MINIMALLY INVASIVE FIXATION OF ACETABULAR FRACTURES

Abstract

Anatomical reduction of the joint is the primary aim in the treatment of acetabular fractures as any other articular fracture. The current standard of care provides open reduction and internal fixation (ORIF) through differentiated surgical approaches which have been associated with relatively high complications rate such as haematomas, superficial and deep infection, and neuro-vascular lesions. Moreover these procedures need long operative times with significant blood loss. To avoid these general and local complications, that sometimes compromise the functional outcome of the operation and the possibility to perform a future arthroplasty, some authors advocated a minimally invasive percutaneous osteosynthesis (MIPO). This approach can also be considered a valid alternative to ORIF in all those cases in which the standard approaches are contraindicated as in open fractures, comminuted fractures in osteoporotic patients or fractures in high risk patients.

Between 2001 and 2006 we performed MIPO techniques for acetabular fractures in 15 patients; the reduction has been evaluated with fluoroscopy during the operation and with CT after the operative procedure. In almost all the cases the reduction has been achieved and maintained using an ileo-femoral external fixator according to the ligamentotaxis technique. The frame is applied in distraction bridging the joint from the contra-lateral iliac wing to the omolateral femoral shaft associating whenever possible percutaneous cannulated 4 mm. screws to optimise the reduction and obtain fragment fixation. The fixator is left in place from a minimum of 20 days to a maximum of 40 days in relation to the comminution of the fracture and/or the quality of the bone.

Following this strategy is possible to achieve good reduction and fracture stability avoiding the poor results of conservative treatment or the risk of major complications related to ORIF. According to the radiological and clinical results obtained the best reduction can be achieved when the treatment is carried out early and the best stability when we associate to the fixator 1 or 2 cannulated screws. The use of external fixation has never compromised the range of movement of the knee (secondary to quadriceps transfixion) and we have never had deep infection related to pin tract problems in the 3 to 6 weeks treatment period.