Reply to the comments of Li et al. to the article: Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall fracture

Abstract

We read your letter regarding our recently published article “Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall fracture” [1]. Posterior wall fractures are the most common acetabular fracture. Most posterior wall fractures are either comminuted or impacted. The soft tissues are frequently detached from the fragments at the time of injury or during the surgery. Primary osteosynthesis of such comminuted and/or impacted fractures involves elevation of the impacted fragments, reduction of the articular surface and filling the void with bone graft/bone graft substitute. The fragments are then buttressed with lag screws and reconstruction plate to support the elevated and comminuted fragments. However, gross comminution and displacement of the fragments along the margin and articular part of acetabulum (osteochondral fragments) makes the fixation difficult by this technique. The orientation of the fragments is also distorted and makes the surgeon frustrated to think of primary osteosynthesis. The main determinants of outcome after posterior acetabular wall fracture fixation are joint congruency and stability. Inability to maintain the congruency and stability will lead to arthritis sooner or later. It is difficult to achieve and maintain articular congruency and stability in severely comminuted wall fracture. In our report, we have described iliac crest strut graft fixation in severely comminuted posterior acetabular wall fracture. By this technique, the comminuted small fragments are excised, the joint is washed and the defect in the posterior wall is reconstructed with appropriately-matched iliac crest strut graft which is buttressed by lag screws and a reconstruction plate. This single piece of bone graft can better withstand axial force compared to multifragmentary posterior wall, even after buttressing with reconstruction plate. This is essential as the graft or bone fragments have to withstand axial loading immediately after surgery during the rehabilitation programme. Again, anatomical reduction of this single bone graft would be easier compared to multiple bone fragments.