| BackgroundManagement of acetabular fractures is a challenge to trauma orthopedic surgeons. The choice of surgical approaches determines the outcome of surgery. The perfect approaches should provided a sufficient exposure of fractures, convenient to reduction and fixation procedures, and less invasive to local soft tissue with less complications. The doom and quadrilateral plate of acetabulum are involved in anterior column fractures companied with central dislocation of femoral head., which are often managed from anterior approach. These parts of acetabular are deep in pelvis, difficult to exposure in clinical procedures. There are many approaches, such as classical ilioinguinal approach and modification, modified Stoppa approach, pararectus approach, none of which was suitable for all patterns of fractures. It is important to choose appropriate approach according to different types of fractures. Minimally Invasive Plate Osteosynthesis techniques are prevail in trauma orthopedic, which emphases protection of soft tissue and blood supply. Fracture reduction was achieved by direct reduction of indirect reduction from several limited soft tissue windows. These concepts are also applicable for acetabular fractures.In surgery of acetabular fractures, plates will be reshaped to contoured to profile of bone surface, which procedure is difficult in surgery account for irregularity of innominatum bone. The combination of development of medical imaging techniques and 3D printing techniques make things different. Life size three-dimensional pelvic model, manufactured from standardised CT scans, using the rapid prototyping process, was used as a template for plates reshape before surgery. The plates were directly used in subsequenct surgery, which make simplify the surgical procedure and shorten the surgical time.In our studies, we present modified TIMI approach base on existing approaches combining the concept of MIPO techniques. Anatomical study was made on cadavers. Then mirror models of health hemipelvis, printed by 3D printer, were used to help plates reshape before surgery. In the clinical studies, the two techniques were used in surgical management of acetabular fractures. Clinical outcomes were described and compared with ilioinguinal approach.Chapter 1 Design and Anatomical Study of Modified Two Incisions Minimally Invasive ApproachPurpose:Design a new approach base on TIMI approach and MIPO technique, and apply on cadavers to evaluate the feasibility of using this approach in anterior surgery of acetabular fractures.Methods:Ten frozen adult cadaveric specimens comprise integrated pelvis,8 male and 2 female, surgical instruments. The minimal pararectus incision was 6 cm, starting cranially at the crossing point between the line connecting the umbilicus with the anterior superior iliac spine and lateral margin of the rectus, then descending along the lateral margin of the rectus. The minimal supra-symphysis incision was 2 cm transversely above the pubic symphysis, and was 6 cm in length. Stepwise dissection were performed to exposure the acetabular, observing anatomical structure at different layers, determining the definitely surgical exposure.Results:(1)The minimal pararectus incision:Superficial dissection was conducted through the external oblique, internal oblique, and transversalis muscles of the abdominal wall. Blunt dissection was performed along the extraperitoneal space. The peritoneum was gently mobilized and retracted craniomedially. Deep dissection proceeded between the external iliac vascular bundle and iliopsoas. The external iliac vascular bundle was retracted medially with a silastic sling, then the iliopsoas was detached from the innominate bone and retracted laterally. The acetabular dome region and quadrilateral plate were exposed.(2)The minimal supra-symphysis incision: The rectus muscle was released from the anterosuperior aspect of the pubic bodies, pubic tubercle, and superior ramus, with the insertion of the rectus abdominus left intact. Further dissection posteriorly along the pelvic brim was performed to safely expose and directly visualize the entire pelvic brim and quadrilateral surface. (3) The tunnel connect two incisions was established by periosteal elevator. (4) The definitely surgical exposure of modified TIMI approach:anterior wall, doom, quadrilateral plate. (5) Anatomical structures vulnerable:peritonum, blader, external iliac vessels, Corona Motis, obturator vessels and nerves.Conclusions:Base on cadaveric study, majority of anterior bone surface, especially doom and quadrilateral plate, could be exposure in modified TIMI approach. Compare to former anterior approaches, it have advantages of minimally invasion, less injury to soft tissue, relatively simple procedures. But there were several structures vulnerable in surgery. Modified TIMI approach may be a alternative method for anterior surgery of acetabular fractures.Chapter 2 Plates Preshape Technique Base on Mirror Hemipelvis model Using 3D printing TechniquePurpose:To explore the feasibility of using 3D mirror hemipelvis model as template for preshaping plates before surgery.Methods:From March 2013 to July 2014,12 consecutive cases of acetabular fracture underwent CT scanning.3D peivic images were reconstructed using software. Inact hemipelvis was divided from the whole pelvis, then obtained the mirror image and save data as DICOM format. A hemipelvis models were made by the 3D printer. Which were marked fractures lines, and used as templates for surgical planning, plates rebending.Results:According to 3D reconstruct image,3D printing mirror model and clinical conditions of each patient, surgical planning were decided that 9 patients used modified TIMI approach with supine position,3 patients used modified TIMI approach with floating position, and estimated the quantities of anterior plates were 1 14-hole-plate, 7 12-hole-plates,4 10-hole-plates, posterior plates were 3 6-hole-plates, 3 7-hole-plates. In next chapter all plates were implanted, which were great contoured to profile of bone surface, and shorten the operation time.Conclusions:3D printing is an advanced technique, which converts 3D image to solid model. Base on solid model, surgeon can master detail of fractures, design precise personalized surgical plan. According to 3D mirror model of inact hemipelvis preshape plates is convenient used in surgery without rebending.Chapter 3 Application of Modified TIMI approach and a preshaped 3D plate in Management of Acetabular FracturesPurpose:To investigate the treatment of acetabular anterior column fractures using a two-incision minimally invasive (TIMI) approach and minimally invasive plate osteosynthesis (MIPO) technique using a preshaped 3D plate.Methods:A group of 12 consecutive cases of acetabular fractures from March 2013 to July 2014 were treated with the TIMI approach.3D mirror models of the uninjured side of the hemipelvis were printed preoperatively; the plates used in surgery were preshaped according to these models. MIPO surgical techniques were applied. All patients had a minimum 1-year radiographic and foundational follow-up.Results:Seven fractures involved the anterior column, four were anterior column with posterior hemitransverse, and one was anterior column with the pubic symphysis. The average surgery time was 200 minutes, and mean blood loss was 1,004 ml. The fracture reduction results as assessed by Matta radiographic outcome scores were good in eight, satisfactory in three, and poor in one patient. Functional outcomes according to the Harris Hip Scores were excellent for nine, good for three. Postoperative complications included incomplete femoral nerve damage and abdominal cavity injury.Conclusions:The TIMI approach is an alternative to the ilioinguinal approach for anterior column acetabular fracture treatment, especially for fractures involving the dome and quadrilateral plate that are feasible for application of MIPO techniques. The technique of preshaping the 3D plate makes the plate better accommodated to the fracture surface and easier to apply in MIPO procedures.Chapter 4 Clinical Outcome Comparison Between Modified Two Incisions Minimally Invasive Approach and Ilioinguinal ApproachPurpose:To compare the clinical outcomes between modified TIMI approach and ilioinguinal approach using in management acetabular fractures.Methods:A total of 12 consecutive cases of acetabular fracture were treated with modified TIMI approach in our institution from March 2013 to July 2014. Another serial of 15 cases of acetabular fractures were reviewed treated with classical ilioinguinal approach from October 2010 to December 2012. Surgeries were completed by the same group surgeon. Surgical time and blood loss were recorded. All patients were followed up at 2 weeks,6 weeks,3 months,6 months, and 1 year postoperatively. Anteroposterior pelvic and Judet radiographs were taken and reviewed by an independent orthopedic trauma surgeon before the treatment results were classified by one of the authors. Postoperative fracture reduction of the acetabular fractures was evaluated on all three views using the Matta radiographic scoring system; displacement of 1 mm or less was considered an anatomic reduction. Harris Hip Scores were used to assess the functional outcome of treatment. The perioperative data and incidence of complications were retrospectively reviewed for all patients, who all had a minimum of 12 months’follow-up. These materials were compared between two groups.Results:Modified TIMI approach group:Average operative time was 200 minutes (range 125-330 minutes). Mean blood loss was 983 ml (range 200-2,500 ml). Patients were followed up for a minimum of 12 months (range 12-28 months). The fracture reduction results were assessed via Matta radiographic scoring as anatomic reduction in seven cases, satisfactory in four, and poor in one. Functional outcome according to the Harris Hip Score system were excellent for nine, good for three. Postoperative complications included incomplete femoral nerve damage in one patient, who returned to normal 3 months postoperatively. Two cases of intraoperative straying into the abdominal cavity were treated by the preperitoneal repair method. There were no serious complications of death, incision infection, nonunion, vascular injury, abdominal wall hernia, or heterotopic ossification. Ilioinguinal approach group:Average operative time was 240 minutes (range 150-360 minutes). Mean blood loss was 1372 ml (range 800-3200 ml). Patients were followed up for a minimum of 12 months. The fracture reduction results were assessed via Matta radiographic scoring as anatomic reduction in 8 cases, satisfactory in 5, and poor in 2. Functional outcome according to the Harris Hip Score system were excellent for nine, good for four, and fair for two. Postoperative complications included incomplete femoral nerve damage in 2 patient, incision superficial infection in 2, femoral nerve injury, heterotopic ossification in 2.Conclusions:Compare to classical ilioinguinal approach, modified TIMI has advantages in surgical time, blood loss and complications with similar outcomes in fractures reduction and hip function. Minimally invasive approach could not substituted classical approach, but it could be a new choice for anterior surgery of acetabular fractures. |
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