import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' ## Indications **Fracture Patterns Requiring Ilioinguinal:** - **Anterior column fracture** - displaced more than 2mm articular step or 5mm gap - **Anterior wall fracture** - displaced with hip instability - **Anterior column + posterior hemitransverse** - classic pattern for this approach - **Both-column fracture** - when anterior displacement predominates - **Transverse fracture** - when significant anterior displacement (rare indication) - **Transverse + posterior wall** - combined approach if anterior component displaced **Radiographic Criteria:** - Articular step-off greater than 2mm on CT - Displacement greater than 5mm at pelvic brim - Loss of secondary congruence in both-column patterns - Medial roof arc angle less than 45 degrees **Patient-Related:** - Polytrauma patient requiring staged fixation (anterior first) - Associated pelvic ring injury requiring symphyseal or ramus fixation - Surgeon preference for anterior approach in transverse patterns - Failed closed reduction with persistent anterior displacement **Technical:** - Need for decompression of femoral neurovascular structures - Planned combined anterior-posterior approach (anterior first) - Quadrilateral plate fracture requiring direct visualization **Absolute:** - Active pelvic infection or sepsis - Previous ilioinguinal surgery with extensive scarring - Severe peripheral vascular disease precluding vessel mobilisation - Medical unfitness for prolonged surgery (3-4 hours) **Relative:** - Morbid obesity (BMI greater than 40) - consider percutaneous techniques - Previous inguinal hernia repair with mesh (requires modification) - Posterior wall fracture as primary pathology (use Kocher-Langenbeck) - Isolated posterior column fracture - Delayed presentation more than 3 weeks (consider extensile approach) ## Pre-operative Planning **History:** - Mechanism of injury (high-energy: MVA, fall from height; low-energy in elderly: hip fracture equivalent) - Associated injuries (head, chest, abdomen, spine - polytrauma common) - Pre-injury mobility and function (independent vs dependent) - Comorbidities (DVT risk, bleeding disorders, anticoagulation) **Examination:** - Neurovascular status - document femoral, sciatic, obturator function - Morel-Lavallee lesion - check for soft tissue degloving (delays surgery) - Abdominal examination - bladder, bowel injury - Associated pelvic ring assessment - pubic symphysis, SI joint - Skin condition - abrasions, lacerations, open fracture wounds **EXAM KEY:** "I document detailed neurological examination pre-operatively as the approach places femoral nerve at risk, and I need baseline to compare post-operatively." **Plain Radiographs (Judet Series):** - AP Pelvis - overall alignment, dome integrity - Inlet view (25-degree caudal) - anterior/posterior displacement, pelvic brim - Outlet view (45-degree cranial) - vertical displacement, sacrum - Obturator oblique (45-degree toward affected side) - anterior column, posterior wall - Iliac oblique (45-degree away from affected side) - posterior column, anterior wall **CT Scan with 3D Reconstruction:** - Axial 2mm slices through acetabulum - Coronal and sagittal reformats - 3D surface rendering for fracture pattern visualization - Assess: marginal impaction, dome integrity, quadrilateral plate, articular fragments **Key Measurements:** - Roof arc angles (medial, anterior, posterior) - surgery if less than 45 degrees - Displacement at pelvic brim in millimetres - Quadrilateral plate involvement - Location and size of marginal impaction **Expected Outcomes:** - Anatomic reduction in 70-85% of cases - Good/excellent clinical outcome in 75-80% at 10 years - Post-traumatic arthritis in 15-25% requiring THA **Specific Risks:** | Complication | Rate | Details | |--------------|------|---------| | LFCN injury | 15-25% | Anterior thigh numbness, usually transient | | Femoral nerve | 2-5% | Quadriceps weakness, usually neuropraxia | | Vascular injury | 1-3% | Corona mortis, external iliac vessels | | Infection | 3-6% | Higher with longer operative time | | HO | 10-30% | Lower than posterior approach | | DVT/PE | 5-10% | Despite prophylaxis | | Hernia | 2-5% | Inguinal or femoral | **Alternatives:** - Non-operative: bed rest 6-8 weeks (risk of malunion, arthritis, prolonged morbidity) - Percutaneous fixation: selected patterns with minimal displacement - Alternative approach: Stoppa, Kocher-Langenbeck, combined approaches ## Equipment - 3.5mm pelvic reconstruction plates (12-16 hole) - 3.5mm cortical screws (20-60mm lengths) - 4.5mm cortical screws for iliac wing - Infrapectineal buttress plates - Spring plates for posterior column - 2.7mm screws for comminution - Large pelvic reduction set - Pointed reduction forceps (Weber, Jungbluth) - Ball spike pushers - Large Hohmann retractors (blunt) - Vessel loops / Penrose drains - Pelvic C-clamp (for ring control) - Long drill bits (150mm) - Fluoroscopy (C-arm) - Cell saver (blood loss 500-2000ml typical) - Foley catheter (mandatory) - Radiolucent table - 4 units PRBC crossmatched - TXA 1g IV at induction ## Anaesthesia and Positioning **Type:** General anaesthesia (mandatory) - Prolonged procedure (3-4 hours) precludes regional alone - Muscle relaxation essential for reduction - Consider arterial line for haemodynamic monitoring **Adjuncts:** - Tranexamic acid 1g IV at induction, repeat at 3 hours - Cell saver for blood conservation - Hypotensive anaesthesia (MAP 60-70) if tolerated - Warming blanket (forced air) **Considerations:** - Avoid nitrous oxide (bowel distension impairs access) - Antibiotic prophylaxis: Cefazolin 2g IV within 60 minutes of incision - Repeat antibiotics every 4 hours or 1.5L blood loss **Position:** Supine on radiolucent operating table **Setup:** - Foley catheter - essential to decompress bladder away from field - Arms on arm boards or tucked (surgeon preference) - Slight hip flexion (10-20 degrees) relaxes iliopsoas - Radiolucent table allows fluoroscopy **Preparation:** - Prepare from costal margin to mid-thigh - Symphysis to contralateral ASIS included - External genitalia excluded from field - Mark incision before prep - Mark LFCN course (1-2cm medial to ASIS) **Fluoroscopy Confirmation:** - Confirm ability to obtain: AP pelvis, inlet, outlet, both Judet obliques - Image intensifier from contralateral side - Screen at head of table ## Surface Anatomy and Landmarks **EXAM KEY:** "I mark the incision from a point 2cm below the iliac crest at the level of ASIS, extending medially along the crest for 8-10cm, then curving distally parallel to and 2cm above the inguinal ligament toward the pubic tubercle. The LFCN typically exits 1-2cm medial to ASIS and must be identified early." ## Surgical Approach - The Three Windows The ilioinguinal approach provides access to the entire anterior column through three anatomically safe windows. Each window has specific boundaries that must be respected to avoid neurovascular injury. ### Lateral Window **Boundaries:** - Lateral: Detached abdominal wall musculature - Medial: Elevated iliacus muscle on iliopsoas tendon - Superior: Iliac crest - Inferior: Pelvic brim **Access Provides:** - Inner table of iliac wing - SI joint (up to 3cm posterior) - Iliac crest and anterior column proximally - Greater sciatic notch (limit of safe dissection) **Structures at Risk:** - Superior gluteal neurovascular bundle (exits above piriformis, 3-4cm from notch) - L5 nerve root (at sacral ala) - Iliac crest bleeding **Development Technique:** 1. Detach external oblique, internal oblique, transversus abdominis from anterior iliac crest 2. Elevate iliacus subperiosteally from inner iliac fossa 3. Identify and protect LFCN (exits 1-2cm medial to ASIS) 4. Expose from anterior iliac crest to pelvic brim 5. Identify greater sciatic notch - do not dissect beyond ### Middle Window **Boundaries:** - Lateral: Iliopsoas muscle (with femoral nerve on surface) - Medial: External iliac vessels - Superior: Continuation of lateral window dissection - Inferior: Inguinal ligament/lacunar ligament **Access Provides:** - Pelvic brim from ASIS to pectineal eminence - Mid-portion of anterior column - Quadrilateral plate (limited view) **Structures at Risk:** - Femoral nerve (lies on iliopsoas, 2-3cm lateral to artery) - External iliac artery and vein - Corona mortis (crosses superior ramus) **Development Technique:** 1. Identify external iliac vessels deep to transversalis fascia 2. Identify iliopsoas muscle with femoral nerve on its surface 3. Mobilise vessels medially using vessel loops (Penrose drains) 4. NEVER use sharp retractors on vessels 5. Identify and LIGATE corona mortis before fracture manipulation ### Medial Window **Boundaries:** - Lateral: Iliopsoas muscle - Medial: Spermatic cord (male) or round ligament (female) - Superior: Pectineal eminence - Inferior: Pubic symphysis **Access Provides:** - Superior pubic ramus - Pectineal eminence - Quadrilateral plate (good view) - Symphysis pubis **Structures at Risk:** - Spermatic cord/round ligament - Bladder (lies medially) - Obturator nerve and vessels (deep to ramus) - Corona mortis (if not already ligated) **Development Technique:** 1. Identify spermatic cord entering inguinal canal 2. Gently retract cord medially with Penrose tape 3. Expose superior pubic ramus and pectineal eminence 4. Identify obturator foramen and canal 5. Protect bladder with gentle medial retraction ## Critical Danger Structures **Corona Mortis** is an aberrant vascular anastomosis between the external iliac (or inferior epigastric) vessels and the obturator vessels. Present in **30-50%** of patients. - **Location:** Crosses superior pubic ramus 4-6cm from symphysis - **Calibre:** Can be arterial (10%) or venous (70%) or both (20%) - **Danger:** If injured during fracture manipulation or fixation, causes massive haemorrhage that is difficult to control in the pelvis **EXAM KEY:** "I identify corona mortis in the medial window BEFORE fracture manipulation. I ligate it between clips or ties. If injured, it causes torrential haemorrhage - the name means 'crown of death' in Latin." ## Operative Technique ### Step 1: Positioning and Preparation 1. Position supine on radiolucent table 2. Insert Foley catheter (mandatory - decompresses bladder) 3. Arms on boards or tucked 4. Prepare from costal margin to mid-thigh, symphysis to contralateral ASIS 5. Mark incision before prep 6. Confirm fluoroscopy: AP pelvis, inlet, outlet, both Judet obliques **Technical Pearl:** "The Foley catheter is not optional - the distended bladder lies directly in the surgical field and is at risk of injury. I confirm fluoroscopy capability before draping." ### Step 2: Incision 1. Begin incision at ASIS level, 2cm below iliac crest 2. Extend medially along iliac crest for 8-10cm 3. Curve distally, running parallel to and 2cm above inguinal ligament 4. Continue toward pubic tubercle (total length 20-25cm) 5. Divide skin and subcutaneous fat 6. Identify and preserve LFCN (exits 1-2cm medial to ASIS) The lateral femoral cutaneous nerve injury rate is 15-25%. Options: - **Preserve:** Identify and protect throughout (preferred) - **Divide:** If preservation impossible, divide sharply and bury proximal end in muscle to prevent neuroma - **Consequence:** Meralgia paresthetica (anterior thigh numbness) - usually transient ### Step 3: Develop Lateral Window 1. Incise external oblique aponeurosis along iliac crest 2. Detach internal oblique and transversus from crest with diathermy 3. Enter between transversalis fascia and peritoneum (extraperitoneal plane) 4. Elevate iliacus subperiosteally from inner table of ilium 5. Continue posteriorly to greater sciatic notch (DO NOT exceed) 6. Identify pelvic brim and sacroiliac joint **Technical Pearl:** "The lateral window is developed entirely subperiosteally on the inner iliac fossa. I do NOT dissect beyond the greater sciatic notch as this risks the superior gluteal neurovascular bundle which exits above piriformis." ### Step 4: Develop Middle Window 1. Identify external iliac artery and vein deep to transversalis fascia 2. Identify iliopsoas muscle with femoral nerve visible on its surface 3. Create window BETWEEN vessels (medially) and iliopsoas (laterally) 4. Mobilise vessels with vessel loops or Penrose drains 5. NEVER use sharp retractors or excessive traction on vessels 6. Release retractors every 15 minutes to prevent nerve injury **KEY STRUCTURES:** - Femoral nerve lies on iliopsoas, 2-3cm lateral to artery at inguinal ligament - External iliac vessels must be mobilised medially with extreme care - This window exposes pelvic brim from ASIS to pectineal eminence ### Step 5: Develop Medial Window and Ligate Corona Mortis 1. Identify spermatic cord (male) or round ligament (female) at internal inguinal ring 2. Gently retract cord medially with Penrose tape 3. Expose superior pubic ramus and pectineal eminence 4. **CRITICAL: Identify corona mortis** - crosses superior ramus 4-6cm from symphysis 5. **Ligate corona mortis** between clips before ANY fracture manipulation 6. Expose quadrilateral plate and symphysis region Present in 30-50% of patients. ALWAYS identify before fracture reduction: 1. Look for vessel crossing superior pubic ramus 2. Ligate between clips or ties (both ends) 3. If not visible, assume it exists deep - careful dissection 4. If injured: immediate pressure, then ligation of both ends ### Step 6: Fracture Reduction - Proximal to Distal **Principle:** Work from stable (iliac crest) to unstable (symphysis) 1. Clear fracture haematoma and fibrous tissue from all lines 2. Begin reduction at iliac wing (stable reference point) 3. Use ball spike pushers and pointed reduction forceps 4. Hold provisional reduction with 2.0mm K-wires 5. Progress distally along pelvic brim 6. Address quadrilateral plate displacement last **Reduction Aids:** - Schanz pins in anterior column for manipulation - Jungbluth clamps across pelvic brim - Farabeuf clamps for symphysis **Technical Pearl:** "I reduce fractures from proximal to distal - the intact ilium is my stable reference. I aim for anatomic reduction at the pelvic brim (less than 1mm step) as this is the primary weight-bearing path through the anterior column." ### Step 7: Definitive Fixation **Pelvic Brim Plate:** - 3.5mm reconstruction plate along entire pelvic brim - Contour to match pelvic brim anatomy - Position on INTERNAL aspect (best biomechanical position) - Minimum 3 bicortical screws each side of fracture - Check screw lengths - avoid joint penetration (iliac oblique view) **Iliac Wing Plate (if needed):** - External surface of ilium through lateral window - 4.5mm reconstruction plate for comminution - Spans from intact ilium to pelvic brim **Quadrilateral Plate (if fractured):** - Infrapectineal buttress plate through medial window - Prevents medial displacement of femoral head - Alternative: posterior column screws from anterior for indirect support **Symphyseal Plate (if required):** - 3.5mm plate on superior pubic surface - Minimum 6-8 cortices each side - Consider two plates for unstable patterns ### Step 8: Final Assessment **Fluoroscopy Views:** 1. AP pelvis - overall reduction 2. Inlet (25-degree caudal) - pelvic ring, anterior displacement 3. Outlet (45-degree cranial) - vertical displacement, sacrum 4. Obturator oblique - anterior column profile 5. Iliac oblique - posterior column profile **Confirm:** - Anatomic reduction (less than 2mm step, less than 5mm gap) - No intra-articular hardware - No joint penetration - Adequate fixation of all fragments - No vascular compression **Technical Pearl:** "Intra-operative fluoroscopy misses 20-30% of intra-articular screw penetration. Post-operative CT is MANDATORY to confirm reduction and hardware position." ## Closure 1. Release all vessel loops and retractors gently 2. Inspect for active bleeding - control with diathermy or clips 3. Check for hematoma formation in retroperitoneum 4. Confirm distal pulses before closure - Place 19Fr Blake drain in lateral window (deep to iliacus) - Consider second drain in medial window if significant dead space - Drains reduce hematoma and HO risk - Remove when output less than 30ml per 8-hour shift (typically 48-72 hours) 1. **Abdominal wall:** Repair external oblique, internal oblique, transversus to iliac crest with 1-0 Vicryl (critical to prevent hernia) 2. **Fascia lata:** Close with 0 Vicryl 3. **Subcutaneous:** 2-0 Vicryl interrupted 4. **Skin:** Staples or 3-0 Monocryl subcuticular ## Intra-operative Complications **Structures:** Corona mortis, external iliac vessels, obturator vessels **Recognition:** - Sudden profuse bleeding - Hypotension - Visible vessel injury **Prevention:** - Ligate corona mortis prophylactically - Vessel loops on external iliacs - Blunt retractors only - Screw lengths less than 20mm through superior ramus **Management:** - Immediate pressure - Call vascular surgery if major vessel - Corona mortis: ligate both ends (may retract into pelvis) - Pack and resuscitate if unstable - Have cell saver running throughout **Femoral Nerve:** - Recognition: Post-op quadriceps weakness, absent knee reflex - Prevention: Blunt retractors, release every 15 minutes, avoid excessive traction - Management: Document, observe (most are neuropraxia), EMG at 6 weeks if not improving **LFCN:** - Recognition: Anterior thigh numbness (meralgia paresthetica) - Prevention: Identify and preserve, or divide cleanly and bury - Management: Reassurance (usually resolves 3-6 months), consider capsaicin cream **Obturator Nerve:** - Recognition: Thigh adductor weakness - Prevention: Screw length less than 20mm through superior ramus - Management: Document, observe, EMG if persistent **Recognition:** - Haematuria in Foley bag - Visible injury during medial window dissection - Urine in field **Prevention:** - Foley catheter to decompress bladder - Gentle retraction only - Stay on bone during dissection **Management:** - Intra-operative urology consultation - Two-layer closure with absorbable sutures - Prolonged catheter drainage (10-14 days) - Cystogram before catheter removal **Recognition:** - Fluoroscopy shows step or gap more than 2mm - Malrotation of fragment - Hardware prominent **Prevention:** - Systematic reduction proximal to distal - Clear fracture surfaces thoroughly - Provisional K-wire fixation before plating - Multiple fluoroscopy views **Management:** - Remove hardware - Re-clear fracture site - Obtain better reduction with alternative clamps/techniques - Accept if cannot improve (document for prognosis) ## Post-operative Care **Monitoring:** - HDU if significant blood loss or comorbidities - Neurovascular observations every 2 hours for 24 hours - Monitor for abdominal compartment syndrome if large retroperitoneal hematoma - Urine output monitoring (minimum 0.5ml/kg/hour) **Medications:** - DVT prophylaxis: LMWH (Enoxaparin 40mg daily) from day 1 - HO prophylaxis: Indomethacin 25mg TDS for 6 weeks (if no contraindications) - Alternative HO prophylaxis: Single fraction radiation 700cGy within 72 hours - Analgesia: PCA then oral, target pain less than 4/10 **Drains:** - Remove when output less than 30ml per 8-hour shift - Typically 48-72 hours **Mobilisation:** - Toe-touch weight bearing only - Use walking frame or crutches - Hip ROM exercises (avoid forced flexion) - Physiotherapy daily as inpatient **Wound Care:** - Inspect at 48 hours for hematoma - Remove staples/sutures at 14-21 days - Watch for signs of infection **Imaging:** - Post-operative CT scan within 48 hours (confirm reduction, hardware position) - 6-week X-ray series (AP pelvis, Judet views) **Weight Bearing Progression:** - 6 weeks: Continue toe-touch if fracture healing - 8-10 weeks: Progress to partial weight bearing - 12 weeks: Full weight bearing as tolerated if radiographic healing **Function:** - 6-week X-ray review - Assess hip ROM, gait pattern - Physiotherapy for strengthening **Work/Activities:** - Sedentary work: 3-6 months - Manual work: 6-12 months - Impact activities: 9-12 months (if fully healed) **Follow-up Schedule:** - 6 weeks: Clinical and radiographic review - 3 months: Assess healing, ROM, function - 6 months: Functional outcome - 1 year: Final radiographs - Annual surveillance if symptoms develop **Complications to Monitor:** - Post-traumatic arthritis (15-25% at 10 years) - AVN (rare in anterior fractures) - HO (check X-rays at 6 weeks) **Hardware Removal:** - Rarely indicated - Consider if symptomatic and healed - Wait minimum 12-18 months ## Viva Scenarios ## Key Exam Points ## References **Original Description:** - Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;(151):81-106. *Classic paper describing the ilioinguinal approach and Judet-Letournel classification* **Anatomical Studies:** - Tornetta P 3rd, Hochwald N, Levine R. Corona mortis: incidence and location. Clin Orthop Relat Res. 1996;(329):97-101. *Found corona mortis in 34% of cadavers* - Darmanis S, Lewis A, Mansoor A, Bircher M. Corona mortis: an anatomical study with clinical implications. Clin Anat. 2007;20(4):433-439. *Venous variant more common than arterial* **Outcomes:** - Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632-45. *Landmark outcomes study - anatomic reduction correlates with clinical outcome* - Giannoudis PV, Grotz MR, Papakostidis C, Dinopoulos H. Operative treatment of displaced fractures of the acetabulum: a meta-analysis. J Bone Joint Surg Br. 2005;87(1):2-9. **Complications:** - Liebergall M, Mosheiff R, Low J, Goldvirt M, et al. Acetabular fractures: clinical outcome of surgical treatment. Clin Orthop Relat Res. 1999;(366):205-16. - Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993. *Definitive textbook on acetabular fractures*

Acetabular Fracture ORIF - Ilioinguinal Approach

Acetabular Fracture ORIF - Ilioinguinal Approach