Reduction and Internal Fixation of Anterior Fracture Patterns through a Limited Ilioinguinal Approach

Fig. 5.1

(a) A 91-year-old male slipped and fell on ice. Initial AP, obturator oblique, and iliac oblique radiographic views (from top, counterclockwise) illustrating a left-sided anterior column posterior hemitransverse type acetabular fracture. (b) CT scan images further delineating the fracture pattern and comminution. (c) ORIF was performed through a limited ilioinguinal approach, using the lateral two windows with contouring and placement of two pelvic reconstruction plates and screws. Intraoperative and postoperative radiographs confirm an acceptable reduction and placement of hardware. Note the extraarticular location of the hardware on the iliac oblique view. (d) Postoperative CT scan images reconfirm reduction and extraarticular hardware placement. (e) Radiographs at 6 weeks illustrate maintenance of reduction and evidence of early fracture healing

../images/395168_1_En_5_Chapter/395168_1_En_5_Fig2a_HTML.jpg — Fig. 5.2

(a) A 52-year-old male was a restrained driver of an automobile involved in a high-speed motor vehicle accident. Initial AP, obturator oblique, and iliac oblique radiographic views (from top, counterclockwise) demonstrate a left-sided anterior column posterior hemitransverse type acetabular fracture with articular comminution and marginal impaction. (b) ORIF was performed through a limited ilioinguinal approach, using the lateral two windows with contouring and placement of multiple pelvic reconstruction plates and screws starting with the reduction and fixation of the fracture extending along the iliac crest. Intraoperative fluoroscopic imaging confirms an acceptable reduction and placement of hardware. Also, note the extraarticular location of the hardware on the iliac oblique view. (c) Radiographs at 30 months illustrate a healed acetabular fracture with maintenance of reduction and fixation with presence of heterotopic ossification (Brooker Grade II)

../images/395168_1_En_5_Chapter/395168_1_En_5_Fig2b_HTML.jpg — Fig. 5.2

(a) A 52-year-old male was a restrained driver of an automobile involved in a high-speed motor vehicle accident. Initial AP, obturator oblique, and iliac oblique radiographic views (from top, counterclockwise) demonstrate a left-sided anterior column posterior hemitransverse type acetabular fracture with articular comminution and marginal impaction. (b) ORIF was performed through a limited ilioinguinal approach, using the lateral two windows with contouring and placement of multiple pelvic reconstruction plates and screws starting with the reduction and fixation of the fracture extending along the iliac crest. Intraoperative fluoroscopic imaging confirms an acceptable reduction and placement of hardware. Also, note the extraarticular location of the hardware on the iliac oblique view. (c) Radiographs at 30 months illustrate a healed acetabular fracture with maintenance of reduction and fixation with presence of heterotopic ossification (Brooker Grade II)

Standard reduction techniques can be utilized to address the anterior column displacement. In high anterior column injuries, pointed reduction clamps across the fracture line at the level of the iliac crest are useful. Placement of a Farabeuf clamp on the ilium or a Schanz screw in the AIIS can help correct the external rotation deformity that is typically seen. Use of a ball spike pusher closer to the pelvic brim can also help control rotation. Reduction of the column is then held with plates or independent screws. Anatomic reduction of the proximal fracture lines is critical, as any malreduction will amplify at the joint level. Lower anterior column injuries can be reduced using techniques similar to those discussed below for the quadrilateral plate.

Reduction of the quadrilateral plate is necessary to resist recurrence of medial displacement. Traction on a Schanz pin placed up the femoral neck and into the head will provide a distal and lateral force to assist in reduction of the protrusio deformity. Access to the quadrilateral plate can be obtained through either the lateral or middle window. Commonly, the long tine of an asymmetric clamp is placed through the middle window onto the quadrilateral surface. The short tine is placed onto the outer table of the ilium through the interspinous notch, providing the lateralization vector required for reduction. Alternatively, a short tine can be placed through the lateral window onto the anterior column.

Once reduced, screws placed from the anterior column into the posterior column along the quadrilateral plate, often passing through the cotyloid fossa, are reliable in maintaining reduction and resisting protrusion. Screws are often placed through the pelvic brim plate, but they can be placed independently as well. The iliac oblique image is utilized to guide trajectory and verify extraarticular placement. Screw placement in the cotyloid fossa is acceptable and often necessary. A long 3.5-mm cortical screw just adjacent and inferior to the acetabulum but superior to the obturator foramen into the ischium is almost always possible and provides excellent fixation.

The preoperative CT scan must be carefully evaluated as not all quadrilateral plate fractures are amenable to this construct. Specifically, the fracture can be too thin to accommodate screw placement or can terminate too anteriorly such that screws through the fragment would not terminate in the posterior column. In these situations, an anterior intrapelvic approach (AIP) may be of benefit.

Once the columns and quadrilateral plate are reduced, attention is turned to addressing marginal impaction, which, if present, is generally located in the anteromedial dome. Through the middle window, a cortical window can be created allowing access to the impaction. A bone tamp is used to reduce impaction around the femoral head as a template. The void is back-filled with allograft and supported by rafting screws placed into the supraacetabular region from the outer table of the ilium.

Postoperative CT scan is useful in evaluating the quality of reduction as well as verifying extraarticular screw placement. When postoperative CT identifies screws that have penetrated the cotyloid fossa, they are carefully evaluated. If it is felt that the screws would be at risk of contacting the femoral head with development of posttraumatic arthrosis, then the screws can be removed prior to initiating weight-bearing activities.

Conclusions

Fixation of acetabular fractures in elderly patients must take into account their physiologic reserve.
Use of the lateral two windows of the ilioinguinal approach allows successful reduction and fixation of many geriatric acetabular fractures with less blood loss and operative time than use of the full ilioinguinal approach.
Careful preoperative planning is necessary prior to selecting an approach.
Reduction of protrusio as well as dome impaction is important to success and can generally be accomplished through use of the lateral two windows of the ilioinguinal approach.