2.10.4 Surgical management of associated both-column fractures (type C)

1 Introduction

Among the associated fracture patterns discussed in Chapter 2.3, both-column fractures are initially the most difficult to understand. This category encompasses a relatively diverse group of injuries linked by a common dissociation of the anterior and posterior columns and loss of any articular continuity with the intact ilium. Medial displacement of the posterior column and medial/cranial displacement of the anterior column by the femoral head produce an image of the intact iliac remnant on the obturator oblique x-ray that Letournel termed the “spur sign” (see Chapter 2.4). Detailed analysis of the fracture patterns within this group is critical for all steps in the treatment pathway, from surgical approach choice to reduction and fixation strategies.

The most useful primary distinction among these fractures is the morphology of the iliac extension of the anterior column component. Letournel [1] made a distinction between fractures ( Fig 2.10.4-1a, b, and d ) where the anterior column extends to the iliac crest and fractures that exit distal to the anterior inferior iliac spine ( Fig 2.10.4-1c ). Although fractures where the anterior column extends to the iliac crest predominate in most clinical series [1–3], a wide variability exists in the number and complexity of secondary fracture planes within the anterior column. As a rule, the low anterior column fractures are surgically more challenging due to reduction difficulties with a smaller anterior column and articular restrictions on implant placement.

The level and orientation of the posterior column fracture also must be carefully evaluated. In most cases the posterior column fracture exits through the cranial portion of the greater sciatic notch, whereas obliquity in the coronal plane is more variable. Other important injury variants include patterns where there is fracture involvement of the inferior portion of the sacroiliac joint, segmental fracture of the posterior column, or significant displacement of an associated posterior wall component. Ipsilateral or contralateral pelvic ring injuries can also be confounding variables. Additionally, as our population ages, there appears to be a trend toward an older demographic distribution of both-column fractures with associated bone density issues and more comminution. Radiographic diagnosis of these injuries can be taxing and should use all the plain radiographic and computed tomographic imaging modalities discussed in Chapter 2.4. This analysis must include not only detailed study of fracture morphology but also displacement and congruency assessment, which form the basis of decisions on surgical intervention discussed in Chapter 2.5.

2 Patient selection/indications

Virtually all displaced associated both-column acetabular fractures are optimally treated surgically. However, local and remote associated injuries and patient comorbidities may affect the timing and goals of intervention. Temporizing skeletal traction may provide some indirect reduction benefit via ligamentotaxis when surgical delay cannot be avoided and is generally most effective when applied early. Soft-tissue considerations, such as local abrasions, open wounds, degloving injury, suprapubic catheters, and colostomies, can mandate staged management in an attempt to limit the potential complications inherent in these clinical scenarios. Secondary congruence as discussed in Chapter 2.5 is a rare indication for nonoperative treatment and requires close follow-up to verify maintenance of acceptable position.

3 Preoperative planning

Accurate radiographic diagnosis, as outlined above, forms the basis for all decision making. This allows an informed approach choice and provides the context for all operating room planning including table choice, imaging modalities/access, instrumentation/implants, anesthesia, and assisting personnel. A thorough mental surgical “rehearsal” of multiple different reduction and fixation strategies should be routine and may ultimately be augmented with virtual surgery planning software.

**Fig 2.10.4-1a–d** Associated both-column fracture variants.

4 Surgical techniques

4.1 Surgical access/approach choice

Fracture pattern is the predominant consideration in surgical approach choice. Many approach alternatives have been proposed to provide exposure for associated both-column injuries. However, most of these fractures are still optimally managed via an ilioinguinal approach [1] (Chapters 2.7 and 2.8). Other anterior approach alternatives have become more popular in the last 10–15 years, most notably the modified Stoppa [4]. This approach is essentially the equivalent of the first and third windows of a standard ilioinguinal dissection. Omitting the second window may be appealing in cases of prior inguinal canal surgery, but there remain fracture patterns where the full exposure is crucial to obtaining an anatomical reconstruction. It is pivotal to remember that joint reduction via this approach lacks direct articular assessment possible via other approaches. It is based on sequential anatomical reductions building from the periphery of ilium toward the joint, supplemented by intraoperative imaging. When this strategy appears unrealistic on the basis of careful preoperative planning, approach alternatives must be considered. These include sequential ilioinguinal/Kocher-Langenbeck [1] approaches with the second approach for management of unacceptable residual posterior wall (or column) displacement after completion of the anterior approach. The extended iliofemoral [1] approach remains useful in younger patients with fractures involving the inferior sacroiliac joint or having complex (segmental) posterior column with or without associated posterior wall involvement. Last, the extended ilioinguinal approach [5] can also be considered in variants when the caudal portion of the sacroiliac joint is involved. Surgeon specific experience with a given approach may either expand or contract the range of indications.

5 Operating room logistics/patient positioning

Intraoperative imaging needs should be anticipated and whenever possible C-arm image intensifier units should be positioned opposite the side of injury prior to surgical preparation and draping. Additionally, adequacy of all necessary imaging projections should be verified before starting the procedure. Operating room personnel traffic should be kept to a minimum. Because most both-column fractures are operated through the ilioinguinal approach, routine pharmacological skeletal muscle paralysis should be used until abdominal wall closure has been completed at the end of the procedure. Positioning obviously varies with approach chosen and table availability as well as surgeon preference. Derivatives of the Judet table have clear advantages for the standard approaches (Kocher-Langenbeck, ilioinguinal, extended iliofemoral). The table is a primary reduction aid via the use of distal and lateral traction ( Fig 2.10.4-2, Fig 2.10.4-3 ). The use of other fracture extension tables has limited utility for these injuries because of design and safety issues. When the Judet (or other equivalent) fracture table is unavailable, the optimum positioning for the ilioinguinal is illustrated in Fig 2.10.4-4 . A completely radiolucent table is desirable. An advantage of this setup is the increase in hip mobility, particularly in flexion. This increases the exposure through the lateral wound interval and also provides easier access through the lateral wound interval and also provides easier access through the second wound interval between the neural and vascular compartments. Traction in this setting is provided using manual or distractor force through a percutaneously placed proximal femoral Schanz screw ( Fig 2.10.4-5 ). This logistical scenario is useful for the modified Stoppa as well. Use of sequential Kocher-Langenbeck or extensile approaches requires prone or lateral decubitus positioning that can be achieved on either the Judet table or a standard radiolucent table with the leg prepared and draped free.

**Fig 2.10.4-2** Fracture table logistics for ilioinguinal approach to an associated both-column fracture.

**Fig 2.10.4-3** Previous patient with distal/lateral traction attachment applied.

**Fig 2.10.4-4** Alternate patient positioning with the lower abdomen and injured hindquarter prepared into a single field on a radiolucent flat top table.

6 Reduction and fixation

Closed reduction and percutaneous fixation has limited if any role in the management of these injuries.

Open reduction and internal fixation through an ilioinguinal approach is recommended.

Figures 2.10.4-2 through 38 provide an overview of common reduction and fixation techniques through an ilioinguinal approach. The first step in this sequence is perfect reduction of the anterior column to the intact ilium. The most common errors in this reduction are rotational, with failure to restore the normal concavity of the internal iliac fossa. This critical initial malreduction compounds with subsequent reduction of secondary anterior column and posterior column fracture components, ultimately dooming the reconstruction to varying degrees of surgical secondary congruence that have been shown not to provide outcomes as durable as anatomical reconstruction [1–3, 6]. Both iliac comminution and posterior extension of the anterior column fracture leaving a small intact iliac segment can increase the complexity of anterior column reduction.

Control and reduction of the posterior column via the ilioinguinal approach can be compromised by segmental posterior column involvement and patterns that involve the inferior aspect of the sacroiliac joint. Atypical patterns that involve significant posterior wall moieties or marked articular comminution also present special challenges.

**Fig 2.10.4-5** Patient setup as in prior picture but with an alternate form of distal/lateral traction via a table attachment accepting a femoral distractor. Since there is no counter traction here via a perineal post, it may be necessary to attach the contralateral hemipelvis and proximal femur to the table via Schanz screws and external fixator or equivalent.

Acetabular fracture surgery is an instrumentation-intensive and implant-specific discipline. Nonetheless, initial reduction strategies for both-column fractures rely on relatively simple distal and lateral traction. In most cases the capsular attachments to both columns are intact and provide an indirect realignment, particularly when this can be achieved in the acute setting before clot and granulation tissue become an impediment. This provides one of the rationales for interim skeletal traction pending definitive surgical treatment. Incomplete fractures can limit the effect of traction because they typically represent a stable fracture displacement. These patterns most often involve the anterior column extension to the crest. The anterior column is hinged at the crest and is displaced along the pelvic brim cranially and posteriorly, thus frequently overlapping the intact ilium. This deformity can be difficult to overcome, even with the use of large tong reduction clamps that span the ilium from the displaced portion of the pelvic brim to the intact (lateral) supraacetabular surface. Additional use of a Schanz screw placed in the area of the anterior inferior iliac spine may be of help as a manipulation aid. Occasionally, it may be necessary to complete this fracture at the crest to facilitate anatomical reduction. Although the incomplete fracture is usually oblique, the osteotomized extension can be made perpendicular to the crest. It is usually helpful to predrill the crest for tangential lag screw fixation before carrying out the osteotomy with a narrow chisel. This pattern then can be managed as the more typical complete anterior column extension to the crest. As noted, rotational malreduction must be avoided; this requires a limited external iliac exposure at the crest for full assessment. Temporary stabilization with clamps and/or K-wires then is replaced with lag or position screws, depending on fracture obliquity. Perimeter reconstruction plates also can be used for fixation but must be carefully contoured to avoid a secondary malrotation.

In concert with the iliac crest reduction, placement of a precontoured pelvic brim plate, either temporary or definitive, is an effective strategy. A single screw placed near the fracture margin into the intact ilium in the area of the sciatic buttress acts as a clamp initially. Ultimately, the plate can act as a buttress as well as an extended washer for screws placed into the posterior column. Alternately, the anterior column can be reduced at the pelvic brim with a tong clamp or picador and held with temporary wire fixation followed by short lag screws across the fracture obliquity just lateral to the brim. Once an anatomical reduction of the anterior column has been achieved, this fixation can be augmented by supraacetabular anterior to posterior lag or position screws. The typical implants used in most acetabular fractures are 3.5 mm variants. Self-tapping screws with slightly larger heads are useful and malleable reconstruction plates are the norm. Larger implants are reserved for cases of significant osteoporosis but should be readily available if needed. Recently introduced locking plates hold some promise for this group.

**Fig 2.10.4-6** Relative common associated both-column fracture with free pelvic brim fragment, intercalary iliac crest segment, and segmental anterior column component.

**Fig 2.10.4-7** Typical displacements—posterior column medial, anterior column medial, and anterior.

**Fig 2.10.4-8** Effect of distal and lateral traction in the acute setting. Preliminary reduction is indirectly largely through the intact capsule and labral complex.

**Fig 2.10.4-9** Preserve, reduces, and temporarily stabilizes pelvic brim fragment(s). This can be done with K-wires or small/mini-fragment screws placed, so that they will not interfere with subsequent pelvic brim plate placement.

**Fig 2.10.4-10** Reduction builds from the iliac crest toward the joint. The Weber clamp (pointed reduction forceps) is the primary aid.

**Fig 2.10.4-11** Avoidance of malrotation is critical. Small malreductions will amplify toward the joint as the sequence progresses.

**Fig 2.10.4-12** A second clamp (Farabeuf or small Weber) place near the fracture may be necessary to counter rotation or shearing secondary to obliquity.

**Fig 2.10.4-13** One or two 3.5 mm screws provide stability either in lag or position mode depending on fracture orientation. In some cases a pelvic reconstruction plate along the perimeter or internal surface of the iliac crest may be appropriate.

**Fig 2.10.4-14** Primary anterior column reduction to intact ilium. Initial control is provided by a Farabeuf or percutaneously placed Schanz screw.

**Fig 2.10.4-15** Fracture obliquity may allow lag screw—predrill if applicable with the fracture displaced to provide ideal trajectory.

**Fig 2.10.4-16a–b** Useful for reduction by spanning from internal iliac fossa to lateral ilium through a small subgluteal exposure. This secondary exposure should be a formal sharp dissection to limit soft-tissue damage.

**Fig 2.10.4-17a–b** Alternate tong clamp placements.

**Fig 2.10.4-18a–c** A precontoured pelvic brim plate as reduction aid as well. A single screw placed in the intact innominate bone provides a clamp-like effect.

**Fig 2.10.4-19a–b** a The iliac crest reduction is stabilized with clamps while an initial lag screw is placed across the primary anterior column fracture. b The crest is then fixed with lag or position screws.

**Fig 2.10.4-20** Percutaneous screws (one or two) are placed (typically nonlagged due to fracture obliquity) from a starting point slightly lateral and distal to the anterior inferior iliac spine.

**Fig 2.10.4-21** Percutaneous screws (one or two) are placed (typically nonlagged due to fracture obliquity) from a starting point slightly lateral and distal to the anterior inferior iliac spine.

**Fig 2.10.4-22** Additional posterior plate fixation stabilizes the plate position on the pelvic brim.

**Fig 2.10.4-23a–b** Final in situ plate contouring can be achieved by plate-specific instruments or screwdrivers and a picador.

**Fig 2.10.4-24a–b** Posterior column reduction—Weber clamp from medial window (equivalent to modified Stoppa visualization).

**Fig 2.10.4-25a–b** Posterior column reduction—quadrangular clamp spanning from first to second window.

**Fig 2.10.4-26a–b** Posterior column reduction—asymmetric clamp with disc spanning from lateral ilium to quadrilateral surface, generally in the first window.

**Fig 2.10.4-27a–b** Posterior column reduction—asymmetric clamp after reduction.

**Fig 2.10.4-28** Posterior column reduction—small radius bone hook can be placed in the lesser sciatic notch to counter posterior displacement or residual medial rotation.

**Fig 2.10.4-29a–b** Posterior column reduction—colinear reduction forceps from internal iliac fossa to lesser sciatic notch through the first or second window.

**Fig 2.10.4-30a–b** The first screw placed to stabilize the posterior column is directed to exit the retroacetabular surface in an effort to close any remaining lateral fracture gap.

**Fig 2.10.4-31a–b** The second screw is directed tangential to the quadrilateral surface and typically ends in the ischium.

**Fig 2.10.4-32a–b** Screw exit points are circled. The screws are tightened in an alternating pattern in an to effort to gain uniform compression. These are usually lag screws that can safely be placed even though they are not perpendicular to the primary fracture place—they compress the posterior column into the “axilla” of intact innominate bone and reconstructed anterior column.

**Fig 2.10.4-33a–b** The low anterior column fracture plane is then reduced with a Weber clamp and fixation in the pubic body is completed.

**Fig 2.10.4-34a–b** In cases where additional posterior column fixation is deemed necessary an additional screw can be placed into the ischium, which travels through the acetabular fossa or is more anterior at the level of the obturator canal. The obturator neurovascular bundle must be protected during insertion and articular safety verified with image intensifier. Arrow indicates acetabular fossa.

**Fig 2.10.4-35** Representative final fixation construct.

**Fig 2.10.4-36a–b** In many cases when the fracture pattern includes a posterior wall component the displacement is modest and can be addressed by limited external iliac dissection and a spanning clamp followed by image intensification–verified lag screw from the internal iliac fossa to the posterior wall fragment. If these techniques are unsuccessful, a secondary Gibson or Kocher-Langenbeck approach for posterior wall component may be necessary.

**Fig 2.10.4-37** Case 1: AP x-ray of an anterior column. Letournel associated both-column fracture in an 18-year-old woman complicated by impacted fractures of the contralateral anterior pelvic ring and ipsilateral lateral compression sacral fracture.

**Fig 2.10.4-38a–d** Case 1: Computed tomographic volume-rendered Judet views and inlet/outlet 3-D projections.

After the primary anterior column fracture has been reduced and stabilized, attention is then turned to reduction of the posterior column that is usually medially displaced and rotated. Once again traction provides the initial reduction force. The final posterior column reduction can be achieved by a variety of methods. Clamps from the quadrilateral surface to the internal iliac fossa or external iliac surface can be placed from any of the three-wound intervals of the ilioinguinal approach or corresponding exposure for the modified Stoppa approach. Other methods include manipulation with a small bone hook placed into the lesser sciatic notch or cerlage wire passed around the innominate bone through the greater sciatic notch via a limited external iliac exposure. Imaging assessment of the reduction using multiple projections is helpful at this point to confirm an anatomical joint profile. Screw fixation of the posterior column is then carried out from the reconstructed pelvic brim, most often through the previously placed plate. The trajectory of these screws is adjusted based on the coronal plane obliquity of the posterior column fracture. For patterns where the fracture is relatively horizontal, these screws can be long and placed down the full length of the column. As fracture obliquity increases, the screw starting point may have to be moved lateral to the pelvic brim to facilitate an exit on the quadrilateral surface. In some cases, the screws may need to be placed percutaneously from an external iliac starting point to obtain the optimum orientation for rotational control. Whenever possible, screw placement through the cotyloid fossa should be avoided because of the relative imprecision of imaging verification of articular safety in this location.

Following completion of the posterior column fixation, remaining low anterior column and pubic fractures are reduced and stabilized to the pelvic brim plate. Final adjustments to the plate contour can be made in situ.

Quadrilateral surface involvement can be addressed with cortical substitution or buttress plates contoured from the internal iliac fossa over the pelvic brim or bridging to the intact sciatic buttress, if needed. However, this portion of the fracture pattern is typically extraarticular and primarily useful as an aid in assessing posterior column reduction. As such it is structurally not a critical component of the internal fixation construct. In these cases, oblique lag or position screws from the internal iliac fossa just lateral to the pelvic brim plate are adequate.

Cases 1–5 depict a representative variety of the challenges encountered with surgical management of associated both-column fractures ( Figs 2.10.4-39 through 72 ).