Experiences with the infra-acetabular screw placement technique in acetabular fracture surgery_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

 WU Min , GUAN Jianzhong , CHEN Xiaotian , WANG Xiaopan , ZHAO Peishuai , LI Renjie , CHEN Jiaqiang , LIU Leyu

Department of Orthopaedics, the First Affiliated Hospital of Bengbu Medical University, Anhui Key Laboratory of Tissue Transplantation, Bengbu Anhui, 233004, P. R. China;

Corresponding author：

WU Min, Email: wumin200207@163.com

Keywords：

Acetabular fracture; infra-acetabular screw; internal fixation

DOI：

10.7507/1002-1892.202405036

Video：

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Objective To investigate the application experiences and effectiveness of the infra-acetabular screw (IAS) placement technique in acetabular fracture surgery. Methods A clinical data of 34 patients with complex acetabular fractures with anterior and posterior columns separation, who were admitted between January 2019 and October 2023 and treated with IAS fixation, was retrospectively analyzed. There were 23 males and 11 females with an average age of 55.3 years (range, 18-78 years). The acetabular fractures caused by traffic accident in 20 cases, falling from height in 12 cases, crushing injury in 1 case, and bruising with a heavy object in 1 case. According to the Letournel-Judet classification, there were 7 cases of anterior column fracture, 8 cases of anterior wall/column plus posterior hemi-transverse fracture, 2 cases of T-shaped fracture, and 17 cases of both-column fracture. The time from injury to surgery was 4-21 days (mean, 8.6 days). The time of IAS placement and the intraoperative blood loss were recorded. After surgery, the X-ray film and CT scan were re-examined, and the modified Matta score was used to assess the quality of fracture reduction. The trajectory of IAS in the channel was analyzed based on CT scan, and the screw length was measured. During follow-up, the fracture healing was observed and the hip function was assessed according to the modified Merle d’Aubigné-Postel scoring system at last follow-up. Results The IAS was successfully implanted in all 34 patients. The length of IAS ranged from 70 to 100 mm (mean, 86.2 mm). The time of IAS placement ranged from 10 to 40 minutes (mean, 20.7 minutes). The intraoperative blood loss ranged from 520 to 820 mL (mean, 716.8 mL). All patients were followed up 8-62 months (mean, 21.8 months). After surgery, 4 patients developed lateral femoral cutaneous nerve injury, 2 developed popliteal vein thrombosis of the lower extremity, 3 developed incision infection, and no surgical complication such as arteriovenous injury or obturator nerve palsy occurred. At last follow-up, the hip function was rated as excellent in 14 cases, good in 13 cases, fair in 4 cases, and poor in 3 cases according to the Merle d’Aubigné-Postel scoring system, with an excellent and good rate of 79.41%. Imaging re-examined showed that the quality of fracture reduction was rated as excellent in 9 cases, good in 19 cases, and poor in 6 cases according to the modified Matta score, with an excellent and good rate of 82.35%; and 25 (73.53%) IAS trajectories were located in the channel. All fractures obtained bony union, and the healing time was 12-24 weeks (mean, 18 weeks). During follow-up, there was no loosening or fracture of the plate and screws. Conclusion IAS placement technique can effectively strengthen internal fixation and prevent fracture re-displacement, making it a useful adjunct for treating complex acetabular fractures with anterior and posterior columns separation.

Citation： WU Min, GUAN Jianzhong, CHEN Xiaotian, WANG Xiaopan, ZHAO Peishuai, LI Renjie, CHEN Jiaqiang, LIU Leyu. Experiences with the infra-acetabular screw placement technique in acetabular fracture surgery. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(9): 1040-1046. doi: 10.7507/1002-1892.202405036 Copy

1.	Clarke-Jenssen J, Wikeroy AK, Roise O, et al. Long-term survival of the native hip after a minimally displaced, nonoperatively treated acetabular fracture. J Bone Joint Surg (Am), 2016, 98(16): 1392-1399.
2.	Lal SR. Outcome of surgical treatment for displaced acetabular fractures: a prospective study. Rev Bras Ortop, 2017, 53(4): 482-488.
3.	Zou R, Wu M, Guan J, et al. Clinical results of acetabular fracture via the pararectus versus ilioinguinal approach. Orthop Surg, 2021, 13(4): 1191-1195.
4.	Culemann U, Marintschev I, Gras F, et al. Infra-acetabular corridor—Technical tip for an additional screw placement to increase the fixation strength of acetabular fractures. J Trauma, 2011, 70(1): 244-246.
5.	曹文豪, 王中鹤, 李嘉琦, 等. HoloSight创伤骨科手术机器人辅助二窗螺钉植入治疗髋臼骨折的临床研究. 中国修复重建外科杂志, 2024, 38(6): 696-702.
6.	Zou R, Wu M, Guan J, Xiao Y, et al. Therapeutic effect of acetabular fractures using the pararectus approach combined with 3D printing technique. Orthop Surg, 2020, 12(6): 1854-1858.
7.	Li R, Zhao P, Guan J, et al. Combined pelvic and acetabular injuries: clinical features and treatment strategies of a unique injury pattern. J Orthop Surg Res, 2023, 18(1): 415. doi: 10.1186/s13018-023-03897-0.
8.	Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. J Orthop Trauma, 2006, 20(1 Suppl): S20-S29.
9.	Wang T, Wei C, Gu S, et al. Radio-anatomical study of anterior-posterior placement sacroiliac screw channel. Eur Spine J, 2022, 31(10): 2572-2578.
10.	d’Aubigné RM, Postel M. The classic: functional results of hip arthroplasty with acrylic prosthesis. 1954. Clin Orthop Relat Res, 2009, 467(1): 7-27.
11.	Arlt S, Noser H, Wienke A, et al. Secure corridor for infraacetabular screws in acetabular fracture fixation—A 3-D radiomorphometric analysis of 124 pelvic CT datasets. J Orthop Surg Res, 2018, 13(1): 119. doi: 10.1186/s13018-018-0833-y.
12.	Gras F, Gottschling H, Schröder M, et al. Sex-specific differences of the infraacetabular corridor: a biomorphometric CT-based analysis on a database of 523 pelves. Clin Orthop Relat Res, 2015, 473(1): 361-369.
13.	Gras F, Marintschev I, Schwarz CE, et al. Screw- versus plate-fixation strength of acetabular anterior column fractures: a biomechanical study. J Trauma Acute Care Surg, 2012, 72(6): 1664-1670.
14.	Marintschev I, Gras F, Schwarz CE, et al. Biomechanical comparison of different acetabular plate systems and constructs—The role of an infra-acetabular screw placement and use of locking plates. Injury, 2012, 43(4): 470-474.
15.	Wang T, Zhao B, Yan J, et al. Finite element analysis of infra-acetabular screw fixation for the treatment of acetabular posterior column fracture. Int Orthop, 2022, 46(3): 623-634.
16.	Chen K, Huang G, Wan Y, et al. Biomechanical study of different fixation constructs for anterior column and posterior hemi-transverse acetabular fractures: a finite element analysis. J Orthop Surg Res. 2023, 18(1): 294. doi: 10.1186/s13018-023-03715-7.
17.	Baumann F, Schmitz P, Mahr D, et al. A guideline for placement of an infra-acetabular screw based on anatomic landmarks via an intra-pelvic approach. J Orthop Surg Res, 2018, 13(1): 77. doi: 10.1186/s13018-018-0786-1.
18.	Fukuoka S, Yorimitsu M, Uehara T, et al. Ideal insertion point and projection of the infra-acetabular screw in acetabular fracture surgery. Injury, 2024, 55(6): 111264. doi: 10.1016/j.injury.2023.111264.
19.	马能峰, 杨民, 陶周善, 等. 通过数字化分析对髋臼下螺钉最大通道参数的测量和置钉可行性的评估. 中国骨伤, 2021, 34(3): 220-225.
20.	吕刚, 马雷, 孙辉, 等. 髋臼下螺钉技术治疗髋臼骨折的疗效分析. 中华创伤骨科杂志, 2021, 23(6): 507-512.
21.	Lim EJ, Sakong S, Son WS, et al. Usefulness of the obturator hook technique for guiding the initial trajectory control in infra-acetabular screw placement. J Orthop Surg (Hong Kong), 2021, 29(1): 2309499021996838. doi: 10.1177/2309499021996838.
22.	陈笑天, 王晓盼, 赵培帅, 等. 钛弹性钉辅助耻骨上支逆行通道螺钉植入手术技巧及临床疗效. 中国修复重建外科杂志, 2023, 37(4): 431-437.
23.	Kanezaki S, Miyazaki M, Notani N, et al. Analysis of computed tomography-based infra-acetabular morphometry to assess the feasibility of infra-acetabular screws. Arch Orthop Trauma Surg, 2020, 140(3): 359-364.

1. Clarke-Jenssen J, Wikeroy AK, Roise O, et al. Long-term survival of the native hip after a minimally displaced, nonoperatively treated acetabular fracture. J Bone Joint Surg (Am), 2016, 98(16): 1392-1399.
2. Lal SR. Outcome of surgical treatment for displaced acetabular fractures: a prospective study. Rev Bras Ortop, 2017, 53(4): 482-488.
3. Zou R, Wu M, Guan J, et al. Clinical results of acetabular fracture via the pararectus versus ilioinguinal approach. Orthop Surg, 2021, 13(4): 1191-1195.
4. Culemann U, Marintschev I, Gras F, et al. Infra-acetabular corridor—Technical tip for an additional screw placement to increase the fixation strength of acetabular fractures. J Trauma, 2011, 70(1): 244-246.
5. 曹文豪, 王中鹤, 李嘉琦, 等. HoloSight创伤骨科手术机器人辅助二窗螺钉植入治疗髋臼骨折的临床研究. 中国修复重建外科杂志, 2024, 38(6): 696-702.
6. Zou R, Wu M, Guan J, Xiao Y, et al. Therapeutic effect of acetabular fractures using the pararectus approach combined with 3D printing technique. Orthop Surg, 2020, 12(6): 1854-1858.
7. Li R, Zhao P, Guan J, et al. Combined pelvic and acetabular injuries: clinical features and treatment strategies of a unique injury pattern. J Orthop Surg Res, 2023, 18(1): 415. doi: 10.1186/s13018-023-03897-0.
8. Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. J Orthop Trauma, 2006, 20(1 Suppl): S20-S29.
9. Wang T, Wei C, Gu S, et al. Radio-anatomical study of anterior-posterior placement sacroiliac screw channel. Eur Spine J, 2022, 31(10): 2572-2578.
10. d’Aubigné RM, Postel M. The classic: functional results of hip arthroplasty with acrylic prosthesis. 1954. Clin Orthop Relat Res, 2009, 467(1): 7-27.
11. Arlt S, Noser H, Wienke A, et al. Secure corridor for infraacetabular screws in acetabular fracture fixation—A 3-D radiomorphometric analysis of 124 pelvic CT datasets. J Orthop Surg Res, 2018, 13(1): 119. doi: 10.1186/s13018-018-0833-y.
12. Gras F, Gottschling H, Schröder M, et al. Sex-specific differences of the infraacetabular corridor: a biomorphometric CT-based analysis on a database of 523 pelves. Clin Orthop Relat Res, 2015, 473(1): 361-369.
13. Gras F, Marintschev I, Schwarz CE, et al. Screw- versus plate-fixation strength of acetabular anterior column fractures: a biomechanical study. J Trauma Acute Care Surg, 2012, 72(6): 1664-1670.
14. Marintschev I, Gras F, Schwarz CE, et al. Biomechanical comparison of different acetabular plate systems and constructs—The role of an infra-acetabular screw placement and use of locking plates. Injury, 2012, 43(4): 470-474.
15. Wang T, Zhao B, Yan J, et al. Finite element analysis of infra-acetabular screw fixation for the treatment of acetabular posterior column fracture. Int Orthop, 2022, 46(3): 623-634.
16. Chen K, Huang G, Wan Y, et al. Biomechanical study of different fixation constructs for anterior column and posterior hemi-transverse acetabular fractures: a finite element analysis. J Orthop Surg Res. 2023, 18(1): 294. doi: 10.1186/s13018-023-03715-7.
17. Baumann F, Schmitz P, Mahr D, et al. A guideline for placement of an infra-acetabular screw based on anatomic landmarks via an intra-pelvic approach. J Orthop Surg Res, 2018, 13(1): 77. doi: 10.1186/s13018-018-0786-1.
18. Fukuoka S, Yorimitsu M, Uehara T, et al. Ideal insertion point and projection of the infra-acetabular screw in acetabular fracture surgery. Injury, 2024, 55(6): 111264. doi: 10.1016/j.injury.2023.111264.
19. 马能峰, 杨民, 陶周善, 等. 通过数字化分析对髋臼下螺钉最大通道参数的测量和置钉可行性的评估. 中国骨伤, 2021, 34(3): 220-225.
20. 吕刚, 马雷, 孙辉, 等. 髋臼下螺钉技术治疗髋臼骨折的疗效分析. 中华创伤骨科杂志, 2021, 23(6): 507-512.
21. Lim EJ, Sakong S, Son WS, et al. Usefulness of the obturator hook technique for guiding the initial trajectory control in infra-acetabular screw placement. J Orthop Surg (Hong Kong), 2021, 29(1): 2309499021996838. doi: 10.1177/2309499021996838.
22. 陈笑天, 王晓盼, 赵培帅, 等. 钛弹性钉辅助耻骨上支逆行通道螺钉植入手术技巧及临床疗效. 中国修复重建外科杂志, 2023, 37(4): 431-437.
23. Kanezaki S, Miyazaki M, Notani N, et al. Analysis of computed tomography-based infra-acetabular morphometry to assess the feasibility of infra-acetabular screws. Arch Orthop Trauma Surg, 2020, 140(3): 359-364.

Chinese Journal of Reparative and Reconstructive Surgery

Experiences with the infra-acetabular screw placement technique in acetabular fracture surgery

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