Comparative Study of Percutaneous Retrograde Screw Fixation and Minimally Invasive Plate Fixation for Acetabular Anterior Column Fractures

doi:10.21203/rs.3.rs-4810396/v1

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Comparative Study of Percutaneous Retrograde Screw Fixation and Minimally Invasive Plate Fixation for Acetabular Anterior Column Fractures

https://doi.org/10.21203/rs.3.rs-4810396/v1

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Objective

To explore the surgical techniques and compare the treatment outcomes of percutaneous retrograde screw fixation and minimally invasive ilioinguinal approach plate internal fixation in the management of acetabular anterior column fractures.

Methods

A retrospective analysis of clinical data from 32 patients with acetabular anterior column fractures treated at Qingdao Municipal Hospital from August 2019 to November 2023 was conducted. Fifteen cases were treated with percutaneous retrograde screw fixation (denoted as the screw group), and 17 cases were treated with minimally invasive ilioinguinal approach plate internal fixation (denoted as the plate group). The average surgical time, intraoperative blood loss, fluoroscopy frequency, pre- and postoperative VAS scores, and postoperative complications were compared between the two groups. Fracture reduction quality was assessed using the Matta standard, and functional scores were evaluated using the Majeed functional scoring scale.

Results

Both groups of patients were followed up for 8–15 months, with an average of 11.84 months. There was no statistically significant difference in average surgical time and hospital stay between the two groups (P > 0.05). Intraoperative blood loss in the screw group was significantly less than that in the plate group (P < 0.05). The fluoroscopy frequency in the screw group was significantly higher than that in the plate group (P < 0.05). There was no statistically significant difference in postoperative complications between the two groups (P > 0.05). The VAS scores at 3 days and 1 month postoperatively were significantly better than those at admission in both groups. There was no statistically significant difference in the VAS scores at admission between the two groups (P > 0.05), but the screw group had better VAS scores at 3 days and 1 month postoperatively compared to the plate group. Matta evaluation of the fracture reduction quality and the Majeed clinical efficacy results showed no statistically significant differences between the two groups (P > 0.05).

Conclusion

Both surgical methods achieved good treatment outcomes. Minimally invasive ilioinguinal approach plate internal fixation required fewer fluoroscopy sessions and exhibited a wider range of indications. On the other hand, percutaneous retrograde screw fixation resulted in less trauma, more pronounced pain relief, and demonstrated superior clinical advantages with broad application prospects.

Acetabular fracture

Percutaneous retrograde screw fixation

Plate fixation

Ilioinguinal approach

Minimally invasive

Acetabular fractures account for 3% of all fractures, with a mortality rate as high as 13.4% [1, 2]. Currently, open reduction and internal fixation have become the gold standard for treating displaced acetabular fractures [3]. However, this approach still has drawbacks, such as significant surgical trauma, substantial blood loss, and prolonged surgical duration. In recent years, minimally invasive techniques have emerged as a new approach for treating acetabular fractures, particularly anterior column fractures, offering advantages such as smaller incisions, reduced intraoperative bleeding, and a lower incidence of incision-related complications [4].

Percutaneous retrograde screw insertion technology for acetabular anterior column fractures is a commonly used minimally invasive technique for fractures involving the pelvic anterior ring or low anterior column of the acetabulum. This approach offers advantages in terms of minimally invasive procedures and superior biomechanics, facilitating accelerated patient recovery, reducing economic burdens, and shortening hospital stays. Consequently, it has gained increasing importance in the treatment of pelvic and acetabular fractures [5–8]. The minimally invasive ilioinguinal approach with plate internal fixation is a feasible method for treating acetabular anterior column fractures, and is characterized by minimal trauma, shorter surgical time, and a significant improvement in hip joint function [9, 10]. This study aimed to retrospectively analyze the clinical data from 32 patients with acetabular anterior column fractures treated at Qingdao Municipal Hospital from August 2019 to November 2023. The study compared the clinical efficacy of two different minimally invasive techniques for the treatment of acetabular anterior column fractures and explored the surgical techniques.

Patient inclusion and exclusion criteria

Inclusion criteria: (1) Patients with fresh fractures involving the low anterior column of the acetabulum, (2) closed fractures, (3) patients with normal and mature bone development. Exclusion criteria: (1) Patients with fractures involving the posterior column of the acetabulum, (2) those with severe complications contraindicating anesthesia and surgery, (3) patients with severe mental disorders and poor compliance, (4) patients with old fractures, (5) those with open fractures or poor soft tissue conditions in the surgical area, (6) patients with pathological fractures, (7) those lost to follow-up or with a follow-up period less than 1 year.

General information

In total, 32 patients with acetabular anterior column fractures were included in the study, ranging in age from 32 to 83 years old, with an average age of 55.22 years old. The causes of injury included 16 cases of traffic accidents, 6 cases of falls, and 10 cases of falls from height. There were 10 cases with concomitant limb fractures, 6 cases with concomitant lumbar vertebral fractures, 3 cases with concomitant head injuries, 4 cases with concomitant chest organ injuries, and 2 cases with concomitant pelvic organ injuries. Based on the surgical method, the patients were divided into a screw group and a plate group. The screw group consisted of 15 patients, comprising 6 males and 9 females, with an age range of 33–83 years old and an average age of (54.9 ± 15.3) years old. The plate group consisted of 17 patients, comprising 8 males and 9 females, with an age range of 32–79 years old and an average age of 55.5 ± 12.8 years old. There were no statistically significant differences in age, gender, or causes of injury between the two groups (P > 0.05) (see Table 1). All the surgeries were performed by senior surgeons in collaboration with junior surgeons.

Table 1

Comparison of general data between two groups of patients with acetabular anterior column fractures
Group	Case	Gender		Age	Cause of injury (case)
Group	Case	male	female	Age	Traffic accident injury	Fall injury	Crush injury
Screw group	15	6	9	54.9 ± 15.3	6	5	4
Plate group	17	8	9	55.5 ± 12.8	10	5	2
Statistical test quantity		χ2 = 0.161 0.688		t=-0.133 0.895	χ2 = 1.548 0.461
P value		χ2 = 0.161 0.688		t=-0.133 0.895	χ2 = 1.548 0.461

Preoperative preparation

Upon admission, the patients were initially administered medications for the symptomatic treatment of other complications as appropriate, such as shock, and femoral traction was applied. Preoperative examinations, including pelvic anteroposterior X-rays, CT scans, and three-dimensional reconstructions, were conducted to assess their condition. Surgical treatment was scheduled after the patient's condition was stabilized.

Surgical procedures

Screw group: The patient lay supine on the orthopedic operating table after anesthesia, disinfection, and draping. Through limb traction and percutaneous insertion of a Kirschner wire for rotation, elevation, and other maneuvers, a closed reduction of the low anterior column fracture of the acetabulum was performed. Once satisfactory reduction was achieved, the reduction was maintained. Standard pelvic inlet and outlet positions were visualized under fluoroscopy, and the needle entry point was positioned near the pubic tubercle. After confirming the entry point and approximate direction, an incision was made, and a 2.5mm guide wire with a reversed sharp tip was inserted. Guided by the pelvic inlet and outlet positions, a bone hammer was used to slowly tap the guide wire to establish the screw channel. Following depth measurement along the guide wire and drilling, a suitable length 6.5 mm diameter hollow screw was inserted. (typical case: Fig. 1)

Plate group: A transverse incision 4–5 cm long was made 2 cm above the pubic tubercle, with careful attention to preserving the spermatic cord (or round ligament of the uterus). The muscle insertion points, including the rectus abdominis and pubic symphysis ligament, were severed, exposing the pubic superior ramus. Dissection was performed along the subperiosteal plane, typically reaching the pubic tubercle prominence. Hemostasis was achieved by applying a tourniquet, followed by a 4 cm incision along the skin lines at a point 4 cm above the anterior superior iliac spine. The abdominal and iliac muscles were detached from the inner plate of the ilium, ensuring protection of the lateral cutaneous nerve of the thigh. Dissection proceeded subperiosteally from the iliac crest toward the pubic superior ramus, connecting with the inner incision, thus forming a subperiosteal tunnel identical to that of the pubic superior ramus and acetabular anterior column.

Based on the anatomical structure of the acetabular anterior column, a pre-bent 3.5 mm reconstruction plate was inserted from the medial side to the lateral side. Initially, two tension screws were fixed at the pubic superior ramus to maintain the anatomical continuity of the acetabular anterior column. Subsequently, 2–3 tension screws were fixed at the ilium to provide compression at the fracture end, stabilizing the acetabular anterior column. (typical case: Fig. 2)

Postoperative management

Following surgery, the prompt completion of postoperative pelvic X-rays, CT scans, and three-dimensional reconstructions was performed to assess the fracture reduction and the position of the internal fixation screws within the channels. Routine infection prevention measures were administered within the first 24 hours postoperatively, accompanied by standard physical or pharmacological prophylaxis for lower limb deep vein thrombosis. On the first day after surgery, flexion and extension functional rehabilitation exercises were initiated for the hip, knee, and ankle joints to prevent joint stiffness. After 6–8 weeks postoperatively, partial weight-bearing was supported with crutches or a walker until fracture healing occurred, gradually transitioning to full weight-bearing and independent walking.

Observation for assessments

The patient records included surgical duration, intraoperative blood loss, and fluoroscopy frequency. Additionally, the hospitalization duration and the occurrence of complications were documented. Visual analog scale (VAS) scores were used for pain assessment at admission, postoperative day 3, and 1 month after surgery. Pelvic fracture reduction quality was evaluated according to the Matta standard: postoperative measurements on pelvic anteroposterior X-rays, with fracture displacement distances categorized as excellent (< 4 mm), good (4–10 mm), fair (11–20 mm), or poor (> 20mm) [11]. Postoperative functional assessments utilized the Majeed functional scoring scale [12], encompassing indicators such as pain, gait, mobility, and work recovery. Follow-up evaluations were conducted at 9–12 months.

Statistical analysis

Statistical analysis was conducted using SPSS 29.0 software. Descriptive statistics for continuous data were expressed as the mean ± standard deviation (‾x ± s), and t-tests were employed for comparisons. Chi-square tests (χ2) were utilized for the categorical data. A significance level of P < 0.05 was considered statistically significant.

In the screw group, all 15 patients underwent successful percutaneous retrograde screw fixation surgery. In the plate group, all 17 patients underwent successful minimally invasive plate fixation surgery using the ilioinguinal approach. All the fractures achieved bony union. Follow-up was conducted for all patients postoperatively, with a duration ranging from 8 to 15 months. There were no statistically significant differences in surgical duration and hospitalization duration between the two groups (P > 0.05). The intraoperative blood loss in the screw group was significantly less than that in the plate group (P < 0.05). Comparison of the intraoperative fluoroscopy frequency revealed a significant increase in the screw group compared to the plate group (P < 0.05, Table 2).

Table 2

Comparison of the therapeutic indexes between two groups of patients with acetabular anterior column fractures
Group	Case	Operation time(min)	Operative blood loss(ml)	Intraoperative fluoroscopy frequency(time)	Hospitalization duration(d)
Screw group	15	59.4 ± 39.3	6.3 ± 2.9	41.3 ± 20.6	16.9 ± 16.5
Plate group	17	75.3 ± 20.7	185.3 ± 86.1	10.0 ± 3.1	19.4 ± 15.7
t-test		-1.458	-8.026	5.823	-0.456
P value		0.155	< .001	< .001	0.652

Postoperative CT scans in the screw group revealed that one patient experienced bone-cutting in the pubic superior ramus due to the screw. In another case, a female patient reported sexual discomfort attributed to screw irritation, leading to the removal of the internal fixation material one year postoperatively. In the plate group, one patient experienced intestinal gas distension on the day of surgery. No instances of peripheral nerve or vascular injury were observed in any patient, or postoperatively. There were no complications, such as incision infection, necrosis, nonunion, internal fixation loosening, genitourinary system damage, or avascular necrosis of the femoral head. A comparison of the postoperative complications between the screw group (2/15) and the plate group (1/17) showed no statistically significant differences (χ2 = 0.521 P = 0.471).

The VAS scores for both groups were significantly improved at 3 days and 1 month postoperatively compared to at admission. There was no statistically significant difference in VAS scores at admission between the two groups (P > 0.05). However, the screw group demonstrated superior VAS scores at 3 days and 1 month postoperatively compared to the plate group (Table 3).

Table 3

Comparison of VAS between two groups of patients with acetabular anterior column fractures at different times(score)
Group	Case	On admission	Three days after surgery	One month after surgery
Screw group	15	6.2 ± 1.0	2.3 ± 0.8	0.9 ± 0.6
Plate group	17	5.8 ± 0.9	3.0 ± 0.7	1.4 ± 0.5
t-test		1.123	-2.755	-2.185
P value		0.270	0.01	0.037

Table 4

Comparison of postoperative Matta fracture reduction score and the Majeed functional score at the final follow—up between two groups of patients with acetabular anterior column fractures (case)
Group	Case	Matta fracture reduction score			Majeed functional score
Group	Case	excellent	good	general	excellent	good	general
Screw group	15	10	5	0	10	3	2
Plate group	17	6	9	2	5	10	2
χ2 value		4.034 0.133			5.332 0.070
P value		4.034 0.133			5.332 0.070

Comparison of the fracture reduction quality assessed by the Matta criteria showed no statistically significant differences between the two groups (P > 0.05). At the final follow-up, the clinical efficacy results based on the Majeed functional scoring scale for the postoperative fractures were comparable between the two groups, with no statistically significant differences (P > 0.05, Table 3).

The treatment of acetabular fractures remains a challenge in trauma orthopedics. Traditional open reduction and internal fixation with plates for acetabular fractures are associated with significant trauma and numerous complications. Minimally invasive treatment for acetabular anterior column fractures is increasingly accepted nowadays due to its various advantages, such as less bleeding, shorter surgery duration, lower postoperative infection rates, and fewer complications. In this study, we found that the application of percutaneous retrograde screw technology and minimally invasive ilioinguinal approach with plate fixation for acetabular anterior column fractures both resulted in favorable treatment outcomes. The ilioinguinal approach with minimally invasive plate fixation required fewer fluoroscopy sessions. Furthermore, the percutaneous retrograde screw technology led to smaller trauma with more noticeable pain reduction.

The minimally invasive ilioinguinal approach with plate fixation for the treatment of acetabular anterior column fractures is associated with less surgical trauma and reduced bleeding. Through indirect reduction, it achieves excellent clinical outcomes, applicable to both low and high types of anterior column fractures. This method can also be utilized for patients with pubic ramus fractures. The screws play a role in compression at the fracture ends, facilitating fracture healing. The technique has lower requirements for fluoroscopic navigation systems. The contraindications include comminuted fractures of the acetabular anterior column, as the indirect closed reduction may not completely anatomically reduce comminuted fractures, thus affecting the later-stage efficacy.

Some studies have suggested that screws fixated in the anterior column of the acetabulum are stable and biomechanically comparable to fixation with steel plates [13]. Therefore, minimally invasive percutaneous screws can be widely used to treat fractures in the anterior column of the acetabulum, with the main indications being non-displaced or mildly displaced fractures [14, 15]. There are two fixation methods: minimally invasive percutaneous antegrade fixation and retrograde fixation. Retrograde channel screw technology is mainly suitable for low anterior column fractures of the acetabulum or fractures of the superior pubic ramus. Its minimally invasive advantages are evident, but due to the anatomical complexity of the acetabulum itself, the "safe passage" for screws in the anterior column of the acetabulum is relatively narrow [16], meaning that this minimally invasive surgery carries a high risk. Additionally, many hospitals lack computerized fluoroscopy navigation systems, and with the use of conventional C-arm X-ray machines for guidance, many doctors are unable to master this technology, leading to its limited adoption.

The key to retrograde channel screw insertion lies in fluoroscopy guidance, and achieving accurate needle entry points and proper alignment often requires repeated and frequent fluoroscopy adjustments, leading to increased X-ray exposure and prolonged surgical time [17]. Routt et al. [18] and Starr et al. [19] reported average fluoroscopy counts of 200 and 480, respectively. Cai et al. [20] utilized an improved percutaneous retrograde channel screw insertion technique to treat pelvic and acetabular injuries, with each screw requiring 32–55 fluoroscopy instances, averaging 45. Our practical experience using Cai’s technique confirms that fluoroscopy is only necessary for the pelvic entrance and exit positions, further simplifying the fluoroscopy process. After overcoming the initial phase of technical unfamiliarity, our proficiency in this technique improved over time, eventually resulting in a notable reduction in both surgical time and fluoroscopy counts. On average, the surgical procedure now takes only 31.8 minutes, with 28 fluoroscopy instances needed for each screw insertion.

Moreover, we present two important clinical insights into the utilization of retrograde channel screw technology: (1) Optimal needle entry point selection, which involves employing fluoroscopy in the pelvic anteroposterior position to ensure that the guide needle is precisely positioned at the lowest point of the pubic symphysis. This strategic placement facilitates the creation of the longest screw channel, making it especially advantageous for fractures located in a relatively high position of the acetabular anterior column. (2) In the case of mildly displaced fractures of the acetabular anterior column, options include leveraging fluoroscopy for Kirschner wire reduction or employing a small incision to aid reduction. Additionally, the insertion of screws can be performed using a "cut-in, cut-out" technique.

The application of minimally invasive percutaneous retrograde channel screw technology and the ilioinguinal approach with a small incision and plate fixation both yield favorable therapeutic outcomes for the treatment of fractures in the acetabular anterior column. The ilioinguinal approach with a small incision and plate fixation requires fewer fluoroscopy instances and exhibits broader indications. On the other hand, percutaneous retrograde channel screw technology results in smaller trauma, noticeable pain reduction, and demonstrates superior clinical advantages with broad prospects for application. However, for severely comminuted fractures of the acetabular anterior column and cases with significant displacement that cannot achieve satisfactory reduction, open reduction with plate and screw fixation remains necessary. Furthermore, due to the study's restricted case count and its retrospective design, reaching more comprehensive conclusions necessitates additional prospective randomized controlled studies with a larger and more diverse sample size.

Acknowledgements

Not applicable.

Funding

This study was not supported by any funding organization.

Author contributions

F.S. and T.F. developed the project. F.S., T.F. and Q.W. performed the surgical procedures, data collection and analysis. T.F. wrote the manuscript. Z.L. and J.M. prepared the tables and figures. All authors reviewed the manuscript.

Ethics approval and consent to participate

This study followed the Declaration of Helsinki and was approved by the Ethics Committee of Qingdao Municipal Hospital (No:2024-LW-049). We informed consent from each patient before any testing was performed.

Competing interests

The authors declare that they have no competing interests.

Data availability

Dataset analyzed in this study is available from the corresponding author on reasonable request.

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No competing interests reported.

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You are reading this latest preprint version

Comparative Study of Percutaneous Retrograde Screw Fixation and Minimally Invasive Plate Fixation for Acetabular Anterior Column Fractures

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Version 1

Abstract

Objective

Methods

Results

Conclusion

Figures

Introduction

Materials and Methods

Patient inclusion and exclusion criteria

General information

Preoperative preparation

Surgical procedures

Postoperative management

Observation for assessments

Statistical analysis

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Version 1