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. 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.

1. Percutaneous fixation of bilateral anterior column
acetabular fractures: A case report

2. 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
b
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
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 fixation has 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 he was under various medications.
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: raju.vaishya@gmail.com (R. Vaishya).
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
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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
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

3. 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 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 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.
a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e42
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. 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 involving weight 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.
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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. Percutaneous internal fixation of pelvicfractures isbecoming
increasingly more popular among trauma surgeons worldwide
duetoreducedsurgicalrelatedmorbidityandfacilitationofearly
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 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 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 acetabulum under
guidance of hip arthroscopy to enable direct visual confir-
mation 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
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 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 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.
a p o l l o m e d i c i n e x x x ( 2 0 1 3 ) 1 e44
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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