Ilioinguinal Approach Research Articles

Digital anatomical study and clinical application of screw placement for quadrilateral plate fractures in the danger zone

BackgroundDirect screw placement for quadrilateral plate fractures in the danger zone of the acetabulum is very difficult. This study was performed to simulate the surgical procedure and try to obtain effective and safe screw angles through the middle window of the ilioinguinal approach in Chinese patients.MethodsWe randomly collected the pelvic computed tomography (CT) scans of 100 adults. DICOM-formatted CT-scan images were imported into Mimics software. The three-dimensional reconstruction (3D) digital model of the semi-pelvis was established. A 3.5 mm cylinder was used to simulate the pathway of the screw from the designated insertion point. The angles of insertion and intersex differences were explored by statistical analyses.ResultsThe screws could be inserted via three angles: medial inclination, anterior inclination and posterior inclination. The mean minimum medial inclination angle (MIMIA) of insertion point A was 4.96° ± 1.11° in males and 8.66° ± 3.40° in females, and the intersex difference was significant. The mean minimum medial inclination angle (MIMIA) of insertion point B was − 5.31° ± 3.69° in males and 1.75° ± 8.95° in females, and the intersex difference was significant. There were no differences between any of the angles for males and females at insertion point O.ConclusionsPreoperative measurement and calculation by digital tools before screw placement for quadrilateral plate fractures of the acetabulum are feasible. Double cortical screws could be placed safely in the danger zone through the middle window of the ilioinguinal approach to increase the stability of the acetabulum.

Which Anterior Acetabular Fracture Surgical Approach is Preferred? A Survey of the Orthopaedic Trauma Association Active Membership.

The goal of this survey was to determine the current surgeon-preferred anterior surgical approach for the treatment of acetabular fractures in North America. Web-based survey; PARTICIPANTS:: Orthopaedic Trauma Association (OTA) members. Active members of the OTA were solicited to participate in an OTA-sponsored survey asking for their preferred standard anterior surgical approach to the acetabulum, along with some general demographic data. The approach choices were: the classic ilioinguinal as described by Letournel, a modified ilioinguinal, the modified Stoppa (Anterior Intrapelvic) with or without a lateral window, the pararectus, and an alternative to be specified by the survey taker. Of the 675 total active OTA membership, 214 (32%) satisfactorily completed the survey. Of the 214 active members, only 32 (15%) prefer the classic ilioinguinal approach and 60 (28%) prefer some type of modified ilioinguinal approach. More than half of the active member respondents (121; 56.5%) prefer the modified Stoppa approach. Statistical analysis of the respondents' demographic data revealed only years in practice to be significantly different among treatment options (P < 0.01) with those with the least time in practice preferring the modified Stoppa. It seems that the modified Stoppa has become the preferred anterior acetabular fracture surgical approach in North America, being especially favored by those more recently in practice. The exact reasons for this change cannot be determined from this survey and are most likely multifactorial. However, training experience may play an important role.

Single Ilioinguinal Approach to Treat Complex Acetabular Fractures with Quadrilateral Plate Involvement: Outcomes Using a Novel Dynamic Anterior Plate-Screw System.

ObjectivesTo evaluate the efficacy and safety of a novel fixation technique referred to as the dynamic anterior plate–screw system for quadrilateral plate (DAPSQ) for complex acetabular fractures with quadrilateral plate involvement through the single ilioinguinal approach.MethodsA total of 32 patients with acetabular fractures, selected between January 2009 and March 2016, were managed by DAPSQ with “quadrilateral screws” through single ilioinguinal approach. The primary outcomes measure was the reduction quality evaluated according to the Matta radiological criteria, and the functional outcomes were evaluated by the modified Merle d'Aubigné score at the last follow‐up. Secondary outcomes were postoperative complications and intraoperative conditions included, for instance, operation time and blood loss.ResultsOf these 32 consecutive patients, 19, 9, and 4 were classified as both columns, anterior column posterior hemi‐transverse, and T‐shaped fractures, respectively, and with an average of 47 months’ follow‐up. Anatomic reduction was obtained in 19 cases (59%), imperfect reduction in 9 cases (28%), and poor reduction in 4 cases (13%). The modified Merle d'Aubigné scores were excellent in 15 cases (47%), good in 13 cases (41%), fair in 2 cases (6%), and poor in 2 cases (6%). Three cases sustained temporary lateral femoral cutaneous nerve injuries. One patient had a superficial wound infection that resolved after debridement. Five patients had posttraumatic arthritis; one of them underwent total hip arthroplasty at 46 months. No cases had quadrilateral screws entering the hip joint.ConclusionThe use of DAPSQ with quadrilateral screws is an effective and safe choice for complex acetabular fractures with quadrilateral plate involvement through the single ilioinguinal approach.

Results of Modified Ilioinguinal Approach in Management of Acetabular and Pelvic Fractures (A Systematic Review and meta-analysis of Literature)

Abstract Background Modified ilioinguinal approach was introduced to manage anterior acetabular fractures to reduce the morbidity &amp; complications of the classic ilioinguinal approach, a less invasive anterior approach consisting of a medial window combined with the lateral window of the ilioinguinal approach. Aim of the Work a systematic review to determine whether the modified ilioinguinal approach is better the classic ilioinguinal approach in managing traumatic acetabular fractures by comparing the results in each study. Materials and Methods 5 studies(from 2010-2017) were included &amp; reviewed the results of 147 patients operated by modified ilioinguinal approach in terms of: operative details, intraoperative &amp; postoperative complications, postoperative reduction quality &amp; final clinical outcome assessment, &amp; results was analyzed &amp; pooled together to reach a satisfactory outcome. Results Modified ilioinguinal approach showed operative time (123.2±6.83 minute), relatively small amount of blood loss (200-1000 ml) &amp; better quality of reduction (84.8% had anatomical reduction, 10.9% had fair reduction, and 4.3% had poor reduction). However there were no significant differences in terms of postoperative complications &amp; final clinical outcome assessment between different studies. Conclusion It was concluded that the modified ilioinguinal approach allowed reduction of anterior column and pelvic ring fractures without requiring dissection through the inguinal neurovascular structures. Results showed that its possible with this approach to reach safe reduction and stable fixation.

Application of self-made spring plate for treatment of acetabular posterior wall fractures

To investigate the application and effectiveness of self-made spring plate in surgical treatment of acetabular posterior wall fracturejavascript:void(0)s. Between June 2013 and June 2017, 38 patients with acetabular posterior wall fractures were treated. There were 27 males and 11 females with an average age of 53 years (range, 28-68 years). The injury caused by traffic accident in 18 cases, falling from height in 15 cases, and tumble in 5 cases. There were 4 cases of simple posterior wall fracture, 18 cases of posterior wall fracture with posterior dislocation of hip joint, 10 cases of posterior wall fracture with posterior column fracture, and 6 cases of posterior wall fracture with transverse fracture. The time from injury to admission was 1-4 days (mean, 2.5 days). The time from injury to operation was 4-8 days (mean, 5 days). After fracture reduction via the Kocher-Langenbeck approach (35 cases) or the combined ilioinguinal approach (3 cases), the spring plate was used to press the posterior wall fracture, and then the reconstruction plate was pressed against the spring plate and fixed to the posterior column. All the incisions healed by first intention. All patients were followed up 12-36 months (mean, 28 months). Five cases of post-traumatic sciatic nerve injury and 2 cases of sciatic nerve injury caused by traction during operation were fully recovered at 3 months after operation. The imaging examination showed that all the fractures healed. The fracture healing time was 10-16 weeks (mean, 12 weeks). There was no ruptures or failures of internal fixation during the follow-up period. There were 2 cases of femoral head necrosis, 1 case of traumatic arthritis, and 1 case of osteomyositis at last follow-up. The hip joint function was rated as excellent in 27 cases, good in 5 cases, fair in 2 cases, and poor in 4 cases according to the Harris scores at 12 months after operation. For the acetabular posterior wall fracture, it has the advantages of easy to use and reliable fixation that the posterior wall fracture is fixed with spring plate firstly, and the spring plate is pressed to fix the posterior column with the reconstruction plate finally.

Meta-analysis of modified Stoppa approach and ilioinguinal approach in anterior pelvic ring and acetabular fractures.

Background:The purpose of this meta-analysis was to compare the efficacy of the modified Stoppa approach (MSA) and ilioinguinal approach (IA) in the treatment of anterior pelvic ring and acetabular fractures.Methods:A literature search was conducted using PubMed, Embase, and Cochrane database for articles that compared MSA and IA in the treatment of anterior pelvic ring and acetabular fractures. All the included articles were evaluated by 2 trained reviewers in accordance with the Cochrane Collaboration Handbook for potential risk. The Jadad decision algorithm and Downs and Black scores were also used to assess the quality of the included studies. The extracted data included operative time, intraoperative blood loss, reduction quality, clinical outcome, and complications.Results:Five articles were included in this meta-analysis, with 186 patients in the MSA group and 219 patients in the IA group. Compared with IA, MSA significantly shortened the operative time (P = .0002), decreased intraoperative blood loss (P = .002), and provided better reduction quality (P = .03). Meanwhile, this meta-analysis suggests no significant difference between MSA and IA regarding clinical outcomes (P = .63) and complications (P = .34). The subgroup analysis of complications also showed no statistically significant difference between the 2 groups (including infection, and vascular and nerve injuries).Conclusion:According to this meta-analysis, the currently available evidence suggests that MSA can significantly shorten operative time, decrease intraoperative blood loss, and provide better reduction quality than IA in the treatment of anterior pelvic ring and acetabular fractures. In addition, in terms of clinical outcomes and complications, no significant differences were found between the 2 groups.Level of Evidence: Level IV, meta-analysis.

Nerve Injury With Acetabulum Fractures: Incidence and Factors Affecting Recovery.

To determine factors associated with nerve injury after acetabulum fracture and to evaluate recovery and outcomes. Retrospective cohort study. Level 1 trauma center. Nine hundred seventy-five skeletally mature patients with acetabulum fracture. Operative and nonoperative management. Nerve injuries, categorized as traumatic or iatrogenic, recovery (none, partial, or complete), and patient-reported functional outcomes with the Musculoskeletal Function Assessment (n = 353, 36.2%). Thirty-two patients (3.3%) experienced nerve injury with 24 (78%) resulting from trauma and 23 with an associated posterior hip dislocation. Eight injuries (25%) were iatrogenic. Thirty-one (97%) occurred in patients with operative fractures (n = 738). The most common fracture pattern associated with nerve injury was transverse posterior wall (31% of injuries). Obesity was more common in patients with nerve injuries (59% vs. 30% in those without nerve injury (P = 0.001), but was not related to age or sex. Sixty-five percent of sciatic nerve injuries were to the common peroneal division only, while none were isolated to the tibial division. All iatrogenic injuries occurred after the ilioinguinal approach (P < 0.001). Overall, 50% experienced partial nerve recovery and 22% had complete recovery. However, 24% of patients with sciatic or common peroneal injuries had no recovery. Thirty-three percent of tobacco smokers experienced no recovery (vs. 26% of nonsmokers). Average Musculoskeletal Function Assessment scores for patients with nerve injuries was 32, similar to those without (33). Posterior acetabulum fracture dislocations are associated with traumatic nerve injury, although 25% of nerve injuries were iatrogenic. Nerve injuries are more common in obese patients. More than one-quarter of patients had no recorded nerve recovery. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Safe Zones for Anterior Acetabular Retractor Placement in Direct Anterior Total Hip Arthroplasty: A Cadaveric Study.

There is paucity of literature evaluating anterior acetabular retractor proximity to the femoral nerve and external iliac vessels during total hip arthroplasty through the direct anterior approach. In this cadaveric study, we evaluated three retractor locations to identify optimal positioning of anterior retractors. A direct anterior approach was performed in 22 hips of 15 cadavers. Anterior acetabular retractors were placed over the anterior acetabular wall in-line with the femoral neck (12-o'clock or middle position). The anterior neurovascular structures were identified through the ilioinguinal approach. Retractors were reinserted at 10-o'clock (right hip; superior) and 2-o'clock (right hip; inferior) locations marked using K-wires. Horizontal and vertical distances from retractor tip positions to neurovascular structures were measured with a digital caliper. Retractor tips moved significantly from lateral to the femoral nerve when placed in the superior position (mean, 2.8 mm) to medial to the femoral nerve in the middle (mean, -2.3 mm) and inferior (mean, -4.8 mm) locations. Retractor tips moved significantly medial toward the external iliac artery when retractors were moved from superior (mean, 15.3 mm) to inferior (mean, 6.6 mm) positions placing the retractor tip closer to the vessels. As retractor placements moved inferior, retractor tips moved medial to neurovascular structures. Inferior retractor positioning placed the femoral nerve and external iliac artery at the risk of injury during the initial retractor placement or adjustment. Retractors should be placed in a relative safe zone superior to the 12-o'clock position to avoid damage to neurovascular structures. IV.

The Pararectus Approach in Acetabular Surgery: Radiological and Clinical Outcome

To evaluate radiological fracture reduction and clinical results using the pararectus approach in complex acetabular fractures involving the anterior column. Retrospective database analysis of prospectively collected data. Level 1 trauma center. 61 patients (48 male and 13 female) with a median age of 55 (range 17-91) years were included. According to the chosen surgical approach, they were divided into 2 groups. The P-group included 43 patients, among them 32 male and 11 female patients with a median age of 55 (range 17-90) years. Eighteen patients [16 male, 2 female; median age: 53 (range 23-91) years] were treated through the ilioinguinal approach (I-group). Anterior surgical procedures through the pararectus or the ilioinguinal approach. Reduction results were rated according to the modified Matta criteria using a measurement protocol of hip joint gaps and steps in computed tomography scans. Operation time, complications, and clinical outcomes median one year postoperatively were compared. In the pararectus group reduction was anatomical in 21 out of 40 analyzed patients (52.5%), imperfect in 11 patients (27.5%), and poor in 8 patients (20%). The mean joint step reduction was 3.7 mm, and the mean joint gap reduction was 12.1 mm. In the ilioinguinal group reduction was anatomical in 9 out of 18 patients (50%), imperfect in 4 patients (22%), and poor in 5 patients (28%). The mean joint step reduction was 1 mm, and the mean joint gap reduction was 7 mm. Operation time was significantly shorter in the P-group (mean: 49 minutes; P < 0.001). This study indicates that acetabular fracture reduction using the pararectus approach is at least comparable with the ilioinguinal approach independent of patients' age. A relevant advantage of the pararectus approach was seen in a significantly shorter operation time. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treatment of complex acetabular fractures involving the posterior column by anterograde lag screws via the ilioinguinal approach

Objective To evaluate the treatment of complex acetabular fractures involving the posterior column by anterograde lag screws via the ilioinguinal approach. Methods A retrospective study was conducted of the 8 patients with complex acetabular fracture involving the posterior column who had been treated at Department of Orthopaedics, The Second Affiliated Hospital to Inner Mongolia Medical University from January 2017 to June 2018. They were 5 males and 3 females, aged from 35 to 62 years (average, 43.5 years). According to the Letournel-Judet classification, 3 cases were T-shaped fractures, 4 anterior column plus posterior hemitransverse fractures and one both column fracture. The interval from injury to operation averaged 8 days (from 7 to 17 days). The anterior acetabulum was fixated by a reconstruction plate and the posterior column by antegrade lag screws, all through the ilioinguinal approach. The quality of fracture reduction, fracture union time, function of the affected hip and complications were recorded. Results By the Matta imaging criteria, the quality of fracture reduction was rated as excellent in 7 cases and as fine in one. Intraoperative major hemorrhage or injury to sciatic nerve occurred in none of the patients. This cohort obtained an average follow-up of 8 months (from 6 to 18 months). All fractures united well after an average of 10 weeks (from 8 to 12 weeks). The function of affected hip evaluated by the improved Merle d’Aubigne & Postel criteria at the last follow-up was excellent in 7 cases and fine in one. Follow-ups revealed no incidence of deep vein thrombosis or heterotopic ossification. Conclusions For patients with complex acetabular fracture involving the posterior column, internal fixation of the anterior acetabulum with a reconstruction plate through the ilioinguinal approach and fixation of the posterior column with antegrade lag screws also through the ilioinguinal approach can result in fine therapeutic effects, because complications like ectopic ossification and sciatic nerve injury related to the Kocher-Langenbeck approach can be prevented. This treatment is particularly suitable for the patients whose condition of the soft tissues at the posterior pelvis is poor. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Bone nails; Surgical approach

Combined anterior and posterior approach revision for complex acetabular fractures

Objective To investigate the clinical effect of combined anterior and posterior approach revision on complex acetabular fractures. Methods A retrospective case series study was performed on the clinical data of 21 patients with complex acetabular fractures who underwent failed surgery through single approach from June 2012 to June 2017. There were 16 males and five females, averagely aged 34.6 years (range, 24-45 years). According to Letournel-Judet classification, there were seven patients with transverse+ posterior wall fracture, five patients with anterior column+ posterior semi-transverse fracture, four patients with double column fracture and five patients with T fracture. The first operation was performed by ilioinguinal approach in nine patients and by Kocher-Langebeck (K-L) approach in 12 patients. Revision surgery was performed using a combined anterior and posterior approach. The operation time and intraoperative blood loss were recorded, and the fracture healing was observed. The quality of fracture reduction was assessed according to Matta reduction criteria, and hip function by the modified D Aubigne and Postel score. The complications during and after operation were recorded. Heterotopic ossification was evaluated according to Brooker's criteria. Results The patients were followed up for 12 to 36 months, with an average of 27 months. The operation time ranged from 180 to 360 minutes, with an average of 270 minutes. Intraoperative bleeding was 1 000-3 800 ml, with an average of 2 000 ml. Fractures were healed, with the healing time ranging from 3.5 to 7 months, with an average of 5 months. According to Matta reduction criteria, there were eight patients with anatomical reduction, 12 with satisfactory reduction and one with unsatisfactory reduction. The improved D Aubigne and Postal score was (11.1±1.9)points preoperatively and (15.6±1.7)points six months after operation (P<0.05), the outcome of hip function was excellent in three patients, good in 14, fair in three, and poor in one, with the excellent and good rate of 81%. There were three patients with transient injury of sciatic nerve, one patient with traumatic arthritis and one with heterotopic ossification of Brooker II. No femoral head necrosis or deep venous thrombosis in the lower extremities was found. Conclusion For complex acetabular fractures, combined anterior and posterior approach revision can promote fracture reduction, fracture healing, and functional recovery, with low incidence of complications. Key words: Acetabulum; Fracture fixation, internal; Reoperation

Direct anterior decompression of L4 and L5 nerve root in sacral fractures using the pararectus approach: a technical note.

To describe a new surgical technique for neurolysis and decompression of L4 and L5 nerve root entrapment after vertical sacral fractures via the pararectus approach for acetabular fractures, and to present four case examples. We retrospectively evaluated four patients suffering radiculopathy from entrapment of the L4 or L5 nerve root in vertical sacral fractures between January and December 2016. The mean follow-up period after surgery was 18 (range 7-27) months. All patients underwent direct decompression and neurolysis of the L4 and L5 nerve roots via the single-incision, intrapelvic, extraperitoneal pararectus approach. In all patients, the L4 and L5 nerve root was successfully visualized and decompressed, proving feasibility of the pararectus approach for this indication. No patient presented with a neural tear. Completeneurologic recovery was present in one patient at last follow-up; two patients had incomplete recovery of their radiculopathy; and one patient had no improvement after nerve root decompression. The pararectus approach allows for sufficient visualisation and direct decompression and neurolysis of the L4 and L5 nerve root entrapped in vertical sacral fractures. Although neurologic recovery was not achieved in all patients in this small case series, the approach may be a suitable alternative to posterior approaches and other anterior approaches such as the lateral window of the ilioinguinal approach.

Technique de réduction des fractures de l’acétabulum à déplacement antéro-médial utilisant un clamp colinéaire par voie ilio-inguinale modifiée

The authors present a surgical technique using a collinear reduction clamp through the modified ilioinguinal approach (MIA) for anteromedially displaced acetabular fractures along with the surgical outcomes. Between October 2010 and June 2015, 15 patients underwent surgical treatment for anteromedially displaced acetabular fractures; 10 both-column fractures and 5 anterior column and posterior hemitransverse fractures. Anteriorly displaced anterior column fragment and medially displaced quadrilateral plate fragment were simultaneously reduced using a collinear clamp and fixed with a 3.5 mm-reconstruction plate through MIA. Postoperatively, anatomical reduction was achieved in 12 patients, while imperfect reduction was achieved in 3. At a mean follow-up of 49.0 months (range, 24–93 months), the mean Postel Merle d’Aubigné score were 16.3 and the mean VAS score was 0.9. Final radiographic grades according to Matta system were excellent in 13 patients and good in 2. Surgical technique using a collinear reduction clamp through the MIA can provide satisfactory outcomes in anteromedially displaced acetabular fractures.

Modified Stoppa approach for acetabular fracture fixation – reduction techniques

Introduction: Since acetabular fractures are intra-articular, accurate anatomic reduction is essential to achieve a good functional outcome. Among the various surgical approaches, ilioinguinal and modified Stoppa approaches are the only available intra-pelvic approaches. Even though ilioinguinal approach is more commonly used, modified Stoppa approach is becoming more popular due to the possibility of visualising and reducing quadrilateral plate fragments as well as fixation of posterior column through anterior approach. The aim of our study was to assess the efficacy of various reduction tools/ techniques for reduction and fixation of fractures operated using modified Stoppa approach. Materials and Methods: We have operated on 16 patients with acetabular fractures through modified Stoppa approach in the age group of 19 years to 70 years (mean 42 years) with male female ratio of 13:3. In patients requiring combined approach, the anterior approach was done first. In all the patients, modified Stoppa was combined with a lateral window. We have used various reduction techniques including transtrochanteric Schanz pin, intra-focal elevators, ball spike, bone hook, iliac crest Schanz pin, Farabeuf forceps, undercontoured plate, etc. Results: Matta’s radiographic reduction criteria showed anatomic reduction in 10 cases. Clinical assessment using Merle d’ Aubigne scoring showed excellent results in 9 cases and good results in 6 cases. Follow up was done for a maximum period of six months. Conclusion: Modified Stoppa approach provides better visualisation of quadrilateral surface and sciatic buttress when compared to the ilioinguinal approach. The use of appropriate reduction techniques helps in achieving good reduction of anterior column, at the same time provides opportunity to fix the posterior column from the anterior aspect using anterior to posterior column screws, obviating the need for a separate posterior approach. Keywords: Modified Stoppa, Acetabulum,

Early Total Hip Arthroplasty for the Treatment of Acetabular Fractures

AbstractEarly total hip arthroplasty in patients with acetabular fractures is considered in rare situations with specific indications. Generally, this treatment option is considered in patients older than 55 or 60 years, but the physiological age must also be considered. The patient should be functional and ambulatory before the injury and healthy enough to tolerate the insult of a surgical procedure of this magnitude. Preexisting conditions such as osteoporosis and osteoarthritis encourage consideration of total hip arthroplasty. Specific injury patterns are predictive of fixation failure in older patients with acetabular fractures. These findings represent worse articular injury and low bone density that would intuitively lead to failure. This “gull sign” or “seagull sign” describes either the central–superior dome impaction seen in high-transverse fractures or the impaction of the subchondral bone on the intact edge of a partial posterior column fracture. Other radiographic predictors of failure in posterior wall fractures include comminution of more than three fragments, involvement of the superior dome in high posterior wall fractures, and marginal impaction. Older patients have a high incidence of these radiographic findings, predictive of fixation failure without arthroplasty. Other injury characteristics including concomitant displaced femoral neck fracture and femoral head injury are also indications for total hip arthroplasty in older patients. Acute hip arthroplasty can be performed using the posterolateral, direct lateral, anterolateral, and anterior approaches to the hip. There are also reports of patients who underwent combined approaches to the hip for stabilization of the injury using the anterior intrapelvic approach and ilioinguinal approach. Combined approaches are generally not recommended. Extended approaches are not recommended or necessary for early arthroplasty in acetabular fractures. This review article highlights recent trends of early total hip arthroplasty in senior patients with acetabular fracture, and the indications for the procedure, complications, clinical outcomes, and technical considerations, with cases to highlight these concepts.

Treatment of complex quadrilateral surface fractures of the acetabulum by internal fixation with dynamic anterior plate-screw system

Objective To explore the clinical efficacy of internal fixation with dynamic anterior plate-screw system for quadrilateral area(DAPSQ) in the treatment of complex acetabular fractures involving the quadrilateral surface. Methods Between January 2005 and January 2017, a series of 143 patients with complex quadrilateral surface fracture of the acetabulum were treated at Department of Orthopaedics, General Hospital of Central Theater Command. They were 86 males 57 females, with a mean age 46.6 years (range, from 19 to 77 years). By the Letournel-Judet classification, there were 38 anterior column plus posterior hemitransverse fractures, 26 T-shaped fractures and 79 double column fractures. They were all closed. The delay from injury to surgery averaged 9.6 days(range, from 3 to 21 days). All the cases were treated with DAPSQ internal fixation via the ilioinguinal approach. Their operation time, intraoperative bleeding volume, quality of fracture reduction, hip function and complications were recorded. Results The operation time for this series ranged from 2.5 to 5.0 hours, averaging 3.8 hours. The intraoperative blood bleeding ranged from 400 to 2,500 mL, with an average of 680 mL. By the Matta criteria for fracture reduction, 76 cases were rated as excellent, 51 as good and 16 as poor, giving an excellent and good rate of 88.8%. The 143 patients were followed up from 4 months to 10 years (mean, 4.1 years). The clinical fracture union was achieved after 2 to 4 months (mean, 3 months). By the modified Merle d’Aubigne & Postel criteria, the affected hips scored 9 to 18 points (mean, 16.3 points) at the final follow-ups, with 64 excellent, 52 good, 19 fair and 8 poor cases, giving an excellent and good rate of 81.1%. The postoperative complications included lesion of lateral femoral cutaneous nerve in 7 cases, urinary tract infection in 15 ones, traumatic osteoarthritis in 20 ones 5 of whom had to receive total hip arthroplasty, and heterotopic ossification (Brooker Grade Ⅰ) in 5 ones. Conclusion Internal fixation with DAPSQ is safe and effective for the treatment of complex acetabular fractures involving the quadrilateral surface. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Bone plates; Bone nails

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

Open Reduction and Internal Fixation of Acetabular Fractures Using the Modified Stoppa Approach.

The modified Stoppa approach is performed for safe and efficient management of acetabular fractures involving the anterior column. This approach avoids dissection of the inguinal canal, the femoral nerve, and the external iliac vessels as seen in the "second window" of the ilioinguinal approach and has thus been shown to be less invasive than the ilioinguinal approach1. As an intrapelvic approach, it facilitates the management of medial displacement fracture patterns involving the quadrilateral plate and dome impaction that typically occur in the elderly2,3. The reduced morbidity of this approach is of particular relevance for elderly patients who must respond to the stresses of injury and surgery with diminished physiological reserves. The specific surgical steps include preoperative planning, patient positioning and setup, a Pfannenstiel incision, superficial and deep dissection, development of the Retzius space and retraction of the bladder, exposure of the superior pubic ramus and iliopectineal eminence, dissection and ligation of a potential corona mortis, exposure of the obturator nerve and vessels, subperiosteal preparation of the pubic ramus with retraction of the external iliac vessels, subperiosteal exposure of the quadrilateral plate with detachment of the internal obturator muscle and exposure of the posterior column, assessment of residual displacement by fluoroscopic views, longitudinal soft-tissue or lateral skeletal traction (optional) for reduction of medial displacement of the femoral head, disimpaction of the acetabular dome fragment and grafting of the supra-acetabular void (optional) under fluoroscopic and arthroscopic (optional) control, and reduction and fixation of extra-articular components (iliac wing posteriorly and pubic ramus anteriorly), the posterior column (infra-acetabular screw), and the quadrilateral plate (buttress plate). Before wound closure, the urine output is checked for occurrence of hematuria, an indication of bladder penetration. The anterior lamina of the rectus sheath is then sutured, and a layered closure performed. The ilioinguinal approach might be used instead. The modified Stoppa approach avoids dissection within the inguinal canal, the second window of the ilioinguinal approach. Therefore, this approach is less invasive and might be an alternative for joint-preserving surgery, especially in the elderly.

Open reduction and internal fixation for acetabular fractures complicated with injury to lower urinary tract: short-term outcomes

Objective To investigate the short-term outcomes and surgical timing in patients who were treated by open reduction and internal fixation (ORIF) for acetabular fractures complicated with injury to lower urinary tract. Methods A retrospective analysis was conducted of the 14 patients with acetabular fracture complicated with lower urinary tract injury who had been treated at Department of Orthopaedics, The First Affiliated Hospital to Nanjing Medical University from January 2011 to September 2017. They were 12 males and 2 females, with an average age of 40.3 years (from 30 to 56 years). According to Letournel-Judet classification, there were one anterior column, 2 transverse, 3 anterior column plus posterior hemi-transverse, one T-shaped, 5 associated both-column and 2 transverse plus posterior wall fractures. The time from injury to surgery ranged from 6.0 to 30.5 days, with an average of 13.4 days. Of the 8 patients with bladder injury undergoing internal fixation of the acetabulum, a modified ilioinguinal approach combined with a Kocher-Langenbeck approach was used in 4, a single modified ilioinguinal approach in 3, and a Stoppa approach combined with an iliac fossa approach in one; of the 6 patients with urethral rupture undergoing internal fixation of the acetabulum, a modified ilioinguinal approach combined with a Kocher-Langenbeck approach was used in 3, a single modified ilioinguinal approach in one, a Kocher-Langenbeck approach in one and a Stoppa approach in one. The fracture union time, outcomes and complications were recorded. Results The mean follow-up time for the 14 patients was 27.2 months (from 12 to 60 months). The fracture union time ranged from 3.0 to 4.5 months, averaging 3.5 months. According to the Majeed’s scoring, the pelvic function at the final follow-up was excellent in 7 patients, good in 4, fair in 2 and poor in one; their scores ranged from 30 to 92 points, averging 80 points. No infection or implant failure occurred during follow-ups. Heterotopic ossification at the acetabulum was observed in one patient whose Brooker grading was IV at the final follow-up. Conclusion The patients with acetabular fracture complicated with lower urethral or bladder injury should be treated with ORIF as soon as possible so that fine clinical outcomes can be achieved. Key words: Acetabulum; Fractures, bone; Fracture fixation, internal; Urethra; Bladder

The incidence and clinical significance of corona mortis vessel

Objective To explore the incidence and clinical significance of corona mortis vessels. Methods From December 2015 to December 2017, 48 patients with pelvic acetabular fractures were treated with the Stoppa approach, including 36 males and 12 females, aged 30 to 67 years, with an average age of 47.2±8.2 years. There were 52 sides of hemipelvis in the all including 44 cases of unilateral pelvic acetabular fractures and 4 cases of bilateral pelvic acetabular fractures. In the 48 patients, there were 6 pelvic fractures, 40 acetabular fractures and 2 pelvic combined with acetabular fractures. According to Judet-Letournel classification: there were 6 cases of anterior column fracture, 4 cases of anterior column with anterior wall fracture, 2 cases of anterior column with posterior transverse fracture, 4 cases of transverse fracture, 6 cases of T shape fracture and 20 cases of double column fracture. According to Tile classification, there were 2 cases of B1 type, 2 cases of B3 type, 2 cases of C1 type, and 2 cases of C2 type. The time from injury to surgery was 5 to 16 days, with an average of 8.3±2.8 days. All patients were treated with the Stoppa approach for reduction and fixation. The incidence, number and type of corona mortis vessels across the superior pubic branch, and the diameter and the distance between the vessels and the pubic symphysiswere detected and recorded. Results In the 52 hemi pelvis, there were 46 sides with an anastomotic blood vessel, and no anastomotic blood vessel was found in 6 sides, with the incidence of corona mortis vessels of 88.5% (46/52). Among them, 36 cases were venous type, with the incidence of 78.3% (36/46); 8 cases were arterial type, with the incidence of 17.4% (8/46); 2 cases were mixed type, with the incidence of 4.3%(2/46); corona mortis venous blood vessel diameter was 1.8-3.7 mm, with an average of 2.9±0.5 mm; arterial blood vessel diameter was 2.4-3.0 mm, with an average of 2.7±0.3 mm; the distance between the vessels and the pubic symphysis was 48-71 mm, with an average of 56.9±5.8 mm. Conclusion The corona mortis vessels are common, with the incidence through Stoppa approach about 88.5%. In the clinical treatment of pelvic acetabular fractures, we should pay attention to careful separation of pubic branches exposed by the Stoppa approach, especially when using ilioinguinal approach to avoid corona mortis vessels injury and haemorrhage. Key words: Pelvis; Acetabulum; Fractures, bone; Blood vessels