AOT Pelvis Acetabulum book sample chapter

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Table of contents

Volume 1 Section 1 1 Principles of the treatment of pelvic ring injuries 1.1 Anatomy of the pelvic ring

3

1.4 General assessment and management of the

61

polytrauma patient

Marvin Tile, James F Kellam

1 Introduction

3

Wolfgang K Ertel, James F Kellam

2 Structural stability

3

1 Introduction

61

3 Interior of pelvis

8

2 General principles

62

3 Principles of damage control

69

4 Relationship of pelvic fractures to injuries in other

71

4 References 1.2 Biomechanics and methods of internal fixation

16 17

John T Gorczyca

1 Introduction

17

2 Anatomical structures

17

3 Concept of pelvic stability

19

4 Injury force patterns

20

5 Biomechanics of pelvic fixation

22

6 Conclusion

35

7 References

36

1.3 Pathoanatomy, mechanisms of injury,

39

and classification Kelly Lefaivre, Peter J O’Brien, Marvin Tile

1 Introduction

39

2 Pathoanatomy

39

3 Mechanisms of injury

41

4 Classification

47

5 Comprehensive classification

52

6 Type 61-A: stable

53

7 Type 61-B: partially stable

54

8 Type 61-C: completely unstable (Young-Burgess

55

systems 5 Specific treatment of pelvic disruption in a multiply

72

injured patient 6 Control of pelvic hemorrhage

76

7 Definite fracture care in the multiply injured patient

80

8 Conclusion

80

9 References

81

1.5 Defining the injury: assessment and principles of

83

management of pelvic ring fractures Richard J Jenkinson, Marvin Tile, Joel Rubenstein

1 Introduction

83

2 Clinical assessment

83

3 Radiographic assessment

87

4 Principles of management of pelvic ring fractures

92

5 References

98

APC III, VS) 9 Pelvic ring disruption associated with acetabular

56

fracture 10 Conclusion

57

11 References

60

XIII

Table of contents

Section 2 Techniques

99

1.6 Surgical approaches to the pelvis

103

1 General considerations

103

(type A)

2 Approaches to the anterior ring

103

Markku T Nousiainen, Philip A Brady

3 Approaches to the posterior ring

153

108

1 Patient selection/indications

153

4 Anterior (intrapelvic) approach to the sacroiliac joint 108

2 Nonoperative management

154

5 Posterior (extrapelvic) approach to the sacroiliac

3 Preoperative planning

154

110

joint and lateral sacrum

4 Surgical techniques

155

6 Sacral approach

113

5 Postoperative care

157

7 References

115

6 Results

157

7 Complications

157

1.7 External fixation of the pelvic ring

117

Pol M Rommens, Alexander Hofmann

1 Introduction

117

2 Biomechanical aspects

117

3 Indications

119

8 Conclusion

157

9 References

158

1.8.4 The management of the injured pelvic ring:

159

internal fixation of the anterior pelvic injuries—

4 Application methods

121

open book type (B1)

5 Pin placement in the iliac crest

123

Sean E Nork

6 Pin placement in the anterior inferior iliac spine

128

1 Introduction

159

7 Frame design

128

2 Nonoperative management

162

8 Aftercare

129

3 Preoperative planning

162

9 Conclusion

129

4 Surgical techniques

163

10 References

131

5 Postoperative care

170

6 Results

170

1.8.1 Internal fixation of the injured pelvic ring:

133

rationale Marvin Tile

7 Complications

171

8 Conclusion

172

9 References

173

1 Introduction

133

2 Benefits of internal fixation

133

3 Risks

135

(type B2)

4 Individual types: rationale

137

Stephen H Sims

5 Conclusion

137

1 Patient selection and indications

6 References

138

2 Nonoperative treatment

176

3 Preoperative planning

177

4 Surgical technique

177

1.8.2 Internal fixation of the injured pelvic ring:

139

navigation Rami Mosheiff, Meir (Iri) Liebergall

XIV

1.8.3 The management of the injured pelvic ring: internal fixation of stable pelvic ring fractures

Michael J Weaver, James F Kellam

1 Patient selection and indications

139

2 Preoperative assessment

140

3 Surgical technique

143

4 Principles of navigation and guidance

144

5 Conclusion

151

6 References

152

1.8.5 Internal fixation of lateral compression fractures 175

175

5 Special fracture considerations

181

6 Postoperative care

185

7 Results

185

8 Conclusion

185

9 References

185

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Table of contents

1.8.6 Internal fixation of unstable fractures

187

(types B3 and C)

Section 3 Special indications

263

1.10 Lumbosacral instability and stabilization

265

Colin V Crickard, Joshua C Patt

1 Introduction

265

1 Patient selection/indications

187

2 Preoperative planning

269

2 Nonoperative management

192

3 Surgical technique

269

3 Preoperative planning

192

4 Decompression technique

272

4 Surgical techniques

194

5 Closure technique

272

5 Postoperative care

230

6 Postoperative care

273

6 Results

231

7 Outcomes

273

7 Complications

231

8 Conclusion

274

8 Conclusion

232

9 References

274

9 References

233

1.11 Open pelvic fracture

275

Milton Lee (Chip) Routt Jr, Timothy S Achor

1.9 Sacral fractures

235

Robert V O’Toole, Ted Manson

1 Introduction

275

1 Introduction

235

2 Classification

275

2 Anatomy

235

3 Initial management

276

3 Neurovascular anatomy

236

4 Preoperative planning

277

4 Clinical importance of the sacral anatomy

237

5 Surgical techniques

278

5 Classification

237

6 Tips and tricks

282

Tim Pohlemann, Jörg H Holstein, Ulf Culemann

6 Incidence and injury mechanism

240

7 Postoperative care

282

7 Patient selection and indications

241

8 Results

283

8 Preoperative planning

244

9 Complications

283

9 Surgical techniques

244

10 Conclusion

283

10 Surgical approaches

248

11 References

284

11 Fracture stabilization and choice of implants

251

12 Completely unstable pelvic ring injury (type C)

255

with major displacement and without

1.12 Pelvic ring disruption in women: genitourinary

285

and obstetrical implications Carol E Copeland

neurological deficit 13 Postoperative care

258

14 Complications

260

15 Conclusion

260

16 References

261

1 Introduction

285

2 The nonpregnant female patient

285

3 The pregnant trauma patient

295

4 Pelvic trauma as a consequence of pregnancy

297

5 Conclusion

301

6 References

302

1.13 Urological injuries in pelvic ring trauma:

305

assessment and management in male patients Ron Kodama, Raj Satkunasivam

1 Anatomy and classification

305

2 Bladder injuries

307

3 Pelvic fracture urethral injuries

309

4 Conclusion

311

5 References

312

XV

Table of contents

1.14 Injury to the pelvis in pediatric patients:

313

the immature skeleton

Section 4 Results and complications

351

1.16.1 Outcomes after pelvic ring injuries:

353

general concept and conclusion

Theddy Slongo

Patrick DG Henry, Richard J Jenkinson, Hans J Kreder

1 Anatomy and classification

313

1 Introduction

353

2 Patient selection and indications

319

2 Outcomes and complications following pelvic

353

3 Preoperative planning

320

ring injuries

4 Surgical techniques

321

3 Injury and treatment factors related to outcome

357

5 Postoperative care

331

4 Conclusion

358

6 Results and outcomes

332

5 References

359

7 Complications

334

8 Conclusion

334

9 References

335

1.15.1 Insufficiency fractures of the pelvis: metabolic

337

1.16.2 Outcomes after pelvic ring injuries:

361

critical review of the world experience Axel Gänsslen

1 Introduction

361

and nonoperative workup

2 Health outcomes and management

361

Aasis Unnanuntana, Anas Saleh, Joseph M Lane

3 Level of evidence and evidence-based practice

363

1 Introduction

337

4 Basis of outcomes evaluation of pelvic ring injuries

363

2 Etiology and pathogenesis

337

5 Outcomes after type A injuries

364

3 Assessment and medical evaluation

338

6 Outcomes after type B injuries

365

4 Nonoperative management

342

7 Outcomes after type C injuries

368

5 Conclusion

344

8 Conclusion

373

6 References

344

9 References

374

1.15.2 Insufficiency fractures of the pelvis:

347

operative management

1.17 Venous thromboembolism in pelvic trauma

377

William H Geerts

Karen Hand, James F Kellam

1 Patient selection and indications

347

2 Preoperative planning

347

3 Surgical techniques

347

4 Postoperative care

348

5 Conclusion

348

6 References

350

1 Introduction

377

2 Epidemiology of venous thromboembolism in

377

pelvic trauma 3 Diagnosis of clinically suspected venous

380

thromboembolism 4 Treatment of venous thromboembolism in patients 382 with pelvic trauma 5 Prevention of venous thromboembolism in

383

pelvic trauma 6 Screening for asymptomatic deep vein thrombosis

388

7 Practical aspects of thrombosis prevention in

389

patients with pelvic fracture

XVI

8 Conclusion

391

9 References

392

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Table of contents

1.18 Complications of pelvic trauma

401

Andrew Grose, David E Asprinio, Marvin Tile

1 Introduction

1.19

401

2 Early complications

401

3 Late complications

408

4 Conclusion

411

5 References

412

Malunion and nonunion of the pelvis:

415

posttraumatic deformity Michael D Stover, William D Lack

1 Incidence

415

2 Etiology

415

3 Deformity

416

4 Definition

416

5 Symptomatology

416

6 Patient evaluation

419

7 Treatment

420

8 References

423

XVII

Table of contents

Volume 2 Section 5 425 Principles of the treatment of acetabular fractures 2.1

Anatomy of the acetabulum

427

2.5 Decision making: nonoperative and operative

481

indications for treatment of acetabular fractures

Carl R Freeman, Michael Leunig, Martin Beck, Reinhold Ganz

1 Introduction

427

Steven A Olson, Michael Zlowodzki

2 Hip development

427

1 Introduction

3 Acetabular landmarks

427

2 Pelvic anatomy

481

4 Acetabular structure

429

3 Fracture classifications

482

5 Radiographic anatomy

430

4 Nonoperative treatment of acetabular fractures

482

6 Hip stability

432

5 Operative treatment of acetabular fractures

485

7 Acetabular orientation

432

6 Choice of operative approach

485

8 Acetabular cartilage

432

7 Special circumstances

492

9 Acetabular biomechanics

433

8 Delayed fracture indications

494

10 Hip circulation

434

9 Acute total hip arthroplasty

494

11 Summary

439

10 Conclusion

495

12 References

439

11 References

495

2.2 Biomechanics of acetabular fractures

441

2.6 General assessment and perioperative

481

497

management of acetabular fractures

Steven A Olson

1 Normal hip mechanics

441

Andrew Grose, Douglas ST Green, Sean E Garvin

2 Acetabular fractures

442

1 Introduction

3 Mechanics of acetabular fixation

444

2 Evaluation of the patient as a whole

497

4 Conclusion

445

3 Evaluation of the patient as a surgical candidate

498

5 References

445

4 Medical optimization and anesthetic management

498

2.3 Pathoanatomy and classification of acetabular

447

fractures Jorge E Alonso, James F Kellam, Marvin Tile

1 Introduction

447

2 Mechanism of injury

447

3 Diagnosing the fracture

4 Letournel-Judet classification (AO/OTA Fracture

497

5 General guidelines for anesthesia for pelvic fractures 499 6 Anesthetic plan: nuances for associated injuries

500

7 Blood/fluid resuscitation

500

8 Conclusion

501

9 References

501

449 453

and Dislocation Classification) 5 Conclusion

468

6 References

470

2.4 Defining the injury: assessment and principles

471

of management of acetabular fractures Markku T Nousiainen, Philip A Brady, Marvin Tile

XVIII

1 Introduction

471

2 Clinical assessment

471

3 Radiographic assessment

471

4 Postoperative assessment

476

5 Imaging of complications and associated injuries

478

6 Conclusion

479

7 References

480

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Table of contents

Section 6 Techniques

503

2.7 Specific surgical approaches and technique

507

Craig S Bartlett III, David L Helfet

1 Introduction

507

2 Indications for surgery and perioperative

507

considerations 3 The geriatric patient

509

4 Timing of surgery

511

5 Preoperative planning

512

6 Selection of the optimal surgical approach

513

7 Specific approaches

518

8 Surgical technique

522

9 Alternative to Kocher-Langenbeck: the modified

532

Gibson approach 10 O ther special technical factors: trochanteric flip

570

osteotomy with surgical dislocation of the femoral head for treatment of fractures of the

2.9.1 Computer-assisted closed techniques of David M Kahler

1 Introduction

611

2 Early experience

612

3 Computer-assisted orthopedic surgery

613

(image-guided surgery) 4 3-D (CT-based) versus 2-D (image intensification-

615

based) surgical navigation for pelvic and acetabular fractures 5 Screw trajectories for specific acetabular fracture

617

patterns 6 Reduction of radiation exposure to patient and

622

surgeon 7 Conclusion

622

8 References

623

2.9.2 Image intensifier−assisted closed techniques of

acetabulum

611

reduction and fixation

625

11 Extension of the ilioinguinal approach

575

reduction and fixation

12 Postoperative management

577

Joshua L Gary, Peter Bates, Adam J Starr

13 Conclusion

579

1 Introduction

14 References

580

2 Screw pathways and image intensifier visualization

625

3 Surgical indications

630

4 Operative techniques

633

2.8 Planning and decision making:

587

surgical approaches David C Dewar, David L Helfet

5 Specific fracture configurations

635

6 Hardware options

636

7 Complications

637

8 References

637

1 Why should we plan?

587

2 Timing

587

3 Imaging

589

4 Planning/templating

590

5 Operating room preparation

592

for acetabular fractures: open methods

6 Specific challenges to reducing individual fracture

592

Jeffrey W Mast

2.10.1 Techniques of reduction and fixation

1 Introduction

patterns

625

639

639

7 Approach planning

596

2 Posterior wall fractures

639

8 Anterior approaches

597

3 Reduction techniques

648

9 Posterior approaches

602

4 Associated fractures

651

10 Transtrochanteric approach

604

5 Conclusion

660

11 Extensile approaches

604

6 References

660

12 Conclusion

609

13 References

609

XIX

Table of contents

2.10.2 Surgical management of wall and column

661

fractures (type A)

757

acetabular fracture

Berton R Moed, David JG Stephen

1 Type A fractures: posterior wall (A1), posterior

Marvin Tile, Dana C Mears

661

column (A2), and anterior column or anterior 2 Type A1: posterior wall fractures

662

3 Type A2: posterior column fractures

672

4 Type A3: anterior column or anterior wall

679

5 Conclusion

688

6 References

689

2.10.3 Surgical management of B types: B1, B2, B3

1 Introduction

757

2 Instrumentation for cable fixation of the acetabulum 757

wall (A3)

691

3 Preferred fractures for the use of cable fixation

760

4 Other applications of cables inserted through the

762

ilioinguinal approach 5 Cable fixation for an acetabular fracture managed

762

with an acute total hip replacement 6 Conclusion

765

7 References

765

2.11.2 Intrapelvic approach in acetabular fractures

David S Wellman, David L Helfet

767

1 Introduction

691

Eero Hirvensalo, Jan Lindahl

2 Patient selection/indications

692

1 Introduction

3 B1: transverse fractures (including transverse with

692

2 Indications

767

3 Technique for the intrapelvic approach

768

an associated posterior wall fragment)

767

4 Transverse with posterior wall

705

4 Reduction and fixation techniques

770

5 B2: partial articular fractures (T-type)

708

5 Complications

774

6 B3: anterior column with posterior hemitransverse

719

6 Conclusion

774

7 References

774

fractures 7 References

726

2.10.4 Surgical management of associated

XX

2.11.1 Cerclage wires and cable fixation for an

727

2.11.3 Use of bone substitutes

775

Jason L Pittman, Thomas A Einhorn

both-column fractures (type C)

1 Introduction

775

Ketih A Mayo

2 Bone cements

775

1 Introduction

727

3 Biological agents used to augment fracture healing

776

2 Patient selection/indications

727

4 Conclusion

778

3 Preoperative planning

727

5 References

779

4 Surgical techniques

728

5 Operating room logistics/patient positioning

729

6 Reduction and fixation

730

7 Postoperative care

756

8 Results

756

9 Complications

756

10 Conclusion

756

11 References

756

2.11.4 Intraoperative assessment of acetabular

781

fractures Christian Krettek, Volker Stüber, Timo Stübig, Musa Citak

1 Introduction

781

2 Intraoperative assessment

781

3 Postoperative imaging

785

4 References

786

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Table of contents

Section 7 Special situations

787

2.12 The elderly patient with an acetabular fracture

789

2.15 Pathological pelvic fractures and acetabular

Eben A Carroll, David L Helfet

2.13

835

reconstruction in metastatic disease

1 Introduction

789

John H Healey, Holly Brown Lenard

2 Acute total hip arthroplasty

790

1 Introduction

835

3 Minimally invasive techniques

793

2 Metastatic disease of the acetabulum

836

4 Open reduction and internal fixation

795

3 Classification

837

5 Technical tricks

795

4 Basic principles

841

6 Treatment failure and delayed total hip arthroplasty 796

5 Technique

842

7 Conclusion

801

6 Tumor-related conditions affecting the pelvis

846

8 References

802

7 Conclusion

846

8 References

848

Acetabular fracture in the pediatric patient:

849

Primary total hip arthroplasty for acetabular

803

fracture

2.16

the immature skeleton

Dana C Mears

1 Introduction

803

Theddy Slongo

2 Indications for an acute total THA

806

1 Anatomy and classification

3 Contraindications to acute THA

809

2 Diagnostics

852

4 Preoperative assessment

810

3 Decision for nonoperative or operative therapy

855

5 Surgical strategies for acute THA with stabilization

810

4 Surgical techniques

857

5 Postoperative care

863

of the acetabulum

849

6 Standard surgical technique

811

6 Results

864

7 Techniques for specific fracture patterns

811

7 Complications

864

8 Small incision techniques for THA and their use

814

for acute acetabular fractures 9 Alternative strategies for fracture fixation and

814

buttressing of bone graft 10 Results

818

11 Complications

819

12 Conclusion

819

13 References

821

2.14 Total hip arthroplasty after acetabular fracture

823

Matthew L Jimenez

1 Introduction

823

2 Total hip arthroplasty for failed treatment of

823

8 Conclusion

865

9 References

866

2.17 Posttraumatic acetabular dysplasia

867

Reinhold Ganz, Lisa M Tibor, Claudio Dora

1 Introduction

867

2 Pathophysiology

867

3 Pathomorphology

867

4 Symptoms

869

5 Surgical correction

869

6 References

870

acetabular fractures 3 Early THA for acute treatment of acetabular fractures 824 4 Late hip arthroplasty

829

5 Technical considerations

829

6 Postoperative management

830

7 Conclusion

833

8 References

833

XXI

Table of contents

Section 8 Results and complications

871

2.18 Early complications

873

Gregory J Schmeling, Jason W Roberts, Emily L Exten

2.22 Malunion and nonunion

913

Michel Oransky, Carlos Sancineto, Mario Arduini

1 Introduction

873

1 Anatomy and classification

913

2 Mortality

873

2 Patient selection/indication

914

3 Thromboembolism

874

3 Preoperative planning

917

4 Infection

875

4 Operative technique

918

5 Nerve injury

877

5 Results

923

6 Malreduction

879

6 Complications

924

7 Failure of fixation

880

7 Conclusion

924

8 Vascular injury

881

8 References

926

9 Intraarticular hardware

882

10 Trochanteric osteotomy

882

11 References

883

2.19 Late complications

885

Gregory J Schmeling, Jason W Roberts, Emily L Exten

2.23 Results of treatment for fractures of the

927

acetabulum Martin D Bircher

1 Introduction

927

2 Natural history: why operate?

927

3 Historical results: methods of assessment and

929

1 Avascular necrosis

885

2 Late infection

886

3 Nonunion

886

4 Letournel’s results: the gold standard

931

4 Heterotopic ossification

887

5 Summary of Letournel’s results

933

5 Posttraumatic osteoarthrosis

890

6 How do we improve outcomes in the 21st century?

936

6 Conclusion

891

7 Conclusion

936

7 References

892

8 References

938

2.20 Surgical management of delayed acetabular

outcomes

893

fractures Eric E Johnson, Devon M Jeffcoat

1 Anatomy

893

2 Patient selection and indications

894

3 Preoperative planning

894

4 Surgical techniques

894

5 Postoperative care

897

6 Results

897

7 Complications

899

8 Conclusion

900

9 References

901

2.21 Late acetabular reconstruction

903

Manyi Wang, Xinbao Wu, Shiwen Zhu

1 Introduction

XXII

903

2 Indications

903

3 Surgical treatment: potential problems

904

4 Surgical algorithm

904

5 Complications

908

6 Results

909

7 Conclusion

911

8 References

912

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

2.7 Specific surgical approaches and technique Craig S Bartlett III, David L Helfet

1

Introduction

Prior to the classic work by Judet and coworkers [1, 2] and Letournel [2–6], there was little understanding of the complex pathoanatomy and proper surgical management of acetabular fractures. However, following the introduction of their classification scheme and novel surgical approaches, the last three decades have seen improvements in surgical approaches, techniques of reduction, and implants, leading to more consistently good results [1–5, 7–16]. However, the management of these difficult fractures remains a challenging problem.

The care of the patient with a pelvic injury begins with prompt resuscitation performed by a trained multidisciplinary trauma team and accurate assessment and stabilization of any life-threatening injuries. Once the patient has been stabilized, definitive treatment should only be undertaken by a surgeon experienced in handling such fractures.

A patient’s functional outcome following an acetabular fracture is dependent on several factors—some controllable but others injury related and inevitable [5, 9, 12, 13, 16–19].

Of the surgical factors, the most important is obtaining an anatomical reduction of the articular surface and fixation stable enough to allow early range of motion while avoiding both acute and late complications. The achievement of these goals can be a demanding and frustrating task, which cannot be accomplished without the following resources [20]: (1) An experienced surgeon who uses atraumatic techniques, including the preservation of the blood supply to the femoral head and articular fragments without causing undue additional trauma; (2) a knowledgeable nursing team able to produce readily the proper and necessary reduction and fixation devices, including the specialized pelvic reduction clamp, instruments, and implants; (3) an accomplished anesthesiologist able to paralyze the patient and able to respond to any eventuality; (4) ± a neurophysiologist to provide nerve monitoring; and (5) an image intensifier table and the ability to obtain intraoperative image intensification or plain x-ray views of the pelvis and hip joint. A thorough understanding of the complex anatomy of the

pelvis is necessary before surgical treatment because surgical outcomes significantly depend on an accurate diagnosis and an appropriately chosen and well-executed approach.

2 Indications for surgery and perioperative considerations

Because malreduction or subluxation of the hip joint can lead to abnormal loading of the articular cartilage with subsequent joint arthrosis [4, 5, 9, 11, 12, 14, 21–25], acetabular fractures should be treated with the same principles granted to other intraarticular fractures. Therefore, the primary goal in their management is to perform an accurate reduction of the articular surface to obtain a congruent hip joint and therefore restore normal joint mechanics. To this end, the decision to perform surgery is based on many factors including the patient, the personality of the fracture, and the capabilities of the surgical team.

However, the patient’s medical condition (associated injuries, comorbidities, etc), physiological age, and functional needs are also key determinants of the treatment algorithm. For example, the presence of an unstable pelvic ring injury in combination with a displaced acetabular fracture poses not just a greater risk physiologically to the patient but also a challenge to the surgeon with respect to accurately reducing the acetabular fracture. Suzuki et al [26] called this a “devastating dyad,” which comprised 5% of all pelvic ring and acetabular injuries requiring admission in their series. They found that, in addition to these patients being significantly more injured compared with those who had sustained an isolated displaced acetabular fracture, residual displacement of the acetabulum after surgical treatment was often the result of incomplete reduction of the pelvic ring injury.

Transverse-type patterns accounted for 61.2% of all acetabular fractures in this combined group with the most frequent pattern a transverse acetabular fracture with associated anterior disruption of the ipsilateral sacroiliac joint. Based on their findings, these authors recommended that accurate reduction of the posterior pelvic lesion be achieved before reconstruction of the acetabulum.

507

Section 6 Techniques 2.7 Specific surgical approaches and technique

Knowledge of the acetabular fracture pattern can help assess the likelihood of other body system injuries as well as the physiological state of the patient with respect to blood loss [27, 28]. Posterior wall, posterior column, and posterior column plus posterior wall injuries are typically caused by axial and posteriorly directed loads as opposed to other acetabular fracture patterns, which are caused by more lateral or trochanteric loads. In one study [28] this latter group was noted to have a statistically higher association with retroperitoneal hematomas (33% vs 13%), and injuries to the spleen (12% vs 4%), liver (11% vs 5%), vascular (9% vs 0%), kidney (6% vs 1%), and bladder (8% vs 1%) compared to the former. In contrast most injuries associated with axial fracture patterns were skeletally based. Incidences of other injuries were not significantly different between the lateral and axial force groups. This included lung (28% vs 23%), lower extremity fractures (35% vs 38%), upper extremity fractures (23% vs 19%), spine fractures (17% vs 16%), and traumatic brain injuries (11% vs 7%). Interestingly, in this study [28] transverse plus posterior wall fractures exhibited intermediate characteristics between axial load and the remaining lateral load patterns. Another report [27] found that patients with isolated acetabular fractures were just as likely as those with isolated pelvic fractures to receive blood transfusions within the first 24 hours of admission.

Importantly, both column, anterior column, anterior column with a posterior hemitransverse, and T-type fracture patterns were more likely to receive a blood transfusion (56%) than other fracture types (28%; P = .003). Both-column (8.8 units) and anterior column with a posterior hemitransverse (6.4 units) fractures required the largest volumes of blood.

A significant patient variable is obesity. This is a growing epidemic in many industrialized countries and presents a significant challenge to the pelvic surgeon. Acetabular fractures in these patients can be more difficult to reduce and complication rates are high. Porter et al [29] compared a nonobese group of patients with groups of obese (BMI > 30 kg/m2) and morbidly obese (BMI > 40 kg/m2) patients.

Anatomical radiographic reductions were achieved in 72% of the nonobese patients, 70% of the obese patients, 72% of the nonmorbidly obese patients, and 61% of the morbidly obese patients. On postoperative computed tomographic (CT) scans, an acceptable reduction was obtained in 47% of the nonobese patients, 44% of the obese patients, 47% of the nonmorbidly obese patients, and 31% of the morbidly obese patients. This same group [30] also found that morbidly obese patients required an average operating time of 293 minutes with greater interoperative blood loss vs 250 minutes in nonmorbidly obese patients. Wound complications (46% vs 12%; P < .0001) and an overall complication rates

508

(63% vs 24%; relative risk, 2.6) were also higher than in nonmorbidly obese patients.

Among the most challenging of comorbid situations is the presentation of a displaced acetabular fracture in the gravid patient. However, a team-oriented approach and the judicious use of radiographic imaging in these patients can minimize the risk to the baby while achieving an acceptable articular reduction. Porter et al [31] reported eight such cases (four posterior wall fractures, three transverse plus posterior wall fractures, and one posterior column fracture) with fetal gestational ages ranging from 5–26 weeks. At the time of surgery, patients with an isolated posterior wall fracture pattern were positioned laterally while the remaining patients were positioned prone. Care was taken to support and appropriately pad each patient’s abdomen and fetus. When a right lateral decubitus position was required, extra care was taken to support the gravid uterus to prevent compression of the vena cava. All surgeries were performed using a Kocher-Langenbeck (KL) surgical exposure and image intensifier used sparingly. No attempt was made to intra­ operatively shield the abdomen from image intensification imaging or monitor the fetus. Postoperatively, both the patient and fetus were immediately evaluated by the obstetric service in the postanesthesia care unit. Infant delivery averaged 27 weeks from the time of acetabular fracture stabilization and all pregnancies reached 36 weeks. Apgar scores were normal in each child including one twin delivery.

With respect to the injury pattern itself, indications for operative fixation include displacement of the articular surface, joint incongruity, unacceptable roof arc measurements, incarceration of an intraarticular fragment within the hip joint, and any subluxation of the femoral head [12, 23, 32–38].

Although most [1, 5, 9, 11–15, 17, 32, 39–57] now agree that anatomical reduction of the weight-bearing surface and concentric reduction of the hip are essential for long-term satisfactory results, the degree of hip joint incongruity that can be tolerated still is not known. This may be due to the limitations of plain films (less accurate and poorer inter­ observer reliability) compared with CT in the diagnosis and assessment of acetabular fractures [50, 58–60].

Helfet and Schmeling [45] observed that an articular step off of > 2 mm or a gap of > 3 mm was associated with a fourfold increase in joint space narrowing at early follow-up. This was confirmed in a prospective study by Matta [9] who achieved an anatomical reduction in 71 of 262 acetabular fractures, with 83% of these patients having good or excellent outcomes at an average follow-up of 6 years. Of 29% with an imperfectly reduced acetabulum, good or excellent results

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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were obtained in 68% of cases if the defect measured 2–3 mm, and only 50% if > 3 mm. Malkani et al [47] and Hak et al [43] have used anatomical specimen models to further support 2 mm or less as the appropriate prerequisite for an acceptable reduction. Considering the importance of the articular reduction with respect to outcome, percutaneous techniques, while having some value in acetabular fracture surgery, should only be considered in certain circumstances [61–65].

However, while achieving an anatomical reduction is critical, this alone may not be sufficient to restore function and achieve a good outcome. While the quality of the reduction appears to be the most important factor with respect to outcome, some [9, 14, 66] have found that the most clearly predictive initial factor is actually damage to the femoral head. Furthermore, numerous studies [17–19, 67] have linked comminution and impaction with poor results. Kreder et al [19] followed up 128 patients treated operatively for a posterior wall acetabular fracture and assessed outcomes using the Musculoskeletal Functional Assessment, Short-Form 36 scores, and x-rays. They found that their patients had profound functional deficits compared with the healthy population and that the fracture pattern, marginal impaction, and residual displacement of > 2 mm were associated with the development of arthritis, which related to poor function and the need for hip replacement.

The location of the acetabular fracture also is important.

Matta et al [9, 23, 33, 34] have shown that an intact 45º roof arc and a congruent hip joint are mandatory to achieve a satisfactory result. Other authors [12, 38, 68, 69] have noted that fractures involving > 40% of the posterior wall will result in instability, whereas those affecting < 20% of the wall are stable. Building on this knowledge, Olson [35] developed strict criteria for consideration of nonoperative treatment: (1) the articular surface must be intact in the superior 10 mm of the joint on CT; (2) without traction, the femoral head must remain congruent with the superior acetabulum on the AP and 45° oblique views; and (3) a minimum of 50% of the posterior wall articular surface must be intact.

Yet such objective criteria cannot be considered absolute, as a number of recent reports [36, 38] have demonstrated that although satisfying the preceding guidelines, some fractures still require stabilization because of dynamic instability. This particular entity can be identified by performing dynamic stress views while the patient is sedated or anesthetized.

Hip joint stability determined by an experienced surgeon using dynamic stress image intensifier with the patient under general anesthesia appears to be predictive of a good result.

Grimshaw and Moed [37] followed up 18 such patients treated nonoperatively after a posterior wall fracture for a minimum of 2 years. The average modified Merle d’Aubigné score of their entire study group was good, and all 15 patients’ x-rays demonstrated a congruent joint with a normal joint space and no evidence of posttraumatic arthritis.

Finally, Olson et al [51] have found that small defects in the posterior wall produce major changes in the articular contact area that may predispose to late posttraumatic degenerative changes even in the presence of clinical stability. Another controversy involves displaced both-column fractures that demonstrate secondary congruence, which some have argued may not routinely require operative reduction and stabilization, especially in the older patient [5, 12, 36, 44, 48, 70]. However, one biomechanical study of anatomical specimen [71] has shown that abnormal increases in stress concentration still occur in the dome of the acetabulum adjacent to the fracture line in such cases.

3

The geriatric patient

With the geriatric patient population, concerns arise regarding the health risks posed by performing a major surgical procedure on an older patient with multiple medical comorbidities and potentially a fragile physiological reserve.

Additionally, there are the limitations of poor bone stock, a potential inability to aggressively rehabilitate the patient, and questions as to whether the patient’s functional needs even dictate fracture reconstruction. Therefore, nonoperative treatment with or without delayed total hip arthroplasty (THA) or possibly primary THA with or without reconstruction of the acetabulum are options. However, outcomes of nonoperative treatment of acetabular fractures are often just as dismal as they are in the younger patient population. Thus age alone should not be a contraindication to surgical reconstruction of an acetabular fracture. Indeed, many studies [17, 57, 70, 72, 73] have shown good functional outcomes after open reduction and internal fixation of these fractures in the elderly. Additionally, to minimize stress on these potentially fragile patients more limited approaches can be considered. For example, using only the lateral two windows of the ilioinguinal approach can lead to a significant reduction in both blood loss and operative time [73].

However, the elderly are at risk of fracture patterns that are associated with poor outcomes [18, 17, 67], and the quality of reduction is strongly related to age, with a decrease in accuracy noted in older patients [9, 13, 14]. At the same time, while a perfect anatomical reduction of the acetabular

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fracture should always remain a goal—in the elderly this may not be as clinically important as it is in younger patients.

Miller et al [70] evaluated 45 patients with a mean age of 67 years (range, 59–82 years) at the time of surgery. X-rays in 26 patients (58%) identified an anatomical reduction, 13 (29%) reductions were imperfect, and 6 (13%) were poor.

Not surprisingly the maximum displacement identified on CT revealed that no reduction was anatomical; 23 (51%) were imperfect and 22 (49%) were poor, although the displacement was not always at the weight-bearing dome.

In contrast to what would be expected from these radiographic findings, SF-36 scores showed functional outcomes comparable with those of the general elderly population, with no correlation with the radiological reduction.

In another review, Carroll et al [57] identified 93 elderly patients (mean age, 67 years) in a prospective database who had undergone operative management of an acetabular fracture. At an average follow-up of 5 years, the overall rate of hip replacement was 31%. Poor fracture reduction (P < .02), the development of avascular necrosis (P < .001), and previous contralateral hip arthroplasty (P = .02) were statistically associated with the need for secondary surgeries. However, functional outcomes measured by the Musculoskeletal Functional Assessment, Short Musculoskeletal Functional Assessment, and SF-36 compared favorably with similar scores reported for acetabular fractures in younger populations and age-matched “non-injured” norms. The authors concluded that there was an acceptably low rate of major complications in their patient group with nearly 70% achieving functional outcomes similar to age- and injury-matched control subjects without the need for secondary surgeries.

Anglen et al [17] also found that anatomical reduction of an acetabular fracture in 27 patients with an average age of 71.6 years (range, 61–88 years) closely correlated with good to excellent radiographic results, and that functional outcomes were similar to age-matched control subjects. However, they also identified an important and specific radiographic finding (superomedial dome impaction) that was predictive of failure. Named the “Gull sign,” patients in this subgroup had inadequate reduction, early fixation failure, or medial/ superior joint narrowing and subluxation. Other studies have also identified high rates of comminution and impaction in the elderly [17–19, 74], femoral head injury [9, 66, 74], and the presence of a subchondral insufficiency fracture [67] as risks for a poor outcome, and therefore, relative indications to consider arthroplasty.

Ferguson et al [18] used a prospective database to compare the clinical details and patterns of displaced acetabular frac-

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tures in 235 patients who were older than 60 years with a second group of 1074 patients younger than 60 years. The incidence of elderly patients with acetabular fractures increased by 2.4-fold between the first and second halves of their 27-year study period (10% vs 24%, P < .001). Fractures with displacement of the anterior column were significantly more common in the elderly compared with the younger patients (64% vs 43%, P < .001). Common radiological features (many predictive of poor outcomes in other studies) of fracture patterns in the elderly included a separate quadrilateral-plate component (50.8%) and roof impaction (40%) in the anterior fractures; and comminution (44%) and marginal impaction (38%) in posterior wall fractures.

Along these same lines, Kreder et al [19] recommended consideration of immediate total hip replacement for patients older than 50 years with marginal impaction and comminution of the wall, since 7 (54%) of 13 such patients in their study required early hip replacement.

Using the above at-risk criteria (when complicating features significantly diminished the likelihood of a favorable outcome after open reduction and internal fixation of a displaced acetabular fracture), Mears and Velyvis [74] performed acute THA in 57 patients with a mean age of 69 years (range, 26–89 years). The mean time from the injury to arthroplasty was 6 days (range, 1–21 days). Their indications included intraarticular comminution as well as full-thickness abrasive loss of the articular cartilage, impaction of the femoral head, and impaction of the acetabulum that involved > 40% of the joint surface, including the weight-bearing dome. At a mean follow-up of 8.1 years the average Harris Hip Score was 89 points and 79% of their patients had an excellent or good outcome. During the initial 6 postoperative weeks, the acetabular cups subsided an average of 3 mm medially and 2 mm vertically but then stabilized, and none were loose at the latest follow-up. Six patients had excessive medialization of the cup but none had late loosening or osteolysis. Nine cups (16%) had notable polyethylene wear but none were revised. There were three late procedures: one for revision of a malaligned cup because of recurrent dislocations, one for removal of hardware from the greater trochanter, and one for excision of heterotopic bone.

For complex fracture patterns, either augmentation of the cup [75], specially designed cups [74, 76], or separate reconstruction of the acetabular fracture as a combined hip procedure [77, 78] can achieve good results. In a retrospective clinical study Tidermark et al [75] treated ten patients with acetabular fracture (mean age, 73 years) with primary THA supported by a reinforcement ring (Burch-Schneider Antiprotrusion Cage) and autogenous bone grafting. The mean

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

operating time was 159 minutes (range, 125–185 minutes) and mean intraoperative blood loss 1,100 mL (range, 700– 1,600 mL). At an average follow-up of 38 months, the reinforcement ring was stable, the bone graft had completely incorporated, and there were no signs of loosening of the acetabular component or stem in any of the patients. Good functional outcomes were noted with all patients still independent of ambulators despite a slightly increased need for walking aids.

Boraiah et al [77] described a combined hip procedure where in a single stage, open reduction and internal fixation for a displaced acetabular fracture was performed followed by primary THA by a team that included both a fellowshiptrained orthopedic trauma surgeon and a fellowship-trained adult reconstructive surgeon. Their group included one transverse, one anterior column with a posterior hemitransverse, one both-column, and 15 posterior wall fractures. Of 15 posterior wall fractures, one was associated with a posterior column fracture, one with a dome fracture, two with transverse fractures, and nine with femoral head impaction. Of 18 patients in the study, 14 were followed up for more than 2 years (average, 3.9 years; range, 1–10.1 years). All but one patient healed successfully. One patient required revision and placement of a constrained prosthesis due to early failure of acetabular component. Harris Hip Scores ranged from 78–99, with a mean of 88. The x-rays showed an average medial displacement of 1.2 mm (range, 0–3 mm) and an average vertical displacement of 1.3 mm (range, 0–4 mm), but no radiographic evidence of acetabular component loosening.

After an aggressive medical workup, Herscovici et al [78] treated 22 elderly patients using a combined hip procedure.

There were nine transverse plus posterior wall patterns, seven anterior column with a posterior hemitransverse patterns, and six both-column injuries. The procedure involved a standard open reduction and internal fixation technique followed by immediate THA under the same anesthesia. The procedures averaged 232 minutes with a blood loss of 1163 mL. At an average follow-up of 29.4 months, hip motion averaged 102° of flexion, 32° of abduction, and 16° of adduction. Harris Hip Scores averaged 74. Five patients required revisions for osteolysis or multiple hip dislocations.

4

Timing of surgery

Fractures of the acetabulum often pose many diagnostic and technical problems. Therefore, acute open reduction and internal fixation rarely are indicated. Exceptions to this include dislocations that cannot be reduced by closed means,

an incarcerated intraarticular fragment following closed reduction, and unstable posterior dislocations that cannot be held in the reduced position because of the marked deficiency of the posterior wall. The former should generally be considered a surgical emergency and a reduction of the dislocation performed as soon as possible after the injury.

However, the exact minimal interval to reduction of a dislocated hip may be less important than previously believed.

In one study, Bhandari et al [56] reported that the quality of fracture reduction was the only significant predictor of radiological grade, clinical function, and the development of posttraumatic arthritis (P < .001) in 109 patients who had an acetabular fracture associated with a posterior dislocation of the hip.

Progressive or sciatic nerve palsy that develops after reduction of the dislocation also should be considered a surgical emergency. Rare indications for emergent surgical intervention include an open fracture of the acetabulum and an anterior column fracture associated with a femoral artery lesion [20].

In all other circumstances, the timing of surgery is more dependent on stabilization of associated visceral, skeletal, and soft-tissue injuries, the completion of all imaging studies necessary for careful preoperative planning, and the availability of an experienced surgeon. A difficult procedure then can be performed on an elective basis with a more experienced operating team, usually between day 2 and day 5 postinjury.

Although deferral of operative treatment for up to 2 weeks usually provides only a minor compromise to the ease of surgical reduction [5, 9, 12, 14, 79], delays of more than 1 week should be avoided if possible. One study [80] has noted an average time to surgery of 11 days for fractures with an acceptable reduction, whereas another [81] demonstrated a correlation with poorer results when surgical stabilization was undertaken after 7 days. Madhu et al [79] retrospectively reviewed 237 patients with displaced fractures of the acetabulum and found that the time to surgery was a significant predictor of radiological and functional outcome for both elementary and associated displaced fractures of the acetabulum (Letournel classification). An anatomical reduction was more likely if surgery was performed within 15 days for elementary patterns and 5 days for associated patterns. Additionally, a good to excellent functional outcome was more likely when surgery was performed within 15 days for elementary fracture patterns, and by 10 days for associated fracture types. Beyond 2 weeks, an anatomical reduction becomes progressively harder to obtain because of the increasingly difficult task of meticulously taking down varying amounts of callus, organizing hematoma, and granulation tissue [3, 5, 11, 12, 14, 39, 40, 42, 48, 55, 82–88]. Letournel himself found that by this time, his rate of anatomical

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reduction had dropped from 75–62% of cases [5]. Dean and Moed [88] noted poor outcomes in three of four patients with posterior wall acetabular fractures undergoing surgical treatment beyond 3 weeks. Two of the three total hip arthroplasties performed were required within only 18 months of the initial reconstructive effort.

5

Preoperative planning

Because patients with acetabular fractures often present with associated visceral injuries and skeletal injuries to such structures as the pelvis, femur, and ipsilateral knee, the preoperative evaluation needs to begin with a thorough physical examination and appropriate trauma workup.

Accurate assessment of the patient’s neurological status also is mandatory because the incidence of preoperative, posttraumatic sciatic nerve compromise following acetabular fractures has ranged from 12–38% [5, 11, 32, 34, 89–94]. For example, Giannoudis et al [94] found that 27 (19.9%) of 136 patients who underwent open reduction and internal fixation of an acetabular fracture had some form of sciatic nerve injury. At initial presentation, 13 patients had a complete foot-drop, ten had weakness of the foot, and four had burning pain and altered sensation over the dorsum of the foot. Of interest, nine of the 13 patients with a foot-drop had evidence of both a proximal acetabular (sciatic) and a distal knee (neck of fibula) nerve lesion, which the authors termed “the double-crush syndrome.” At the final follow-up, clinical examination and electromyography (EMG) studies showed full recovery in five of the ten patients with initial muscle weakness and complete resolution in all four patients with sensory symptoms (burning pain and hyperesthesia). However, at a mean follow-up of 4.3 years, only two of the 13 patients who presented initially with complete foot-drop had some improvement in sensory and motor function, while no improvement was seen in the others, including all nine with the double-crush lesion.

Another important part of the preoperative workup includes both prophylaxis and surveillance for deep vein thrombosis (DVT), which has been reported to occur in as many as 35–60% of patients with pelvic fractures [95–98]. Patients with acetabular fractures awaiting transfer to another institution for their definitive care are at especially high risk for DVT and require prophylaxis. Steele et al [99] highlighted the importance of the early administration of chemical prophylaxis. In 103 consecutive patients prospectively studied after undergoing surgical stabilization of pelvic and acetabular fractures, the authors noted a proximal DVT rate of 10% and pulmonary embolus rate of 5%. Proximal DVT

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developed in only 2 (3%) of 64 patients who had received low-molecular-weight heparin within 24 hours of injury, but in 8 (22%) of 36 patients who received low low-molecular-weight heparin more than 24 hours after the injury (P < .01). Letournel and Judet [5] reported a 3% incidence of clinically evident DVT with four fatal and eight minor pulmonary emboli in a series of 569 patients, despite most receiving anticoagulant prophylaxis. In a prospective study, Geerts et al [95] demonstrated a 60% incidence of DVT in patients with primary lower extremity orthopedic injuries, and Kudsk et al [96] observed a 60% incidence of silent DVT by venography in patients with multiple trauma immobilized 10 days or more. Montgomery and et al [100] used magnetic resonance venography (MRV) to evaluate 45 consecutive patients with displaced acetabular fracture, noting 24 asymptomatic thrombi in the thigh and pelvis of 15 patients (33%).

Although most studies have found MRV to be highly specific and sensitive [98, 100–103], some have questioned its value [104–106]. Stover et al [105] reported a low incidence of MRV and CT venography detected thromboses in their series of 30 subjects. Deep vein thrombosis was detected in five patients; however, only one subject had DVT identified by both imaging techniques and only one of the five identified DVTs was confirmed by standard contrast venography. Other authors have questioned whether the efficacy of present day screen techniques merits their use at all. Borer et al [106] reviewed 973 patients with pelvic or acetabular fracture treated over two consecutive 2-year periods: the first with routine screening and the second when routine screening had been discontinued. Discontinuation of screening for DVT did not change the rate of pulmonary embolus in their patients with closed fractures of the pelvis or acetabulum (1.4% without screening vs 2% with routine screening).

The overall rate of pulmonary embolus was 17 (1.7%) of 973 patients, and the rate of fatal pulmonary embolus was only 3 (0.31%) of 973 patients. Finally, they calculated that the estimated cost of the 237 MRVs and 302 diagnostic ultrasounds performed during the first half of their study was $464,532, indicating a significant cost incurred for questionable value.

Despite the present ongoing controversy regarding optimal preoperative prophylaxis and surveillance, during the preoperative period we prefer low-molecular-weight heparin combined with an intermittent pneumatic compression device, and MRV to rule out DVT [97, 100, 101]. If a significant clot is diagnosed, most patients undergo placement of an inferior vena caval filter and are treated with intravenous heparin before surgery. While controversy exists with respect

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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to prophylactic inferior vena cavals because they appear to be safe and effective in preventing pulmonary embolus in patients with pelvic trauma and established venous thrombosis, their use should be considered for polytrauma and intensive care unit patients or when anticoagulation is an issue [107–109].

and method of fixation for the major fracture fragments.

These decisions are made with the expectation that the entire procedure can be performed through a single operative incision.

6

A thorough understanding of the complex pathoanatomy involved is extremely important before attempting operative fixation. An accurate diagnosis of the basic fracture pattern can be accomplished with three basic roentgenograms described by Judet et al [1]: an AP view of the pelvis, an iliac oblique view of the acetabulum, and an obturator oblique view of the acetabulum. This initial roentgenographic survey, with accurate delineation of all fracture lines, provides vital information that dictates the treatment plan. If surgery is indicated, this information also helps the surgeon select the optimal surgical approach. To this end, the classification scheme of Letournel helps describe the fracture and determine the surgical approach, while having substantial inter­observer reliability (kappa > 0.7) when used by surgeons who have been taught how to interpret the images or by those who treat acetabular fractures on a regular basis [110]. The addition of conventional CT scans with thin slice (1–3 mm) axial cuts allows for better appreciation of the extent of injury. Although CT provides little additional information regarding simple column fractures, it is particularly helpful in evaluating the integrity of the dome, posterior lip, sacrum, sacroiliac joint, and femoral head; and delineating the rotation of the columns or presence of intraarticular bony fragments [35, 50, 58–60, 111, 112]. Although obtaining both the plain films and a CT scan may seem redundant, intraoperative decision making and technique depends on a clear understanding of the former. These are superior for evaluating hip joint congruency and can be compared with intraoperative and postoperative images.

Advances in imaging software technology have led to the development of 3-D CT, which can help provide a better understanding of the spatial relationship of the fracture pattern relative to the pelvis as a whole. Although its role is not yet altogether defined, it can be useful when viewed real time on a monitor that allows visualization of the fracture from various projections. Moreover, 3-D CT scans can be used in conjunction with plain roentgenograms including Judet views and axial CT scans for teaching to facilitate preoperative planning, and especially in late cases, such as acetabular nonunions and malunions. It is often helpful to transfer the fracture lines from these radiographic studies to a model pelvis. Such a 3-D perspective can assist the surgeon in the selection of the optimal surgical approach, reduction technique,

Selection of the optimal surgical approach

The surgeon must use a surgical exposure that will afford the best opportunity to restore joint congruency by anatomical reduction and stabilization of the articular surface, while resulting in the least morbidity. To this end, Mayo [10] has identified five major factors that affect this decision: (1) the fracture pattern; (2) the local soft-tissue conditions; (3) the presence of associated major systemic injuries; (4) the age and projected functional status of the patient; and (5) the interval from injury to surgery. Under most circumstances, the fracture pattern is the major determinant. Therefore, it is important to accurately classify the fracture using either the Letournel-Judet [3–5, 7] (Table 2.7-1) or Comprehensive Classification [113] system (Table 2.7-2) [7]. Importantly, any additional injuries to the pelvic ring also must be considered [26]. Finally, the selection of the proper surgical exposure also is to a large extent driven by the experience of the operating surgeon.

Type of fracture

Approach

Anterior Cephalad to iliopectineal

Iliofemoral

Eminence Complex patterns requiring exposure to the symphysis and quadrilateral plate

Ilioinguinal

Posterior wall or posterior column

Posterior Kocher-Langenbeck

Transverse, with posterior wall involvement

Posterior Kocher-Langenbeck, transtrochanteric; sequential or combined anterior and posterior approach

Transverse, no posterior wall

Approach depends on the level, obliquity, and displacement of the fracture; anterior and posterior combined/extensile

T-type

Approach depends on pattern: may be posterior, anterior, extensile, or some combination

Both-column

Ilioinguinal, modified ilioinguinal, extended iliofemoral, triradiate, transtrochanteric, or combined

Table 2.7-1 Guidelines for choice of approach to acetabular fractures (Letournel-Judet).

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Section 6 Techniques 2.7 Specific surgical approaches and technique

When open treatment is indicated, most acetabular fractures can be treated with a single more limited anterior or posterior surgical approach [4, 5, 10, 14, 37, 45, 52, 74, 114–121]. Using the technique of indirect reduction with a single nonextensile approach in 84 complex acetabular fractures involving two columns, Helfet and Schmeling [45, 116] reported a success rate of 91%, a deep infection rate of 0%, and an incidence of significant heterotopic ossification (HO) of 2%. Therefore, if an adequate preoperative evaluation of the patient and fracture pattern has been performed, then it is rare that a second surgical approach will be required. This is important because extensile exposures involve greater patient morbidity compared with single anterior or posterior approaches, including increased operative time, blood loss, infection,

Type A: partial articular, involving only one of the two columns A1 (posterior wall fracture)

Kocher-Langenbeck lateral decubitus

A2 (posterior column)

Kocher-Langenbeck

A3 (anterior column or wall)

Ilioinguinal

Type B: partial articular, involving a transverse component B1 (pure transverse)

Approach depends on the level and obliquity of the transverse component, direction of rotation, and the column with the major displacement. For most fractures, a Kocher-Langenbeck (prone) will be successful. For transtectal pure transverse (81-2) and difficult associated transverse and posterior wall fractures (81-3), an extensile approach may be preferred.

B2 (T-shaped)

If the major displacement is posterior, particularly in the infratectal or juxtatectal type, and there is an associated posterior wall fracture, then the KocherLangenbeck should be utilized. When the major displacement or rotation is primarily anterior, then the ilioinguinal should be used. The patient should be prepared for both exposures in case a supplemental approach is required. For fractures, which are transtectal, comminuted, displaced, or of late presentation, an extensile approach may be required.

B3 (anterior column and posterior hemitransverse)

Ilioinguinal

Type C: fractures (complete articular: both-columns) C1 (high variety, extending to the iliac crest)

Ilioinguinal, unless there is complex involvement of the posterior column and/or wall, which will necessitate an extensile approach

C2 (low variety, extending to the anterior border of the ilium)

Same as C1

C3 (extension into the sacroiliac joint)

C3 extended iliofemoral

Table 2.7-2 Choice of approach to acetabular fractures (AO/OTA Fracture and Dislocation Classification).

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nerve injury abductor weakness, joint stiffness, and HO [5, 10, 11, 23, 32, 40, 42, 48, 54, 55, 66, 83, 122–127]. However, for more complex fracture patterns involving both acetabular columns and those delayed past 2–3 weeks, an extensile or combined anteroposterior surgical exposure may be necessary for visualization and reduction [3, 5, 11, 12, 40, 42, 47, 48, 52–55, 66, 82–84, 87, 115, 126–128]. An extensile approach also might be considered in lieu of the ilioinguinal should there be a nearby suprapubic catheter or colostomy, which presents a greater risk for infection [40].

Although the classic extended iliofemoral approach [3–5, 66, 128] is presently the preferred extensile exposure for the surgical stabilization of acetabular fractures, other extensile approaches have been described. Senegas et al [129] reported a transtrochanteric approach, which is a modification of the Ollier approach and allows limited exposure of the anterior column above the supraacetabular region. Another transtrochanteric approach that has been used in the past is a modification of the Gibson approach (see “Alternative to KL: The Modified Gibson Approach”), which involves a straight lateral incision [2, 54, 120, 130, 131]. Finally, some authors [66, 127, 132] have described a T-shaped modification of the extended iliofemoral approach, which involves osteotomies of the iliac crest to facilitate closure and rehabilitation.

Some authors [133, 134] popularized the triradiate approach.

These later approaches require osteotomy of the greater trochanter that carries the additional risk of nonunion and also has been associated with an increased risk of HO [122, 124]. Perhaps blunt trauma to the gluteal muscle mass and peritrochanteric region is the most troubling finding when planning a posterior or extended approach. Contusions and abrasions over this region may herald the presence of the Morel-Lavallée lesion. The area is usually fluctuant secondary to a large hematoma and fat necrosis developing under the degloved skin and subcutaneous tissues. Despite their closed nature, they are associated with high rates of secondary bacterial contamination and must be addressed with surgical decompression, debridement, and drainage before definitive fracture care [135, 136]. Another relative contraindication for a posterior or extensile approach is the presence of a closedhead injury, which has the potential in and of itself to lead to massive HO [135–139]. In these cases, the ilioinguinal approach has been recommended if the fracture pattern permits [139].

6.1

Fracture patterns affecting primarily one column

Fracture patterns that strictly involve only the posterior elements, such as the posterior wall (type A1), posterior column (type A2), and comminuted posterior variants are best exposed through KL approach. Prone or lateral positioning is

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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at the discretion of the surgeon. In contrast, fracture patterns that involve primarily the anterior aspect of the acetabulum, such as the anterior column (type A3), anterior wall (type A3), and anterior column with a posterior hemitransverse component (type B3) are best suited for the anterior ilioinguinal approach. Anterior column variants, which exit in the vicinity of the iliopectineal eminence, are termed “low,” as opposed to fractures with a large iliac fragment that are described as “high” [140]. In certain cases, such as with some of the “high” variants, a more limited exposure, such as with the standard iliofemoral (Smith-Petersen) approach [20] or its modification [141] might suffice. The choice of the proper approach for more complex fracture patterns may not be as straightforward.

6.2

Transverse fracture patterns

In the case of the pure transverse (type B1) and the T-type (type B2) fractures, the choice of the optimal approach depends on the column with the greatest involvement, direction of rotation and displacement, height of the fracture relative to the femoral head, obliquity of the transverse fracture, presence of impaction, and status of the acetabular walls. The degree of displacement and extent of wall involvement is best seen on CT (Fig 2.7-1, Fig 2.7-2).

If the anterior column has the greatest displacement after preoperative assessment, then the ilioinguinal is the approach of choice. However, more commonly the posterior column demonstrates the major displacement and rotation.

A

a

B

b

Fig 2.7-1a–b For transverse fractures of the acetabulum the choice of anterior or posterior approach depends on many factors, including the rotation of the transverse fracture. If this rotation is anterior as depicted in A (ie, an anterior gap is noted on axial computed tomography) then the approach should be anterior, whereas if the rotation is posterior as shown in B and is associated with any major fragments of the posterior wall, then the approach should be posterior (Kocher-Langenbeck).

In these cases, particularly with an infratectal or juxtatectal fracture, KL approach should be used. The presence of an associated posterior wall fracture also mandates a posterior or extensile approach. Among the most difficult fractures are the high transverse (transtectal) and T-type fracture patterns with involvement of the weight-bearing dome. These variants often require an extensile approach or a combined anterior and posterior exposure in order to gain adequate access to the roof of the acetabulum to facilitate anatomical restoration of the articular surface.

One study [142] provided some guidelines when determining whether the fracture should be approached from either KL or an extensile approach. The authors noted that 80% of transverse plus posterior wall fracture patterns were amenable to the former but that the presence of two of the following three conditions mitigated more for an extensile approach: (1) transtectal transverse fractures because the anterior displacement in these cases may be difficult to control from the posterior aspect of the pelvis and precise reduction of the roof is imperative; (2) associated symphysis disruption and/or contralateral pubic rami fractures as the “hinge reduction” mechanism for the ischiopubic segment is lost; and (3) the presence of an extended posterior wall pattern, where posterior visualization gives no indication of the quality of the reduction of the transverse component of the fracture.

(In such cases the surgeon must look to other areas, such as the articular surface or anterior column cortex.)

Clearly, the novice pelvic surgeon should not attempt a single nonextensile approach for complex transverse and T-type fracture patterns. In cases when the surgeon is uncertain regarding his/her abilities to reduce such fractures through a single approach but wishes to proceed in such fashion, the patient should be prepared and draped in the floppy lateral position [52, 86, 114–116, 128]. This will permit the use of a combined anterior and posterior approach, if necessary. If a combined approach is planned or should the anterior column reduction be found to be impossible through KL approach, the posterior column can be reduced and stabilized from the lateral decubitus position. Following this, the patient is turned to the semisupine position to permit anterior column reduction and fixation via the ilioinguinal, iliofemoral, or other anterior approach. The disadvantage of using combined approaches in the floppy lateral position is that visualization of the fracture pattern from either approach is suboptimal. An alternative strategy is to extend an anterior limb from the midportion of the KL incision to the anterior superior iliac spine, effectively converting the approach to the extensile triradiate approach.

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6.3

Finally, a simple alternative for difficult fractures, such as those with a split into the superior weight-bearing surface of the joint, is to perform a supplemental greater trochanteric osteotomy. This may facilitate the exposure without resorting to a combined or extensile approach. Removal of the greater trochanter will improve visualization of the posterior column and the superior and posterior aspects of the acetabulum, allow palpation of the anterior column, and lessen the traction on the superior gluteal vessels and nerve [20, 83, 143–147].

For T-type or transverse fractures with posterior and superior wall involvement, this technique also allows palpation and visualization of the anterior portion of the fracture.

a

e

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b

Both-column fractures

Associated both-column (type C) fractures are the most impressive for their involvement and displacement of both the anterior and posterior columns, and their complete dissociation from the intact ilium and axial skeleton. In most cases, particularly when the posterior column is a single fragment that can be reduced anteriorly from within the pelvis, an ilioinguinal approach is in order. However, Matta [148] has warned that a clear distinction must be drawn between reduction of both-column fractures and reduction of T-shaped fractures through the ilioinguinal approach, as the latter can be difficult. This is because with both-column

c

d

Fig 2.7-2a–e Computed tomography of both-column fracture. a Axial view revealing significant dome comminution. The anterior column segment is externally rotated (large white arrowhead) and the femoral head is displaced medial to the dome of the acetabulum. Medially, the top of the quadrilateral plate can be seen (large black arrowhead).

Posteriorly, the “spur sign” can be seen (small white arrow). The spur sign is the lowest portion of the intact iliac wing, which tapers to a small spike of bone without any articular attachments.

Adjacent to this is a free superolateral fragment from the posterior column (smaller white arrowhead). b Axial view through the upper portion of the joint. The anterior column segment (large white arrowhead) is in continuity with the superolateral fragment (smaller white arrowhead) indicating that ligamentotaxis may reduce these fragments indirectly. The femoral head has displaced medially along with the posterior column and quadrilateral plate (large black arrowhead). The lowest portion of the spur sign is more clearly delineated (small white arrow). c Axial view through the middle portion of the joint. The lower portion of the free superolateral fragment is tapering into the posterior wall (smaller white arrowhead) with a small fragment in the fracture site. The quadrilateral plate and remaining posterior column is seen (large black arrowhead). d 3-D reconstruction facilitating perception of fracture configuration: obturator oblique view. The anterior column segment is externally rotated (large white arrowhead). Posteriorly, the lateral spur sign can be seen (small white arrow). Anterior to the spur sign is the separate superior and lateral posterior column and wall fragment. e 3-D reconstruction: iliac oblique view. The anterior column segment is displaced and externally rotated (large white arrowhead). The femoral head is displaced centrally, medializing the quadrilateral plate and posterior column. Posteriorly, the medial side of the spur sign can be seen (small white arrow).

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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fractures, the joint capsule and acetabular labrum often remain firmly attached to both the anterior and posterior column fragments, allowing their reduction from within the pelvis by hinging them on their capsular attachments. In a T-shaped fracture, the posterior column is typically torn away from its capsular attachments and therefore cannot be easily hinged back into place.

Although the ilioinguinal is frequently the approach of choice, both-column fractures require excellent surgical access to the entire ilium, often necessitating an extensile approach such as the extended iliofemoral approach (or one of its modifications) or combined anterior and posterior approaches.

These alternatives are generally preferred when patients are taken to the operating room late or when there are complex fracture patterns that extend into the sacroiliac joint (type C3), involve the weight-bearing dome, have fragmentation of the posterior column, or are associated with a posterior wall fragment large enough to require surgical stabilization.

Because extensile exposures are associated with the highest incidence of HO and postoperative morbidity [5, 32, 66, 122, 125–127, 134, 149, 150], some surgeons have promoted the use of a simultaneous or sequential anterior and posterior approach to treat complex fracture patterns that involve displacement of both anterior and posterior structures [52, 84, 86, 115, 128, 151].

6.4

Operating room preparation

General, regional, or combinations—these are the types of anesthesia advocated and depend on many factors, including the institution, patient factors, length of the procedure, and the desire or need for intraoperative nerve monitoring.

Obviously, regional is most preferable (not only intra­ operatively but also for postoperative pain management) but requires dedicated and involved anesthesiologists as part of the team. The addition of epidural catheterization may also be beneficial because of reduced inhalation anesthetic requirement [10], reduced blood loss, and improved post­ operative pain relief. However, while epidural anesthesia combined with general anesthesia has been shown to reduce hospital length of stay, improve postoperative pain control, reduce time to mobilization, and reduce intraoperative blood loss in arthroplasty patients, its benefits have been questioned by some with respect to treating a patient with an acetabular fracture. Strauss et al [152] found that the addition of epidural anesthesia added an average of 19 minutes to the anesthesia time (P = .01) but did not improve length of stay, pain scores, or time to rehabilitation. One benefit was a decreased amount of blood loss, but only 100 mL on average, which the authors noted was of unlikely clinical significance.

Because of the magnitude of the operative procedure, prophylactic antibiotics are used in all cases. The preferred drug is cephalosporin given intravenously immediately before surgery. A Foley catheter is placed in the patient’s bladder and vascular access is obtained with two large-bore intravenous catheters. Patients with advanced age or significant medical conditions may require placement of an additional arterial or central line. Although bleeding should not be profuse, the possibility of major hemorrhage is real; therefore, 4–6 units of blood should be available during the operative procedure. We also routinely use an intraoperative cell saver to minimize patient exposure to homologous blood.

This permits recycling of about 20–30% of the effective blood loss [135]. While many surgeons believe that intraoperative red blood cell salvage is useful when excessive blood loss is expected, its routine use has been questioned by others.

Scannell et al [153] used this technique in 32% of their 186 patients undergoing surgical stabilization of an acetabular fracture. The average volume of blood autotransfused was 345 mL. No differences were observed in the rates (58.3% vs 48%, P =.1883) or the mean volumes (770 vs 518 mL, P = .0537) of intraoperative and postoperative allogeneic blood transfusions between the salvage and nonsalvage groups. Not surprisingly, the total blood-related charges for the blood salvage group were significantly higher ($1958 vs $694, P = .0001).

With respect to positioning, the patient is placed on a radiolucent operating table that allows intraoperative traction and image intensifier. The selection of the type of table to be used is controversial and based on the surgeon’s preference.

The exact setup is dictated by the surgeon’s planned exposure: prone, supine, or lateral. All bony prominences are well padded and the patient is supported on a bean bag, or gel or foam rolls. With posterior and extensile approaches, the sciatic nerve is in danger and constant vigilance and protection of the nerve is mandatory. Protection is afforded by the maintenance of knee flexion and hip extension throughout the procedure because this position lessens tension on the sciatic nerve [5, 154].

When available, intraoperative sciatic nerve monitoring using both somatosensory evoked potentials (SSEPs) [53, 93, 95, 155] and EMG [89, 156] has been shown to afford a degree of protective surveillance. Likely because of its ability to provide “real time” information, the latter has been shown to be more sensitive and specific than the former [89, 156].

However, no EMG signal is produced in the absence of nerve irritation. In contrast, the advantage of SSEP is that a monitored signal represents intact nerve function. While SSEP

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Section 6 Techniques 2.7 Specific surgical approaches and technique

and EMG can be helpful, particularly to the less experienced surgeon, some have questioned their value. Two retrospective studies [157, 158] by experienced pelvic surgeons have yielded results similar to those reported in unmonitored patients as well as a high rate of false-negative readings when using SSEPs [157]. Haidukewych et al [157] found that the use of intraoperative monitoring did not decrease their rate of iatrogenic sciatic palsy. They compared 140 unmonitored acetabular fracture surgeries with 112 monitored procedures.

Traumatic nerve palsies were present in 11(7.9%) of 140 unmonitored patients and 13 (11.6%) of 112 monitored patients (P = .314). There were 14 (5.6%) iatrogenic sciatic nerve palsies in 252 cases: 4 (2.9%) in the unmonitored group and 10 (8.9%) in the monitored group (P = .037).

Interestingly, iatrogenic sciatic nerve injury was more common for ilioinguinal approaches in both groups. Also, for seven of the ten iatrogenic palsies in the monitored group, the intraoperative monitoring had been normal. The addition of EMG to SSEP monitoring, however, reduced the rate of iatrogenic injuries from 11.8–2.8% (P = .164).

Although controversial, these techniques should still be considered especially in patients at risk of developing an iatrogenic sciatic nerve injury; that is, those already demonstrating preoperative nerve compromise and those with a fracture pattern that includes a posterior column or wall fracture. When used, we prepare the entire extremity free and insert sterile subdermal electrodes. The sensory electrodes are inserted adjacent to the common peroneal and posterior tibial nerves and the motor adjacent to the tibialis anterior, peroneus longus, and abductor hallicus.

Video 2.7-1 Kocher-Langenbeck approach—prone position.

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7

Specific approaches

Video 2.7-1 and Video 2.7-2 demonstrate the posterior Kocher-

Langenbeck approach.

7.1

Posterior Kocher-Langenbeck approach

7.1.1 History

In 1958, Judet and Lagrange [2] combined the benefits of the Kocher (1907) and Langenbeck (1874) approaches to the hip to gain better access to the posterior column of the acetabulum through the greater and lesser sciatic notches (Fig 2.7-3).

7.1.2 Indications

The posterior approach is recommended for isolated posterior wall fractures and isolated fractures of the posterior column.

In experienced hands and with proper preoperative planning, it may also be used for transverse or T-type fractures of the infratectal or juxtatectal variety, especially those with associated posterior wall involvement.

7.1.3 Access

This approach (Fig 2.7-3) provides direct access to the retroacetabular surface of the innominate bone (posterior column) from the ischium to the greater sciatic notch, including visualization of the entire posterior wall of the acetabulum.

Indirect access to the quadrilateral surface is possible by palpation through the greater and lesser sciatic notches, allowing assessment after the reduction of fractures involving the quadrilateral plate and pelvic brim (anterior column).

The greater sciatic notch also provides a window for the placement of specially designed clamps to manipulate and reduce these fractures.

Video 2.7-2 Kocher-Langenbeck approach—lateral.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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7.1.4 Position

The patient is positioned either in the lateral decubitus position or prone on pillows or bolsters. The distinction between these two different positions is dependent on the fracture pattern or personality. The former simplifies intraoperative management, particularly for the anesthesia team, and is used primarily for posterior wall (type A1) and simple posterior column (type A2) fractures. In this position, the weight of the leg often hinders the reduction of transverse (type B1) fractures, thus mitigating in favor of prone positioning.

One study [159] has noted a trend toward a greater degree of residual fracture displacement of transversely oriented fractures treated by the KL approach with the patient in the

lateral position compared with those positioned prone. However, no significant differences were observed in operative time, estimated blood loss, or perioperative complications between the two groups. The hip is extended slightly and the knee flexed 90° throughout the procedure to minimize the incidence of iatrogenic sciatic nerve injury (Fig 2.7-4).

7.1.5 Advantages

This approach is familiar to most surgeons who perform hip reconstruction surgery or unipolar or THA. Muscle dissection is minimal, as is blood loss, and exposure is adequate for both the posterior column and posterior wall.

a

Access by touch (or finger access) Visual access

Fig 2.7-3 Access to the pelvis via the Kocher-Langenbeck approach.

b Fig 2.7-4a–b Patient prone on Judet-type fracture table with hip extended, knee flexed, and distal femoral skeletal traction in place.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

7.1.6 Disadvantages and dangers Superior gluteal neurovascular bundle

One major limitation of the KL approach is that the superior gluteal neurovascular bundle limits access to the superior iliac wing and is at risk during exposure of the greater sciatic notch and sciatic buttress. Therefore, the exposure is limited, especially if the transverse limb extends into the area of the greater sciatic notch [20]. Injury to the bundle can result from severe displacement of the sciatic notch because of high transverse fractures with marked medial rotation, or from an iatrogenic insult during surgery [10, 160, 161].

Letournel and Judet [5] reported an incidence of 3.5% in their series. The neurovascular bundle is at greatest risk during exposure of the greater sciatic notch and must be protected from undue traction or damage by carefully placed retractors. Furthermore, the surgical team must use extreme caution when applying traction to the gluteus medius to better visualize the lateral wall of the ilium because this act may tear the artery, with disastrous consequences, or stretch the nerve, causing permanent paralysis of the hip abductors.

Vascular injury can occur either during the exposure or fracture reduction [5, 10, 160]. Control of bleeding is crucial in this situation. Initially, packing of the area may provide hemostasis. Failing this, ligation of the bleeding vessel must be performed. The surgeon must avoid haphazardly placed vascular clips because the proximity of the superior gluteal nerve places it at risk of accidental ligation with disastrous results for the patient. Should a bleeding superior gluteal vessel retract into the pelvis in the midst of a posterior approach, an osteotomy of the sciatic notch can be performed to identify and control the bleeding vessel.

Sciatic nerve

When the KL approach is used, the sciatic nerve is always in danger and therefore must be protected at all times (Fig 2.7‑5). To this end, the knee joint must be flexed and the hip extended throughout the procedure, and the nerve protected by the short external rotator muscles by way of a tagged suture in the conjoint tendon. The first assistant must maintain a constant watch to ensure that any retraction of the nerve is gentle. Special retractors inserted into the greater or lesser sciatic notch with a small hook may be useful but constant vigilance is still required.

Although controversial, as discussed above [89, 156–158], intraoperative sciatic nerve monitoring is still preferred by many surgeons as it can detect sciatic nerve compromise through intraoperative monitoring of EMG activity (immediately) or via significant unilateral changes in amplitude

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and latency of the SSEPs. If nerve compromise is detected, then the surgical team must promptly respond by releasing traction and removing any retractors that have been placed against the nerve until the EMG activity ceases or the potentials return to baseline.

Pudendal nerve

The pudendal nerve is at risk as it exits the pelvis through the greater sciatic notch and reenters through the lesser sciatic notch. It can be injured through vigorous dissection or poorly placed retractors around the ischial spine. It also can be injured through excessive traction on a fracture table at the level of the perineal post.

Medial femoral circumflex artery

The medial femoral circumflex artery is at risk during exposure of the posterior column. Its branches are buried in the muscle of the quadratus femoris (Fig 2.7-6) and can be injured if the quadratus femoris muscle is released at its insertion on the femur. The vessel emerges between the quadratus femoris muscle and obturator externus adjacent to the femur where it is at maximal risk.

Heterotopic ossification

This complication occurs after all approaches to the outer aspect of the ilium with rates ranging from 18–90% [5, 25, 32, 122, 124, 162–164]. It is frequently noted along the gluteus minimus and the debridement of any necrotic muscle in this location may decrease the risk of its occurrence [166].

Hip abductor weakness

Posterior approaches had been associated with a significant loss of hip abductor strength, possibly because of careless dissection of the gluteus maximus muscle and damage to branches of the superior gluteal nerve [166–168]. Dickinson et al [166] noted that posterior approaches were associated with a 50% or greater loss of hip abductor strength at an average 21-month follow-up, with less than half of the patients demonstrating a normal gait and seven of 22 having a residual Trendelenburg gait.

In contrast, Borrelli et al [167], although still observing that poor functional outcome was associated with muscle weakness, noted that normal muscle strength could be regained in some patients and that most demonstrated only minor changes in gait at follow-up. Building on this earlier work, in two reports Borrelli et al [60, 169] compared 15 patients with a displaced acetabular fracture treated via a posterior KL approach, to similar group treated via an anterior ilioinguinal approach. Hip muscle strength was evaluated and correlated with functional outcome using the Musculoskeletal

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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3

4

2

5

Fig 2.7-5 Posterior exposure of the sciatic nerve, tagging and incision of the piriformis and external rotators, right side: (1) gluteus medius; (2) piriformis; (3) external rotators: superior and inferior gemelli and obturator internus; (4) sciatic nerve; (5) quadratus femoris; (6) vastus lateralis; and (7) released femoral insertion o f gluteus maximus tendon.

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1

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4

3 2

5 1

9

6

7

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Fig 2.7-6 Completed exposure of the posterior column and wall and hip joint through the Kocher-Langenbeck approach, right side: (1) superior gluteal neurovascular bundle exiting sciatic notch; (2) piriformis; (3) sciatic nerve retractor in the greater sciatic notch; (4) obturator internus between the gemelli; (5) Hohmann retractor in the lesser sciatic notch; (6) released femoral insertion of gluteus maximus tendon; (7) quadratus femoris; (8) posterior hip capsulotomy; and (9) Hohmann retractor under the gluteus medius.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

Function Assessment (MFA) questionnaire [60]. At an average follow-up of 44 months, patients treated via the posterior (KL) approach had an 8% overall strength deficit, including an extension strength deficit of 4%, an abduction deficit of 20%, an adduction deficit of 0%, and a flexion deficit of 7% [60]. In both studies, a relationship was noted between the hip extension/flexion work and maximum torque and hip adduction work and maximum torque and MFA score and that the greater the muscle strength recovery by the patient, the greater their functional outcome. The authors [169] therefore postulated that to maximize the functional outcome of patients after a fracture of the acetabulum that particular attention is paid to postoperative strengthening protocols.

Taking their research a step further, they next correlated gait with functional outcome observing that several of the limb kinematics for the affected and the unaffected limbs were different when patients treated by an anterior surgical approach were compared with those treated by a posterior approach as well as able-bodied cohorts. When gait was compared with MFA scores, worsening function correlated with decreased kinematics and stride length. A multivariate regression analysis indicated that both hip rotation (which was associated with hip strength) and hip adductor work strength were important predictors of final MFA scores.

This further supported the authors’ initial hypothesis that maximizing hip muscle strength may improve gait, and

improvement in hip muscle strength and gait is likely to improve functional outcome as measured by the MFA. Of interest was that in each of these later studies [60, 169] both surgical approaches produced the same gait outcomes, suggesting that gait changes after injury and treatment are related to factors other than the surgical approach.

8

Surgical technique

Prior to the surgical incision, all bony landmarks are outlined with a sterile marking pen, including the posterior superior iliac spine, greater trochanter, and shaft of the femur. The incision for the KL approach is then centered over the posterior half of the greater trochanter. It begins 5 cm distal and lateral to the posterior superior iliac spine, curves over the tip of the greater trochanter, and travels along the lateral aspect of the femoral shaft for approximately 8 cm, ending just distal to the insertion of the gluteus maximus tendon (Fig 2.7-7).

The iliotibial band then is incised up to the greater trochanter until the fascia overlying the gluteus maximus muscle is encountered. This fascia then is incised and the underlying muscle gently split in line with its fibers by blunt dissection, with two fingers aiming toward the posterior superior iliac

1

2

Fig 2.7-7 Surgical incision for the Kocher-Langenbeck approach, right side.

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Fig 2.7-8 Finger splitting of the gluteus maximus proximal to the greater trochanter—this separates the upper one-third (blood supply: superior gluteal artery) from the lower two-thirds (blood supply: inferior gluteal artery), right side. (1) Fibers of gluteus maximus; (2) iliotibial band.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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spine (Fig 2.7-8). If the gluteus maximus muscle is divided too far medially, the inferior gluteal neurovascular bundle may be compromised. Therefore, in order not denervate a significant portion of hip abductor muscle, the muscle should not be split proximal to the first neurovascular pedicle. Next, the trochanteric bursa is incised and the gluteus maximus tendon partially released (if desired) at the level of its insertion into the femur to decrease tension. At this point, it is imperative to identify and isolate the sciatic nerve, which can be consistently located along the medial aspect of the quadratus femoris muscle (Fig 2.7-5). Fractures of the posterior wall or column of the acetabulum may have significant associated soft-tissue injuries, such as avulsion of the tendon of the piriformis muscle that can distort normal anatomy and place the sciatic nerve at risk for an iatrogenic injury. Once the sciatic nerve has been identified, it should be followed to its pelvic exit at the greater sciatic notch. After identifying the sciatic nerve, the short external rotators are visualized and placed on stretch by gentle internal rotation of the hip.

Exposure of the posterior column of the acetabulum is performed in a stepwise manner from the greater sciatic notch to the ischial tuberosity, avoiding injury to the sciatic nerve.

The piriformis and the conjoined tendons of the obturator internus and gemelli (superior and inferior) muscles should each be isolated, tagged, released, and reflected from their femoral insertions (Fig 2.7-6). It is at this junction of the procedure that an understanding of the architecture of the medial femoral circumflex artery is crucial. As the course of its ascending branch is constant in this area [170], the critical blood supply to the femoral head can be preserved by protecting the quadratus femoris muscle and releasing the external rotators a minimum of 1.5–2 cm from their insertions (Fig 2.7-6; see also Fig 2.7-52 and Fig 2.7-53).

Once the piriformis muscle has been released, it is retracted toward the sciatic notch to gain exposure of the superior aspect of the posterior column of the acetabulum. Additional exposure of this area is provided by a Hohmann retractor inserted into the ilium under the tendon of the gluteus medius muscle (some careful stripping of the minimus may also be required). However, caution also should be taken to identify and protect the superior gluteal neurovascular bundle as it exits the greater sciatic notch in the region of the sciatic buttress. Excess traction on the bundle from too vigorous a dissection, excessive retraction on the hip abductors, or poorly placed retractors in this area may tear the artery or stretch the nerve, leading to disastrous consequences (Fig 2.7‑6).

Retraction of the conjoined tendons of the obturator internus and gemelli allows elevation of the obturator internus muscle by blunt dissection, exposing its bursa and the posterior column of the acetabulum (Fig 2.7-6). After release of the bursa, the obturator internus muscle is then followed into the lesser sciatic notch where a blunt curved Hohmann or sciatic nerve retractor is carefully inserted. The dissection around the area of the ischial spine must be meticulous because the pudendal neurovascular bundle is at risk as it exits the pelvis through the greater sciatic notch and reenters through the lesser sciatic notch. Retraction of the conjoined obturator internus tendon gives access to the lesser sciatic notch and affords a measure of protection to the sciatic nerve and pudendal neurovascular structures, which cross over (posterior to) the tendon.

In contrast, although retraction of the piriformis tendon provides access to the greater sciatic notch, it does not protect the sciatic nerve that exits the notch deep (anterior) to the tendon. Although careful placement of blunt Hohmann retractors in the lesser and greater sciatic notches provides a clear exposure of the entire retroacetabular surface, the assistant must be vigilant regarding the sciatic nerve. This requires the maintenance of minimal and only intermittent tension, while balancing the protective soft-tissue layer of the tendon of the obturator internus between the retractor and the nerve. For complex fracture patterns, dissection should be performed to allow placement of a finger through the greater sciatic notch to palpate the medial fracture line along the quadrilateral surface. This may require release of the sacrospinous ligament or osteotomy of the ischial spine (Fig 2.7-9). If further exposure of the posteroinferior aspect of the acetabulum is required, then the quadratus femoris muscle can be released from its pelvic origin along the ischium but not from its femoral insertion where the medial femoral circumflex artery is at risk. The bursa of the hamstrings overlying the ischial tuberosity can be cleared with an elevator to expose the tendonous origin of the hamstring muscles. In rare instances, when access to the superior weight-bearing surface of the acetabulum is necessary (high transtectal transverse or T-type fractures), osteotomy of the greater trochanter can be considered.

At this point, the entire posterior column can be visualized from the greater sciatic notch to the ischial tuberosity. The posterior articular surface of the femoral head usually can be easily visualized through the fractured posterior wall or column and a rent in the capsule is almost always seen. The hip capsule throughout the exposure should be preserved to as great an extent as possible to preserve the blood supply to the femoral head. Posterior wall and column fragments

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Section 6 Techniques 2.7 Specific surgical approaches and technique

are identified and their edges debrided sharply. Intraarticular fragments can be removed at this point by distracting the hip joint using femoral traction with either a fracture table (Fig 2.7-4) or a femoral distractor (Fig 2.7-10). By internal rotation, the hip may be “redislocated” and washed of all small fragments of articular cartilage and bone [20].

After reduction of the hip joint and further exposure of the entire posterior column from the ischial spine to the greater sciatic notch, the fracture may be reduced and stabilized in an appropriate manner. Techniques from the posterior approach will depend on the specific fracture pattern, which is usually

a

a posterior wall, posterior column, transverse, or T-type.

Posterior wall (type A1) fractures are routinely thought of as simple fractures to treat. However, this belief is incorrect, as their reconstruction is often complicated by significant comminution or marginal impaction (Fig 2.7-11, Fig 2.7-12) [18, 19, 39, 50, 170, 171]. These two entities make posterior wall fractures more difficult to treat, leading to among the poorest outcomes for all fractures of the acetabulum if ignored, especially when an associated posterior column or transverse fracture also is present [5, 18, 19, 32, 39, 172]. Marginal impaction of the articular surface is relatively common after a fracture of the posterior wall, occurring in 16–47% of

b Fig 2.7-9a–c Inspection of the quadrilateral plate through a Kocher-Langenbeck approach. a The quadrilateral plate may be inspected, if necessary, after dividing the insertion of the insertion of the sacrospinous ligament from the ischial spine or after removing its insertion onto the ischial spine with an osteotome. The surgeon should make certain that the structures in both the superior and the inferior gluteal notch are protected. b Once the ligament has been released, a finger can be inserted to assess the adequacy of reduction of any fracture line along the quadrilateral plate. c A periosteal elevator may also be used for this purpose.

c

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cases, and usually associated with a posterior hip dislocation [19, 39, 50, 170, 171]. As the femoral head dislocates, it not only fractures the posterior wall but also implodes the articular surface. Impacted fragments are readily identified on the preoperative CT scan and when exposed at the time of surgery are usually noted to be rotated 90° so that the surgeon looks directly at the articular surface (Fig 2.7-11b and d).

It is of paramount importance that large fragments be

anatomically reduced at the time of surgery to maintain joint congruity.

After cleaning the joint of debris and stabilizing an associated column or transverse fracture, traction is released and the femoral head used as a template for the articular reduction.

The medial aspect of each cortical wall fragment should be cleared of enough soft tissue to permit visualization of its

Fig 2.7-10 "Saw bones" pelvis in the prone position with femoral distractor applied to allow hip joint distraction. Note the Schanz screw in the sciatic buttress and the Schanz screw in the femur, placed through a small split in the vastus lateralis just distal to the greater trochanter.

a

b

c

Fig 2.7-11a–d a Posterior dislocation of the hip. As the femoral head rotates out of the acetabulum, a segment of the articular surface is often impacted. b This is clearly seen on computed tomography, where a large fragment of articular cartilage has been impacted as the head dislocated. Even after reduction of the head, the fragment remains in the unreduced impacted position (arrow). c The impacted fragment drives the posterior wall fracture apart, and reduction cannot be achieved without first disimpacting the fragment. d The clinical appearance is typical. On exposing the hip joint, a segment of articular surface is rotated 90° to its anatomical position. In this case, note the segment of articular cartilage. Normally, it should lie adjacent to the femoral head and not in clear view of the surgeon through the Kocher-Langenbeck approach.

d

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Section 6 Techniques 2.7 Specific surgical approaches and technique

reduction, while retaining as much of its capsular attachments as possible to preserve its blood supply. Extremely small and avascular fragments should be discarded. Next, any impacted articular fragments are gently elevated into a position congruent with the femoral head. These fragments must be carefully derotated by gently teasing them up with an elevator until they are congruous with the femoral head (Fig 2.7-12b). It is critical to leave as much metaphyseal bone attached to these chondral fragments as possible or it may be impossible to buttress their stability in their reduced position.

The reduction of marginally impacted fragments invariably produces a metaphyseal defect underlying the articular fragment(s), which is generally filled with autogenous cancellous bone graft. In most instances, this is easily obtained through a small window in the greater trochanter and used to buttress the reduced marginal fragments (Fig 2.7-12c). For large defects, structural allograft croutons can supplement the autograft. Another option is the use of bone graft substitutes, such as calcium-phosphate cement, which has been shown to partially restore normal joint-loading parameters [173]. It is extremely difficult to get any form of internal fixation into marginally impacted fragments, although focally placed bioabsorbable pins or small screws [174] can be considered.

If the latter is used, they will be covered over by the reduced wall fragment(s) and thus present potential problems with their removal, should further surgery become necessary.

Therefore, the maintenance of the position of reduced marginally impacted fragments is generally dependent on the bone graft or other suitable material and replacement of the main wall fragment on top. However, these marginally impacted fragments may be avascular and collapse in the postoperative period. The prognosis for the joint depends on how large these fragments are and whether good stability has been retained.

Next, the wall fragments are reduced and held in place by the straight ball spike pusher, followed by provisional fixation with K-wires. A reconstruction plate 3.5 is applied in the buttress mode over the reduced posterior wall and anchored to the ilium proximally and ischium distally. Underbending of this plate, in relation to the posterior wall, will aid in reduction of the construct and compress the fracture (Fig 2.7‑13). To best prevent fracture displacement, one or more lag screws (through or outside the plate) should be placed across the posterior wall into the posterior column.

When the posterior wall is comminuted, it is not possible to restore all small articular fragments with individual lag screws. In this situation, one can use spring hook plates (either prefabricated plates or short one-third tubular plates

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with their tips cut off through a hole and the newly created prongs bent downward to create small hooks) [7, 23, 50, 140, 175–177]. These plates are affixed in a loaded fashion underneath the posterior wall buttress plate more medially, but with the spring-loaded lateral hooks providing a buttressing effect to the comminuted posterior wall (Fig 2.7-14). Other options to buttress thin, small, or comminuted posterior wall fragments and thereby serve as cortical substitution include modified distal radius T-plates [178] or cervical H-plates [179].

Fractures involving the posterior column (type A2) generally result in posterior-medial displacement and internal rotation of the posterior column, as viewed from a posterior aspect.

After debridement of the fracture and removal of all comminuted fracture fragments and/or organizing hematoma, posterior column fracture reduction is accomplished by correcting the rotation with a Schanz screw in the ischium and the use of a pelvic reduction clamp in the greater sciatic notch to correct the medial displacement (Fig 2.7‑15). The gluteal neurovascular bundle can be damaged during this maneuver, and must be monitored. Alternatively, the reduction is accomplished by screw-holding clamp applied to 3.5 mm or 4.5 mm bicortical screws (depending on the clamp) inserted into each of the main column fragments. Care must be taken to position the screws away from the area of eventual plate placement. These clamps allow distraction, debridement, and compression of the fracture. After reduction and provisional fixation with a K-wire, direct visual inspection of the posterior fracture line best assesses displacement of the column, whereas rotation is best judged by digital palpation through the greater and lesser sciatic notches. A smooth quadrilateral surface is usually indicative of correct rotational alignment. When an accurate reduction has been confirmed, a reconstruction plate 3.5 is applied from the ischium to the ilium. A lag screw across the column fracture prevents redisplacement. If combined with a posterior wall fracture, the posterior column reduction should be addressed first followed by double plating, one for the column and one for the wall, as necessary.

Transverse (type B1) fractures require techniques similar to those used for posterior column fractures. However, although the retroacetabular fracture line in a transverse fracture may appear much the same as in the posterior column fracture, in these fracture types it is necessary to reduce not only the posterior column portion of the transverse fracture but also the anterior displacement and malrotation. Displacement can be controlled using the two-screw technique (Fig 2.7-15c) with a screw-holding reduction clamp, as described for the posterior column fracture. The surgeon can use this clamp

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

a

b

c

Fig 2.7-12a–c Reduction and fixation of a marginally impacted fragment of articular cartilage. a Note the impacted fragment at the tip of the K-wire. b Using the femoral head as the template and pillar for reduction, the fragment is gently teased with an elevator.

On some occasions impaction is so great that an osteotome is required to develop a plane. c The fragment is held in place in the anatomically reduced position with a cancellous bone graft.

Fig 2.7-13 Posterior placement of an undercontoured (underbent) plate during the reduction of a posterior wall fracture will direct compressive forces across the fragment(s), thus effecting a stable reduction.

a

b

c

d

Fig 2.7-14a–d a–c Spring hook plate technique for small posterior wall fragments. d Fashioning a spring hook plate.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

b

Fig 2.7-15a–c Model pelvis, in prone position, of a transverse with a posterior wall fracture. a Posterior view demonstrating pelvic reduction clamp with pointed ball tips inserted into the greater sciatic notch, a Schanz pin placed in the ischium, and a screw in each major fragment to assist reduction. Also note the aluminum template placed where a contoured reconstruction plate 3.5 will be applied. b Inner table view displaying proper orientation of the pelvic reduction clamp with pointed ball tips. c Posterior view demonstrating the use of screw holding pelvic reduction clamp.

a

c

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Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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for distraction and debridement of the fracture line, all the way to the anterior column, and subsequently for manipulation and temporary reduction of the transverse fracture component. Rotation also can be controlled with either a Schanz pin in the ischium or pelvic reduction clamp with pointed ball tips placed into the sciatic notch. An elegant maneuver is to first secure a plate into one of the fracture fragments, and then to use the plate as a reduction tool.

After provisional fixation and inspection, stabilization is obtained with a reconstruction plate 3.5 applied to the medial border of the retroacetabular surface and lag screw(s).

This plate should be overcontoured to achieve compression of the anterior column segments as it is tightened down to the posterior column (Fig 2.7-16). Under contouring, as performed for posterior wall fractures, actually leads to distraction of the anterior column in transverse fractures.

To prevent displacement of the anterior column, a posteroanterior column lag screw is required for all transverse fracture types. This screw usually can be placed through the posterior buttress plate and must be oriented parallel to the quadrilateral surface to avoid joint penetration. Finger palpation along the quadrilateral plate helps in assuring correct position for the screw. This should be checked with image intensification on the operating table using multiple views, especially looking at the obturator oblique to assess the screw’s position in the anterior column and to ensure its extraarticular placement.

a

b

T-shaped (type B2) fractures are among the most difficult of all fracture types to manage. It is a complex variant of the transverse fracture pattern, in which the inferior ischiopubic segment has been separated into anterior and posterior fragments by a vertical stem component. Because of this, it is impossible to control the separate anterior column fragment by direct manipulation of the posterior column fragment(s) when working through a posterior approach, except possibly by ligamentotaxis through nondisrupted joint capsule. Therefore, successful fixation of this fracture through a posterior approach is dependent on the surgeon’s ability to obtain an indirect reduction of the anterior column and to confirm an accurate reduction by palpation of the anterior column and stem component through the greater sciatic notch. To achieve such a reduction, the surgeon must be familiar with the placement of instruments into the sciatic notch, and their use to manipulate the anterior column fragment after the provisional stabilization of the posterior column. For example, a small bone hook or pusher, gently introduced along the quadrilateral plate, can be used to derotate and pull the displaced portion of the anterior column posteriorly. This reduces this segment into the acute angle between the intact proximal anterior column and the reconstructed posterior column. Once an acceptable reduction has been accomplished, definitive fixation is achieved by the application of a posterior buttress plate and posterior to anterior lag screws as in transverse fractures. Care must be taken that implants for provisional or definitive fixation of

Fig 2.7-16a–b a Posterior placement of an overcontoured (overbent) plate during the fixation of a transverse fracture results in compressive forces over the anterior portion of the fracture and an optimal reduction. b In contrast, placement of an under­ contoured (underbent) plate during the reduction of a transverse fracture will lead to distraction of the fracture anteriorly.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

one column do not cross into the opposite column, hindering or preventing its reduction [54], and to avoid intraarticular or intrapelvic placement of the lag screws. The wound is closed in a meticulous fashion following completion of the operative procedure. The tendons of the piriformis and obturator internus muscles are reattached at the greater trochanter along with the remainder of the short external rotators. If a release of the gluteus maximus insertion has been required, this too is repaired at its insertion along the femur. Two suction drains are placed over the external rotators followed by closure of the iliotibial band and the fascia overlying the gluteus maximus muscle. A subcutaneous suction drain is inserted and the skin meticulously closed.

8.1 Modified limited exposure using KocherLangenbeck

Several authors have proposed more limited versions of KL including a gluteus maximus–splitting approach [180] or working through limited windows by not releasing the conjoint and piriformis tendons [168, 181]. Josten and Trabold [168] compared a group of nine patients who underwent such a limited approach to a group of nine who underwent the standard KL and found hip muscle strength and gait to be improved compared to the latter (not statistically significant), with a shorter operative time and similar articular reductions.

8.2.5 Disadvantages and dangers

The same neurovascular structures are at risk as in the standard KL, except that increased stripping of the gluteus medius and minimus muscles leads to a significantly higher risk for abductor weakness and/or HO [20, 124, 165, 182]. Heterotopic ossification is often noted along the gluteus minimus and the debridement of any necrotic muscle here may decrease the risk of this complication [165]. Furthermore, the unique disadvantages of this approach include the risk for nonunion of the trochanter. Also, the risk of avascular necrosis of the femoral head theoretically is increased by the potential inter­ ference with the posterior blood supply. Finally, visualization of most of the anterior column cannot be achieved except by looking into the hip joint or by palpating through the greater sciatic notch because this approach is still limited to the posterior column.

8.2.6 Surgical technique

This is the same as KL, with the lateral decubitus position more usual.

The skin incision is identical to that for the posterior KL approach, except that the lateral portion is longer [20]. If the standard KL approach has been performed but the surgeon desires greater access, it is a simple matter to osteotomize the greater trochanter and gain access to the superior wall of the acetabulum and a portion of the anterior column (Fig 2.7-17). The anterior column can be stabilized only by retrograde screw fixation (it is impossible to use a plate); however, the superior weight-bearing surface of the acetabulum will be visualized laterally, and intraarticularly by division of the capsule and traction. For this approach, initially the technique is identical to that for the posterior KL approach; then, the greater trochanter is predrilled to accept one or two screws at closure and simply is cut using a Gigli saw. The Gigli saw is much safer and avoids the risk of sawing into the femoral head. This technique as classically performed does not spare the vastus lateralis origin on the fragment and therefore requires more robust fixation. Therefore, at the time of closure, adequate fixation is obtained by two 6.5 mm cancellous lag screws (with or without tension band wires).

8.2.4 Advantages

8.2.7 Trochanteric flip osteotomy

This modification (osteotomy) extends the exposure to the anterior inferior iliac spine with improved visualization and access to the posterior column and superior aspect of the

A preferred alternative to the classic trochanteric osteotomy above is known as the trochanteric “flip” osteotomy. It was originally described by Ganz for surgical dislocation of the

8.2

Transtrochanteric approach

8.2.1 Indications

The indications for the transtrochanteric approach are the same as those for the KL but this variation affords better visualization of higher transtectal, transverse, and T-type lesions.

8.2.2 Access

Access to the upper part of the posterior column into the greater sciatic notch is increased compared to the standard KL approach. Trochanteric osteotomy also allows visualization of the lateral aspect of the acetabular superior wall anteriorly to the anterior inferior spine of the ilium.

8.2.3 Position

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acetabulum (including the weight-bearing dome) [20, 83, 143–147]. Removal of the trochanter also removes much of the tension from the superior gluteal vessels and nerves and, thus, protects them. The standard KL approach can be extended this way at any time should increased exposure be required.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

hip and subsequently has been used successfully by, others [143–147]. This technique involves taking a thinner cut through the greater trochanter and leaving the origin of the vastus lateralis attached to the distal portion of the trochanter (see “Other special technical factors: trochanteric flip osteotomy with surgical dislocation of the femoral head for treatment of fractures of the acetabulum”). When using this modification, fixation can be performed with 3.5 mm screws [144, 147]. The improved blood supply and stability afforded by this technique improves the exposure and minimizes

a

b

Gluteus medius

Gluteus minimus Capsule

c

complications and may even improve results. Tannast et al [147] evaluated 54 patients with acetabular fractures treated by a trochanteric flip osteotomy at a mean follow-up of 4.4 years. An anatomical reduction had been achieved in 50 hips (93%), which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis and only four patients subsequently required total hip replacement. Good to excellent results were achieved in 44 hips (81.5%) with functional outcomes better than those previously reported.

Piriformis tendon

Fig 2.7-17a–c Osteotomy of the greater trochanter affords increased access to the superior portion of the posterior column and into the greater sciatic notch. It also allows visualization of the lateral aspect of the acetabular superior wall in the area of the anteroinferior spine. Removal of the trochanter also diminishes the tension on the superior gluteal vessels and nerve. The initial approach is identical to the Kocher-Langenbeck. a If, in the course of that exposure, the surgeon wishes increased access, the greater trochanter is predrilled and osteotomized as has been classically described. b Access in the area of the greater sciatic notch anterior to the anteroinferior spine is increased. In this case the muscles are retracted with two Steinmann pins inserted into the lateral ilium. Note the superior gluteal vessels and nerve exiting the superior gluteal notch. In this drawing, the capsule has been elevated from the acetabular rim, allowing excellent exposure to the interior of the joint so that the articular fractures may be inspected. c An alternative to the classic trochanteric osteotomy is to create a digastric osteotomy, as described by Ganz.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

9 Alternative to Kocher-Langenbeck: the modified Gibson approach Video 2.7-3 demonstrates the alternative to Kocher-Langenbeck:

the modified Gibson approach. The modified Gibson or similar surgical exposures as described by several authors [2, 54, 130, 131, 183], and most recently promoted by Moed [120] offer a useful alternative to KL. The Gibson is essentially a modification of the Kocher approach with the main difference being that the former has a vertical skin incision, and that the deeper fascial incision and plane of dissection lies just anterior to the gluteus maximus rather than splitting it. The modified Gibson offers the advantages of increased anterosuperior direct access to the innominate bone, decreased risk of iatrogenic injury to the nerve supply of the anterior portion of the gluteus maximus muscle, and minimal need for trochanteric osteotomy. Furthermore, there is often contusion of the soft tissues in the area along the KL incision. By skirting this area, the Gibson avoids further insult to these damaged tissues, thus lessening the risk of wound complications. The Gibson can be used in almost any situation where KL would be utilized, including the surgical treatment of posterior wall, posterior column, and selected transverse or T-shaped fracture types. Its only potential disadvantage is that the exposure has some limitations posteroinferiorly.

A straight incision measuring 20–30 cm in length, depending on patient size, begins midlaterally and is centered over the greater trochanter (Fig 2.7-18). The incision is deepened down through the subcutaneous tissue to the iliotibial band. The anterior border of the gluteus maximus is identified by isolating the branches from the inferior gluteal artery that run

Video 2.7-3 Gibson approach with a digastric greater trochanteric osteotomy.

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within the fascia between the gluteus medius and maximus muscles before perforating the fascia lata to continue into the subcutaneous tissues. The fascial incision begins just distal to the level of the greater trochanter midlateral in the thigh and courses proximally, staying anterior to the anterior border of the gluteus maximus and leaving a cuff of tissue attached to the gluteus for repair later (Fig 2.7-19).

Superiorly, the gluteus medius muscle must be separated from this thick fascia (called the gluteal fascia at this level).

Posterolateral retraction of the gluteus maximus muscle is facilitated by release of its femoral insertion distally, and if necessary, a partial release of its anterosuperior origin and fascia from the iliac crest. The subsequent deep dissection is the same as with the KL approach (see “Kocher-Langenbeck approach”).

9.1

Anterior iliofemoral approach

The anterior iliofemoral approach is shown in Video 2.7-4.

9.1.1 History

This approach is essentially a modification of the SmithPetersen anterior approach to the hip, with stripping of the muscles off of the interior aspect of the pelvis.

9.1.2 Indications

Anterior column fractures and variants in which the main displacement is cephalad to the hip joint (“high” fractures) can be treated using this approach. The iliofemoral is often also the preferred anterior approach when the surgeon desires simultaneous visualization of both the anterior and posterior columns via two separate approaches rather than a single extensile exposure [52, 123].

Video 2.7-4 The iliofemoral approach.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

B

C

A

2 D

3

1

Fig 2.7-18 Modified Kocher posterior approach to the hip as described by Gibson. The greater trochanter is outlined by green dashes (D). The angled line (ADE) shows the location of the Kocher-Langenbeck skin incision superimposed on the gluteal fascia.

The angled line (BDE) shows the location of Gibson's original skin incision superimposed on the gluteal fascia. The straight line (CDE) shows the current skin incision for the approach. (1) Gluteus maximus muscle; (2) gluteal fascia; (3) tensor fasciae latae muscle; and (4) iliotibial tract.

4

E

7 6 5

8

4 3

9

10 1 2

Fig 2.7-19 Drawing of the fascial incision showing underlying anatomical structures: (1) quadratus femoris; (2) gluteus maximus muscle and tendon; (3) inferior gemellus; (4) obturator internus; (5) superior gemellus; (6) piriformis; (7) gluteus medius; (8) piriformis branch of the inferior gluteal artery; (9) trochanteric branches of the medial femoral circumflex artery; and (10) sciatic nerve.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

9.1.3 Access

Exposure of the anterior column is possible to the iliopectineal eminence by flexing and adducting the hip. Also, the lateral aspect of the iliac crest is accessible.

aspect of the pelvis. For even greater access, the sartorius and inguinal ligament insertion may be divided 1 cm distal to the anterosuperior spine, or an osteotomy of the spine performed. In this approach, the lateral cutaneous femoral nerve of the thigh almost always is sacrificed.

9.1.4 Position

The patient is placed in the supine position, unless combined with a posterior approach, in which case the floppy lateral position is used.

9.1.5 Advantages

This commonly used approach, known to most hip surgeons, requires no dissection of the femoral vessels.

9.1.6 Disadvantages and dangers

Access to the anterior column of the acetabulum is limited and fixation of the distal anterior column can be accomplished only with screws. Plates can be used only in the proximal area. The main neurovascular structure at risk is the lateral femoral cutaneous nerve (LFCN) of the thigh, which is often sacrificed with residual numbness causing minimal problems for the patient. If careless exposure passes medial to the iliopectineal eminence, then the femoral artery and vein are at risk. Careless exposure posteriorly in the vicinity of the sacroiliac joint can damage the L5 nerve root.

Finally, excessive stretch on the iliopsoas muscle increases the risk of injury to the femoral nerve.

Lefaivre et al [141] have described a modification of the SmithPetersen/iliofemoral approach, which significantly increases the surgical exposure. While this modification remains more limited than the extended iliofemoral approach, it does not encounter the same degree of risk and can therefore be useful for certain complex anterior column injuries.

It involves two osteotomies of the iliac crest. First, the anterior superior iliac spine (ASIS) is osteotomized taking a 2 cm long by 1 cm high block, which allows medial retraction of the sartorius, inguinal ligament, and abdominal wall structures. Next, a more posterior osteotomy creates a 1.5 cm high tricortical block off the next 10–12 cm length of ilac wing. This fragment of bone is then retracted laterally with the hip abductors. Closure of the abdominal wall insertions and hip abductor origins is simplified as the two bone blocks are repaired at the end of the procedure with lag screws.

9.2

Anterior ilioinguinal approach

The anterior ilioinguinal approach is shown in Video 2.7-5.

9.2.1 History

9.1.7 Surgical technique

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The skin incision begins 1 cm lateral or 1 cm medial to the iliac crest and is carried anteriorly over the anterior superior iliac spine. It then travels along the inguinal ligament in the fashion of the ilioinguinal approach, or as noted in Fig 2.7-20 in the interval between sartorius and tensor fasciae latae to the middle third of the thigh [20].

The ilioinguinal approach was developed and introduced

by Letournel in the early 1960s [5, 184, 185] and has consistently produced good results in capable hands [3–5, 57, 72, 73, 119, 140, 148, 185, 186]. The problems with infection early on (with rates up to 30%) involved primarily the retropubic space of Retzius and were solved by moving the medial portion of the incision slightly proximal, placing drains in

The periosteum is raised from the iliac crest, and the iliopsoas muscle is stripped from the interior aspect of the ilium, anterior to the sacroiliac joint and the greater sciatic notch, both of which can be visualized easily. Stripping of the iliopsoas muscle is simple because the muscle is not attached to the interior aspect of the pelvis by Sharpey’s fibers [20]. If access to the hip joint is needed, then the interval between sartorius and tensor fasciae latae may be developed by extending the dissection along the lateral aspect of the ilium. This requires stripping the lateral muscles by removing Sharpey’s fibers and allows visualization of the anterior aspect of the capsule and the anterior inferior iliac spine. Further dissection medially along the anterior column is possible to the iliopectineal eminence. A portion of the capsule and direct head of the rectus may be raised to allow access to the interior

Video 2.7-5 Ilioinguinal approach—Letournel.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

a

Iliacus

Sartorius

Rectus femoris

Gluteus minimus Tensor fasciae latae

b Fig 2.7-20a–b Iliofemoral approach. a Skin incision. The posterior aspect of the incision would be 1 cm lateral to or 1 cm medial to the iliac crest and not over the bone itself. The distal limb may be as shown, along the lateral border of sartorius or following the line of the iliolinguinal approach.

This is more versatile, as it allows the surgeon to switch to a more extensile iliolinguinal approach if necessary. The interval to reach the deep muscles is between the sartorius medially and the tensor fascia femoris laterally. b Deep dissection by removal of muscles from the outer, and often the inner, aspect of the pelvis. This approach allows easy access to the greater sciatic notch, and cerlage wires may be inserted with ease through this approach. The approach is often used in combination with the posterior Kocher-Langenbeck approach when the surgeon prefers a combined approach rather than a single extensile approach.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

the retropubic space, and using prophylactic antibiotics [148].

This approach creates three working portals or windows: (1) the internal iliac fossa bounded medially by the iliopsoas; (2) bounded by the iliopsoas and the femoral nerve laterally and the femoral vessels medially, giving access to the pelvic brim and quadrilateral space; and (3) medial to the femoral vessels, giving access to the superior pubic ramus and retropubic space of Retzius.

9.2.2 Indications

The ilioinguinal exposure is appropriate for all anterior lesions (anterior wall, anterior column, anterior with posterior hemitransverse) when access is required to the anterior aspect of the acetabulum distal to the iliopectineal eminence.

Fractures proximal to the iliopectineal eminence may be approached by the anterior iliofemoral approach. The ilioinguinal is also frequently used by experienced hands to treat both-column fractures in which the posterior column component consists of a single large fragment. Finally, this approach is used for transverse, or T-types, in which the rotation and displacement of the transverse limb is anterior.

9.2.3 Access

This approach offers direct visualization of the interior of the iliac wing, anterior sacroiliac joint, entire anterior column, and pubic symphysis (Fig 2.7-21).

9.2.4 Position

The patient is placed in the supine position on an image intensification table, supported on a bean bag, and protected at all bony prominences. A support can be placed under the sacrum to aid in preparing and draping or under the contralateral buttock to improve visualization of the quadri­ lateral surface during the procedure. If a simultaneous combined anterior and posterior approach is being considered, then the floppy lateral position is used, which allows the patient to be rolled from front to back.

9.2.5 Advantages

Excellent access is afforded to the anterior and internal aspects of the entire pelvis and acetabulum. Also, HO is minimal because the iliopsoas muscle is only loosely attached to the ilium.

9.2.6 Disadvantages and dangers

In its pure form, this approach is extraarticular with the reduction achieved almost entirely by indirect means and performed outside the acetabulum through the three windows. Therefore, the presence of retained intraarticular fragments, as well as the articular surface reduction itself cannot be visualized. Neither does this approach provide access to posterior wall fractures. A major disadvantage is possible damage to the femoral or other vessels, including laceration and thrombosis because of traction, or to the femoral or obturator nerves. Postoperative hernia also is a theoretical concern. The presence of a preexisting suprapubic catheter militates against the use of the ilioinguinal exposure because of concerns regarding infection. Other contraindications include abdominal distention, ileus, or other conditions that result in abdominal rigidity.

Femoral vessels

a

b Access by touch (or finger access)

Corona mortis

Visual access

A retropubic communication between the external iliac or deep inferior epigastric artery and the obturator artery, known as the corona mortis [5, 187, 188], may arise and extend over the anterior column in the area of the superior pubic ramus (Fig 2.7-22). Alternatively, this vessel can represent

Fig 2.7-21a–b Access to the pelvis via the ilioinguinal approach, right side. a The lateral (outer) bony pelvis. b The medial (inner) bony pelvis.

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The femoral vessels are at risk during mobilization of the vascular compartment off of the iliopectineal fascia. They must be isolated with a blunt retractor or wide ribbon penrose drain and protected throughout the procedure (see Fig 2.7‑26a, Fig 2.7-28, Fig 2.7-29). The lymphatics in this area are often overlooked, which if disrupted can result in significant postoperative lymphedema [148]. Leaving the conjoint tendon intact over their surface protects them from undue dissection and retraction.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

the origin of the obturator artery from the external iliac system. Estimates of the prevalence of an anomalous origin of the obturator artery have ranged from 10–40% [5, 10, 140, 188]. However, the higher end of this range is probably the more accurate figure. Teague et al [187] encountered retropubic anastomoses in 37% of their ilioinguinal exposures, with 43% of these patients having multiple vessels along the posterosuperior aspect of the superior ramus. Furthermore, two studies of anatomical specimen [187, 188] have detailed a large number of both arterial and venous anas-

tomoses, with arterial anastomoses in 34% and 43% of specimens, venous anastomoses in 70% and 59%, and both arterial and venous anastomoses in 20% and 27%, respectively (84% and 73% of the specimens had at least one venous or arterial connection of approximately ≥ 2 mm diameter). That there appears to be a higher incidence of vascular connections based on studies of anatomical specimen is likely because of the impact of the fracture pattern with the potential disruption of some of these connections at the time of the injury.

External iliac artery and vein

Internal iliac artery and vein

Inguinal ligament

External iliacobturator anastomosis

a

Fig 2.7-22a–b a Behind the body of the pubis the pubic branch of the obturator artery forms an anastomosis with the pubic branch of the inferior epigastric artery. b The obturator artery arises from the inferior epigastric via the pubic anastomosis. In a study of 283 limbs, the obturator artery arose from the internal iliac artery in 70%, from the inferior epigastric or external iliac in 25.4%, and from both equally in 4.6%.

Urinary bladder External iliac artery and vein

Internal iliac artery and vein

Inguinal ligament

Inferior epigastric artery and vein

Obturator artery and vein

Urinary bladder

b

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Section 6 Techniques 2.7 Specific surgical approaches and technique

Femoral nerve

9.2.7 Surgical technique

The femoral nerve is at risk during mobilization and excessive retraction of the iliopsoas muscle (Fig 2.7-28). Hip flexion aids in relaxation of the iliopsoas muscle, minimizing the need for any undue retraction. Interestingly, muscle weakness after this approach is not limited to the hip flexors alone [60, 169]. As previously discussed in detail, see “Specific approaches, posterior KL approach, hip abductor weakness”.

Fifteen patients with a displaced acetabular fracture treated via an anterior, ilioinguinal approach were compared with a similar group treated via a posterior KL approach [60, 169].

At an average follow-up of 44 months, patients treated via the anterior approach had an overall muscle strength deficit of 9%, including an extension strength deficit of 6%, an abduction deficit of 16%, an adduction deficit of 11%, and a flexion deficit of 7% compared with the unaffected side [60].

In these studies, both strength [60] and gait [169] correlated with functional outcome. Of interest was that both surgical approaches (posterior and anterior) produced the same gait outcomes, suggesting that gait changes after injury and treatment are related to factors other than surgical approach [169].

The cutaneous incision travels 1 cm medially or laterally along the anterior two thirds of the iliac crest in a curvilinear fashion toward the anterior superior iliac spine, where it then continues parallel to the inguinal ligament ending just beyond the midline at a point 2 cm above the pubic symphysis (Fig 2.7-23).

The proximal aspect of the approach is exposed first by releasing the lateral insertion of the external oblique muscle in the avascular plane between its insertion and that of the abductor muscles (Fig 2.7-24). A subperiosteal dissection is carried out elevating the abdominal musculature along with the iliacus muscle to expose the internal iliac fossa (Fig 2.7‑25,

Lateral femoral cutaneous nerve

Because of its position and variable anatomy, [189, 190] the LFCN is at risk when mobilizing the transversalis abdominus and internal oblique muscles off the inguinal ligament just medial to the anterior superior iliac spine. The nerve also can be stretched during mobilization and excessive retraction of the iliopsoas muscle. Patients should be warned preoperatively to expect this complication; approximately 35% develop loss of sensation and 5% develop meralgia parasthetica [189].

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Inguinal canal

An inadequate closure of the floor of the inguinal canal can lead to a direct hernia. To avoid this complication, a sound closure of the insertion of the transversalis abdominus muscle and the internal oblique muscle into the inguinal ligament is necessary. The contents of the spermatic cord are at risk during exposure of the external inguinal ring and should be carefully isolated and retracted with a penrose drain (see Fig 2.7-25, Fig 2.7-26).

Obturator neurovascular structures

The obturator artery and nerve are at risk during exposure, reduction, and fixation of the quadrilateral surface and must be protected with carefully placed retractors.

b Fig 2.7-23a–b The ilioinguinal incision, right side. a Obturator oblique view. b Lateral view.

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Fig 2.7-24a–b Exposure of iliac crest and external oblique fascia, right side: (1) abdominal muscles freed from crest; (2) iliacus; (3) iliac crest; (4) gluteus medius; (5) external oblique fascia; (6) anterior superior iliac spine; (7) inguinal ligament; (8) superficial inguinal ring; and (9) spermatic cord.

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Fig 2.7-28). Dissection is easy in this area because no Sharpey’s fibers connect the iliopsoas to the medial surface, except at the iliac crest [20]. However, a nutrient artery often is encountered along the iliac fossa [191], which requires hemostasis. The dissection is carried posteriorly to the sacroiliac joint and inferiorly to the greater sciatic notch.

Next, the iliac fossa is packed with sponges and attention directed to the inguinal portion of the exposure.

If the dissection is to be taken to the symphysis pubis (as is normally required), the external inguinal ring (the termination of the inguinal canal) and the structures exiting it must be identified, isolated, and protected using a penrose drain (Fig 2.7-25). These structures include the spermatic cord in the male, the round ligament in the female, the ilioinguinal nerve, and the genital branch of the genitofemoral nerve.

Knowledge of these structures as well as the pertinent anatomy of the inguinal region is crucial to the next portion of the procedure.

The external oblique aponeurosis is the most superficial layer of the abdominal wall muscles (Fig 2.7-25) and is encountered under the subcutaneous tissue. Medially, below the level of the umbilicus, it forms the superficial lamina of the rectus sheath. Distally, the termination of its aponeurosis forms the inguinal ligament, which is firmly attached to the iliac wing laterally and pubic tubercle medially. Inferiorly, the inguinal ligament rotates to a horizontal orientation

(known as the “shelving border”), which forms the inferior wall of the inguinal canal [140]. The internal oblique muscle lies deep to the external oblique and superficial to the underlying transversus abdominis (Fig 2.7-25). It takes its origin in part from the iliac crest and investing fascia of the iliopsoas. Its aponeurotic termination is medially continuous with the anterior layer of the rectus sheath and inferiorly fuses with the transversus aponeurosis forming the conjoint tendon (falx inguinalis) [140]. The transversus abdominis is the deepest of the three abdominal wall flat muscles, with its fibers running horizontally forward, becoming aponeurotic and blending into the anterior rectus sheath medially (Fig 2.7‑25). The conjoint tendon continues distally to merge into the shelving border of the inguinal ligament.

The external oblique aponeurosis is incised 5 mm from its insertion on the inguinal ligament from the ASIS to the external inguinal ring or just above the ring (Fig 2.7-24, Fig 2.7‑25). The inferior flap is gently retracted with Allis clamps to identify the conjoint tendon (internal oblique and transversalis abdominus muscles) and its distal insertion into the inguinal ligament. This exposes the structures in the inguinal canal, a triangular cavity that measures approximately 4 cm in the adult [140]. The anterior wall is formed by the external oblique aponeurosis, the inferior wall by the shelving portion of the inguinal ligament, and the posterior wall by structures derived from the transversus abdominis [140]. The deep inguinal ring is formed from a

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Fig 2.7-25 Release of external oblique fascia and conjoint tendon, right side: (1) packing sponge in the iliac fossa; (2) clamps carefully retracting the two flaps of the incised external oblique fascia; (3) incision of the conjoint tendon (internal oblique and transversalis fascia) at its insertion into the inguinal ligament (note the preserved lateral femoral cutaneous nerve passing under the tendon and just lateral to the scalpel); (4) spermatic cord; and (5) ilioinguinal nerve.

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defect in the transversalis fascia. The spermatic cord (male) or round ligament (female) passes through this. The ilioinguinal nerve emerges from the lateral border of the psoas major muscle, extends forward on the iliacus, and pierces the transversus abdominis and internal oblique to traverse the inguinal canal [140]. The genital branch of the genitofemoral nerve penetrates the deep ring to lie along the posterior aspect of the cord or round ligament.

A thickening of the endoabdominal fascia over the pelvic exit of the iliacus and psoas muscles (psoas sheath), known as the iliopectineal fascia, merges into the inguinal ligament and is the boundary between the true and false pelvis. This fascia serves as a major anatomical landmark for the next portion of the dissection as it separates the structures running under the ligament into two compartments: the lateral lacuna musculorum (iliopsoas, femoral nerve, and LFCN of the thigh) and the medial lacuna vasorum (external iliac vessels and lymphatics). Lateral to the iliopectineal fascia, while applying gentle tension on the inferior leaf of the external oblique, the conjoint tendon is incised from the inguinal ligament with a 2 mm cuff of inguinal ligament with it to facilitate its repair later (Fig 2.7-25). Here, care must be maintained to avoid injury to the lateral femoral cutaneous nerve, which courses immediately beneath the conjoint tendon just medial to the ASIS [5, 140, 189, 190]. Hospodar et al [190] recorded the nerve’s location as an average of 20 mm medial to the ASIS in 68 dissections of anatomical specimen. However, the nerve’s anatomy is variable, with it traveling up to 4 cm or more medially and having a different course, such as passing through the inguinal ligament or sartorius muscle [189, 190].

As the incision proceeds medially, the reflection of the iliopectineal fascia is encountered (Fig 2.7-26, Fig 2.7-27). Extreme care must be exercised, as the femoral vascular bundle lies just medial to this structure. Be careful when exposing, elevating, and mobilizing the femoral vessels. The entire sheath should be freed and protected, including the lymphatics, so that postoperative edema does not become a problem. Also, massive thrombosis of the femoral artery or vein may occasionally occur with this approach. Because of these concerns, and in contrast to the classic description [5, 148], we prefer to leave the conjoint tendon intact over the femoral artery, vein, and lymphatics. This avoids any unnecessary dissection (Fig 2.7-26, Figs 2.7-28–30) and protects these structures from undue traction.

Medial to the vessels, the conjoint tendon can be incised, if required, and the ipsilateral rectus abdominis muscle released (if needed as the classic approach dictates) 1 cm from its

anterior insertion from the pubic tubercle to the pubic symphysis (Fig 2.7-26, Fig 2.7-30). This portion of the exposure allows access to the space of Retzius and the symphysis (Fig 2.7-26c, Fig 2.7-30). It should be appreciated that in the presence of anterior pelvic ring injuries, one or both of the rectus abdominis muscles may already be avulsed off the pubic tubercle and ramus, in which case the bladder is at increased risk of iatrogenic injury during the exposure. Keeping the bladder decompressed with a Foley catheter lessens such risks. A final consideration is that an associated anterior pelvic ring injury might require fixation across the pubic symphysis necessitating an exposure with or without a partial release of the contralateral rectus abdominis muscle.

The iliopectineal fascia must be isolated and excised to access the quadrilateral surface (Fig 2.7-26, Fig 2.7-27). Laterally the iliopsoas muscle and the femoral nerve are carefully and bluntly separated off the iliopectineal fascia with a small elevator, blunt-tipped scissors, or hemostat, and mobilized with a 1 inch penrose drain (not shown). The femoral vasculature and lymphatics are next delicately dissected off the iliopectineal fascia medially, maintaining these structures as a unit with the overlying conjoint tendon. Frequently, small vessels penetrate this fascia and require ligation. Once the iliopectineal fascia has been isolated and the adjacent structures gently retracted, it is divided down to the ilio­ pectineal eminence and posteriorly along the pelvic brim to just anterior to the sacroiliac joint using scissors or a scalpel under direct visualization.

A broad penrose drain then is passed around the femoral vessels, lymphatics, and the overlying conjoint tendon (Fig 2.7-28). Dissection is carried out along the pelvic brim, under the femoral vessels and surrounding lymphatics, to expose the middle fossa (the quadrilateral plate) (Fig 2.7-29).

At this point, it is important to search for the corona mortis, a variable retropubic anastomosis, which should be ligated if identified (Fig 2.7-22). There is normally an anastomosis between the inferior epigastric and the obturator artery, which must be ligated or clipped [20, 84], but if the entire obturator artery crosses the column and is inadvertently divided disastrous consequences may ensue. When mobilizing the femoral vessels the surgeon should inspect the area under vessels in an attempt to identify such anomalous vessels (on average 6 cm from the symphysis but ranging widely) [188] to ligate them.

Access to the acetabulum through the ilioinguinal approach is now complete. Medial retraction of the iliopsoas muscle and femoral nerve allows access to the internal iliac fossa and anterior sacroiliac joint. This area is known as the first

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Section 6 Techniques 2.7 Specific surgical approaches and technique

(lateral) window of the ilioinguinal approach (Fig 2.7-28).

The second (middle) window is visualized by lateral retraction of the iliopsoas muscle and the femoral nerve, and medial retraction of the femoral vasculature allowing access to the pelvic brim, quadrilateral surface, and posterior column (Fig 2.7-29). The third (medial) window is exposed by lateral retraction of the femoral vasculature and lymphatics, which allows access to the superior ramus and pubic symphysis

(Fig 2.7-30). The contents of the inguinal canal can be mobilized either medially or laterally as needed. The obturator vessels and nerves can be visualized through either the second or third window and require protection during exposure and reduction of the fracture. A limited subperiosteal exposure of the outer surface of the anterior iliac wing occasionally is needed to apply pelvic reduction clamp to control either the iliac wing fragments or the posterior column.

Fig 2.7-26a–c a Excision of iliopectineal fascia: (1) external oblique; (2) retraction laterally (retractor not shown) of the iliopsoas, (3) femoral nerve; and (4) lateral femoral cutaneous nerve; (5) reflected distal flap of external oblique fascia to expose (6) inguinal ligament; (7) release of the iliopectineal fascia off the iliopectineal eminence; (8) medial retraction of the femoral vessels; and (9) penrose drain around spermatic cord. b Anatomy of the iliopectineal fascia: (1) anterior superior iliac spine; (2) femoral nerve; (3) psoas muscle; (4) iliopectineal fascia; (5) inguinal ligament; and (6) alternative midline split between rectus muscles as opposed to detaching ipsilateral rectus (see also Fig 2.7‑26c). c Medial incision of rectus sheath with exposure of superior pubis and symphysis: (1) bladder and space of Retzius; (2) symphysis pubis; and (3) penrose drain around spermatic cord.

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Fig 2.7-27a–b a Release of external oblique and conjoint tendons, left side: (1) external oblique and conjoint tendons; (2) femoral nerve; (3) iliopsoas muscle; (4) lateral femoral cutaneous nerve; and (5) iliacus muscle mobilized off inner table of the pelvic wing. b Excision of the iliopectineal fascia, left side: (1) femoral vessels retracted and protected by blunt right angle retractor; (2) lateral femoral cutaneous nerve; (3) iliopectineal fascia; and (4) psoas muscle and femoral nerve.

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Fig 2.7-28 Lateral window of ilioinguinal, right side: (1) iliopsoas muscle; (2) sacroiliac joint; (3) internal iliac fossa; (4) penrose drain around iliopsoas and femoral nerve (the lateral femoral cutaneous nerve can also be included though not in this drawing); (5) penrose drain around femoral vessels; and (6) penrose drain around spermatic cord.

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Fig 2.7-29 Middle window of ilioinguinal, right side: (1) penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve; (2) pelvic brim; (3) iliopectineal fascia released down to iliopectineal eminence; (4) obturator artery and nerve; (5) penrose drain around femoral vessels; and (6) penrose drain around spermatic cord.

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Fig 2.7-30 Medial window of ilioinguinal, right side: (1) penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve; (2) penrose drain around femoral vessels; (3) bladder and space of Retzius; (4) pubic tubercle and cut end of rectus muscle; and (5) symphysis pubis.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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Reduction of the acetabular fracture should be performed in a stepwise fashion according to the preoperative plan.

Unlike most other articular fractures, acetabular fracture reduction generally proceeds from the periphery toward the joint in a sequential fashion. Every step is critical to the outcome of the procedure, including an accurate reduction of all fracture fragments, since the articular surface is not directly visualized through this approach. Because peripheral malalignment can result in major articular incongruence (a main concern with this approach as the major portion of the articular reduction is by indirect means peripherally), reduction of each fracture segment must be performed painstakingly and exactly. Each fracture line should be carefully irrigated and debrided to remove hematoma and small fragments. The hip joint also is irrigated and loose fragments removed through the displaced portion of the articular fracture. Both the exposure and stabilization of the fracture can be aided by hip flexion to relax structures crossing anterior to the hip joint. A Schanz screw inserted through the lateral aspect of the femur into the femoral head followed by distal traction also can be extremely helpful because it can facilitate fracture reduction through ligamentotaxis. This is especially useful in cases where the femoral head has protruded through the quadrilateral surface.

pubis, to provide an anatomical template for subsequent reduction of the posterior column to the reduced anterior column. An incomplete anterior column fracture may require completion to permit an adequate reduction. The anterior column segment is typically shortened and externally rotated (Fig 2.7-2). To reduce this segment to the intact iliac wing (“spur” sign) (Fig 2.7-32, also see Fig 2.7-2, Fig 2.7-34, Fig 2.7‑37a), a significant amount of longitudinal traction is often required.

Definitive fixation of most fracture types involves a reconstruction plate molded along the iliac fossa, across the iliopectineal eminence to the pubic tubercle and pubic column (Fig 2.7-31). This should not cross the symphysis pubis unless there are associated ramus fractures, or if there is involvement of the symphysis pubis with an associated pelvic ring injury.

This plate must be perfectly molded; otherwise its fixation to the pelvis can lead to malreduction of the acetabular fracture. The plate is stabilized to the internal iliac fossa, superior to the acetabulum, with 3.5 mm cortex screws, and medially to the pubic tubercle and ramus. Fixation within the thin central area of the iliac fossa should be avoided. In contrast, the sciatic buttress and quadrilateral plate, proximal to the acetabulum, provide the most optimal purchase for stabilization of the anterior column to the iliac wing and posterior column.

Reconstruction of anterior column with a posterior hemitransverse (type A3) and both-column (type C) fractures begins with reduction of the individual peripheral fracture fragments to portions of the intact pelvis. Working from the periphery toward the articular surface, fragments are sequentially reduced and provisionally stabilized. This process requires patience and a 3-D understanding of the pelvic anatomy. The iliac crest portion of the fracture can be reduced with pointed reduction clamps or specially designed pelvic reduction clamp, and then stabilized by any combination of lag screws or reconstruction plates (Fig 2.7-31). It is often helpful to predrill a gliding hole before fracture reduction to assure optimal lag screw position in the thin cortical cap of the iliac crest. Screws also can be placed from anteriorly into the sciatic buttress.

For anterior column with a posterior hemitransverse fractures, the anterior column is next reduced to the intact iliac wing and temporarily stabilized with a K-wire or 3.5 mm lag screw into the sciatic buttress through the lateral window of the ilioinguinal approach. Then through the middle window, any anterior wall fracture is reduced. Finally, any superior pubic rami and displaced pubic column fractures are reduced and provisionally stabilized through the medial window.

For both-column fractures, the reconstruction must be performed perfectly, from the iliac crest to the symphysis

Fig 2.7-31 Example of contoured pelvic reconstruction plate, anterior screw placement, posterior screw placement, and posterior column lag screw placement from an ilioinguinal approach, right side.

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Following anatomical reduction and stabilization of the anterior column, the rotated and medially displaced posterior column is reduced to the restored anterior column. This is mandatory for both-column fractures and anterior column with a posterior hemitransverse fractures where the hemitransverse component is high, cutting into the greater sciatic notch. However, when the hemitransverse component of the later exits lower at the level of the ischial spine or lesser sciatic notch, the inferior segment can be difficult to manipulate and small amounts of displacement should be accepted, rarely mitigating for a supplemental posterior approach.

Fig 2.7-32 A significant amount of traction is needed to reduce the anterior column to the intact iliac wing, the inferior portion represented by the “spur sign” (white arrow). The spur sign is classically seen best on the obturator oblique view but often better delineated on computed tomography (see Fig 2.7-2).

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Reduction of the posterior column segment often requires lateral and anterior traction of the hip, via the Schanz screw in the femoral head, and specially designed pelvic reduction clamp. One tine of the clamp is placed on the outer surface of the ilium through a small limited exposure, and the other tine is placed through the lateral or middle window of the ilioinguinal exposure onto the quadrilateral plate and/or posterior column (Fig 2.7-33). A small supplemental bone hook gently slid down the quadrilateral plate, or specialized collinear clamp can hook the ischial spine and pull the posterior column up to the anterior column. Once posterior column has been reduced, 3.5 mm lag screws are inserted through the pelvic brim superior to the acetabulum and into the posterior column (Fig 2.7-34). Be careful to avoid intra­ articular placement of these lag screws, which are often up to 110 mm in length. This requires a cautious appreciation of the location of the acetabulum relative to the fixed pelvic landmarks (ie, inferior to the anterior inferior iliac spine

Fig 2.7-33a–b “Saw bones” left hemipelvis: using an offset large pelvic clamp to obtain reduction. The longer arm of the clamp is placed along the quadrilateral plate and the shorter arm inserted through an interval between the anteroinferior and anterior superior iliac spines to lie on the outer table of the iliac wing. a Iliac oblique view. b Obturator oblique view.

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and under the iliopectineal eminence). Therefore the “safe zones” to avoid intraarticular penetration by screws are: (1) posterior to the anterior inferior iliac spine and (2) anterior to the iliopectineal eminence (Fig 2.7-35). To best prevent joint penetration when near the edges of these safe zones,

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Fig 2.7-34a–c Posterior column lag screw. Note the entry point at the tip of the drill adjacent to the pelvic brim and just anterior to the sacroiliac joint. A lag screw in this area tends to pull the posterior column up to the anterior column, thus reducing it; however, incorrect placement allows it to penetrate the joint. The posterior column must have provisional fixation with a pointed reduction clamp (a) or a cerclage wire (b and c), as seen in this case demonstrating a both-column fracture. c The posterior lag screw is inserted. Image intensification Judet views should be checked during placement. On the iliac oblique view, the screw passes posterior to the hip joint and anterior to the sciatic notch. On the obturator oblique view, the screw is aimed toward the ischium.

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Fig 2.7-35a–d Safe and danger zones for anterior-to-posterior screw placement, right side.

All represent safe screws parallel to the quadrilateral plate, yet variable relative to the cotyloid fossa. (1) Iliopectineal eminence; (2) safe zone for posterior column lag screw; and (3) danger zone posterior to the iliopectineal eminence and anterior to the anterior inferior iliac spine: screws placed in this area are at high risk to penetrate the joint.

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After completion of fracture reduction and fixation, drains are inserted into the space of Retzius (if it has been opened), over the quadrilateral surface, and along the internal iliac fossa. If torn or detached during the surgical exposure, then the rectus abdominus muscle is next reattached to the pubis with strong suture or suture anchors. The floor of the inguinal canal is repaired by suturing the conjoint tendons of the transversalis abdominis and the internal oblique muscles to the inguinal ligament with nonabsorbable sutures. The roof of the inguinal canal is restored by repair of the external oblique aponeurosis and external inguinal ring, allowing passage of the spermatic cord in the male and the round ligament in the female. The external oblique muscle is then reattached to the inguinal ligament and the iliac crest using nonabsorbable sutures. A superficial suction drain is inserted, and the skin closed.

9.3

Modifications of the ilioinguinal approach

A number of modifications of the anterior ilioinguinal approach have been described. These include using the modified Stoppa approach (see “Modified Stoppa approach”) [119] with or without the middle window, creating three windows distal to the inguinal ligament rather than proximal to it [186], or extending the classic ilioinguinal distally [192], laterally [185], or even posteriorly (Fig 2.7-36, Fig 2.7-37).

Fig 2.7-36 Ilioinguinal approach with T extension to allow intraarticular visualization of the hip joint. By developing the interval between the sartorius and tensor (the Smith-Petersen approach) with or without division of the conjoint insertion of the ilioinguinal ligament and sartorius, the anterior aspect of the hip joint can be approached, as noted in the iliofemoral approach. This combined approach affords a complete view of the medial surface of the pelvis through the ilioinguinal approach, and the anterior aspect of the hip joint as noted in the iliofemoral approach. This approach is valuable if cerlage wires are to be used for reduction techniques and also for the placement of the large clamp for reduction.

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A significant advantage to using the Stoppa exposure medially is that detachement of the rectus insertion is not required, which facilitates both an easier and stronger surgical closure.

It is advantageous that the decision to use many of these options can be made either during preoperative planning or implemented during the operative procedure. The major disadvantage of several of these modifications is the stripping of lateral muscles with the risk of HO and the possibility of devascularization of articular fragments. Prophylaxis against HO is recommended when additional stripping of the abductor muscles is performed. Additionally, the failure to maintain strict subperiosteal dissection can lead to injury of the sciatic nerve and superior gluteal neurovascular structures.

Occasionally, it may be desirable for the surgeon to visualize the hip joint intraarticularly. This can be accomplished easily by combining the ilioinguinal with the Smith-Petersen iliofemoral approach (see “Other special technical factors: extension of the ilioinguinal approach”) [20, 192]. A vertical incision is made, starting at the anterosuperior spine or slightly more medially (Fig 2.7-36), and extended distally.

The sartorius insertion to the anterosuperior spine usually is predrilled and removed with a small oscillating saw or osteotome, allowing access to the lateral aspect of the pelvis.

The remainder of the approach is the standard iliofemoral one. This outer table exposure may be limited but it allows the passage of cerclage wires, which can be valuable in reducing some fractures [20, 185, 193, 194].

Another modification of the ilioinguinal involves a more limited extension of the lateral incision (Fig 2.7-37) [185]. This consists of limited elevation of the gluteus medius and minimus from the lateral aspect of the ilium, starting at the gluteal tubercle and continuing anteriorly to the interspinous notch and posteriorly to the greater sciatic notch. Care is taken to preserve the attachment of the muscles to the iliac crest posterior to the gluteal tubercle. The periosteal elevator must maintain contact with the bone at all times to avoid injury to the sciatic nerve, superior gluteal nerve, and superior gluteal vessels as the subperiosteal dissection continues posteriorly. Through this approach, a pelvic clamp can be placed on each side of the innominate bone to aid reduction, and implants, including cerclage wire or lateralto-medial lag screws become possible [185, 194].

For both-column fractures, which extend into the sciatic buttress or sacroiliac joint, the classic ilioinguinal approach provides inadequate visualization. As an alternative to extensile approaches in these cases, Weber and Mast [195] described a modification of the ilioinguinal approach that incorporates the posterior approach to the sacroiliac joint.

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c d Fig 2.7-37a–e a Exposure of lateral ilium after elevation of gluteus medius and minimus muscles. b Temporary stabilization of fracture using pelvic clamp on each side of the innominate bone. c Position of cerclage wire through greater sciatic notch and interspinous notch. d Diagram demonstrates cerclage wire as an aid to fracture reduction. e Position of drill for lateral to medial lag screw placement.

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The patient is positioned on a radiolucent operating table with the affected side rotated up 45°. By tilting the table down 45° toward the affected side, the patient is thus oriented in the supine position and by rotating the table up 45°, the patient reaches a lateral position that allows posterior exposure. The ilioinguinal portion of the procedure is performed as described. However, the incision along the iliac crest is carried more posteriorly to the posterior superior iliac spine, then directed straight inferiorly as described in the classic approach to the sacroiliac joint. After the dissection is carried through the subcutaneous tissue to the gluteus fascia, the gluteus maximus muscle is released from the posterior crest and sacrum. A subperiosteal dissection then is performed to the level of the fracture.

9.4.3 Access

This approach provides excellent visualization of the pelvic ring, including the medial wall, dome, and quadrilateral plate. Further posterior dissection with elevation of the external iliac vessels allows exposure of the sacroiliac joint and sacral ala.

9.4.4 Positioning

The patient is placed supine on a radiolucent operating room table. The entire lower abdominal and pelvic region as well as the entire hindquarter of the affected side is prepared and draped completely free. The surgeon assumes a position on the side opposite the fractured acetabulum.

9.4.5 Advantages

9.4

Modified Stoppa approach

For a presentation of the modified Stoppa approach, see Video 2.7-6.

9.4.1 History

The anterior Stoppa surgical approach was originally described in the hernia literature [196, 197]. It has since been modified and promoted by Cole and Bolhofner [83] for acetabular fracture surgery and is now one of the more preferred approaches for certain fracture types [83, 117–119, 121].

Excellent access is afforded to the anterior and internal aspects of the entire pelvis and acetabulum. Like the ilioinguinal and anterior iliofemoral approaches, this exposure can be combined with KL when required. Some advantages over the ilioinguinal approach include preservation of the lateral femoral cutaneous nerve, less direct surgical exposure of the femoral vascular structures, including the lymphatics, and better exposure of some fracture types, including those involving the medial wall of the acetabulum [83].

9.4.6 Disadvantages and dangers

9.4.2 Indications

An excellent alternative to the ilioinguinal or more extensile approaches, this exposure has produced good articular reductions and outcomes when treating a variety of fracture types— even those with significant displacement of the posterior column [83, 117, 118, 121]. Such fracture types include displaced anterior column or wall fractures, transverse fractures, T-shaped fractures, both-column fractures, and anterior column or wall fractures associated with a posterior hemitransverse component.

Like the ilioinguinal, this approach is essentially extraarticular, which does not provide direct visualization of posterior structures and requires indirect reduction maneuvers. Therefore, it should not be used in the presence of sciatic buttress comminution, fractures more than 3 weeks old, and fractures with pure posterior pathology. The presence of a preexisting suprapubic catheter mitigates against the use of this approach because of concerns regarding infection. Additional contraindications include abdominal distention, ileus, or other conditions that result in abdominal rigidity. With the exception of the lateral femoral cutaneous nerve, the same structures are at risk as during the ilioinguinal approach. It is particularly important with this exposure to pay attention to the location of the obturator neurovascular bundle and the lumbosacral trunk at all times.

9.4.7 Surgical technique

The surgical incision begins 2 cm superior to the symphysis pubis in a transverse fashion with the length extending approximately from the ipsilateral external inguinal ring to the contralateral external ring. The rectus abdominus muscle is split vertically from inferior to superior with care taken to stay extraperitoneal in the proximal portion (Fig 2.7-38).

Protecting the bladder, the rectus is retracted superiorly, Video 2.7-6 Ilioinguinal approach—intrapelvic modification.

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with sharp dissection used to elevate the rectus in order to expose the symphysis body and superior pubic ramus (Fig 2.7‑39).

Fig 2.7-38 Acetabular fracture fixation via a modified Stoppa limited intraplevic approach. A transverse incision is made 2 cm above the symphysis. Anterior fascia is incised at the midline.

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Fig 2.7-39a–b a Elevation of the rectus insertion on the pubis. b Bony anatomy as seen through the window of Fig 2.7-39a.

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The rectus and neurovascular structures next are retracted laterally and anteriorly to protect them. The remainder of the surgical procedure is performed beneath the iliac vessels, femoral nerve, and psoas muscle. A plethora of vascular anastomoses are often encountered, most being communications of the inferior epigastric and obturator vessels [83] (Fig 2.7-40, Fig 2.7-41). Anastomoses of the external iliac extending to the bladder and multiple nutrient vessels are also common. These are ligated as necessary with suture ligation or vascular clips. As with the ilioinguinal approach, this portion of the exposure places vascular structures at risk, particularly if a “corona mortis” is present. The initial vascular obstruction is an anastomotic branch between the inferior epigastric and the obturator vessel. This is always present but variable in size. Another common obstacle is the nutrient vessel branch from the iliolumbar artery, which is often severed by the fracture or torn during elevation of the iliacus.

Prior to elevation of the posterior iliacus, this vessel should be clipped to avoid excessive hemorrhage. Large lymph nodes also may need to be retracted or excised as necessary to improve visualization. Despite these structures, appropriate placement of retractors provides adequate exposure (Fig 2.7‑40).

Further access is developed from anterior to posterior along the pelvic brim, sharply dividing and elevating the iliopectineal fascia superiorly and the obturator fascia inferiorly.

Fig 2.7-40 Anastomotic branch between the inferior epigastric and obturator vessels is visualized. Retraction of the rectus and external iliac vein is performed by the superior retractor. Inferiorly, the obturator neurovascular bundle passes parallel to and below the pelvic brim.

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Complete access to the sacroiliac joint can be obtained by working posteriorly, although extreme care should be taken to avoid damaging the L5 nerve root and obturator neurovascular bundle. Elevation of the psoas muscle further exposes the sciatic buttress and posterior aspect of the pelvic brim. Exposure to the sacral ala is obtained with gentle retraction of the psoas and iliac vessels (Fig 2.7-41).

With the exposure completed, flexion, rotation, abduction, and adduction of the hip are possible through the freely draped limb; these improve visualization. Flexion, in particular, relaxes the retracted anterior structures. Limited tension on a sacral retractor just lateral to the lumbosacral trunk is recommended because the lumbosacral trunk and obturator nerves are tethered closely to the superior lateral corner of the obturator foramen.

Reduction techniques include medial-to-lateral pushing with a blunt or spiked ball tip impactor. A bone hook can be placed in the greater sciatic notch to elevate the posterior column.

Lateral traction can be applied via a Schanz screw in the proximal femur. Longitudinal traction can be obtained through the use of a femoral distractor or a fracture table. Multiple plate configurations are possible, including a reconstruction plate contoured over the inferomedial aspect of the pelvic brim (infratectal plating) and spring or hook plate constructs (Fig 2.7-42, Fig 2.7-43, Fig 2.7-44) [83, 117, 118, 121].

Fig 2.7-41 Elevation of the iliacus and psoas allows exposure of the iliac fossa. Elevation of the obturator internus exposes the medial wall and obturator fossa. Dissection medial to the sacroiliac joint allows exposure of the lateral sacral ala for Hohmann retractor placement. Because the obturator neurovascular bundle crosses the operative field, it must be protected throughout the case.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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Fig 2.7-42a–b Anterior column with associated anterior wall fracture reduced with an infratectal reconstruction plate.

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Fig 2.7-43a–b Large medial wall fracture fragment is reduced with a distal radius plate or other T-plate. This has been placed in an antiglide fashion to stabilize the thin quadrilateral plate, with screws only in the thick sciatic buttress.

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Fig 2.7-44a–b Posterior column fragment is reduced with a hooked reconstruction plate.

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With respect to the infratectal area, a study of anatomical specimen by Guy et al [198] has identified safe zones to avoid joint penetration by screws (Fig 2.7-45). Anteriorly, screws should be placed up on the superior pubic ramus no more than 5 mm posterior to the obturator canal. Posterior to the acetabulum, screws should not be inserted more than 11 mm anterior to the edge of the sciatic notch.

9.5

The approach is indicated for complex fracture patterns when a major extensile approach is required for the posterior and lateral aspects of the hemipelvis (as per triradiate), exposure of both the anterior and posterior columns are needed for acute both-column lesions (type C), and for late reconstructive cases. It has particular value when fracture comminution extends into the sciatic iliac joint.

Extended iliofemoral approach

The extended iliofemoral approach is shown in Video 2.7-7.

9.5.1 History

Introduced by Letournel in 1974 [3, 5], the extended iliofemoral approach is an anatomical approach that follows an internervous plane, reflecting anteriorly the femoral nerve-innervated muscles and posteriorly the muscles innervated by the superior and inferior gluteal nerves. The posterior flap is mobilized as a unit without damaging its major neurovascular bundle (Fig 2.7-46) [5]. When used by experienced surgeons, high rates of anatomical reductions and good outcomes have been achieved, although complication rates remain higher than with other approaches [3, 5, 66, 126, 127].

Fig 2.7-45 The “safe zone” for extraarticular screw placement during intrapelvic acetabular surgery. (From Guy P, Al-Otaibi M, Harvey EJ, et al. J Orthop Trauma. 2010 May;24(5):279–283.)

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9.5.2 Indications

9.5.3 Access

This approach provides direct visualization of the entire outer aspect of the ilium, the posterior column and wall down to the ischium, and the hip joint (Fig 2.7-47). With further dissection and retraction of the iliopsoas and abdominal muscles medially, exposure of the internal aspect of the ilium is also possible.

9.5.4 Position

The patient is supported on a bean bag and placed in the lateral decubitus position on a radiolucent operating table.

The hip is kept extended and the knee flexed throughout the procedure to minimize sciatic nerve injury.

Video 2.7-7 The extended iliofemoral approach.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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9.5.5 Advantages

This is an excellent extensile approach to the entire hemipelvis, the outer wall of the ilium, and the posterior column and posterior wall.

9.5.6 Disadvantages and dangers

The major technical limitation of the extended iliofemoral exposure is access to the low anterior column [10], where the dissection becomes more difficult and dangerous medial to the iliopectineal eminence. In this area, the iliopsoas and iliopectineal fascia block the exposure with the more medial vascular structures at risk.

Heterotopic ossification is a complication of all approaches to the outer aspect of the ilium with rates ranging from 18–90% [5, 9, 25, 66, 122, 124, 126, 127, 162]. It is particularly common and severe after extensile approaches with a larger proportion of patients suffering functional limitations [5, 9, 25, 66, 122, 126, 127, 160, 162]. Letournel [5] himself reported its occurrence in 46% of his extended iliofemoral approaches compared with 21% for all other approaches (these rates were 69% and 24%, respectively, before his use of prophy-

Fig 2.7-46 The extended iliofemoral approach for exposure of a comminuted left both-column acetabular fracture.

The femoral head can be seen and there is a Schanz pin in greater trochanter, parallel with femoral neck. (From: Sledge CB, ed. Master Techniques in Orthopaedic Surgery: the Hip. Philadelphia: Lippincott-Raven, 1998, with permission.)

laxis). Furthermore, HO was severe (Brooker III and IV) in 35% of patients when an extended iliofemoral was performed within 3 weeks of injury. Matta [9, 148] noted a significant loss of motion in 20% of a similar group of patients and significant HO affecting the Merle d’Aubigné and Postel score in 30% of patients, though no uniform prophylaxis was used. Even with prophylaxis, Alonso et al [149] encountered HO in 86% of their patients and a 14% rate of Brooker III or IV HO. Therefore, an associated closed head injury might be considered a relative contraindication for this approach [10]. Heterotopic ossification is often noted along the gluteus minimus and the debridement of any necrotic muscle in this location may decrease the risk of this complication [165].

Sciatic nerve

As with all posterior approaches, the sciatic nerve is at risk during exposure of the posterior column and needs to be identified along the belly of the quadratus femoris muscle as in the KL approach, and then protected behind the conjoint tendon (Fig 2.7-52). Tension on the nerve should be minimized by maintaining the hip extended and the knee flexed at all times.

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a Access by touch (or finger access) Visual access

Fig 2.7-47a–b Access to the right pelvis via the extended iliofemoral approach. a The lateral (outer) bony pelvis. b The medial (inner) bony pelvis.

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Lateral femoral cutaneous nerve

The LFCN is at risk during exposure along the anterior superior iliac spine. It can also sustain a traction injury during mobilization of the soft tissues. Patients should be warned preoperatively to expect this complication.

Superior gluteal neurovascular bundle

As with KL approach, this neurovascular structure is at risk for injury. It is of particular concern during this approach because the entire abductor flap is mobilized around this pedicle tendon (Fig 2.7-52).

Abductor muscle flap necrosis

A major concern is the vascularity of the large gluteus medius and gluteus minimus muscle flap. In this approach, all lateral muscles are detached from the ilium with the additional ligation of their anterior collateral supply from the inferior epigastric artery and are thus ultimately hinged on their only remaining blood supply—the superior gluteal pedicle. Some have expressed concern that if this vessel has been damaged by the fracture, embolization to control bleeding, or the surgical approach, then the hip abductor flap may be at risk for complete ischemic necrosis.

Some authors [160, 199] have described this in detail and recommended preoperative arteriography for all acute cases.

However, concerns regarding abductor muscle flap necrosis may be more theoretical than clinical [5, 160, 199]. In over 400 acetabular fractures addressed with an extended iliofemoral approach by Letournel, Matta, Mast, and Martimbeau, there have been no reports of abductor flap necrosis [5].

Alonso et al [149] did not observe this complication using either an extended iliofemoral or triradiate approach in 59 cases of complex acetabular fractures.

Furthermore, Auerbach et al [200] evaluated 18 patients with acetabular fracture treated with selective transcatheter arterial embolization (TAE) and two with nonselective unilateral TAE. Eleven of these patients underwent orthopedic surgical procedures, eight of which involved open reduction and internal fixation of the acetabulum or hemiarthroplasty of the hip (none was an extended iliofemoral approach).

No complications of gluteal muscle or pelvic skin necrosis, wound infection, renal failure, or anaphylaxis were noted in any of these cases.

Finally, massive abductor necrosis resulting from a superior gluteal artery injury combined with an extended iliofemoral approach is described based on animal and anatomical specimen studies only [201–203]. A canine study by Tabor et al [199] found that although necrosis of muscle and loss of mass

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occurs after the extended iliofemoral approach in the presence of gluteal vessel injury, this does not appear to be functionally significant. In their study, none of the gluteal muscle flaps suffered complete ischemic necrosis. Thus, some collateral flow to the abductor muscles appears to be present and may increase in the presence of a superior gluteal vessel injury.

Femoral neurovascular structures

The iliopsoas muscle and the iliopectineal eminence lie at the medial extent of the extended iliofemoral approach.

Further medial dissection without an ilioinguinal incision places the femoral neurovascular structures at great risk (Fig 2.7-54).

9.5.7 Surgical technique (extended iliofemoral approach)

There are three main stages to the dissection [5]: (1) elevation of all gluteal muscles with the tensor fasciae latae; (2) division of the abductors and external rotators of the hip; and (3) an extended capsulotomy along the lip of the acetabulum.

The end result is complete exposure of the outer aspect of the ilium and the whole posterior column inferiorly to the upper part of the ischial tuberosity. Furthermore, this approach can be extended to allow a limited exposure of the internal iliac fossa and the anterior column to the level of the iliopectineal eminence. Thus, simultaneous extensile exposure of both the anterior and posterior columns is possible, which permits direct visualization of their reduction and fixation (Fig 2.7-46). As this approach creates significant soft-tissue flaps, it is important to keep them moist with wet sponges throughout the procedure.

The incision is in the form of an inverted J (Fig 2.7-48). It begins at the posterior superior iliac spine and extends around the iliac crest toward the anterior superior iliac spine. From here, the distal arm of the incision proceeds along the anterolateral aspect of the thigh for a distance of 15–20 cm (Fig 2.7-48b) [5, 10]. There is a tendency for the surgeon to extend this more medially than desired. To avoid this, one should visualize a point 2 cm lateral to the superolateral pole of the patella. With the leg held in neutral rotation, this location is generally in line with the desired incision [5, 10]. As the incision is carried distally, a gentle curve posteriorly may be helpful in more obese patients [10].

The exposure begins in a stepwise fashion by first identifying the avascular fascial periosteal layer along the iliac crest between the abdominal muscle insertions and hip abductor origins and sharply releasing the tensor fasciae latae muscle and the gluteus medius muscles subperiosteally from the outer aspect of the iliac crest (Fig 2.7-49, Fig 2.7-50). Often it

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Fig 2.7-48a–b Skin incision, right side. a The inverted J skin incision, right side. b Anterolateral view: the inverted J skin incision with distal extension for the extended iliofemoral approach.

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Fig 2.7-49 Exposure of right iliac crest and anterior distal limb: (1) avascular "white line;" (2) fascia covering tensor fasciae latae muscle; and (3) fascia covering sartorius muscle.

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Fig 2.7-50 Subfascial reflection of tensor fascia lata and abductor muscle origins from right iliac crest: (1) avascular “white line;” (2) tensor fascia lata muscle; (3) gluteus medius insertion into trochanter; (4) gluteus minimus muscle; (5) "no name" fascia covering rectus and vastus lateralis; (6) rectus femoris muscle; (7) sartorius muscle; and (8) ascending branch of the lateral femoral circumflex artery.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

is easiest to start in the area of the gluteus medius tubercle where landmarks are more obvious, and to progress posteriorly and anteriorly from this point. Posteriorly, the strong fibrous origin of the gluteus maximus should be sharply released from the crista glutei [114]. Under direct vision, the musculature along the external surface of the iliac wing is released in a subperiosteal fashion from the outer aspect of the iliac crest up to the superior border of the greater sciatic notch and anterosuperior aspect of the hip joint capsule, as in the Smith-Petersen incision (Fig 2.7-50, Fig 2.7-51). Be careful to identify and to protect the superior gluteal neurovascular bundle as it exits the greater sciatic notch.

Next, the distal limb of the incision is developed. To protect the LFCN and most of its branches, the incision is carried through the fascial sheath of the tensor fasciae latae muscle (Fig 2.7-50, Fig 2.7-51). Having incised the fascia overlying the tensor fasciae latae muscle, the muscle belly is reflected off the fascia and retracted laterally to expose the fascia overlying the rectus femoris. The exposure stays lateral to the branches of the LFCN and therefore places them at minimal risk.

Small vessels from the superficial circumflex artery are divided and coagulated between the superior and inferior spines [5], the fascial layer overlying the rectus femoris muscle is divided longitudinally, and the reflected and direct heads of the muscle are retracted medially to expose the aponeurosis over the vastus lateralis muscle (Fig 2.7-51), where a small vascular pedicle often requires coagulation [5]. The aponeurosis over the vastus lateralis muscle can be divided longitudinally to expose the underlying ascending branches of the lateral circumflex vessels, which must be isolated and ligated (rarely, these vessels can be spared if a more limited exposure is acceptable). Next, the thin sheath of the iliopsoas muscle is exposed and longitudinally incised, and an elevator used to strip the muscle from the anterior and interior aspects of the hip capsule. At this point, any remaining musculature along the external surface of the iliac wing is released in a subperiosteal method, while protecting the superior gluteal neurovascular bundle as it exits the greater sciatic notch (Fig 2.7-51). The exposure of the iliac wing is complete after the reflected head of the rectus femoris has been released from its insertion.

As described by Letournel [3], the posterior column is then exposed by dividing the insertions of the gluteus minimus, gluteus medius, and short external rotator muscles from the greater trochanter (Fig 2.7-52). First, the gluteus minimus tendon is identified over the anterior portion of the greater trochanter, tagged, and transected, leaving a small 3–5 mm cuff for repair. The gluteus minimus muscle also has extensive

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attachments to the superior aspect of the hip capsule, which need to be released. Posteriorly and superiorly, the gluteus medius tendon, measuring 15–20 mm in length also is isolated, tagged, and transected, leaving a 3–5 mm cuff for repair. It is important to sequentially and carefully transect and tag these structures for subsequent reattachment. In contrast to sharply releasing the abductor and external rotator insertions into the greater trochanter as per Letournel [3], another option is to instead perform a greater trochanteric osteotomy, which will provide equal visualization, while also ensuring adequate reattachment. This can be performed in the classic fashion (Fig 2.7-17) [20] or as a trochanteric flip osteotomy [66, 126, 127, 144–146] (see “Other special technical factors: trochanteric flip osteotomy with surgical dislocation of the femoral head for treatment of fractures of the acetabulum”).

After releasing the gluteus minimus and gluteus medius insertions onto the greater trochanter (or performing a trochanteric ostetomy), the tensor fasciae latae and gluteal muscles are held in continuity as a flap and reflected posteriorly to expose the external rotators. From this point, the posterior dissection is similar to KL. To decrease tension, the tendonous femoral insertion of the gluteus maximus muscle is identified and transected with a cuff for repair.

The sciatic nerve is identified and the tendons of the piriformis muscle, obturator internus muscle, and inferior and superior gemelli muscles are tagged and transected. The piriformis muscle is followed toward the greater sciatic notch and the obturator internus muscle to the lesser sciatic notch, where retractors can be inserted, allowing complete exposure to the posterior column of the acetabulum (Fig 2.7-53). This completes the exposure of the posterior column and the lateral aspect of the iliac crest.

Although medial exposure of the anterior column is limited by the iliopsoas muscle and iliopectineal eminence, further access to the internal iliac fossa and acetabulum is possible.

This can be obtained by subperiosteal release of the sartorius and direct head of the rectus or by osteotomy of the superior and/or inferior iliac spines, respectively (Fig 2.7-53, Fig 2.7-54). The insertion of the external oblique muscle on to the crest also can be subperiosteally released to reveal the inner table of the pelvis. The internal iliac fossa is then further exposed through subperiosteal dissection of the iliacus muscle. However, such extensile exposure of both the outer and inner tables of the iliac wing, especially in the presence of local fractures, increases the likelihood of iliac bone devascularization. Although such devascularization is rare, Matta and Merritt [40] have warned of its occurrence, especially in associated both-column fractures. To avoid this

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Fig 2.7-51 Proximally, the abductor and tensor fascia lata muscles have been stripped subperiosteally from the outer table of the right ileum. Distally, the ascending branch of the lateral circumflex artery has been ligated; (1) tensor fasciae latae muscle; (2) gluteus medius muscle; (3) gluteus minimus muscle; (4) greater trochanter; (5) two heads of the rectus muscle; (6) ligated ascending branch of the lateral femoral circumflex artery; and (7) piriformis tendon.

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Fig 2.7-52 The abductors of the right hip have been tagged and their insertions into the greater trochanter released, allowing their muscle pedicle to be retracted to expose the sciatic nerve. The external rotators have also been marked for release: (1) gluteus minimus tendon; (2) gluteus medius tendon; (3) gluteus maximus tendon; (4) superior gluteal neurovascular bundle; (5) sciatic nerve; (6) piriformis and conjoint tendons marked for release; (7) hip joint capsule and reflected head of rectus; (8) greater trochanter; (9) ligated ascending branch of the lateral femoral circumflex artery; (10) gluteus minimus tendon; and (11) gluteus medius tendon.

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Fig 2.7-53 Retraction of right hip external rotator muscles and release of gluteus maximus insertion distally. Medially, the anterior superior and inferior iliac spines have been marked for either release or osteotomy if required. (1) Blunt Hohmann in lesser sciatic notch, the conjoint tendons have been positioned between the retractor and the sciatic nerve; (2) stumps of ligated piriformis and conjoint tendons, preserving the deep branch of the medial femoral circumflex artery; and (3) hip joint capsule.

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Fig 2.7-54 Maximal exposure of right acetabulum: (1) gluteus medius muscle; (2) gluteus minimus muscle; (3) blunt Hohmann in lesser sciatic notch; (4) greater trochanter; (5) tensor fasciae latae muscle; (6) malleable retractor under the iliacus muscle; (7) superior gluteal neurovascular bundle; (8) piriformis muscle; (9) sciatic nerve; (10) spiked Hohmann retractor over the anterior capsule of the hip; and (11) hip joint capsule.

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potentially disastrous complication, they suggested leaving the direct head of the rectus femoris and anterior hip joint capsule attached to the anterior column at a minimum. The blood supply to the dome of the acetabulum also is at risk during dissection at the anterior inferior iliac spine [203].

Visualization of the acetabular articular surface can be performed with a marginal capsulotomy, leaving a cuff of tissue for repair followed by distraction of the hip joint with either a Schanz screw placed into the femoral head or with a femoral distractor (Fig 2.7-46, Fig 2.7-55). At this point, the limits of the extended iliofemoral approach have been reached and reduction of the fracture fragments can now be performed according to the preoperative plan.

As in the ilioinguinal exposure, both-column (type C) fractures require sequential reconstruction from the periphery toward the acetabulum (Fig 2.7-56, Fig 2.7-57). First, the iliac wing is stabilized with lag screws and/or reconstruction plates 3.5. Next, and under direct visualization of the acetabular articular surface, the posterior column is reduced to the iliac wing by similar techniques as discussed in the section on KL approach. Prior to definitive reduction, a gliding hole can be inserted into the proximal aspect of the posterior column from superior to inferior, assuring the correct position of the gliding hole in the middle of the posterior column.

Following reduction, it is then possible to insert a 4.5 or 3.5 mm cortical lag screw down the posterior column.

Additional stabilization is accomplished with a reconstruction plate 3.5 molded to the posterior column.

With direct visualization of the acetabular articular surface, the anterior column can now be reduced and attached to the intact (or reconstructed) segment. Fixation is achieved with 3.5 mm lag screws inserted from the anteroinferior spine into the sciatic buttress, anteriorly from the inner table or crest into the intact ilium and superoposterior column, and/or anterior column lag screws from the lateral aspect of the iliac wing. Generally, the latter requires insertion three-finger breadths proximal to the superior aspect of the articular surface (4–6 cm), and one finger breadth posterior to the gluteal ridge on the outer aspect of the iliac crest (Fig 2.7-58, Fig 2.7-59) [5, 204]. The lag screw is then angled from posterosuperior to anteroinferior directly down the superior pubic ramus with the assistance of intraoperative image intensifier. Care must be taken to assure that this screw remains extraarticular and does not penetrate the anterior aspect of the superior ramus, in the area of the iliopectineal eminence where the femoral vasculature is closely adherent.

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Fig 2.7-55 Close-up of acetabular joint exposure of patient: (1) femoral head; (2) loose articular fragment. (From: Sledge CB, ed.

Master Techniques in Orthopaedic Surgery: the Hip. Philadelphia: Lippincott-Raven, 1998, with permission.)

For T-shaped (type B2) and the more comminuted variants, the anterior column may be reduced first with respect to the residual acetabular “roof’ portion of the ilium [134]. The screw-holding forceps and 4.5 mm screws proximal and distal to the posterior column fracture improve distraction, debridement of the fracture surfaces, and reduction. A laminar spreader in the fracture site also is useful. For additional control, a Schanz screw is placed in the ischium or a pelvic clamp in the greater sciatic notch. Definitive stabilization is similar to that described for the both-column fracture, with lag screw fixation of the two columns and a posterior buttress plate.

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Fig 2.7-56a–c Reduction of an associated both-column right acetabular fracture. a A laminar spreader is placed in the fracture site to expose the joint and allow debridement: (1) femoral head in joint; (2) superolateral dome fragment with capsular attachments; (3) greater trochanter; and (4) intact iliac wing. b The gliding hole is predrilled for the anterior-to-posterior column screw. c A Farabeuf clamp affixed to screws is used to reduce the anterior column to the superolateral fragment, and a pelvic reduction clamp affixed to screws is used to reduce the anterior-to-posterior column (posterior column portion not shown). (From: Sledge CB, ed. Master Techniques in Orthopaedic Surgery: the Hip. Philadelphia: Lippincott-Raven, 1998, with permission.)

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Fig 2.7-57 Completed reconstruction of comminuted left bothcolumn acetabular fractures. Reconstruction proceeds centripetally from the periphery: (1) anterior-to-posterior column lag screw; and (2) greater trochanter. (From: Sledge CB, ed. Master Techniques in Orthopaedic Surgery: the Hip. Philadelphia: Lippincott-Raven, 1998, with permission.)

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Fig 2.7-58a–d Anterior column lag screw. a Note the point of insertion posterior to the anteroinferior spine. Remember the large mass of soft tissue (hip abductors) in this area. This screw can be inserted only with adequate retraction, and usually through an extensile approach. b When it is accurately placed, excellent reduction and fixation of the anterior column may be achieved. c Because of the thinness of the anterior column just proximal to the iliopectineal eminence (10–12 mm), it is not difficult for the drill bit and the screw to enter the hip joint. d At the iliopectineal eminence the femoral artery and vein are tethered tightly to the anterior column by the iliopectineal fascia and may be damaged by the drill bit penetrating anteriorly.

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Superior

along the iliac crest and repair of the fascia overlying the proximal thigh. Active hip abduction, any adduction, and flexion past 90° should be avoided for 6–8 weeks.

30°

9.6

90°

Triradiate approach

9.6.1 History

4.6 cm Anterior

Posterior

This approach was developed and promoted by Mears [133, 134]. Most recently, a modified triradiate approach (MTRI) has been developed by the same surgeon, which preserves the abductor muscle attachment to the greater trochanter, avoids trochanteric osteotomy, and preserves the antero­ superior hip-joint capsule, including the contiguous origins of the indirect and direct heads of the rectus femoris [205].

9.6.2 Indications

The triradiate is an extensile approach to the posterior and lateral aspects of the hip for difficult transtectal transverse, T-type lesions, and both-column fractures with posterior wall involvement.

Inferior

Fig 2.7-59 The angles of inclination for screw placement. Angle 1 (90°): the angulation between the longitudinal axis of the anterior column and the line connecting the apex of the sciatic notch and anterior interspinous notch measured in the sagittal plane. Angle 2 (30°): the angulation between the longitudinal axis of the anterior column and the posterolateral surface of the iliac wing measured in the transverse plane.

9.6.3 Access

Access is afforded to the entire posterior column and posterior wall area, and to the entire lateral aspect of the iliac crest, back to the iliac tubercle area or beyond (Fig 2.7-60).

Visualization of these areas is valuable in high both-column fractures.

9.6.4 Position

The patient is placed in the lateral decubitus position.

After completion of the operative repair, two deep suction drains are placed along the external surface of the iliac wing, posterior column, and vastus lateralis muscle. If the internal iliac fossa has been exposed, a third drain is placed here. A subcutaneously placed drain also should be considered. All drains should exit anteriorly. The hip capsule is repaired first, followed by reattachment of the tendonous femoral insertion of the gluteus maximus and the short external rotators. The tendons of the gluteus minimus and gluteus medius muscles are also sutured to their respective attachment sites on the greater trochanter with multiple sutures (or the trochanteric osteotomy stabilized with screws).

Letournel has recommended five or six sutures for each tendon [5]. Reattachment of the origin of the gluteal muscles and tensor fasciae latae muscle to the iliac crest can be facilitated by hip abduction. If a medial exposure had been required, the origins of the sartorius and direct head of the rectus femoris muscles are reattached through drill holes (or by lag screws if osteotomies have been performed). This is followed by reattachment of the external oblique muscle

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9.6.5 Advantages

Compared with the standard KL, access to the lateral wall of the ilium and to the posterior aspect of the ilium and ischium is markedly increased. Also, the approach allows a skin bridge across the iliac crest posteriorly, which preserves some blood supply to the gluteal muscles and therefore is theoretically safer than the extended iliofemoral approach.

9.6.6 Disadvantages and dangers

If a careful surgical technique is not used, particularly during the early portions of the exposure, then this approach can result in a higher rate of wound problems related to viability of the skin flaps. Of additional concern is a marked increase in HO as encountered with all approaches that strip the lateral muscles off the ilium. Furthermore, this approach may result in the division of the lateral cutaneous nerves to the thigh, a nuisance complication. The triradiate approach also is limited in that it leaves a segment of the gluteal musculature in place, preventing mobilization of the superior gluteal neurovascular bundle. This hinders access to the

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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sacroiliac joint and posterior ilium adjacent to the posterior superior iliac spine [5]. Finally, the disadvantages and dangers inherent to KL and transtrochanteric approaches also apply.

a

b

c

d

e

Fig 2.7-60a–e Triradiate transtrochanteric approach. a Skin incision. Note that the anterior limb of the skin incision may be taken posteriorly to expose the iliac crest or anteriorly to expose the internal aspect of the pelvis. No skin flaps must be raised. All dissection must be carried through the skin and through the fascia to create a thick anterior flap for elevation. b The tensor fasciae latae muscle is exposed without raising skin flaps. c The anterior aspect of the tensor fasciae latae may be divided, or (preferably) the plane between the tensor fasciae latae and the sartorius is developed and the dissection carried out in that plane to the iliac crest. Posteriorly the fibers of the gluteus maximus fascia and muscle are split. d Removal of the greater trochanter exposes the lateral and posterior aspects of the ilium. At the superior aspect, the muscle may be removed posterior to the fracture lines as noted. e Capsulorraphy of the hip joint may be performed, or the capsule may be stripped from the lateral ilium. Great care must be taken to ensure that the fragments are not devitalized, and in many instances the capsule is left intact to ensure blood supply to the fragments.

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9.6.7 Surgical technique

The incision is T- or Y-shaped (Fig 2.7-60a), the posterior and inferior limbs exactly that of the posterior KL, the anterior limb rising at the greater trochanter and moving anterior toward the superior spine of the iliac crest. If further access to the lateral aspect of the ilium is required, then the incision is carried posteriorly along the crest (Fig 2.7-60a) until the most posterior fracture line is reached. Osteotomy of the greater trochanter, as previously described, affords access to the entire anterolateral aspect of the ilium. Anteriorly, the tensor muscle may be divided or the surgeon may dissect anterior to it between the tensor and the sartorius, exposing the anterior border of the gluteus medius (Fig 2.7-60b–c) [20].

This muscle, with the underlying gluteus minimus, is stripped from the lateral wall of the ilium (Fig 2.7-60d). The blood supply is maintained by the superior gluteal vessels and by the muscular aponeurosis over the posterior aspect of the iliac crest (Fig 2.7-60e).

Extreme care must be taken to ensure the viability of the skin flaps. The skin should not be undermined; the flaps should contain the underlying tensor fasciae latae muscle and fibrous layer (Fig 2.7-60b). Skin necrosis should be avoided if this principle is adhered to strictly. Almost all acetabular fractures involving the posterior column may be approached by this exposure, which affords excellent visualization of the fracture.

Rüedi et al [130] have described a modification of this approach: a straight incision beginning in the midportion of the iliac crest and extending 10 cm distal to the greater trochanter. The tensor fasciae latae is split to the level of the crest and opened like a book. The greater trochanter is then divided and the gluteus medius split to the greater sciatic notch. The advantage of this approach is that it allows easy access to the iliac crest when the crest is fractured, usually with the anterior column. Access also is provided to the posterior column.

If complete visualization of the anterior column is required, the anterior limb may be carried anteriorly and the iliopsoas mobilized from inside the pelvis; in fact, an ilioinguinal approach is possible. Great care must be taken to ensure preservation of the blood supply to all articular fractures when the muscles are stripped from the inner and outer surfaces of the pelvis. In this situation, the joint capsule should only rarely be incised, especially with both-column fractures because it may contain the only remaining blood supply to the periarticular fracture fragments. Instead, an extraarticular reduction is recommended [20].

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9.7

Combined approaches

9.7.1 History

Because of the high risk of morbidity, including HO and other complications of the extensile approaches, there has been a trend toward using simultaneous or staged anterior and posterior (KL) approaches [42, 52, 84, 86, 115, 128, 151].

The combination of an anteroposterior approach allows simultaneous access to the anterior and posterior columns without resorting to an extensile exposure.

When using the strategy of a combined approach, frequently, the iliofemoral/Smith-Petersen approach [186] is all that is required for the anterior portion of the exposure [52, 128].

However, the ilioinguinal or even modified Stoppa approaches are also viable options, with some authors even preferring the routine use of the former [115]. Routt Swiontkowski [52] chose an iliofemoral approach for the associated anterior exposure (23 cases) when fractures involved the anterior column cephalad to the iliopectineal eminence, and an ilioinguinal approach (one case) when the anterior column portion of the fracture was more caudad or when access to the symphysis pubis was required for reduction and fixation.

Using such simultaneous combined approaches, they were able to obtain an anatomical reduction in 88% of their cases. Complications included an incidence of iatrogenic nerve injury of 8% and an 8% incidence of significant functional limitation because of HO. Moroni et al [85] believing that the disadvantage of operating on a patient in the lateral decubitus position (as required for a simultaneous approach) is more important compared to the benefit of being able to manipulate both the anterior and posterior columns simultaneously, recommend a staged combined approach. The most displaced and comminuted column is treated first with the ilioinguinal approach performed in the supine position and KL in the prone position.

Following closure of wounds, the patient is repositioned for the next portion of the procedure and the second approach performed. These authors reported that they achieved a satisfactory or anatomical reduction in 89% of cases. Complications included an incidence of iatrogenic nerve injury of 6%, significant wound drainage 17%, and 6% avascular necrosis. No patient demonstrated significant functional limitation because of HO. 9.7.2 Indications

Combined approaches may be used instead of a single extensile approach (triradiate, extended iliofemoral) when access to both columns is required. Thus, it is indicated for

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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some transverse and T-type fractures (type B) and both-column fractures (type C). Harris et al [128] have noted that the combined approach is most useful in transverse, transverse plus posterior wall with wide anterior displacement, T-type fractures with significant anteroinferior displacement, and both-column fractures with posterior wall involvement.

9.7.5 Advantages

Excellent visualization is gained of the anterior and posterior aspects with less dissection than for the extensile approaches. This should lead to fewer complications, such as HO or neurovascular injury.

9.7.6 Disadvantages

9.7.3 Access

Posteriorly, access is gained to the posterior wall and posterior column, and if the greater trochanter is osteotomized, to an even wider area (see “Transtrochanteric approach”).

Anteriorly, depending on the anterior exposure used, access may be gained to the entire anterior column, including sacroiliac joint to the symphysis pubis.

9.7.4 Position

Several options are available. The simplest setup involves placing the patient in the floppy lateral position without fixed supports [128, 151]. This is the more common technique and allows two teams of surgeons to work simultaneously.

If the table itself has rotational control then another possibility is to position the patient within a stabilized inflated bean bag halfway between the supine and the lateral position. In this way, by tilting the table to either side, the patient reaches an orientation either close to the supine or close to a lateral position [195]. While this can be helpful if only a single surgical team is performing the procedure, the setup is time consuming.

a

b

The obvious disadvantage of this approach is the requirement of two skilled teams of surgeons, or the necessity of one team working back and forth between the two approaches.

Furthermore, the operating surgeon(s) cannot see the entire fracture pattern through one approach. By placing the patient in the floppy or fixed lateral position, both the anterior and posterior exposures are compromised to some degree with respect to visualization (as opposed to a supine position for anterior exposures and a prone position for posterior approaches). Moving the patient back and forth from the supine to the prone position also makes reduction and fixation more difficult. Finally, simultaneous combined approaches have the potential to lead to excessive loss of blood and a higher rate of infection.

9.7.7 Surgical technique

The techniques of both the anterior iliofemoral and ilioinguinal approaches have already been described, as has the posterior KL, with or without trochanteric osteotomy. The techniques are exactly the same, only in this situation they are used together (Fig 2.7-61).

c

Fig 2.7-61a–c The incisions used for the combined approach. a Lateral decubitus position. b Supine position. c Floppy lateral position.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

9.8

Technical points

9.8.1 Traction

Some traction is essential for the reduction of almost any acetabular fracture but especially those with intact capsule or soft tissues. Without adequate traction, either by traction table or surgical assistants, anatomical reduction is virtually impossible to achieve. Traction may be achieved either preoperatively or intraoperatively.

9.8.2 Preoperative traction

This is extremely important in polytrauma patients because operative reduction may have to be delayed. Preoperative traction maintains the closed reduction of anterior or posterior dislocations in most instances, and with central displacement of the head distracts the articular cartilage of the head away from the jagged edges of the ilium. In particular, pressure necrosis can develop quickly; therefore, traction becomes important. Usually, traction should be applied with a supracondylar femoral pin. A trochanteric pin should never be used at this stage because it could interfere with surgical approaches in the region of the greater trochanter.

9.8.3 Intraoperative traction

In addition to facilitating the reduction, intraoperative traction also is useful to subluxate the femoral head from within the acetabulum. This allows the surgeon to inspect the articular surface and remove loose bodies or redundant ligamentum teres, which will prevent a concentric reduction. Intraoperative traction can be applied by several means.

and inferior pubic rami preclude its use because the perineal post tends to increase the pelvic deformity [48]. Fourth, the post occasionally hinders reduction. Fifth, specific complications have been associated with traction (eg, pudendal nerve palsy, skin necrosis). Sixth, the fracture table may limit full motion of the extremity (eg, hip flexion with the ilioinguinal approach). Seventh, and most important, it is possible to achieve similar traction and limb positioning without the fracture table.

The patient is placed on a totally radiolucent table that can rotate (“Jackson” type or Modular Table System) and drape the affected extremity “free,” which allows full and unrestricted manipulation of the hip joint during surgery. During surgery various means of intraoperative traction are available (see “Manual traction” below). Until the issue has been studied more rigorously, surgeon’s preference dictates whether a traction table is used but either way the patient’s fracture must be intraoperatively x-ray “visible.” If a traction table is used because that is the surgeon’s preference, it is incumbent on that surgeon to choose a versatile one; that is, one that allows manipulating the limb in almost any position (prone, supine, lateral) and still permits image intensification. Presently, there are some traction tables with various attachments that some have found useful. For example, one of the authors routinely uses an arc-shaped traction device that attaches to the Jackson table and the patient’s traction pin to assist with intraoperative pelvic fracture reductions.

9.10 Manual traction

9.9

Traction table

The classic method for intraoperative traction has been the Tasserit (“Judet”-type) fracture table, which was especially designed for this purpose and permits lateral and skeletal traction as well as image intensification throughout the procedure. However, although this type of table has been deemed invaluable by Letournel and others as an intraoperative tool [5, 39, 40, 48, 148], its universal application is still a controversial recommendation and is usually based on the preference of the surgeon. In fact, the Tasserit table is no longer commercially available. One drawback to the use of a fracture table is that the assistance of an unscrubbed surgeon or a technician trained in its use is essential to enable manipulation of the limb during operation [20].

Helfet and many other surgeons [7, 20, 45, 114] rarely uses a traction table, for several reasons. First, a Tasserit table is not available. Second, a fracture table with a central post may hinder unbridled image intensification views intra­ operatively. Third, fractures of the contralateral superior

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The alternative to the traction table is to apply traction directly to the femoral head by various means, such as a sharp hook placed around the greater trochanter, a corkscrew driven into the femoral neck, or with the femoral distractor applied to Schanz pins in the proximal femur and greater sciatic buttress (Fig 2.7-62).

Manual pull: Traction can be applied to the limb with the patient in any position by direct pull through the thigh on the flexed knee. The knee should always be flexed to prevent traction on the sciatic nerve, and with anterior exposures the hip should be flexed to prevent traction on the femoral artery and nerves. Direct pull on the thigh by an assistant is not effective in maintaining constant traction throughout the operative procedure, although its intermittent use can be helpful.

Corkscrew: A corkscrew or large Schanz pin applied through the lateral femur into the femoral head and connected to a T-handle chuck can afford excellent traction, particularly

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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in young individuals (Fig 2.7-62a). The pin is inserted through a hole in the upper lateral femur, just distal to the trochanteric ridge, aiming along the edge of the calcar into the hard subchondral bone of the femoral head. The device often loosens during the procedure in older patients with porotic bone. There also is a theoretical possibility of interfering with the blood supply to the femoral head, although this would be extremely unlikely.

Large, sharp hook: A large, sharp bone hook (Fig 2.7-62b1–b3) may be placed in the fossa between the greater trochanter and the femoral neck, the same entry point used in closed femoral nailing. If the greater trochanter has not been osteotomized, traction can be applied by easily splitting the tendon of insertion of the gluteus medius and placing the

hook through it. The theoretical disadvantage of this technique is interference with the blood supply to the femoral head but the main blood supply is more posterior or medial; therefore, this would be extremely unlikely.

Schanz pin(s): A Schanz pin inserted into the medial portion of the ischial tuberosity and attached to a T-handle chuck (Fig 2.7-62c) allows manipulation of the malreduced posterior column. This technique is particularly helpful when reducing transverse type fractures, especially in the lateral position. Pulling directly up toward the ceiling reduces the fracture line and rotating the Schanz pin can correct rotational deformities of the posterior column. It is virtually impossible to derotate the posterior column without this maneuver [21].

b1

c

a

b2

b3

Fig 2.7-62a–c Intraoperative manual traction. Traction may be applied through the limb in any position, so long as the knee is flexed. However, this is not as effective as traction applied directly to the femur.

These helpful hints bear remembering: (a): A corkscrew inserted into the femoral head with a T-handle allows direct traction.

This is helpful with normal bone, although in osteoporotic bone the corkscrew may pull out. (b1 and b2): A large, sharp hook inserted over the greater trochanter, should it be intact, or, alternatively, over the osteotomized distal end of the trochanter (b3). This is an excellent form of traction.

The hook has a T-handle, and there is no potential for pull out, as the sharp end of the hook is inserted in extremely strong bone. (c): Insertion of a Schanz pin with a T-handle into the ischial tuberosity allows rotation of the posterior column and is an essential aid to reduction of transverse or T-fractures.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

The universal large distractor: An elegant technique, and our preference, is to use this to distract and inferiorly subluxate the femoral head from the acetabulum (Fig 2.7-10).

Typically, its application involves the insertion of two 5 mm Schanz pins—one into the sciatic buttress proximally and another into the femur at the level of the lesser trochanter.

Traction and limb positioning can then be “dialed in.”

9.11 Assessment of reduction and fixation

Prior to closure, the reconstructed acetabulum should be assessed using visualization, palpation, and intraoperative x-rays to confirm that a satisfactory reduction has been achieved and to ensure there have been no inadvertent intraarticular hardware placement. Because intraarticular hardware penetration can lead to rapid chondrolysis, it is imperative that the surgeon does not leave the operating room until the absence of intraarticular hardware has been confirmed. Depending on the exposure used, the adequacy of the reduction of the posterior column to the anterior column is determined by digital palpation along the quadri­ lateral surface, either directly from within the pelvis or through the greater and lesser sciatic notches. Division of the sacrospinous ligament or osteotomy of the ischial spine is often required when palpating the reduction through the two notches (Fig 2.7-9).

Range of motion of the hip with a finger along the quadrilateral surface can detect the presence of any crepitation in the joint, indicative of residual bony fragments or intra­ articular hardware. Auscultation with a sterile stethoscope also has been shown to be efficacious [20, 206]. If possible, the quality of the reduction and presence of intraarticular hardware should be ascertained by inspection of the articular surface through the capsulorrhaphy and direct traction.

Where visualization is not possible, a small blunt elevator can be inserted through the capsular incision in an attempt to palpate a protruding screw and determine articular step off.

Intraoperative image intensification AP and Judet views (obturator and iliac 45° oblique) are essential to ensure an adequate reduction of the columns and a concentric reduction of the articular surface. Image intensifier also is the most sensitive intraoperative means of confirming the proper extraarticular placement of hardware, especially the posterior to anterior lag screws [207–209]. For example, intraarticular screw placement can be ruled out by directing the image intensification view parallel to the quadrilateral surface, aiming down the lag screw. Along the posterior wall, intra­ articular penetration of screws can be ruled out by orienting

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the C-arm to the iliac oblique view then rolling the C-arm further (and often the fracture table as well) with spot views until no hardware is observed in the joint.

We routinely obtain CT scan on postoperative day 5. This allows a more critical evaluation of the fracture reduction and the identification of any residual intraarticular bone fragments or implants [50, 59, 60]. The limitations of plain films were highlighted by Moed et al [50] who found that although 92 (98%) of 94 patients had reductions initially graded as anatomical after surgical stabilization of posterior wall fractures, postoperative CT in 59 cases revealed incongruity of > 2 mm in 15% and fracture gaps of up to 22 mm in 75%. This may have implications with respect to studies, which have only evaluated fracture reductions with plain films and might explain why some patients have had poor results after seemingly anatomical reconstructions. One drawback of CT is that it has been noted to produce a highfalse positive rate when detecting intraarticular screw placement [207]. Follow-up with plain films for at least 2–5 years is recommended as radiographic results at 2 years more closely correlate with 10-year survival rates [210] and avascular necrosis can occur as many as 5 years after the initial injury [21].

10 Other special technical factors: trochanteric flip osteotomy with surgical dislocation of the femoral head for treatment of fractures of the acetabulum 10.1 Introduction

The standard KL approach is mainly used for posterior wall and column fractures, certain transverse or T-shaped fractures, and fracture dislocation patterns [5, 9]. Evaluation of fracture reduction predominantly relies on the extraarticular fracture lines of the retroarticular surface and palpation of the quadrilateral surface. A posterior capsulotomy and traction on the femur allows only limited visualization into the hip joint [5]. Intraarticular inspection is facilitated in the presence of posterior wall comminution and is limited in the presence of fracture patterns with small posterior rim fragments or an intact posterior wall. Fracture lines of the anterior column, such as in transverse or T-shaped fractures, are hardly visible; intraarticular visual control of reduction of comminuted posterior wall fractures is restricted as well.

A limited exposure of the supraacetabular region may pose a further difficulty of the standard KL approach in fractures with involvement of the anterosuperior dome area [5, 83, 120, 182] (Video 2.7-8).

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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Video 2.7-8 Heuter direct anterior approach to the hip joint.

Based on a technique for safe surgical femoral head dislocation without the risk of avascular necrosis of the head [143–147, 211, 212], the trochanteric flip osteotomy extends exposure to the superior rim area and provides visualization of the entire hip joint for treatment of selected acetabular fractures.

Furthermore, less vigorous traction and manipulation of the gluteus medius and minimus muscles is required to visualize and treat more superior and anterior areas of the acetabulum, thereby minimizing damage to these critical structures [144]. Surgical dislocation of the femoral head can be performed in either direction posteriorly or anteriorly, even in patients with a prior traumatic posterior fracture dislocation. Exposure of the entire head and acetabulum allows for more accurate evaluation of cartilage damage, complete removal of free fragments, accurate assessment of anatomical reduction, safe extraarticular placement of fixation screws, and fixation of associated femoral head fractures. This has been found to be helpful, especially for extended posterior wall fracture patterns, comminuted posterior wall fractures, and transverse or T-shaped fractures alone or combined with posterior wall involvement. Of note, these fracture types are typically more difficult to treat and are among the ones with the least favorable results [5, 9, 68, 213–216].

10.2 Surgical technique 10.2.1 Positioning

The patient is placed in a lateral decubitus position with padding of the uninvolved leg on a regular operating table.

No traction is applied to the involved leg. The surgeon is positioned at the back side of the patient.

10.2.2 Surgical approach

A KL-type skin incision is used. The fascia lata is incised in line with the skin incision. The gluteus, maximus muscle fiber bundles are split carefully longitudinally. After longi-

tudinal incision and dissection of the trochanteric bursa, the posterior border of the gluteus, medius muscle, and its tendinous insertion at the posterosuperior edge of the greater trochanter is exposed. In the same way the posterosuperior origin of the vastus lateralis muscle at the innomnate tubercle and femur has to be identified and mobilized over a distance of approximately 10 cm. With an oscillating saw a trochanteric osteotomy, with the vast majority of the gluteus medius muscle insertion and the entire origin of the vastus lateralis muscle attached to it (digastric osteotomy) is performed. Thereby, a small portion of the most posterior gluteus medius tendon insertion has to remain attached to the stable trochanteric portion to prevent the osteotomy from being too medial, and thereby risking damage to the deep branch of the medial femoral circumflex artery and/ or its subsynovial ramifications (Fig 2.7-63). After osteotomy, these fibers are cut sharply, allowing the trochanteric fragment to be flipped anteriorly. The osteotomy runs lateral to the insertion of the short external rotators, which remain attached to the proximal femur. Some fibers of the piriformis muscle insertion that remain attached to the trochanteric fragment have to be cut close to the lifted trochanter to facilitate its flipping. The deep branch of the medial femoral circumflex artery remains protected, since the artery crosses posterior to the obturator externus tendon and runs cranially, anterior to the remaining external rotator muscles (Fig 2.7‑63).

As a next step, the interval between the inferior border of the gluteus minimus muscle and superiorly to the piriformis muscle and tendon has to be identified and entered.

Subsequent release of the origin of the gluteus minimus and vastus lateralis and vastus intermedius muscles from the underlying bone and capsule allows the trochanteric fragment to be mobilized further anteriorly. Positioning of the leg in progressive external rotation and flexion by an assistant facilitates this surgical step. Finally, the entire anterior and superior aspect of the capsule becomes fully exposed (Fig 2.7‑64). For complete joint visualization, an anterior and superior capsulotomy is performed and the femoral head is dislocated in the anterior direction. In cases with an intact capsule, the capsulotomy is done close to the acetabular rim cranially and posteriorly and is directed toward the proximal femur, anteriorly and inferiorly, thereby creating a Z-shaped opening (as viewed on the right side). Modification of the capsulotomy according to the wall fracture pattern may be needed and has to be performed such that the remaining capsular attachments to the acetabular wall fragments are preserved (Fig 2.7-64). Care is taken not to damage the labrum. Through adduction and external rotation of the leg, the femoral head subluxates or can be dislocated anteriorly.

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Section 6 Techniques 2.7 Specific surgical approaches and technique

For complete dislocation, the round ligament insertion into the femoral head has to be transected if it is still intact.

A circumferential view of the acetabulum and a nearly circumferential view of the femoral head are obtained through this maneuver (Fig 2.7-65). Comminuted posterior and superior wall fragments can be reduced and fixed with screws and a plate with the head dislocated (Fig 2.7-66, Fig 2.7‑67). In the same way, a long anterior column screw with a posterosuperior entry point and directed toward the upper pubic ramus can be placed under direct visual control to confirm extraarticular placement (Fig 2.7-67). Posterior dislocation of the femoral head can be done instead of, or in addition to, an anterior dislocation but the exposure of the acetabulum is more limited. For more extensile exposure of the retroacetabular area, the piriformis tendon may be released or the interval between gemellus inferior and obturator externus muscles can be entered. Finally, if further visualization of the lower portions of the posterior wall and column is necessary then as in KL exposure, the conjoined tendon of the obturator internus and gemelli can be released a minimum of 1.5–2 cm from its insertion to protect the deep branch of the medial femoral circumflex artery [170].

5

10.2.3 Closure

After dislocation of the femoral head the round ligament is resected in order not to interfere with joint motion. The capsule is closed with 2-0 absorbable sutures. Be careful not to tighten the capsule too much because this might compromise the femoral head perfusion by tension on the terminal arterial branches within the superior retinaculum [211]. Transected tendons of the external rotators should be reattached. The reattachment of the osteotomized, greater trochanter is achieved by two to three 3.5 mm cortex screws.

The rest of the wound is closed within layers after placement of a drain.

10.2.4 Aftertreatment

Weight bearing is protected, with the patient limited to 5–10 kg for 8 weeks. Flexion of the hip is restricted to 90°.

No muscle exercises are allowed. In cases with major muscle contusion or a history of HO, prophylactic treatment with oral indomethacin 75 mg per day is given for 3 weeks or radiation considered. Conventional x-rays are obtained 8 weeks after surgery. In most cases the osteotomy of the greater trochanter is solidly healed at this point. Progressive weight bearing until full-weight bearing is allowed through a further 2–3 weeks. Active muscle exercises for regaining strength of the gluteus medius muscle are started. In cases where the osteotomy does not seem to be solidly healed, another 4 weeks of protected weight bearing is recommended.

2

1

4 3

Fig 2.7-63 Digastric trochanteric osteotomy with the oscillating saw leaving most of the gluteus medius tendon attached to the fragment cranially and the insertion of the vastus lateralis muscle attached to the fragment caudally: (1) gluteus medius muscle; (2) vastus lateral muscle; (3) gemelli and obturator internus muscles; (4) piriformis muscle; and (5) deep branch of the medial femoral circumflex artery.

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Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

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1

a

b

Fig 2.7-64a–b Exposure of the capsule and posterosuperior wall fragments (1). a The capsulotomy (dotted line) is made as an extension of the traumatic capsular laceration, preserving the capsular attachments of the main rim fragments. b Classically, a Z-shaped capsulotomy is performed in the presence of an intact capsule to best preserve the blood supply to the head. However, in the setting of trauma, the form of the capsulotomy is dictated by existing capsular damage.

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Fig 2.7-65 Complete intraarticular exposure after anterior surgical dislocation of the femoral head.

Fig 2.7-66 Visualization during reduction and screw fixation of free articular fragments or posterosuperior rim fragments with the femoral head dislocated.

Fig 2.7-67 Placement of a long screw in the anterior column with an entry point posterosuperior to the acetabulum with the femoral head dislocated. Intraarticular screw placement can be excluded by visual control.

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11

Extension of the ilioinguinal approach

11.1 Introduction

The ilioinguinal approach for treatment of acetabular fractures has been popularized predominantly by Letournel [3, 184]. This approach uses three windows through intervals between muscles and blood vessels to access the anterior column of the pelvis. The posterior column is addressed indirectly, mainly through the second (middle) window.

Difficulties arise in low anterior column fractures and/or comminution of the anterior wall, in which exposure is usually limited by the iliopsoas muscle. Obesity may provide another significant obstacle for adequate exposure and fracture manipulation. Modification of the ilioinguinal approach by combining it with an extension, such as a Smith-Petersen approach [217], seems beneficial in these selected cases [192].

The extension exploits the internervous plane between the sartorius and rectus femoris muscles with the femoral nerve, and the tensor fasciae latae and gluteus medius muscles with the superior gluteal nerve. An osteotomy of the ASIS and release of the rectus femoris muscle origins allows mobilization and medial retraction, especially of the iliopsoas muscle that largely increases access through the first window and to the anterior wall. Furthermore, anterior access to the hip joint is provided with the option of intraarticular inspection and removal of intercalated or free intraarticular fragments. The surgical extension with osteotomy of the ASIS and mobilization of the muscles to the medial side also helps to decrease tension on the LFCN and thus decreases the rather frequent nerve damage with a classic ilioinguinal approach [189, 190].

configuration of the incision includes the classic ilioinguinal skin incision connected with an additional longitudinal incision of about 12–15 cm length (Fig 2.7-36, Fig 2.7-68). The latter meets the first incision immediately lateral to the ASIS and is directed distally and slightly laterally. The deep dissection through the first (lateral) window is the same as for the classic ilioinguinal approach, with elevation of the iliacus muscle off the inner table of the iliac wing. At ASIS, this modified approach turns into the Smith-Petersen approach. The internervous interval is exploited between the sartorius and rectus femoris muscles with the femoral nerve (medially) and the tensor fasciae latae and gluteal muscles with the superior gluteal nerve (laterally) [217]. If needed, the second and third (medial) window of the classic ilioinguinal approach are exposed in the usual way before proceeding with the Smith-Petersen extension. After that the first step of the extension is to develop the interval between the tensor fasciae latae and sartorius muscles. An osteotomy of ASIS with the attached inguinal ligament and sartorius muscle is performed with a chisel or small oscillating saw. The osteotomized fragment has an approximate size of 2 × 1 cm, which should allow screw fixation at the end of the procedure. Thus, LFCN is retracted medially with the sartorius muscle (Fig 2.7-69). The straight and reflected heads of the rectus femoris muscle are transected at the anterior inferior iliac spine. Relaxation and retraction of the medial structures is obtained by placing the leg in moderate flexion with the help of a rolled-up towel or knee holder.

Posterior to the rectus muscle and lateral to the iliacus muscle is the iliocapsularis muscle, which covers the anterior aspect of the hip joint capsule. It has to be dissected sharply off the

11.2 Surgical technique 11.2.1 Positioning

A regular operating table is chosen and no traction is applied. The patient is placed in the supine position with the affected leg mobile, without any specific padding under the buttocks. Preferably, a radiolucent table is chosen to allow for an intraoperative imaging to judge the fracture reduction.

11.2.2 Surgical approach

The lateral part of the incision starts at the same point at the junction of the posterior and middle third of the crista iliaca, as originally described for the ilioinguinal approach but runs initially almost vertical, staying laterally to the crista iliaca and ASIS. At approximately 5 cm distal and lateral of the ASIS, the incision is curved medially at an angle of about 100° toward the symphysis (Fig 2.7-68). Alternatively, an incision with three limbs can be used. This triradiate

Fig 2.7-68 Curved skin incision (solid line) for approach to the left hip joint. Triradiate-shaped incision (dashed line) with the inferior limb similar to a Smith-Petersen approach.

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anterior capsule and reflected medially together with the main iliacus muscle [218]. Opening of the iliopectineal bursa and medial retraction of the iliopsoas muscle allows abundant exposure of the entire anterior wall, including the iliopectineal eminence without stretching of the LFCN.

There is excellent visualization and access to low fracture lines of the anterior column and separate or comminuted anterior wall fragments (Fig 2.7-70), allowing anatomical reduction, especially when comminuted, and even buttressing with a small plate. Intercalated fragments that may block

reduction can be extracted more easily from the fracture gap by using a laminar spreader. This even allows visualization of the femoral head and extraction of intraarticular fragments through the fracture gap (Fig 2.7-71). There is easier access to fracture lines of the quadrilateral surface, which also can be reduced by placing one leg of a curved reduction clamp near the anterior inferior iliac spine through the enlarged first window (Fig 2.7-72). This is especially helpful in cases with comminution of the low anterior column and anterior wall because it may become extremely difficult to get a firm grip with the reduction clamp through the

1

2 1

3

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2

Fig 2.7-69 Medial retraction of the osteotomized anterior superior iliac spine (1) with attached sartorius muscle. Rectus femoris muscle still attached to the anterior inferior iliac spine (2). Lateral retraction of the tensor fasciae latae muscle (3).

Fig 2.7-70 Exposure after detachment of the rectus femoris muscle and mobilization of the iliopsoas and iliocapsularis muscles medially; (1) anterior aspect of the hip joint capsule; (2) iliopectineal bursa.

Fig 2.7-71 Spreading of the main fragments with a laminar spreader.

Fig 2.7-72 Reduction of the posterior column by placing one leg of a curved reduction clamp on the quadrilateral surface with the other leg placed around the anterior inferior iliac spine.

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

second window in order to reduce the quadrilateral surface and posterior column. Digital control of reduction of the quadrilateral surface in the same way is facilitated through the enlarged first window. If needed, the abductors can be partially taken off the outer wing of the ilium subperiosteally. Occasionally, this may be necessary to judge fracture lines on the outside of the iliac wing, for placing a reduction clamp, or for improving access to the hip joint. In most cases, however, tunneling of the musculature between the ASIS and anterior inferior iliac spine is sufficient, leaving the main origin of the tensor fasciae latae, gluteus medius, and minimus muscles intact. The hip joint can be opened by a T-shaped capsulotomy. Subsequently, the femoral head can be subluxated by gentle traction with a bone hook placed just above the lesser trochanter on the femoral neck (Fig 2.7-73). This does not endanger the deep branch of the medial circumflex artery, representing the main blood supply to the femoral head [170]. Intraarticular access allows for assessment of the articular surfaces of the femoral head and acetabulum, fixation or excision of free fragments, inspection of the labrum and intraarticular control of fracture reduction, and extraarticular placement of screws.

If not done before the Smith-Petersen part of the approach, the second and third windows of the ilioinguinal can be opened even now in the same way as originally described.

To restore tension on the inguinal ligament for easier dissection, the osteotomized ASIS may be temporarily reattached with a small pointed clamp to its original position. After that the skin incision and further steps can be performed in the usual way.

Fig 2.7-73 After a T-shaped capsulotomy, the femoral head can be subluxated with limited insight into the hip joint, or it can even be dislocated.

11.2.3 Closure

The hip capsule is closed at the end of the procedure. The straight and the reflected origins of the rectus muscle are reattached, thereby using nonabsorbable transosseus sutures for the straight portion. The sartorius muscle is reattached with its ostetomized bony origin (ASIS) using a 2.7 mm or 3.5 mm screw. The remainder of the closure is in layers.

Deep drains are left in place for 1–2 days.

11.2.4 Aftertreatment

Active leg raising is not allowed for the first 6 weeks to obtain uneventful healing of the reattached muscles. Protected weightbearing with 5–10 kg is maintained for 8 weeks.

Prophylactic treatment by oral indomethacin or radiation may be considered in cases with major muscle contusion or a patient’s history of HO.

12

Postoperative management

Deep infection is a devastating complication following fixation of acetabular fractures, with an incidence as high as 9% but probably nearer 4–5% [5, 9, 24, 40, 124]. Because of such concerns, we advocate the routine use of prophylactic antibiotics, multiple suction drains in all recesses to prevent hematoma formation, surgical evacuation of hematomas, and if present, debridement of the Morel-Lavallée lesion over the greater trochanter [5, 135, 136]. Drains are not discontinued until output has tapered to 10–20 mL per 8-hour shift, usually by 48–72 hours. Intravenous cefazolin is continued for a minimum of 48–72 hours and until the suction drains are removed. Serous drainage following pelvic surgery is not uncommon and often improves when range of motion activity, such as a continuous passive motion (CPM) machine, is discontinued [20, 52]. However, if it persists beyond 1 week, formal wound exploration, drainage, and debridement should be considered. The use of incisional negative pressure wound therapy for draining wounds may be helpful in avoiding infection, particularly in the obese patient. After lengthy procedures or more extensile approaches, or in the presence of persistent drainage, some have anecdotally noted that a longer duration of antibiotic treatment of up to 7–10 days may be beneficial [171].

The indications for prophylaxis for HO are controversial.

Certainly, mild amounts of heterotopic bone often form after surgical reconstruction of the acetabulum in as many as 90% of patients [5, 9, 50, 53, 122–124, 162, 219, 221]. In most cases, its presence is of little functional significance. However, in approximately 5–14% of cases [34, 40, 52, 134, 219] but reportedly as high as 53% of cases [220], HO is substantial

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enough to cause significant restriction of hip motion; therefore, some form of prophylaxis is often desirable. Rarely, HO formation can even be severe enough to encase the sciatic nerve and lead to neurological deterioration [164, 222].

However, surgical release of the nerve in such situations or for other causes of sciatic neuropathy after acetabular fractures can be helpful. Issack et al [222] evaluated ten patients with acetabular fracture-associated sciatic neuropathy who underwent release of the nerve from scar tissue and heterotopic bone. All patients had partial to complete relief of radicular pain, diminished sensation, and paresthesias after nerve release, while only four of seven with motor loss (two of five with a foot drop) demonstrated improvement.

Various risk factors have been identified for HO, including the extended iliofemoral and KL approaches; associated head, abdominal, and chest injuries; trochanteric osteotomy, T-type fractures, greater severity of articular damage, sciatic nerve damage, and male gender [66, 82, 83, 123, 126, 127, 139, 162, 219]. Heterotopic bone formation is particularly common and severe with the extended iliofemoral approach because of stripping of the external surface of the iliac wing [5, 25, 32, 122, 153, 162]. In contrast, the ilioinguinal approach has the lowest incidence of HO [5, 32]. Although two studies [123, 162] have failed to note a correlation with the posterior KL approach, Letournel [5] observed significant heterotopic bone formation in 5% of cases. While this rate was not as great as that observed in his patients after the extended iliofemoral approach (14%), it was almost ten times that seen after an ilioinguinal approach (0.6%). The most common forms of prophylaxis against HO are indomethacin (75 mg daily) [5, 53, 88, 66, 127, 162, 220, 221, 223, 224] and low-dose radiation therapy (700–1,000 cGy in single or divided doses) [5, 66, 89, 122, 127, 138, 220, 221, 223, 225–227], both of which have been shown to decrease the rate of significant HO formation after surgical treatment of acetabular fractures when given early. At least one study [220] has found both modalities to be equally effective and several others [127, 221] suggest that the two in combination are superior.

However, while indomethacin has remained the more commonly used modality; several prospective studies [163, 219] have questioned its efficacy. Recently, Karunakar et al [163] were unable to demonstrate a statistically significant reduction in the incidence of severe HO with the use of indomethacin compared with a placebo (P = .722). The authors concluded that they could not recommend the routine use of indomethacin for prophylaxis against HO after isolated fractures of the acetabulum. Another concern related to the use of indomethacin is the increased risk of nonunion. In a prospective randomized study, Burd et al [228] reviewed 282

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patients who had had open reduction and internal fixation of an acetabular fracture. At least one concomitant longbone fracture was present in 112 cases.When comparing patients who received indomethacin to those who did not (this later group included patients treated with low-dose radiation), a significant difference was noted in the nonunion rate of the long-bone fractures (26% vs 7%; P = .004).

Despite the above concerns, our routine prophylaxis for all patients continues to be 25 mg indomethacin orally three times daily (or 75 mg sustained release orally once daily) for 6 weeks if they undergo KL or extensile approach. Those patients for whom indomethacin is contraindicated or have other risk factors are treated with low-dose radiation therapy, usually a single dose of 700 cGy. Other authors [66, 127] prefer low-dose radiation with or without indomethacin for extensile approaches. We do not routinely administer prophylaxis to patients who undergo fixation through an ilioinguinal approach unless a limited subperiosteal exposure of the outer cortex of the ilium was performed for insertion of pelvic reduction clamp.

As already discussed at the beginning of this chapter, venous thromboembolism (VTE) remains a serious concern. Therefore, routine postoperative VTE prophylaxis is recommended because of the high risk of DVT and its potential catastrophic sequela of pulmonary embolism [97, 100]. This includes sequential compression devices and pharmacological therapy.

A therapeutic level of warfarin (Coumadin) with an international normalization ratio is efficacious, although lowmolecular-weight heparin is gaining popularity [20, 87, 101, 229]. However, the major downside of early postoperative anticoagulation is hematoma formation. Also, the optimal duration of postoperative anticoagulation is unclear. Although full-weight bearing and therefore absolute mobilization of the patient typically are delayed for at least 8 weeks, long-term anticoagulation with warfarin presents difficulties such as reliable monitoring and theoretical concerns such as bleeding complications.

A protocol used by Fishmann et al [230] attempted to balance the desire to minimize postoperative hematoma formation while providing an adequate time window for postoperative anticoagulation in the patient with pelvic trauma. Patients were routinely treated with knee-high graduated elastic stockings (TED) and external pneumatic compression (EPC) devices preoperatively, with noninvasive screening being performed via duplex ultrasonography within a few hours of admission. The EPCs were worn at all times during the postoperative period except during physical therapy or nursing care. When the drains were removed (between 48 and

Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas

Craig S Bartlett III, David L Helfet

72 hours postoperatively), warfarin therapy was started with an initial dose of 7.5 mg and adjusted daily (twice weekly on discharge) to obtain a therapeutic index of 1.3–1.4 times control (international normalized ratio, 2:3). The EPCs were discontinued 2 days after this level of anticoagulation had been maintained. After discharge, the patients continued prophylactic warfarin therapy for 3 more weeks. Patients younger than 22 years did not receive postoperative warfarin.

The authors [230] reported that they significantly reduced their overall incidence of venous thrombosis from 27–3%, with a more modest decrease in the rate of proximal vein thrombosis from 3–12% to 2%. The rate of postoperative wound hematoma was only 1.5%, with a rate of nonfatal pulmonary embolism of 1%.

Strong evidence-based recommendations for VTE identification and/or prevention in patients with pelvic and acetabular fractures remain lacking in the literature. A recent metaanalysis [231] of eleven studies comprising 1760 subjects compared five types of interventions: mechanical compression devices, inferior vena cava filters, low-molecular-weight heparins, ultrasound screening, and magnetic resonance venography screening. However, most studies were observational designs with minimal control data for comparison.

The authors concluded that presently there is only limited data to guide prophylactic decisions and that no one strategy can be considered optimal until well-designed clinical trials to prevent and detect VTE in pelvic and acetabular trauma have been performed. Furthermore, despite prophylaxis, DVT remains a common finding in the high-energy orthopedic trauma patient [232]. Therefore the specific thromboembolic prophylactic regimen used remains the decision of the treating physician. Our postoperative anticoagulation regimen includes compression boots while hospitalized, and 6 weeks of low-dose warfarin therapy.

At the end of the operative procedure the surgeon must scrupulously evaluate the osteosynthesis. Rehabilitation may be instituted early if the patient is young, the bone good, and the internal fixation stable. This includes early mobilization with the patient encouraged to sit up and dangle within the first 24–48 hours following surgery. In some cases, Hamilton Russell traction also can be used for the first few days. To prevent stiffness in the hip joint, CPM also has been used in the immediate postoperative period. Experimental studies by Salter et al [233] suggest this has a marked beneficial effect on the joint. Some [20] have also noted its application helpful in clinical experience. We do not routinely use CPM during the postoperative period because we have not had difficulty regaining hip motion in this patient population. If CPM is to be used, the internal fixation must be

stable lest the fragments become displaced and anatomical reduction lost.

After removal of the drains, usually by day 3, patients are allowed partial-weight bearing (not more than 9 kg) with the foot flat using crutches or a walker for 6–8 weeks. Range of motion exercises are also instituted, although some limitations may be set depending on the presence of significant posterior wall involvement and whether a trochanteric osteotomy was required (in the case of an extended iliofemoral approach or a trochanteric osteotomy, active abduction is avoided for 6–8 weeks). Strengthening exercises and gait training are initiated by the physical therapist. However, weight bearing is not advanced for a minimum of 6–8 weeks.

Acetabular fractures with a concomitant neurological injury can pose a difficult rehabilitation problem because of lack of motor activity or neurogenic pain, and frequently require treatment in conjunction with a pain management service. Careful follow-up care is mandatory. If x-rays indicate good healing with no loss of the stable internal fixation, weight bearing usually can be advanced at 8 weeks, with full-weight bearing achieved by 12–14 weeks.

A troublesome occurrence is the loss of reduction during the early postoperative period. This is especially true in elderly patients with osteopenic bone where it is important to adequately buttress the fractures [90, 229, 234, 235]. The stability of the internal fixation must be questioned for older patients, those with osteoporotic bone, and in cases of severe marginal impaction where there is concern about dislodgement of the fragments. In such cases, it is best to err on the side of caution before allowing the patient to ambulate. Some [20] have even recommended consideration of skeletal traction for a full 6 weeks. At that point, healing of the cancellous bone usually is adequate to begin the rehabilitation program. Early ambulation for this group of individuals is particularly dangerous because loss of the anatomical reduction usually spells disaster for the joint. It is far better to risk the extra weeks of bed rest and minimize complications of thromboembolic disease by using anticoagulants than to jeopardize the fracture by prematurely releasing the patient to a rehabilitation program.

13

Conclusion

The learning curve for the successful management of acetabular fractures is steep [5, 9, 12–14, 16]. However, a careful and complete preoperative assessment of the fracture pattern and displacement are invaluable in choosing the optimal approach to the acetabulum as well as the proper means of

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reduction and fixation. Every acetabular fracture has a specific character or personality, and thus, its treatment must be individualized.

14 1.

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Fractures of the Pelvis and Acetabulum—Principles and Methods of Management Marvin Tile, David L Helfet, James F Kellam, Mark Vrahas