Posterior Wall Fragments in Acetabular Both-Column Fractures: Morphology, Type, and the Significance of its Projection

Abstract

Objective: Most both-column acetabular fractures are combined with posterior wall fragments. However, the morphology of this posterior wall is varied, and how to fix this posterior wall remains a controversial topic. To investigate the morphological characteristics of posterior wall fragments of both-column acetabular fractures and select corresponding fixation methods.

Methods: Data from 352 patients with acetabular fractures admitted to the level one trauma centre in our hospital between January 2006 and December 2022 were collected. The morphology of posterior wall fragments was observed and analyzed in 83 cases of both-column acetabular fractures and classified according to the consistency of posterior wall morphology. A fracture map of the posterior wall was created on a normal template according to the three morphological types of posterior wall fragments. Finally, the high-incidence area of the posterior wall fracture was projected onto the iliac fossa and the medial side of the posterior column to guide the fixation of the posterior wall fragment using the anterior intrapelvic approach.

Results: Fractures were divided into four types: I, large posterior wall fragment which was high in the ilium bone (34 cases, 41.0%); II, posterior wall fragment in the acetabular parietal region (18 cases, 21.7%); III, posterior wall marginal fracture (10 cases, 12.0%); and IV, non-combined posterior wall fracture (21 cases, 25.3%). The most common morphologies of the posterior wall fragments of the first two types were mapped and projected onto the anterior iliac inner plate and medial side of the posterior column, where the corresponding area could be used to guide the insertion of the internal fixation.

Conclusion: Both-column acetabular fractures combined with posterior wall fractures can be divided into four types according to the morphology of the posterior wall fragment. Understanding the corresponding three-dimensional morphology and projection position of different types of these fragments can help surgeons determine the position and orientation of internal fixation of posterior wall fractures.

Keywords

Acetabular Both-Column Fracture / Classification / Internal Fixation / Mapping / Morphology of Posterior Wall Fragment

References

[1] Tile M. Fractures of the Pelvis and Acetabulum. 3rd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2003.

[2] Larson CB. Fracture dislocations of the hip. Clin Orthop Relat Res. 1973; 92: 147.

[3] Yang Y, Zou C, Fang Y. Mapping of both column acetabular fractures with three-dimensional computed tomography and implications on surgical management. BMC Musculoskeletal Disord. 2019; 20(1): 255.

[4] Scott WW, Fishman EK, Magid D. Acetabular fractures: optimal imaging.[J]. Radiology. 1987; 165(2): 537–539.

[5] Garrett J, Halvorson J, Carroll E, Webb LX. Value of 3-D CT in classifying acetabular fractures during orthopedic residency training. Orthopedics. 2012; 35(5): e615–e620.

[6] Shin KH, Choi JH, Han SB. Posterior wall fractures associated with both-column acetabular fractures can be skilfully ignored. Orthop Traumatol Surg Res. 2020; 106(5): 885–892.

[7] Yang Y, Zhong H, Hu J, Zhong Z, Xu D, Cao S, et al. Internal fixation via only the modified Stoppa approach for central hip dislocation complicated with fracture of the posterior acetabular wall. Chin J Orthop Trauma. 2022; 24(5): 409–413.

[8] Yang Y, Zou C, Fang Y. A study on fracture lines of the quadrilateral plate based on fracture mapping. J Orthop Surg Res. 2019; 14(1): 310.

[9] Feng X, Zhang S, Luo Q, Fang J, Lin C, Leung F, et al. Definition of a safe zone for antegrade lag screw fixation of fracture of posterior column of the acetabulum by 3D technology. Injury. 2016; 47(3): 702–706.

[10] Zhao B, Zhang W, Li H, Han L, Han S, Yang X, et al. The largest secure corridor of the infra-acetabular screw-a 3-D axial perspective analysis. BMC Musculoskelet Disord. 2021; 22(1): 551.

[11] Cole PA, Mehrle RK, Bhandari M, Zlowodzki M. The pilon map: fracture lines and comminution zones in OTA/AO type 43C3 pilon fractures. J Orthop Trauma. 2013; 27(7): e152–e156.

[12] Armitage BM, Wijdicks CA, Tarkin IS, Schroder LK, Marek DJ, Zlowodzki M, et al. Mapping of scapular fractures with three-dimensional computed tomography. J Bone Jt Surg Am. 2009; 91(9): 2222–2228.

[13] Letournel EJR. Fractures of the Acetabulum. 2nd ed. New York: Springer-Verlag; 1993.

[14] Chen KN, Wang G, Cao LG, Zhang MC. Differences of percutaneous retrograde screw fixation of anterior column acetabular fractures between male and female: a study of 164 virtual three-dimensional models. Injury. 2009; 40(10): 1067–1072.

[15] Moroni A, Caja VL, Sabato C, Zinghi G. Surgical treatment of both-column fractures by staged combined ilioinguinal and Kocher-Langenbeck approaches. Injury. 1995; 26(4): 219–224.

[16] Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Jt Surg Br. 2005; 87(1): 2–9.

[17] Tosounidis TH, Giannoudis PV. Use of inlet-obturator oblique view (Leeds view) for placement of Posterior Wall screws in acetabular fracture surgery. J Orthop Trauma. 2017; 31(4): e133–e136.

[18] Wang H, Utku K, Zhuang Y, Zhang K, Fu YH, Wei X, et al. Post wall fixation by lag screw only in associated both column fractures with posterior wall involvement. Injury. 2017; 48(7): 1510–1517.

[19] Tian S, Chen Y, Yin Y, Zhang R, Hou Z, Zhang Y. Morphological characteristics of Posterior Wall fragments associated with acetabular both-column fracture. Sci Rep. 2019; 9(1): 20164.

[20] Olson SAMJ. Fractures of the acetabulum, hip dislocations, and femoral head fractures. In: MW Chapman, editor. Chapman’s orthopaedic surgery. 3rd ed. Philadelphia: Lippincott Williams & Wikins; 2001.

[21] Harris AM, Althausen P, Kellam JF, Bosse MJ. Simultaneous anterior and posterior approaches for complex acetabular fractures. J Orthop Trauma. 2008; 22(7): 494–497.

[22] Guerado E, Cano JR, Cruz E. Simultaneous ilioinguinal and Kocher-Langenbeck approaches for the treatment of complex acetabular fractures. Hip Int. 2010; 20(Suppl 7): S2–S10.

[23] Routt ML Jr, Swiontkowski MF. Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure. J Bone Jt Surg Am. 1990; 72(6): 897–904.

[24] Min BW, Lee KJ, Jung JW, Kim GW, Song KS, Bae KC, et al. Outcomes are equivalent for two-column acetabular fractures either with or without posterior-wall fractures. Arch Orthop Trauma Surg. 2018; 138(9): 1223–1234.

[25] Chen MJ, Hollyer I, Wadhwa H, Tigchelaar SS, van Rysselberghe NL, Bishop JA, et al. Management of the posterior wall fracture in associated both column fractures of the acetabulum. Eur J Orthop Surg Traumatol. 2021; 31(6): 1047–1054.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.