Injury, Int. J.

Care Injured 41 (2010) 339342

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Mapping the columns of the acetabulumImplications for percutaneous xation

Abdulsalam Shahulhameed a, Craig S. Roberts a,*, Christopher L. Pomeroy a,
Robert D. Acland a, Peter V. Giannoudis b
a
University of Louisville, Department of Orthopaedic Surgery, 210 East Gray Street, Suite 1003, Louisville, KY 40202, USA
b
University of Leeds, Department of Orthopaedic Surgery, Beckett Street, Leeds LS9 7TF, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Knowledge of the bony thickness of the acetabular columns is one requisite for safe execution of
Accepted 3 August 2009 percutaneous xation of acetabular fractures. We performed a cadaveric study to determine
anatomical dimensions of the columns of acetabulum with reference to percutaneous screw xation.
Keywords: Twenty-two hemipelves (11 pairs) from 6 male and 5 female cadavers were measured and statistically
Columns analysed.
Anterior In the anterior column, the psoas groove displayed the least vertical thickness of 15.1 mm (range,
Posterior
12.118.2 mm), followed by the obturator canal with 15.9 mm (range, 12.220.6 mm). The mean
Acetabulum
thickness of the posterior column wall of the acetabulum along the screw path displayed 21.3 mm
(range, 16.530.3 mm). This study provides a clinical map for safe passage of both antegrade and
retrograde percutaneous screws. Anatomic data suggests that 7.3 mm cannulated screws can be safely
accommodated by the anterior and posterior columns of the acetabulum.
2009 Elsevier Ltd. All rights reserved.

Introduction Materials and methods

Open reduction and internal xation is the standard treatment
for displaced fractures of the acetabulum.2,47 However, extensive
surgical approaches are associated with infection, neurovascular
injury, heterotopic ossication, avascular necrosis of the femoral
head, and thromboembolism.2,4,6,7 Nonoperative treatment of bed
rest and traction is also associated with poor results.4
Percutaneous screw xation is an alternative approach with
satisfactory results reported for nondisplaced or minimally
displaced acetabular fractures in patients with severe soft tissue
injury, burns, and an increased risk for major surgery.3,811
However, this procedure is technically demanding and limited
by the adjacent neurovascular structures and narrow columns of
bone. Ebraheim et al.1 reported an anatomical study about the axis
of inclination for antegrade anterior column screw xation. To our
knowledge, there are no studies in the English literature that
measured the thickness of the anterior and posterior columns of
the acetabulum. The purpose of this study was to map and measure
the bony thickness of anterior and posterior columns of
acetabulum, with special reference to the technique of percuta-
neous screw xation of these columns.
* Corresponding author. Tel.: +1 502 852 6964; fax: +1 502 852 7227.
E-mail address: craig.roberts@louisville.edu (C.S. Roberts).
This was an Institutional Review Board-exempt study of 11
pairs of adult cadaveric pelves with a mean age of 77.8 years
(range, 6087 years) obtained through the bequeathal program at
a Level-I trauma centre. Causes of death included rectal cancer,
hypokalemia, pneumonia, lung metastasis, malignant melanoma,
Alzheimers dementia, chronic obstructive pulmonary disease,
ventricular brillation, acute myocardial infarction, breast cancer,
and lung cancer. There was no history of prior pelvic or hip
surgeries in any of the specimens.
All soft tissues were removed from the pelvis and the specimens
were stored in a freezer at 30 F to preserve tissue integrity before
measurement. Anatomic landmarks were marked with an indelible
marker based on locations there were relevant to percutaneous
xation.
A pilot study was performed in one hemipelvis by making 1 cm
sections of the anterior and posterior columns of the acetabulum in
a plane perpendicular to the surface of the bone. The thickness of
the wall in both the anteroposterior (AP) and vertical planes was
measured using a standard measuring caliper. On the other
hemipelvis, drill holes were made using a 2.5 mm drill bit at
identical points perpendicular to the surface of the bone. The depth
of these holes was measured using a small fragment set depth
gauge. Because both measurements were comparable, the decision
was made to measure the thickness of the data points by drilling
holes to simulate actual surgery.

00201383/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2009.08.004
340 A. Shahulhameed et al. / Injury, Int. J. Care Injured 41 (2010) 339342

Fig. 1. Anterior column. (A) The coronal plane thickness of the anterior column from anterior view (ab, vertical thickness at psoas groove; cd, vertical thickness at iliopectineal
eminence; ef, vertical thickness at the anterior horn; gh, vertical thickness at obturator canal; ij, vertical thickness at pubic tubercle; kl, vertical thickness at pubic symphysis).
(B) The transverse plane thickness of the anterior column from inlet view (mn, anteroposterior thickness at psoas groove; op, anteroposterior thickness at iliopectineal
eminence; qr, anteroposterior thickness at the anterior horn; st, anteroposterior thickness at obturator canal; uv, anteroposterior thickness at pubic tubercle; wx,
anteroposterior thickness at pubic symphysis). (C) Exit of anterior column screw in the retroacetabular area (z, exit point of anterior column screw in the retroacetabular
surface; yz, posterior distance from AIIS; zz0 , superior distance from the acetabular rim; ASIS, anterior superior iliac spine; AIIS, anterior inferior iliac spine).

Anterior column measurement
The starting point for the anterior column screw was marked at
the inferior border of the pubic tubercle in line with the superior
margin of the obturator foramen. We used the retrograde entry site
described by Starr et al.11 in their study of percutaneous xation. A
2.5 mm calibrated drill bit (Synthes, Paoli, PA), 200 mm in length,
was used to drill a hole along the centre of the anterior column
without entering into the hip joint or pelvic cavity. Once the drill
exited the retroacetabular surface, the exit point was marked and
its distance measured in relation to the rim of acetabulum and
anterior inferior iliac spine (AIIS). In all cases, the exit was along the
line that connected AIIS and greater sciatic notch. The length of the
drill hole was directly read from the drill bit. All measurements
throughout the study were repeated three times by the same
examiner and averaged.
Anatomical landmarks along the anterior column were chosen
based on locations that were considered relevant to percutaneous
screw xation. Fig. 1 shows the data points in the anterior column.
Measurements in both the AP and vertical axis were made at the
pubic bone near the symphysis, pubic tubercle, obturator canal,
anterior border of anterior horn, apex of iliopectineal eminence
and psoas groove. The AP measurements were made using dial
callipers (Sears Craftsman, Japan). The thickness of the bone in the
vertical axis was measured after drilling holes at the designated
points using a 2.5 mm (Synthes, Paoli, PA) drill bit and a standard

Fig. 2. Posterior column. (A) Lateral view of the posterior column (ab, depth of upper third posterior wall; cd, depth of middle third posterior wall; ef, depth of lower third
posterior wall; gh, depth of ischial tuberosity). (B) Posterior view of the posterior wall (ij, width of upper third of posterior wall; kl, width of middle third of posterior wall; mn,
with of lower third of posterior wall; op, width of ischial tuberosity; qr, length of ischial tuberosity). (C) Exit of posterior column screw (t, exit of posterior column screw in the
iliac fossa; st, distance from SI joint; tu, distance from pelvic brim).
 A. Shahulhameed et al. / Injury, Int. J. Care Injured 41 (2010) 339342 341

mini-fragment depth gauge (Synthes, Paoli, PA). The thickness was Table 2
Anteroposterior thickness of anterior column (mm).
measured to the nearest 0.1 mm.
Reference points N Minimum Maximum Mean S.D.
Posterior column measurement Pubic symphysis 22 8.9 19.3 14.682 2.9585
Pubic tubercle 22 10.2 23.5 16.886a 3.3713
The starting point for the posterior column screw was the Obturator canal 22 15.9 32.1 20.182 4.0682
centre of the inferior surface of the ischial tuberosity. This entry Anterior horn 22 22.8 36.9 29.132 4.0106a
Apex of iliopectineal 22 21.7 36.1 28.600 3.8888
site was chosen for consistency as described by Starr et al.11 The
eminence
same 2.5 mm  200 mm calibrated drill bit was drilled along the Psoas groove 22 32.2 44.8 38.186 4.0939
centre of posterior column and the exit at the iliac fossa was a
Statistically signicant side-to-side difference (p = 0.026).
marked. The distance of this exit point in relation to the sacroiliac
joint and pelvic brim was measured. The length of drill hole was
read directly from the drill bit. The average measurement of 3 Table 3
Vertical thickness of anterior column (mm).
readings was calculated.
Posterior wall dimensions were measured at 3 locations at the Reference point N Minimum Maximum Mean S.D.
upper, middle, and lower borders of the posterior wall. The upper Pubic symphysis 22 38.2 57.5 47.259 5.2142
border was at the level of the greater sciatic notch, the lower Pubic tubercle 22 11.9 20.1 15.932 2.9604a
border was at the level of the upper margin of ischial spine, and the Obturator canal 22 12.2 20.6 15.891 2.4146
middle border was located between the above two points. The Anterior horn 22 17.8 25.9 20.505 2.2351
Apex of iliopectineal 22 13.4 22.6 17.695 2.5440
width was measured using a standard caliper. The depth at the
eminence
above mentioned data points was measured after drilling a hole Psoas groove 22 12.1 18.2 15.114 1.8831
from the centre point into the hip joint using a 2.5 mm drill and a
Statistically signicant side-to-side difference (p = 0.029).
depth gauge. The length, width, and thickness of the ischial
tuberosity were measured with callipers. Fig. 2 shows the
reference points in the posterior column. Table 4
Dimension of posterior column reference points (mm).
For drilling, the pelvis was mounted vertically in an anatomical
position on the arthroscopic work table using a bone holding clamp Reference points N Range Minimum Maximum Mean S.D.
applied to the sacrum. Once the anterior column measurements IT length 22 15.9 46.2 62.1 53.886 4.7365
were completed, the pelvis was repositioned, the clamp was IT thickness 22 14.4 24.1 38.5 29.236 3.4806
applied to the pubic symphysis, and the posterior column IT depth 22 12.8 30.6 43.4 38.723 3.0270
measurements were made. PW upper part 22 12.6 45.6 58.2 51.264 4.1101
PW middle 22 12.6 37.8 50.4 43.959 3.6245
PW lower 22 11.7 42.1 53.8 46.618 3.0326
Statistical analysis PW upper thickness 22 13.2 17.1 30.3 22.909 3.0552
PW middle thickness 22 4.8 16.9 21.7 19.386 1.4708
Descriptive statistics were calculated for each data point and PW lower thickness 22 13.3 16.5 29.8 21.591 3.4779
the length of column. Wilcoxon signed rank test for side-to-side IT, ischial tuberosity; PW, posterior wall.
comparisons of line length and select reference point thickness
measurement were calculated using SPSS Version 16.0 (SPSS
Institute, Chicago, IL) for Windows (Microsoft, Redmond, WA). An and the vertical thickness of the pubic tubercle (p = 0.029) were the
a level of p < 0.05 was used to indicate statistical signicance. two reference points that showed statistically signicant side-to-
side difference. All of the other reference points failed to display
Results signicant side-to-side differences.

The mean length of the anterior column screw hole ranged from Discussion
10.5 to 13.2 cm, and the mean length of the posterior column screw
hole varied from 12.0 to 15.4 cm. Descriptive measurements for Our study suggested that the maximum vertical thickness along
anterior and posterior column screw hole lengths and points of exit the anterior wall was near the anterior horn (mean, 20.5 mm),
are shown in Table 1. There were no side-to-side statistically followed by the apex of the iliopectineal eminence (mean,
signicant differences in line length and exit points. Descriptive 17.69 mm). The least thickness was in the bony psoas groove
measurements for anterior and posterior column reference points (mean, 15.11 mm), the obturator canal (mean, 15.89 mm), and the
are shown in Tables 24. Although the posterior column reference pubic tubercle (mean, 15.93 mm). In terms of the AP width, the
points did not show any side-to-side differences, reference points anterior column narrowed beyond the anterior horn of the rim
in the anterior column were signicantly different (p = 0.026) (radiological tear drop) by 3350% in the region of superior pubic
(Table 3). The AP width of the anterior wall near the anterior horn ramus. The mean measurement near the anterior horn was 2.9 cm,
which decreased to 1.52 cm for the remaining portion of superior
Table 1
pubic ramus. However, the thickness of the bone was found to be
Dimensions of anterior and posterior columns (cm). sufcient to accommodate a 7.3 mm cannulated screw.
Ebraheim et al.1 in an anatomic study described the angle of
Reference points N Minimum Maximum Mean S.D.
inclination for the axis of the anterior column screw, along with the
AC screw length 22 10.5 13.2 12.009 .8141 dimensions for the starting point in the retroacetabular area.
PC screw length 22 12.0 15.4 13.850 1.0211
However, details regarding the thickness of the anterior wall and
AC screw exit from rim 22 2.1 4.4 3.232 .5826
AC screw exit from AIIS 22 3.1 6.4 4.827 .8373 the superior pubic ramus were not provided. In our study, holes
PC screw exit from SI joint 22 3.0 4.9 3.959 .5198 were drilled across the entire length of the anterior column from
PC screw exit from pelvic brim 22 2.2 3.9 3.114 .4411 the pubic tubercle to the retroacetabular area to simulate the
AC, anterior column; PC, posterior column; AIIS, anterior inferior iliac spine; SI, clinical situation. In addition, we measured both vertical thickness
sacroiliac joint. and AP width of the anterior column to identify potential areas of
342 A. Shahulhameed et al. / Injury, Int. J. Care Injured 41 (2010) 339342
perforation of the cortex during screw insertion. During this
process, we identied the approximate starting point for both
antegrade and retrograde insertion of anterior column screws.
The anterior column screw may be inserted either in an
antegrade or retrograde manner as described by Starr et al.11 All of
our screw holes exited in the retroacetabular surface in line with
AIIS (mean, 4.8 cm posterior to the AIIS) and above the acetabular
rim (mean, 3.2 cm superior to the rim). Our observation is
consistent with the measurements described by Letournel and
Judet4 who recommended the starting point be located 34 cm
from the acetabular roof.
From the retroacetabular surface to the anterior horn (radio-
graphic tear drop), there is sufcient bony thickness for the
insertion of the anterior column screw. The exception is in the
region of the psoas groove (just medial to the AIIS), which showed
the least thickness. Beyond the anterior horn, the superior ramus
tapers both in the vertical and AP dimensions and is surrounded by
important neurovascular structures. Therefore, increased caution
is recommended to prevent perforation of the cortex and injury to
vital structures. We believe the psoas groove and the obturator
canal are the critical areas where there is the highest risk of screw
perforation of the cortex.
The posterior column screw may be inserted percutaneously in
a retrograde manner as described by Starr et al.11 Our study
provides dimensions for posterior column screw insertion from the
iliac fossa in an antegrade manner (Table 1). Although it is well
known that the retroacetabular area has sufcient bone stock for
screw insertion, this study provides measurements of the
thickness of the wall of the hip joint along the screw path.
There are limitations to our study. We used only 22 hemipelves
from 6 male and 5 female cadavers. The older age of the cadavers
and osteoporosis may have reduced the thickness of the bone, but
this would represent the worst-case scenario during actual
surgery. Although we used standard measuring instruments and
adopted uniform techniques, the curved dimensions of the
acetabular column may have contributed to some measurement
error. However, we believe we were able to minimise this potential
problem by reproducibly making measurements in two anatomical
planes, and averaging 3 readings for each data point.
In conclusion, this study provides anatomic measurements of
bony thickness for both the anterior and posterior columns of the
acetabulum for antegrade and retrograde percutaneous screw
xation. For the anterior column, the anterior wall at the level of
anterior horn and the iliopectineal eminence displayed the
maximum thickness. The bony psoas groove (just medial to AIIS),
obturator canal, and pubic tubercle showed the least vertical
dimensions. Beyond the anterior horn of the acetabulum (tear
drop), the superior ramus tapers in both planes which warrants
extra precautions as important structures are present on either
side of the ramus. There is also sufcient bony thickness for the
posterior column screw to be safely inserted from either the
retrograde or antegrade direction without penetration into the hip
joint. An understanding of the anatomical constraints of the bony
thickness of the columns is a requisite to safe percutaneous
insertion of both anterior and posterior column screws.
Conict of interest
The authors acknowledge institutional support provided by
Synthes.
Acknowledgements
The authors thank Mr. Troy, L. Nukes and Mr. Stephen Anderson,
coordinators of the Bequeathal Program, for their assistance with
the cadaver dissections.
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