially produced guide or navigation device.
... While there is not an abundance of literature on early weightbearing with PAO, there is some support in the trauma literature, specifically for acetabular fractures, that patients can undergo early weight-bearing without placing them at excessive risk for fracture displacement [38]. A study by Kazemi et al showed in a series of 22 patients who underwent percutaneous fixation for acetabular fractures who were permitted full weight-bearing immediately postoperatively resulted in no loss of reduction and similar outcomes to other studies at 12-month follow-up [39]. ...
Background
Periacetabular osteotomy (PAO) is an effective surgical procedure for managing acetabular dysplasia. The purpose of this study was to analyze the biomechanical properties of novel PAO constructs that incorporate orthopaedic trauma techniques. We hypothesize that these fixation methods will create a stiffer construct that tolerates higher loads to failure.
Methods
Twenty bio-composite hemi-pelvises underwent PAO with the following fixation configurations: Group A: 4 iliac crest (IC) screws; Group B: 3 IC screws; Group C: 2 IC screws, 1 retrograde anterior column (AC) screw, and 1 lateral compression type-2 (LC2) screw directed from the anterior inferior iliac spine to the posterior inferior iliac spine; Group D: 1 AC screw, 1 LC2 screw, 1 posterior column screw; Group E: 2 LC2 screws, 1 AC screw. Constructs were loaded to failure on a material testing hydraulic press, and ultimate strength, stiffness, and osteotomy displacement were measured.
Results
The highest load to failure was seen in group D (2511 N), which was significantly more than groups A (1528 N, P = .0114) and B (1348 N, P < .0001). The stiffest construct was group E (602 N/mm) compared to groups A (315 N/mm, P = .0439) and B (243 N/mm, P = .0008). Failure occurred most often with a fracture in the posterior column.
Conclusions
This study supports column fixation methods used in orthopaedic trauma for PAO as biomechanically advantageous to traditional fixation techniques. These constructs may be beneficial to patients with weight-bearing concerns or early rehabilitation needs.
... The management algorithm of patients with fracture of both acetabula is still controversial among specialists; some authors have reported good clinical outcome with conservative management [3,5]; while others have recorded cementless THA as management plan [6,7,9,15,16]; in contrast, other scholars have regarded ORIF as the gold standard approach [8,15]. However percutaneous fixation has also been been suggested, but this can only be applied in cases with non-displaced or fairly displaced fracture [23]. In our study, we considered surgical management (ORIF) in all our patients. ...
Background
Bilateral acetabular fracture is a very rare presentation among the trauma patients, as the pattern and the degree of the forces required to fracture both acetabula is very unique. The primary purpose of this study is to report a series of adult patients presenting with post-traumatic bilateral acetabular fracture without any history of pathological or metabolic bone disease.
Patients and methods
In this retrospective study, 18 cases of traumatic bilateral acetabular fracture were included. There was predominance of both column (four patients on left and six on right) followed by anterior column (two patients left and four on right) and posterior wall (three patients left and right). They were treated surgically through open reduction and internal fixation. All cases were followed up for at least 13 months. Matta’s criteria were used for radiological evaluation on plain radiographs. Functional outcome was evaluated using the Merle d’Aubigne and postel score at final follow-up.
Results
No patients were lost during the follow-up period; there was one case of surgical site infection. There were three cases of postoperative osteoarthritis, one case of heterotrophic ossification, one case of persistent sciatic nerve palsy and one case of lateral femoral cutaneous nerve palsy. The radiological evaluation according to Matta’s criteria revealed anatomic reduction in 12 patients, imperfect reduction in three patients while other three patients had poor reduction. According to modified Merle d’Aubigne and Postel score, 10 cases were rated as excellent, five cases as good and three cases presented fair (one case) to poor (two cases) results.
Conclusion
We report an unusual case series of bilateral acetabular fracture successfully managed surgically with good clinical outcome. With the increasing incidence of route traffic accidents, such cases would probably be recurrent in the upcoming years.
... 16,18,19 The objective of surgery for acetabular fractures is to reconstruct the joint congruency, fixate the bone fragments, prevent further fracture displacement and allow rapid mobilisation and rehabilitation. 20 Percutaneous fixation of fractures involving the anterior and posterior acetabular columns, although still a relatively new concept in South Africa, has been described previously. 1,9 Percutaneous fixation of the sacroiliac joint has long been considered the gold standard of treatment for posterior element instability of the pelvis and is well-established treatment. ...
... Wound healing, infection and blood loss are all complications that are more attributable to open procedures rather than the actual fractures. 3,20 Where fractures are amenable and/or patients have contraindications for major procedures, percutaneous procedures should ideally be used. Giannoudis et al. found in the early results of many studies that patients had a shorter hospital stay and decreased morbidity when treated with percutaneous techniques. ...
... The percutaneous technique is, however, more technically challenging than open reduction and fixation due to acetabular geometry. 20 The technique is recommended with the use of cannulated intramedullary screws to treat non-displaced to slightly displaced fractures, especially in the elderly who cannot receive total joint arthroplasty, and in osteoporotic and/or obese patients. 20 This study demonstrates how preoperative CT scans can be used to determine 'functional' bone corridors to help guide fluoroscopic screw choice and placement. ...
BACKGROUND: Percutaneous acetabular screw fixation remains a technically challenging procedure, despite good outcomes being reported with appropriate patient selection. In the developing world, where intraoperative computer tomography (CT) guidance (O-arm) and dedicated screws are not readily available, this procedure becomes even more challenging, as surgeons often place screws under fluoroscopic guidance only. Additionally, incorrect screw sizing can lead to cortical breaching with catastrophic vascular damage and other serious consequences. This study aimed to demonstrate how surgeons working with intraoperative fluoroscopy can use preoperative three-dimensional (3D) reconstructed CT scans to plan and safely insert screws into these 'functional fluoroscopic corridors', and to compare column sizes for screw selection in the South African population to existing literature. METHODS: A retrospective study using data obtained from CT scans of adult patients was performed. Three-dimensional reconstructions of the pelvis were used to create a novel technique of simulating the 'functional' bone corridors used during fluoroscopic surgery in order to take the measurements of the anterior and posterior acetabular columns in 301 patients (163 male and 138 female). Exclusion criteria were: any previous trauma and fractures of the pelvis, congenital abnormalities and tumours involving the bony pelvis. We also demonstrate the use of this technique in a clinical case. RESULTS: Our study confirmed that column sizes in the South African population are in keeping with previous publications. We demonstrate how this novel preoperative 3D-CT planning technique can be used to identify intraoperative surgical corridors using fluoroscopy. CONCLUSION: Although column sizes in the South African population are shown to be in keeping with international literature, our study demonstrates a novel technique for using 3D CT reconstructions preoperatively, in the same orientation used intraoperatively with fluoroscopy, to help guide screw size choice and placement. This technique shows promise for reducing cortical breaches in settings where intraoperative O-arms are not available, as appropriately sized screws can be preselected on an individualised basis. Level of evidence: Level 3
... Based on the previous research, the entry point of the percutaneous retrograde lag screw is the sciatic tuberosity [5]. The majority of the literature reported [6,7] that on the condition that the patient is in the supine position and retrograde lag screws are placed, the patient needs to fully flex the hip and knee to effectively reach the sciatic tuberosity and specify the nail entry point while avoiding injury to the sciatic nerve. A prone or lateral position has also been reported [5]. ...
Background
Currently, there is a lack of research investigating the feasibility of employing anterograde lag screw fixation through the iliac crest for minimally invasive percutaneous treatment of the posterior acetabular column, which encompasses retrograde and anterograde screw fixation in posterior acetabular lag screw fixation. And consequently, the purpose of this study was to examine the anatomical parameters of anterograde lag screw fixation of the posterior column of the pelvis through the iliac crest as well as to investigate the intraoperative fluoroscopy technique, to furnish a scientific rationale supporting the practical utilization of this method within clinical settings.
Methods
In this study, pelvic CT data of 60 healthy adults, including 30 males and 30 females, were accumulated. The mimics 21.0 software was developed to reconstruct the three-dimensional pelvis model, simulate the anterograde lag screw fixation of the posterior column of the acetabulum through use of the iliac crest, and precisely identify the insertion point: Utilizing the widest iliac tubercle as the starting point, the insertion point was moved toward the anterior superior iliac spine by 1.0 cm at a time until it reached 4.0 cm. With a total of five insertion points, all oriented toward the lesser sciatic notch, the initial diameter of the virtual screw measured 5.0 mm, and it was progressively enlarged by 1.0 mm increments until reaching a final diameter of 8.0 mm. Besides, the longest lengths of virtual screws with distinct diameters at divergent entry points were measured and compared. At the same time, the intraoperative fluoroscopy technique for optimal access was analyzed.
Results
The cross-section from the iliac crest to the lesser sciatic notch was irregular, with multiple curved shapes. Furthermore, the diameter of the screw was determined by the anteroposterior radians and width of the iliac crest plate, while the screw length was determined by the curvature of the square body. On the condition that the screw diameter of the D channel (3.0 cm outward from the widest part of the iliac tubercle to the lesser sciatic notch) was 5 mm, 6 mm as well as 7 mm, the longest screw lengths were (145.6 ± 12.8) mm, (143.6 ± 14.4) mm and (139.9 ± 16.6) mm, correspondingly, indicating statistically substantial distinctions from other channels (P < 0.0001). Intraoperative fluoroscopy demonstrated that the C-arm machine was tilted (60.7 ± 2.9) ° to the iliac at the entrance position and perpendicular to the D-channel at the exit position.
Conclusion
It is possible to use the new channel to fix the posterior column of the acetabulum with an anterograde lag screw through the iliac crest. In specific, the channel is 3.0 cm outward from the widest part of the iliac tubercle to the lesser sciatic notch. Providing a wide channel, long screw insertion, and high safety, this technique offers a novel approach for minimally invasive treatment of posterior column fractures of the acetabulum.
... Open reduction internal fixation (ORIF) requires great exposure with a high risk of several intra-and postoperative complications, including massive hemorrhage, deep venous thrombosis, neurovascular injuries, heterotopic ossification (HO), and infection [6][7][8]. After the introduction of closed reduction using percutaneous screw fixation by Routt., et al. [9] several authors have used this percutaneous fixation technique for the treatment of patients with Pelvic Ring Fracture and Acetabular Fracture [10][11][12][13][14][15][16][17]. The advantages of percutaneous screw fixation noted in these studies of pelvic and acetabular fractures includes less soft tissue injury, less blood loss, and a lower rate of infection. ...
... Also, early weight bearing ambulation will be possible with this type of fixation [12,18]. However, the technique may be associated with few complications, such as the increased neurovascular injuries, internal organ injuries, misplacement of screw, and screw fracture [5,13,14,17,[19][20][21][22][23]. ...
... Soft tissue planes remain undamaged, which would subsequently facilitate total hip arthroplasty if necessary [2,3]. However, acetabular geometry makes percutaneous screw insertion a difficult procedure [4]. ...
Background: Percutaneous fixation offers advantages over open reduction in fractures of the pelvis and acetabulum. The aim of this study is to describe the safety of percutaneous screw surgery in patients with pelvic and acetabulum fractures. Methods: An observational, retrospective, longitudinal and descriptive study was performed. The records of adult patients with pelvic and acetabulum fractures with less than 3mm displacement, who underwent percutaneous surgery from 2009 to 2018 were reviewed. The mechanism of injury, associated injuries, type of fracture, days of in-hospital stay, in-hospital death, trans-surgical or post-surgical complications and degree of bone healing were studied. Results: 531 patients were recorded, 454 met the inclusion criteria. The average age was 41.7, the mechanism of high energy injury had a higher prevalence, 52% of patients had some associated injury, the most frequent being fractures in pelvic limbs. The most common fracture was type AO61B2 fracture at 38.1%. The average in-hospital stay was 10.7 days. 15 patients (3.3%) had some complication, the main one being mal positioning of the osteosynthesis material. Two patients died in-hospital due to associated injuries. 100% of the patients presented bone consolidation grade 3-4 in the Montoya classification. Conclusions: Percutaneous surgery in pelvis and acetabulum fractures is a safe surgical procedure, since it is associated with low in-hospital mortality, has a low percentage of complications, decreases in-hospital stay and has a high rate of bone consolidation. It is a procedure that requires special training and a long learning curve.
... 4 A screw if not placed correctly can violate the margins of the anterior column thus injuring the articular surface and possibly the vital structures around it. 5 There have been a few studies in which the morphological variations of the anterior column and the narrow zones of its osseous corridor have been analysed. 6,7,8 , However, only 2 CT based studies have precisely measured the morphometric variations and defined the direction of screws to be inserted into the anterior column. ...
