Modified and new approaches for pelvic and acetabular surgery

A guideline for placement of an infra-acetabular screw based on anatomic landmarks via an intra-pelvic approach

BACKGROUND

Due to demographic changes, more and more fracture patterns involving anterior acetabular structures occur. The infra-acetabular screw is seen a useful tool to increase stability in fixation of the acetabular cup. However, the exact position of this screw in relation to anatomic landmarks which are intra-operatively palpable via an intra-pelvic approach has not yet been determined.

METHODS

This biomorphometric experimental study references the ideal screw position of an infra-acetabular screw to anatomic landmarks palpable via an intra-pelvic approach. Therefore, we created a computer tomography-based 3D-model of 40 patients (20 women, 20 men) who received a computer tomography (CT) scan of the pelvis for any other reason than an acetabular fracture.

RESULTS

The entry point of an ideal infra-acetabular was of high constancy. At mean, this point was 10.2 mm caudal and 10.4 mm medial of the ilio-pubic/ilio-pectineal eminence. This reference is independent of age, gender, or physical dimensions. However, we found gender-dependent differences for the angulation and the length of the screw.

CONCLUSIONS

This study provides a comprehensive guideline to determine the ideal entry point for an infra-acetabular screw via an intra-pelvic approach. The entry point is located 10.2 mm caudal and 10.4 mm medial of the ilio-pubic/ilio-pectineal eminence.

TRIAL REGISTRATION

Clinical Trial Registry University of Regensburg Z-2017-0930-1 . Registered 04. Dec 2017.

Outcome after Surgical Management of Acetabular Fractures: A 7-Year Experience

Objective

To determine the functional and radiologic results of surgical treatment in patients with acetabular fractures.

Methods

This was a retrospective cross-sectional study. We retrospectively reviewed medical records of patients operatively treated acute acetabular fractures at a level I trauma center (Shahid Rajaee) and an orthopedic center (Shahid Chamran) both in southern Iran (Shiraz) with minimally 1 year follow up over a period of 7 years from April 2009 to March 2016. Functional and radiographic outcomes, and complication were considered as main outcomes.

Results

A total number of 79 patients completed the study. Fifty-five patients were operated through Kocher-Langenbeck approach, and 18 were operated through the standard ilioinguinal approach, and 6 patients were operated through the standard ilioinguinal approach combined with Kocher-Langenbeck approach. The mean follow-up of patients was 45.6 months. The average operative time was 162.4±78.5 min, and the median blood loss was 500 ml. Functional results were excellent in 41 patients (51.9%), good in 12 (15.2%), fair in 13 (16.5%), and poor in 13 patients (16.5%). Radiologic results were excellent in 27 cases (34.2%), good in 17 cases (21.5%), fair in 18 cases (22.8%), and poor in 16 (16.5%). Osteoarthritis of hip (60.8%) and AVN of head of femur (22.8%) were two most common complications. In addition, there wasn't any significant difference between surgical approaches regarding clinical and radiographic outcomes.

Conclusion

The operative treatment for acetabular fractures gives universally satisfactory results. Thereafter, this study provides evidence that ilioinguinal approach is a good choice for anterior fractures, Kocher-Langenbeck is a good choice for posteriors fractures, and combined approach may be a good choice in the management of acetabular fractures involving two columns.

Biomechanical Comparison of Intrapelvic and Extrapelvic Fixation for Acetabular Fractures Involving the Quadrilateral Plate

OBJECTIVES

Elderly patients represent the fastest growing and most difficult to treat population sustaining acetabular fractures. When treated surgically, isolated extrapelvic or combined intrapelvic-extrapelvic constructs may be used. No biomechanical or clinical study has compared the merits of these 2 techniques in cadaveric models. This research aims to biomechanically quantify the additional benefit of intrapelvic fixation to a standard extrapelvic fixation construct.

METHODS

Ten cadaveric pelves underwent standardized anterior column and quadrilateral plate fracture creation. One hemipelvis from each subject received isolated extrapelvic fixation, whereas the other received adjunctive intrapelvic fixation. Specimens were then subjected to a 50% of body weight (BW) nondestructive stiffness test followed by loading to failure. For the 50% BW test, displacement at 50% BW and stiffness were calculated. For the load to failure test, stiffness, elastic energy, and plastic energy were calculated. Yield point, force at clinical failure (defined at 2 mm of displacement), and maximum force were also identified. A Wilcoxon matched-pairs t test was used to compare fixation groups.

RESULTS

The addition of an intrapelvic plate improved construct performance for all test parameters. A statistically significant difference (P < 0.05) was reached for yield force, maximum force, and plastic energy.

CONCLUSIONS

These findings demonstrate that the addition of intrapelvic plating may offer distinct advantages in prevention of catastrophic construct failure in situations in which significant lateral to medial force is applied to the greater trochanter such as patient falling.

Injury of the obturator nerve in the modified Stoppa approach for acetabular fractures

INTRODUCTION

The modified Stoppa approach for acetabular fractures has become popular. However, the possibility of injury to the obturator nerve with this approach has not been sufficiently considered. We have experienced a case of nerve entrapment in severely displaced fractures. Therefore, we performed a retrospective study to: (1) evaluate the incidence of obturator nerve injury in the modified Stoppa approach for acetabular fractures; (2) analyze the relationship between the extent of displacement of the quadrilateral plate and injury to the obturator nerve.

HYPOTHESIS

We hypothesized that obturator nerve injury would be related to a marked medial displacement of the quadrilateral plate.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 22 patients with acetabular fractures that were surgically treated with the modified Stoppa approach. The medial displacement of the quadrilateral plate was measured on a three-dimensional reconstruction image with the inlet view. Postoperative electrodiagnostic tests were performed based on clinical suspicion of neurological injury. Nerve injuries were divided into initial trauma or postoperative complication, and recovery of nerve function was evaluated. We identified the incidence of obturator nerve injury and analyzed the relationship between obturator nerve injury and medial displacement of the quadrilateral plate.

RESULTS

The incidence of obturator nerve injury was 2/22 (9.1%), and all injuries resulted from the initial trauma. The average displacement of the quadrilateral plate was 15.9±13.4mm. Patients were divided into two groups, using a displacement of 24mm as a cutoff point, identified using a receiver operating characteristic curve analysis. There were 16 patients in group 1 (<24mm) and 6 patients in group 2 (≥24mm). The incidence of obturator nerve injury from trauma was 0/16 (0%) in group 1 and 2/6 (33.3%) in group 2 (P=0.018).

CONCLUSIONS

No cases of postoperative obturator nerve injury were identified. Preoperative obturator nerve injury was more common in patients with a displacement of the quadrilateral plate≥24mm.

LEVEL OF EVIDENCE

IV, retrospective study.

Minimally invasive treatment of both-column acetabular fractures through the Stoppa combined with iliac fossa approach

Both-column fractures are the most complicated group of acetabular fractures. Although great progress of surgical technique has been made, the choice of approach is controversial. All the fragments could be exposed and managed through combined ilioinguinal and Kocher-Langenbeck (IL+KL) approaches, which has been widely used to conduct the both-column fractures. However, the clinical popularization may be restricted for high rate of complication. Most internal area of the hemipelvis could be exposed through Stoppa combined with iliac fossa (S+IF) approach. The majority of both-column fractures were managed through IL+KL approaches or S+IF approach in our institution. The comparison of the two surgical methods was done in this study. The purpose is to examine whether S+IF approach could achieve the satisfactory reduction and fixation for both-column fractures.

Minimally invasive plate osteosynthesis on anterior pelvic ring injury and anterior column acetabular fracture

INTRODUCTION

In performing surgery for fractures of the pelvis and acetabulum, various surgical approaches have been introduced with their own advantages and drawbacks. The extensile nature of ilioinguinal approach gives excellent exposure but was related to wound healing problems. Modified stoppa has a higher difficulty and poses a risk for neurovascular injury. In this study, we elaborate our experience using the Modified Stoppa approach with additional lateral window while adding few modifications to simplify the procedure and facilitate future implant removal.

METHODS

A prospective-retrospective cohort involving 30 anterior pelvic ring and/or anterior column acetabulum fracture patients were conducted from 2012-2016. Fifteen cases were prospectively treated using the modified approach since 2014, while the remaining fifteen cases that were treated using Ilioinguinal approach were retrospectively reviewed. Intraoperative parameters such as blood loss, duration of surgery, quality of reduction (Matta) and postoperative functional outcome (Majeed and Hannover score) at 12 months period were recorded and evaluated by a blinded reviewer.

RESULT

There were no significant differences between the two groups in mean age, sex and fracture type. The mean blood loss in the MIPO group were 325 ± 225 mL versus 710.67 ± 384.51 mL in the control group (p = 0.002). Duration of surgery were 149.33 ± 91.92 minutes in MIPO group versus 235.71 ± 65.79 minutes in ilioinguinal group (p = 0.014). There were no significant differences noted between the two groups in the quality of reduction and postoperative functional outcome, either by using Majeed or Hannover pelvic score. No complications were found after a 12-months follow up period. Two modified cases already had their implant removed and during the procedure, fibrotic tissue were minimal making the implant removal was less complicated and easier.

CONCLUSIONS

Modified stoppa and lateral window technique can be used as a safe and effective alternative approach for anterior pelvic ring fracture and/or anterior column acetabulum fracture. This approach decreased the duration of surgery and blood loss without compromising the quality of reduction and functional outcome in patients.

Internal fixation of acetabular fractures in an older population using the TIMI approach - Midterm results of a prospective study

INTRODUCTION

The incidence of geriatric acetabular fractures continues to increase due to demographic changes. In the elderly, anterior column fractures are common, and standard approaches are associated with a considerable risk for surgery-associated complications. Therefore, a minimally invasive approach was developed in our department. The aim of this study was to examine early and mid-term results regarding the use of this novel two-incision minimally invasive (TIMI) approach in patients aged over 55 years with acetabular fractures.

METHODS

From July 2007 to April 2014, 47 patients aged over 55 years were treated via the TIMI approach; these patients were included in the present prospective study. The patients' characteristics, data, and early phase of care were assessed during acute care. A radiological evaluation comprised pre- and postoperative CT scans and x-rays, including Judet views at follow-up. Follow-up examinations were performed after 6 and 24 months and comprised a clinical and radiological examination and an evaluation of hip function (Harris Hip Score) and health-related quality of life (EQ-5D).

RESULTS

The mean age of the patients was 74±11years, with a gender ratio of 35/12 (m/f). The average operation time was 93±30min, and perioperative blood loss amounted to 858±463ml. In total, five (11%) complications associated with the operative procedure occurred, and revision surgery was necessary in three patients. We observed no wound infections, abdominal wall hernias or cases of heterotopic ossification in our sample. The Harris Hip Score at six months after surgery was 81, and it slightly improved to 84 after 24 months. The mean EQ5D index was 0.91 at six months after surgery and 0.92 at 24 months after surgery.

CONCLUSION

The TIMI approach represents a valuable alternative to the ilioinguinal and modified Stoppa approach for the treatment of acetabular fractures located in the anterior column, which are often observed in geriatric patients.

LEVEL OF EVIDENCE

Therapeutic Level II (Prospective cohort study).

The origins and current applications of classic eponymous terms for pelvic and acetabular fractures: A historic review

We present the historical background of 5 eponymous terms in pelvic and acetabular injury treatment. The eponymous terms Duverney fracture, Malgaigne fracture, Judet-Letournel classification, Kocher-Langenbeck approach and Stoppa approach are discussed. After presenting the original description by the coining author, a short biography of the author is given. For each eponymous term the current clinical implication is given and discussed afterwards.

Surgical Treatment of Displaced Acetabular Fractures Using a Modified Stoppa Approach

A retrospective evaluation was performed of 36 patients (25 males and 11 females; average age, 44 years) with displaced acetabular fractures who were treated with a modified Stoppa approach. Fractures included 18 anterior columns, 2 both columns, 8 anterior columns with posterior hemitransverse, 6 transverse, and 2 T-type, according to the Judet and Letournel classification. Range of motion, Harris Hip Scores, and Merle d'Aubigné scores were evaluated. Pre- and postoperative measurements taken included displacements and gaps on axial, coronal, and sagittal computed tomography (CT) images and postreduction quality assessed radiologically. Mean follow-up was 14.7 months. Mean perioperative bleeding was 970 cc (range, 800-1250 cc). Mean Harris Hip Score was 77.9, mean Merle d'Aubigné score was 16.4, mean flexion was 105.2°, and mean extension was 16.9°. Anatomical reduction of the acetabular fracture was achieved in 29 (80.5%) patients; it was satisfactory in 5 (13.8%) and poor in 2 (5%). Mean preoperative displacements on axial, coronal, and sagittal sections were 4.1, 3.6, and 3.1 mm, respectively, and mean postoperative displacements were 0.2, 0.3, and 0.2 mm, respectively. Mean preoperative gap distance was 14.5 mm, and mean postoperative gap distance was 1.1 mm. Postoperative foot drop was observed in 2 patients, obturator nerve damage in 1, partial iliac vein damage in 1, and avascular necrosis of the femoral head in 1. Despite a steep learning curve, the modified Stoppa approach is a good alternative to the ilioinguinal approach. It can be used to treat many complex acetabular fractures.

3D surgical printing and pre contoured plates for acetabular fractures

We describe the methodical and possibilities of 3D surgical printing in preoperative planning of acetabular fractures showing a case of a 45-year-old with an associated transverse fracture of the left acetabulum with posterior wall fracture, with multiple fragments, and posterior ipsilateral hip dislocation, defending the do it your-self mode.

A combination of three-dimensional printing and computer-assisted virtual surgical procedure for preoperative planning of acetabular fracture reduction

OBJECTIVE

Treatment of acetabular fractures remains one of the most challenging tasks that orthopaedic surgeons face. An accurate assessment of the injuries and preoperative planning are essential for an excellent reduction. The purpose of this study was to evaluate the feasibility, accuracy and effectiveness of performing 3D printing technology and computer-assisted virtual surgical procedures for preoperative planning in acetabular fractures. We hypothesised that more accurate preoperative planning using 3D printing models will reduce the operation time and significantly improve the outcome of acetabular fracture repair.

METHODS

Ten patients with acetabular fractures were recruited prospectively and examined by CT scanning. A 3-D model of each acetabular fracture was reconstructed with MIMICS14.0 software from the DICOM file of the CT data. Bone fragments were moved and rotated to simulate fracture reduction and restore the pelvic integrity with virtual fixation. The computer-assisted 3D image of the reduced acetabula was printed for surgery simulation and plate pre-bending. The postoperative CT scan was performed to compare the consistency of the preoperative planning with the surgical implants by 3D-superimposition in MIMICS14.0, and evaluated by Matta's method.

RESULTS

Computer-based pre-operations were precisely mimicked and consistent with the actual operations in all cases. The pre-bent fixation plates had an anatomical shape specifically fit to the individual pelvis without further bending or adjustment at the time of surgery and fracture reductions were significantly improved. Seven out of 10 patients had a displacement of fracture reduction of less than 1mm; 3 cases had a displacement of fracture reduction between 1 and 2mm.

CONCLUSIONS

The 3D printing technology combined with virtual surgery for acetabular fractures is feasible, accurate, and effective leading to improved patient-specific preoperative planning and outcome of real surgery. The results provide useful technical tips in planning pelvic surgeries.

Internal versus external fixation of the anterior component in unstable fractures of the pelvic ring: pooled results from a systematic review

PURPOSE

Improving reduction of the pelvic ring improves long-term functional outcomes for patients. It has been demonstrated that posterior internal fixation is necessary to adequately control fractures to the posterior ring and there is evidence that supplementing this with fixation of the anterior ring improves stability. It is accepted that internal fixation provides greater stability than external fixation of the anterior ring but long-term differences in radiographic and functional outcomes have not yet been quantified.

METHODS

A search of electronic databases, reference lists and review articles from 1989 to 2015 yielded 18 studies (n = 884) that met our inclusion criteria. We included studies that discussed pelvic ring injuries in adults, reported functional or radiological outcomes or complications by anterior ring intervention and exceeded 14 patients. We excluded biomechanical and cadaver studies.

RESULTS

Internal fixation of the anterior pelvic ring had better functional and radiographic outcomes. Residual displacement of >10 mm was less common with internal fixation (ER 0.12, 95 % CI 0.06-0.24) than external fixation (ER 0.31, 95 % CI 0.11-0.62). Unsatisfactory outcomes also occurred at a lower rate (ER 0.09, 95 % CI 0.03-0.22) compared to external fixation (ER 0.32, 95 % CI 0.18-0.50). Losses of reduction (ER 0.02, 95 % CI 0.01-0.04 versus ER 0.07, 95 % CI 0.02-0.21), malunions (ER 0.03, 95 % CI 0.01-0.08 versus ER 0.07, 95 % CI 0.02-0.21) and delayed/non-unions (ER 0.02, 95 % CI 0.01-0.05 versus ER 0.04, 95 % CI 0.02-0.07).

CONCLUSIONS

Internal fixation of the anterior pelvic ring as supplementary fixation for unstable injuries to the pelvic ring appears to result in better radiographic and functional outcomes as well as fewer complications. However, data that separated outcomes and complications in relation to interventions of the anterior pelvic ring were limited. More studies looking specifically at outcomes in relation to the type of anterior ring intervention are needed.

Application of an innovative computerized virtual planning system in acetabular fracture surgery: A feasibility study

INTRODUCTION

Acetabular fracture surgery is amongst the most challenging tasks in the field of trauma surgery and careful preoperative planning is crucial for success. The aim of this paper is to describe the preliminary outcome of the utilization of an innovative computerized virtual planning system for acetabular fractures.

METHODS

3D models of acetabular fractures and surrounding soft tissues from six patients were constructed from preoperative CT scans. A novel highly-automatic segmentation technique was performed on the 3D model to separate each fracture fragment, then 3D virtual reduction was performed. Additionally, the models were used to assess potential surgical approaches with reference to both the fracture and the surrounding soft tissues. The time required for virtual planning was recorded. After surgery, the virtual plan was compared to the real surgery with respect to surgical approach and reduction sequence. A Likert scale questionnaire was completed by the surgeons to evaluate their satisfaction with the system.

RESULTS

Virtual planning was successfully completed in all cases. The planned surgical approach was followed in all cases with the planned reduction sequence followed completely in five cases and partially in one. The mean time required for virtual planning was 38.7min (range 21-57, SD=15.5). The mean time required for planning of B-type fractures was 25.0min (range 21-30, SD=4.6), of C-type fracture 52.3min (range 49-57, SD=4.2). The results of the questionnaire demonstrated a high level of satisfaction with the planning system.

CONCLUSION

This study demonstrates that the virtual planning system is feasible in clinical settings with high satisfaction and acceptability from the surgeons. It provides a viable option for the planning of acetabular fracture surgery.

Stoppa approach for intrapelvic damage control and reconstruction of complex acetabular defects with intra-pelvic socket migration: A case report

•

A novel surgical technique for reconstructing pelvic defects in hip revision surgery is described.

•

The Stoppa approach allows for pelvic damage control and reconstruction of bone defect.

•

The bone reconstruction is made by combining an intrapelvic plating with augmented socket reconstruction.

Introduction

Failed hip arthroplasty with intrapelvic acetabular migration can be challenging due to the potential damage of intrapelvic structures.

Presentation of the case

We present a case of a 75 year-old lady with failed hip arthroplasty with loosening of implants and intra-pelvic migration of the cup, antiprotrusio cage mesh, screws and plate. A modified Stoppa approach was performed, a part of the migrated elements were safely removed, the intrapelvic structures were controlled, and the bone defect was reconstructed through the Stoppa approach combined with the lateral window of ilioinguinal approach by means of bone struts and metallic plates, which is a novel technique. Then an extended posterolateral hip approach was done and the acetabulum was reconstructed using porous tantalum augments and morselized allograft. A cemented constrained socket was implanted. After one-year follow-up the patient is able to walk with one crutch without pain.

Discussion

Due to intrapelvic migration, the implants used in hip arthroplasty may become entrapped between the anatomical structures lodged in the pelvis and cause damage to them. A careful preoperative assessment and planning are mandatory. A migrated socket can be inaccessible through a conventional hip approach and removal could be very difficult and dangerous.

Conclusion

The Stoppa approach in hip revision surgery can be a complement to traditional approaches to control the intrapelvic structures, remove migrated implants of previous surgery and reconstruct the pelvic defect.

Digital anatomical measurements and crucial bending areas of the fixation route along the inferior border of the arcuate line for pelvic and acetabular fractures

Background

Better understanding of three-dimensional (3D) morphology of the pelvis at the area of inferior border of the arcuate line is very important, which could guide the surgeons to treat pelvic and acetabular fractures more efficiently. The objective of this study is to provide references for screw placement and design of anatomical internal fixators for the fixation route along the pelvic inferior border of the arcuate line.

Methods

Seventy five cases of computed tomography (CT) scan data were collected using Medical Image Database in Shanghai General Hospital between December 2009 and November 2010. 44 males and 31 females, aging from 21 to 91 years (average: 57.8 years) were enrolled. Using MIMICS 13.0, these data were used for three dimensional (3D) reconstructions of pelvic model. A curve from the pubic tubercle, along the inferior border of the arcuate line, to the sacroiliac joint was depicted and then divided into 11 equal parts. The measurements of whole length of the curve, the radius of the curvature and the thickness of bone at each decile point were performed, respectively.

Results

The thinnest bone thickness at acetabular area was 17.24 ± 2.90 mm and 9.94 ± 2.69 mm for male and female, respectively. The radius of curvature at the decile points 1, 8 and 10 were smaller compared with the surrounding points.

Conclusions

Using a screw shorter than 10 mm perpendicular to the bone surface along the inferior border of the arcuate line can avoid intra-articular screw penetration. There should be more recontouring of the plate at the areas of pubic tubercle and posterior edge of the acetabulum when placing a fixator along this fixation route. This study provides solid guidance for pelvic and acetabular surgeries as well as designing of anatomical fixators along inferior border fixation route at this area.

Surgical exposures and options for instrumentation in acetabular fracture fixation: Pararectus approach versus the modified Stoppa

BACKGROUND

As an alternative to the modified Stoppa approach, the Pararectus approach is used clinically for treatment of acetabular fractures involving the anterior column. The current study assessed the surgical exposure and the options for instrumentation using both of these approaches.

METHODS

Surgical dissections were conducted on five human cadavers (all male, mean age 88 years (82-97)) using the modified Stoppa and the Pararectus approach, with the same skin incision length (10cm). Distal boundaries of the exposed bony surfaces were marked using a chisel. After removal of all soft-tissues, distances from the boundaries in the false and true pelvis were measured with reference to the pelvic brim. The exposed bone was coloured and calibrated digital images of each inner hemipelvis were taken. The amount of exposed surface using both approaches was assessed and represented as a percentage of the total bony surface of each hemipelvis. For instrumentation, a suprapectineal quadrilateral buttress plate was used. Screw lengths were documented, and three-dimensional CT reconstructions were performed to assess screw trajectories qualitatively. Wilcoxon's signed rank test for paired groups was used (level of significance: p<0.05).

RESULTS

After utilization of the Pararectus approach, the distances from the farthest boundaries of exposed bone towards the pelvic brim were significantly higher in the false but not the true pelvis, compared to the modified Stoppa approach. The percentage (mean±SD) of exposed bone accessible after utilizing the Pararectus approach was 42±8%, compared to 29±6% using the modified Stoppa (p=0.011). In cadavers exposed by the Pararectus approach, screws placed for posterior fixation and as a posterior column screw were longer by factor 1.8 and 2.1, respectively (p<0.05), and screws could be placed more posteromedial towards the posterior inferior iliac spine or in line with the posterior column directed towards the ischial tuberosity.

CONCLUSION

Compared to the modified Stoppa, the Pararectus approach facilitates a greater surgical access in the false pelvis, provides versatility for fracture fixation in the posterior pelvic ring and allows for the option to extend the approach without a new incision.

Fixation of acetabular fractures via the ilioinguinal versus pararectus approach

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded.

A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans.

There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001).

These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach.

This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns.

Cite this article: Bone Joint J 2015;97-B:1271-8.

Digital anatomical measurements of safe screw placement at superior border of the arcuate line for acetabular fractures

Background

Screw penetration into hip joint is a severe complication during acetabular fracture surgery, which might result in osteoarthritis and chondrolysis. The purpose of this study was to obtain the safe and effective screw angles and lengths at acetabular area of the fixation route along the superior border of the arcuate line.

Methods

A total of 98 uninjured pelvises of Chinese adults were examined. Each person’s computed tomography (CT) scans were reconstructed to create a three-dimensional pelvic model. A curve of the fixation route was delineated and five cross-sections from the pubic tubercle to the sacroiliac joint direction were constructed perpendicularly to the curve. The minimum safe direction, which was tangent to the acetabulum, was measured in the middle three sections and then recorded as the angle α. The maximum effective direction, which was determined by a 14 mm arc and the quadrilateral surface, was also measured in the above sections and then recorded as the angle β. The maximum screw lengths for the five sections were measured.

Results

The ranges of safe and effective screw insertion angles for the 2nd, 3rd, 4th cross-sections were 21.09±13.57°~40.45±13.60°, 30.43±14.05°~47.54±12.67°, 23.84±11.60°~37.13±8.45°, respectively. The maximum screw lengths for the five sections were 15.89±3.80 mm, 58.83±27.66 mm, 42.94±22.41 mm, 72.43±6.73 mm, 40.99±6.33 mm. The male group showed significantly greater minimum safe angle compared to the female group in the 2nd, 3rd, and 4th sections (p<0.05).

Conclusions

The screw insertion at the acetabular area for the female requires greater minimum safe angle towards the quadrilateral surface than the male.

Modified Stoppa approach for surgical treatment of acetabular fracture

Background

We analyzed the extent of the comminution in the acetabular weight-bearing area, the clinical and radiographic results, and the complications after a minimum 2-year follow-up of the modified Stoppa approach for the treatment of acetabular fractures, and we attempted to evaluate the efficacy of the operative technique.

Methods

All of the 22 patients, who needed the anterior approach for the treatment of acetabular fractures at our hospital from November 2007 to November 2010, were subjected to surgery via the modified Stoppa approach. Fracture pattern, operative time, blood loss during the operation, quality of reduction, number of bony fragments in the acetabular weight-bearing area, and postoperative complications were assessed by retrospectively analyzing the medical records and the radiographic examinations. The results after the operation were analyzed based on the criteria of Matta.

Results

The clinical results were excellent in 3 cases, good in 13 cases, and poor in 4 cases, while the radiographic results were excellent in 5 cases, good in 13 cases, and poor in 2 cases. Although the quality of reduction and the clinical results according to the extent of comminution were statistically significant (p = 0.03 and p = 0.04, respectively), the radiographic results were not statistically significant (p = 0.74).

Conclusions

It can be concluded that the modified Stoppa approach could be used as an alternative to the classic ilioinguinal approach. In addition, comminution of the acetabular fracture was an important factor causing non-anatomic reduction and finally unsatisfactory clinical results.

Accuracy of reduction and early clinical outcome in acetabular fractures treated by the standard ilio-inguinal versus the Stoppa/iliac approaches

In acetabular fractures, the correct choice of the surgical approach is mandatory to achieve accurate reduction and to avoid complications. Anterior approaches include the ilio-inguinal, the Stoppa, the ilio-femoral and the para-rectal exposures. The first two are the most commonly used approaches nowadays. The aim of this study was to compare these two approaches. The standard three window ilio-inguinal approach was compared to the intra-pelvic Stoppa approach with an added iliac window. The study enrolled 54 patients. Patients were divided into two groups. The first group consisted of 33 patients presented with acetabular fractures and had ORIF starting with an ilio-inguinal exposure. This group was compared to a second group of 21 patients who were treated with the Stoppa/iliac window approach. All patients were treated by one surgical team. The accuracy of reduction, the early clinical results and the approach related complications were compared.

Evolution of the anterior intrapelvic (Stoppa) approach for acetabular fracture surgery

With their description of an approach that took advantage of the preperitoneal/retroperitoneal space to access the posterior pelvic ring, Hirvensalo et al and Cole and Bolhofner launched a series of developments that would complement the pelvic and acetabular surgeon's armamentarium in addressing injuries in this area. From this point on, additional contributors developed clinically relevant study designs to identify safety parameters and quantify expected outcomes and prognosis. The knowledge dissemination cycle has now extended to the development of instruments and implants to assist surgeons with this approach and to better serve patients.

Reduction of the posterior column in displaced acetabulum fractures through the anterior intrapelvic approach

The anterior intrapelvic approach can be used for the reduction and fixation of displaced fractures of the acetabulum. Reduction techniques and options for placement of fixation deviate to some degree from those used with the traditional ilioinguinal approach secondary to the surgeon's perspective and available vectors. Here, we present several techniques for the application of reduction clamps, reduction techniques, and fixation options for the posterior column in displaced fractures of the acetabulum treated through the anterior intrapelvic approach.

Clinical results of acetabular fracture management with the Pararectus approach

INTRODUCTION

To present the accuracy of reduction, complications and results two years after open reduction and internal fixation of displaced acetabular fractures involving the anterior column (AC) through the Pararectus approach. Frequencies for conversion to total hip replacement in the early follow up, the clinical outcome in preserved hips, and the need for an extension of the approach (1st window of the ilioinguinal approach) are compared to the literature about the modified Stoppa approach.

METHODS

Forty-eight patients (mean age 62 years, range: 16–98; 41 male) with displaced acetabular fractures involving the AC (AC: n = 9; transverse fracture: n = 2; AC and hemitransverse: n = 24; both column: n = 13) were treated between 12/2009 and 12/2011 using the Pararectus approach. Surgical data and accuracy of reduction (using computed tomography) were assessed. Patients were routinely followed up at eight weeks, 6, 12 and 24 months postoperatively. Failure was defined as the need for total hip arthroplasty. Twenty-four months postoperatively the outcome was rated according to Matta.

RESULTS

In four patients there were four intraoperative complications (minor vascular damage in two, small perforations of the peritoneum in two) which were managed intraoperatively. Fracture reduction showed statistically significant decreases (mean ± SD, pre- vs. postoperative, in mm) in “step-offs”: 2.6 ± 1.9 vs. 0.1 ± 0.3, p < 0.001 and “gaps”: 11.2 ± 6.8 vs. 0.7 ± 0.9, p < 0.001. Accuracy of reduction was “anatomical” in 45, “imperfect” in three. Five (13%) from 38 available patients required a total hip arthroplasty. Of 33 patients with a preserved hip the clinical outcome was graded as “excellent” in 13 or “good” in 20; radiographically, 27 were graded as “excellent”, four as “good” and two as “fair”. An extension of the approach was infrequently used (1st window ilioinguinal approach in 2%, mini-incision at the iliac crest in 21%).

CONCLUSION

In the treatment of acetabular fractures involving the anterior column the Pararectus approach allowed for anatomic restoration with minimal access morbidity. Results obtained by means of the Pararectus approach after two years at least parallel those reported after utilisation of the modified Stoppa approach. In contrast to the modified Stoppa approach, a relevant extension of the Pararectus approach was almost not necessary.

Treatment of acetabulum fractures through the modified Stoppa approach: strategies and outcomes

BACKGROUND

Since the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures.

QUESTIONS/PURPOSES

We evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d'Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united.

METHODS

Between September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9-59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys.

RESULTS

Merle d'Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united.

CONCLUSIONS

In agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Minimally invasive surgery (MIS) of anterior ring fracture combined with pubic symphysis separation

Background

The aim of this study was to evaluate the reliability of open reduction and minimally invasive plate osteosynthesis (MIPO) for anterior ring fracture combined with pubic symphysis separation and to explore the operative techniques and therapeutic efficacy.

Material/Methods

We used minimally invasive plate osteosynthesis (MIPO) to treat anterior ring fracture combined with pubic symphysis separation.

Results

During postoperative follow-up, all patients recovered well, with no fat liquefaction, infection, femoral nerve or iliac blood vessels injury, deep vein thrombosis, heterotopic ossification, or any and other complications.

Conclusions

The MIS or MIPPO for anterior ring fracture combined with pubic symphysis separation has the advantages of short operation time and less blood loss. This clinical operation is safe and feasible, with therapeutic efficacy.

The Stoppa approach versus the ilioinguinal approach for anterior acetabular fractures: a case control study assessing blood loss complications and function outcomes

BACKGROUND

The modified Stoppa approach was introduced to manage fracture of the anterior column instead of the ilioinguinal approach to reduce morbidity. However there is no clinical evidence to confirm its efficiency. Therefore this study was designed to ascertain: (1) if the Stoppa approach versus ilioinguinal allows less blood loss, (2) if functional and radiological results are superior to that of the ilioinguinal approach, (3) if the rate of complication was different.

HYPOTHESIS

The modified Stoppa approach allows less blood loss than the ilioinguinal in management of fractures of the anterior column of the acetabulum.

PATIENTS AND METHODS

Nineteen patients who were treated with the ilioinguinal approach (Group A) at a mean follow-up of 33 months and 17 patients who were treated with the modified Stoppa approach (Group B) at a mean follow-up of 28.9 months were retrospectively reviewed. Patients were called to the final follow-up examination, mean follow-up durations were set and the functional evaluation of patients was made with measurement of range of motion, Harris Hip Scores (HHS), and Merle D'Aubigné score.

RESULTS

Average blood loss was determined at a mean 1170 mL (range, 750-2150 mL) in Group A and at a mean 1110 mL (range, 450-2000 mL) in Group B (P=0.168). The mean HHS (group A=89.4 [73-99] and group B=88.4 [75-97]) and Merle D'Aubigné scores (group A=16.8 [13-18] and group B=16.5 [13-18]) showed no significant difference between the groups (P=0.169). At the final follow-up, the mean hip flexion was found to be 106.83 ± 12.47 and the hip extension was 10.33 ± 6.12 in Group A, while these values were 103.71 ± 14.32 and 10.69 ± 8.17 in Group B (NS between groups regarding flexion [P=0.678] and extension [P=0.445]). The complication rate was 31% in Group A (6 patients) and 23% in Group B (4 patients) (P>0.05).

DISCUSSION

Both surgical approaches give successful results in the treatment of acetabular fractures. Contrary to expectations, there was no difference in the amount of bleeding at the wound site from the Stoppa technique, even though it is minimally invasive, compared to the ilioinguinal approach.

LEVEL OF EVIDENCE

Level III retrospective case control study.

Comparison of acetabular fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified Rives-Stoppa) surgical approaches

OBJECTIVE

To compare the reduction quality, surgery time, and early postoperative complications between the 2 following surgical approaches: the ilioinguinal and the anterior intrapelvic (AIP or modified Rives-Stoppa).

DESIGN

Retrospective study.

PATIENTS

Comparison of 122 patients operated in our center between 1996 and 2003 with the ilioinguinal approach and 103 cases operated between 2004 and 2011 with the AIP approach.

SETTING

Level 1 trauma center, acetabular fracture surgery referral center.

OUTCOME MEASUREMENT

The patients' demographics, fracture type, fracture reduction quality, surgery time, and postoperative complications were compared.

RESULTS

Anatomic reduction was achieved in 84 patients (68.9%) treated by the ilioinguinal approach and in 85 patients (82.5%) treated by the AIP approach (P = 0.018). In both the columns, acetabular fracture type anatomic reduction was achieved in 54.2% of the ilioinguinal group and 79.4% of the AIP group (P = 0.018). In the ilioinguinal group, surgery time decreased as the number of surgeries increased (P = 0.021), whereas a similar trend was not found in the AIP group. Fracture type distribution and complication rates were similar for both the groups.

CONCLUSIONS

The AIP approach is a safe alternative that offers better exposure and possibly improved reduction quality of acetabular fractures compared with the ilioinguinal approach. We believe that the major advantage of the AIP approach is that it enables reduction of the posterior column and the quadrilateral plate from the contralateral side and enables application of a buttress plate below the pelvic brim.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

INTRODUCTION

Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation.

METHODS

This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients.

RESULTS

The average time to operation was 4 days. Average blood loss was 110mL. Operative time averaged 95min. Maximum fracture displacement averaged 10mm preoperatively and 1.3mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d'Aubigné score, functional outcome was good to excellent in all patients.

DISCUSSION AND CONCLUSION

Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures.

The Ilioinguinal Approach versus the Anterior Intrapelvic Approach to the Acetabulum: A Review

The ilioinguinal approach (IIA) to the acetabulum has been used as a golden standard for fifty years to treat “anterior” acetabular fractures. Since its introduction by Hirvensalo and Cole, the anterior intrapelvic approach (AIPA) has been adopted by some surgeons, whilst others remain devoted to the IIA. IIA is routinely used in the Republic of Macedonia. The aim of this study is to present a review of literature for two different anterior approaches for the treatment of acetabular fractures used in modern day surgery, focussing on AIPA and its priorities and comparing it to IIA.We performed a search, mainly electronically, and retrospective analysis of existing literature. We have identified and selected two representative and well-systematized papers for IIA, and six for AIPA. We presented the advantages and disadvantages, priorities and weaknesses of both approaches separately, comparing complications, risks and results. Based on the facts presented regarding the advantages of AIPA with a focus on visualization, accessibility and biomechanical justification, the approach should be implemented in our everyday practice and we are comfortable in stating this preference, especially due to the fact that upon comparison of the complication rate there is no significant difference between the two approaches.

Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach

INTRODUCTION

Data concerning outcome after management of acetabular fractures by anterior approaches with focus on age and fractures associated with roof impaction, central dislocation and/or quadrilateral plate displacement are rare.

METHODS

Between October 2005 and April 2009 a series of 59 patients (mean age 57 years, range 13-91) with fractures involving the anterior column was treated using the modified Stoppa approach alone or for reduction of displaced iliac wing or low anterior column fractures in combination with the 1st window of the ilioinguinal approach or the modified Smith-Petersen approach, respectively. Surgical data, accuracy of reduction, clinical and radiographic outcome at mid-term and the need for endoprosthetic replacement in the postoperative course (defined as failure) were assessed; uni- and multivariate regression analysis were performed to identify independent predictive factors (e.g. age, nonanatomical reduction, acetabular roof impaction, central dislocation, quadrilateral plate displacement) for a failure. Outcome was assessed for all patients in general and in accordance to age in particular; patients were subdivided into two groups according to their age (group "<60yrs", group "≥60yrs").

RESULTS

Forty-three of 59 patients (mean age 54yrs, 13-89) were available for evaluation. Of these, anatomic reduction was achieved in 72% of cases. Nonanatomical reduction was identified as being the only multivariate predictor for subsequent total hip replacement (Adjusted Hazard Ratio 23.5; p<0.01). A statistically significant higher rate of nonanatomical reduction was observed in the presence of acetabular roof impaction (p=0.01). In 16% of all patients, total hip replacement was performed and in 69% of patients with preserved hips the clinical results were excellent or good at a mean follow up of 35±10 months (range: 24-55). No statistical significant differences were observed between both groups.

CONCLUSION

Nonanatomical reconstruction of the articular surfaces is at risk for failure of joint-preserving management of acetabular fractures through an isolated or combined modified Stoppa approach resulting in total joint replacement at mid-term. In the elderly, joint-preserving surgery is worth considering as promising clinical and radiographic results might be obtained at mid-term.

The posterior approach to pelvic ring injuries: A technique for minimizing soft tissue complications

Surgical techniques and fixation strategies for the treatment of unstable posterior pelvic ring injuries continue to evolve. The safety of the posterior surgical approach in particular has been questioned due to historically high rates of wound related complications. More contemporary studies have shown lower infection rates, however concern still persists. These concerns for infection and wound necrosis have led, in part, to increased interest in closed reduction and percutaneous fixation for treatment of these injuries but an open posterior approach remains the optimal strategy in some injury patterns. We describe herein a modified posterior approach to the pelvis designed to minimize wound related complications and present our clinical results demonstrating wound complication rates consistent with contemporary publications.

[A novel two-incision minimally invasive method for the treatment of anterior acetabular fractures]

OBJECTIVES

To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures.

INTERVENTION

The first TIMI incision is performed using a pararectal approach at the level of the proximal third of the arcuate line of the ilium. After transection of the abdominal wall the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held back using a retraction system. After fracture reduction and fixation by isolated screws a conventional reconstruction plate is inserted for fracture neutralization.

RESULTS

Since January 2008 we have performed the TIMI method in 88 cases with good results. Recently we have published the data of a first series with 26 patients that were seen at least 12 months after surgery. The mean operative time was 109 ± 30 min and all incisions showed primary healing. Postoperative radiological examination revealed an anatomic reduction in 20 fractures and a satisfactory reduction in 6. There were no local soft tissue complications and no revisions were needed. Follow-up examinations were performed after a minimum of 12 months in 19 patients (73%). The average Harris hip score (HHS) was 86.6 ± 8. Quality of life was comparable to control persons in the same age group.

CONCLUSIONS

The TIMI approach represents a viable alternative to the ilioinguinal approach. Despite the limited number of incisions a comparable quality of fracture reduction is achieved. The authors believe this technique would be most useful in patients with a higher risk for postoperative soft tissue complications.

Newly modified Stoppa approach for acetabular fractures

PURPOSE

We present our experience of using a newly modified Stoppa approach combined with a lateral approach to the iliac crest in patients with acetabular fractures in reference to fracture reduction and fixation, technical aspects, and the incidence of complications.

METHODS

We used a consecutive group of 29 adult patients with acetabular fractures treated operatively with a newly modified Stoppa approach between 2009 and 2011. The newly modified Stoppa approach was performed to fix the acetabular fractures with main anterior displacement and the anterior and lateral parts of the pelvis. This approach was combined with a lateral approach on the iliac crest for fractures of the iliac wing.

RESULTS

All the patients were followed up for at least 1.5 years. Of the 29 patients, ten anterior column, two associated both column, seven anterior column with posterior hemi-transverse, four transverse, and six T-type fractures. The average blood loss was 950 mL, and average operative time was 155 minutes. Anatomic or satisfactory reduction was achieved in 96 % of the acetabular fractures. Two patients had mild symptoms of the lateral femoral cutaneous nerve and improved within three months.

CONCLUSIONS

The newly modified Stoppa approach provides excellent visualization to the anterior column, quadrilateral surface and permits good postoperative results for treatment of acetabular fractures. We considered this technique as a viable alternative for the ilioinguinal approach when exposure of the anterior acetabulum is needed.

The two-incision, minimally invasive approach in the treatment of acetabular fractures

OBJECTIVES

To present a novel two-incision minimally invasive (TIMI) method for the treatment of anterior acetabular fractures.

DESIGN

Prospective consecutive case series.

SETTING

Level I University Trauma Centre.

PATIENTS

Twenty-six patients (mean age, 67 ± 19 years).

INTERVENTION

The first TIMI-incision is performed by a pararectal approach at the level of the proximal third of the arcuate line of the ilium. After transection of the abdominal wall, the iliac vessels are mobilized medially and the neuromuscular bundle laterally. The second approach lies above the medial pubic bone. The soft tissue is held using a retraction system. After fracture reduction and fixation by isolated screws, a conventional reconstruction plate is inserted for fracture neutralization.

MAIN OUTCOME MEASUREMENTS

Perioperative course, postoperative radiological evaluation, functional outcome Harris hip score, and quality of life (EQ 5D).

RESULTS

Mean operative time was 109 ± 30 mins. All incisions healed primarily. Postoperative radiological exam revealed an anatomic reduction in 20 fractures and a satisfactory reduction in 6. There were no local soft-tissue complications, and no revisions were needed. Follow-up examinations were performed after a minimum of 12 months in 19 patients (73%). The Harris hip score was 86,6 ± 8. Quality of life was comparable to persons in the same age group.

CONCLUSION

The TIMI approach represents a viable alternative to the ilioinguinal approach. Despite the limited incisions, a comparable quality of fracture reduction is achieved. The authors believe this technique would be most useful in those patients with a higher risk for postoperative soft-tissue complications.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Safe surgical technique for associated acetabular fractures

Associated acetabular fractures are challenging injuries to manage. The complex surgical approaches and the technical difficulty in achieving anatomical reduction imply that the learning curve to achieve high-quality care of patients with such challenging injuries is extremely steep. This first article in the Journal's "Safe Surgical Technique" section presents the standard surgical care, in conjunction with intraoperative tips and tricks, for the safe management of all subgroups of associated acetabular fractures.

Superior border of the arcuate line: Three dimension reconstruction and digital measurements of the fixation route for pelvic and acetabular fractures

PURPOSE

To obtain a series of parameters describing the shape and bone thickness of the fixation route along the superior border of the arcuate line, so as to provide references for pelvic and acetabular surgery and design pelvic anatomic internal fixators.

METHOD

A total of 175 complete pelvic computed tomography (CT) scans of normal adult pelvises were collected. Each person's CT scans were reconstructed to create a three-dimensional pelvic model. A curve of the fixation route was delineated and divided into 11 equal parts. The total length of the curve, the radius of curvature, and the bone thickness at each decile point were all measured. The position of the pelvic inlet, the anterior and posterior sagittal diameter were measured.

RESULTS

The radius of curvature at each decile point were 29.18 ± 15.53, 55.27 ± 29.48, 43.04 ± 14.42, 59.62 ± 21.02, 91.67 ± 52.01, 78.9 ± 38.66, 75.76 ± 25.87, 61.75 ± 16.68, 54.62 ± 14.88, and 43.61 ± 19.10 mm, respectively. The anterior and posterior sagittal diameter of the pelvic inlet was 66.01 ± 9.15 and 41.36 ± 8.19 mm, respectively. For all groups divided by the ratio of the posterior and the anterior sagittal diameter, the decile points 1, 3, and 10 had smaller radii of curvature than the before and after points, respectively.

CONCLUSIONS

The curve of the fixation route along superior border of arcuate line has a relatively greater bending degree at the pubic tubercle, iliopubic eminence and close to the sacroiliac joint. With the transition of the pelvic inlet shape from android to gynecoid and platypelloid type, the bone surface at the iliopubic eminence becomes flatter. Pelvic and acetabular surgery could be more accurate by referring to the previous key bending points and the change of the pelvic inlet shape.

Comminuted quadrilateral plate fracture fixation through the iliofemoral approach

Comminuted quadrilateral plate fracture with medial displacement is a technically difficult fracture to treat. Minimal bone stock, proximity to the hip joint with limited surgical access, and difficulty in obtaining a stable fixation at this area, contribute to the surgical challenge of open reduction and internal fixation. Fixation of a medial buttress plate in an infrapectineal fashion is a well-described technique to address such fractures. However, this plate alone may be inadequate to buttress all the fragments in a grossly comminuted quadrilateral plate fracture. An additional spring plate is often placed underneath the infrapectineal plate to hold the fracture fragments. Conventionally, these spring plates are fixed to the ilium superiorly while the other end buttresses the quadrilateral plate when placed underneath the infrapectineal reconstruction plate. The standard ilioinguinal approach and modified Stoppa approach have been described for the surgical access to the quadrilateral plate. Both the approaches have some limitations in addressing quadrilateral plate fracture. The ilioinguinal approach requires extensive dissection and mobilisation of inguinal neurovascular bundle. The modified Stoppa approach does not permit visualisation of the entire anterior column and the hip joint. The authors, in this article, describe the fixation of the comminuted quadrilateral plate fracture through the iliofemoral approach combined with a medial ilioinguinal window. The technique involves fixation of a spring plate (Allis T-plate) at right angle to the infrapectineal buttress plate (90°-90° plate construct). The vertical limb of the T-plate is fixed to the iliopectineal eminence whereas the horizontal limb buttresses the quadrilateral plate Hence, this technique addresses fractures of both the iliopectineal eminence and the quadrilateral plate. Other than that, the iliofemoral approach permits direct visualisation of the entire anterior column and the hip joint without the necessity to dissect the ilioinguinal neurovascular structures.

Quadrilateral plate fractures of the acetabulum: an update

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures, which are not specifically defined by any current classification system. Their incidence is increasing due to the rising number of elderly osteoporotic fractures. They have always been notoriously difficult fractures to treat. We present a systematic review of conservative and operative management and their respective outcomes over the last century.

Surgical management of posterior hip dislocations associated with posterior wall acetabular fracture: a study with a minimum follow-up of 15 years

OBJECTIVES

To evaluate the long-term outcome after surgical management of posterior hip dislocations associated with posterior wall acetabular fracture and to depict prognostic factors that may affect surgical results.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS AND METHODS

Between 1983 and 1991, 19 patients with traumatic posterior hip dislocation associated with posterior wall fracture of the acetabulum were retrospectively reviewed. The clinical criteria proposed by Merle d'Aubigne were used for the evaluation of the patient's clinical status. Matta's radiologic scoring system was used for the analysis of the radiologic data. The Brooker scoring system was used to assess the extent of heterotopic ossification after acetabular fracture surgery.

RESULTS

There were 17 male patients and two female. The age range at the time of injury was 16 to 54 years with a mean age of 36 years. Follow-up ranged from 15 to 23 years (mean, 18.5 years). At final follow-up, radiographic outcomes were excellent in six patients (31.58%), good in 11 (57.89%), and fair in two (10.53%) patients. The mean clinical score was 15, ranging from 9 to 18. Clinical outcome was excellent in 10 cases (52.63%), good in six cases (31.58%), and fair in three cases (15.79%). When an anatomic reduction was achieved intraoperatively, excellent or good radiographic and clinical results were shown in 100% and 87.50% of the patients, respectively.

CONCLUSION

The adequacy of surgical reduction will determine the long-term outcome of surgically managed posterior hip dislocations associated with posterior wall acetabular fracture.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Pararectus approach for anterior intrapelvic management of acetabular fractures

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues.

In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

An interactive surgical planning tool for acetabular fractures: initial results

Background

Acetabular fractures still are among the most challenging fractures to treat because of complex anatomy, involved surgical access to fracture sites and the relatively low incidence of these lesions. Proper evaluation and surgical planning is necessary to achieve anatomic reduction of the articular surface and stable fixation of the pelvic ring. The goal of this study was to test the feasibility of preoperative surgical planning in acetabular fractures using a new prototype planning tool based on an interactive virtual reality-style environment.

Methods

7 patients (5 male and 2 female; median age 53 y (25 to 92 y)) with an acetabular fracture were prospectively included. Exclusion criterions were simple wall fractures, cases with anticipated surgical dislocation of the femoral head for joint debridement and accurate fracture reduction. According to the Letournel classification 4 cases had two column fractures, 2 cases had anterior column fractures and 1 case had a T-shaped fracture including a posterior wall fracture.

The workflow included following steps: (1) Formation of a patient-specific bone model from preoperative computed tomography scans, (2) interactive virtual fracture reduction with visuo-haptic feedback, (3) virtual fracture fixation using common osteosynthesis implants and (4) measurement of implant position relative to landmarks. The surgeon manually contoured osteosynthesis plates preoperatively according to the virtually defined deformation. Screenshots including all measurements for the OR were available.

The tool was validated comparing the preoperative planning and postoperative results by 3D-superimposition.

Results

Preoperative planning was feasible in all cases. In 6 of 7 cases superimposition of preoperative planning and postoperative follow-up CT showed a good to excellent correlation. In one case part of the procedure had to be changed due to impossibility of fracture reduction from an ilioinguinal approach. In 3 cases with osteopenic bone patient-specific prebent fixation plates were helpful in guiding fracture reduction. Additionally, anatomical landmark based measurements were helpful for intraoperative navigation.

Conclusion

The presented prototype planning tool for pelvic surgery was successfully integrated in a clinical workflow to improve patient-specific preoperative planning, giving visual and haptic information about the injury and allowing a patient-specific adaptation of osteosynthesis implants to the virtually reduced pelvis.

Prone or lateral? Use of the Kocher-Langenbeck approach to treat acetabular fractures

PURPOSE

This retrospective, institutional review board approved study with no patients excluded was designed to test the hypothesis that the prone position is advantageous for repair of acetabular fractures, via a posterior approach.

METHODS

In 104 consecutive cases fixed by open reduction and internal fixation using the Kocher-Langenbeck approach, 50 were performed in the prone position and 54 in the lateral position by four attending surgeons at a level I trauma center. These cases were assigned to each surgeon according to the call schedule and positioned on the operating table depending on the preference of the assigned surgeon. Arbeitsgemeinschaft fuer Osteosynthese/Association for the Study of Internal Fixation (AO/ASIF) classification and radiologic outcome were evaluated by standard radiographs of the hip and computerized tomography scans, demographic data were taken from the medical records. Except for the time from injury to surgery (p = 0.003), both groups were comparable, nevertheless the fractures were more severe in the prone one.

RESULTS

With equivalent radiologic outcomes according to Matta, Brooker, Epstein, and Helfet between both groups, a significantly higher rate of infection (p = 0.017) and need for revision surgery (p = 0.009) were found in the prone group.

CONCLUSION

No advantage to either position for the posterior approach to acetabular fractures could be found. Because most of the severe fractures were performed prone, we propose that the larger number of more difficult fractures in this group may cause an increased likelihood of loss of reduction. The higher infection rate in the prone group may be caused by the longer inpatient wait for definitive fixation, leading to a higher risk of nosocomial colonization.

The anterior intra-pelvic (modified rives-stoppa) approach for fixation of acetabular fractures

OBJECTIVES

Report the technical aspects, radiographic results, and complications after minimum 1-year follow up of the anterior intra-pelvic (AIP or modified Rives-Stoppa) approach as an alternative to the ilioinguinal approach for the treatment of acetabular fractures.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

MATERIALS AND METHODS

All skeletally mature patients requiring an anterior approach for fixation of an acetabular fracture with minimum 1-year clinical and radiographic follow up were included. Charts and radiographs were reviewed for fracture pattern, time to surgery, operative time, blood loss, quality of reduction, and perioperative complications. A consecutive group of 57 patients treated by a single surgeon using the AIP approach was identified as a subset of a larger series 536 acetabular fractures treated by the same surgeon between February 2004 and February 2008.

RESULTS

Of the 57 patients, average time to operation was 5 days and a supplemental lateral window was required in 34 patients (60%). Average blood loss was 750 mL, and average operative time was 263 minutes. One patient (1.8%) had a vascular injury requiring embolization. One patient (1.8%) had a wound infection in the lateral window, two patients (3.5%) developed a direct inguinal hernia requiring surgical repair, and one patient (1.8%) had atrophy of the ipsilateral rectus abdominus without hernia. Of the 50 patients with minimum 1-year follow up, there were 22 associated both column, 12 anterior column, seven anterior column posterior hemitransverse, six transverse, and three T-type fractures. Seventy percent of the reductions were graded excellent, 22% were graded good, and 8% poor. Clinical outcomes (Merle D'Aubigne) at 1 year were 36% excellent, 55% good, and 10% poor. Thirteen patients (26%) were noted to have significant weakness of the hip adductors (obturator nerve palsy) postoperatively; all but one resolved and improved within 6 months.

CONCLUSION

Use of the AIP (modified Rives-Stoppa) approach for the treatment of acetabular fractures permits good to excellent reduction in the majority of cases while giving excellent visualization and access to the quadrilateral plate and posterior column. The AIP approach has a complication rate that is comparable to the ilioinguinal approach. We recommend the use of this technique as a potential alternative (but not replacement) to the classic ilioinguinal approach when anterior exposure of the acetabulum is required.

Modified stoppa approach for acetabular fractures with anterior and posterior column displacement: quantification of radiographic reduction and analysis of interobserver variability

OBJECTIVES

To quantify the reduction of acetabular fractures with displacement of the anterior and posterior column by using only a single anterior approach that combines the modified Stoppa approach with the lateral window of the classic ilioinguinal approach. The second objective was to evaluate the interobserver variability of our technique for radiographic evaluation of the reduction.

SETTING

Level I trauma referral center.

PATIENTS

A consecutive cohort of 17 patients with displaced acetabular fractures treated operatively with use of only an anterior approach that combined the modified Stoppa approach with the lateral window of the ilioinguinal approach. To be included in the study, patients had to have at least 5 mm of posterior column displacement and had to have undergone no other approaches.

OUTCOME MEASURES

Primary outcome was radiographic evidence of reduction as measured by a technique that evaluates five parameters of postoperative reduction. Interobserver variability was evaluated with interclass correlation. Secondary outcomes included operative time, blood loss, and complications.

RESULTS

Anatomic reduction of the articular surface was obtained in 14 (82%) patients, imperfect radiographic reduction in three (18%), and poor radiographic reduction in none (0%). Average anterior column displacement improved from 17.5 mm preoperatively to 0.5 mm postoperatively. Average posterior column displacement improved from 13.0 mm to 1.2 mm. Average femoral head medialization improved from 12.5 mm to 1.0 mm. Average quadrilateral surface medialization improved from 15.2 mm to 0.6 mm. Four complications occurred in three patients, including one deep infection, one seroma, and two instances of symptoms in the lateral femoral cutaneous nerve. Our technique for grading the radiographic outcome yielded relatively high interobserver reliability preoperatively with interclass correlation values ranging from 0.72 to 0.96 for the five measured parameters. Postoperative reliability was worse.

CONCLUSION

Anatomic or imperfect reduction of certain acetabular fractures involving displacement of both the anterior and posterior columns, even with significant (greater than 5 mm) displacement of the posterior column, can be obtained through the modified Stoppa window and the lateral window of the ilioinguinal approach. The method for evaluating preoperative displacement had excellent reliability.

Management, complications and clinical results of femoral head fractures

A systematic review of the literature was conducted to investigate data regarding femoral head fractures, particularly focusing on their management, complications and clinical results. Twenty-nine eligible articles, meeting prespecified inclusion criteria, reported on 453 femoral head fractures in 450 patients (mean age of 38.9 years with a mean follow-up of 55.6 months). 84.3% of patients had been victims of an automobile accident. The most widespread classification scheme used was that of Pipkin (65.4% of cases) whereas clinical results were evaluated mainly according to Thompson-Epstein criteria (63.3% of cases). Fracture-dislocations, in their majority, were managed with emergent closed reduction, followed by definite treatment (closed or open), aiming at anatomic restoration of both fracture and joint incongruity. Regarding Pipkin 1 subtype, fractured fragment excision seems to give better results compared to ORIF (p=0.07), while for the more challenging Pipkin 2 fractures the principles of anatomic reduction and stable fixation should be applied. Wound infection was encountered with a rate of 3.2% of surgical cases and sciatic nerve palsy complicated 3.95% of fracture-dislocations. Major late complications included avascular necrosis (11.9%), post-traumatic arthritis (20%) and heterotopic ossification (16.8%). Neither the trochanteric-flip nor the anterior approach seems to put in more danger the femoral head blood supply compared to the posterior one, with the former giving promising long-term functional results and lower incidence of major complication rates.

Surgical techniques-How do I do it? Open reduction and internal fixation of posterior wall fractures of the acetabulum

Posterior wall fractures are the commonest type of acetabular fracture. Nonoperative management is associated with significant complications and poor outcome. Consequently, open reduction and internal fixation has become increasingly common. In this article, inaugurating the new section of "how do I do it", we present our current approach to the treatment of posterior wall fractures of the acetabulum, including the preoperative planning, the details of the operative procedure in terms of patient's positioning and draping, surgical approach, osteosynthesis and wound closure.