Injury, Int. J. Care Injured 45 (2014) 995–999
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures Osama Farouk a,*, Ayman Kamal b, Mahmoud Badran a, Wael El-Adly a, Kamal El-Gafary a a b
Orthopaedic Department, Assiut University Hospitals, 71526 Assiut, Egypt Trauma Unit, Assiut University Hospitals, 71526 Assiut, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 1 February 2014
Introduction: Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation. Methods: This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients. Results: The average time to operation was 4 days. Average blood loss was 110 mL. Operative time averaged 95 min. Maximum fracture displacement averaged 10 mm preoperatively and 1.3 mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigne´ score, functional outcome was good to excellent in all patients. Discussion and conclusion: Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Acetabular fracture Minimal invasive Para-rectus approach Mini-open reduction Limited open reduction Fracture reduction Surgical approach Percutaneous fixation Lag screw
Introduction Management of acetabular fractures remains a challenge for orthopaedic surgeons [1]. The treatment options for acetabular fractures range from non-operative treatment for un-displaced fractures to operative fixation with extensile approaches [2,3]. As
* Corresponding author. Tel.: +20 12 22443531; fax: +20 88 2333327. E-mail addresses: [email protected], [email protected] (O. Farouk). http://dx.doi.org/10.1016/j.injury.2014.02.006 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
any articular fracture, the gold standard for the treatment of displaced acetabular fractures is the anatomical restoration of the articular surface and stable internal fixation [4]. Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss, infection and complications of extensive wounds. Closed reduction and percutaneous lag screw fixation under fluoroscopic guidance was described in minimally displaced acetabular fractures [5–9]. CT guided fixation of acetabular fractures with percutaneous placed lag screws has been used successfully. However, this technique is limited by fracture pattern, questionable sterility of
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O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
the CT suite, radiation exposure and prolonged surgical time [10]. Failure of closed reduction of the fracture is the main concern in minimal invasive fixation of acetabular fractures. The need for direct manipulation of the fracture to achieve anatomical reduction was the basis of this preliminary report of minimal invasive para-rectus approach for mini-open reduction of displaced acetabular fractures. This work has been approved by the ethical committee of our institution. Patients and methods In this preliminary study, we report the use of a mini-open anterior approach to manipulate and reduce acetabular fractures. From January 2009 to June 2012, 32 patients with simple transverse acetabular fractures (AO type 62B1) were treated with percutaneous columnar lag screw fixation. In all patients, closed reduction was done by fracture manipulation under fluoroscopy, longitudinal traction of the limb and side traction with a pin inserted in the trochanteric region, if needed. Failure of achieving adequate closed reduction of the fracture was an indication of using mini-incision to manipulate and reduce the fracture. We report the use of mini-para-rectus approach for limited open reduction in eight out of the thirty two patients, after failed closed reduction techniques. All were simple transverse anteriorly displaced acetabular fractures. Gap displacements were excluded from this study. Age ranged from 22 to 49 years (average 33 years). Seven patients were males and one was a female. Anteroposterior and Judet oblique views of the acetabulum together with multidetector CT scan were done for all patients. Timing of surgery ranged from 3 to 7 days after injury. Instruments and implants for possible classic open reduction using standard approaches, and plate fixation were standby in all cases. Surgical technique All patients were supine on a radiolucent fracture table. The surgeon stood on the contralateral side of the affected hip. An oblique mini-incision (3–4 cm) parallel to the fibres of external abdominal oblique muscle was made lateral to the lateral border of rectus abdominis muscle, just above and medial to the midinguinal point (Fig. 1A). The incision lies within Hesselbach’s triangle; bounded by the lateral border of rectus abdominis muscle medially, the inferior epigastric vessels laterally and the inguinal ligament inferiorly [11]. Pointing to the fracture under fluoroscopy served precise localisation of incision (Fig. 1B). The external abdominal oblique aponeurosis was incised along its fibres (Fig. 2). Identification and retraction of the ilioinguinal nerve was done to avoid its injury. The arched fibres of internal abdominal oblique muscle were displaced medially with spermatic cord in male patients (Fig. 3), or round ligament in the female patient, to expose the posterior wall of inguinal canal; the fascia transversalis. The external iliac vessels were palpated laterally to localise their position and prevent their injury. The inferior epigastric vessels were identified (Fig. 4). They were mobilised and protected in four patients and ligated in the other four. The fascia transversalis was incised to open the extraperitoneal space. Two Deaver retractors were used to protect and retract the external iliac vessels laterally and protect the urinary bladder and parietal peritoneum medially. The fracture site was palpated and a long blunt bone impactor was inserted (Fig. 5A), guided by finger palpation, to manipulate the fracture. Using this bone impactor, it was possible to manipulate the fracture through this portal from anterior and medial sides. This manipulation aimed to push the displaced anterior column posteriorly and to derotate and push the medial surface of the posterior column with the quadrilateral plate laterally to reduce
Fig. 1. (A) A diagram showing the mini-para-rectus approach as a small oblique incision (3–4 cm) lateral to the lateral border of the rectus abdominis muscle, and above and medial to the mid-inguinal point. (B) Pointing to the fracture site under fluoroscopy served precise localisation of skin incision. (ASIS: Anterior superior iliac spine, PT: Pubic tubercle).
Fig. 2. The external abdominal oblique aponeurosis was incised along its fibres.
O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
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Fig. 3. Care was taken to avoid injury of spermatic cord, it was protected and retracted medially with the arched fibres of internal abdominal oblique muscle.
Fig. 4. The inferior epigastric vessels were identified. They were mobilised and protected in four patients and ligated in the other four.
the fracture (Fig. 5B–D). Longitudinal and side traction of the hip joint helped to unload the fracture site and facilitate reduction. Fracture reduction was maintained by the bone impactor during screw fixation (Fig. 6A). Care was taken to prevent its slippage in order to avoid injury of the external iliac vessels anteriorly and the obturator nerve and vessels posteriorly. Assessment of fracture reduction was done by fluoroscopy and finger palpation to feel any step-off. Percutaneous standard anterior column lag screw fixation was done using 7.3 mm partially threaded cannulated screws in all cases [5,6]. The antegrade technique was used in six patients and the retrograde technique in two (Fig. 6B and C). Care was taken during screw insertion to avoid hip penetration or passing outside the anterior column corridor. The position of lag screw was fluoroscopically checked in anteroposterior, obturator oblique views of the hip joint and inlet view of the pelvis. Fracture stability after fixation was checked by fluoroscopy and finger palpation while stressing the fracture by manipulation of the hip joint. In two
patients, posterior column lag screw was added through a small iliac incision. At the end of surgery, anatomical closure of this small wound was done without the use of suction drain. Blood transfusion was not needed in any patient. Post-operative management Post-operative imaging for the assessment of fracture reduction was done for all patients. Touchdown weight bearing was permitted for the first 6 weeks after surgery. Then, partial weight bearing was permitted with progression to full weight bearing on complete fracture healing. Follow-up After hospital discharge, patients were observed periodically every 4 weeks for radiological and clinical assessment till healing
Fig. 5. Steps of fracture reduction. (A) A blunt ended long bone impactor was inserted through this small portal. (B–D) This long blunt bone impactor was used to manipulate the fracture through this portal from the anterior and medial sides. This manipulation aimed to push the anterior column posteriorly and to derotate and push the medial surface of the posterior column with the quadrilateral plate laterally to reduce the fracture.
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O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
Fracture reduction Maximum fracture displacement averaged 10 mm (range, 7– 15 mm) preoperatively and 1.3 mm (range, 0–3 mm) postoperatively. According to radiologic Matta score [3], anatomical reduction of the fracture (0–1 mm displacement) was achieved in five patients and imperfect (2–3 mm displacement) in three. Follow up averaged 27 months (range, 12–40 months). Wound healing occurred in all patients without complications as infection or dehiscence of the scar. Fracture union was achieved without secondary displacement in all patients. Average time to fracture healing and full weight bearing was 14 weeks. There was no screw misplacement or failure. There was no case of heterotopic ossification. Functional outcome: Fast functional recovery was observed in all patients. According to the modified Merle d’Aubigne´ score [12], functional outcome at the last follow up was good to excellent in all patients (average score 16.5). Discussion
Fig. 6. (A) Fracture reduction was maintained by the bone impactor during screw fixation. (B and C) Percutaneous anterior column lag screw fixation was done in all cases. The antegrade technique was used in six patients and the retrograde technique in two.
of the fracture, then every 12 weeks for further functional assessment. Results Operative data Average time to operation was 4 days (range, 3–7 days). Average blood loss was 110 mL (range, 60–170 mL). Operative time averaged 95 min (range, 75–125 min).
Fractures of the acetabulum are among the difficult injuries to treat by orthopaedic surgeons. Options for reduction and fixation of the fracture include extensive surgical approaches with the possibility of morbidities such as infection, blood loss and wound complications [1–3]. However, minimal invasive surgery has the advantage of low infection rate, minimal blood loss and fewer wound complications. The use of classic columnar percutaneous lag screws in fracture acetabulum requires adequate reduction of the fracture which could be achieved by closed methods or limited open reduction to help fracture reduction [5–9]. Methods of closed reduction include hip manipulation, longitudinal or side traction of the limb, and joystick technique by insertion of Steinmann pin in the iliac bone to manipulate the fracture [9]. Percutaneous columnar lag screw fixation is recommended in cases of nondisplaced fractures or in gap displacement of fracture, where approximation of the fragments can be achieved by using only lag screws. In order to apply this technique of fixation in displaced transverse acetabular fractures, two options are available; either the classic open approaches such as ilioinguinal approach [13,14] and modified Stoppa approach [15–18], or a minimal invasive approach to decrease the risk of complications associated with the classic open approaches. Starr et al. [7,8] described a novel minimal invasive reduction technique using a special pelvic reduction clamp. A ball spike was introduced through a stab wound just proximal and medial to the anterior superior iliac spine. With the hip flexed to relax the iliopsoas, the inner tine of the clamp was passed down the inner cortex of the iliac wing, over the brim of the true pelvis, and down along the medial surface of the quadrilateral plate, and then seated on the flat surface of the quadrilateral plate distal to the fracture. The outer tine of the clamp was passed through the abductor musculature and was seated in the supraacetabular region in the cephalad fragment of bone. Closing the clamp will reduce the fracture by moving the caudal fragment lateral. This technique opened the door for limited open reduction of acetabular fractures combined with percutaneous columnar lag screw fixation. In this study, a minimal invasive para-rectus approach was used for limited open reduction of displaced acetabular fractures with the following advantages: (1) It is possible to push the fracture not only from medial to lateral, but also from anterior to posterior, (2) the minimal invasive para-rectus approach also allows fracture palpation to check reduction and feel any step-off, (3) it also allows palpation of the fracture to check its stability after screw fixation, and (4) the introduction of a pushing instrument through a small direct anterior portal under vision and
O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
guided by finger palpation for fracture manipulation is safer than introducing a clamp blindly to the medial surface of the quadrilateral plate. The disadvantages of the minimal invasive para-rectus approach are (1) the need for an assistant holding the pushing instrument, (2) the difficulty of maintaining the pushing instrument to keep fracture reduction till percutaneous columnar screw insertion, and (3) the proximity of this portal to neurovascular and vital structures. For this reason, familiarity with the anterior acetabular approaches [13– 20] is essential before using the minimal invasive para-rectus approach to avoid complications which may occur through this small incision. These complications are the same as any other anterior approach, such as injury of external iliac vessels, obturator nerve and vessels, spermatic cord and ilioinguinal nerve. Another advantage of this small incision is the possible extension to a modified Stoppa approach [17] or a standard para-rectus approach [20] in case of failure of the limited open reduction. This minimal invasive para-rectus approach combined with percutaneous columnar lag screw fixation can be used in simple transverse anteriorly displaced acetabular fractures, but not in multi-fragmentary fractures or in severe fracture displacements. It can be used as well to fix the transverse component of T-shaped fractures with the same criteria. The technique cannot be used, when there is associated posterior wall fracture with posterior hip instability. This study is a preliminary report of the minimal invasive pararectus approach as an alternative for limited open reduction of acetabular fractures. However, there is still a need to include more patients, and possibly to run a comparative study of classic anterior approaches in order to draw sound conclusions regarding possible morbidity and functional outcome of both techniques.
Conclusion This preliminary report describes a mini-open reduction technique of anterior displaced transverse acetabular fractures with percutaneous lag screw fixation. This mini para-rectus approach has the advantages of minimal soft tissue dissection and minimal blood loss. It helps the inclusion of more acetabular fractures for percutaneous columnar screw fixation.
Conflict of interest All authors disclose no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.
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Acknowledgement The authors would like to acknowledge the sincere effort and assistance of Dr. Amr Atef, Assistant Lecturer, Orthopaedic Department, Assiut University Hospitals, in drawing the illustration of the approach (Fig. 1A). References [1] Matta JM, Merritt PO. Displaced acetabular fractures. Clin Orthop Relat Res 1988;230:83–97. [2] Matta JM, Mehne DK, Roffi R. Fractures of the acetabulum: early results of a prospective study. Clin Orthop Relat Res 1986;205:241–50. [3] 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. [4] Giannoudis PV, Tzioupis C, Papathanassopoulos A, Obakponovwe O, Roberts C. Articular step-off and risk of posttraumatic osteoarthritis: evidence today. Injury 2010;41:986–95. [5] Parker PJ, Copeland C. Percutaneous fluoroscopic screw fixation of acetabular fractures. Injury 1997;28:597–600. [6] Kahler DM. Percutaneous screw insertion for acetabular and sacral fractures. Tech Orthop 2003;18(2):174–83. [7] Starr AJ, Jones AL, Reinert CM, Borer DS. Preliminary results and complications following limited open reduction and percutaneous screw fixation of displaced fractures of the acetabulum. Injury 2001;32(Suppl 1):SA45–50. [8] Starr AJ, Borer DS, Reinert CM. Technical aspects of limited open reduction and percutaneous screw fixation of acetabular fractures. Oper Tech Orthop 2001;11(3):218–26. [9] Crowl AC, Kahler DM. Closed reduction and percutaneous fixation of anterior column acetabular fractures. Comput Aided Surg 2002;7(3):169–78. [10] Gay SB, Sistrom C, Wang GJ, Kahler DA, Boman T, McHugh N, et al. Percutaneous screw fixation of acetabular fractures with CT guidance: preliminary results of a new technique. AJR Am J Roentgenol 1992;158(4):819–22. [11] Bax T, Sheppard BC, Crass RA. Surgical options in the management of groin hernias. Am Fam Phys 1999;59(1):143–56. [12] D’Aubigne RM, PosteL M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg Am 1954;36(3):451–75. [13] Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. J Orthop Trauma 2006;20:S20–9. [14] Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62–76. [15] Hirvensalo E, Lindahl J, Bostman O. A new approach to the internal fixation of unstable pelvic fractures. Clin Orthop Relat Res 1993;297:28–32. [16] Hirvensalo E, Lindahl J, Kiljunen V. Modified and new approaches for pelvic and acetabular surgery. Injury 2007;38:431–41. [17] 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;305:112–23. [18] Ponsen KJ, Joosse P, Schigt A, Goslings JC, Luitse JS. Internal fracture fixation using the Stoppa approach in pelvic ring and acetabular fractures: technical aspects and operative results. J Trauma 2006;61:662–7. [19] Keel MJ, Ecker TM, Siebenrock KA, Bastian JD. Rationales for the Bernese approaches in acetabular surgery. Eur J Trauma Emerg Surg 2012;38(5):489–98. [20] Keel MJ, Ecker TM, Cullmann JL, Bergmann M, Bonel HM, Bu¨chler L, et al. The pararectus approach for anterior intrapelvic management of acetabular fractures: an anatomical study and clinical evaluation. J Bone Joint Surg Br 2012;94:405–11.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures Osama Farouk a,*, Ayman Kamal b, Mahmoud Badran a, Wael El-Adly a, Kamal El-Gafary a a b
Orthopaedic Department, Assiut University Hospitals, 71526 Assiut, Egypt Trauma Unit, Assiut University Hospitals, 71526 Assiut, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 1 February 2014
Introduction: Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss and complications of extensive approaches. Closed reduction and percutaneous lag screw fixation can be done in minimally displaced acetabular fractures. Open reduction is indicated, if there is wide displacement. In this study, we report the use of a mini-open anterior approach to manipulate and reduce anteriorly displaced transverse acetabular fractures combined with percutaneous lag screw fixation. Methods: This report included eight patients. All had anterior displaced simple transverse acetabular fractures. An oblique mini-incision was made above and medial to the mid-inguinal point, and lateral to the lateral border of rectus abdominis muscle. The external abdominal oblique aponeurosis was incised along its fibres. The arched fibres of internal abdominal oblique were displaced medially above the inguinal ligament to expose and incise the fascia transversalis. Care was taken to avoid injury of ilioinguinal nerve, inferior epigastric vessels, and spermatic cord. The external iliac vessels were palpated and protected laterally. A blunt long bone impactor was introduced through this small incision to manipulate and reduce the fracture under fluoroscopic control. Fluoroscopic guided percutaneous lag screw fixation was done in all patients. Results: The average time to operation was 4 days. Average blood loss was 110 mL. Operative time averaged 95 min. Maximum fracture displacement averaged 10 mm preoperatively and 1.3 mm postoperatively. According to Matta score, anatomical reduction of the fracture was achieved in five patients and imperfect in three. Follow up averaged 27 months. Wound healing occurred without complications and fracture union was achieved without secondary displacement in all patients. Average time to fracture healing was 14 weeks. According to the modified Merle d’Aubigne´ score, functional outcome was good to excellent in all patients. Discussion and conclusion: Limited open reduction can solve the problem of fracture reduction, which is the main concern in minimal invasive fixation of acetabular fractures. It may help the inclusion of displaced acetabular fractures for percutaneous lag screw fixation. This mini-para-rectus approach has the advantages of minimal soft tissue dissection with the possible anatomical reduction of simple transverse displaced acetabular fractures. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Acetabular fracture Minimal invasive Para-rectus approach Mini-open reduction Limited open reduction Fracture reduction Surgical approach Percutaneous fixation Lag screw
Introduction Management of acetabular fractures remains a challenge for orthopaedic surgeons [1]. The treatment options for acetabular fractures range from non-operative treatment for un-displaced fractures to operative fixation with extensile approaches [2,3]. As
* Corresponding author. Tel.: +20 12 22443531; fax: +20 88 2333327. E-mail addresses: [email protected], [email protected] (O. Farouk). http://dx.doi.org/10.1016/j.injury.2014.02.006 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
any articular fracture, the gold standard for the treatment of displaced acetabular fractures is the anatomical restoration of the articular surface and stable internal fixation [4]. Minimal invasive fixation has been reported as an alternative option for treatment of acetabular fractures to avoid blood loss, infection and complications of extensive wounds. Closed reduction and percutaneous lag screw fixation under fluoroscopic guidance was described in minimally displaced acetabular fractures [5–9]. CT guided fixation of acetabular fractures with percutaneous placed lag screws has been used successfully. However, this technique is limited by fracture pattern, questionable sterility of
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O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
the CT suite, radiation exposure and prolonged surgical time [10]. Failure of closed reduction of the fracture is the main concern in minimal invasive fixation of acetabular fractures. The need for direct manipulation of the fracture to achieve anatomical reduction was the basis of this preliminary report of minimal invasive para-rectus approach for mini-open reduction of displaced acetabular fractures. This work has been approved by the ethical committee of our institution. Patients and methods In this preliminary study, we report the use of a mini-open anterior approach to manipulate and reduce acetabular fractures. From January 2009 to June 2012, 32 patients with simple transverse acetabular fractures (AO type 62B1) were treated with percutaneous columnar lag screw fixation. In all patients, closed reduction was done by fracture manipulation under fluoroscopy, longitudinal traction of the limb and side traction with a pin inserted in the trochanteric region, if needed. Failure of achieving adequate closed reduction of the fracture was an indication of using mini-incision to manipulate and reduce the fracture. We report the use of mini-para-rectus approach for limited open reduction in eight out of the thirty two patients, after failed closed reduction techniques. All were simple transverse anteriorly displaced acetabular fractures. Gap displacements were excluded from this study. Age ranged from 22 to 49 years (average 33 years). Seven patients were males and one was a female. Anteroposterior and Judet oblique views of the acetabulum together with multidetector CT scan were done for all patients. Timing of surgery ranged from 3 to 7 days after injury. Instruments and implants for possible classic open reduction using standard approaches, and plate fixation were standby in all cases. Surgical technique All patients were supine on a radiolucent fracture table. The surgeon stood on the contralateral side of the affected hip. An oblique mini-incision (3–4 cm) parallel to the fibres of external abdominal oblique muscle was made lateral to the lateral border of rectus abdominis muscle, just above and medial to the midinguinal point (Fig. 1A). The incision lies within Hesselbach’s triangle; bounded by the lateral border of rectus abdominis muscle medially, the inferior epigastric vessels laterally and the inguinal ligament inferiorly [11]. Pointing to the fracture under fluoroscopy served precise localisation of incision (Fig. 1B). The external abdominal oblique aponeurosis was incised along its fibres (Fig. 2). Identification and retraction of the ilioinguinal nerve was done to avoid its injury. The arched fibres of internal abdominal oblique muscle were displaced medially with spermatic cord in male patients (Fig. 3), or round ligament in the female patient, to expose the posterior wall of inguinal canal; the fascia transversalis. The external iliac vessels were palpated laterally to localise their position and prevent their injury. The inferior epigastric vessels were identified (Fig. 4). They were mobilised and protected in four patients and ligated in the other four. The fascia transversalis was incised to open the extraperitoneal space. Two Deaver retractors were used to protect and retract the external iliac vessels laterally and protect the urinary bladder and parietal peritoneum medially. The fracture site was palpated and a long blunt bone impactor was inserted (Fig. 5A), guided by finger palpation, to manipulate the fracture. Using this bone impactor, it was possible to manipulate the fracture through this portal from anterior and medial sides. This manipulation aimed to push the displaced anterior column posteriorly and to derotate and push the medial surface of the posterior column with the quadrilateral plate laterally to reduce
Fig. 1. (A) A diagram showing the mini-para-rectus approach as a small oblique incision (3–4 cm) lateral to the lateral border of the rectus abdominis muscle, and above and medial to the mid-inguinal point. (B) Pointing to the fracture site under fluoroscopy served precise localisation of skin incision. (ASIS: Anterior superior iliac spine, PT: Pubic tubercle).
Fig. 2. The external abdominal oblique aponeurosis was incised along its fibres.
O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
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Fig. 3. Care was taken to avoid injury of spermatic cord, it was protected and retracted medially with the arched fibres of internal abdominal oblique muscle.
Fig. 4. The inferior epigastric vessels were identified. They were mobilised and protected in four patients and ligated in the other four.
the fracture (Fig. 5B–D). Longitudinal and side traction of the hip joint helped to unload the fracture site and facilitate reduction. Fracture reduction was maintained by the bone impactor during screw fixation (Fig. 6A). Care was taken to prevent its slippage in order to avoid injury of the external iliac vessels anteriorly and the obturator nerve and vessels posteriorly. Assessment of fracture reduction was done by fluoroscopy and finger palpation to feel any step-off. Percutaneous standard anterior column lag screw fixation was done using 7.3 mm partially threaded cannulated screws in all cases [5,6]. The antegrade technique was used in six patients and the retrograde technique in two (Fig. 6B and C). Care was taken during screw insertion to avoid hip penetration or passing outside the anterior column corridor. The position of lag screw was fluoroscopically checked in anteroposterior, obturator oblique views of the hip joint and inlet view of the pelvis. Fracture stability after fixation was checked by fluoroscopy and finger palpation while stressing the fracture by manipulation of the hip joint. In two
patients, posterior column lag screw was added through a small iliac incision. At the end of surgery, anatomical closure of this small wound was done without the use of suction drain. Blood transfusion was not needed in any patient. Post-operative management Post-operative imaging for the assessment of fracture reduction was done for all patients. Touchdown weight bearing was permitted for the first 6 weeks after surgery. Then, partial weight bearing was permitted with progression to full weight bearing on complete fracture healing. Follow-up After hospital discharge, patients were observed periodically every 4 weeks for radiological and clinical assessment till healing
Fig. 5. Steps of fracture reduction. (A) A blunt ended long bone impactor was inserted through this small portal. (B–D) This long blunt bone impactor was used to manipulate the fracture through this portal from the anterior and medial sides. This manipulation aimed to push the anterior column posteriorly and to derotate and push the medial surface of the posterior column with the quadrilateral plate laterally to reduce the fracture.
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O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
Fracture reduction Maximum fracture displacement averaged 10 mm (range, 7– 15 mm) preoperatively and 1.3 mm (range, 0–3 mm) postoperatively. According to radiologic Matta score [3], anatomical reduction of the fracture (0–1 mm displacement) was achieved in five patients and imperfect (2–3 mm displacement) in three. Follow up averaged 27 months (range, 12–40 months). Wound healing occurred in all patients without complications as infection or dehiscence of the scar. Fracture union was achieved without secondary displacement in all patients. Average time to fracture healing and full weight bearing was 14 weeks. There was no screw misplacement or failure. There was no case of heterotopic ossification. Functional outcome: Fast functional recovery was observed in all patients. According to the modified Merle d’Aubigne´ score [12], functional outcome at the last follow up was good to excellent in all patients (average score 16.5). Discussion
Fig. 6. (A) Fracture reduction was maintained by the bone impactor during screw fixation. (B and C) Percutaneous anterior column lag screw fixation was done in all cases. The antegrade technique was used in six patients and the retrograde technique in two.
of the fracture, then every 12 weeks for further functional assessment. Results Operative data Average time to operation was 4 days (range, 3–7 days). Average blood loss was 110 mL (range, 60–170 mL). Operative time averaged 95 min (range, 75–125 min).
Fractures of the acetabulum are among the difficult injuries to treat by orthopaedic surgeons. Options for reduction and fixation of the fracture include extensive surgical approaches with the possibility of morbidities such as infection, blood loss and wound complications [1–3]. However, minimal invasive surgery has the advantage of low infection rate, minimal blood loss and fewer wound complications. The use of classic columnar percutaneous lag screws in fracture acetabulum requires adequate reduction of the fracture which could be achieved by closed methods or limited open reduction to help fracture reduction [5–9]. Methods of closed reduction include hip manipulation, longitudinal or side traction of the limb, and joystick technique by insertion of Steinmann pin in the iliac bone to manipulate the fracture [9]. Percutaneous columnar lag screw fixation is recommended in cases of nondisplaced fractures or in gap displacement of fracture, where approximation of the fragments can be achieved by using only lag screws. In order to apply this technique of fixation in displaced transverse acetabular fractures, two options are available; either the classic open approaches such as ilioinguinal approach [13,14] and modified Stoppa approach [15–18], or a minimal invasive approach to decrease the risk of complications associated with the classic open approaches. Starr et al. [7,8] described a novel minimal invasive reduction technique using a special pelvic reduction clamp. A ball spike was introduced through a stab wound just proximal and medial to the anterior superior iliac spine. With the hip flexed to relax the iliopsoas, the inner tine of the clamp was passed down the inner cortex of the iliac wing, over the brim of the true pelvis, and down along the medial surface of the quadrilateral plate, and then seated on the flat surface of the quadrilateral plate distal to the fracture. The outer tine of the clamp was passed through the abductor musculature and was seated in the supraacetabular region in the cephalad fragment of bone. Closing the clamp will reduce the fracture by moving the caudal fragment lateral. This technique opened the door for limited open reduction of acetabular fractures combined with percutaneous columnar lag screw fixation. In this study, a minimal invasive para-rectus approach was used for limited open reduction of displaced acetabular fractures with the following advantages: (1) It is possible to push the fracture not only from medial to lateral, but also from anterior to posterior, (2) the minimal invasive para-rectus approach also allows fracture palpation to check reduction and feel any step-off, (3) it also allows palpation of the fracture to check its stability after screw fixation, and (4) the introduction of a pushing instrument through a small direct anterior portal under vision and
O. Farouk et al. / Injury, Int. J. Care Injured 45 (2014) 995–999
guided by finger palpation for fracture manipulation is safer than introducing a clamp blindly to the medial surface of the quadrilateral plate. The disadvantages of the minimal invasive para-rectus approach are (1) the need for an assistant holding the pushing instrument, (2) the difficulty of maintaining the pushing instrument to keep fracture reduction till percutaneous columnar screw insertion, and (3) the proximity of this portal to neurovascular and vital structures. For this reason, familiarity with the anterior acetabular approaches [13– 20] is essential before using the minimal invasive para-rectus approach to avoid complications which may occur through this small incision. These complications are the same as any other anterior approach, such as injury of external iliac vessels, obturator nerve and vessels, spermatic cord and ilioinguinal nerve. Another advantage of this small incision is the possible extension to a modified Stoppa approach [17] or a standard para-rectus approach [20] in case of failure of the limited open reduction. This minimal invasive para-rectus approach combined with percutaneous columnar lag screw fixation can be used in simple transverse anteriorly displaced acetabular fractures, but not in multi-fragmentary fractures or in severe fracture displacements. It can be used as well to fix the transverse component of T-shaped fractures with the same criteria. The technique cannot be used, when there is associated posterior wall fracture with posterior hip instability. This study is a preliminary report of the minimal invasive pararectus approach as an alternative for limited open reduction of acetabular fractures. However, there is still a need to include more patients, and possibly to run a comparative study of classic anterior approaches in order to draw sound conclusions regarding possible morbidity and functional outcome of both techniques.
Conclusion This preliminary report describes a mini-open reduction technique of anterior displaced transverse acetabular fractures with percutaneous lag screw fixation. This mini para-rectus approach has the advantages of minimal soft tissue dissection and minimal blood loss. It helps the inclusion of more acetabular fractures for percutaneous columnar screw fixation.
Conflict of interest All authors disclose no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.
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