Editor’s note:  The following article is a review of a video available via the AAOS Orthopaedic Video Theater (OVT). AAOS Now routinely reviews OVT Plus videos, which are vetted by topic experts and offer CME. For more information, visit aaos.org/OVT.

Acetabular fracture reconstruction is a challenge, owing to the deep anatomic location of injury and the many neurovascular structures that must be avoided during surgical exposure. Involvement of the posterior acetabular wall is implicated in 35 percent to 75 percent of cases and may be associated with articular incongruity. The latter phenomenon is termed “marginal impaction” and occurs when the affected articular fragment and subchondral bone are rotated and impacted into the underlying cancellous bone. These fractures require elevation of the articular surface and placement of bone graft to fill the resulting defect.

The AAOS OVT video “Management of Posterior Wall Acetabulum Fracture with Marginal Impaction Using Greater Trochanteric Autograft” demonstrates the use of autograft harvested from the greater trochanter to fill the bony defect that remains after elevation of a marginally impacted posterior wall acetabular fracture (Fig. 1). After grafting, plates are placed below the subchondral surface to support the bone graft until healing.

In the presented case, the female patient was aged 61 years and sustained an isolated posterior wall acetabular fracture with dislocation after a motor vehicle collision. Plain films and CT imaging revealed a large zone of marginal impaction, and the patient was indicated for operative fixation. The surgical team used a standard Kocher-Langenbeck approach to visualize the posterior acetabular surface, and they removed free chondral debris from the injury site. To harvest autograft, they made a longitudinal incision over the greater trochanter and identified the fascia of the vastus lateralis. Electrocautery was used to fill in three sides of a rectangle into the fascia, and a 2.5 mm drill bit was used to create holes along the incision. An osteotome was used to connect the drill holes, elevate the lateral cortex, and create a “trapdoor” to the trochanter. Curettes were used to harvest cancellous autograft, and the trapdoor was folded back into position.

The posterior wall was then reflected anteriorly to expose the femoral head and the site of marginal impaction. An osteotome was placed between the site of marginal impaction and the cortical portion of the posterior column. Mobilization of the articular fragment left a space which required filling. To prepare for bone grafting, 2.4 mm T plates were under-contoured to fit posteriorly to the marginally impacted site. These plates were positioned to act like rebar, support the bone graft until healing, and prevent dislocation with weightbearing. After graft and plate placement, intraoperative fluoroscopy was used to confirm subchondral rebar plate placement and ensure anatomic reduction of the posterior wall. Further implants were contoured to stabilize fracture fragments and applied as necessary. Postoperatively, the authors noted using CT scans to monitor rebar plate positioning; however, long-term follow-up on their technique is pending.

Overall, this is a detailed and technically excellent demonstration of the steps required for reconstructing a marginally impacted posterior wall acetabular fracture with the use of greater trochanteric autograft. This video will be of high educational value to both novice and expert orthopaedic surgeons.

Neil Jain, MD, is a postdoctoral orthopaedic surgery research fellow at St. Luke’s University Health Network in Bethlehem, Pennsylvania.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania.

References

1. Giannoudis PV, Kanakaris NK, Delli Sante E, et al: Acetabular fractures with marginal impaction: mid-term results. Bone Joint J 2013;95-B(2):230-8.
2. Martins e Souza P, Giordano V, Goldsztajn F, et al: Marginal impaction in posterior wall fractures of the acetabulum. AJR Am J Roentgenol 2015;204(4):W470-4.

Video details

Title: Management of Posterior Wall Acetabulum Fracture with Marginal Impaction Using Greater Trochanteric Autograft
Authors: Chibuzo Chinoso Akalonu, MD; Akeelein Forrest, BS; Izuchukwu Kenneth Ibe, MD; George V. Russell Jr, MD, MBA, FAAOS; Jeffrey Cole Stephens Sr, BA
Published: Jan. 31, 2024
Time: 12:12
Tags: Trauma, Acetabular Fractures, Autograft, Fracture

Visit aaos.org/OVT to view this award-winning title and more than 1,600 other videos from across orthopaedic topics, institutions, practice management, and industry.