Standard Ilioinguinal Approach Research Articles

569 Resection of Massive Pelvic Chondrosarcoma Using Custom Made 3D Printed Jig: A Case Report

Abstract Background The pelvis is a complex structure associated with major neurovascular structures and so pelvic surgery can be challenging. In the field of skeletal tumours, the surgeon's main aim is to achieve adequate margins, which modern 3D printed technology can assist with. Method A 43-year-old man was found to have a 20(CC) x 13(AO) x 9.3(TR) cm chondrasarcoma at the inner aspect of the right iliac bone. The patient was consented for right sided type 1 hemipelvectomy and tumour resection using customised 3D Printed Jig. A 64-slice spiral CT pelvis was transferred to an image processing software (Materialise Mimics 21.0 and Materialise 3 Matic 13.0) to generate a 3D model. The Jig was printed by the FDM machine in ABS material and sterilised. Incision was made through standard ilioinguinal approach and tumour was visualised. Soft tissue was dissected over the posterior aspect of the Ilium for the placement of the jig and then fixed with k wire, following which osteotomy was done. Results Postoperatively the patient had no complications. At final follow up of 4 years, the patient was independently ambulant. Post op x-ray showed no signs of tumour recurrence at the operated site. Conclusions This case highlights the importance of preoperative planning and the use of modern technology in surgical resection. Customised 3D printed jigs help surgeons achieve good resections with R0 margins.

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

To determine the functional andradiologicresultsof surgical treatment in patients with acetabular fractures. This was a retrospective cross-sectional study. We retrospectively reviewed medical records of patients operatively treated acute acetabular fractures at a level I trauma center (Shahid Rajaee) and an orthopedic center (Shahid Chamran) both in southern Iran (Shiraz) with minimally 1 year follow up over a period of 7 years from April 2009 to March 2016. Functional and radiographic outcomes, and complication were considered as main outcomes. A total number of 79 patients completed the study. Fifty-five patients were operated through Kocher-Langenbeck approach, and 18 were operated through the standard ilioinguinal approach, and 6 patients were operated through the standard ilioinguinal approach combined with Kocher-Langenbeck approach. The mean follow-up of patients was 45.6 months. The average operative time was 162.4±78.5 min, and the median blood loss was 500ml. Functionalresultswere excellent in 41 patients (51.9%), good in 12 (15.2%), fair in 13 (16.5%), and poor in 13 patients (16.5%). Radiologicresultswere excellent in 27 cases (34.2%), good in 17 cases (21.5%), fair in 18 cases (22.8%), and poor in 16 (16.5%). Osteoarthritis of hip (60.8%) and AVN of head of femur (22.8%) were two most common complications. In addition, there wasn't any significant difference between surgical approaches regarding clinical and radiographic outcomes. The operative treatment for acetabular fractures gives universally satisfactory results. Thereafter, this study provides evidence that ilioinguinal approach is a good choice for anterior fractures, Kocher-Langenbeck is a good choice for posteriors fractures, and combined approach may be a good choice in the management of acetabular fractures involving two columns.

Modified ilioinguinal approach in combined surgical exposures for displaced acetabular fractures involving two columns.

The purpose of this study is to assess the advantages of modified ilioinguinal approach in combined surgical exposures for displaced acetabular fractures involving two columns management. 73 patients with displaced acetabular fractures involving two columns underwent open reduction and internal fixation through combined surgical approaches between 2006 and 2014 in our hospital. The modified ilioinguinal approach combined with Kocher–Langenbeck approach group (group A) included 46 patients. The standard ilioinguinal approach combined with Kocher–Langenbeck approach group (group B) included 27 patients. Outcome was assessed in operative time, blood loss, function outcomes and complications. In group A, the average operative time was 123.2 min, and the average blood loss was 586.2 ml. Anatomic reduction was achieved in 39 patients (84.8 %). The functional recovery was good in 37 patients (80.4 %). Complications related to the approach were observed in 10 patients (21.7 %). In group B, the average operative time was 161.5 min, and the average blood loss was 830 ml. Anatomic reduction was achieved in 24 patients (88.9 %). The functional recovery was good in 22 patients (81.5 %). Complications related to the approach were observed in 9 patients (33.3 %). This study demonstrates that both combined approaches permits good postoperative function results for treatment of acetabular fractures involving two columns. However, the modified ilioinguinal approach combined with Kocher–Langenbeck approach provides less operative time, blood loss and complications.

A short buttress plate fixation of posterior column through single ilioinguinal approach for complex acetabular fractures.

The goal of this study was to evaluate the safety and efficacy of a new technique for posterior column fixation through the standard ilioinguinal approach. We conducted a retrospective review involving 33 consecutive patients with complex acetabular fractures treated using a short buttress plate fixation of posterior column through single ilioinguinal approach. Radiographic evaluation was performed using criteria described by Matta. Functional outcome was assessed using modified Postel Merle D'Aubigné score. Between 2008 and 2013, 33 adult patients with mean age of 46years and mean follow up of 37.5months were enrolled. Anatomic reduction was obtained in 61% of cases, imperfect reduction in 24% of cases and poor reduction in 15% of cases. The average modified Merle d'Aubigné score was 15: categorized as excellent in seven, good in 18, fair in three, and poor in four. One patient died at 15days because of pulmonary embolism. Four patients sustained temporary lateral femoral cutaneous palsy. At final follow up, two patients had severe post-traumatic arthritis; one of them underwent a total hip arthroplasty at 93months. None of the patients had loss of reduction. A short buttress plate fixation of posterior column through single ilioinguinal approach for complex acetabular fractures is a safe and effective method.

Short-segment fixation through a limited ilioinguinal approach for treating anterior acetabular fractures: a historical-control study.

We evaluated the potential advantages of short-segment fixation of certain anterior acetabular fracture patterns through a limited ilioinguinal approach. Two patient groups were studied. The first group comprised 22 patients (20 men, two women; average age 36 years) treated using the short-segment fixation protocol through a limited ilioinguinal approach. We modified the use of short pelvic brim plates, spring plates and posterior-column screws as reduction and fixation tools (leaving the distal end of the fracture unfixed) to keep the dissection entirely lateral to the iliac vessels. The second (control) group comprised 31 patients with matched fracture patterns fixed through the standard ilioinguinal approach. All patients were followed up for a minimum of two years. The estimated amount of blood loss (primary outcome measure), operative time, postoperative radiographic assessment of reduction quality and functional score assessment (secondary outcome measures) were compared between groups. The short-segment-fixation group had significantly less blood loss (p < 0.0001) and shorter operative time (p = 0.002) compared with the control group. However, there were no significant differences in the quality of fracture reduction and functional scores between groups at the final follow-up. No major complications were encountered in either group. Short-segment fixation through a limited ilioinguinal approach is a safe and effective alternative for treating certain patterns of anterior acetabular fractures. Decreased blood loss and shorter operative time with less soft tissue dissection are the main advantages of this approach.

Percutaneous fixation of anterior column acetabular fracture in a renal transplant recipient.

Renal transplantation, performed per million population, ranges from 30 to 60 in developed countries. The transplanted kidney is generally placed in iliac fossa; therefore the treatment procedure of the pelvic trauma in these patients should be selected carefully. The gold standard technique for the treatment of displaced acetabulum fractures is open reduction and internal fixation. Our patient had received a living-related-donor renal transplant due to chronic renal failure. In the second year of transplantation, she had been injured in a motor-vehicle accident, and radiographs showed a right acetabular anterior column fracture and left pubic rami fractures. The patient was treated with percutaneous fixation techniques and at one year of postoperative period there was no evidence of degenerative signs and the clinical outcome was good. Beside having the advantage of avoiding dissection through the iliac fossa by the standard ilioinguinal approach, percutaneous techniques, with shorter surgical time, decreasing soft tissue disruption, and the potential for early discharge from hospital might be ideal for a renal transplant recipient carrying a higher risk of infection. Percutaneous fixation of selected acetabular fractures in a renal transplant recipient would presumably have the potential to decrease the morbidity associated with traditional open surgical procedures.

Comminuted quadrilateral plate fracture fixation through the iliofemoral approach

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

Operative Treatment of Acetabular Fractures in an Older Population Through a Limited Ilioinguinal Approach

To compare treatment of acetabular fractures in elderly patients through a limited approach versus a standard ilioinguinal approach and assess changes in outcome and morbidity. Retrospective cohort comparison analysis. Tertiary referral center. Between January 1992 and January 2006, 143 patients 55 years of age or older were treated for acetabular fractures. Of these, 41 were treated through either a traditional or limited ilioinguinal approach. Patients with unilateral surgeries and a minimum follow-up of 2 years were included. Open reduction and internal fixation of acetabular fractures through a limited (lateral two windows) approach versus traditional three window ilioinguinal approach. Radiographic assessment of healing, reduction quality, progression to arthritis and total hip arthroplasty, operative time, length of stay, complications, SF-36, Musculoskeletal Functional Assessment, and the Short Musculoskeletal Functional Assessment. The two groups were equivalent in terms of preinjury comorbidities, mechanism of injury, type and severity of fracture pattern, time to surgery, length of hospitalization, and incidence of postoperative complications. The overall rate of secondary total hip arthroplasty was 26.8% and was equivalent between the two groups. Functional outcome scores were comparable. The use of the lateral two windows was associated with a significant reduction in both blood loss and operative time. The limited ilioinguinal approach to certain fracture patterns commonly seen in the elderly was associated with a decreased blood loss and surgical time. Moreover, there was no negative impact on outcomes in our cohort. The benefits of decreased blood loss and shorter operative time have a potential positive impact on management of these injuries. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Transsection of the rectus abdominis muscle in the treatment of acetabular fractures: Operative technique and outcome in 21 patients

Background A standard ilioinguinal approach is often insufficient for reduction and stabilization of the medial acetabular wall and the dorsal column in acetabular fractures. To avoid extended approaches, we have used a medial extension of the approach by transverse splitting of the rectus abdominis muscle. We have thus been able to reduce and stabilize transverse and oblique fractures of the dorsal column and the medial acetabular wall and to fix plates in a mechanically better position below the pelvic brim. To evaluate the procedure, especially the risk of abdominal hernia, we started a prospective study.Patients and methods Over 2 years, we treated 21 consecutive patients using a transverse splitting of the rectus abdominis muscle—either as an extension of the standard ilioinguinal approach or in combination with parts of this approach or a Kocher-Langenbeck approach. The patients were evaluated clinically and radiographically after 1 year.Results The clinical and radiographic results were excellent or good in 18 patients. Complications occurred in 5 patients. No hernias were observed.Conclusions Our small study indicates that the procedure described is a useful and safe complement to the intrapelvic approaches. The procedure does not provide better reduction than extended approaches, but may help to avoid them in some cases.