Closed reduction and percutaneous fixation of anterior column acetabular fractures

The current standard treatment of anterior column acetabular fractures includes formal open reduction with internal fixation (ORIF) through a variety of anterior approaches. These approaches have been associated with significant blood loss, infection, lengthy operative times, and neurovascular complications. It therefore seems reasonable to consider less invasive alternatives to conventional treatment methods. A technique for percutaneous reduction and fixation of a particular acetabular fracture pattern is presented. Execution of this technique has been facilitated by the use of image-guided surgical navigation.

A retrospective review was performed on 23 patients who had suffered an acute anterior column fracture of the acetabulum (OTA 62-A3.2, 62-A3.3, 62-B3.2, 62-B3.3) managed with closed reduction and internal fixation using large-bore cannulated screws over an 11-year period. An additional three patients treated during the study period underwent formal ORIF with plates and screws after failure of attempted closed reduction, and were not included in this analysis. Eight of the 23 patients had an associated posterior hemitransverse fracture that was also managed with minimally invasive fixation. A variety of surgical navigation techniques were used to allow accurate percutaneous screw placement: CT-guided percutaneous fixation was performed in 10 patients (1990-1995); fluoroscopy alone was used in four patients (1995-1998); and computer-assisted virtual fluoroscopy was used in nine patients (1999-2002). Some fractures were nondisplaced but potentially unstable, and involved the superior weight-bearing dome; others required closed manipulation using Schanz-pin joysticks placed into the iliac wings and held in place with a temporary external fixator. One patient required a limited open reduction followed by percutaneous screw fixation. After confirmation of adequate reduction, one to three large-bore cannulated screws were placed percutaneously using previously defined safe trajectories. All patients were managed postoperatively with early mobilization and physical therapy.

The average preoperative and postoperative displacements were 8.9 and 2.4 mm, respectively. No patient had a loss of reduction during healing. As experience was gained with the computer-assisted imaging, total fluoroscopy times were as little as 6 s, and were routinely kept below 45 s. None of the patients experienced infection, significant blood loss, or iatrogenic neurologic or visceral injury. No symptomatic heterotopic ossification was noted. Of those patients available for follow-up at a minimum of 2 years, the average HSS self-administered hip score was 91.

We believe that our findings substantiate percutaneous reduction and internal fixation of anterior column acetabular fractures as a safe and effective alternative to formal ORIF, with a low anticipated complication rate and excellent outcome.