Anterior Intrapelvic Approach Research Articles

Medial surface plating of posterior column through the anterior intrapelvic approach in acetabulum fractures with involvement of both columns.

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures. We retrospectively reviewed the data from R G Kar Medical College, Kolkata, India, from June 2018 to April 2023. Overall, there were 34 acetabulum fractures involving both columns managed by medial buttress plating of posterior column. The posterior column of the acetabular fracture was fixed through the AIP approach with buttress plate on medial surface of posterior column. Mean follow-up was 25 months (13 to 58). Accuracy of reduction and effectiveness of this technique were measured by assessing the Merle d'Aubigné score and Matta's radiological grading at one year and at latest follow-up. Immediate postoperative radiological Matta's reduction accuracy showed anatomical reduction (0 to 1 mm) in 23 cases (67.6%), satisfactory (2 to 3 mm) in nine (26.4%), and unsatisfactory (> 3 mm) in two (6%). Merle d'Aubigné score at the end of one year was calculated to be excellent in 18 cases (52.9%), good in 11 (32.3%), fair in three (8.8%), and poor in two (5.9%). Matta's radiological grading at the end of one year was calculated to be excellent in 16 cases (47%), good in nine (26.4%), six in fair (17.6%), and three in poor (8.8%). Merle d'Aubigné score at latest follow-up deteriorated by one point in some cases, but the grading remained the same; Matta's radiological grading at latest follow-up also remained unchanged. Stabilization of posterior column through AIP by medial surface plate along the sciatic notch gives good stability to posterior column, and at the same time can avoid morbidity of the additional lateral window.

Early Treatment of Acetabular Fractures via an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion.

To determine if time from hospital admission to surgery for acetabular fractures using an anterior intrapelvic (AIP) approach affected blood loss. Multicenter retrospective study. Three level 1 trauma centers at 2 academic institutions. 195 adult (age >18) patients with adequate records to complete analysis and no pre-existing coagulopathy. AIP approach without other significant same day procedures (irrigation and debridement and external fixation were the only other allowed procedures). Multiple methods for evaluating blood loss were investigated, including estimated blood loss (EBL), calculated blood loss (CBL), and packed red blood cell (PRBC) transfusion requirement. On continuous linear analysis, increasing time from admission to surgery was significantly associated with decreasing CBL at 24 hours (-1.45 mL per hour by Gross, p=0.003; -0.440 g of Hgb per hour by Hgb balance, p=0.003) and 3 days (-1.69 mL per hour by Gross, p=0.013; -0.497 g of Hgb per hour by Hgb balance, p=0.010) postoperative, but not EBL or PRBC transfusion. Using 48-hours from admission to surgery to define early versus delayed, blood loss was significantly greater in the early group compared to delayed [453 (IQR 277-733) mL early versus 364 (IQR 160-661) delayed by Gross, p=0.017; 165 (IQR 99-249) g early versus 143 (IQR 55-238) g delayed by Hgb balance, p=0.035], but not EBL or PRBC transfusion. Additionally, in multivariate linear regression, neither giving tranexamic acid nor administering prophylactic anticoagulation for venous thromboembolism on the morning of surgery affected blood loss at 24 hours or 3 days postoperative. There is higher blood loss with early surgery using an AIP approach, but early surgery did not affect PRBC transfusion and may not be clinically relevant. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of Obturator Vein Hemorrhage by Pubic Ramus Osteotomy During Acetabular Fixation - a Technical Trick.

It is known that hemorrhage from pelvic ring and acetabular fractures can cause hemodynamic instability. Methods to improve visualization and thus management of bleeding vessels are not commonly described. This report highlights techniques to manage hemorrhage from a retracted obturator vein during the definitive fixation of a complex acetabular fracture. After uncomplicated modified Stoppa anterior intrapelvic approach, abrupt and profuse bleeding was encountered from the distal end of a lacerated obturator vein, which had retracted into the obturator foramen. With unsuccessful attempts to achieve hemostasis, a superior pubic osteotomy was performed which allowed excellent visualization of the bleeding vein and ligation. It must be emphasized that the surgeon attempted all these other measures before performing an osteotomy. This technical trick contributes to the overall knowledge as a means of achieving emergent hemostasis associated with distal obturator vessel hemorrhage, a well described risk in complex acetabular fractures.

Morphometric measurements for potential dangers of anterior intra-pelvic approach in women: A cadaveric study.

This study aimed to improve the surgical anatomical knowledge of pelvic/acetabular trauma surgeons by providing detailed morphometric data on some of the most vulnerable arteries and nerves due to constant bony landmarks during anterior intra-pelvic approach fixation of acetabular fractures in women. Ten hemipelvis were dissected from 5 female cadavers. The following measurements relative to the symphysis were performed: (1) the distance of the corona mortis anastomosis and (2) the bisection of the external iliac vein with the pubic ramus. In addition, dis- tance to the pelvic brim at the level of pectineal convexity of the following structures was measured: (3) depth of obturatory neurovascu- lar bundle, (4) superior vesical artery, and (5) vaginal artery. Also, the clock position of the (6) gluteal superior and inferior vessels due to sciatic notch in the supine position. Due to antero-superior corner of sacroiliac joint (7) location of the common iliac artery bifurcation, (8) location of the bifurcation of internal iliac vessels to truncuses, (9) bifurcation of superior gluteal artery and lateral sacral artery, and (10) L5 nerve were measured. The descriptive statistics were given as medians and ranges as this is a descriptive anatomical study without comparisons. The median distance of corona mortis to symphysis pubis was 59.5 mm (range = 58-61). The external iliac vein bisected the pubic arm 68.5 mm (range=65-70) lateral to the symphysis pubis. At the level of pectineal convexity (about the middle of the pelvic brim), obturatory neurovascular bundle, superior vesical artery, and vaginal artery were 15 mm (range=13-16), 24 mm (range=23-25), and 36 mm (range=34-38) inferior to the pelvic brim, respectively. The superior gluteal vessels leave the sciatic notch at 12 o'clock position in supine position. Inferior gluteal vessels leave the sciatic notch at 31⁄2 o'clock position (given for left side). Common iliac artery bifurcation bisects the SI joint 5 mm (4-7) superior to antero-superior corner of the Sacro-iliac (SI) joint. The internal iliac artery gives its posterior trunk 18 mm (range=15-20) straightly anterior to antero-superior corner of the SI joint. Bifurcation of superior gluteal artery and lateral sacral artery was 11 mm (range = 10-12) away from the beginning of the posterior truncus. L5 root's medial margin was 9 mm (range = 7-10) medial to this landmark, where its lateral margin was on the SI joint (2 mm medial to 2 mm lateral). The majority of the bleeding complications of the major branches of the internal and external iliac arteries and neurologic palsies due to obturatory nerve and L5 nerve root damage within the operative field of the anterior intra-pelvic approach can be avoided or managed by utilizing morphometric data provided from this study. N/A.

Arthroplastie de la hanche en première intention pour fracture de la colonne antérieure en gériatrie, par abord antérieur combiné à une voie intra-pelvienne

BackgroundManagement of anterior column acetabular fracture in the elderly is challenging. Open reduction and internal fixation do not allow early weight-bearing and are associated with a high risk of failure compared to younger patients. Therefore, acute fixation and total hip arthroplasty may be an option. Material and methodThis technical note describes a combined procedure: anterior intrapelvic approach for fracture fixation and a direct anterior approach to the hip for THR. ResultsFracture reduction and arthroplasty were achievable in all five patients. The mean operative time was 289min, and the mean blood loss was 2120mL. At short term, no complication was noticed. ConclusionCombining these two “muscle-sparing” approaches could help manage anterior column fractures in elderly patients. Level of evidenceIV.

A new classification for quadrilateral plate fracture of acetabulum

BackgroundRecently, quadrilateral plate (QLP) fractures of acetabulum have attracted increasing attention. However, evidence for the appropriate classification of QLP fractures is still lacking, making it difficult to understand and manage these fractures. This study aimed to introduce a new classification for QLP fractures and evaluate its reproducibility. MethodsA series of 1101 consecutive patients with acetabular fractures from 8 level-I trauma centers were enrolled in this study. All patients underwent preoperative radiograph and computed tomography imaging. QLP fractures were identified and classified using the new and Judet-Letournel classification system. The inter- and intra-observer reliabilities (kappa coefficients, κ) of these two systems were investigated by 4 observers. Furthermore, surgical approaches and fixation methods for each fracture type are described. ResultsIn total, 243 (243/1101, 22%) patients with QLP fractures were identified and included in this analysis. The mean κ value of the intra-observer reliability was 0.84 (range, 0.763−0.919) for the new classification, indicating excellent agreement, and the inter-observer reliability was 0.762 (range, 0.625−0.876), indicating substantial agreement. The values were 0.649 (range, 0.523−0.708) and 0.584 (0.497−0.646), respectively, according to the Judet-Letournel classification. Six cases (6/243, 2.5%) could not be classified using the Judet-Letournel classification. The selection of surgical approaches and fixation methods depends on the fracture type; however, an anterior intra-pelvic approach and buttressing fixation using the plate or screw are preferred for QLP fractures. ConclusionThis study presents a new classification for QLP fractures, showing higher intra- and inter-observer reliabilities than those obtained using the Judet-Letournel classification. This allowed us to obtain an in-depth and comprehensive understanding of QLP fractures. Additionally, the new classification might guide further studies on surgical strategies for QLP fractures. Level of EvidenceLevel II

Acute total hip replacement by direct anterior approach combined with intrapelvic fixation for geriatric acetabular fracture of the anterior column

Management of anterior column acetabular fracture in the elderly is challenging. Open reduction and internal fixation do not allow early weight bearing and are associated with a high risk of failure compared to younger patients. Therefore, acute fixation and total hip arthroplasty may be an option. This technical note describes a combined procedure: anterior intrapelvic approach for fracture fixation and a direct anterior approach to the hip for THR. Fracture reduction and arthroplasty were achievable in all five patients. The mean operative time was 289min, and the mean blood loss was 2120mL. At short term, no complication was noticed. Combining these two “muscle-sparing” approaches could help manage anterior column fractures in elderly patients. Level of evidence: IV.

Surgical approach of T-type acetabular fractures does not affect quality of reduction on postoperative CT or the likelihood of postoperative complications

IntroductionT-type acetabular fractures are rare but challenging injuries. The purpose of this study was to evaluate for associations between chosen surgical approach for T-type acetabular fracture fixation, reduction quality, and complications. MethodsRetrospective, single institution study of T-type acetabular fractures who underwent surgical fixation. Surgical interventions included open reduction and internal fixation (ORIF) through an anterior intrapelvic approach (AIP) (modified Rives-Stoppa) and/or posterior (Kocher-Langenbeck [KL]), or percutaneous screw fixation. The primary outcome was reduction quality on routine postoperative computed tomography (CT) scan and postoperative complications. ResultsDuring the study period (March 2016 – October 2022), 22 patients presented with T-type acetabular fractures. Surgical approaches included AIP [31.8% (7/22)], percutaneous [27.3% (6/22)], AIP+KL [22.7% (5/22)], and KL [18.2% (4/22)]. On CT scans, 9.0% (2/22) had anatomic reductions, 27.2% (6/22) had fair reductions, and 63.6% (14/22) had poor reductions based on Matta Reduction Criteria. There was no observed difference in reduction quality between surgical approaches. Poor reductions (> 3 mm) were not associated with surgical approach, fracture classification, unstable pelvic ring injuries, posterior wall fractures, T-stem component, transverse component, preoperative articular displacement, preoperative femoral head protrusion, or surgeon experience. Complications occurred in 50.0% (11/22) of patients. No observed difference in complication rates was noted between the surgical approaches. ConclusionT-type acetabular fractures are challenging injuries with few patients achieving anatomic reduction on postoperative CT scans and half of patients developing complications.

Resection of Traumatic Triradiate Bar Led To Restored Triradiate Growth

Case: A 2-year-old boy suffered an injury to the acetabular physis resulting in the formation of an osseus bar across all 3 limbs of the triradiate, growth arrest, and secondary hip dysplasia. This condition was treated with bony bar resection using an anterior intrapelvic approach. Over a follow-up period of more than 3 years, there was notable restoration of triradiate cartilage growth. Conclusion: Our case demonstrates that resection of a triradiate bar can be an effective treatment of premature traumatic triradiate closure. Early recognition and intervention are preferable before secondary changes in the acetabulum have fully developed.

Osteoid osteoma of the quadrilateral surface of the medial wall of the acetabulum treated with the anterior intrapelvic approach

Acetabular osteoid osteoma is very rare entity. The author reports on a lesion in a 33-years-old lactating female after 12 months of delay in diagnosis. Its periarticular location on the quadrilateral surface of the medial wall and its proximity to the obturator neurovascular bundle made its accessibility by the available minimally invasive treatment options difficult and dangerous. Surgical access through the traditional hip approaches is infeasible. Stoppa intrapelvic approach allowed direct visualization and en bloc resection of the lesion. Pain disappeared immediately after surgery with rapid improvement of her function. Temporary traction obturator neuropraxia was the only complication encountered. Full functional recovery was detected after three months and continued till the latest one-year follow-up with no recurrence manifestations.

Full endoscopic anterior intrapelvic plate osteosynthesis: a cadaveric feasibility study

In this investigation, it was assumed that it must be possible to visualize the intrapelvic aspect as accustomed by pelvic surgeons using the anterior intrapelvic (modified Stoppa) approach. Moreover, it was hypothesized, that plate mountings will not only be possible for the symphysis but also at the supra- and infrapectineal aspect as well as to the posterior column. Ten anonymized cadaveric specimens were included in this study. A standard laparoscopic totally extraperitoneal (TEP) approach was used. A total of 10 landmarks were defined that are usually within reach in the open anterior intrapelvic (AIP) approach. Moreover, five different plate mountings were tested. The locations were chosen in accordance with the indication spectrum suitable for open surgery through the traditional AIP approach. It was possible to gain intrapelvic visibility in seven of ten cases. In all of those seven cases, it was technically possible to place plates to the symphysis, superior pubic ramus, as well as longer anterior column plates up to the aspect posterior of the acetabulum. In the last four of the seven cases, it was possible to mount plates to the infrapectineal aspect as well as the posterior column, too. The team, previously trained in arthroscopic surgical techniques as well as pelvic trauma surgery, observed a steep learning curve. This investigation demonstrated, that endoscopic anterior intrapelvic plate osteosynthesis was feasible in the majority of the cases in a series of ten cadaveric models. New instruments will be needed such as extra-long rasp elevators, ball-spikes as well as devices to hold and position plates and extra-long self-holding screwdrivers. With these, endoscopic pelvic surgery will likely be a realistic option for selected pelvic trauma cases in the future.

A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients

Aim and objectiveTo study the radiological and functional outcomes as well as complications in the management of fractures involving both columns of the acetabulum using a single surgical approach.DesignType IV, prospective clinical study.SettingLevel I trauma centre.Materials and methodsInclusion criteria were as follows: (a) patients over 20 year of age and (b) patients suffering from acetabular fractures involving both columns as per Letournel and Judet classification, namely transverse, transverse + posterior wall, T type, anterior column posterior hemi-transverse (ACPHT) and associated both columns. Exclusion criteria were as follows: (a) patient suffering from isolated anterior column, posterior column, anterior wall, posterior wall and posterior wall + column fractures; (b) patient who have undergone surgical procedures of the hip prior to trauma; and (c) compound acetabular fractures. A total of 23 patients having both column acetabulum fractures were included prospectively from June 2016 to December 2018 and followed up till 1 year postoperatively. Open reduction and internal fixation were performed through one of three described approaches, i.e., iliofemoral, Kocher-Langenbeck, and anterior intrapelvic or ilioinguinal.ResultsOur study population consisted of 30.4% transverse, 39.1% associated both columns, 21.7% T type and 8.7% anterior column + posterior hemi-transverse. Of these, 65.2% were operated using the Kocher-Langenbeck approach, while 30.4% of patients required the anterior intrapelvic approach. The remaining 4.3% of patients were operated by the iliofemoral approach. Anatomic reduction was achieved in 100% of our study population with remaining displacement less than or equal to 1°mm. At 1-year follow-up, all fractures showed a satisfactory union with an excellent Matta index in 100% study subjects. Complications at 1 year included one case of foot drop, which was present preoperatively but failed to improve and one case of post-traumatic arthritis. Average Harris Hip score (HHS) and mean Merle D'Aubigne (MDA) scores suggested good clinical outcomes in the study population.ConclusionsA single approach can be used to achieve good functional and radiological outcomes in carefully selected bicolumnar fractures of the acetabulum, with less approach-related morbidity.Clinical significanceTraditionally, multiple approaches are used for acetabulum fractures involving both columns, but with proper patient selection, single approach can be used with good functional and surgical outcomes.How to cite this articlePatil A, Attarde DS, Haphiz A, et al. A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients. Strategies Trauma Limb Reconstr 2021;16(3):152–160.

A device that facilitates screwing at an appropriate angle in quadrilateral surface fractures: 105-degree drill attachment.

Within this study, we aimed to investigate the radiological and functional outcomes of acetabular fractures involving quadrilateral surface using 105° drill attachment in the anterior intrapelvic approach. The 35 patients who underwent surgical treatment from January 2016 and January 2020 for acetabular fractures involving quadrilateral surface with anterior intrapelvic approach using 105° drill attachment and a minimum of 12 months of postoperative follow-up were included. Perioperative complications, operation duration, and the quality of reduction were evaluated. Reduction quality was classified as poor, imperfect, and anatomic. Functional evaluation was performed according to the Harris Hip Score (HHS) and Merle d'Aubigne Score. Among 35 patients (median age 36 (21-80)), radiological results of the acetabular fixations were anatomic, imperfect, and poor in 28 (80%), 5 (14.3%), and 2 (5.7%) patients, respectively. Postoperative 1-year functional outcomes with Merle d'Aubigne scores and HHS were median 18 (10-18) and 90 (60-96), respectively. The clinical outcomes of the patients showed concordance with reduction quality. The median operation duration was 180 minutes (range 125-270). Iatrogenic neurovascular damage was not noted in any patients. Reduction and fixation of deep intrapelvic fractures are risky and difficult due to the narrow anatomy and adjacent crucial neurovascular structures. As the 105-degree drill application is safe and easy to intervene in, short surgery duration and satisfactory results with minimum complications can be obtained with a 105 angulated drill in the deep pelvic region.

Anterior Intrapelvic Plating of the Sacroiliac Joint-A Cadaveric Quantification of Visualized Area with Case Series.

The objective of this study was to quantitatively describe the area available on the sacrum for reduction and plating using the Anterior Intrapelvic approach and describe its use clinically in a case series. The area available for plate and screw placement on 5 cadavers was on average 1007 ± 231 mm3. The cranial/caudal dimension at greatest length was 39.78 ± 6.91 mm, and the greatest length medial to the sacroiliac joint was 30.91 ± 3.43 mm. The major anatomic restraints to visualization were the S1 nerve root and the external and internal iliac vessels. Large fragment plates had an area overlying the sacrum of 360 mm3, and all sacrum had an area for at least two plates. The exposure was succesfully used for reduction, fixation and direct inspection of neural elements in 4 patients, demonstrating the anterior intrapelvic approach can be expanded to the lateral sacrum.

Anterior intrapelvic approach and suprapectineal quadrilateral surface plate for acetabular fractures with anterior involvement: a retrospective study of 34 patients

BackgroundThe purpose of the study is to evaluate the use of the suprapectineal quadrilateral surface (QLS) plates associated with the anterior intrapelvic approach (AIP) to the acetabulum in the surgical treatment of acetabular fractures with anterior involvement.MethodsWe did a retrospective study of patients surgically treated with QLS plates and AIP for acetabular fractures with the involvement of the anterior column, between February 2018 and February 2020, in our Hospital. The following data were recorded: mechanism of injury, the pattern of fracture, presence of other associated injuries, the time before performing the surgery, surgical approach, position on operating table, time of surgery, intraoperative bleeding, hospitalization time, intraoperative and postoperative complications. Follow-ups were performed at 1, 3, 6, 12 months, then annually. The clinical-functional outcome was assessed with the Merle d’Aubigne Postel score (MAP) modified by Matta; while the radiological outcome with the Matta Radiological Scoring System (MRSS). A Chi-square test was utilized to examine associations between parametric variables.ResultsWe included 34 patients, mean age 62.1, with an average follow-up of 20.7 months. The most frequent traumatic mechanism was road trauma. There were 15 isolated anterior columns and 19 associated patterns. There were 5 cases of associated visceral injuries, and 10 cases of other associated skeletal fractures. All patients were in the supine position. The surgical approach used was the AIP in all cases, with the addition of the first window of the ilioinguinal approach in 16 cases and of the Kocher-Langenbeck approach in 2 cases. The average time before performing the surgery was 8.5 days. The mean time of the surgery and the mean length of stay after surgery were 227.9 min and 8.2 days, respectively. There weren’t cases of intra-operative complications, while there were postoperative complications in 5 patients. The MRSS was judged anatomical in 26 cases, imperfect in 7 cases and poor in 1 case. The average MAP value was 15.2. We observed a significant relationship between the radiological outcome and the clinical outcome (p < 0.05).ConclusionsThe QLS plates in association with the AIP approach represent an effective treatment strategy for the treatment of acetabular fractures with anterior involvement.

Acetabular Fracture Involving the Quadrilateral Surface in the Elderly Treated with Supra-Pectineal Buttress Plate: A Center Experience

Due to their osteopenic bone, specific fracture patterns involving the quadrilateral plate are very frequent in acetabular fractures in elderly patients. This has led to a growth in the use of both anterior intrapelvic (modified Stoppa) approach and infra and supra-pectineal quadrilateral buttress plates was seen in recent years.

The influence of bone quality on radiological outcome in 50 consecutive acetabular fractures treated with a pre-contoured anatomic suprapectineal plate

PurposeTo investigate the range of indications of an anatomical-preshaped three-dimensional suprapectineal plate and to assess the impact of the bone mass density on radiologic outcomes in different types of acetabular fractures.Patients and methodsA consecutive case series of 50 acetabular fractures (patient age 69 ± 23 years) treated with suprapectineal anatomic plates were analyzed in a retrospective study. The analysis included: Mechanism of injury, fracture pattern, surgical approach, need for additional total hip arthroplasty, intra- or postoperative complications, as well as bone mass density and radiological outcome on postoperative computed tomography.ResultsMost frequently, anterior column fracture patterns with and without hemitransverse components as well as associated two column fractures were encountered. The anterior intrapelvic approach (AIP) was used in 98% (49/50) of the cases as primary approach with additional utilization of the first window of the ilioinguinal approach in 13/50 cases (26%). Determination of bone density revealed impaired bone quality in 70% (31/44). Postoperative steps and gaps were significantly greater in this subgroup (p < 0.05). Fracture reduction quality for postoperative steps revealed anatomic results in 92% if the bone quality was normal and in 46% if impaired (p < 0.05). In seven cases (14%), the plate was utilized in combination with acute primary arthroplasty.ConclusionA preshaped suprapectineal plate provides good radiological outcomes in a variety of indications in a predominantly geriatric cohort. Impaired bone quality has a significantly higher risk of poor reduction results. In cases with extensive joint destruction, the combination with total hip arthroplasty was a valuable option.

Outcomes of Direct Infrapectineal Buttress Plate for Quadrilateral Surface Fractures of Acetabulum Using an Anterior Intrapelvic Approach.

PurposeReduction and stable fixation of the quadrilateral plate are challenging primarily due to its location in the true pelvis, limited bone stock, juxta-articular nature, and its comminution. The current study aimed to investigate the quality of reduction and functional outcomes after open reduction and internal fixation (ORIF) with infrapectineal buttress plating of the quadrilateral surface via an anterior intrapelvic approach.Materials and MethodsWe conducted a retrospective review of twenty-one patients with acetabular fractures involving quadrilateral plate operated at Ghurki Trust Teaching Hospital between January 2017 and December 2018. Radiological assessment of the quality of reduction was conducted using criteria described by Matta. Functional outcomes were evaluated using a modified Postel Merle d'Aubigné score.ResultsThe current study included 15 males and 6 females with a mean age of 40.67±12.17 years (range, 22–62 years). The most common fracture pattern was anterior column and posterior hemi-transverse in eight patients followed by true bicolumn and T-type fractures in seven and four patients respectively. Both transverse fractures were transtectal. The quality of reduction according to Matta criteria was anatomical in 14 patients, imperfect in five and poor in two. Functional outcomes were excellent in 47.6% cases, good in 42.9%, and fair in 9.5% cases. Both patients with fair outcomes had non-anatomical reduction, and one required total hip arthroplasty at a later time.ConclusionQuadrilateral plate reconstruction with an infrapectineal buttress plate applied though an anterior intrapelvic approach provides high rates of anatomical reduction and yields good functional outcomes.

Treatment sequence of combined pelvic injury, consisted of upper pubic ramus fracture, sacroiliac joint dislocation with open book injury, using Stoppa approach

Among pelvic serious injuries is the so-called “open book” injury of the pelvis, with Sacroiliac Joint Disruption (SIJD) in combination with upper pubic ramus or anterior column fracture, contralateral or ipsilateral, or both. This combination of pelvic injury could be classified according Young and Burgess classification as LCIII or CM type (Combined Mechanism) and as 61-B3.1 61-B3.2 following AO/OTA classification. Specifically, the upper pubic ramus fracture can be classified according to Nakatani classification as type I medial of the foramen, type II within the foramen and type III lateral to the foramen. The difficulty to deal with these fractures is how to close and reduct the pubic symphysis in mechanically stable way since there is fracture in one or both the upper pubic ramus. The existence of these fractured elements, in this type of pelvis injury allow a lot of degrees of freedom which must be managed from the surgeon in the proper sequence. The incision and the approach are also mandatory for successfully treating these lesions. Anterior Intrapelvic Approach (AIP) or Stoppa approach in conjunction with the first window of ilioinguinal approach is the most appropriate surgical exposure for reduction and fixation.

Sequential ilioinguinal or anterior intrapelvic approach with anterior approach to the hip during combined internal fixation and total hip arthroplasty for acetabular fractures.

This study examined the complications and outcomes of geriatric acetabular fractures treated with open reduction internal fixation (ORIF) and total hip arthroplasty (THA) performed via combined ilioinguinal or anterior intrapelvic (AIP) approach to acetabulum and anterior approach to the hip. Eight patients with a fracture of the acetabulum were treated at a Level I trauma center between 2010 and 2019 with combined ORIF/THA using an ilioinguinal or AIP approach for the acetabulum and a separate anterior approach to the hip. Wound dehiscence, peri-incisional skin necrosis, surgical site infection, dislocation, fracture union, acetabular component stability, and heterotopic ossification (HO) were utilized as outcome measures. Merle d'Aubigné-Postel scores were collected for the six patients that had one-year minimum follow-up. The mean patient age was 77years. Four patients had anterior wall fractures, two had associated both column fractures, and two had anterior column-posterior hemitransverse fractures. All fractures healed with stable fixation of the acetabular component by 6 months. There were no instances of skin necrosis, dislocation, infection, or re-operation. One patient had a superficial wound dehiscence that resolved with local wound care. One patient developed radiographic HO but was clinically asymptomatic. The mean Merle d'Aubigné-Postel score was 15.8 (range = 14-16). Our small series of geriatric patients with fracture of the acetabulum treated with combined ORIF/THA, via the ilioinguinal or AIP approach with a separate anterior approach to the hip, demonstrates satisfactory outcomes with low complications after one-year of follow-up. Further research of these challenging injuries with more patients is warranted in order to determine the subset of fracture types best treated with this method and THA survivorship.