Percutaneous fixation of bilateral anterior column acetabular fractures

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The treatment of displaced acetabular fractures with open
reduction and internal fixation has gained general acceptance. This is done either by anterior, posterior or combined approaches depending on the location of these fractures. These procedures may be associated with various complications like significant blood loss, infection, lengthy operative times, heterotopic ossification and neurovascular complications.

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Percutaneous fixation of bilateral anterior column acetabular fractures

  1. 1. Percutaneous fixation of bilateral anterior column acetabular fractures
  2. 2. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e4 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Case Report Percutaneous fixation of bilateral anterior column acetabular 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, India Registrar, Department of Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India c Fellow, Department of Orthopaedic Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India b article info abstract Article history: We report a rare case of a multiple fractures with bilateral anterior column acetabular Received 12 September 2012 fractures treated with percutaneous screw fixation for both acetabular fractures under Accepted 26 April 2013 fluoroscopy guidance. It is a demanding procedure due to the complex anatomy of the Available online xxx 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 Keywords: Acetabular extensile surgery) and in minimally displaced fractures. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. Fractures Percutaneous Screw Fixation 1. Introduction The treatment of displaced acetabular fractures with open reduction and internal fixation has gained general acceptance.1 This is done either by anterior, posterior or combined approaches depending on the location of these fractures. These procedures may be associated with various complications like significant blood loss, infection, lengthy operative times, heterotopic 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 invasive 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 he was under various medications. On examination, the patient was anxious with mild dyspnea, 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: raju.vaishya@gmail.com (R. Vaishya). 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 Please cite this article in press as: Vaishya R, et al., Percutaneous fixation of bilateral anterior column acetabular fractures: A case report, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.04.001
  3. 3. 2 a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e4 internally rotated. Movements of both hips were painful. Urinary catheter was in situ. There was swelling and deformity of right wrist. Investigations revealed anemia (Hb e 9.4 gm%), icterus (Total billirubin e 3.2 dl/mg & Direct billirubin e 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 percutaneous guide wire aided by a C-arm was placed in the anterior 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 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. 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 Carm. 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). Postoperative period was uneventful. Sutures were removed after 10 days. The patient was pain free 1 week after the operation Fig. 3 e Pre-op. X-ray of right wrist (AP view), showing distal radial fracture. Please cite this article in press as: Vaishya R, et al., Percutaneous fixation of bilateral anterior column acetabular fractures: A case report, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.04.001
  4. 4. a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e4 3 Fig. 6 e Intra-op. X-ray picture of placement of guide wire in anterior column. Fig. 4 e Pre-op. X-ray of right wrist (Lateral 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 patient 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 standard for displaced fracture involving weight bearing dome and Fig. 5 e Post-op. X-ray pelvis, with screws in situ. 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 confirmation 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. 7 e Diagrammatic picture showing the direction of screw placement in anterior column. Please cite this article in press as: Vaishya R, et al., Percutaneous fixation of bilateral anterior column acetabular fractures: A case report, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.04.001
  5. 5. 4 a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e4 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 minimally displaced fractures requiring fixation with limited surgical exposure. Fig. 8 e Diagrammatic picture showing the direction of screw placement in scarum. Percutaneous internal fixation of pelvic fractures is becoming increasingly more popular among trauma surgeons worldwide due to reduced surgical related morbidity and facilitation of early mobilization. Visualization of the pelvic bony anatomy during percutaneous fixation is difficult, making the procedure technically demanding.4 The benefits of percutaneous fixation techniques in terms of blood loss, infection, lengthy operative times, neurovascular complications and rapid mobilization have been well 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 simultaneous 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 acetabulum under guidance of hip arthroscopy to enable direct visual confirmation about the quality of the reduction and avoiding any acetabular penetration with 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 Conflicts of interest All authors have none to declare. references 1. Attias N, et al. The use of a virtual three-dimensional model to evaluate the intraosseous space available for percutaneous screw fixation of acetabular fractures. J Bone Joint Surg Br. November 2005;87-B(11). 2. Crowl AC, Kahler DM. Closed reduction and percutaneous fixation of anterior column acetabular fractures. Comput Aided Surg. 2002;7(3):169e178. 3. Jae-Hyuk Yang MD, Devendra Kumar Chouhan MS, Kwang-Jun Oh MD. Percutaneous screw fixation of acetabular fractures: applicability of hip arthroscopy. 2010;26(11):1556e1561. 4. Vioreanu Mihai H, Mulhall Kevin J. Intra-operative imaging technique to aid safe placement of screws in percutaneous fixation of pelvic and acetabular fractures. Acta Orthop Belg. 2011;77:398e401. 5. Gay SB, Sistrom C, Wang GJ, et al. Percutaneous screw fixation of acetabular fractures with CT guidance: preliminary results of a new technique. AJR Am J Roentgenol. 1992;158:819e822. 6. Starr AJ, Reinert CM, Jones AL. Percutaneous fixation of the columns 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 and hardware placement during acetabular surgery. J Orthop Trauma. 1999;13:414e417. 8. Lin Yu-Chuan, et al. Percutaneous antegrade screwing for anterior column fracture of acetabulum with fluoroscopicbased computerized navigation. Arch Orthop Trauma Surg. 2008. http://dx.doi.org/10.1007/s00402-007-0369-9. Please cite this article in press as: Vaishya R, et al., Percutaneous fixation of bilateral anterior column acetabular fractures: A case report, Apollo Medicine (2013), http://dx.doi.org/10.1016/j.apme.2013.04.001
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