comminuted quadrilateral plate fracture fixation through the iliofemoral approach
DESCRIPTION
Journal ArticleTRANSCRIPT
![Page 1: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/1.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 1/8
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
![Page 2: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/2.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 2/8
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
![Page 3: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/3.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 3/8
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
![Page 4: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/4.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 4/8
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.
R.K. Sen et al. / Injury, Int. J. Care Injured 44 (2013) 266–273 269
![Page 5: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/5.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 5/8
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.
R.K. Sen et al. / Injury, Int. J. Care Injured 44 (2013) 266–273270
![Page 6: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/6.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 6/8
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.
R.K. Sen et al. / Injury, Int. J. Care Injured 44 (2013) 266–273 271
![Page 7: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/7.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 7/8
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
R.K. Sen et al. / Injury, Int. J. Care Injured 44 (2013) 266–273272
![Page 8: Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach](https://reader036.vdocuments.us/reader036/viewer/2022081805/5695cf6f1a28ab9b028e14ee/html5/thumbnails/8.jpg)
7/21/2019 Comminuted Quadrilateral Plate Fracture Fixation Through the Iliofemoral Approach
http://slidepdf.com/reader/full/comminuted-quadrilateral-plate-fracture-fixation-through-the-iliofemoral-approach 8/8
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.
R.K. Sen et al. / Injury, Int. J. Care Injured 44 (2013) 266–273 273