Bone graft from greater trochanter in posterior wall fractures with impacted fragments
© The Author(s) 2014
Received: 22 November 2013
Accepted: 5 March 2014
Published: 27 March 2014
Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.
Materials and methods
Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.
The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.
Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.
Level of evidence
KeywordsPosterior wall fractures Impacted fragment Bone loss Autograft Hip dislocation Intra-articular fragments
Posterior acetabular wall fracture is the most common type of acetabular fracture [1–9], accounting for 47 % of total acetabular fractures, according to Letournel and Judet . The majority of posterior wall fractures are comminuted with impacted fragments [10–12], usually in the elderly population. This fracture usually occurs in association with posterior hip dislocation, which leads to displacement of bone fragments [2, 13, 14]. According to the Judet classification, this fracture can be divided into two types. The first type includes free fragments or fragments attached to the joint capsule. The second type includes impacted fragments, with or without bone loss . Comminuted fractures are usually seen in females over 50 years old and in elderly populations due to osteoporosis which increases bone fragility [15–17]. The reconstruction of the posterior wall is technically demanding. This can be more complicated when more than 50 % of the joint surface is involved, which may lead to hip joint instability [1, 6, 11, 12]. Many studies also emphasize the importance of the surgeon’s experience; it has been demonstrated that 19–25 % of fair or poor results may occur following surgeries performed by experienced surgeons, whereas this may increase to 55–56 % when the surgery is performed by less experienced surgeons [4, 18–20]. The aim of this study was to assess the results of the surgical technique for the treatment of comminuted posterior acetabular wall fracture in association with an impacted segment using an autogenous trochanteric bone graft.
Materials and methods
Patient’s demographic and fracture characteristics
Mechanism of injury
Time of hip reduction
Fall from height
5 Days after trauma
Fall from chair
Within 6 h of injury
Within 6 h of injury
Within 6 h of injury
Within 6 h of injury
Within 6 h of injury
The clinical results according to Merle d’Aubigne and Postel scoring modified by Matta were as follows: excellent (=18 points) in one case, very good (=17 points) in four cases, good (15–16 points) in four cases, poor (<13 points) in one case.
Number of patients
Excellent (=18 points)
Very good (=17 points)
Good (=15–16 points)
Poor (<13 points)
Radiologic criteria of Matta 
Number of patients
Excellent (normal hip joint)
Good (joint narrowing less than 1 mm)
Poor (advanced joint change)
Comminuted fracture in association with an impacted segment of the posterior wall occurs following femoral head dislocation, or when it sinks into the acetabulum, causing compression of the trabecular bone and consequent bone loss. A CT scan is indicated in any cases of acetabular fracture or hip dislocation. Due to inefficiency of plain X-ray alone to recognize the impacted segment or intra-articular fragments, a CT scan must be performed to provide a more accurate assessment of the fracture pattern.
The patient should be treated surgically within 7–10 days following the trauma, in order to get a good reduction. After 10 days, fibrous callus formation may make the surgical reduction less effective. In addition, early consolidation of impacted fragments can occur and may lead to a misdiagnosis of this type of fracture, which can result in malunion.
After the reduction of the fragments, different materials may be used to fill the bone defect, including artificial bone substitutes and allograft or autogenous cancellous bone grafts.
It is important to consider the mechanical properties of the material that is used to fill the gap. Inability of the substituted material to provide good mechanical properties leads to collapse of the graft following weight-bearing. This may result in impacted fragment reduction failure and nullifies the benefits of surgery. From a mechanical point of view, artificial or synthetic bone substitutes possess good osteointegrative and conductive properties; however, being completely reliant on viable periosteum/bone and the higher costs with respect to other options limits the use of artificial bone substitute [25–27]. The frozen allograft also provides good mechanical and biological properties, although the risk of infection and disease transmission remain the main concerns when using these grafts [28, 29]. An autogenous graft has by far the most osteogenic potential and in our opinion is the best choice for filling a bone defect in cases of comminuted fractures in association with an impacted segment. The autogenous graft may be harvested from the iliac crest near to the posterior superior iliac spine [30, 31] or from the greater trochanter. A second incision is required to take the graft from the iliac crest, which may add other complications such as irritation of the donor site in the following months [32–35]. Harvesting the graft from the greater trochanter does not need another surgical incision, and in our experience the graft provides good quality properties without resulting in any severe complications or donor-site pain. In our series we did not encounter any notable complications related to this surgical technique. However, femoral head necrosis was observed in one case due to non-reducible posterior hip dislocation in an 89-year-old patient without any relation to surgical technique. The best choice for the diagnosis of femoral head necrosis may be MRI, but the presence of metallic implants (plate) near to the hip joint can cause substantial image artifacts in MRI which make the diagnosis of femoral head necrosis very difficult or even impossible. We made the diagnosis using plain X-ray and CT scan. This surgical technique which uses trochanteric autogenous bone grafts provides good functionally and radiographically results. We believe that this technique can be safe and has a low risk of severe complications for the treatment of posterior acetabular wall fracture with impacted segments and bone defects. However, this study was clearly limited due to the small number of cases and the absence of a control group. The efficacy of this surgical technique needs a study with a longer follow-up to demonstrate osteoarthritic changes of the hip joint following this procedure.
Conflict of interest
All patients gave informed consent prior to being included in the study. The study, authorized by the local ethical committee, was performed in accordance with the ethical standards of the 1964 Declaration of Helsinki as revised in 2000.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.
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