Comparison of anterior-only and combined anterior-posterior approaches for complex acetabular fractures

Complex acetabular fractures involving both columns (T-type, both-column, and anterior column with posterior hemitransverse) often require combined anterior-posterior surgical exposures. Advances in anterior intrapelvic fixation raise the possibility that the posterior column can be reduced and stabilized from the intrapelvic side alone in selected cases, avoiding an additional posterior exposure. We compared radiological and clinical outcomes between an anterior-only intrapelvic strategy and a combined anterior-posterior strategy.

This retrospective comparative study included 31 patients with T-type, both-column, or ACPHT acetabular fractures: 12 treated through the modified Stoppa approach alone (anterior-only) and 19 treated with combined Kocher-Langenbeck and anterior intrapelvic exposures (combined). Postoperative CT-based reduction quality (Matta-based thresholds), Harris Hip Score (HHS), Majeed Pelvic Score, complications, and perioperative transfusion requirements were compared between groups.

Anatomic reduction was achieved in 50.0% of the anterior-only group and 36.8% of the combined group (p = 0.710). Native-hip HHS (83.0 vs. 81.0, p = 0.229) and Majeed scores (76.0 vs. 79.0, p = 0.795) were comparable between groups. Total cumulative erythrocyte suspension transfusion was higher in the combined group (median 3 vs. 2 units, p = 0.003), reflecting its greater cumulative operative burden. Reduction quality, rather than surgical strategy, was associated with outcome: post-traumatic arthritis occurred in 7.7% of patients after anatomic reduction versus 50.0% after non-anatomic reduction (p = 0.020), and native-hip HHS was significantly higher after anatomic reduction (82 vs. 74, p = 0.036). Major vascular injury occurred in three patients (9.7%), all during the anterior intrapelvic exposure.

In selected complex acetabular fractures, an anterior-only modified Stoppa strategy can achieve radiological and clinical outcomes comparable to a combined anterior-posterior approach when satisfactory reduction and stable fixation of the posterior component can be obtained from the intrapelvic side. Reduction quality, rather than the number of surgical exposures, should remain the principal determinant of the surgical strategy.