import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Absolute Indications:** - Displaced anterior column fracture with greater than 2mm step or gap at articular surface - Roof arc angle less than 45 degrees on AP view (dome involvement) - Roof arc angle less than 25 degrees on oblique views - Incongruous hip joint on CT scan - Associated anterior wall component with displacement **Relative Indications:** - Marginal roof impaction on CT - Quadrilateral plate medialization threatening joint congruity - Young, active patient with anatomically reducible fracture - Polytrauma patient requiring early mobilization **Absolute Contraindications:** - Severe medical comorbidities precluding surgery - Active local or systemic infection - Severe soft tissue compromise (Morel-Lavallée lesion not debrided) **Relative Contraindications:** - Elderly patient with low-demand lifestyle and preserved joint congruity - Osteoporotic bone precluding stable fixation - Delayed presentation greater than 3 weeks (relative - may still attempt) - Associated femoral head fracture (Pipkin IV) may alter approach **Consider Non-operative:** - Roof arc angles greater than 45 degrees AP, greater than 25 degrees obliques - Less than 2mm displacement with congruent hip - Secondary congruence with stable hip **Essential Imaging:** - AP pelvis radiograph - Judet views (obturator and iliac obliques at 45 degrees) - CT with 2mm axial cuts and 3D reconstructions - Roof arc measurements on AP and oblique views **CT Assessment:** - Fracture pattern classification (Letournel) - Articular step/gap measurement - Marginal impaction presence and location - Quadrilateral plate displacement - Femoral head integrity (Pipkin lesion) **Approach Selection:** | Pattern | Preferred Approach | |---------|-------------------| | Anterior column only | Ilioinguinal or Stoppa | | Anterior + quadrilateral plate | Modified Stoppa preferred | | Anterior column + posterior hemitransverse | Ilioinguinal (extended) | | Both column (anterior predominant) | Ilioinguinal | **Pre-operative Optimization:** - Skeletal traction if delay greater than 24 hours - DVT prophylaxis from admission - Surgeon experience - consider referral for complex patterns - Blood products available (2-4 units pRBC) **Positioning:** - Radiolucent table (flat top) - Folded towel for ipsilateral buttock elevation - Foley catheter - Sequential compression devices **Surgical Instruments:** - Pelvic reduction set (ball spike, Farabeuf, pointed reduction forceps) - Hohmann and Army-Navy retractors - Malleable retractors for vessel protection - Vessel loops (for external iliacs) - Lighted suction retractor (optional but helpful) **Implants:** - 3.5mm reconstruction plates (8-10 hole) - 3.5mm and 4.5mm cortical screws (various lengths 24-60mm) - 2.0mm K-wires for provisional fixation - Quadrilateral plate/infrapectineal plate if medial wall involved **Equipment:** - C-arm fluoroscopy (confirm views before draping) - Cell saver if significant blood loss anticipated - Bipolar electrocautery **External iliac vessels**. Location: Middle window between iliacus and psoas - 10-15mm from pelvic brim **Femoral nerve**. Location: Lateral to external iliac artery in iliopsoas groove - retract laterally with iliopsoas **Lateral femoral cutaneous nerve**. Location: Exits pelvis 10-20mm medial to ASIS under inguinal ligament **Corona mortis**. Location: Superior pubic ramus, 50-80mm above symphysis - present in 30-50% - MUST ligate **Obturator nerve and vessels**. Location: Obturator foramen - protect with Hohmann retractor in medial window **Spermatic cord/round ligament**. Location: Medial window - retract medially with soft Penrose drain The ilioinguinal approach provides access through three anatomical windows created between neurovascular structures: **Lateral Window:** - Created by elevating external oblique aponeurosis from iliac crest - Subperiosteal elevation of iliacus from inner table - Exposes iliac wing from SI joint to ASIS - No major neurovascular structures at risk - Used for proximal fracture reduction and plate fixation **Middle Window (Critical):** - Between external iliac vessels (retracted medially) and iliopsoas/femoral nerve (retracted laterally) - This is the internervous interval - NO muscle splitting - Exposes pelvic brim from AIIS to iliopectineal eminence - Primary working window for anterior column plating - External iliac artery/vein 10-15mm from pelvic brim **Medial Window:** - Between iliopsoas (lateral) and spermatic cord/round ligament (medial) - Exposes quadrilateral plate and superior pubic ramus - Corona mortis must be identified and ligated - Obturator nerve/vessels protected with Hohmann in obturator foramen **Modified Stoppa Approach:** - Alternative for medial wall/quadrilateral plate access - Pfannenstiel incision 2-3cm above symphysis - Rectus muscles retracted laterally - Space of Retzius developed - Direct view of quadrilateral plate from medial side - Can be combined with lateral window of ilioinguinal **Patient Position**: Supine on radiolucent flat-top table with folded towel under ipsilateral buttock (15-20 degree rotation toward contralateral side improves pelvic brim access) **Surgical Approach**: Ilioinguinal three-window approach or modified Stoppa for quadrilateral plate-predominant fractures **Incision**: - Ilioinguinal: From ASIS along iliac crest 6-8cm, then curving anteromedially toward pubic symphysis (total 15-20cm) - Modified Stoppa: Pfannenstiel incision 2-3cm above symphysis (10-12cm) with optional lateral extension **Pre-incision Checklist:** - Confirm fluoroscopy views before draping (AP, inlet, outlet, both Judets) - Foley catheter in place - Antibiotics administered (cefazolin 2g IV within 60 minutes) - DVT prophylaxis ### Step 1: Position patient supine on radiolucent table Position patient supine on radiolucent table with folded towel under ipsilateral buttock to rotate pelvis 15-20 degrees toward contralateral side. This rotation improves access to pelvic brim and facilitates fluoroscopic imaging. Insert Foley catheter to decompress bladder and monitor urine output. Ensure C-arm can obtain AP, inlet (40 degrees caudal), outlet (40 degrees cranial), and obturator/iliac oblique (Judet) views before draping. **EXAM KEY**: Proper positioning critical - towel rotation improves pelvic brim visualization. Test all fluoroscopy views before prepping - repositioning mid-surgery is disruptive and wastes time. - Inadequate rotation limits pelvic brim access - Bladder injury if catheter not placed before surgery ### Step 2: Mark skin incision for ilioinguinal approach Mark skin incision beginning at ASIS, following iliac crest medially for 6-8cm, then curving anteriorly and inferiorly toward pubic symphysis. Total incision length 15-20cm depending on patient size and fracture extent. Identify ASIS, pubic tubercle, and inguinal ligament as landmarks. Mark lateral femoral cutaneous nerve exit point (10-20mm medial to ASIS). **EXAM KEY**: The three-window approach provides comprehensive anterior column access. Lateral window = iliac wing, Middle window = pelvic brim (main working window), Medial window = quadrilateral plate. - Incision too short limits exposure - LFCN injury if incision placed directly over nerve ### Step 3: Develop lateral window Incise skin and subcutaneous tissue to iliac crest. Identify and protect LFCN if encountered (10-20mm medial to ASIS). Elevate external oblique aponeurosis from iliac crest laterally. Continue subperiosteally elevating iliacus from inner table of ilium using Cobb elevator. Expose iliac wing from SI joint posteriorly to ASIS anteriorly. Place Hohmann retractors over crest to maintain exposure. **EXAM KEY**: Lateral window provides access to iliac wing fractures and allows placement of proximal screws. Purely subperiosteal dissection - no neurovascular structures at risk if staying on bone. - LFCN neuropraxia from retraction (15-30% incidence) - Superior gluteal artery if dissection extends too far posteriorly beyond SI joint ### Step 4: Develop middle window (critical) Identify the interval between external iliac vessels (located medially) and the iliopsoas muscle with femoral nerve (located laterally). This is the TRUE internervous plane of the ilioinguinal approach. Gently retract external iliac vessels medially with malleable retractor placed deep to vessel loops. Retract iliopsoas and femoral nerve laterally. Clear fracture hematoma. Expose pelvic brim from AIIS to iliopectineal eminence. **EXAM KEY**: Middle window is the PRIMARY working window where most anterior column plates are positioned. External iliac vessels are only 10-15mm from pelvic brim - GENTLE retraction only. Femoral nerve lies on iliopsoas muscle. - External iliac vessel injury (catastrophic bleeding) - Femoral nerve neuropraxia from excessive retraction - Lymphatic injury causing lymphocele ### Step 5: Develop medial window Identify interval between iliopsoas muscle (lateral) and spermatic cord in males/round ligament in females (medial). Retract spermatic cord/round ligament medially with soft Penrose drain. Elevate iliopsoas from pelvic brim. Identify and LIGATE corona mortis if present (30-50% of patients, located 50-80mm from symphysis). Place Hohmann retractor into obturator foramen to protect obturator neurovascular bundle. Expose quadrilateral plate and superior pubic ramus. **EXAM KEY**: Corona mortis MUST be actively sought and ligated - arterial and venous connections both possible. If injured, vessel retracts into pelvis causing difficult-to-control bleeding. Two clips on each side before cutting. - Corona mortis hemorrhage (potentially catastrophic) - Obturator nerve/vessel injury - Bladder injury with medial dissection ### Step 6: Modified Stoppa approach (alternative) For quadrilateral plate-predominant fractures: Make Pfannenstiel incision 2-3cm above pubic symphysis. Divide anterior rectus sheath transversely. Retract rectus muscles laterally to develop space of Retzius (retropubic space). Elevate peritoneum and bladder superiorly with ribbon retractor. Access quadrilateral plate directly from medial aspect. Provides superior visualization of medial wall compared to ilioinguinal medial window. **EXAM KEY**: Stoppa approach increasingly popular for anterior column with quadrilateral plate involvement. Can combine with ilioinguinal lateral window (first window) for extended access while avoiding middle and medial window neurovascular risks. - Bladder injury during space of Retzius development - External iliac vein injury at pelvic brim ### Step 7: Reduce fracture - work from proximal to distal Use ball spike pusher to manipulate iliac wing fragment. Establish stable reduction of proximal fragment to stable iliac wing first. Then reduce pelvic brim fracture working distally using pointed reduction forceps. Reduce articular surface to less than 1mm step/gap. Use Farabeuf clamps or large pelvic reduction clamps across brim to maintain reduction. Verify reduction visually through windows and with fluoroscopy on all views. **EXAM KEY**: Reduction sequence critical - establish stable proximal reference (iliac wing) then work distally to pubic ramus. Pelvic brim reduction determines articular congruity. Anatomic brim = anatomic joint. - Inadequate reduction leads to poor outcome - Iatrogenic fracture comminution with forceful reduction - Clamp injury to vessels if placed without direct visualization ### Step 8: Provisionally fix with K-wires or lag screws Once anatomic reduction achieved, hold with 2.0mm K-wires across fracture. Consider provisional lag screws (3.5mm cortical) if fracture geometry allows. Confirm reduction on AP and BOTH Judet views before definitive plating. Assess articular reduction through windows - should be less than 1mm step/gap. Check roof arc measurements on fluoroscopy confirm dome not involved. **EXAM KEY**: Do NOT proceed to plating without confirming anatomic reduction on all views (AP + both Judets). Once plate applied and screws tightened, reduction cannot be easily adjusted. K-wires allow revision if needed. - Accepting malreduction (leads to arthritis) - Joint penetration with provisional K-wires ### Step 9: Apply reconstruction plate along pelvic brim Contour 3.5mm pelvic reconstruction plate (8-10 holes) to match pelvic brim curvature precisely. Position plate from iliac wing (proximal) across anterior column to superior pubic ramus (distal). Place minimum 3 screws in iliac wing segment, 3-4 screws across pelvic brim, 2-3 screws in pubic ramus. All screws directed away from hip joint. Confirm no articular penetration on fluoroscopy. **EXAM KEY**: Plate MUST be precisely contoured to pelvic brim anatomy - poorly contoured plate displaces fracture when screws tightened. Use plate benders progressively. Test fit before drilling. - Loss of reduction from poor plate contouring - Intra-articular screw penetration - Neurovascular injury from long screws ### Step 10: Add lag screws where fracture geometry allows Simple fracture patterns may allow independent lag screw fixation through or outside plate. Use 3.5mm or 4.5mm cortical screws in lag fashion. Ensure compression perpendicular to fracture plane. Measure carefully and confirm no joint penetration on all fluoroscopy views including Judets. **EXAM KEY**: Lag screws provide interfragmentary compression - biomechanically superior to plate-only neutralization when fracture geometry favorable. Check screw length on AP AND both Judet views. - Intra-articular screw (even 1-2mm penetration damages cartilage) - Over-compression causing comminution ### Step 11: Address quadrilateral plate if medially displaced Quadrilateral plate medialization common with anterior column fractures, causing loss of hip joint congruity (femoral head subluxation). If displaced: apply buttress plate from medial approach (Stoppa or ilioinguinal medial window). Infrapectineal plate or curved quadrilateral buttress plate positioned to prevent medial subluxation. Spring plate technique for comminuted medial wall. **EXAM KEY**: Quadrilateral plate medialization NOT addressed by anterior column plate alone - requires specific medial buttress fixation. Femoral head follows medial wall - if wall goes medial, head subluxes medially = poor outcome. - Missing medial wall displacement (subluxation postop) - Obturator nerve injury during infrapectineal plating ### Step 12: Obtain final fluoroscopic images Obtain complete fluoroscopic series: AP pelvis, inlet view (40 degrees caudal tilt), outlet view (40 degrees cranial tilt), obturator oblique (45 degrees toward affected side), iliac oblique (45 degrees away). Assess articular reduction (less than 1mm step/gap), implant position, screw lengths, joint penetration. Rotate C-arm through arc to dynamically assess joint space for screw penetration. **EXAM KEY**: Judet views essential - Obturator oblique shows anterior column and posterior wall (look INTO obturator foramen). Iliac oblique shows posterior column and anterior wall. Dynamic arc through joint catches occult penetration. - Missing intra-articular hardware - Accepting malreduction visible on oblique views ### Step 13: Irrigate and achieve hemostasis Copious irrigation with 3-6 liters warm normal saline. Achieve meticulous hemostasis with bipolar electrocautery - avoid monopolar near vessels/nerves. Place closed suction drains (14Fr flat Blake drain) in each window due to large dead space. Bring drains out through separate stab incisions lateral to main wound. **EXAM KEY**: Hematoma formation increases infection risk and delays wound healing. Drains reduce hematoma - remove when output less than 30-50mL per 24 hours (typically 24-48 hours postoperatively). - Electrocautery injury to vessels/nerves - Hematoma if inadequate hemostasis ### Step 14: Close in layers Repair external oblique aponeurosis to iliac crest periosteum with 0 Vicryl interrupted sutures. Close inguinal ligament repair/transversalis fascia. Close Scarpa's fascia with 2-0 Vicryl. Skin closure with staples or 3-0 Monocryl subcuticular. Apply sterile adhesive dressing. Consider abdominal binder for patient comfort. **EXAM KEY**: Meticulous fascial closure reduces inguinal hernia risk (2-5% with ilioinguinal approach). External oblique must be securely reattached to crest. Hernia more common if fascial closure inadequate. - Inguinal hernia from inadequate fascial repair - Wound dehiscence ### Step 15: Postoperative protocol Touch weight bearing (10kg foot-flat) for 6 weeks, then progressive weight bearing to full by 12 weeks. Hip ROM exercises begin postoperative day 1-2 (avoid active hip flexion against resistance for 6 weeks to protect iliopsoas repair). VTE prophylaxis with LMWH (enoxaparin 40mg daily) or DOAC (rivaroxaban 10mg daily) for minimum 35 days. Follow-up radiographs at 2 weeks (wound check), 6 weeks, 12 weeks, 6 months, 12 months. CT at 6-12 weeks if reduction quality uncertain. **EXAM KEY**: Protected weight bearing allows fracture healing while preventing fixation failure. Early ROM prevents stiffness. VTE prophylaxis MANDATORY - pelvic trauma with immobilization = very high risk for DVT/PE. - VTE without adequate prophylaxis - Fixation failure with premature weight bearing - Stiffness without early ROM 1. Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Springer-Verlag; 1993. 2. 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):1632-1645. 3. Cole JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res. 1994;(305):112-123. 4. Sagi HC, et al. Comparative radiographic and clinical outcome of two-column acetabular fractures. J Orthop Trauma. 2011;25(12):745-750. 5. Okcu G, Erkan S. The corona mortis: a clinical anatomical study and its surgical importance. Orthopedics. 2004;27(10):1061-1064. 6. Rubin GD, et al. Corona mortis: incidence and location. Clin Anat. 2005;18(2):108-114. 7. Hirvensalo E, Lindahl J, Böstman O. A new approach to the internal fixation of unstable pelvic fractures. Clin Orthop Relat Res. 1993;(297):28-32. 8. Mears DC. Surgical treatment of acetabular fractures in elderly patients with osteoporotic bone. J Am Acad Orthop Surg. 1999;7(2):128-141. 9. Giannoudis PV, et al. Operative treatment of displaced fractures of the acetabulum. A meta-analysis. J Bone Joint Surg Br. 2005;87(1):2-9. 10. Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. 3rd ed. Lippincott Williams & Wilkins; 2003.

Anterior Column Acetabular Fracture ORIF

Anterior Column Acetabular Fracture ORIF