Combined direct anterior approach and navigation-assisted percutaneous anterograde posterior column fixation for acetabular periprosthetic fractures.

Abstract

Objective: Management of acetabular periprosthetic fractures using a combined direct anterior approach (DAA) with or without proximal intrapelvic Levine extension and navigation-assisted percutaneous anterograde posterior column screw fixation.

Indications: Acute and subacute non-displaced or minimally displaced periprosthetic posterior column fracture, pathological fracture, or osteolysis of the posterior column.

Contraindications: Highly displaced posterior column, and/or comminuted fractures, narrow osseous corridor, large abdominal pannus, and inguinal skin infection.

Surgical technique: A classic DAA approach with or without proximal extension is performed, as for acetabular revisions. The hip is then dislocated, and both the femoral head and insert are extracted. The stability of the acetabular component is assessed. If it is found to be loose, the acetabular component is removed, and the fracture line is evaluated. Following this step, if criteria for anterograde percutaneous screw fixation are met, a minimally invasive stab incision over the iliac crest is performed. After calibration of the navigation system and 3D computed tomography (CT) data acquisition, the fascia is sharply opened, and blunt dissection of the iliac muscle is performed using a Cobb elevator under hip flexion to protect the femoral nerve and iliac muscle. After defining the trajectory in three planes using the navigation system, pre-drilling is performed with a 2.8-mm K-wire. Subsequently, a 7.5-mm fully threaded screw is inserted, and intraoperative CT is repeated to verify the correct screw position. The procedure is then completed by replacing the acetabular component via the DAA if it was loose. Additional screw fixation through the acetabular implant is advised.

Results: Based on our preliminary experience, this technique offers a safe alternative with favorable outcomes compared to combined anterior and posterior approaches. It diminishes soft tissue trauma and procedural complexity while retaining the advantages of the anterior approach. The utilization of navigation allows for precise screw positioning and enhances surgical accuracy. Consequently, this surgical technique enables the increasing number of DAA surgeons to address rare complications using their preferred approach.