Fri., 10/17/08 Pelvis/Injury Prevention, Paper #32, 12:08 pm OTA-2008
Direct Inside-Out Plating of the Quadrilateral Surface and Posterior Column Using the Stoppa Window of the Ilioinguinal Approach
Bruce H. Ziran, MD1 (n); Wade R. Smith, MD2 (n); Takashi Suziki, MD2 (n);
Barbara M. Hileman, BA1 (n); Mary-Kate Barrette-Grischow, MA, MPH1 (n);
1St. Elizabeth Health Center, Youngstown, Ohio, USA;
2Denver Health Medical Center, Denver, Colorado, USA
Purpose: The ilioinguinal or modified Stoppa approaches are used for the majority of acetabular fractures involving anterior and central elements. The posterior column and quadrilateral surface are not always easily stabilized, because of their particular anatomic characteristics and location. Usually, these lesions are stabilized with spring plates or posterior column screws that are placed through the lateral window. The posterior column and quadrilateral surface may be difficult to manipulate or reduce through standard ilioinguinal windows. Also, considering the physiologic forces possible, they may not provide sufficient stabilization. We propose using the Stoppa window of the ilioinguinal approach from the contralateral side of the table, to directly manipulate and fix the posterior column/quadrilateral surface with stronger fixation. The purpose of this report is to describe the technique and preliminary experience with this particular method.
Methods: Inclusion criteria were all patients requiring an ilioinguinal approach with posterior column or quadrilateral surface involvement (severe enough to allow the risk of protrusion) that was difficult to address from the lateral window, or who may have needed a secondary posterior approach. Exclusion criteria were patients with little posterior column involvement, those who could be well stabilized via standard techniques, or those without significant quadrilateral involvement. The surgical approach consisted of two incisions (corresponding to the lateral and medial windows of the ilioinguinal) without involving the middle window. The surgeon worked from the ipsilateral lateral window, or contralateral medial window. All patients were followed until healing, and both perioperative complications and parameters and routine outcome data were recorded.
Results: Out of a total of 345 acetabular fractures in a 3-year period, 25 met inclusion criteria. There were 18 males and 7 females, with mean age of 49 years (range, 20-71). Fracture patterns were: 15, both column; 3, transverse; 4, anterior hemitransverse; and 3, T-type. Fixation was achieved with 3.5-mm reconstruction plates. Mean operative time and blood loss were 155 minutes (range, 126-300) and 1000 cm3 (range, 50-3100), respectively. None of the patients required extension of the two incisions to become a formal ilioinguinal approach or required a second approach. We identified 6 traumatic obturator nerve/vessel injuries and 12 corona mortise veins, which were ligated. There were two iatrogenic obturator vein injuries. All reductions were within 1 to 2 mm and there were no fixation failures, infections, or wound complications. Thus far, no patient has required further surgery. There were two cases of deep vein thrombosis and no cases of lymphedema.
Discussion: The subinguinal window (modified Stoppa) described is a useful adjunct to acetabular fracture fixation. It does not interfere with the vessel sheath and allows unobstructed visualization of the entire posterior column and quadrilateral surface, and allows them to be manipulated and stabilized directly, without incident. Use of this approach could potentially prevent the need for a second approach for posterior elements (posterior column, posterior element of transverse), and reduce the risk of protrusion. Using the strong bone of the sciatic buttress and iliopectineal ridge approaching the sacroiliac joint, direct buttress plating of the posterior column or quadrilateral surface is possible. We believe this technique is useful when standard approaches and methods may not be adequate.
If noted, the author indicates something of value received. The codes are identified as a-research or institutional support; b-miscellaneous funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts disclosed, and *disclosure not available at time of printing.
• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.