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Tips and Pearls

Reduction of Posterior Column in Displaced Acetabular Fractures Using Bone Holding Forceps

Fahmy, Mahmoud MD; Abdelazeem, Ahmed H. MD

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doi: 10.1097/BTO.0000000000000443
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Abstract

Reduction of the posterior column in displaced acetabular fractures either in the elementary form (posterior column or transverse fracture) or in the associated form (with posterior wall or anterior column fracture) is considered a challenging mission.1–3 In addition, difficulty in achieving reduction increases as the fracture line is passing high in the column encroaching near the superior gluteal bundle with narrow operative field.4–6

Many reduction tools have been introduced to reduce the posterior column fracture anatomically and allow for easy fixation such as Farabeuf clamp, jungblth forceps, bone hook, pointed reduction forceps, and shanz screw in the ishcium for rotation control. However, these reduction tools have some limitations and may be technically demanding in some cases.7–9

We suggest a technical trick in reducing such a fracture using the large bone holding forceps (Verbrugge forceps) that seems to be easier, and more efficient in achieving anatomic reduction.

Theoretically and practically, it combines the advantage of 2 instruments: the bone hook and the Farabeuf clamp, because of its shape and way of application. It corrects displacement and rotation in 1 step without using an adjuvant instrument or narrowing the corridor for the plate application on the posterior surface.

METHODS

The first step is to apply a 4.5 cortical screw in the proximal stable part above the fracture line planning it to be away from the plate application. Second is to apply the broad end of the bone holding forceps to the screw head firmly. We then use the long tapered end as a hook curving on the under surface of posterior column (Figs. 1, 2).

FIGURE 1
FIGURE 1:
Intraoperative photograph showing exposure of the posterior column fracture while the suction tube is pointing inside the fracture.
FIGURE 2
FIGURE 2:
Intraoperative photograph showing application of bone holding forceps with anatomical reduction of posterior column fracture.

The surgeon starts to derotate the distal fragment while correcting the displacement and closing the gap by holding both limbs of the forceps together. Anatomic Fracture reduction is then confirmed by the intraoperative fluoroscopy before applying your definitive fixation.

The idea of using the bone holding forceps has many advantages. First the long hooked blade act like a bone hook that can rest on the inner aspect of the posterior column pulling upward and controlling rotation while the wide blunt part will rest on the screw head. In this way surgeon can easily attack the fracture plane correcting both rotation and displacement leaving most of the surface of post column free for applying the plate.

RESULTS

We used this technique for reduction in 30 patients with displaced acetabular fractures. Twenty of them have transverse fracture, 5 posterior column, and 5 associated both column fractures. In all cases we obtained anatomical reduction of the posterior column with <2 mm displacement and no rotation.

DISCUSSION

Open reduction and internal fixation is the gold standard for treatment of displaced acetabular fracture. However, reduction of these fractures is difficult and challenging even in the hands of experienced surgeon.1–3

Using bone holding forceps in reduction has succeeded to solve many problems faced by other reduction tools. For example, using jungbluth forceps with anchoring screws sometimes narrow the available surface for fixation which can be an obstacle while operating patient with small stature with small framework. In addition, it requires a very accurate direction for the anchoring screws to have the optimum reduction. Any change in the plane of screws not matching the plane of the fracture will result in displacement or rotation.10–13 This disadvantage is not found in our technique as the surgeon can change the plane of application of bone holding forceps with no limitation of the anchoring screws.

Pointed reduction forceps used in reduction of these fractures sometimes are weak and could not hold strongly the reduction before fixation.3,14 Bone holding forceps is strong in comparison to theses pointed forceps because of its strong high profile.

Bone hook is one of the simplest methods used in reduction, but it needs continuous upward pulling from the assistant through the process of internal fixation and any change in the magnitude of pulling could affect the anatomical reduction.3,14 Using bone holding forceps is superior to the bone hook in achieving anatomical reduction without needing the continuous pulling.

CONCLUSIONS

We recommend using bone holding forceps in reduction of the posterior component of the displaced acetabular fracture as an easy way, not technically demanding, efficient in controlling and holding the posterior column fracture.

REFERENCES

1. Fahmy M, Karim MA, Khaled SA, et al. Single versus double column fixation in transverse fractures of the acetabulum: a randomised controlled trial. Injury. 2018;49:1291–1296.
2. Con Dailey SK, Phillips CT, Radley JM, et al. Achieving anatomic acetabular fracture reduction—when is the best time to operate? J Orthop Trauma. 2016;30:426–431.
3. Kistler BJ, Sagi HC. Reduction of the posterior column in displaced acetabulum fractures through the anterior intrapelvic approach. J Orthop Trauma. 2015;29:S14–S19.
4. Wang ZF, Hong ZH, Wang MZ, et al. A reduction clamp for an aiming component in associated acetabular fractures. Indian J Orthop. 2015;49:101.
5. Lal H, Bansal P, Sabarwal VK, et al. Tension band wire for acetabular fracture fixation: a technical note. J Orthop Surg. 2011;19:386–388.
6. Aly TA, Hamed H. Posterior acetabular column and quadrilateral plate fractures: fixation with tension band principles. Orthopedics. 2013;36:e844–e848.
7. Suzuki T, Smith WR, Mauffrey C. Safe surgical technique for associated acetabular fractures. Patient Saf Surg. 2013;7:7.
8. Ruan Z, Luo CF, Zeng BF, et al. Percutaneous screw fixation for the acetabular fracture with quadrilateral plate involved by three-dimensional fluoroscopy navigation: surgical technique. Injury. 2012;43:517–521.
9. Calafi LA, Routt ML. Direct hip joint distraction during acetabular fracture surgery using the AO universal manipulator. J Trauma. 2010;68:481–484.
10. Amoretti N, Huwart L, Hauger O, et al. Percutaneous screw fixation of acetabular roof fractures by radiologists under CT and fluoroscopy guidance. AJR Am J Roentgenol. 2013;200:447–450.
11. Sen RK, Tripathy SK, Aggarwal S, et al. A safe technique of anterior column lag screw fixation in acetabular fractures. Int Orthop. 2012;36:2333–2340.
12. Gary JL, Lefaivre KA, Gerold F, et al. Survivorship of the native hip joint after percutaneous repair of acetabular fractures in the elderly. Injury. 2011;42:1144–1151.
13. Hu Y, Li H, Qiao G, et al. Computer-assisted virtual surgical procedure for acetabular fractures based on real CT data. Injury. 2011;42:1121–1124.
14. Ward AJ, Chesser TJ. The role of acute total hip arthroplasty in the treatment of acetabular fractures. Injury. 2010;41:777–779.
Keywords:

acetabular fractures; bone holding forceps; reduction

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