Keywords
acetabulum - fractures, bone - pelvis
Introduction
Acetabulum fractures constitute 2 to 8% of all fractures and result mostly from high-energy
trauma.[1]
[2] Since 1964, with Judet and Letournel, osteosynthesis of deflected acetabulum fractures
is believed to ensure better results than conservative treatment.[2] Fractures of two columns of the acetabulum, according to the Letournel classification,
are one of the three most common types in frequency, indication, and surgical complexity,
with the initial deviation and the presence of intra-articular fragments being the
greatest predictors of a less favorable result, and the reduction closer to the anatomical
the main predictor of good results.[1]
[2]
[3]
[4]
[5]
[6]
[7] These fractures result essentially from lateral compression mechanisms, being the
only type of fracture that reaches the two columns whose fracture traces are above
the acetabulum, causing a floating acetabulum, without any part connected to the axial
skeleton.[1]
[4]
[8] Surgical options include: anterior approach with indirect reduction and fixation
of the posterior spine; anterior approach followed by posterior approach, either at
the same surgical time (which implies repositioning), or in different surgical times;
posterior approach followed by an anterior approach, which is a rare approach, since
it should usually start with the anterior route; extended iliofemoral approach, increasingly
unadvised because of its high extent and aggressiveness; posterior approach with indirect
reduction and fixation of the anterior spine.[2]
[4]
[6]
[8]
[9] In line with this latter option, the authors present a surgical option (double simultaneous
and lateral decubitus approach: Kocher-Langenbeck approach and iliac crest approach)
based on the first three clinical cases and their clinical and imaging results.
Case Report
Case 1
Female patient, 59 years old, victim of a hit-and-run, arrives at our center with
trauma to the right hemi-hip. The imaging study allowed the diagnosis of a fracture
of the two columns of the acetabulum with posterior iliac involvement and central
dislocation of the femoral head. Skeletal traction was applied to the femoral condits
with weight corresponding to 10% of the body weight, and the patient was hospitalized.
After surgical planning, progress was made for definitive treatment: reduction and
osteosynthesis of the iliac with two plaques and reduction of the posterior spine
fracture, and osteosynthesis with plaque via the Kocher-Langenbeck route combined
with the iliac crest approach. For better access to the anterior fracture component,
fixed with two plates, osteotomy of the large trochanter was required. The postoperative
protocol was one commonly used in the institution for this type of lesions and common
to the following cases: early initiation of mobilization and muscle strengthening
according to scar evolution, discharge of the operated limb during the first 6 weeks
and progressive partial load during the following 6 weeks, with total autonomous load
allowed at 3 months. With 3 years of evolution, the patient is satisfied, without
pain, with autonomous gait and joint mobility similar to the contralateral pelvis,
with a Harris Hip Score of 84 points ([Fig. 1]).
Fig. 1 X-ray images at obturator oblique and oblique acetabular views, with typical spur
sign on the first image (a) 3D reconstructions (b) Radiological control in inlet, alar and obturator at the 3rd postoperative year (c) Photograph of the patient with scars of the routes used (d).
Case 2
A 49-year-old male patient was admitted to the emergency department after a 7-meter-high
fall with trauma to the right hemi-hip and thoracic trauma, resulting in costal arches
fractures with associated pneumothorax and fracture of the two columns of the acetabulum
with high extension to the iliac and with central dislocation of the head. After evaluation
and multidisciplinary stabilization, we opted for a closed reduction of the central
dislocation under anesthesia with fluoroscopic control and application of skeletal
traction in the distal femur. After clinical stabilization, definitive surgical treatment
was performed: open reduction and osteosynthesis via the Kocher-Langenbeck route combined
with the iliac crest approach. The patient complied with the rehabilitation protocol
and, at 9 months of evolution, the patient is satisfied and walking without support
or limitation in daily life activities, with a Harris Hip Score of 95 points ([Fig. 2]).
Fig. 2 Images of anteroposterior radiography of the pelvis and 3D ACT images for better
characterization of the fracture of two columns of the right acetabulum with high
extension to the iliac (a) Intraoperative image after maneuvers to reduce central dislocation (b) Radiological control in the anteroposterior view of the right pelvis, obturator
oblique and oblique acetabular view of the right pelvis in the postoperative period,
with acceptable reduction and absence of intra-articular screws.
Case 3
A 69-year-old male patient referred from another institution after a 3-meter-high
fall that resulted in a fracture of the two columns of the left acetabulum with high
extension to the iliac. After clinical stabilization, complete imaging study and planning,
definitive surgical treatment was performed: open reduction and osteosynthesis with
posterior spine plate, indirect reduction of the anterior spine and open reduction
of iliac fracture, and fixation with two plates and screw in compression via the Kocher-Langenbeck
route combined with the iliac crest approach. With 7 months of evolution, the patient
presents autonomous gait and is without pain, with a Harris Hip Score of 91 points
([Fig. 3]).
Fig. 3 Images of anteroposterior radiography of the pelvis and 3D ACT images for better
characterization of the fracture of two columns of the left acetabulum with high extension
to the iliac (a) Intraoperative control image (b) Radiological control in the anteroposterior view of the pelvis, obturator oblique
and oblique acetabular view of the left pelvis in the immediate postoperative period
(c) Anteroposterior radiograph of the pelvis at the 3rd month (d).
Discussion
Two-column fractures are among the most common acetabular fractures and are characterized
as complex and surgically challenging.[1]
[2]
[3]
[4]
[5]
[7] The three clinical cases presented in the present case report represent much of
what characterizes them: mechanisms of high energy injury, essentially lateral energy
vector, and junction of fracture traces above the acetabulum, which is disconnected
from the axial skeleton. The surgical decision and planning for patients with this
type of lesion requires experience in the different acetabular approaches and implies
a deep understanding of the mechanism of injury and diversion of fragments. A detailed
evaluation of the patient and of the associated lesions, and a complete imaging study
including 3D computed tomography (CT) reconstructions is essential. This planning
is the most important step for global success. The authors present three clinical
cases in which the characteristics of the lesion dictated the option taken. [Fig. 4 ]shows the positioning and the approach, and [Fig. 5] is representative of the suggested reduction and fixation sequence. In the opinion
of the authors, the main advantages of this option are: extrapelvic surgery, performed
in a single surgical time and positioning, without a potential for complications similar
to that of an extended approach. Additionally, in case of intra-articular fragments
or associated fractures of the femoral head, it is possible to associate safe pelvis
dislocation. In conclusion, despite the need for more forward-looking, randomized,
and comparative studies, with relevant samples and follow-up time, the authors believe
that the addition of the iliac crest approach to the Kocher-Langenbeck route may be
a very attractive option to take into account in the surgical treatment of fractures
of two acetabulum columns with greater posterior spine deviation and high extension
to the iliac pathway.
Fig. 4 Positioning of the patient in lateral decubitus and prior marking of the incisions
(a) Posterior view of the positioning, and the image intensifier enters in this plane
(b).
Fig. 5
Above: The three main fragments of fractures of two columns of the acetabulum: anterior
column, posterior column, and posterior iliac. The latter is connected to the axial
skeleton and encompasses the sciatica chamfering; the anterior column (with essentially
medial deviation) and the posterior column (with medial and posterior deviation) are
free, with their deviation more easily noticeable in the obturator oblique view, where
the sciatic chamfering in situ laterally and the medial deviation of the columns and
acetabulum (spur sign) are visualized. (6) Below: suggested order of reduction and osteosynthesis of fragments by simultaneous approaches
(Kocher-Langenbeck route and iliac crest approach): 1st – reduction and fixation of the posterior column to the posterior iliac; 2nd – temporary reduction of the upper portion of the anterior spine to the posterior
iliac; 3rd – reduction of the distal part of the anterior column and its fixation to the posterior
iliac and/or posterior column; 4th – definitive fixation of the upper portion of the anterior column to the posterior
iliac.
