Authors of section

Authors

Derek Donegan, Michael Huo, Michael Leslie

Executive editor

Michael Baumgaertner

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Anterior column screw fixation

1. Principles

Fracture morphology and surgeon's experience will dictate the choice of fixation method to achieve fracture stability and maintain cup stability.

Intraoperative fractures occurring during component removal or after the arthroplasty surgery, are typically associated with chronic problems related to total hip replacement. In the setting of infection, loosening, or osteolysis the cup may need to be removed.

For further information about standard techniques for ORIF in native acetabular fractures, please refer to the acetabulum section of the AO Surgery Reference. 

Anterior column screw fixation

2. Implant selection

Column screw fixation is typically performed with non-cannulated screws when the fracture is reduced openly as the starting point is easily visualized.

Column screw fixation

Percutaneous methods are often aided using cannulated screw fixation. Ideally, screws with an outer diameter over 6.5 mm will provide the most rigid guide pin and prevent guide pin complication.

Percutaneous screw insertion

The column corridors must allow for screws of this caliber.

The column corridors must allow for screws of this caliber

3. Reduction

Anterior column fractures can be more challenging to address and typically do not need to be surgically addressed if there is an intact posterior column. However, in the setting of an unstable cup, with fracture or to prevent late instability, the anterior aspects of the joint should be reduced and stabilized.

Anterior column fracture reduction

4. Screw application in antegrade fashion

The anterior column can be addressed through an open exposure or through a percutaneous approach.

Exposure through open posterior approach

The posterior approach to the hip, with the patient in a lateral position, can easily be extended to expose the screw entry point on the proximal ileum. The screw can be inserted across the fracture site into the low anterior column.

Exposure through open posterior approach

Percutaneous approach

The antegrade percutaneous approach is performed through a stab incision along with the outer table with the patient in a supine or lateral position.

Percutaneous approach

Anterior column fixation

A long guidewire is inserted, and its placement confirmed utilizing fluoroscopy or intraoperative CT.

Anterior column fixation

Consider drilling the entry point of the anterior column.

Drilling the entry point of the anterior column

The screw is inserted over the guidewire.

The screw is inserted over the guidewire
Note: This approach is highly dependent on intraoperative fluoroscopy and the surgeon must be experienced in performing this procedure, particularly when the patient is in the lateral position.

5. Screw application in retrograde fashion

When a fracture has been identified intraoperatively, effort should be made to utilize the surgical exposure that is already available.

Percutaneous approach

For this technique, the patient should be placed supine. The retrograde approach is performed through a stab incision past the midline to allow for entry at the pubic tubercle of the affected side.

Percutaneous approach
Note: Patient anatomy must allow for safe access to the anterior column, which may be limited in obese patients.
Patient anatomy must allow for safe access to the anterior column

Anterior column fixation

A long guide-pin is inserted, and its placement confirmed utilizing fluoroscopy or intraoperative CT.

Anterior column fixation

Consider drilling the entry point of the anterior column.

Drilling the entry point of the anterior column

The screw is inserted over the guidewire.

The screw is inserted over the guidewire

6. Aftercare following ORIF

Postoperative management

Postoperative management should include careful monitoring of hematocrit and electrolytes particularly in the elderly patients.

Postoperative IV antibiotics should be administered up to 24 hours.

Consideration should be given to anticoagulation for a minimal course of 35 days. If there are thromboembolic complication this treatment is extended.

Drains can be discontinued when output is less than 30 to 50 cc per 12 hours.

Patient mobilization

Immediate mobilization of the patient should commence. If fracture stability will allow, the patient should be made weight bearing as tolerated as soon as possible. Long periods of limited weight bearing are extremely detrimental to patient recovery.

Patient mobilization with limited weight bearing

Precautions against hip dislocation

Hip precautions can be extremely important in patients who have suffered intraoperative acetabular fracture. Much work has been done to minimize the surgical exposure during hip arthroplasty to decrease the risk of dislocation. These advantages are typically removed when acetabular stabilization need to be performed. A dislocation in the postoperative course of such a patient can be disastrous.

Patients are instructed to follow standard hip precautions against dislocation based upon the surgical approaches for hip arthroplasty.

Wound healing

Avoidance of edema postoperatively is critical for both wound healing and patient mobilization. This can be aided by pneumatic compression devices. If negative pressure wound therapy is utilized, it can be discontinued after 5 to 7 days. Staples or sutures are typically removed at 14 to 21 days.

Pneumatic compression device