Acetabular Reconstruction Fixation Methods in Associated Fracture Patterns

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Bruce H. Ziran

Department of Orthopaedic Trauma, St. Elizabeth Health Center and Department of Orthopaedic Surgery, Northeastern Ohio Universities College of Medicine, Youngstown, Ohio, U.S.A.

Daniel R. Schlatterer and Robert M. Harris

Department of Orthopaedic Trauma, Atlanta Medical Center, Atlanta, Georgia, U.S.A.

INTRODUCTION TO ASSOCIATED FRACTURE PATTERNS OF THE ACETABULUM

The associated patterns of acetabular fractures were described by Letournel and are described elsewhere in this text. They tend to be more severe in nature and require very thorough planning to ensure appropriate access. In all but the posterior column/posterior wall fracture pattern, both anterior and posterior aspects of the acetabulum are involved and need to be considered when planning. While the definition of each fracture pattern is well described, there will be frequent situations where the fracture pattern is transitional. It is important to try to understand the essential features and behavior of each pattern, the so called "personality" of the fracture, so that an appropriate tactic can be performed. An example of fracture personality is the presence of intra-articular foreign bodies. A fracture pattern amenable to an anterior approach may not permit adequate access to the joint to remove joint debris. This "personality" of the fracture may mandate a sequential or extensile approach as opposed to a standard approach. Osteopenia and concomitant pelvic disruption are further characteristics of the fracture personality. These two issues are addressed in this chapter. Finally, many of the concepts of the previous chapter are applicable in this chapter and appropriately referenced.

POSTERIOR COLUMN AND POSTERIOR WALL ACETABULAR FRACTURES

This pattern is relatively rare. Often a posterior wall fracture will be found to have a minimally displaced or occult column fracture (or transverse fracture). These fractures behave and are better classified as posterior wall fractures, as recommended by Letournel, since the essential lesion is the posterior wall. True posterior column fractures have definite displacement. Nonetheless, the treatment paradigm is similar and will utilize a posterior approach. The options of positioning and traction for the posterior approach have been described in the preceding chapter. The preferred method of one author (B.Z.) is with a lateral position and the use of skeletal traction, both longitudinal and lateral, as previously described in the section on "Simple Fracture Patterns" (Chapter 11, Fig. 2). The other authors (D.S., R.H.) also prefer a lateral position, but uses a five- to six-inch stack of folded towels tucked deep into the groin between the legs. Gentle downward pressure at the flexed knee reduces the weight of the femoral head on the acetabulum. The stack of towels, combined with longitudinal and lateral traction via the trochanteric Schantz pin, results in very good joint exposure for posterior fractures (Chapter 11, Fig. 3). Reduction techniques for an associated posterior wall and column fracture will be similar to a simple posterior column and a simple posterior wall fracture. For this associated pattern, it is most logical to begin with column fixation first, followed by the posterior wall. This sequence (column first then wall) permits restoration of a "foundation" upon which to restore the posterior wall. With the column reduced and the wall not reduced, an opportunity exists to widely inspect the reduced column through the joint surface. The position of the column can be modified if need be, and then one can proceed with the posterior wall. Keep in mind that operative management of displaced posterior column fractures have a higher risk of injury to the sciatic nerve, especially in patterns involving the sciatic notch (Fig. 1). In all cases, a good documentation of any

Figure 1 Intraoperative view of impingement of sciatic nerve by posterior fragment. The posterior column fracture is close to the sciatic notch and may damage the sciatic nerve, especially with an associated posterior wall fracture.

dysfunction prior to surgery is essential to avoid any misunderstandings if postoperative dysfunction is encountered. For severely displaced fractures and in cases of subtle deficits, consideration should be given to nerve monitoring, mostly to document a deficit prior to surgical intervention, but also to ensure that surgical tactic does not worsen the problem. Some centers utilize intraoperative neuro-monitoring, but this has not been routine in our practices. Equally important during operative management of fracture patterns involving the sciatic notch are the superior gluteal vessels and nerve. Overzea-lous retraction can injure these structures. Hemostasis can be very challenging as the vessels are prone to retract into the pelvis. Debriding intervening fracture hematoma and periosteum at the notch level is also very dangerous. Care should be taken to visualize these neurovascular structures as they exit the notch and come "around the corner." Judicious use of Cobb elevators and curettes is imperative.

Depending on the level of the posterior column fracture and the body habitus of the patient, the exposure may require more cephalad exposure, in which case, implementing the trochanteric slide, or flip osteotomy is recommended. The reduction of the posterior column needs to be ensured and can be determined by viewing and palpating the posterior cortical borders and by palpation through the greater and lesser sciatic notches into the area of the quadrilateral surface. In some cases, provisional fixation can be obtained via lag screws, especially when there is an extensive posterior wall fracture, wherein use of a plate for the column might interfere with reduction of the wall segment. In these cases, logical surgical tactic to sequence the reduction steps is critical to ensure an anatomic reduction. An example may be a situation where a single lag screw cannot be used for temporary stabilization. In this situation, use of reduction clamps that engage screws placed on each side of the fracture (Farabeuf or pelvic reduction) is needed (Fig. 2). In these cases, reduction is achieved, but the clamps can obstruct free access to the posterior wall elements, and in cases where there is marginal impaction the reduction and fixation tactic may be difficult. In such cases of potential clamp obstruction, treatment of the wall first and then addressing the posterior column second is sometimes the easier sequence to follow. Kirshner wires can then provide provisional fixation after finalizing the posterior wall reduction. The final step of stabilizing both with a spanning plate may be more elegant than struggling with exposure and access. To assist with the rotation and reduction of the column fragment, a Schantz pin can be placed into the ischial tuberosity and used as a "joystick" to effect a reduction (Chapter 11, Fig. 20). Alternatively, use of angled pelvic reduction clamps placed through the sciatic notch may achieve and maintain reduction of the more anterior parts of the column. The advantage of pelvic reduction clamp or Farabeufs that engage separately placed screws is that they can help with translational maneuvers and then compress the bone directly. The second author, D.S., frequently implements a flattened three hole 1/3 tubular plate (or 3.5 mm reconstruction plate) for the posterior column component. The advantages of this method are many and include compression across the fracture. In addition, pelvic clamps and screws are not typically necessary after fixation with the 1/3 tubular plate. Partial fixation with a thin plate permits clamp removal, which in turn improves access and options to overlay a longer 3.5 mm reconstruction plate for additional fixation. Care must be taken when using this method that the corners of the plate do not overhang either sciatic notch. This runs the risk of irritating the neurovascular structures and the short external rotator tendons. The plate

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Figure 2 (A) Demonstration of reduction clamps around screws to help reduce column fragments. (B) Patient in prone position with fracture of posterior column. (C) Intraoperative view of Farabeuf clamps and reduction. Note that space is tight. (Continued)

Figure 2 (Continued) (D) Alternative method of using same post screws but now placing a plate in position and using a Verbrugge clamp to effect a reduction with plate in place (images courtesy of Rodrigo Pesantez, MD). (E) Alternate method using tenaculums. (F) Bone model showing temporary screw and a posterior column plate over an extensive posterior wall fracture. (Continued )

Figure 2 (Continued) (D) Alternative method of using same post screws but now placing a plate in position and using a Verbrugge clamp to effect a reduction with plate in place (images courtesy of Rodrigo Pesantez, MD). (E) Alternate method using tenaculums. (F) Bone model showing temporary screw and a posterior column plate over an extensive posterior wall fracture. (Continued )

Figure 2 (Continued) A buttress plate would be required to adequately stabilize the posterior wall component. In some cases, the screws can be placed surrounding the posterior wall segment to allow space for the posterior column plate (G).

corners can be cut and then smoothed with the knurled portion of a "quick connect" or other power drill adapter with a knurled portion. Simply turn the drill on and use the knurled portion as a grinder.

As in most situations, two good screws (in the plate) on both sides of the fracture are generally enough to ensure fixation. In cases where the fracture of the posterior column extends cephalad to the hip joint or into the angle of the sciatic notch, fixation of the column to the posterior ilium may be performed with lag screws. Depending on the quality or amount of bone available for fixation, one should consider use of two screws with or without washers. The plate used for the posterior wall fracture will supplement these screws, as the screws are generally not sufficient by themselves. In cases where the vertical component of the posterior column fracture enters the obturator foramen and through the ischial ramus, reduction of the cephalad portion of the column may not be sufficient to ensure a congruent joint reduction, and the inferior portion needs to be evaluated. In these cases, pelvic reduction forceps through the sciatic notch may help pull the column into place. If there is a tendency towards rotation, slight overrotation of the plate may assist in maintaining the reduction.

Once the posterior column is satisfactorily secured, the posterior wall can be addressed as described in Chapter 11 in the section on "Posterior Wall Fractures." An advantage of addressing the column fracture first is that it allows easier visualization of the articular surface to ensure a satisfactory reduction of the articular surface. This can be done with in line traction. In such cases, however, care should be taken if the hip is subluxed with traction to make sure the posterior column fracture and fixation is not disrupted. If there is comminution of the posterior wall that requires a "spring" plate, anticipation of this technique should be considered during fixation of the column so that the column fixation does not interfere with the placement of the spring plate. Ideally, the spring plates are placed first and the reconstruction plate overlaps the spring plates.

There are cases where the posterior wall fracture extends very posteriorly. As the posterior wall fracture line approaches the sciatic notches, less posterior column is available for fixation without interfering with reduction of the posterior wall. In these extreme cases, the fracture may appear to be nearly segmental, where the posterior wall exits via part of the column. These fractures can be very difficult to reduce and fix because of the lack of access to posterior column surface. In these cases, lag screw fixation, either from column to ilium or vice versa, should be considered for fixation of the posterior column. Alternatively, if the posterior wall is one large piece, the order of fixation may be reversed, such that the wall is fixed provisionally to the column, thereby simplifying the fracture, and then reducing and fixing the column. Another upside of this fracture pattern is that the wall fragment is large and amendable to lag screws and/or buttress plating. Finally, another technique to consider in such cases is to (i) ensure that the wall can be reduced, (ii) reduce and plate the posterior column, and then (iii) remove a small portion of the most posterior extent of the wall fragment (which is not articular or structural) to allow the wall to seat along side the column plate. A second reconstruction plate can then be placed (adjacent to the first posterior column recon plate) over the posterior wall for buttressing purposes (Fig. 3).

Figure 3 (A) A posterior column and wall fracture showing the extent of posterior wall injury and the little remaining space available in the posterior column for fixation. In this case, the column was plated first, and then the posterior cortex of the posterior wall was trimmed to allow reduction of the wall next to the plate. (B) A fragment of bone from the same fracture impinging on sciatic nerve and incarcerated in the greater sciatic notch.

Figure 3 (A) A posterior column and wall fracture showing the extent of posterior wall injury and the little remaining space available in the posterior column for fixation. In this case, the column was plated first, and then the posterior cortex of the posterior wall was trimmed to allow reduction of the wall next to the plate. (B) A fragment of bone from the same fracture impinging on sciatic nerve and incarcerated in the greater sciatic notch.

TRANSVERSE ACETABULAR POSTERIOR WALL FRACTURES

The surgical approach for an isolated transverse fracture varies. High-fracture patterns can be approached anteriorly and a low-fracture pattern can be approached posteriorly. The preoperative planning to a transverse posterior wall fracture begins with determining if the posterior wall is unstable and operative. If so, then some form of a posterior approach is mandatory. The decision that follows is whether a simple approach, an extensile approach, or a combined posterior and anterior approach is indicated. In Letournel's original text, he occasionally described the use of an extended iliofemoral approach for transtectal transverse fractures with anterior displacement and an associated posterior wall fracture. However, as the use of this approach diminishes, some advocate a sequential approach if needed, and few advocate simultaneous approaches. Frequently, the transverse fracture is most displaced posteriorly and can be hinged back, as described for the simple transverse pattern. The reduction maneuvers and techniques used for this component of the fracture are similar to those described in the individual sections of the previous chapter dedicated to posterior column and transverse fractures. Again we use the lateral position for this fracture.

In these cases, it is important to digitally palpate the pelvic brim via the sciatic notch to ensure that the anterior portions of the fracture are sufficiently reduced. Plate contouring is a subtle but important point in posterior plate fixation of a transverse fracture. An under-contoured plate can result in anterior fracture line gapping. Over-contouring the reconstruction plate used for the transverse fracture will minimize anterior fracture line gapping. This point is nicely demonstrated on saw-bone models of transverse fractures (Chapter 11, Fig. 20). Use of the Schantz pin inserted into the ischial tubersosity and angled pelvic reduction clamps through the notch will assist in the reduction of this fracture. Since the posterior wall is fractured, visualization of the reduction via inspection of the joint is facilitated, and acceptable reduction ensured. As in posterior column/posterior wall fractures, the posterior fixation should be addressed elegantly. The column fixation can be with screws across that angle of the sciatic notch or a slightly over-bent and twisted plate to assist with the anterior portion of the reduction. If it is determined that the anterior segment of the fracture cannot be adequately reduced, or stabilized, then we recommend addressing the anterior component with a separate (sequential) surgical approach. In these cases, the fixation of the posterior elements must be performed in such a manner that they do not interfere with the anterior elements. As such, keeping screws more posterior and using a more flexible construct (longer plate, wider separation of screws) will facilitate the anterior reduction. This may be one indication for locking plates with locking screws short of the anterior column.

In transtectal transverse fracture patterns, we have not reflexively opted for an extended iliofemoral approach. Instead, we used the posterior approach and ensured that the fracture line is accurately reduced via direct visualization. In some cases, the trochanteric flip osteotomy was used to gain access to the superior/anterior portions of the acetabulum, as well as allow access as far anterior as the anterior inferior iliac spine. We feel that this approach, while a more extensile posterior approach, is preferable to an extended iliofemoral. Also, it allows easier placement of the anterior column screw, which can be fairly difficult to place. This screw, as described previously, begins in the superior aspect of the acetabulum and courses along the anterior column and provides sufficient "intramedullary" fixation of the anterior column (Chapter 11, Fig. 21). It can be placed in a retrograde fashion as well but would require a separate surgical prep and drape. It should be noted that placement of this particular screw in the lateral position without an extensile approach is fairly difficult. Most surgeons prefer to place this screw supine, prone, or with use of an extensile approach. However, good knowledge of the pelvic anatomy and appropriate visualization with an image intensifier will facilitate this screw in the lateral position.

The posterior wall fracture will be addressed as described in the previous section on "Posterior Column and Posterior Wall Acetabular Fractures." The elements of the wall fracture will be varied, and fixation will depend on the morphology and location of the fracture. In superior fracture patterns, the quality of reduction is most important since this area is the primary load-bearing section of the acetabulum. Again, a trochanteric flip of greater trochanter osteotomy can be utilized to gain access for visualization and stabilization. In the more inferior fracture patterns, this technique is obviated and more conventional methods can be used (Fig. 4).

T-SHAPED ACETABULAR FRACTURES

The T-shaped fracture can be one of the most challenging and difficult of the acet-abular fractures to treat. It is also a fracture that will incur numerous varying opinions on surgical tactic, but most agree that an accurate reduction is the key to success. The radiographic features that distinguish the T-fracture from its analogs [a low anterior column, posterior hemitransverse, a transverse with pubic fracture, and posterior column-anterior hemitransverse (which Letournel lumped with T-shaped)] have been discussed elsewhere but include a fracture that involves or exits via the ischial ramus. The surgical tactic for T-fractures begins with identifying the essential pathology to be addressed. The transverse component and the stem, along with the presence or absence of an operative posterior wall and the nature of the displacements, will guide the surgeon toward the optimal surgical approach. The axial CT scan can facilitate examination of the posterior wall and overall fracture pattern. Involvement of the posterior wall can rule in or rule out the need for a posterior approach. For fractures with operative posterior wall involvement, the decision is then either sequential approaches or an extensile approach with the possibility of a trochanteric osteotomy. Unlike a transverse fracture or a both-column fracture, in T-shaped fractures the femoral head is usually completely separated from the columnar segments, either by dislocation or protrusion into the pelvis (Fig. 5). Also, there is usually loss of the ligamentous attachments that facilitate reduction of each segment using ligamentotaxis. This feature makes choosing the correct surgical approach and having tools available to facilitate reduction very important.

In general, the segment with the most displacement or location of the transverse component will dictate the preferred approach. If the posterior approach is chosen, the posterior fragment can be reduced and stabilized to the posterior iliac segment at the sciatic angle. Use of a few screws will allow the removal of the reduction clamps. It is important to verify that the posterior segment is reduced, not just along the posterior cortical border, but also along the quadrilateral surface and up to the pelvic brim. This

Figure 4 (A) Pre- and (B) postoperative radiographs of a transverse posterior wall fracture. Note the individual screws placed behind the acetabulum that capture some of the anterior transverse component. (C) Schematic of screw trajectory. Source: From Ref. 2.
Posterior Wall Fracture
Figure 5 (A) T-fracture with posterior dislocation and posterior wall fracture. (B) T-fracture with central protrusion and impaction. The T-fracture can be one of the most difficult acetabular injuries to treat and has a relatively poor prognosis.

is best done with digital palpation. Also, it is important to ensure that the provisional fixation of this segment does not exit the posterior segment and interfere with reduction of the anterior segment. Again, as mentioned earlier in this chapter, this may be an indication for short locking screws in locking plates.

To reduce the anterior segment, angled pelvic clamps (also called the Matta clamps) are carefully placed through the notch to reduce the anterior segment. It is important to place one tine on the anterior fragment and the other on the intact iliac bone. If excessive force is placed on the provisionally fixed posterior segment, it can cause displacement or, worse, further comminution. Once reduced, there are several options for fixation. For the anterior segment, screws placed along the posterior border of the posterior segment can course behind the acetabulum and, depending on the location of the stem of the T, may secure the anterior fragment. Alternatively, these screws may be placed through a plate as well (Fig. 6). In many circumstances, the anterior column screw is desirable because of the stability afforded by its intramedullary position. This screw can be placed percutaneously or with some added dissection through the exposed but remaining transmuscular. It is usually not necessary to detach any of the abductor mechanism for this screw. The

Figure 6 (A-C) Radiographs and CT scan of a transischial T-fracture dislocation with posterior wall fracture. (Continued)

Anterior Column Screw Ray
Figure 6 (Continued) In this case, screws through the plate provided fixation to the anterior column (D).

cutaneous entry point for this percutaneous screw is a position midway between the greater trochanter and iliac crest. The osseous insertion site is 4 to 6 cm superior to the acetabular roof. Fluoroscopic guidance is imperative with this screw to ensure that it does not enter the joint or injure the anterior vascular structures. Please see Chapter 6 on percutaneous fracture management for optimal fluoroscopic imaging. Regarding definitive fixation, a plate traversing the posterior segment will generally be sufficient, along with any supplemental screws that have been placed (Fig. 7).

In some cases, the posterior fragment may not be the first to be reduced and stabilized, and it can be pulled out a bit to visualize the anterior reduction directly. If there is a posterior wall fracture, it will need to be addressed as a separate entity. Because the plating of the T-fracture will often have the plate in a more posterior position (to allow placement of the screws into the anterior fragment), this plate may not sufficiently cover the posterior wall fragment. In this case, the use of a spring plate or two may provide the stability needed. If after all maneuvers the anterior fragment is either insufficiently reduced or stabilized (drifts after fixation, indicating insufficient fixation), then the patient should be considered for a sequential anterior approach that addresses the anterior problem directly. Prior to doing so, the surgeon should ensure that none of the posterior fixation interferes with reduction of the anterior fragment (Fig. 8). This may require removal of several posterior screws and further destabiliza-tion of the overall fracture. However, since the anterior fragment will be addressed definitively with an anterior approach, it is of little consequence to remove several posterior screws.

Alternatively, a transverse fracture can be approached anteriorly first followed by a posterior approach. The second author, D.S., has found utility in placement of a percutaneous anterior column screw with the patient supine. The patient is then reposi-tioned and redraped for a more formal posterior approach. The supine position (or prone) is ideal for fluoroscopic imaging of the anterior column screw. In acute fractures (prior to organization of the fracture hematoma), closed reduction of the anterior portion of the fracture is often possible with manipulation of the ipsilateral lower extremity. The added time for repositioning, prepping, and draping is about 20 minutes and this is more than offset by the fluoroscopic imaging permitted. Furthermore, through the

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Anterior Posterior Acetabular Screw
Figure 7 (A) The trajectory of the anterior column screw in a pelvis model. This screw should be placed with fluoroscopic guidance as described in a previous chapter. (Continued)
Tha Fluoroscopic Micro Separation

Figure 7 (Continued) (B-D) A severe transverse-posterior wall fracture with an extended tran-sischial stem. While technically not a T, it is probably a transitional variant, and demonstrates the use of a plate for posterior fixation and the anterior column screw for the anterior segment of the transverse acetabular fracture.

Figure 7 (Continued) (B-D) A severe transverse-posterior wall fracture with an extended tran-sischial stem. While technically not a T, it is probably a transitional variant, and demonstrates the use of a plate for posterior fixation and the anterior column screw for the anterior segment of the transverse acetabular fracture.

Figure 8 (A, B) A T-fracture that required a sequential anterior then posterior approach. This is the same fracture depicted in Figure 5B. The fracture had anterior impaction of the dome as well the femoral head. (Continued)

Figure 8 (Continued) (C, D) While such fractures frequently are approached from the posterior aspect first, this fracture was treated with an anterior approach first, with distraction of the anterior limb and treatment of the impacted dome (elevation and grafting), followed by subarticular screw stabilization (gray arrow), and then by an anterior plate. Note multiple unfilled screw holes in the middle of the anterior plate. The anterior screw placement is such that it does not interfere with the second stage, which is posterior column fixation using a standard posterior plate.

Figure 8 (Continued) (C, D) While such fractures frequently are approached from the posterior aspect first, this fracture was treated with an anterior approach first, with distraction of the anterior limb and treatment of the impacted dome (elevation and grafting), followed by subarticular screw stabilization (gray arrow), and then by an anterior plate. Note multiple unfilled screw holes in the middle of the anterior plate. The anterior screw placement is such that it does not interfere with the second stage, which is posterior column fixation using a standard posterior plate.

posterior approach, the fracture reduction can be continued even with the anterior column screw in place. The guidewire is passed back through the cannulated screw and then the screw is backed out proximal to the fracture line. The anterior screw does not need to be entirely removed. With just the guidewire past the fracture line, there is enough wiggle room to improve the overall reduction. This facilitates reduction of the transverse fracture from the posterior aspect without losing the direction for the anterior column screw. Once the reduction is satisfactory, the cannulated screw is readvanced over the guidewire, and "front and back" fixation is achieved.

In cases where there is a majority of anterior involvement and displacement (and with absence of posterior pathology such as a posterior wall), it may be suitable to approach the fracture from an anterior approach. Also, with recent advances in technique and the use of a modified Stoppa or a "subinguinal" window of the ilioinguinal approach, the posterior column can be addressed from the front and stabilized from "inside-out." In this context, the standard ilioinguinal approach is utilized for the majority of the fracture treatment, but most of the work is done via the lateral and medial windows. From the medial window, the surgeon goes to the opposite side of the table and works under the muscle and vascular bundle and in front of the bladder. With this approach, the entirety of the quadrilateral surface can be directly seen and plated, and the posterior column can be manipulated directly into place. As in the posterior approach, provisional fixation is usually into the sciatic buttress, but in this case, the screws are placed inside out. Furthermore, direct plating of the posterior column from the inside of the pelvis can be performed. We have found the subinguinal window of the standard ilioinguinal approach to be very utilitarian. In fact, the need for use of the middle window has declined precipitously. The lack of dissection around the vascular and lymphatic trunk appears to be beneficial and at little cost to exposure and fixation. As such, as more reports on this technique are published, it may supplant traditional methods.

Summarily, for fixation of the T-shaped fracture using the anterior approach, there is little previous literature describing methodology. Even Letournel himself claimed it was infrequent in his practice. We recommend beginning with the posterior lesion and moving forward. The posterior column segment can be lifted and rotated into place from the inside of the pelvis. Often a bone hook into the sciatic notch can help pull the posterior column back into position. There are three simple fixation options. The first is a direct inside to out screw into the sciatic buttress. These screws are usually quite strong and provide reasonable provisional fixation. Another option is the standard posterior column screws placed via the lateral window of the ilioinguinal. Finally, for added stability, a quadrilateral plate can be placed, spanning from the greater sciatic angle, across the quadrilateral surface, and towards the ischial or pubic ramus (Chapters 11 and 12, Fig. 9). In fact, some cases that have comminuted quadrilateral surface pieces that cannot be secured with standard plate positions are well secured with this plate. The plate functions as a buttress to prevent protrusions. It can be slightly underbent to provide a lateralizing effect on the fragment. Furthermore, it will not interfere with future hip replacement and represents the medial limit of the acetabulum in cases of arthroplasty. We have found this plate to be very useful (Fig. 10). We have not found the traditionally described "spring" plates to be easy to apply and question the ability of a relatively thin plate to resist the loads of the hip,

Figure 9 Access to the posterior column and quadrilateral surface from inside the pelvis, using the subinguinal window. (A) The medial window of the ilioinguinal or the Pfannensteil is used for access, and the neurovascular structures are "lifted" anteriorly. The bladder is retracted and the obturator nerve and vessels are in view. They can be mobilized and protected during reduction and fixation. Bone model showing location of sciatic buttress screws (B). An internal posterior column plate (C). (Continued)

Figure 9 Access to the posterior column and quadrilateral surface from inside the pelvis, using the subinguinal window. (A) The medial window of the ilioinguinal or the Pfannensteil is used for access, and the neurovascular structures are "lifted" anteriorly. The bladder is retracted and the obturator nerve and vessels are in view. They can be mobilized and protected during reduction and fixation. Bone model showing location of sciatic buttress screws (B). An internal posterior column plate (C). (Continued)

Quadrilateral Plate
Figure 9 (Continued) A plate spanning the quadrilateral surface to the ischium (D) and along the pelvic brim (E).

especially when loaded as a cantilever as opposed to the buttressing mode of the plate we describe. Fixation of the anterior segment with this approach is straightforward and can be done with a standard plate along the pelvic brim or in some cases with the use of a retrograde ramus screw.

We emphasize that the choice of approach is determined by the "personality" of the fracture, and T fractures can be very problematic. As Letournel stated himself, while the majority of fractures can be treated via a posterior approach, occasionally a supplemental anterior approach is needed. We concur in that a single approach is not the goal, and, if needed, a second approach should be done to ensure an accurate reduction. Whether one begins with an anterior or posterior approach, the ability to intraoperatively concede that a single approach may not be enough to do the job right is far more admirable than struggling with one approach. Likewise, it is preferable to have two surgical events and two surgical scars instead of one unacceptable treatment.

Figure 10 Intraoperative view of internal pelvic brim plate along side standard anterior plate via the subinguinal window of the ilioinguinal (Fig. 9). The internal pelvic brim plate was used to buttress the quadrilateral surface comminution. Note the visualization of the posterior aspect of the plate, which is near the anterior sacro-iliac joint and just above the sciatic notch. The two screws (arrows) are placed into the sciatic buttress. The retractor is over the obturator structures, and the bladder is top right of the image.

Figure 10 Intraoperative view of internal pelvic brim plate along side standard anterior plate via the subinguinal window of the ilioinguinal (Fig. 9). The internal pelvic brim plate was used to buttress the quadrilateral surface comminution. Note the visualization of the posterior aspect of the plate, which is near the anterior sacro-iliac joint and just above the sciatic notch. The two screws (arrows) are placed into the sciatic buttress. The retractor is over the obturator structures, and the bladder is top right of the image.

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