Anterior Ilioinguinal Approach Research Articles

Special contoured pelvic brim reconstruction titanium plate combined with trans-plate buttress screws (quadrilateral screws) for acetabular fractures with quadrilateral plate involvement through the anterior ilioinguinal approach.

Managing complicated acetabular fractures involving the quadrilateral plate (QLP) can be challenging for surgeons, especially when complicated by comminution and osteoporosis. Traditional implants do not provide sufficient fixed strength or a proper match. The new-type pre-contoured infrapectineal buttress plates may have drawbacks, such as inaccurate fitting on the medial surface of QLP and an inability to apply reversed compression force to resist medial displacement of femoral head. Therefore, the primary purpose of this study is to introduce a novel technique that utilizes a special contoured pelvic brim reconstruction titanium plate combined with quadrilateral screws to reduce and stabilize acetabular fractures involving the QLP through the ilioinguinal approach. Additionally, the secondary purpose is to evaluate both clinical effectiveness and radiological outcomes of this technique for QLP fractures. We conducted a retrospective analysis of prospectively collected data from 48 patients (31 males and 17 females) who suffered from acute displaced fractures of the QLP and were treated between January 2012 and December 2019 using a special contoured plate combined with quadrilateral screws. The patients' mean age was 47.56 ± 11.31 years (range: 19-73 years). Fracture patterns included 20 both-column fractures, 12 anterior column and posterior hemitransverse fractures, eight T-type fractures, five transverse fractures and three anterior column fractures with the QLP affected, all of which had femoral head protrusion. Immediate postoperative reduction quality was evaluated according to Matta's criteria. Final clinical functions were assessed during follow-up using the modified Merle d'Aubigné and Harris Hip scores (HHS). The patients were followed up for an average of 48.36 ± 12.94 months (ranging from 24 to 84 months). The mean operative time was 246.08 ± 54.30 min (ranging from 178 to 397 min), and the average blood loss was 715.16 ± 263.84 ml (ranging from 400 to 2000ml). The radiological grading at postoperative stage showed anatomical reduction in 30 patients (62.50%), satisfactory reduction in 14 patients (29.17%), and poor reduction in four patients (8.33%). At the final follow-up, no re-protrusion of the femoral head was observed. In terms of functional outcome, the mean modified Merle d'Aubigné-Postel score was excellent in 26 patients (54.17%), good in 17 patients (35.42%), fair in four patients (8.33%), and poor in one patient (2.08%). The HHS was excellent in 23 patients (47.92%), good in 20 patients (41.67%), fair in four patients (8.33%), and poor in one patient (2.08%). The average HHS was 87.38 ± 7.86 (ranging from 52 to 98). Postoperative complications included lateral femoral cutaneous nerve injury in two patients, delayed wound healing and subsequent development of an inguinal hernia in one patient. Late complications were observed in two patients, with one case of heterotopic ossification and another case of post-traumatic osteoarthritis underwent hip arthroplasty within two years after surgery. Our results indicate that employing the contoured plate specifically designed for QLP injuries, in conjunction with quadrilateral screws through the ilioinguinal approach, can lead to positive outcomes in the treatment of displaced acetabular fractures involving the QLP. This straightforward and efficient technique offers a viable option for surgeons who are managing complex acetabular fractures.

The Outcome of Bicolumnar Acetabular Fracture Treated by Single Anterior Ilioinguinal Approach

Background: Acetabular fracture therapy, being complicated, is generally treated by non-operative methods due to a lack of surgeons’ expertise in pelvis surgery. The surgical exposure and reduction of acetabular fractures may become more direct and practical with the altered technique since it is closer to the acetabular quadrilateral plate. This study aimed to determine the efficacy of a single anterior illio-inguinal approach for the management of a Bi-columnar acetabulum fracture. Methods: Sixty patients, fulfilling the selection criteria were selected for descriptive case series from Orthopedic Surgery Department at Lahore General Hospital, from 02-12-2020 to 02-06-2021. After informed consent, surgery was performed on all patients under general anesthesia. Patients were followed-up and evaluated for efficacy in OPD after 12 weeks of surgery with a Harris hip score. All demographic and other information was recorded on a Proforma. SPSS 22 was used to assess data. Post-stratification, efficacy was compared by using chi-square, p-value ≤0.05 was considered significant. Results: Out of 60 patients, 45(75 %) were male, whereas 15(25%) were female (Mean age 52.71±10.50yrs). The Mean of duration fracture (in days) and Harris score are 11.03±5.29 and 2.83±0.45 respectively. The efficacy concerning lateral side was 60% for left side and 26.7% for right side. Efficacy was higher in less than 10 days old fractures at 55.0% while after 10 days it was 31.7%. We found that the percentage of efficacy was 86.7%. Conclusion: The current study concluded that the anterior illio-inguinal approach is highly effective (p=0.001) in the management of acetabular fractures. Keywords: Acetabulum; Pelvic; Fracture; General Surgery.

Application of a novel acetabular reduction clamp for treatment of acetabular posterior column fracture

Objective To investigate the effect of our self-developed acetabular reduction clamp in the treatment of fractures of acetabular posterior column. Methods The data were retrospectively analyzed of the 32 patients who had been treated for acetabular posterior column fractures using our self-developed acetabular reduction clamp at Department of Minimally Invasive Surgery, Zhengzhou Orthopaedics Hospital from August 2016 to June 2018. They were 17 males and 15 females, aged from 18 to 62 years (average, 41.3 years). According to the Letournel-Judet classification, there were 9 simple posterior column fractures, 14 posterior column plus posterior wall fractures, 4 T-shaped fractures and 5 double column fractures. The Kocher-Langenbeck (K-L) incision was used for simple posterior column and posterior column plus posterior wall fractures, and the K-L combined with anterior ilioinguinal approach for T-shaped and double column fractures. The displaced posterior column fracture was repositioned with our novel reduction clamp before pelvic reconstruction plate was used for fixation. The quality of fracture reduction, fracture union time, complications and hip function score at the last follow-up were recorded. Results This series of 32 patients were followed up for 7 to 20 months (average, 12.9 months). According to the Matta scores for fracture reduction at the last follow-up, 15 cases were excellent, 16 good and one poor, yielding an excellent and good rate of 96.9%. The fracture union time ranged from 3 to 6 months (average, 4.7 months). According to the modified Merle d＇Aubign scores at the last follow-up, hip function was excellent in 18 cases, good in 11 and fair in 3, yielding an excellent and good rate of 90.6%. Postoperative symptomatic distraction injury to the sciatic nerve appeared in 2 patients, postoperative wound lipid liquefaction developed in one and heterotopic ossification of Brooker grade Ⅱ was observed in 2 patients during follow-up. Conclusion In the treatment of acetabular posterior column fracture with open reduction and internal fixation with pelvic reconstruction plate through the K-L approach, our novel acetabular reduction clamp can be used safely and effectively to assist fracture reduction, leading to satisfactory results. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Reduction

Bullet Extraction from the Sacroiliac Joint with an Arthroscopically Assisted Dual Guidewire Technique: A Case Report.

Patients with intra-articular gunshot wounds (GSWs) are presenting with increasing frequency at many trauma centers. These injuries necessitate a specific treatment regimen that includes a thorough irrigation and debridement as well as surgical exploration of the joint, typically through an open approach. The bullet must be removed from the joint because retained bullets and clothing material in joints can cause several complications, including mechanical symptoms, damage to the articular cartilage1, posttraumatic arthritis2, and, rarely, lead poisoning3. Access to the sacroiliac (SI) joint can be challenging given its location and proximity to surrounding vital structures. An open anterior ilioinguinal approach with use of the lateral window technique can increase blood loss and morbidity. The posterior approach to the SI joint allows for limited intra-articular access and has increased rates of wound complications4. Open approaches carry a theoretical increased risk of wound complications (e.g., infection, hematoma, and dehiscence) and can also be very time-consuming. The exposure and closure in cases where the SI joint needs to be exposed are extensive. Although arthroscopic surgery can be more costly, it affords the patient the advantage of a smaller wound, decreased morbidity at the surgical site, and potentially a decreased length of hospital stay5. For these reasons, percutaneous approaches are gaining favor over open approaches. In 2008, Lee et al. were the first to describe the arthroscopic approach to the SI joint utilizing solely a bullet track6. This technique used one guidewire that was drilled through the bullet for extraction. In our case report, we describe the surgical technique that was used to perform an arthroscopically assisted bulletectomy from the SI joint with use of a dual guidewire technique via the bullet track with arthroscopic as well as fluoroscopic guidance. The patient and …

An Analysis of Gait Changes and Functional Outcome in Patients Surgically Treated for Displaced Acetabular Fractures

To determine the relationship between gait, muscle strength, and functional outcome in patients who underwent Open Reduction Internal Fixation (ORIF) of a displaced acetabular fracture using an anterior ilioinguinal approach and to compare gait and functional outcome in patients who have undergone ORIF via an anterior approach with a similar group of patients who have undergone ORIF of a displaced acetabular fracture via a posterior approach and a group of able-bodied cohorts and to investigate relationships between gait, strength, and functional outcome within the entire group of patients. Case series. University Medical Center. Thirty patients were studied, each with an isolated displaced acetabular fracture who were surgically treated; 15 patients were treated using an anterior ilioinguinal approach, and 15 were treated using a posterior Kocher-Langenbeck approach. Primary outcome measures included gait analysis (speed and kinematics), hip muscle strength, and functional outcome as assessed with the Musculoskeletal Function Assessment (MFA) questionnaire. Several of the limb kinematics for the affected and the unaffected limbs was different when patients treated by an anterior surgical approach were compared with those treated from a posterior approach and able-bodied cohorts. Maximum ankle dorsiflexion was greater in the unaffected limb of the anterior group versus the posterior approach group but was equal to the able-bodied cohorts (AB). Both the affected and the unaffected limbs of the anterior group had larger angles for knee flexion at the time of initial contact compared with the posterior group and AB. Both limbs of the anterior group had significantly more knee flexion and less hip rotation than the posterior group but not from AB. There were no differences in trunk inclination between the surgical groups, but the combined group had greater inclination compared with AB. Average MFA score was 17 +/- 12 (range, 0-47) for the anterior group and 22 +/- 17 (range, 0-57) for the posterior group, respectively. MFA scores did not differ significantly based on surgical approach, fracture pattern, or sex. When gait was compared with MFA scores, an inverse relationship was discovered for the group as a whole. That is, worsening function (increased MFA) correlated with decreased kinematics and stride length. Additionally, greater hip strength was associated with additional hip rotation and increased gait speed. A multivariate regression analysis indicated that both hip rotation (which was associated with hip strength) and hip adductor work strength were important predictors of final MFA scores. Detailed gait analysis and functional outcome determination indicate that patients treated surgically for a displaced acetabular fracture, either via an anterior or posterior approach, have alterations in their gait, muscle strength, and functional outcome. Maximizing hip muscle strength may improve gait, and improvement in hip muscle strength and gait is likely to improve functional outcome as measured by the MFA. Finally, because both surgical approaches seem to produce the same gait outcomes, it suggests that gait changes after injury and treatment are related to factors other than surgical approach.

Results after operative treatment of transverse acetabular fractures

BackgroundTreatment of the transverse acetabular fracture is known to have worse results than other fracture types, although this fracture belongs to the elementary fracture group. The operative results of the transverse acetabular fracture, however, have not been well documented. To determine the results and factors that affect the choice of operative treatment for transverse acetabular fractures, we retrospectively reviewed 15 cases of transverse fracture. MethodsA total of 15 patients had a transverse fracture, with an average follow-up period of 43 months; there were 8 patients with and 7 without a posterior wall fracture. There were 11 men and 4 women, with a mean age of 46.6 years. In seven cases there was also comminution of the weight-bearing dome. The surgical approaches used were the anterior ilioinguinal approach in 4 patients, the posterior approach in 10 patients, and the combined approach in 1 patient. Postoperative radiographic results were evaluated by Matta’s criteria. Final clinical results were evaluated by a modified Merle d’Aubigne scoring system. ResultsAll of the fractures healed. The average time for fracture healing was 17.5 weeks. Postoperative radiology revealed six cases of anatomical reduction, five cases of imperfect reduction, and four cases of poor reduction. According to the clinical results, nine patients had satisfactory results (three excellent, six good), and six had unsatisfactory results (three fair, three poor). Regarding complications, there were four cases of traumatic osteoarthritis and three of heterotopic ossification. The patients with an anatomical reduction had a higher satisfactory result rate. Comminution of the transverse fracture seemed to have an adverse influence on the postoperative radiologic result as well as a correlation with the development of traumatic arthritis. ConclusionsTransverse acetabular fractures, if not reduced anatomically, may have a tendency toward traumatic osteoarthritis and poor clinical outcome. Comminution of the dome may portend poor results.

Anterior fixation of the sacroiliac joint

An unstable pelvic ring fracture requires surgical stabilization. The anterior ilioinguinal approach to the sacroilliac (SI) joint is recommended for a vertically, posteriorly, or laterally displaced hemipelvis because it allows for a direct visualization and it affords for an anatomic reduction of the SI joint. Other indications for use of the anterior approach include the need for fixation of associated acetabular, iliac wing, or symphyseal fractures. This technique is not applicable for fractures of the sacrum because of the proximity to the L5 nerve root. Biomechanical data supports the use of anterior plating for rigid osseous stabilization of the SI joint. Other techniques of internal fixation include transiliac screws, posterior tension band plate, and sacral bars. These methods place important neurologic and vascular structures at risk. Further, a posterior approach has inherent difficulty in reducing a SI disruption and may cause a higher incidence of skin necrosis. This article describes the advantages and the technique of anterior stabilization of the SI joint in the management of an unstable pelvic ring fracture.

Results in Patients with Craniocerebral Trauma and an Operatively Managed Acetabular Fracture

Results in 23 patients with significant craniocerebral trauma (Glasgow Coma Scale less than or equal to 10) and displaced acetabular fracture requiring surgery were reviewed after a minimum follow-up of 1 year. Despite a postoperative anatomic reduction in all but one case, clinical outcome for these hips was poor, with an average Harris hip rating of 59. Patients older than 40 years had a significantly poorer outcome than did younger patients (p = 0.004). Postoperative problems occurred in 70% of patients (n = 16); the largest portion of these represented symptomatic heterotopic bone, which occurred in 61%. None of the four patients who had an anterior ilioinguinal surgical approach had symptomatic heterotopic ossification. The average Glasgow outcome score was 3.9 out of 5, and 20 of the 23 patients, despite a prolonged convalescence, were able to return to independence and self-care. The authors conclude that patients with combined significant craniocerebral trauma and an operatively managed displaced acetabular fracture are likely to have compromised hip function despite a well-executed osteosynthesis. This was especially true for those patients over age 40 in this series. The authors suggest that if the fracture pattern permits it, the operative management of the acetabular fracture in these patients be by an anterior ilioinguinal approach, so as to minimize the formation of heterotopic bone.