percutaneous fixation of bilateral anterior column acetabular fractures

$: Percutaneous fixation of bilateral anterior column acetabular fractures$
Percutaneous fixation of bilateral anterior column acetabular fractures

Case Report

Percutaneous fixation of bilateral anterior columnacetabular fractures: A case report

Raju Vaishya a,*, Rajesh Kumar b, Raj Ram Maharjan c

a Sr Consultant, Department of Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, IndiabRegistrar, Department of Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, Indiac Fellow, Department of Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India

a r t i c l e i n f o

Article history:

Received 12 September 2012

Accepted 26 April 2013

Available online xxx

Keywords:

Acetabular

Fractures

Percutaneous

Screw

Fixation

a b s t r a c t

We report a rare case of a multiple fractures with bilateral anterior column acetabular

fractures treated with percutaneous screw fixation for both acetabular fractures under

fluoroscopy guidance. It is a demanding procedure due to the complex anatomy of the

pelvis and the varying narrow safe bony corridors. But it is a safe option in patients with

multiple medical co-morbidities (which may be hazardous to long surgical procedures and

extensile surgery) and in minimally displaced fractures.

Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction

The treatment of displaced acetabular fractures with open

reduction and internal fixationhas gained general acceptance.1

This is done either by anterior, posterior or combined ap-

proaches depending on the location of these fractures. These

procedures may be associated with various complications like

significant blood loss, infection, lengthy operative times, het-

erotopic ossification and neurovascular complications.2

There are clinical situations where open reduction is either

not feasible (due to associated medical problems) or when the

fractures are not significantly displaced, then minimal inva-

sive means of internal fixation of these fractures seems to be

an attractive option. Percutaneous screw fixation of the

anterior column of the acetabulum has been a challenging

task because of its unique anatomy (narrow corridor of bone)

and risk of intra-articular penetration.3

2. Case report

A 63-year-gentleman was presented with a history of pain in

pelvic region and unable to bear weight after he sustained an

injury due to fall from a staircase of about 12 feet height, 5

days ago. He also had complaints of pain, swelling and

deformity of right wrist. Patient was a known case of CAD,

HTN and obesity for which hewas under variousmedications.

On examination, the patient was anxious with mild dys-

pnea, supported with oxygen inhalation. He has had a bruise

around pelvic and buttock region with right hip flexed &

* Corresponding author. Tel.: þ91 9810123331.E-mail address: [email protected] (R. Vaishya).

Available online at www.sciencedirect.com

journal homepage: www.elsevier .com/locate/apme

a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1e4

Please cite this article in press as: Vaishya R, et al., Percutaneous fixation of bilateral anterior column acetabular fractures: Acase report, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.04.001

0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.http://dx.doi.org/10.1016/j.apme.2013.04.001

internally rotated. Movements of both hips were painful.

Urinary catheter was in situ. There was swelling and defor-

mity of right wrist.

Investigations revealed anemia (Hb e 9.4 gm%), icterus

(Total billirubine 3.2 dl/mg&Direct billirubine 1.1 dl/mg). His

ECG showed prolonged QT suggestive of an old myocardial

infarct. However, his dobutamine stress echocardiography

was negative for reversible ischemia, but there was pre

existing LV wall motion abnormality at the pre existing LV

wall motion abnormality at the LV apex, distal ½ of the IVS as

well as the distal LV anterolateral was present. There was

increase in LVEF from 35% in the basal condition to 42% after

dobutamine infusion.

Plain radiographs of the pelvis (AP view) showed bilateral

superior & inferior pubic rami fractures with involvement of

both anterior columns of the acetabulum (Fig. 1). This was

further confirmed by CT scan (Fig. 2). 3-D CT scans showed

anterior column fracture of acetabulum (bilateral) and inferior

pubic rami fractures (bilateral) and fracture of right sacral ala.

Fracture displacement was more on right side than left side.

The wrist X-rays showed comminuted, intra-articular

fracture of the right distal radius (Figs. 3 and 4).

2.1. Procedure details

The fracture fixation of the pelvis & right distal radius was

done under general anesthesia. The pelvic fractures were

fixed by a minimally invasive method of stabilization, using

7.3-mm cannulated screws (Fig. 5), under intra-operative

fluoroscopic imaging. Following fracture reduction, a percu-

taneous guide wire aided by a C-arm was placed in the ante-

rior column of the acetabulum & upper pubic ramus in an

anterograde mode in supine position (Fig. 6).

The starting point of guide wire was 4e5 cm posterior to

the ASIS (Fig. 7). The guide wire was driven down into the

superior ramus using the inlet-iliac oblique (to ensure that the

guide wire does not penetrate the inner pubic ramus cortex)

and the inlet-obturator oblique view (to ensure that the guide

pin does not penetrate into the hip). The guide wire was over

drilled by cannulated drill. Subsequently, a partially threaded

cannulated screw was inserted. The quality of fracture

reduction and the placement of screw were evaluated by C-

arm. The same process was repeated on another side to fix

anterior column of acetabulum. The right sacral fracture was

also fixed percutaneously by a 7.0 mm cannulated cancelous

screw, under image intensification (Fig. 8).

The total operative time was 75 min, (including turning of

patient into prone position for sacral screw fixation). Post-

operative period was uneventful. Sutures were removed after

10 days. The patient was pain free 1 week after the operation

Fig. 1 e Pre-op. X-ray pelvis (AP view), showing bilateral

pubic rami fractures.

Fig. 2 e 3-D CT scan of pelvis, showing bilateral anterior

column fractures & right sacral fracture.

Fig. 3 e Pre-op. X-ray of right wrist (AP view), showing

distal radial fracture.



and had good functional recovery thereafter. No complication

was noted post-operatively. The patient was mobilized in bed

immediately but weight bearing with walker was deferred

until 1 month and full weight bearing was allowed after 2

months of the fracture fixation. At 6months review, the pa-

tient had fully painless mobility and full range of both hip

movements with no pain.

3. Discussion

Open reduction and internal fixation has been the gold stan-

dard for displaced fracture involvingweight bearing dome and

fractures with intra-articular fragments.4 However, extensile

exposure can lead to various complications, like excessive

bleeding, infection, neurovascular injury etc. In patients with

various medical co-morbidities and fracture with minimal

displacement particularly the narrow anterior column can be

fixed by a minimally invasive method percutaneous screw

fixation under fluoroscopic guidance with a low anticipated

complication rate and excellent outcome. Gay et al were the

first to report on successful percutaneous fixation of mildly

displaced acetabular fracture under CT guidance. Good

reduction was achieved in five of six patients.5 Starr et al6

revealed about three displaced acetabular fractures fixed

with cannulated screws under fluoroscopic guidance. Norris

et al7 provided the idea that intra-operative fluoroscopy was

as useful as CT for the evaluation of reduction and confir-

mation of extra-articular placement of implants. Pre operative

routine plain X-ray of the pelvis may not reveal the details of

the fracture & hence CT scan is the investigation of choice, in

our opinion.

Fig. 4 e Pre-op. X-ray of right wrist (Lateral view), showing

distal radial fracture.

Fig. 5 e Post-op. X-ray pelvis, with screws in situ.

Fig. 6 e Intra-op. X-ray picture of placement of guide wire

in anterior column.

Fig. 7 e Diagrammatic picture showing the direction of

screw placement in anterior column.

a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1e4 3


Percutaneous internalfixationofpelvic fractures isbecoming

increasingly more popular among trauma surgeons worldwide

dueto reducedsurgical relatedmorbidityandfacilitationofearly

mobilization. Visualization of the pelvic bony anatomy during

percutaneous fixation is difficult, making the procedure tech-

nically demanding.4 The benefits of percutaneous fixation

techniques in terms of blood loss, infection, lengthy operative

times, neurovascular complications and rapid mobilization

have beenwell described and are significant, but this technique

is only appropriate for certain fractures and the gold standard

treatment of many pelvic and acetabular fractures remains

formal open reduction with internal fixation.4

Percutaneous screwing for anterior column fractures in the

acetabulum is a demanding procedure.8 Surgeons who

perform this kind of procedure must be familiar with the 3D

anatomy of the pelvis and pelvic radiographic anatomy in

multiple planes including inlet, outlet, iliac oblique and

obturator oblique views. At the same time, it requires simul-

taneous multi-planar radiographic confirmation of pin and

screw intra-operatively, which increases the difficulty of this

procedure. Jae-Hyuk Yang et al3 had performed percutaneous

screw fixation of the anterior column of the acetabulumunder

guidance of hip arthroscopy to enable direct visual confir-

mation about the quality of the reduction and avoiding any

acetabular penetrationwith the screw. The additional benefits

of this method were joint lavage and debridement of the hip

joint, together with the possibility of reducing the number of

fluoroscopic images required.3

In our case, we successfully used percutaneous screws to

fix minimally displaced bilateral anterior column fractures of

the acetabulum & the sacral fracture under C-arm guidance.

All the fractures healed smoothly without loss of reduction

and there was good functional recovery in short term after

operation through a minimally invasive approach.

The treatment goal of acetabular fracture is anatomic or

near-anatomic reduction of the articular surface. At the same

time, prevention of complications related to surgical exposure

is as important as quality of reduction of articular surface.

Therefore, it is reasonable to develop a method to fix mini-

mally displaced fractures requiring fixation with limited sur-

gical exposure.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Attias N, et al. The use of a virtual three-dimensional model toevaluate the intraosseous space available for percutaneousscrew fixation of acetabular fractures. J Bone Joint Surg Br.November 2005;87-B(11).

2. Crowl AC, Kahler DM. Closed reduction and percutaneousfixation of anterior column acetabular fractures. Comput AidedSurg. 2002;7(3):169e178.

3. Jae-Hyuk Yang MD, Devendra Kumar Chouhan MS, Kwang-JunOh MD. Percutaneous screw fixation of acetabular fractures:applicability of hip arthroscopy. 2010;26(11):1556e1561.

4. Vioreanu Mihai H, Mulhall Kevin J. Intra-operative imagingtechnique to aid safe placement of screws in percutaneousfixation of pelvic and acetabular fractures. Acta Orthop Belg.2011;77:398e401.

5. Gay SB, Sistrom C, Wang GJ, et al. Percutaneous screw fixationof acetabular fractures with CT guidance: preliminary resultsof a new technique. AJR Am J Roentgenol. 1992;158:819e822.

6. Starr AJ, Reinert CM, Jones AL. Percutaneous fixation of thecolumns of the acetabulum: a new technique. J Orthop Trauma.1998;12:51e58.

7. Norris BL, Hahn DH, Bosse MJ, Kellam JF, Sims SH.Intraoperative fluoroscopy to evaluate fracture reduction andhardware placement during acetabular surgery. J OrthopTrauma. 1999;13:414e417.

8. Lin Yu-Chuan, et al. Percutaneous antegrade screwing foranterior column fracture of acetabulum with fluoroscopic-based computerized navigation. Arch Orthop Trauma Surg. 2008.http://dx.doi.org/10.1007/s00402-007-0369-9.

Fig. 8 e Diagrammatic picture showing the direction of

screw placement in scarum.



Apollo hospitals: http://www.apollohospitals.com/Twitter: https://twitter.com/HospitalsApolloYoutube: http://www.youtube.com/apollohospitalsindiaFacebook: http://www.facebook.com/TheApolloHospitalsSlideshare: http://www.slideshare.net/Apollo_HospitalsLinkedin: http://www.linkedin.com/company/apollo-hospitalsBlog:Blog: http://www.letstalkhealth.in/

percutaneous fixation of bilateral anterior column acetabular fractures

Health & Medicine