Integrative surgical approach for complex transverse-posterior wall fractures of the acetabulum: A case series of 21 patients evaluating mid-term outcomes

Abstract

Introduction

Complex-fractures-of-acetabulum represent a significant challenge due to their complicated nature and their crucial role in the function and stability of hip joint. Associated-transverse-posterior-wall(TPW) fractures of acetabulum have been categorized as partial-articular-fractures by the AO/ATO-classification. The cornerstone for a good-to-excellent outcome is anatomical reduction and rigid-internal-fixation. The management of TPW-fractures has shown significant advancements, but there is still debate regarding the best surgical approach.

Methods

The study was conducted in a level-1-tertiary-trauma-care-centre, involving patients with an TPW- fractures-of-the-acetabulum. During Jan-2015 to Jan-2023, 512-acetabulum-fractures were managed-surgically. Out-of-which, 87-patients had TPWfracture. 21-patients who-underwent surgical-fixation using a combined-approach: Kocher-Langenbeck(KL) and iliofemoral(IF)-approaches were included in this study. Post-operative-radiological results were graded according to Matta-score. Functionaloutcome-analysis was done using EuroQOL-5D-score. The occurrence and rate-ofcomplications were evaluated.

Results

TPW-fractures had incidence of 17% among acetabulum-fractures. The Meanage: 39-years and male-to-female ratio was 19:2. Mean-follow-up: 30.5 (months). 47.6% had multiple-fractures and 38.1% were-polytraumatized. On arrival, 71.5% had hip-dislocation,19% had sciatic-nerve-injury. Excellent-to-good anatomic-reduction in 85.7%. Excellent-to-good functional-outcomes in 86%. An iatrogenic-sciatic-nerveinjury was seen in two-patients. Avascular-necrosis (AVN),heterotrophicossification (HO),and post-traumatic-osteoarthritis (OA) were seen in 14.3%, 33.3%, and 9.5% respectively. The rate-of-conversion to THR was 4.7%.

Conclusion

In cases of complex TPW-fractures-of-the-acetabulum with complete displacement and/or comminution, the integrative use of the KL and IF-approach provides comprehensive and controlled exposure for the reduction and fixation of both columns and walls, thereby facilitating excellent-reduction and stable-fixation. For-those presenting with comminution at posterior-wall or column and simple anteriorcolumn-fracture, the IF-approach should be employed first to stabilize the anteriorcolumn, followed-by of posterior-wall & column using KL-approach. Contrarily, in cases without posterior-wall or column-comminution, initial-fixation and stabilization of posterior aspect can be performed using KL-approach. Subsequently, if intra-operative assessment reveals an anterior-column displacement greater-than-2mm and intraoperative roof-arc-angle less than 45degrees, iliofemoral-approach should be utilized to address anterior-column if indirect reduction from the posterior-approach proves insufficient.