Main takeaway: Accurate reduction and safe implant placement in complex acetabular fractures can be enhanced by intra-operative O-arm navigation, enabling precise screw trajectories and confirmation of reduction while limiting soft-tissue morbidity.
A 33-year-old female sustained T type acetabular fracture involving anterior and posterior column after a road traffic accident. Definitive fixation comprised open reduction and anterior column plating with adjunct screw fixation in posterior column from anterior approach under O-arm navigation. Intraoperative 3D imaging enabled trajectory planning and immediate verification of reduction and hardware position. Early outcomes demonstrated maintained reduction and stable fixation on postoperative imaging. This report describes the indications, technique, and early postoperative course, and discusses the value of O-arm–assisted navigation for complex acetabular fracture surgery.
Acetabular fracture; anterior column; medial wall; O-arm; intra-operative 3D navigation; cannulated screw fixation;
A successful outcome in acetabular fracture management depends on the involvement of both columns.Fractures involving both columns require both columns require anatomical reduction and fixation of each column,necessitating two separate surgical approaches.Such cases also pose challenges in patient positioning during surgery. Two-dimensional fluoroscopy can be limited by pelvic overlap and variation in pelvic tilt, increasing the risk of intra-articular screw placement or insufficient fixation [2,3]. Intraoperative 3D imaging with O-arm and navigation provides multiplanar visualization for trajectory planning, real-time guidance, and immediate verification of reduction and implant position, potentially improving accuracy and safety while reducing soft-tissue dissection [7,9].
A 33-year-old female presented following a high-energy road traffic accident with left hip pain, inability to bear weight, and pelvic tenderness.Common peroneal nerve was involved in left lower leg resulting in foot drop. Initial radiographs and CT pelvis demonstrated: T type transverse acetabular fracture involving anterior and posterior column.
The patient was positioned supine on a radiolucent table.the patient had previously undergone a laparotomy through a pfannenstiel incision ,the medial (ilioinguinal) window could not be utilised. Therefore,exposure was achieved through a lateral window approach,which provided limited access to the acetabulum. Through a Iliofemoral approach the anterior column fracture was exposed and reduced and stabilized using reconstruction plate.Posterior column was reduced and held .Then a clamp was placed in this exposed iliac crest to hold the array.
O-arm acquisition was performed to obtain intraoperative 3D datasets. Navigation registration was completed, and planned screw trajectories were mapped to avoid the cotyloid fossa and femoral head [7,9]. cannulated screws were inserted along the planned paths to buttress the posterior column, with live navigation confirming Guide wire orientation and depth. A confirmatory O-arm spin verified extra-articular screw positions, maintenance of reduction, and appropriate hardware lengths.The screw position and reduction was confirmed with the available O arm. Intraoperative blood loss was modest; no complications occurred.
Deep venous thrombosis prophylaxis and multimodal analgesia were initiated. Hip range-of-motion exercises started on postoperative day along with bed side sitting. Gentle hip and knee assisted mobilization. Serial radiographs at early follow-up showed stable construct and preserved joint space. Intraoperative O-arm multiplanar reconstructions documented extra-articular screw placement and anatomic restoration of the anterior column and medial wall buttress. At subsequent clinical review, the patient demonstrated improving gait with minimal pain . No wound complications were observed.
Preoperative images:
This case highlights that combining anterior column plating with posterior column screw fixation through a single anterior approach under O arm navigation is a feasible and effective technique for T type acetabular fractures.Complex acetabular injuries require accurate reduction and stable fixation to minimize the risk of post-traumatic arthritis [1,4]. Anterior approaches allow direct reduction of the anterior column; however, addressing the posterior column can be challenging with conventional two-dimensional guidance due to limited visualization and overlapping anatomy [6]. O-arm navigation offers several advantages:
Multi planar planning and guidance for safe, extra-articular screw placement [7,9]
Immediate confirmation of reduction and implant position with a single spin
Potential reduction in fluoroscopy time and radiation to the surgical team
Minimization of additional exposures or extensive dissection for visualization
The construct in this case—rigid anterior column plate with navigation-guided screws buttressing the Posterior column —provides both column stability and subchondral support [5,8]. Postoperative 3D confirmation mitigates the risk of unrecognized intra-articular hardware, a key cause of poor outcomes in acetabular fixation [1].
Recent studies have demonstrated improved accuracy and reduced complications with computer-assisted navigation in acetabular fracture surgery [3,7]. The integration of real-time 3D imaging with surgical navigation represents a significant advancement in complex pelvic trauma management, allowing surgeons to achieve optimal reduction and hardware placement while minimizing surgical morbidity [9].
The anterior approach with O arm navigation guidance for fixation of both columns in T type acetabular fractures is a promising minimally invasive alternative to dual approaches ,offering accurate reduction and stable fixation with fewer complications. Intraoperative 3D navigation facilitates precise screw trajectories, confirms reduction, and may decrease complications associated with malpositioned implants [7,9]. Early results in this patient demonstrate stable fixation and satisfactory early clinical progress.
[1] Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results inpatients managed operatively within three weeks after the injury. J Bone Joint SurgAm. 1996;78(11):1632–1645.
[2] Hsu CE, Chang W, Hsu RW. Percutaneous fixation of acetabular fractures. Orthopedics. 2013;36(10):e1326–e1333.
[3] Keel MJ, Siebenrock KA, Romero J, et al. Computer-assisted fixation of acetabular fractures: a technique report. Injury. 2012;43(6):956–961.
[4] Maempel JF, Anderson IG, Chesser TJ. Current concepts: acetabular fractures. Orthop Trauma. 2020;34(5):291–298.
[5] Wiesel BB, Skeete K. Anterior column acetabular fractures: review and surgical techniques. J Orthop Trauma. 2021;35(Suppl 7):S35–S42.
[6] Moed BR. Minimally invasive techniques in acetabular fracture surgery. Injury. 2016;47(Suppl 1):S82–S88.
[7] Wang J, Zhang J, Zhang H, et al. Accuracy of minimally invasive percutaneous screw placement for acetabular fractures under intraoperative 3D imaging navigation. J Orthop Surg Res. 2022;17:563.
[8] Pryor GA, Patterson JT, Moed BR. External fixation and percutaneous screw fixation of acetabular fractures. J Orthop Trauma. 2017;31(Suppl 2):S10–S13.
[9] Harty M, Guevara CJ, KlattAE. Use of O-arm intraoperative 3D fluoroscopy in pelvic and acetabular fracture fixation. Orthopedics. 2019;42(3):e295–e300.
[10] Moed BR, Acharya AB, Rasouli MR, et al. Bilateral acetabular fractures: case report and review of the literature. Clin Orthop Relat Res. 2005;439:226–232.
Dr.Singaravadivelu D.Ortho, M.S.Ortho,PhD Senior Consultant & Academic Lead – Orthopaedic Surgery Kauvery Hospital, Alwarpet, Chennai.
Dr.Keerthivasan M.S.Ortho,DNB (Ortho),FISS Consultant Orthopaedic Spine Surgeon Kauvery Hospital, Alwarpet, Chennai.
Dr Aarif Raja Ortho 2nd Year PG Resident Kauvery Hospital, Alwarpet, Chennai.
