Use of the Guardian table extension during periacetabular osteotomy is associated with an increased risk of intraoperative posterior column fractures.

The Guardian table is widely utilized for combined hip arthroscopy and periacetabular osteotomy (PAO) due to its postless traction design and the ability to perform both procedures without the need for redraping. This retrospective cohort study reports one surgeon's use of the Guardian table extension during combined hip arthroscopy and PAO and the occurrence of intraoperative posterior column fractures. Seventy-two consecutive PAO procedures performed at a single institution between February 2023 and January 2025 were analysed. Procedures involving concomitant hip arthroscopy (n = 26) utilized the Guardian table, whereas those without arthroscopy (n = 46) used a conventional radiolucent table. Patient demographics, clinical data, and complications were reviewed. Additionally, mechanical testing quantified table stability by measuring peak absolute acceleration ('table bounce') using accelerometry during simulated malleting. The incidence of intraoperative posterior column fractures was significantly higher with the Guardian table (4/26, 15.4%) compared to the conventional table (0/46, 0%; P = .0062). Mechanical testing demonstrated significantly greater table bounce for the Guardian table (69.1 ± 3.4 m/s2 versus 28.2 ± 4.4 m/s2, P < .001). Patient characteristics and surgical complexity did not differ significantly between fracture and non-fracture cases. These findings suggested that the Guardian table extension system was associated with increased risk of posterior column fractures, likely due to lack of distal support and stability. Surgeons should consider alternative table setups or intraoperative support modifications to mitigate this risk during PAO procedures.