Treatment of Two-column Acetabular Fractures by Double Extrapelvic Approach: Three Clinical Cases

Fractures of two columns of the acetabulum according to the Letournel classification are among the most common in frequency, indication and surgical complexity. These are mainly the result of lateral compression mechanisms and are characterized by originating a disconnected acetabulum from the axial skeleton. Its surgical treatment may include: isolated anterior or posterior approach; combined, at the same surgical time or not; or broad approaches. The authors present another surgical option with association of the Kocher-Langenbeck pathway with the iliac crest approach simultaneously and in the same positioning (lateral decubitus) based on the first three clinical cases performed and their clinical and imaging results. In addition to the presentation of the cases, a description of the three characteristic fragments of this type of acetabular fractures, the approach pathway, and the reduction sequence performed are made. From the results obtained and the associated advantages, the authors believe that the addition of the iliac crest approach to the Kocher-Langenbeck pathway may be a very attractive option to consider in the surgical treatment of properly selected fractures of two columns of the acetabula.

Keywords
acetabulum; fractures, bone; pelvis

Authorship

João Boavida Address for correspondence João Boavida, Integrated Master's degree inMedicine, Orthopedics Service, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal (e-mail: joaoboavida8@gmail.com).

Orthopedics Service, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, PortugalCentro Hospitalar e Universitário de Coimbra EPEPortugalCoimbra, PortugalOrthopedics Service, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal

https://orcid.org/0000-0001-5411-5194

Paulo Gil Ribeiro

https://orcid.org/0000-0001-9915-7662

Paulo Costa

https://orcid.org/0000-0001-6375-7869

Catarina Quintas

https://orcid.org/0000-0002-6067-6622

Diogo Lino Moura

https://orcid.org/0000-0003-4037-2442

António Figueiredo

https://orcid.org/0000-0001-6165-7880

Address for correspondence João Boavida, Integrated Master's degree inMedicine, Orthopedics Service, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal (e-mail: joaoboavida8@gmail.com).

Conflict of Interests

The authors have no conflicts of interests to declare.

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Figures

Figures (5)

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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 ).

Thumbnail

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.

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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 ).

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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 ).

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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): 1^st – reduction and fixation of the posterior column to the posterior iliac; 2^nd – temporary reduction of the upper portion of the anterior spine to the posterior iliac; 3^rd – reduction of the distal part of the anterior column and its fixation to the posterior iliac and/or posterior column; 4^th – definitive fixation of the upper portion of the anterior column to the posterior iliac.

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 ).

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.

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 ).

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): 1^st – reduction and fixation of the posterior column to the posterior iliac; 2^nd – temporary reduction of the upper portion of the anterior spine to the posterior iliac; 3^rd – reduction of the distal part of the anterior column and its fixation to the posterior iliac and/or posterior column; 4^th – definitive fixation of the upper portion of the anterior column to the posterior iliac.

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Treatment of Two-column Acetabular Fractures by Double Extrapelvic Approach: Three Clinical Cases

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[1] Address for correspondence João Boavida, Integrated Master's degree inMedicine, Orthopedics Service, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal (e-mail: joaoboavida8@gmail.com).