Injury, Int. J.

Care Injured 44 (2013) 266273

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Injury
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Technical note

Comminuted quadrilateral plate fracture xation through the iliofemoral

approach
Ramesh Kumar Sen a,*, Sujit Kumar Tripathy a,b, Sameer Aggarwal a, Tarun Goyal a,c,
Santosh Kumar Mahapatra d
a

Department of Orthopaedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Department of Orthopaedics, Friarage Hospital, Northallerton, UK-DL6 1JG, United Kingdom
Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
d
Ispat General Hospital, Rourkela, India
b
c

A R T I C L E I N F O

A B S T R A C T

Article history:
Accepted 4 November 2012

Comminuted quadrilateral plate fracture with medial displacement is a technically difcult fracture to
treat. Minimal bone stock, proximity to the hip joint with limited surgical access, and difculty in
obtaining a stable xation at this area, contribute to the surgical challenge of open reduction and internal
xation. Fixation of a medial buttress plate in an infrapectineal fashion is a well-described technique to
address such fractures. However, this plate alone may be inadequate to buttress all the fragments in a
grossly comminuted quadrilateral plate fracture. An additional spring plate is often placed underneath
the infrapectineal plate to hold the fracture fragments. Conventionally, these spring plates are xed to
the ilium superiorly while the other end buttresses the quadrilateral plate when placed underneath the
infrapectineal reconstruction plate. The standard ilioinguinal approach and modied Stoppa approach
have been described for the surgical access to the quadrilateral plate. Both the approaches have some
limitations in addressing quadrilateral plate fracture. The ilioinguinal approach requires extensive
dissection and mobilisation of inguinal neurovascular bundle. The modied Stoppa approach does not
permit visualisation of the entire anterior column and the hip joint. The authors, in this article, describe
the xation of the comminuted quadrilateral plate fracture through the iliofemoral approach combined
with a medial ilioinguinal window. The technique involves xation of a spring plate (Allis T-plate) at
right angle to the infrapectineal buttress plate (908908 plate construct). The vertical limb of the T-plate
is xed to the iliopectineal eminence whereas the horizontal limb buttresses the quadrilateral plate
Hence, this technique addresses fractures of both the iliopectineal eminence and the quadrilateral plate.
Other than that, the iliofemoral approach permits direct visualisation of the entire anterior column and
the hip joint without the necessity to dissect the ilioinguinal neurovascular structures.
2012 Elsevier Ltd. All rights reserved.

Keywords:
Quadrilateral plate fracture
Anterior column fracture
Iliopectineal eminence
Iliofemoral approach
Modied Stoppa approach
Ilioinguinal approach

Introduction
Open reduction and internal xation is the gold standard
treatment for displaced acetabular fractures involving weightbearing dome and fractures of intra-articular fragments. The goal
of treatment relies on restoration of articular anatomy with stable
internal xation, allowing early mobilisation for the patient.1 This
can be achieved using various combinations of plates and screws.
However, the choice of surgical approach depends on the fracture
pattern, displacement, skin condition at the operative site, and
surgeons preference.2,3

* Corresponding author at: Department of Orthopaedics, Postgraduate Institute

of Medical Education and Research, Sector-12, Chandigarh 160012, India.
Tel.: +91 9914209744.
E-mail address: senrameshpgi@yahoo.in (R.K. Sen).
00201383/$ see front matter 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2012.11.002

The quadrilateral plate forms the medial boundary of the hip

joint. Hence, inadequate reduction and stabilisation of quadrilateral plate fractures lead to incongruous joints and early arthritis. A
quadrilateral plate fracture with medial displacement is usually
seen in anterior column fractures, anterior column and posterior
hemitransverse fractures, T-type fractures, or both-column fractures. Along with the respective column xation, the quadrilateral
plate in such cases needs medial buttressing to prevent medial
subluxation of the femoral head.1,4,5
The quadrilateral plate is a very thin bone and the outer surface
forms the articular surface of the hip joint, therefore, direct screw
xation is not possible. The technique of oblique screw xation
along the pelvic brim and parallel to the quadrilateral plate has
high chances of joint penetration, and this technique is limited to
simple non-comminuted quadrilateral plate fracture.6 The xation of a medial buttress plate in an infrapectineal fashion has
been described for quadrilateral plate fractures with medial

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267

opposite to the medial dislocating force (Fig. 2). The authors have
treated these injuries through the iliofemoral approach though
literature till date has no mention of the iliofemoral approach for
xation of such fractures.912
Patients and methods

Fig. 1. Bone model showing the conventional spring plate technique for xation of
quadrilateral plate fracture. The vertical limb of T plate (spring plate) is xed to the
ilium and the horizontal part buttresses the quadrilateral plate when placed
underneath an iliopectineal reconstruction plate.

displacement.5 However, extensive comminution of the quadrilateral plate cannot be effectively buttressed with this infrapectineal plate alone. In such instances, additional xation of a
spring plate beneath the infrapectineal plate is needed. Tile7 and
Mast et al.8 described the use of various plates i.e., small-fragment
T-plate, semitubular plate, and the 3.5-mm reconstruction plate
(used as spring plate) to buttress the quadrilateral surface. One
end of these spring plates is xed to the ilium whereas the other
limb buttresses the quadrilateral plate when placed underneath
the medial-buttressing infrapectineal reconstruction plate
(Fig. 1). Often, the quadrilateral plate comminution in an anterior
column fracture extends up to the iliopectineal eminence and
needs additional xation with a superior plate (iliopectineal
plate).5 Placing an iliopectineal plate alone can address the
comminution over the iliopectineal eminence but without
effective buttressing force on the spring plate. Contrary to it,
infrapectineal reconstruction plate alone provides a better
butressung force over the spring plate but without holding the
iliopectineal comminution.
The authors in this article report a slight modication of the
buttress technique to address the combined fractures of the
iliopectineal eminence and quadrilateral plate. In this technique,
the spring plate (contoured small fragment T-plate) is xed
directly over the iliopectineal eminence, and hence, stabilises the
iliopectineal fracture. The horizontal limb of the small fragment Tplate buttresses the quadrilateral surface and xes the vertical
limb to the iliopectineal eminence. When an infrapectineal
reconstruction plate is placed along the pelvic brim and tightened,
it pushes the T-plate (both the plate forms 908 angle: 908908 plate
construct) underneath, thus exerting a counteracting force exactly

From 1996 to 2010, the senior author (RKS) treated 590 cases of
acetabular fractures. The documentations of all these patients
were retrieved from the trauma registry. The data of those patients
who had comminuted anterior column fractures involving the
iliopectineal eminence and quadrilateral plate, and were operated
through the iliofemoral approach, was analyzed. For inclusion in
this study, the patients were required to have a complete set of
preoperative and postoperative radiographs, computed tomographic scans, and have completed at least two years of follow-up.
There were 22 patients with both column fracture and 14 patients
with anterior column fracture who had comminuted quadrilateral
plate fracture with medialisation, as well as iliopectineal fracture.
Immediately after their arrival to our emergency services, the
patients received all emergency resuscitative measures. Once
haemodynamic stability was achieved, they were evaluated for
orthopaedic injuries. Preoperative skeletal traction was applied to
maintain the stability of the femoral head and to avoid pressure
necrosis on the femoral head cartilage. The patients were operated
on when they were medically t. The average delay in surgery from
the time of injury was 4 days (minimum of 1 day to a maximum of
16 days).
The preoperative radiographs and CT scan in these patients
showed medial subluxation of the femoral head with comminution
in the iliopectineal eminence and/or quadrilateral plate (Fig. 3A
C). In all these patients, the comminuted anterior column was
reduced rst and xed; the posterior column was then, indirectly
reduced with various techniques using the Cobb elevator, ball
spike, pelvic clamp, lag screws or plate. Whenever required the
posterior column was xed with an ilio-ischial screw. Postoperative radiographs were evaluated for the quality of reduction
(Fig. 3D). Fracture reduction was graded using the criteria given by
Matta.13
Non-weight bearing on the injured side was advised for six
weeks, with range-of-motion exercises starting immediately after
the operation. Then, gradually increasing weight-bearing commenced and complete weight-bearing was restricted until
radiological signs of the union were observed. Low molecular
weight heparin was administered and graduated compression
stocking was applied in the postoperative period until the patients
were mobilised. Patients were evaluated clinically (for pain,
mobility, range of motion, gait, neurovascular status) and
radiologically (for loss of reduction, degenerative changes,
osteonecrosis and heterotopic ossication) at three weeks, six
weeks, three months, six months, 12 months, and every year

Fig. 2. Bone model depicting our surgical technique in the xation of comminuted anterior column and quadrilateral plate fracture. The T plate acting as a spring plate
buttresses the quadrilateral surface with its horizontal limb; the vertical limb holds the fracture fragments along the iliopectineal line and in the supra-acetabular area. The
vertical limb is xed to the supra-acetabular region with one or two holding screws. Placement of an infrapectineal reconstruction plate along the pelvic brim exerts force over
the spring plate and hence buttresses the quadrilateral surface. As both the plates are right angle to each other, it is called as 908908 construct.

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Fig. 3. Preoperative radiograph (A) and computed tomographic scan (B, C) showing comminuted anterior column fracture involving the quadrilateral plate and iliopectineal
eminence; there is medial subluxation of the femoral head. Postoperative radiograph (D) shows anatomical reduction of the fracture operated through the iliofemoral
approach.

thereafter. The average follow up was 3.2 years (minimum of two

years and maximum of 5.5 years). The clinical and the radiological
data at the latest follow-up were graded using the Merle DAubigne
and the Matta scores respectively. According to the Merle
DAubigne clinical grading system, the pain, gait, and range of
motion of the hip were each assigned a maximum of six points. The
three individual scores are summed to derive the nal score which
is interpreted as excellent for 1718 points, good for 1516
points, fair for 1314 points, and poor for less than 13 points.
Radiological assessment using the Matta scoring system interpreted excellent for a normal appearing hip joint, good for mild
changes with minimal sclerosis and joint narrowing (<1 mm), fair
for intermediate changes with moderate sclerosis and joint
narrowing (<50%), and poor for advanced changes. Other than
the degenerative changes, the radiographs were also evaluated for
avascular changes in the femoral head and heterotopic ossication
around the hip joint.

Surgical technique
The patient is placed in the supine position on a radiolucent
table with a sandbag under the affected hip. The ipsilateral limb is
draped freely into the eld so that the hip and knee joints can be
moved as required during surgery. The Urinary Foley catheter is
inserted into the bladder for improved visualisation, bladder
protection, and monitoring of uid balance (Fig. 4A). An
appropriate preoperative prophylactic antibiotic is administered.

The anterior column fracture is accessed through the iliofemoral approach. A skin incision is made along the iliac crest (about
10 cm proximal to antero superior iliac spine, posterior to gluteus
medius pillar) and is extended up to the anterolateral aspect of the
thigh passing through the antero-superior iliac spine (ASIS,
Fig. 4A). The scar directly over the iliac crest is poorly tolerated,
thus, the incision is made superior or inferior to the crest. Fascialata is incised along the incision and the surgical plane is developed
between the tensor fascia lata and the sartorius. Care should be
taken to preserve the lateral femoral cutaneous nerve. A supercial
dissection is carried out to strip out the deep fascia from the outer
border of iliac crest. The periosteum and the gluteal muscles of 2
2.5 cm length and 1 cm depth are stripped out from the anterior
and outer side of iliac crest to facilitate ASIS osteotomy. Before ASIS
osteotomy, the subperiosteal exposure of the internal iliac fossa is
carried out and the interval is packed with sponge until the distal
exposure is developed. Osteotomy of the ASIS (1 cm depth and
2 cm length) is performed (Fig. 4B); the osteotomised bone
fragment with the iliacus and external oblique muscles, inguinal
ligament, lateral femoral cutaneous nerve, and neurovascular
bundles are retracted medially with a Deaver retractor (Fig. 5A).
Distal extension is developed between the tensor-sartorious
interval for at least 1215 cm. The ascending branches of the
lateral femoral circumex artery and vein are ligated at about
10 cm distal to ASIS, under the thick aponeurotic fascial layer over
the rectus femoris muscle. The distal extension of the dissection
facilitates wide exposure of the internal pelvis and the anterior
column.

Fig. 4. (A) Diagram showing line of incision for the iliofemoral approach- along the iliac crest extending upto the anterolateral aspect of thigh passing through antero-superior
iliac spine. (B) Hand diagram shows antero superior iliac spine (ASIS) osteotomy-2 cm length and 1 cm depth, iliacus muscle is lifted up subperiosteally from the internal
pelvic fossa.

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269

Fig. 5. (A) ASIS along with its attachments (sartorius and inguinal ligament) and iliopsoas retracted medially. (B) Anterior column reduction using pelvic clamp and ball spike.

The hip joint is exed and adducted to facilitate easy retraction

of the muscle bulk, medially. The periosteum and fascia adherent
to the iliopectineal eminence is carefully stripped out using the
periosteum elevator to avoid injury to the external iliac vessels and
the obturator vessels. A Deaver retractor is carefully placed to
retract medially the important neurovascular structures such as,
the external iliac vessels, obturator vessels, iliopsoas muscle, and
the osteotomised inguinal ligament with its attachments. This
facilitates wide exposure of the anterior column. The obturator
internus muscle is lifted up from the quadrilateral surface and a
malleable retractor is placed to expose the quadrilateral plate. The
rectus femoris is detached from the antero-inferior iliac spine to
identify the hip joint capsule. Now, the anterior column is
completely exposed. The fracture-reduction of the anterior column
is started from peripheral to central, starting with the proximal end
of the fracture, at the level of the iliac crest (or below), and ending
at the acetabular fossa. The peripheral reduction must be

anatomical, since displacement there will aggravate malreduction

at the acetabular fossa. The anterior column fractures are xed
with the pelvic reconstruction plate with or without the lag screw
or neutralisation plate along the iliac crest in a standard fashion as
indicated. The lateral and longitudinal traction over the femur in a
exed-hip position reduces the medially-dislocated hip joint. The
comminuted iliopectineal eminence and quadrilateral plate are
reduced over the femoral head (that acts as mould) with the help of
a ball spike and temporarily held with pelvic reduction clamp
(Figs. 5B and 6A). Provisional K-wires (2 mm) are inserted to hold
the reduction. An Allis T-buttress plate (commonly used for distal
radius fracture) of adequate length (usually 4- or 5-hole plate) is
used to buttress the fragments. The plate is bent (>908) to contour
over the iliopectineal eminence with the horizontal limb resting
against the quadrilateral plate in an intrapelvic, infrapectineal
fashion (and hence, buttressing the comminuted fragments,
Fig. 6A). No screws are put directly on the quadrilateral surface.

Fig. 6. (A) Intraoperative clinical photograph showing reduction of anterior column with pelvic clamp and ball spike through the iliofemoral approach. Allis-T-plate is placed
over the iliopectineal eminence and is pushed with a ball spike. (B) The infrapectineal reconstruction plate pushes the underneath spring plate to buttress the quadrilateral
surface. (C) The medial window for xation of the medial end of the infrapectineal reconstruction plate.

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Fig. 7. Diagram showing sliding of infrapectineal reconstruction plate through

medial window (Pfennenstiel incision).

One or two holding screws (12 or 14 mm small fragment cortical

screw) are inserted through the vertical limb of the plate to x it to
the iliopectineal eminence of the anterior column (Fig. 6B). This Tplate stabilises all the comminuted fragments of the iliopectineal
eminence and quadrilateral plate, thus serving as a holding plate.
Care should be taken to protect the obturator neurovascular
bundle near the medial wall of the acetabulum. In cases of gross
comminution, where reduction is difcult or cannot be achieved,
and if there are intra-articular fragments, the hip capsule is cut to
observe and palpate the hip joint to assess articular congruency
and remove intra-articular fragments, if any. Subchondral impactions of femoral head and acetabular surface can also be managed
(by elevation and cortical-bone graft support) after incising the hip
capsule.
A 9- or 10-hole 3.5 mm reconstruction plate is contoured to t
in the infrapectineal (just inferior to iliopectineal line) region
inside the pelvis (Fig. 6B). The plate is over-countered to provide
maximum buttress over the T-plate and other unsupported (those
are unsupported by the Allis T-plate) fractured bone fragments of
the quadrilateral surface. The plate is secured posteriorly with two
or three screws (1424 mm small fragment cortical screws) placed
superiorly to the sciatic notch in the sciatic buttress region.
Anteriorly, the plate is xed to the posterior aspect of superior
pubic ramus using two or three screws (1224 mm small fragment
cortical screws). If the fracture comminution extends up to the
superior ramus, the plate is xed to the pubic symphysis in the

midline. For exposure of the symphysis pubis, a midline

Pfannelstein incision is made (Figs. 6C and 7). This is extended
in the subcutaneous plane to reach up to the fascia over the rectus
abdominis. Fascia is incised vertically and the rectus abdominis is
spited along the linea alba. The lateral extent of the approach is
limited by the spermatic cord (or the round ligament) emerging
from the supercial inguinal ring. Deep into the rectus abdominis
and the superior pubic rami, we carry out a blunt dissection to
create an exptraperitoneal plane. The urinary bladder is separated
by blunt nger dissection in the space of Retzius extending
laterally along the superior and the posterior aspect of the superior
pubic rami. Care is taken to identify and ligate the corona mortis
(present in 1015% of normal individuals) in this region to avoid
excessive bleeding. This medial window provides enough space
for the placement of screws anteriorly through the plate (Figs. 6C
and 7). The reconstruction plate is slid through the medial window
up to the sciatic notch in an infrapectineal fashion (Fig. 7). On
tightening the screws in the reconstruction plate, the T plate
underneath pushes the quadrilateral plate and hence, buttresses it
(Fig. 6C). This indirect buttressing technique provides rigidity and
strength to the xation of the medial quadrilateral surface. The
reduction is checked under the image intensier. In both-column
fractures, proximal part of posterior column fracture is xed with
screws or plate through this approach. The posterior column is
reduced with various techniques, including the use of pelvic
clamp, ball spike, cob elevator, lag screws, or plate for reduction.
Wherever required, the posterior column is reduced with a bone
hook and a 4.5 mm ilio-ischial screw is passed from a point 1 cm
lateral to the pelvic brim point taken 2 cm anterior to the
sacroiliac joint.
The osteotomised ASIS is xed to the ilium with two small
fragment screws. The wound is closed in layers after placing a
negative suction drain.
Results
There were 28 males and 8 females in this series. The average
age was 38 years (minimum of 18 years and maximum of 56 years).
The average blood loss was 350 ml (ranges from 200 ml to 600 ml),
and the mean operative time was 130 min (ranges from 90 min to
220 min). Two patients had intra-operative bleeding because of
injury to the corona mortis and the obturator artery. Both these
bleedings were controlled by compression packing. Postoperatively, supercial wound infection was seen in four patients; three of
these patients were managed with intravenous antibiotics, and the
other patient required a debridement of the wound.
In both-column fractures, the posterior column fracture was
simple and non-comminuted and we could achieve reduction
indirectly with various manoeuvres as described, through the same
approach. On the postoperative radiographs, 30 patients (83.3%) had
anatomic articular reduction (within 1 mm) and 6 patients (16.7%)
had good reduction (between 1 and 3 mm). There was no residual

Fig. 8. (A and B) Right side comminuted anterior column and quadrilateral plate fracture in a 50 year female. (C) Immediate radiograph after surgery with our 908908 plate
construct technique showing good reduction. (D) 6 Months after surgery, complete union was noticed with maintained good reduction of the joint.

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271

Fig. 9. (A and B) Gross comminution of anterior column and quadrilateral plate in a 40 year female with both-column fracture. (C) After open reduction and internal xation
through the iliofemoral approach with the 908908 plate construct, the fracture is anatomically reduced and stable. As there was extensive comminution in the anterior
column towards the ilium, second spring plate, xed to the ilium, was used. (D) After one year, the fracture has completely united and the reduction is maintained.

subluxation seen in any patient (Figs. 3, 8 and 9). Radiological

evidence of union was seen in all patients after a mean period of
three months. Two patients had paresthesia along the lateral aspect
of the thigh because of lateral femoral cutaneous nerve injury. Both
of them recovered completely within six months. Three patients had
hip adductor muscles weakness (power 3/5) in the postoperative
period (because of obturator nerve palsy), but all of them recovered
fully within six months. Grade I and II (Brookers) heterotopic
ossication was seen in 2 patients till the last follow-up. Clinical
outcome as per Merle DAubigne score at the latest follow up showed
excellent in 18 patients (50%), good in 10 patients (27.8%), fair in 5
(13.9%), and poor in 3 (8.3%) patients. Radiological grading at the
last follow-up showed excellent in 22 (61.1%), good in 6 (16.7%),
fair in 6 (16.7%), and poor in 2 (5.5%) patients. Two of three patients
with poor outcomes needed arthroplasty for post-traumatic
coxarthritis.
Discussion
In this study we reported the comminuted quadrilateral plate
fracture xation through the iliofemoral approach. The comminution of the quadrilateral plate was a part of anterior column or
both-column fracture in this series. Even in both-column fractures,
as the posterior column fracture was not comminuted or
segmental and the anterior column was grossly displaced, we
used the iliofemoral approach. We could achieve reduction of the
posterior column by various manoeuvres, including the use of
pelvic clamp, bone hook, lag screw, or neutralisation plate.
Anterior column and QP fractures were traditionally xed
through Ilioinguinal approach. Because of mobilisations of inguinal
canal and major neurovascular bundles with this approach, there
was increased surgical morbidity with long surgical duration,
bleeding, and postoperative complications. To avoid such complications, in the early 1990s, Cole10 and Hirvensalo et al.12
independently described an approach to anterior acetabulum
through an intrapelvic dissection from the midline. The principal
difference between ilioinguinal and their approach was in avoiding
the middle window, thus sparing dissection into the inguinal
canal and major inguinal neurovascular structures. Their approach
was a modication of an intrapelvic approach described by Rives
et al.14,15 for the repair of inguinal hernia using Dacron mesh. The
modied Stoppa approach provides access to the pubic body,
superior ramus, pubic root, ilium above and below the pectineal
line, quadrilateral plate, medial aspect of posterior column, sciatic
buttress, and the anterior sacroiliac joint. Few authors described a
second incision (lateral window of ilioinguinal approach) for
access to upper ilium and crest.4,9,16 Though the modied Stoppa
approach provides wide access to the pelvic brim (from pubic body
to anterior sacroiliac joint) and quadrilateral plate, and avoids
dissection into inguinal structures, it cannot permit access to hip
joint for evaluation of articular congruency. The combined
modied Stoppa and lateral window of ilioinguinal approaches

also do not permit access to the anterior wall of acetabulum. The

exposure of the iliopectineal eminence in the supra-acetabular
region is also relatively restricted as the ASIS remains intact along
with its attachment which does not allow direct visualisation, thus,
the surgeon has to work in a narrow eld of vision for xation of
the quadrilateral plate and anterior column (particularly in low
and very low anterior column fractures).
While operating on acetabular fractures through the modied
Stoppa approach, Sagi et al.9 in 2010 reported poor reduction in
associated both-column fractures, impacted anterosuperior dome,
and comminuted fractures of the pubic root and anterior wall region.
They admitted that currently, surgeons are extending the lateral
window inferiorly at the ASIS (in the manner of Smith Peterson
approach) to address these fractures. The iliofemoral approach along
with the medial window is nearly the same approach that was
mentioned by Sagi et al. for these difcult fractures.
Iliofemoral approach provides wide access to internal pelvis
and the anterior column. Combined with medial window of
ilioinguinal approach, the surgeon can have access to the pelvic
brim starting from the pubic symphysis to the anterior sacroiliac
joint, the whole of the ilium above and below the iliopectineal line,
supra-acetabular part of iliopectineal eminence, and the quadrilateral plate. The principal advantage of the exposure is that this
approach allows direct visualisation of the hip joint, which can be
evaluated for articular congruency and subchondral impaction.
The chances of neurovascular injury are minimised because of the
osteotomy of ASIS which relaxes the muscles and neurovascular
bundles on the medial side of pelvis. We found signicant
reduction in bleeding and surgical time while operating the QP
through this approach. The reduction quality and clinical outcome
in our series were comparable or even better to some of the
previous report (Table 1).
Other than the approach, the method described for xation of
comminuted QP and iliopectineal eminence fracture in this report
is unique. The xation of the T-plate over the iliopectineal
eminence addresses the fractures of both the quadrilateral plate
and the iliopectineal eminence, which is a common pattern of
injury in anterior column fractures. The Allis-T-plate (45 holes
plate) needs to be moulded more than 908 to x it over the
iliopectineal eminence. In this way, the vertical limb stabilises the
fracture over the iliopectineal eminence and the horizontal limb
rests on the quadrilateral surface. When an overlying infrapectineal reconstruction plate is xed below the pelvic brim and
tightened, the T-plate buttresses the quadrilateral surface exerting
a counterforce exactly opposite to the medial dislocating force of
the femur head (Fig. 2). Farid17 described a plate wire composite
for these types of fractures. As per his technique, the cerclage wire
was meant to hold the medial acetabular wall directly by passing
over the anterior column between the anterior superior and
anterior inferior iliac spine. Even by this technique, the fracture
fragments over iliopectineal eminence in the supra-acetabular
region could not be xed. Our technique of placement of T-plate

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272

Table 1
Clinical outcome and complications associated with different approaches to anterior column acetabulum.
Study

Approach/no.
of patients

Reduction quality

Clinical outcome

Complications

Matta11

Ilioinguinal
(n = 119 patients)

Anatomical reduction-74%,
satisfactory reduction-16%,
unsatisfactory reduction
in 10%

3 Year-excellent in 37%,
good in 47%, fair in
14%, and poor in 2%

13% complications
Femoral artery laceration-1
Femoral nerve palsy-1
Wound infection-3

Letournel6

Ilioinguinal
(n = 146 patients)

Anatomical reduction in
61% of both-column
fractures, 86% of
anterior column fractures,
and 68% of anterior column
with posterior hemitransverse
fractures

3 (2.1%) Infections
8 (6%) Femoral/sciatic nerve
palsies (one femoral nerve palsy
was permanent)
2 (1.4%) Abdominal hernia
3 (2.1%) External iliac vein injuries
One thrombosis of internal or
External iliac artery
One bladder injury
9% Incidence of ectopic bone
formation

Sagi et al.9

Modied Stoppa +/
lateral window
(n = 57 patients)

Excellent to good reduction

in 92%

1 Year clinical outcome

good to excellent
in 88% patients

5 complications related to surgical

approach
1 each of a superior gluteal artery
injury
1 lateral window wound infection
2 direct inguinal hernias requiring
surgical repair
1 atrophy of the ipsilateral rectus
abdominus muscle without hernia
Average blood loss 690 ml (1503000 ml)
Surgical duration 263 min 9120336 min)

Anatomic reduction 82%,

imperfect 18%.

Average operative time-4.7 h (range

38 h 48 min)
Blood loss 1063 ml (3502950 ml) Fluid
replacement 5 L (2 to 12.3 L)
4 complications in 3 patients: one had
a deep infection, one had seroma, and
two had mild symptoms in lateral
femoral cutaneous nerve distribution.
Two additional patients needed implant
removal

Hirvensalo et al.12

Lower midline +/
lateral window
(n = 164 patients)

Anatomic reduction (12 mm):

84%, 35 mm malreduction: 9%,
> 5 mm malreduction: 7%

3.9 Years: Harris Hip Score

> 80: 106 (75%) patients,
6079 in 22 (16%) and < 60
in 13 (9%) patients

Failure of xation 6
Hardware in acetabular joint space 4
Supercial infections 2
Ileus with bowel perforation 1
Multiorgan failure resulting to death 1
Deep venous thrombosis 5
Pulmorary embolism 1
Lateral cutaneous nerve lesion 20
Necrosis of the femoral head 20
Heterotopic ossication 5
Secondary osteoarthritis: 14
Total arthroplasty needed: 23 cases

Our study

Iliofemoral +/
medial window
of ilioinguinal
(n = 36 patients)

Anatomical reduction in 83.3% of

patients and good reduction in
the remaining 17.7%

3.2 Years: excellent to

good outcome in 78%

Obturator and corona mortis artery

injury-2 patients
wound infection-4
ectopic bone formation-2 patients

holds the fracture fragments further lower in the anterior column,

and the function of cerclage-wire is served by the T-plate.
The 908908 plate construct design as described in this article
can better address the comminuted QP and iliopectineal eminence
fractures. Fixation of such fractures through the iliofemoral
approach is less morbid and does not require extensive dissection.
We recommend the iliofemoral approach as an alternative to the
ilioinguinal and the modied Stoppa approach for the xation of
comminuted anterior column fractures involving the quadrilateral
plate.
Funding
None.

Conict of interest disclosure

None.

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