The subinguinal retroperitoneal approach for fractures of the acetabulum: a modified ilioinguinal approach

Quadrilateral plate fractures of the acetabulum: Classification, approach, implant therapy and related research progress

The quadrilateral plate (QP) is an essential structure of the inner wall of the acetabulum, an important weight-bearing joint of the human body, which is often involved in acetabular fractures. The operative exposure, reduction and fixation of QP fractures have always been the difficulties in orthopedics due to the special morphological structure and anatomical features of the QP. Fortunately, there have been many effective methods and instruments developed for QP exposure, reduction and fixation by virtue of the combined efforts of numerous orthopedists. At the same time, each method presents with its own advantages and disadvantages, resulting in different prognoses. It is necessary to have a thorough understanding of the anatomy, radiology and fixation techniques of the QP in terms of patient prognosis optimization. In this paper, the anatomical features, definition and classification of QP, operative approach selection, implant internal fixation methods and efficacy were reviewed.

The Use of Anterior Superior Iliac Spine Osteotomy to Access the Anterior Column in Tumor Resection: A Case Report

CASE

A 24-year-old woman with chondrosarcoma of the superior pubic ramus underwent a Type III pelvic resection through an ilioinguinal approach, modified with anterior superior iliac spine (ASIS) osteotomy. The osteotomy mobilized the ASIS and sartorious distally, exposing the anterior wall and superior ramus. A custom cutting guide was placed on the anterior acetabular wall for en bloc superior ramus resection with hip-sparing osteotomy and negative margins.

CONCLUSION

ASIS osteotomy for sartorius mobilization improves visualization of the anterior column of the acetabulum and heals more reliably than sartorius tenotomy, therefore should be considered during tumor resection involving the anterior column, superior ramus, or acetabular wall.

Safety Precautions for the Corona Mortis using Minimally Invasive Ilioinguinal Approach in Treatment of Anterior Pelvic Ring Fracture

Objective

To explore the safety of the corona mortis of the minimally invasive plate insertion in treatment of the anterior pelvic ring fracture by studying the relationship between the vessel and the position of plate.

Method

The corona mortis was dissected out of eight adult cadavers and were simulated for the insertion of the anterior ring minimally invasive plate, and the presence of the anastomotic branch (the corona mortis) in the suprapubic branch area was observed. After the Corona mortis stripped off, the data was measured, such as the length, vessel diameter, distance from the pubic tubercle, and the maximum vertical distance between the corona mortis and the pubis. The measured data and the previous literatures were analyzed to study the morphology of the corona mortis and the position relation between the corona mortis and the placement of subperiosteal tunnel through the minimally invasive ilioinguinal approach.

Results

Out of the 16 unilateral pelvises, the corona mortis were observed on 12 unilateral pelvises with an incidence rate of 75%. Amongst them, there were seven cases of vein anastomosis (incidence of 43.75%), three cases of arterial anastomosis (incidence of 18.75%), and two cases of both arterial anastomosis and vein anastomosis (incidence of 12.5%). The corona mortis length ranged between 24.5 and 37.5 mm (average of 30.7 ± 3.6 mm); the diameter ranged between 1.6 and 3.5 mm (average of 2.5 ± 0.5 mm) and the distance between the vessels and the pubic tubercle was between 53.9 and 65.2 mm (average of 59.0 ± 3.6 mm). Above the pubis, the corona mortis originated from the iliac or the inferior epigastric vessel. It crossed the pubic branch to the dorsal side of the pubis and proceeded downward to anastomize with the obturator vessels near the obturator. Toothless tweezers were used to peel and lift up the corona mortis from the pubic bone. The maximum vertical distance between the corona mortis and the pubis ranged between 8.8 and 18.3 mm (average of 12.6 ± 3.0 mm).

Conclusion

The corona mortis have a high rate of incidence, with a large number of differences in the type and shape of blood vessels among patients. Following peeling, the movement between the corona mortis and pubic bone is limited. Nevertheless, the plate and bone exfoliator still passed safely. Therefore, when surgeons use the minimally invasive ilioinguinal approach to establish channels, the process of subperiosteal stripping must be performed to avoid any accidental injury.

Digital Anatomy to Improve Screw Insertion Techniques for Plate-Screw Fixation of the Pubic Body

Objectives

This study aims to investigate screw insertion sites on the pubic body and the safe screw insertion parameters of a plate-screw fixation system based on the premise of avoiding damage to the inguinal canal and disruption of the rectus abdominis at the pubic symphysis and pubic crest.

Research Methods

Excluding cases with poor image quality, tumors, malformations, and fractures, the data of 80 healthy adults (40 males and 40 females aged from 21 to 83 years old, with an average age of 51.65 years) undergoing a computed tomography (CT) scan of the pelvis between January and June of 2017 were collected from Shandong Provincial Hospital. The CT scans were imported to Mimics® software to reconstruct three-dimensional pelvic models. A 3.5 mm pelvic reconstruction plate was placed starting at the outer edge of the pubic tubercle and along the pelvic brim. The two innermost screw insertion sites were marked. The safe range for the screw insertion sites was then determined. The screw insertion plane was selected to measure the safe screw insertion parameters. The length of the screw, the direction of insertion, and intersex differences were then explored via statistical analyses.

Results

The medial inclination angles (MIAs) of the screw insertion plane for males and females were 30.42±7.95° and 32.88±10.65°, respectively, with no statistically significant differences. For the medial screw, the maximum anterior inclination angle (MAIA), the maximum screw length, and the maximum posterior inclination angle (MPIA) were 46.51±4.01°, 12.40±9.53 mm, and 11.78±10.22° on average, respectively, with no significant differences by gender (P>0.05). For the lateral screw, the MAIA was 10.35±9.46° and showed no gender differences (P>0.05), but the male group had a greater MPIA (male 11.80±11.00° vs. female 6.23±7.91°, P<0.05) and maximum screw length (male 55.71±6.36 mm vs. female 48.68±8.65, P<0.001). For the tangential screw, the maximum screw length, MIA, and anterior/posterior inclination angle (APIA) were 52.19±8.33 mm, 31.65±9.42°, and 7.53±10.18°, respectively, with no significant differences in the angles by gender (both P>0.05), although the screw length in the male group was significantly longer than that in the female group.

Conclusions

Insertion of two screws into the pubic body through a plate from the lateral side of the pubic tubercle is safe and can maintain the origin of the rectus abdominis and the integrity of the inguinal canal compared to traditional plate-screw fixation. Considering that the pubic body is thinner on the lateral side, we suggest a more medial inclination angle for the lateral screw.

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.

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.

Cerclage wiring in displaced associated anterior column and posterior hemi-transverse acetabular fractures

PURPOSE

The effects of cerclage wiring in the open reduction and internal fixation of displaced associated anterior column and posterior hemi-transverse acetabular fractures were evaluated.

METHODS

This is a retrospectively clinical study of such cases where the main surgical strategy was open reduction and internal fixation with cerclage wire and reconstruction plates. Data on 12 cases treated between 1992 and 2011 were collected. The mean follow-up period was 32 (12-132) months.

RESULTS

Reduction with a fracture gap of less than 2 mm without articular stepping and solid union was achieved in all 12 cases. Postoperative complication developed in one case of symptomatic arthritis. Excluding the case with symptomatic arthritis, the other cases had good to excellent final D'Aubigne and Postel functional results.

CONCLUSIONS

Cerclage wiring is very useful and effective in the reduction and fixation of displaced associated anterior column and posterior hemi-transverse acetabular fractures, and supplemental fixation with reconstruction plates and screws is necessary.

Modified ilioinguinal approach to the acetabulum and pelvis from beneath the inguinal ligament: a subinguinal approach

The ilioinguinal approach is favoured for fractures of the anterior part of the pelvis, but it is associated with some technical difficulties and it is not suitable for some complex fractures. In 2008, a modified ilioinguinal approach was introduced by Farid Yr which afforded visualisation of the inside and outside of the pelvis. The approach involves retroperitoneal access below the inguinal ligament to preserve the integrity of the inguinal canal and allows exposure of anterior and medial wall fractures as well as the anterior hip capsule. Despite the dimensions of the procedure, closure is anatomical because repair of the inguinal canal floor is not required. We report the use of this approach in 17 patients with T-type fractures of the acetabulum, transverse fractures of acetabulum, Tile C1 pelvic fractures, malunion of the pelvis and acetabular dysplasia. The approach is recommended in complex cases of acetabular surgery (including obese or muscular patients) and complicated or old fractures in which a better exposure is required. It is useful in visualisation of the anterior wall and labrum and intra articular structures, and in viewing the internal anatomy of the pelvis and acetabulum. It may be a suitable approach for periacetabular osteotomy.

Cerclage wire-plate composite for fixation of quadrilateral plate fractures of the acetabulum: a checkrein and pulley technique

Acetabular fractures with complete or incomplete quadrilateral plate separation frequently present with central displacement of the femoral head. Failure of stable fixation of medial wall fractures leaves residual subluxation despite reduction of other fracture components. Several fixation techniques may be either technically demanding or insufficient for stable fixation in conditions of comminution, osteoporosis, or neglected injuries. The proposed wire-plate composite uses a reconstruction spring plate over the pelvic brim for medial wall buttressing. One hole on its true pelvic limb provides a pulley to deviate a cerclage wire or cable passed through the greater sciatic notch into the true pelvis. This enhances buttressing against medial protrusion. Application through anterior approaches is simple and fixation is reliable in difficult fractures without the risk of joint penetration because all quadrilateral plate buttressing implants remain extraosseous.