Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach

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Technical note

Comminuted

quadrilateral

plate

fracture

fixation

through

the

iliofemoral

approach

Ramesh Kumar Sen a,*, Sujit Kumar Tripathy a,b, Sameer Aggarwala, Tarun Goyal a,c,Santosh Kumar Mahapatra d

aDepartment of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, IndiabDepartment of Orthopaedics, Friarage Hospital, Northallerton, UK-DL6 1JG, United KingdomcDepartment of Orthopaedics, All India Institute of Medical Sciences, New Delhi, Indiad Ispat General Hospital, Rourkela, India

Introduction

Open reduction and internal fixation is the gold standard

treatment

for

displaced

acetabular

fractures

involving

weight-

bearing

dome

and

fractures

of

intra-articular

fragments.

The

goal

of treatment relies on restoration of articular anatomy with stable

internal fixation, allowing early mobilisation for the patient.1 This

can

be

achieved

using

various

combinations

of

plates

and

screws.

However,

the

choice

of

surgical

approach

depends

on

the

fracture

pattern, displacement, skin condition at the operative site, and

surgeon’s preference.2,3

The

quadrilateral

plate

forms

the

medial

boundary

of

the

hip

joint. Hence, inadequate reduction and stabilisation of quadrilat-

eral plate fractures lead to incongruous joints and early arthritis. A

quadrilateral

plate

fracture

with

medial

displacement

is

usually

seen

in

anterior

column

fractures,

anterior

column

and

posterior

hemitransverse fractures, T-type fractures, or both-column frac-

tures. Along with the respective column fixation, the quadrilateral

plate

in

such

cases

needs

medial

buttressing

to

prevent

medial

subluxation

of

the

femoral

head.1,4,5

Thequadrilateral plate is a very thinbone andtheouter surface

forms the articularsurface of the hip joint, therefore, direct screw

fixation is not possible. The technique of oblique screw fixation

along the pelvic brim and parallel to the quadrilateral plate has

high chances of joint penetration, and this technique is limited to

simple non-comminuted quadrilateral plate fracture.6 The fixa-

tion of a medial buttress plate in an infrapectineal fashion has

been described for quadrilateral plate fractures with medial

Injury, Int. J. Care Injured 44 (2013) 266–273

A R T I C L E I N F O

Article history:

Accepted 4 November 2012

Keywords:

Quadrilateral plate fracture

Anterior column fracture

Iliopectineal eminence

Iliofemoral approach

Modified Stoppa approach

Ilioinguinal approach

A B S T R A C T

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

obtaininga stablefixationat this area, contribute to thesurgical challenge of open reductionand 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 theother endbuttresses thequadrilateral platewhen placed underneath the

infrapectineal reconstruction plate. The standard ilioinguinal approach andmodified 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. Themodified Stoppa approach does not

permit visualisation of the entire anterior column and thehip joint. The authors, in this article, describe

thefixation of the comminuted quadrilateral plate fracture through the iliofemoral approach combinedwith a medial ilioinguinal window. The technique involves fixation of a spring plate (Allis T-plate) at

right angle to the infrapectineal buttress plate (908–908 plate construct). Thevertical limb of theT-plate

is fixed to the iliopectineal eminence whereas the horizontal limb buttresses the quadrilateral plate

Hence, this techniqueaddresses fracturesof both theiliopectineal eminence andthe quadrilateralplate.

Other than that, the iliofemoral approach permits direct visualisation of the entire anterior columnand

the hip joint without the necessity to dissect the ilioinguinal neurovascular structures.

2012 Elsevier Ltd. All rights reserved.

* Corresponding author at: Department of Orthopaedics, Postgraduate Institute

of Medical Education and Research, Sector-12, Chandigarh 160012, India.

Tel.: +91 9914209744.

E-mail address: [email protected] (R.K. Sen).

Contents

lists

available

at

SciVerse

ScienceDirect

Injury

journ al hom epage: www.els evier .com/locat e/ injur y

0020–1383/$ – see front matter

2012 Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.injury.2012.11.002
















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displacement.5 However, extensive comminution of the quadri-

lateral plate cannot be effectively buttressed with this infra-

pectineal plate alone. In such instances, additional fixation of aspring plate beneath the infrapectineal plate is needed. Tile7 and

Mast et al.8describedthe useof various plates i.e., small-fragment

T-plate, semitubular plate, and the 3.5-mm reconstruction plate

(used as spring plate) to buttress the quadrilateral surface. One

end of these spring plates is fixed to the ilium whereas the other

limb buttresses the quadrilateral plate when placed underneath

the medial-buttressing infrapectineal reconstruction plate

(Fig. 1). Often, the quadrilateral plate comminution in an anterior

column fracture extends up to the iliopectineal eminence and

needs additional fixation with a superior plate (iliopectineal

plate).5 Placing an iliopectineal plate alone can address the

comminution over the iliopectineal eminence but without

effective buttressing force on

the

spring

plate.

Contrary

to it,

infrapectineal reconstruction plate alone provides a betterbutressung force over the spring plate but without holding the

iliopectineal comminution.

The

authors

in

this

article

report

a

slight

modification

of

the

buttress

technique

to

address

the

combined

fractures

of

the

iliopectineal eminence and quadrilateral plate. In this technique,

the spring plate (contoured small fragment T-plate) is fixed

directly

over

the

iliopectineal

eminence,

and

hence,

stabilises

the

iliopectineal

fracture.

The

horizontal

limb

of

the

small

fragment

T-

plate buttresses the quadrilateral surface and fixes the vertical

limb to the iliopectineal eminence. When an infrapectineal

reconstruction

plate

is

placed

along

the

pelvic

brim

and

tightened,

it

pushes

the

T-plate

(both

the

plate

forms

908 angle:

908–908

plate

construct) underneath, thus exerting a counteracting force exactly

opposite to the medial dislocating force (Fig. 2). The authors have

treated these injuries through the iliofemoral approach though

literature till date has no mention of the iliofemoral approach for

fixation of such fractures.9–12

Patients and methods

From

1996

to

2010,

the

senior

author

(RKS)

treated

590

cases

of

acetabular fractures. The documentations of all these patients

were retrieved from the trauma registry. The data of those patients

who

had

comminuted

anterior

column

fractures

involving

the

iliopectineal

eminence

and

quadrilateral

plate,

and

were

operated

through the iliofemoral approach, was analyzed. For inclusion in

this study, the patients were required to have a complete set of

preoperative

and

postoperative

radiographs,

computed

tomo-

graphic

scans,

and

have

completed

at

least

two

years

of

follow-up.

There were 22 patients with both column fracture and 14 patients

with anterior column fracture who had comminuted quadrilateral

plate

fracture

with

medialisation,

as

well

as

iliopectineal

fracture.

Immediately

after

their

arrival

to

our

emergency

services,

the

patients received all emergency resuscitative measures. Once

haemodynamic stability was achieved, they were evaluated for

orthopaedic

injuries.

Preoperative

skeletal

traction

was

applied

to

maintain

the

stability

of

the

femoral

head

and

to

avoid

pressure

necrosis on the femoral head cartilage. The patients were operated

on when they were medically fit. The average delay in surgery from

the

time

of

injury

was

4

days

(minimum

of

1

day

to

a

maximum

of

16 days).

The preoperative radiographs and CT scan in these patients

showed

medial

subluxation

of

the

femoral

head

with

comminution

in

the

iliopectineal

eminence

and/or

quadrilateral

plate

(Fig.

3A–

C). In all these patients, the comminuted anterior column was

reduced first and fixed; the posterior column was then, indirectly

reduced with various techniques using the Cobb elevator, ball

spike,

pelvic

clamp,

lag

screws

or

plate.

Whenever

required

the

posterior column was fixed with an ilio-ischial screw. Postopera-

tive radiographs were evaluated for the quality of reduction

(Fig. 3D). Fracture reduction was graded using the criteria given byMatta.13

Non-weight bearing on the injured side was advised for six

weeks, with range-of-motion exercises starting immediately after

the operation. Then, gradually increasing weight-bearing com-

menced

and

complete

weight-bearing

was

restricted

until

radiological signs of the union were observed. Low molecular

weight heparin was administered and graduated compression

stocking was applied in the postoperative period until the patients

were mobilised. Patients were evaluated clinically (for pain,

mobility, range of motion, gait, neurovascular status) and

radiologically (for loss of reduction, degenerative changes,

osteonecrosis and heterotopic ossification) at three weeks, six

weeks, three months, six months, 12 months, and every year

Fig. 1. Bone model showing the conventional spring plate technique for fixation of

quadrilateral plate fracture. The vertical limb of T plate (spring plate) is fixed to the

ilium and the horizontal part buttresses the quadrilateral plate when placed

underneath an iliopectineal reconstruction plate.

Fig. 2. Bone model depicting our surgical technique in the fixation of comminuted anterior column and quadrilateral plate fracture. The T plate acting as a spring plate

buttresses the quadrilateral surface with its horizontal limb; the vertical limb holds the fracture fragments along the iliopectineal line and in the supra-acetabular area. The

vertical limb is fixed to the supra-acetabular region with one or two holding screws. Placement of an infrapectineal reconstruction plate along the pelvic brim exerts force over

the

spring

plate

and

hence

buttresses

the

quadrilateral

surface.

As

both

the

plates

are

right

angle

to

each

other,

it

is

called

as

908

–908

construct.

R.K. Sen et al. / Injury, Int. J. Care Injured 44 (2013) 266–273 267



thereafter. The average follow up was 3.2 years (minimum of two

years and maximum of 5.5 years). The clinical and the radiological

data at the latest follow-up were graded using the Merle D’Aubigne

and the Matta scores respectively. According to the Merle

D’Aubigne clinical grading system, the pain, gait, and range of

motion of the hip were each assigned a maximum of six points. The

three individual scores are summed to derive the final score which

is interpreted as ‘excellent’ for 17–18 points, ‘good’ for 15–16

points, ‘fair’ for 13–14 points, and ‘poor’ for less than 13 points.

Radiological assessment using the Matta scoring system inter-preted ‘excellent’ for a normal appearing hip joint, ‘good’ for mild

changes with minimal sclerosis and joint narrowing (<1 mm), ‘fair’

for intermediate changes with moderate sclerosis and joint

narrowing (<50%), and ‘poor’ for advanced changes. Other than

the degenerative changes, the radiographs were also evaluated for

avascular changes in the femoral head and heterotopic ossification

around the hip joint.

Surgical

technique

The patient is placed in the supine position on a radiolucent

table

with

a

sandbag

under

the

affected

hip.

The

ipsilateral

limb

is

draped freely into the field so that the hip and knee joints can bemoved as required during surgery. The Urinary Foley catheter is

inserted into the bladder for improved visualisation, bladder

protection,

and

monitoring

of

fluid

balance

(Fig.

4A).

An

appropriate

preoperative

prophylactic

antibiotic

is

administered.

The anterior column fracture is accessed through the iliofe-

moral approach. A skin incision is made along the iliac crest (about

10 cm proximal to antero superior iliac spine, posterior to gluteus

medius pillar) and is extended up to the anterolateral aspect of the

thigh passing through the antero-superior iliac spine (ASIS,

Fig. 4A). The scar directly over the iliac crest is poorly tolerated,

thus, the incision is made superior or inferior to the crest. Fascia-

lata is incised along the incision and the surgical plane is developed

between the tensor fascia lata and the sartorius. Care should be

taken to preserve the lateral femoral cutaneous nerve. A superficialdissection is carried out to strip out the deep fascia from the outer

border of iliac crest. The periosteum and the gluteal muscles of 2–

2.5 cm length and 1 cm depth are stripped out from the anterior

and outer side of iliac crest to facilitate ASIS osteotomy. Before ASIS

osteotomy, the subperiosteal exposure of the internal iliac fossa is

carried out and the interval is packed with sponge until the distal

exposure is developed. Osteotomy of the ASIS (1 cm depth and

2 cm length) is performed (Fig. 4B); the osteotomised bone

fragment with the iliacus and external oblique muscles, inguinal

ligament, lateral femoral cutaneous nerve, and neurovascular

bundles are retracted medially with a Deaver retractor (Fig. 5A).

Distal extension is developed between the tensor-sartorious

interval

for

at

least

12–15

cm.

The

ascending

branches

of

the

lateral femoral circumflex artery and vein are ligated at about10 cm distal to ASIS, under the thick aponeurotic fascial layer over

the rectus femoris muscle. The distal extension of the dissection

facilitates

wide

exposure

of

the

internal

pelvis

and

the

anterior

column.

Fig. 3. Preoperative radiograph (A) and computed tomographic scan (B, C) showing comminuted anterior column fracture involving the quadrilateral plate and iliopectineal

eminence; there is medial subluxation of the femoral head. Postoperative radiograph (D) shows anatomical reduction of the fracture operated through the iliofemoral

approach.

Fig. 4. (A) Diagram showing line of incision for the iliofemoral approach- along the iliac crest extending upto the anterolateral aspect of thigh passing through antero-superior

iliac spine. (B) Hand diagram shows antero superior iliac spine (ASIS) osteotomy-2 cm length and 1 cm depth, iliacus muscle is lifted up subperiosteally from the internal

pelvic

fossa.

R.K. Sen et al. / Injury, Int. J. Care Injured 44 (2013) 266–273268



The hip joint is flexed and adducted to facilitate easy retraction

of the muscle bulk, medially. The periosteum and fascia adherent

to the iliopectineal eminence is carefully stripped out using the

periosteum elevator to avoid injury to the external iliac vessels and

the obturator vessels. A Deaver retractor is carefully placed to

retract medially the important neurovascular structures such as,

the external iliac vessels, obturator vessels, iliopsoas muscle, and

the osteotomised inguinal ligament with its attachments. This

facilitates

wide

exposure

of

the

anterior

column.

The

obturator

internus muscle is lifted up from the quadrilateral surface and amalleable retractor is placed to expose the quadrilateral plate. The

rectus femoris is detached from the antero-inferior iliac spine to

identify

the

hip

joint

capsule.

Now,

the

anterior

column

is

completely

exposed.

The

fracture-reduction

of

the

anterior

column

is started from peripheral to central, starting with the proximal end

of the fracture, at the level of the iliac crest (or below), and ending

at

the

acetabular

fossa.

The

peripheral

reduction

must

be

anatomical, since displacement there will aggravate malreduction

at the acetabular fossa. The anterior column fractures are fixed

with the pelvic reconstruction plate with or without the lag screw

or neutralisation plate along the iliac crest in a standard fashion as

indicated. The lateral and longitudinal traction over the femur in a

flexed-hip position reduces the medially-dislocated hip joint. The

comminuted iliopectineal eminence and quadrilateral plate are

reduced over the femoral head (that acts as mould) with the help of

a

ball

spike

and

temporarily

held

with

pelvic

reduction

clamp

(Figs. 5B and 6A). Provisional K-wires (2 mm) are inserted to holdthe reduction. An Allis T-buttress plate (commonly used for distal

radius fracture) of adequate length (usually 4- or 5-hole plate) is

used

to

buttress

the

fragments.

The

plate

is

bent

(>908)

to

contour

over

the

iliopectineal

eminence

with

the

horizontal

limb

resting

against the quadrilateral plate in an intrapelvic, infrapectineal

fashion (and hence, buttressing the comminuted fragments,

Fig.

6A).

No

screws

are

put

directly

on

the

quadrilateral

surface.

Fig. 5. (A) ASIS along with its attachments (sartorius and inguinal ligament) and iliopsoas retracted medially. (B) Anterior column reduction using pelvic clamp and ball spike.

Fig. 6. (A) Intraoperative clinical photograph showing reduction of anterior column with pelvic clamp and ball spike through the iliofemoral approach. Allis-T-plate is placed

over the iliopectineal eminence and is pushed with a ball spike. (B) The infrapectineal reconstruction plate pushes the underneath spring plate to buttress the quadrilateral

surface. (C) The medial window for fixation of the medial end of the infrapectineal reconstruction plate.




One or two holding screws (12 or 14 mm small fragment cortical

screw) are inserted through the vertical limb of the plate to fix it to

the iliopectineal eminence of the anterior column (Fig. 6B). This T-

plate stabilises all the comminuted fragments of the iliopectineal

eminence and quadrilateral plate, thus serving as a holding plate.

Care should be taken to protect the obturator neurovascular

bundle near the medial wall of the acetabulum. In cases of gross

comminution, where reduction is difficult or cannot be achieved,

and if there are intra-articular fragments, the hip capsule is cut to

observe and palpate the hip joint to assess articular congruency

and

remove

intra-articular

fragments,

if

any.

Subchondral

impac-

tions of femoral head and acetabular surface can also be managed(by elevation and cortical-bone graft support) after incising the hip

capsule.

A

9-

or

10-hole

3.5

mm

reconstruction

plate

is

contoured

to

fit

in

the

infrapectineal

(just

inferior

to

iliopectineal

line)

region

inside the pelvis (Fig. 6B). The plate is over-countered to provide

maximum buttress over the T-plate and other unsupported (those

are

unsupported

by

the

Allis

T-plate)

fractured

bone

fragments

of

the

quadrilateral

surface.

The

plate

is

secured

posteriorly

with

two

or three screws (14–24 mm small fragment cortical screws) placed

superiorly to the sciatic notch in the sciatic buttress region.

Anteriorly,

the

plate

is

fixed

to

the

posterior

aspect

of

superior

pubic

ramus

using

two

or

three

screws

(12–24

mm

small

fragment

cortical screws). If the fracture comminution extends up to the

superior

ramus,

the

plate

is

fixed

to

the

pubic

symphysis

in

the

midline. For exposure of the symphysis pubis, a midline

Pfannelstein incision is made (Figs. 6C and 7). This is extended

in the subcutaneous plane to reach up to the fascia over the rectus

abdominis. Fascia is incised vertically and the rectus abdominis is

spited along the linea alba. The lateral extent of the approach is

limited by the spermatic cord (or the round ligament) emerging

from the superficial inguinal ring. Deep into the rectus abdominis

and the superior pubic rami, we carry out a blunt dissection to

create an exptraperitoneal plane. The urinary bladder is separated

by blunt finger dissection in the space of Retzius extending

laterally along the superiorand theposterior aspect of the superior

pubic rami. Care is taken to identify and ligate the corona mortis

(present in 10–15% of normal individuals) in this region to avoid

excessive bleeding. This medial window provides enough space

for theplacement of screws anteriorly through the plate (Figs. 6C

and7).Thereconstruction plate is slid through themedial window

up to the sciatic notch in an infrapectineal fashion (Fig. 7). On

tightening the screws in the reconstruction plate, the T plate

underneath pushesthequadrilateral plate and hence, buttressesit

(Fig.6C).This indirectbuttressingtechniqueprovides rigidity and

strength to the fixation of the medial quadrilateral surface. The

reduction is checked under the image intensifier. In both-column

fractures, proximal part of posterior column fracture is fixed with

screws or plate through this approach. The posterior column isreduced with various techniques, including the use of pelvic

clamp, ball spike, cob elevator, lag screws, or plate for reduction.

Wherever required, the posterior column is reducedwith a bone

hook and a 4.5 mm ilio-ischial screw is passed from a point 1 cm

lateral to the pelvic brim point taken 2 cm anterior to the

sacroiliac joint.

The osteotomised ASIS is fixed to the ilium with two small

fragment screws. The wound is closed in layers after placing a

negative suction drain.

Results

There were 28 males and 8 females in this series. The average

age was 38 years (minimum of 18 years and maximum of 56 years).The

average

blood

loss

was

350

ml

(ranges

from

200

ml

to

600

ml),

and

the

mean

operative

time

was

130

min

(ranges

from

90

min

to

220 min). Two patients had intra-operative bleeding because of

injury to the corona mortis and the obturator artery. Both these

bleedings

were

controlled

by

compression

packing.

Postoperative-

ly,

superficial

wound

infection

was

seen

in

four

patients;

three

of

these patients were managed with intravenous antibiotics, and the

other patient required a debridement of the wound.

In

both-column

fractures,

the

posterior

column

fracture

was

simple

and

non-comminuted

and

we

could

achieve

reduction

indirectly with various manoeuvres as described, through the same

approach. On the postoperative radiographs, 30 patients (83.3%)had

anatomic

articular

reduction

(within

1

mm)

and

6

patients

(16.7%)

had

good

reduction

(between

1

and

3

mm).

There

was

no

residual

Fig. 7.

Diagram

showing

sliding

of

infrapectineal

reconstruction

plate

throughmedial window (Pfennenstiel incision).

Fig. 8. (A and B) Right side comminuted anterior column and quadrilateral plate fracture in a 50 year female. (C) Immediate radiograph after surgery with our 908–908 plate

construct

technique

showing

good

reduction.

(D)

6

Months

after

surgery,

complete

union

was

noticed

with

maintained

good

reduction

of

the

joint.




subluxation seen in any patient (Figs. 3, 8 and 9). Radiological

evidence of union was seen in all patients after a mean period of

three months. Two patients had paresthesia along the lateral aspect

of the thigh because of lateral femoral cutaneous nerve injury. Both

of them recovered completely within six months. Three patients had

hip adductor muscles weakness (power 3/5) in the postoperative

period (because of obturator nerve palsy), but all of them recovered

fully within six months. Grade I and II (Brookers) heterotopic

ossification was seen in 2 patients till the last follow-up. Clinical

outcome as per Merle D’Aubigne score at the latestfollow up showed‘excellent’ in 18 patients (50%), ‘good’ in 10 patients (27.8%),‘fair’ in 5

(13.9%), and ‘poor’ in 3 (8.3%) patients. Radiological grading at the

last follow-up showed ‘excellent’ in 22 (61.1%), ‘good’ in 6 (16.7%),

‘fair’ in 6 (16.7%),and ‘poor’ in 2 (5.5%) patients. Two of three patients

with poor outcomes needed arthroplasty for post-traumatic

coxarthritis.

Discussion

In this study we reported the comminuted quadrilateral plate

fracture fixation through the iliofemoral approach. The comminu-

tion of the quadrilateral plate was a part of anterior column or

both-column

fracture

in

this

series.

Even

in

both-column

fractures,

as the posterior column fracture was not comminuted orsegmental and the anterior column was grossly displaced, we

used the iliofemoral approach. We could achieve reduction of the

posterior

column

by

various

manoeuvres,

including

the

use

of

pelvic

clamp,

bone

hook,

lag

screw,

or

neutralisation

plate.

Anterior column and QP fractures were traditionally fixed

through Ilioinguinal approach. Because of mobilisations of inguinal

canal

and

major

neurovascular

bundles

with

this

approach,

there

was

increased

surgical

morbidity

with

long

surgical

duration,

bleeding, and postoperative complications. To avoid such compli-

cations, in the early 1990s, Cole10 and Hirvensalo et al.12

independently

described

an

approach

to

anterior

acetabulum

through

an

intrapelvic

dissection

from

the

midline.

The

principal

difference between ilioinguinal and their approach was in avoiding

the

‘‘middle

window,’’

thus

sparing

dissection

into

the

inguinalcanal

and

major

inguinal

neurovascular

structures.

Their

approach

was

a

modification

of

an

intrapelvic

approach

described

by

Rives

et al.14,15 for the repair of inguinal hernia using Dacron mesh. The

modified Stoppa approach provides access to the pubic body,

superior

ramus,

pubic

root,

ilium

above

and

below

the

pectineal

line,

quadrilateral

plate,

medial

aspect

of

posterior

column,

sciatic

buttress, and the anterior sacroiliac joint. Few authors described a

second incision (lateral window of ilioinguinal approach) for

access

to

upper

ilium

and

crest.4,9,16 Though

the

modified

Stoppa

approach

provides

wide

access

to

the

pelvic

brim

(from

pubic

body

to anterior sacroiliac joint) and quadrilateral plate, and avoids

dissection into inguinal structures, it cannot permit access to hip

joint

for

evaluation

of

articular

congruency.

The

combined

modified

Stoppa

and

lateral

window

of

ilioinguinal

approaches

also do not permit access to the anterior wall of acetabulum. The

exposure of the iliopectineal eminence in the supra-acetabular

region is also relatively restricted as the ASIS remains intact along

with its attachment which does not allow direct visualisation, thus,

the surgeon has to work in a narrow field of vision for fixation of

the quadrilateral plate and anterior column (particularly in low

and very low anterior column fractures).

While operating on acetabular fractures through the modified

Stoppa approach, Sagi et al.9 in 2010 reported poor reduction in

associated both-column fractures, impacted anterosuperior dome,and comminuted fracturesof the pubic root and anterior wall region.

They admitted that currently, surgeons are extending the lateral

window inferiorly at the ASIS (in the manner of Smith Peterson

approach) to address these fractures. The iliofemoral approach along

with the medial window is nearly the same approach that was

mentioned by Sagi et al. for these difficult fractures.

Iliofemoral approach provides wide access to internal pelvis

and the anterior column. Combined with medial window of

ilioinguinal approach, the surgeon can have access to the pelvic

brim starting from the pubic symphysis to the anterior sacroiliac

joint, the whole of the ilium above and below the iliopectineal line,

supra-acetabular part of iliopectineal eminence, and the quadri-

lateral

plate.

The

principal

advantage

of

the

exposure

is

that

this

approach allows direct visualisation of the hip joint, which can beevaluated for articular congruency and subchondral impaction.

The chances of neurovascular injury are minimised because of the

osteotomy

of

ASIS

which

relaxes

the

muscles

and

neurovascular

bundles

on

the

medial

side

of

pelvis.

We

found

significant

reduction in bleeding and surgical time while operating the QP

through this approach. The reduction quality and clinical outcome

in

our

series

were

comparable

or

even

better

to

some

of

the

previous

report

(Table

1).

Other than the approach, the method described for fixation of

comminuted QP and iliopectineal eminence fracture in this report

is

unique.

The

fixation

of

the

T-plate

over

the

iliopectineal

eminence

addresses

the

fractures

of

both

the

quadrilateral

plate

and the iliopectineal eminence, which is a common pattern of

injury

in

anterior

column

fractures.

The

Allis-T-plate

(4–5

holesplate)

needs

to

be

moulded

more

than

908

to

fix

it

over

the

iliopectineal

eminence.

In

this

way,

the

vertical

limb

stabilises

the

fracture over the iliopectineal eminence and the horizontal limb

rests on the quadrilateral surface. When an overlying infrapecti-

neal

reconstruction

plate

is

fixed

below

the

pelvic

brim

and

tightened,

the

T-plate

buttresses

the

quadrilateral

surface

exerting

a counterforce exactly opposite to the medial dislocating force of

the femur head (Fig. 2). Farid17 described a plate wire composite

for

these

types

of

fractures.

As

per

his

technique,

the

cerclage

wire

was

meant

to

hold

the

medial

acetabular

wall

directly

by

passing

over the anterior column between the anterior superior and

anterior inferior iliac spine. Even by this technique, the fracture

fragments

over

iliopectineal

eminence

in

the

supra-acetabular

region

could

not

be

fixed.

Our

technique

of

placement

of

T-plate

Fig. 9. (A and B) Gross comminution of anterior column and quadrilateral plate in a 40 year female with both-column fracture. (C) After open reduction and internal fixation

through the iliofemoral approach with the 908–908 plate construct, the fracture is anatomically reduced and stable. As there was extensive comminution in the anterior

column towards the ilium, second spring plate, fixed to the ilium, was used. (D) After one year, the fracture has completely united and the reduction is maintained.




holds

the

fracture

fragments

further

lower

in

the

anterior

column,

and

the

function

of

cerclage-wire

is

served

by

the

T-plate.

The 908–908 plate construct design as described in this article

can better address the comminuted QP and iliopectineal eminence

fractures.

Fixation

of

such

fractures

through

the

iliofemoral

approach

is

less

morbid

and

does

not

require

extensive

dissection.

We recommend the iliofemoral approach as an alternative to the

ilioinguinal and the modified Stoppa approach for the fixation of

comminuted

anterior

column

fractures

involving

the

quadrilateral

plate.

Funding

None.

Conflict

of

interest

disclosure

None.

References

1. Tile M, Helfet D, Kellam J. Fractures of the pelvis and acetabulum. 3rd ed.Baltimore: Lippincott Williams & Wilkins; 2003.

2. Judet R, Judet J, Letournel E. Fractures of the acetabulum: classification andsurgical approaches for open reduction: preliminary report. Journal of Bone and Joint Surgery 1964;46:1615–38.

3. Matta M. Operative indications and choice of surgical approach for fractures of the acetabulum. Techniques in Orthopaedics 1986;1:13–22.

4. Helfet DL, Borrelli J, DiPasquale T, Sanders R. Stabilization of acetabular frac-tures in elderly patients. Journal of Bone and Joint Surgery 1992;74:753–65.

Table 1

Clinical outcome and complications associated with different approaches to anterior column acetabulum.

Study Approach/no.

of patients

Reduction quality Clinical outcome Complications

Matta11 Ilioinguinal

(n = 119 patients)

Anatomical reduction-74%,

satisfactory reduction-16%,

unsatisfactory reduction

in 10%

3 Year-excellent’ in 37%,

‘good’ in 47%, ‘fair’ in

14%, and ‘poor’ in 2%

13% complications

Femoral artery laceration-1

Femoral nerve palsy-1

Wound infection-3

Letournel6 Ilioinguinal(n = 146 patients)

Anatomical reduction in61% of both-column

fractures, 86% of

anterior column fractures,

and 68% of anterior column

with posterior hemitransverse

fractures

– 3 (2.1%) Infections8 (6%) Femoral/sciatic nerve

palsies (one femoral nerve palsy

was permanent)

2 (1.4%) Abdominal hernia

3 (2.1%) External iliac vein injuries

One thrombosis of internal or

External iliac artery

One bladder injury

9% Incidence of ectopic bone

formation

Sagi et al.9 Modified Stoppa +/

lateral window

(n= 57 patients)

Excellent’ to good reduction

in 92%

1 Year clinical outcome

good to excellent

in 88% patients

5 complications related to surgical

approach

1 each of a superior gluteal artery

injury

1 lateral window wound infection

2

direct

inguinal

hernias

requiringsurgical repair

1 atrophy of the ipsilateral rectus

abdominus muscle without hernia

Average blood loss 690 ml (150–3000 ml)

Surgical duration 263 min 9120–336 min)

Anatomic reduction 82%,

imperfect 18%.

– Average operative time-4.7 h (range

3–8 h 48 min)

Blood loss 1063 ml (350–2950 ml) Fluid

replacement 5 L (2 to 12.3 L)

4 complications in 3 patients: one had

a deep infection, one had seroma, and

two had mild symptoms in lateral

femoral cutaneous nerve distribution.

Two additional patients needed implant

removal

Hirvensalo et al.12 Lower midline +/

lateral window

(n= 164 patients)

Anatomic reduction (1–2 mm):

84%, 3–5 mm malreduction: 9%,

>5 mm malreduction: 7%

3.9 Years: Harris Hip Score

> 80: 106 (75%) patients,

60–79 in 22 (16%) and

< 60

in 13 (9%) patients

Failure of fixation 6

Hardware in acetabular joint space 4

Superficial infections 2

Ileus with bowel perforation 1

Multiorgan failure resulting to death 1

Deep venous thrombosis 5

Pulmorary embolism 1

Lateral cutaneous nerve lesion 20

Necrosis of the femoral head 20

Heterotopic ossification 5

Secondary osteoarthritis: 14

Total arthroplasty needed: 23 cases

Our study Iliofemoral +/

medial window

of ilioinguinal

(n= 36 patients)

Anatomical reduction in 83.3% of

patients and good reduction in

the remaining 17.7%

3.2 Years: ‘excellent’ to ‘

good’ outcome in 78%

Obturator and corona mortis artery

injury-2 patients

wound infection-4

ectopic bone formation-2 patients




5. Qureshi AA, Archdeacon MT, Jenkins MA, Infante A, DiPasquale T, Bolhofner BR.Infrapectineal plating for acetabular fractures: a technical adjunct to internalfixation. Journal of Orthopaedic Trauma 2004;18:175–8.

6. Letournel E, Judet R. Fractures of the acetabulum. 2nd ed. New York: Springer-Verlag; 1993.

7. Tile M. Fractures of pelvis and acetabulum. 2nd ed. Baltimore: Williams &Wilkins; 1995.

8. Mast J, Jakob R, Ganz R. Planning and reduction techniques in fracture surgery.Berlin: Springer-Verlag; 1989.

9. Sagi HC, Afsari A, Dziadosz D. The anterior intrapelvic approach for fixation of acetabular fracture. Journal of Orthopaedic Trauma 2010;24(5):263–70.

10.

Cole JD,

Bolhofner

BR.

Acetabular fracture

fixation

via a

modified Stoppalimited intrapelvic approach: description of operativetechnique and prelim-inary treatment results. Clinical Orthopaedics and Related Research 1994;305:112–23.

11. Matta JM. Operative treatment of acetabular fractures through the ilioinguinalapproach. A 10 year perspective. Clinical Orthopaedics and Related Research1994;305:10–9.

12. Hirvensalo E, Lindhal J, Kijonen V. Modified and new approaches for pelvic andacetabular surgery. Injury 2007;38:431–41.

13. Matta JM. Fractures of the acetabulum: accuracy of reduction and clinicalresults in patients managed operatively within three weeks after the injury. Journal of Bone and Joint Surgery 1996;78:1632–45.

14. Rives J, Stoppa R, Fortesa LN. Dacron patches and their place in surgery of groinhernia. 65 cases collected from a complete series of 274 hernia operations. Annales de Chirurgie 1968;22:159–71.

15. Stoppa RE, Rives JL, Warlaumont CR, Palot JP, Verhaeghe PJ, Delattre JF. The useof Dacron in the repair of hernias of the groin. Surgical Clinics of North America1984;64:269–85.

16.

Anderson

RC,

O’Toole

RV,

Nascone

JW, Sciadini

MF, Frisch

M, Turen

CW.Modified Stoppa approach for acetabular fractures with anterior and posteriorcolumn displacement: quantification of radiographic reduction and analysis of interobserver variability. Journal of Orthopaedic Trauma 2010;24:271–8.

17. Farid YR. Cerclage wire-plate composite for fixation of quadrilateral platefractures of the acetabulum: a checkrein and pulley technique. Journal of Orthopaedic Trauma 2010;24(5):323–8.


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Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach