Abstract

Injuries of the acetabulum are often challenging in treatment and aftercare. One reason is the required surgical approach, which has high complication rates, including vascular lesion, hernias, and wound infection. We present an alternative endoscopic-assisted approach for the internal fixation of acetabular fractures to avoid the Pfannenstiel incision. An endoscopic approach similar to that used for endoscopic hernia surgery was used. The ilioinguinal approach’s lateral window was used to achieve reduction and insertion of a reconstruction plate. The purpose of this study is to describe a minimally invasive technique as a possible method to reduce hospitalization and complications. Another goal is to give detailed technical recommendations and to assess the potential pitfalls of this surgical approach. The APACHE technique is a safe and suitable minimally-invasive approach for the successful treatment of complex acetabular fractures and can be considered in similar cases.

Open reduction and internal fixation are the preferred therapy in displaced acetabular fractures in the elderly with reported good to excellent results.1Displaced acetabular fractures in the elderly: Results after open reduction and internal fixation. The operation is challenging, starting with an approach that is associated with blood vessel or nerve injuries, and it is mostly performed in specialized centers.2Russell G.V. Nork S.E. Chip Routt M.L. Perioperative complications associated with operative treatment of acetabular fractures.,3Fensky F. Lehmann W. Ruecker A. Rueger J.M. Ilioinguinal approach: Indication and technique. The worldwide gold standard for the treatment of fractures of the anterior column is either the ilioinguinal approach or the modified Stoppa approach.4Ma K. Luan F. Wang X. et al.Randomized, controlled trial of the modified Stoppa versus the ilioinguinal approach for acetabular fractures.,5Acetabulum fractures: Classification and management. Both provide an excellent overall view of the acetabulum but can also result in complications such as hernia, hematoma, thrombosis, lesions of vessels or nerves, and impaired wound healing.6Ochs B.G. Marintschev I. Hoyer H. et al.Changes in the treatment of acetabular fractures over 15 years: Analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU).Minimally invasive arthroscopic techniques have been increasingly used in trauma and orthopaedic surgery over the last decades with excellent results and reduced morbidity. The goal is to reduce the iatrogenic damage and to minimize the invasiveness of every operation.7[Actual relevance of minimal invasive surgery in fracture treatment]., 8Yu D. Yu R. Zhang J. Chen T. Zhang B. Arthroscopic treatment of adult displaced tibial eminence fractures with anchor and PushLock fixation., 9Arthroscopic surgery: A historical perspective. We present an alternative surgical approach for minimally invasive endoscopic-assisted internal fixation of the acetabular fracture and share our experience, tips, and tricks. The anterior plating of the acetabulum in hemi-endoscopic (APACHE) technique combines the gold standard of the lateral window of the ilioinguinal approach with a minimally invasive endoscopic procedure. This made it possible to perform the surgery without the Pfannenstiel incision and keep the rectus abdominal muscle completely intact. The assumed advantages include reducing postoperative pain and achieving better remobilization because detaching the muscle was not necessary. In addition, smaller incisions are associated with a lower infection rate and the prevention of nerve and vessel lesions.MethodBefore surgery X-ray series and computed tomography (CT) scans are obtained. In the showed example the fracture is classified as an A 3.2 injury according to the Arbeitsgemeinschaft für Osteosynthesefragen guidelines and as an anterior column plus posterior hemitransverse according to Letournel (Fig 1).

Fig 1(a) An 81-year-old female patient with an anterior column plus posterior hemitransverse fracture of the acetabulum. Technique: X-ray ap of the left hip. The iliopectineal line (green arrow) is interrupted, which is a sign of an anterior fracture of the acetabulum. The blue arrow marks the fracture line. (b) Digitally reconstructed computed tomography scan of the pelvis in sagittal view. showing a visible split and dislocation of the anterior column (blue arrow). The green arrow marks the posterior column, the x marks the femur head.

The surgical procedure is performed in an interdisciplinary setting by an experienced general surgeon and an orthopaedic surgeon. The study was approved by the Medical Ethics Committee (University Ethics Committee No. 248/18).

 Operative Technique Approach

The patient is placed in a supine position on a carbon table that allows imaging by image intensifier fluoroscopy. A Foley catheter is inserted to minimize the risk of a bladder injury.

To visualize the superior pubic ramus, the standard procedure for endoscopic inguinal hernia repair with a total extraperitoneal approach is chosen.10Bittner R. Arregui M.E. Bisgaard T. et al.Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)]. The endoscopy terminal (Visera 4K UHD; Olympus, Tokyo, Japan) is placed at the patient’s feet. Through an infraumbilical midline incision of about 15 mm, the subcutaneous tissue and Scarpa’s fascia is dissected next to the right anterior layer and the rectus sheath is incised longitudinally. Retracting the rectus muscle laterally, a balloon trocar (Herloon; B. Braun Aesculap, Tuttlingen, Germany) is introduced and guided down to the symphysis strictly on the posterior layer of the rectus sheath. The correct placement is verified with a 30° endoscope (CH-S400; Olympus). Subsequently, the balloon is inflated to bluntly dissect the preperitoneal space, as shown in Figure 2, according to the guidelines for endoscopic treatment of inguinal hernias.10Bittner R. Arregui M.E. Bisgaard T. et al.Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)].,11Die evidenzbasierte TEP-Technik. The balloon trocar is then replaced by a 12-mm port (MIT-System; B. Braun Aesculap), which was sutured in place, and a “pneumopreperitoneum” (15 mm Hg, UHI-4 Insufflation Unit; Olympus) is established. While the infraumbilical port is used primarily for the endoscope, 1 additional port (Kii; Applied Medical, Rancho Santa Margarita, CA) is placed in the midline under direct visualization, according to the patient’s anatomy (Fig 3). The port is established roughly midway between the symphysis and the umbilicus. The tissue is then dissected from medial to lateral starting from the pubic tubercle, using a raspatory and a laparoscopic scissor. The arcus mortis needs to be identified and clipped. The iliopectineal fascia is released and divided from the pelvic brim and os pubis by careful retraction of the femoral vessels cranially and laterally. This step is essential to place the plate safely beneath the vessels (Video 1). The lateral window of the ilioinguinal approach is used to access the pelvic bone from the sacroiliac joint to the lateral border of the iliopsoas muscle.3Fensky F. Lehmann W. Ruecker A. Rueger J.M. Ilioinguinal approach: Indication and technique.

Fig 2Schematic drawing of the abdomen, sagittal view. The picture illustrates the total extraperitoneal approach to visualize the pubic bone and the acetabulum. The balloon trocar (green arrow) is placed in the preperitoneal space to bluntly dissect it for surgery. The correct placement was checked via endoscope.

Fig 3Anterior view of the operational area (schematic drawing). The first incision is an infraumbilical midline incision of about 15 mm (green arrow). One additional incision was made more caudal also in the midline (blue arrow). The infraumbilical port is used primarily for the endoscope whereas further ports can be used for numerous instruments. On the left iliac crest, the lateral window of the ilioinguinal approach is shown (orange arrow). This approach can be used to guide in the reconstruction plate (x).

 Reduction

The reduction can be achieved through the lateral window. First, the split of the os ilium is reduced and held with the help of pointed reduction forceps. The anterior column is reduced with a straight balls spike, and preliminary fixation is provided by intramedullary K-wires. The posterior hemitransverse can be reduced with a long lag screw in the posterior column of the acetabulum.

 Fixation

A large-fragment titanium reconstruction plate is used (DePuy Synthes, Raynham, MA). The plate is inserted through the lateral approach and channeled under the neurovascular pathway using a FiberStick (Arthrex, Naples, FL) that is connected to the plate.

The distal trocar is used to drill the threaded hole using a 3.2 mm twist drill bicortically into the superior pubic ramus. The screw length is measured with the help of marks on the drill. Depending on the grip and the bone quality, 4.0 mm cancellous screws or 4.5 cortex screws can be implanted. Figure 4 shows the intraoperative view of the plate during fixation. The reduction and implant position is checked by fluoroscopy in standardized planes (AP, inlet, and outlet views). Figure 5 shows the final result after plate fixation. Table 1 summarizes pearls and pitfalls of the technique, and Table 2 shows advantages and disadvantages.

Fig 4Intraoperative view of the plate after final fixation (green arrow). The medial parts of the reconstruction plate and the 3 medial screws are visible. The epigastric vessels can also be seen (blue arrow).

Fig 5(a) Postoperative X-ray of the pelvis showing the final result after endoscopic-assisted plate fixation of the left acetabulum. On the left side the large-fragment titanium reconstruction plate is (blue arrow). Two further compression screws are visible (green arrows). (b) Postoperative computed tomography scan of the pelvis in sagittal view after plate fixation. One screw and parts of the plate are visible (green arrow). The fracture line is marked with a blue arrow. Anatomical reduction is achieved (Compare Fig. 1b).

Table 1Pearls and Pitfalls

Table 2Advantages/Disadvantages

 Aftercare

After surgery, the patient is not allowed to bear weight on the affected extremity for 6 weeks. There is no restriction on the mobility of the hip joint, and the patient is allowed to sit up straight. Consistent physiotherapy is performed from day 1 after surgery, and thrombosis prophylaxis needs to be provided with a low molecular heparin until remobilization and full weightbearing resumed. Follow-up examinations and X-ray controls after 6 and 12 weeks are recommended.

DiscussionThe APACHE technique offers a promising alternative approach for anterior plate fixation of the acetabulum that does not compromise the rectus abdominis and pyramidalis muscles. In our experience, the area in which the muscles are reattached can cause pain, and this may be a relevant factor in the delayed mobilization of the patient. Other authors have also described residual suprapubic pain after ORIF of the anterior pelvis that does not correlate with implant failure or inadequate reduction.12Giannoudis P.V. Chalidis B.E. Roberts C.S. Internal fixation of traumatic diastasis of pubic symphysis: Is plate removal essential?. The APACHE approach also reduces the required Pfannenstiel incision from approximately 6 to 8 cm to two incisions of 1.5 cm each. This may reduce the rate of surgical site infection, which is reported to be 3–11% after the Pfannenstiel approach, and also leads to a better aesthetic result.13Operative treatment of acetabular fractures through the ilioinguinal approach: A 10-year perspective.,14Anglim B. O’Connor H. Daly S. Prevena negative pressure wound therapy applied to closed Pfannenstiel incisions at time of caesarean section in patients deemed at high risk for wound infection. The extraperitoneal approach is associated with a minimal risk of lesions of the spermatic cord in male patients and allows excellent visualization of the corona mortis vessels. The blood loss in the presented case was 640 mL. Other authors describe higher blood losses of between 450 and 2150 mL for the modified Stoppa or the ilioinguinal approach.15Ruchholtz S. Buecking B. Delschen A. et al.The two-incision, minimally invasive approach in the treatment of acetabular fractures.,16Elmadağ M. Güzel Y. Acar M.A. Uzer G. Arazi M. The Stoppa approach versus the ilioinguinal approach for anterior acetabular fractures: A case control study assessing blood loss complications and function outcomes. Another complication of the standard approach is lesions of the urinary bladder. The observed rate of bladder lesions using the total extraperitoneal approach procedure for hernia repair is extremely low at 0.15%.17Tamme C. Scheidbach H. Hampe C. Schneider C. Köckerling F. Totally extraperitoneal endoscopic inguinal hernia repair (TEP).Other authors also see the advantages of a less-invasive approach and have presented alternative strategies to treat acetabulum fractures. A minimally invasive technique was introduced by Ruchholtz et al.15Ruchholtz S. Buecking B. Delschen A. et al.The two-incision, minimally invasive approach in the treatment of acetabular fractures. in 2012. They describe a 2-incision minimally invasive approach to treat fractures of the anterior column.15Ruchholtz S. Buecking B. Delschen A. et al.The two-incision, minimally invasive approach in the treatment of acetabular fractures. The authors describe a good visualization of the fracture side combined with a low complication rate. Nevertheless, in their procedure, a notching of the rectus abdominis muscle and a bikini line incision is still necessary. Wolf et al.18Wolf H. Wieland T. Pajenda G. Vécsei V. Mousavi M. Minimally invasive ilioinguinal approach to the acetabulum. describe a similar approach with a longitudinal incision in the median lower abdomen and an extraperitoneal exposure of the pubic symphysis in 23 clinical cases. The authors found a reduction of complications associated with the classic ilioinguinal approach and good access to the fracture site.18Wolf H. Wieland T. Pajenda G. Vécsei V. Mousavi M. Minimally invasive ilioinguinal approach to the acetabulum.Further studies describe modifications of established approaches or less invasive techniques with the goal of reducing complications and providing good exposure to the area of interest.19Less invasive anterior iliac approach and compression osteosynthesis for the treatment of high anterior column fractures of the acetabulum., 20Zhuang Y. Cao S. Lin Y. Li R. Wang G. Wang Y. Minimally invasive plate osteosynthesis of acetabular anterior column fractures using the two-incision minimally invasive approach and a preshaped three dimension plate., 21Mauffrey C. Hake M. Kim F.J. Flexible 3D laparoscopic assisted reduction and percutaneous fixation of acetabular fractures: Introduction to a new surgical option. Trulson et al.22Trulson A. Küper M.A. Trulson I.M. et al.Endoscopic approach to the quadrilateral plate (EAQUAL): A new endoscopic approach for plate osteosynthesis of the pelvic ring and acetabulum—A cadaver study. performed a cadaver study to investigate the possibility of endoscopic preparation of the pelvic ring. The study demonstrated the feasibility of visualizing the acetabulum and para-acetabular anatomic structures from the symphysis to the iliosacral joint, including the quadrilateral region. The study notes a considerable potential for clinical use but also underlines the difficulties in fracture reduction using an endoscopic approach.22Trulson A. Küper M.A. Trulson I.M. et al.Endoscopic approach to the quadrilateral plate (EAQUAL): A new endoscopic approach for plate osteosynthesis of the pelvic ring and acetabulum—A cadaver study. The APACHE approach requires excellent knowledge of the anatomy of the pelvis and experience in laparoscopic techniques. To carry out this approach, an interdisciplinary team and considerable resources are necessary. There is a potential learning curve that will take some time in the beginning, and the approach is not applicable in all fracture types. We consider fractures of the anterior wall, anterior column, and associated anterior column plus posterior hemitransverse, as well as injuries to both columns as suitable indications for the APACHE approach.We see an enormous potential to reduce the rate of common complications such as hernia or surgical site infection. An endoscopic approach to plate the pubic symphysis has already become the standard procedure in our and other institutions.23Küper M.A. Trulson A. Trulson I.M. et al.EASY (endoscopic approach to the symphysis): A new minimally invasive approach for the plate osteosynthesis of the symphysis and the anterior pelvic ring—A cadaver study and first clinical results. In cases of massive soft tissue damage to the pelvis, the technique can be helpful because the approach lies cranial to the fracture site. In addition, we believe that the approach has some advantages in massively obese patients compared to an open approach.

The APACHE technique is an alternative approach for fractures of the anterior acetabulum column. It is a logical development to push the limits of minimally invasive acetabulum surgery and will become a standard procedure in future trauma management.

Supplementary Data

Video 1

This video describes the key aspects of the anterior plating of the acetabulum in hemiendoscopic technique. The images show an anterior fracture of the left acetabulum. The first picture shows a schematic drawing of the abdomen and illustrates the approach to visualize the pubic bone and the acetabulum. A balloon trocar is placed in the preperitoneal space to bluntly dissect it for surgery. The second picture shows the infraumbilical midline incision of about 15 mm. One more incision can be seen more caudal also in the midline. The infraumbilical port is used primarily for the endoscope whereas further ports can be used for numerous instruments. The tissue is then dissected from medial to lateral starting from the pubic tubercle, using a raspatory and a laparoscopic scissor. The arcus mortis needs to be identified and clipped. The iliopectineal fascia is released and divided from the pelvic brim and os pubis by careful retraction of the femoral vessels cranially and laterally. This step is essential to place the plate safely beneath the vessels. The fracture reduction is achieved through the lateral window of the ilioinguinal approach. A large-fragment titanium reconstruction plate is used for plate fixation. The distal trocar is used to drill the threaded hole using a 3.2 mm twist drill bicortically into the superior pubic ramus.

References

Displaced acetabular fractures in the elderly: Results after open reduction and internal fixation.

Injury. 45: 1908-1913Russell G.V. Nork S.E. Chip Routt M.L.

Perioperative complications associated with operative treatment of acetabular fractures.

J Trauma. 51: 1098-1103Fensky F. Lehmann W. Ruecker A. Rueger J.M.

Ilioinguinal approach: Indication and technique.

J Orthop Trauma. 32: S12-S13Ma K. Luan F. Wang X. et al.

Randomized, controlled trial of the modified Stoppa versus the ilioinguinal approach for acetabular fractures.

Orthopedics. 36: e1307-e1315

Acetabulum fractures: Classification and management.

Clin Orthop Relat Res. : 81-106Ochs B.G. Marintschev I. Hoyer H. et al.

Changes in the treatment of acetabular fractures over 15 years: Analysis of 1266 cases treated by the German Pelvic Multicentre Study Group (DAO/DGU).

Injury. 41: 839-851

[Actual relevance of minimal invasive surgery in fracture treatment].

Ther Umsch. 62: 145-151Yu D. Yu R. Zhang J. Chen T. Zhang B.

Arthroscopic treatment of adult displaced tibial eminence fractures with anchor and PushLock fixation.

Medicine (Baltimore). 99e21237

Arthroscopic surgery: A historical perspective.

Orthop Nurs. 27 (): 349-354Bittner R. Arregui M.E. Bisgaard T. et al.

Guidelines for laparoscopic (TAPP) and endoscopic (TEP) treatment of inguinal hernia [International Endohernia Society (IEHS)].

Surg Endosc. 25: 2773-2843

Die evidenzbasierte TEP-Technik.

Chirurg. 88: 288-295Giannoudis P.V. Chalidis B.E. Roberts C.S.

Internal fixation of traumatic diastasis of pubic symphysis: Is plate removal essential?.

Arch Orthop Trauma Surg. 128: 325-331

Operative treatment of acetabular fractures through the ilioinguinal approach: A 10-year perspective.

J Orthop Trauma. 20: S20-S29Anglim B. O’Connor H. Daly S.

Prevena negative pressure wound therapy applied to closed Pfannenstiel incisions at time of caesarean section in patients deemed at high risk for wound infection.

J Obstet Gynaecol. 35: 255-258Ruchholtz S. Buecking B. Delschen A. et al.

The two-incision, minimally invasive approach in the treatment of acetabular fractures.

J Orthop Trauma. 27: 248-255Elmadağ M. Güzel Y. Acar M.A. Uzer G. Arazi M.

The Stoppa approach versus the ilioinguinal approach for anterior acetabular fractures: A case control study assessing blood loss complications and function outcomes.

Orthop Traumatol Surg Res. 100: 675-680Tamme C. Scheidbach H. Hampe C. Schneider C. Köckerling F.

Totally extraperitoneal endoscopic inguinal hernia repair (TEP).

Surg Endosc. 17: 190-195Wolf H. Wieland T. Pajenda G. Vécsei V. Mousavi M.

Minimally invasive ilioinguinal approach to the acetabulum.

Injury. 38: 1170-1176

Less invasive anterior iliac approach and compression osteosynthesis for the treatment of high anterior column fractures of the acetabulum.

Clin Orthop Surg. 10: 279-285Zhuang Y. Cao S. Lin Y. Li R. Wang G. Wang Y.

Minimally invasive plate osteosynthesis of acetabular anterior column fractures using the two-incision minimally invasive approach and a preshaped three dimension plate.

Int Orthop. 40: 2157-2162Mauffrey C. Hake M. Kim F.J.

Flexible 3D laparoscopic assisted reduction and percutaneous fixation of acetabular fractures: Introduction to a new surgical option.

Injury. 47: 2203-2211Trulson A. Küper M.A. Trulson I.M. et al.

Endoscopic approach to the quadrilateral plate (EAQUAL): A new endoscopic approach for plate osteosynthesis of the pelvic ring and acetabulum—A cadaver study.

Z Orthop Unfall. 157: 22-28Küper M.A. Trulson A. Trulson I.M. et al.

EASY (endoscopic approach to the symphysis): A new minimally invasive approach for the plate osteosynthesis of the symphysis and the anterior pelvic ring—A cadaver study and first clinical results.

Eur J Trauma Emerg Surg. 45: 745-755Article InfoPublication History

Published online: June 19, 2021

Accepted: March 26, 2021

Received: January 5, 2021

Publication stageIn Press Corrected ProofFootnotes

K.K. and K.W. contributed equally to this work.

The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.

Identification

DOI: https://doi.org/10.1016/j.eats.2021.03.030

Copyright

© 2021 by the Arthroscopy Association of North America. Published by Elsevier.

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