Ilioinguinal approach versus Anterior Intra-pelvic approach to the
acetabulum – review
Ilir Hasani1, Gjorgji Velkovski
University Clinic for TRAUMATOLOGY, Faculty of Medicine, Ss. Cyril and Methodius University Skopje,
Republic of Macedonia
Key words: acetabulum, anterior intrapelvic approach, Stoppa approach, modification of Stoppa
approach, minimally invasive anterior approach to the acetabulum, review
Abstract
Ilioinguinal approach (IIA) to the acetabulum has been used as a golden standard for 50 years to treat “anterior” acetabular
fractures. Since Hirvensalo and Cole have introduced the Anterior Intra-pelvic Approach (AIPA), some of surgeons have
accepted and some of them stay devoted to the IIA. In our country we use IIA routinely and we have not introduced the AIPA.
The aim of this study is to present review of literature for two different anterior approaches for treatment of acetabular
fractures that require anterior approach, used in modern era of surgery, with focus on the Anterior intra-pelvic approach of
Hirvensalo and its priorities comparing to ilioilguinal approach of Letorunel.
Material and methods: We have conducted a search, mainly electronically, and retrospective analysis of the existing literature.
We have identified and recruited 2 papers that are well systematized and representative for IIA, and 6 for AIPA.
Results: We have presented the advantages and disadvantages, the priorities and the week sides of both approaches
separately, comparing complications, risks and the results.
Conclusion: According to the presented facts regarding advantages of the AIPA with focus on visualization, accessibility,
biomechanical justification, the approach has to be implemented in our everyday practice and we are comfortable to prefer it,
especially because of the fact that comparing the complication rate there is no significant difference between the both
approaches. Based on the low incidence of complication we can consider this approach relatively safe in hands of experienced
surgeon, but technically demanding.
1
Corresponding author at: University Clinic for TRAUMATOLOGY, Faculty of Medicine, Ss. Cyril and Methodius University Skopje, Vodnjanska
17; Republic of Macedonia Tel.: +38970236680.
E-mail addresses: ilirku@yahoo.com
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Introduction
Acetabular fractures are rare fractures presenting with annual incidence of 3 patients per 100.000 inhabitants1. They affect
mostly the young population, with male predominance of approximately 70-75% 1,2, even though there is a trend of raising the
incidence in elderly patients group2,3,4,5 proportionally with rising of average age of the population worldwide 4,5 and also slight
but significant increase over time in the incidence among women1. The most common mechanism of injury is high energy
trauma associated mostly with motor vehicle accident in the younger population, while ground-level fall was the main reason
for osteoporotic acetabular fractures in the elderly patients associated with low energy mechanism of injury5.
Acetabular fracture of younger population group is associated mainly with high energy trauma. There are two main direction of
forces that when acting to the hip can cause an acetabular fracture: forces that are parallel to the diaphysis of the femur and
forces acting in the bigger trochanter and are parallel to the femoral neck6,7. The fracture pattern is directly associated with
degree of flexion of the hip, degree of rotation of the femoral neck and for sure the direction and amount of energy that is
delivered on the hip during the injury6,7. According to the original work of Letournel and Judet 7,8, firstly described on 1960
followed by serial of modification and definitively published on 1965, the acetabular fractures are classified on 2 main groups
(elementary and complex) and 5 subgroups for both groups.
Elementary fracture types
Associated fracture types
Posterior wall
Posterior column/wall
Posterior column
Transverse/posterior wall
Anterior wall
T-type
Anterior column
Anterior fracture/posterior hemitransverse
Transverse
Both column
Table 1 Letournel's original classification of acetabular fractures9
This classification has been included in the comprehensive classification of Tile10, which has been completely accepted from the
AO classification of the fractures.
Type A Partial articular, involving only one of the two columns
A1: Posterior wall fracture
A2: Posterior column fracture
A3: Anterior wall or column fracture
Type B
Partial articular, involving a transverse component
B1: Pure transverse fractures
B2: T-Shaped fractures
B3: Anterior column and posterior hemitransverse
Type C
Complete articular fractures, both columns
C1: High variety, extending to the iliac crest
C2: Low variety, extending to the anterior border of the ilium
C3: Extension into the sacroiliac joint
Table 2 Comprehensive classification system that integrates the principles of Letournel classification 10
The acetabular fractures that are related to high energy trauma are very often followed by other injuries of the trunk6,1,2,
mainly with head injury almost in 50% of cases, also with limb injury, head, chest, genitourinary and spinal injury respectively2.
They are sometimes related also to pelvic fractures that in literature is called “devastating dyad”11.
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The most common fracture patterns in the elderly group are the fracture displacement of the anterior structures (both column
fractures, anterior column, anterior with posterior hemitransverse12, anterior wall). The most characteristic features of the
fractures in elderly population is roof impaction, involvement of the quadrilateral lamina13 and also but not so frequently
damage of the femoral head, hip dislocation2. They are very challenging for treatment. High energy trauma is responsible for
44% of cases of acetabular fractures in elderly population group, with fracture patterns similar to those of young age 5. During
the 60s it was contraindicated to operate on these fractures. But with modern advancement on acetabular surgery, considering
the fact that insufficient fixation leads to non-union and insufficient reduction raise the possibility to early arthrosis, absolutely
it is preferable and also useful to operate on these fractures to prevent non-unions and also early arthrosis12.
According to the approach for treating the acetabular fractures, they can be classified on fractures that require anterior
approaches (fractures with main displacement in the anterior structures), fractures that can be treated with posterior
approaches (fractures with main displacement in the posterior structures) and also fracture patterns that need combined or
extensive approaches (fractures with wide displacement in both structures)6.
The focus of our review is the fractures that can be treated with anterior approaches and also the approaches itself. Through
anterior approaches can be treated these acetabular fracture patterns: anterior wall, anterior column, anterior column/wall
with posterior hemi transverse, both column fractures, transversal transtectal fractures6.
If we look back to the history, there is almost one century difference from the time when the posterior approaches where
introduced since Langebeck in 1874 and later one Kocher 1909 has described the posterior approach to the hip called KocherLangenbeck, with introducing the anterior approach that was brought up from Letournel E. in 19658. Before that the treatment
was mainly conservative and only 20 cases of operative treatment of acetabular fractures have been identified. After
introduction of ilioinguinal approach (IIA) on 1965 it was established as golden standard for treating the anterior fracture
patterns of the acetabular fractures for both young and elderly group of people. It has been widely accepted and implemented
both in Europe and widely. It has been related to very good results when is in hands of an experienced surgeon 14,15,16,6. It was
very resistant to time changes, and has survived like golden standard almost half of decade without modification.
Even though the IIA is a universal approach, as we mentioned above, recently there is a big number of publication that refer a
modification of this approach17,18,19,20,21. It is a wide accepted theory in surgery that if there are a lot of described approaches or
techniques for a condition it means that there is limitation or insufficiency of that approach or technique so the scientists
permanently search for something better.
IIA is technically very demanding approach it is very laborious exposure especially when dealing with previously prepared
inguinal canal due to operative treatment of groin hernias, etc. It is quite aggressive approach and time consuming. It is
followed by tissue damage related with access morbidity and complicated closure of the wound. It is a bit risky since we deal
with the main vascular and neural „highways“ of the lower extremities. It has no access to lamina quadrigemina and it’s
reduction and fixation is indirect and quite complicated6. The posterior column is also unnaccessable22. The corona mortis is
very hard to identify and ligate. Furthermore the IIA has been associated with 10 % complication rate: which includes hernias,
thrombosis, lesion of the femoral vesels, lymphoedema, haematoma and wound healing problems 23. Even these complications
has been much rare in hands of experienced surgeons, still there is a major concern of possible injuries of neurovascular
structures21.
The above mentioned facts have pushed surgeons to “look for something better, easier, and related to fewer problems”. Also
parallel with rising the incidence of the acetabular fractures in elderly population there is a need for developing surgical
technique, also looking for less aggressive approach to reduce access morbidity, operative time and blood loss.
Hirvensalo 24 has worked on modification of well established and well known approach of Rives and Stoppa 25 anterior approach
that was used in abdominal surgery to treat big anterior wall abdominal hernias.
Modified Stoppa approach or so called Anterior Intra-Pelvic Approach (AIPA)26 to the anterior acetabulum and pelvis through
an intrapelvic dissection from the midline has been firstly described in 1993 by Hirvensalo 24, and later on independently in
1994 by Cole27, which has advantage to access much better the inner side of the inominate bone under the pelvic brim
including the quadrilateral lamina. Some authors also claim that can access also the posterior column with this approach 22. The
anatomical reduction and fixation has been done much easily through this approach. Hirvensalo approach has immediately
been a tough topic in international literature and conferences and after a short period of it has been widely accepted
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internationally. The indication has been widened also to the younger population even though initially was designed for elderly
one, particularly for the quadrilateral plate that was the most complicated part to access, reduce and fix. Surgeons that use this
approach claim that there is no more need for IIA for treatment of “anterior fractures” of the acetabulum.
Although this approach is less invasive and has theoretical advantages comparing with IIA, very often (app 60% 26) there is still a
need for the “first window” of the IIA to visualize the iliac wing.
That’s why other authors have continued to search further for another single approach through which we could deal with
anterior fractures of the acetabulum. As alternative of Standard approaches, there is quite a lot of other papers that prove
other less invasive or different approaches, but there is not enough evidence and clinical prove that they are superior to
Letournels and Hirvensalo one.
For example Keel and coworkers28 are pioneers of discovering, implementing in clinical practice, publicizing and promoting
single approach through which we could deal with anterior fractures of the acetabulum, that they have called Pararectus
approach. It is the only approach that through only one window can visualize all the inner side of the innominate bone including
the lower part of the innominate bone under the pelvic brim and also the inner side of the iliac bone, through mobilizing and
trans-positioning the iliopsoas muscle.
Last decade was known with implementing the navigation systems in orthopedic trauma surgery with very special focus on
spine, pelvic and acetabular surgery10,29. Since we search for lowering the operative approach, the image guidance systems will
help us to achieve the smallest incisions, the highest precision, reduce radiation, lower the revisions and for sure better
functional results.
We present review of literature for two different anterior approaches for treatment of acetabular fractures that require
anterior approach and are used in modern era of surgery in the last and ongoing century, with focus on the Anterior intrapevic
approach of Hirvensalo and its priorities comparing to ilioilguinal approach of Letorunel.
Material and methods
In our study we have mainly searched electronically in well known databases like PUBMED, HINARI, AoFoundation multi-journal
search, mainly using the keywords: “approaches acetabular fractures”, “anterior modified approaches acetabular fractures”.
We have looked on all articles that describes anterior approaches, the classical one like Ilio-inguinal one and also the
modifications. The most important one were the articles with clinical results and complication rate of different anterior
approaches and also original articles that describe new approaches, even though they are with small number of patients.
Also we have used traditional classical books from Macedonia in Macedonian language, but also books in English language.
We have identified 6 publications30,22,27,31,26,32 that report significant number of patients with fractures of acetabulum operated
with AIPA with well systematized with regard to complications and results, so it would make sense the comparison. Also we
have identified quite a lot of publications that report complication and results after IIA, but due to representativeness we have
selected only two, and one of them is the largest series of the author of the IIA that is presented in his work15.
We have excluded case reports, biomechanical studies, technical notes, letters to the editor and editorials.
The results were presented in the table, based on the treatment method, outcome and complications.
Results and discussion
Surgeons work on finding the ideal approach with minimally invasiveness, less blood loss, shorter operative time, good
visualization and manipulation, easily and rigid fixation. Below we will present the evidence on studies comparing the
complication rate, risks and results between AIPA and IIA.
About the visualization and the accessibility
The main advantage of AIPA, that almost all authors that use this approach agree, comparing with IIA is the wide and better
manipulation field for putting the instruments and hardware, especially when there is a fracture in the quadrilateral surface and
the posterior column. So it could be used as an easy alternative of IIA to operate on specific fracture pattern.
In contrast to Kocher-Langenbeck approach, both anterior approaches are extraarticular so they do not visualize the joint itself
and the reduction is indirect. But this approach ensures wide view in the true pelvis and access to the pubic bone including the
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body and the root and the following brim (ilio-pectineal line) of the pelvis to the anterior sacroiliac joint, the quadrilateral plate
and the inner side of the posterior column.
Andersen R. et al.22 have presented 17 patients treated with AIPA as they called “non-extensile” approach to treat acetabular
fractures with anterior and posterior column major dislocation. The advantage to reconstruct the posterior column (e.g. in both
column fractures) through single approach is very beneficial for the patient, since we avoid the consequences of the combined
approach that is quite mutilating, considering the fact that posterior Kocher-Langenbeck approach is followed with 7% of
heterotopic ossification comparing with IIA that is related to less that 1% in bigger series14. AIPA as IIA is related to low rate of
HO that is shown in
Table 4.
Patients with bilateral acetabular fracture that require anterior approach and especially patients with fractures of the
acetabulum combined with pelvic ring injury, combination so called “devastating dyad” 11; are the ones that can benefit mostly
from the AIPA. Bilateral exposure from the midline combined with lateral window from the IIA, so called from Hirvensalo
ilioanterior approach30 enable us to work in whole inner part of the pelvis, including the true pelvis. Thus we can avoid the
bilateral IIA, which is very aggressive approach32.
The only part of innominate bone that cannot be reached through the AIPA is the region of anterior wall of the acetabulum
including the root of pubis and also the dome. These fractures should be approached either through the classical IIA or by AIPA
combined with lateral window of IIA through extending the lateral window distally in the form of Smith-Petersen approach. In
their study Sagi et al. reported for 4 patients (from 57 included in the study) that required conversion to IIA to access dome or
pubic root or anterior wall, but it was at the start of this surgical procedure26. Opposite to that Hirvensalo et al.30 refer that
there were no exclusion criteria for using AIPA in a large serial of patients. Although the AIPA has not been intended to replace
the IIA but to be as an easy alternative to IIA for specific pattern of fractures31, surgeons that have started to practices the AIPA
confirm that they do not do any single IIA for the treatment of acetabular fractures.
About biomechanics
Medial wall fractures of the acetabulum, involving the quadrilateral plate with central dislocation of the femoral head are very
challenging for fixation. Since it is very often a result of low energy trauma in elderly patients with a minimal bone stock and
because of its close relationship to the hip joint, with limited access, it is a surgical challenge for reposition and fixation. The
problem became much more difficult if we consider the fact that the fracture is located in the true pelvis that cannot be
visualize but is only palpable through the IIA.
Different fixation techniques have been described to reduce and fix this quadrilateral plate and to medially buttress the medial
wall against the fracture mechanism through IIA. Letournel noted in his monograph15 the difficulties that he has with these kind
of fractures patterns. He proposed putting the long screws through the reconstructive ileopectineal plate, parallel to
quadrilateral lamina. This procedure is very challenging for the surgeons and with high possibilities for complications related to
hip joint penetration. Tile10 in his book describes tangential screw that penetrates and hold the lamina medially. Quite a lot of
studies has reported successful retention of the medial wall with cerclage wiring33,34,35,36. Other authors also has reported a
successful retention of the medial wall with a medial buttressing plate (that can be 1/3 semitubular, H-plate12, Reconstruction
plate10, T-plate37) with short limb placed under the reconstructive iliopectineal plate and the long one buttressing the
quadrilateral lamina. Culemann et al.12 has compared different fixation techniques with conventional reconstructive plates with
or without medial buttressing plate and locking implants in a biomechanical study, and concluded that both techniques ensure
sufficient stabilization of the medial wall to prevent protrusion of the quadrilateral plate.
In contrast to classical IIA, the need to put the plate against the fracture forces has pushed up Hirvensalo 24,30 and Cole27, and
they brought up the AIPA that allow us infrapectineal plating that is more rigid and biomechanically more reasonable since it is
placed in the same plane with the fracture comparing to other techniques that are tangential or perpendicular to acting
forces38.
Laflamme et al.39 in his work, because of the possibilities of failure of these patterns of fracture accessing through the IIA,
considers the infrapectineal plating as an alternative of total hip arthroplasty, and the elderly with ACPHT fracture can expect
good functional results, with low complication rate.
About the risk of intraoperative complications – injury of neurovascular structures
In the AIPA and IIA, we deal mainly with the same anatomical neurovascular structures but we look on them from the opposite
side. The main theoretical advantage of AIPA, because we avoid preparation the main vascular structures, would have been
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decreasing the incidence of intra operative injury of the big blood vessels with catastrophic consequences for the patient, that
is the most disturbing drama that can happen in the operative theatre. Our comparative analysis presented in the
Table 1,
Letournel15
does not support this hypothesis, even though
in his series has slightly more percentage of injuries of internal iliac
vein comparing with others.
Retro pubic anastomosis of the external iliac vessels and the obturator vessels or so called “Corona mortis” is a term that was
descriptively used in the past and especially in the Letournel’s IIA as the most dangerous point of the operation that can lead to
massive bleeding6,15. Opposite to that, the anastomosis during AIPA is routinely identified and ligated, and this is a standard
step of the procedure. Even though we are used to think that this dangerous anastomosis is not so often present, and was so
presented in our classical books15, the recent anatomical studies confirm that this anastomosis is present in high percentage,
from 66.7% to 90% with more than half of them when present being with larger diameter than 3 mm40. The obturator vessels
including the anastomosis with the external iliac ones are subject of variations40. If this anastomosis of external iliac vessels and
the obturator vessels is present, and has big caliber, considering the fact as we mentioned above that is a subject of variations,
it can cause serious problems during the IIA. In practice this is unusual and in literature mainly there is a bleeding that has been
successfully controlled.
Since the iliolumbal vessels are so close to the iliopectineal line they are also subject of interest during the AIPA 40. No injury has
been referred in the literature. It is quite interesting that the superior gluteal artery injury has not been mentioned in other
anatomic and clinical studies of interest during the AIPA even though Claude Sagi et al.26 have reported intraoperative bleeding
from superior gluteal artery that required packing and embolisation.
If the femoral nerve and lateral cutaneous nerve of the thigh were subject of injury during the IIA, since the AIPA has started to
been implemented in the clinical practice, the obturator nerve injury of different grades has been brought up as a subject of
interest during this approach. The nerve crosses the iliopectineal line most often in 2 cm distance from the sacroiliac joint, but
with variation40. Sagi et al.26 report a significant adductor weakness in ¼-th of patients, which has recovered after 6 months to
one year after injury/surgery except one. Hirvensalo et al.30, in his study do not refer any injury of obturator nerve, but Cole et
al.27 refer 2 of them.
IIA
No.pt.
Vascular injury
158 IIA
1 injury to the external
iliac vein
3 injuries of the internal
iliac vein
(2.53%)
116
1 laceration of the
femoral artery (0.86%)
Hirvensalo et al.30
164
Andersen R. et al.22
Cole et al.27
Wolf H. et al. 31
Sagi et al.26
17
55
23
57
1 laesion of external
iliac vein after AIPA in
pelvic fracture surgery
(0.61%)
0
0
NR
Superior gluteal artery
injury
20,
leaving permanent
discomfprt in one
female pt
2
0
NR
0
0
NR
0
0
NR
Ponsen et al. 32
25
1 injury of common
femoral artery (4%)
NR
1
NR
Letournel E.
Judet R.15 within
3 weeks
Matta J. 41
Lateral femoral
cutaneous nerve
40 (22.5%)
NR
Femoral nerve palsy
2 transient palsies of
the femoral nerve
1 permanent loss of
the function of
iliopsoas
1
Sciatic
palsies
5 (2.7%)
Obturator nerve
1 peroneal
palsy
0
0
AIPA
NR
0
2
NR
¼ of all pt paslies,
all recovered but
one
NR
Table 3 Intraoperative and immediate postoperative complications
6|Page
About the tissue sparing and postoperative complications
Authors confirm that there is no more need for the middle window of the IIA22 when “Stoppa” window is opened. Avoiding of
the middle window has advantage because we don’t need to open the inguinal canal that theoretically will lead us to less
abdominal wall complication, less operative time, less infection rate, but also very important advantage is that the femoral
blood vessels including lymphatic and nerve are left within their fasciae as we stay far from them and theoretically we would
expect decreased rate of the DVT and other forms of trombembolic complication and also decreased rate of lymphedema. We
analyze the rate of these complications in the selected literature to see if the literature supports these hypothetical advantages
of AIPA versus IIA, or not.
Trombembombolic complications
If we look at the literature the results of large series are comparable to both approaches and they do not allow us to conclude
in favor of one from both approaches. Letournel E.15 in his book refers for 14 DVT’s (2.46%) and 8 PE’s (1.40%) of 569 operated
patients with acetabular fractures, 158 from them where with IIA within 3 weeks after injury. We couldn’t find in his book the
percentage of trombembolic complication that is related only to IIA, and also because of the change on trombo-prophylaxis
during the years when the study has been done and the cases where collected, thus the results are not comparable with other
series. Matta J.14 in his paper refer no DVT and 3 PE (2.58%) of 119 IIA’s. Hirvensalo E et al.24 refer 5 DVT confirmed with
ultrasound or venography (3.04%) and 1 PE (0.60%) on 164 patient treated with AIPA. Ponsen et al. refers a quite big number of
trombembolic complications, but they are related also to patients with pelvic fractures that are included in this study. One of
the DVT’s has developed to PE. Other authors that are listed in the Table below do not refer trombembolic complications after
AIPA.
Letournel15 in his book refer lymphangitis, oedematous swelling at the upper thigh with redness and warmth was seen when he
has started to use IIA. Since he started not to dissect so close the femoral vessels, the phenomena has not appeared no more.
There are no cases of lymphedema after AIPA in the reviewed literature.
IIA
Letournel E.
Judet R.15
within 3 weeks
Matta J. 41
No.pt.
569
(158 IIA)
DVT
14/569
PE
8/569 (1.40%)
2/158
3.86%
Groin hernias
2 (0.35%)
8 (1.4%) asymmetry of
anterior abdominal wall
Heterotopic ossification
7 (4.2%)
1 significant (0.6%)
116
NR
3(2.58%)
2.58%
0
Significant 1/116
5
(4 of them without sy)
NR
AIPA
Hirvensalo et
al.30
164
5(3.04%)
1 (0.06%)
3.1%
0
Andersen R. et
al.22
Cole et al.27
Wolf H. et al. 31
Sagi et al.26
17
0
0
0
0
55
23
57
0
0
0
0
0
0
0
0
0
1
Ponsen et al. 32
25
3(12%)
1(4%)
12%
2 direct (3.5%)
1 atrophy of rectus
(1.75%)
0
0
NR
NR
NR
Table 4 Trombembolic, anterior abdominal wall complication, and Heterotopic ossification in AIPA and IIA
Inguinal canal
When we are at the less invasiveness of this approach we could point out also the sparing of the inguinal canal from dissecting.
This will take less operative time to prepare and for closure but the most important is that we would expect significant decrease
of the rate of groin hernias. Literature does not support this hypothesis.
Letournell15 in his book refers for 2 hernias that require operative intervention and 8 asymmetries of anterior abdominal wall
on coughing. Matta et al.14 in his study refer no groin hernias as a complication of IIA. Claude Sagi et al.26 report for two direct
7|Page
groin hernias and one atrophy of the rectus abdominis muscle on 57 operated patients with AIPA, Cole et al.27 reports 1 inguinal
hernia on 55 operated patients with AIPA. Matta J.14
Operative time
The time is an important factor of the surgery but not the most important one. Longer operative time is related with more
complication related to more tissue trauma and exposure of the wound that leads to increased level of infection, more blood
loss, and increased rate of other local and general complications. Longer operative with more blood loss time makes the
“surgeons second hit” stronger that increases the possibility for adverse outcome especially in elderly patients, politraumatised
or exhausted one.
The operative time is related to type of operative approach. It depends also from the surgeons experience and surgical team,
and also from other technical facilities. If we would have excluded other factors, theoretically (especially if we consider the
preparation of the inguinal canal and also closure of the wound) the AIPA should have been done faster than IIA.
The information about the operative time is insufficient in the literature, since different institutions measure the beginning and
the end of the operative time differently, and also some papers do not refer the operative time. Anyhow, according to the
literature that we have selected as a base for this review that is presented in the
Table 5, we cannot vote in favor of one or other approach.
Infection
Our analysis of the literature presented in the
Table
5 does not show any significant difference in the rate of infection comparing both approaches. Higher level of wound
infection in the Leoturnel’s15 series has been explained from him because of absence of use of prophylactic antibiotics before
1990. After that the incidence of infection has been decreased to 1.4% that is comparable with the incidence after AIPA in the
presented literature. It is noticed that mainly the source of infection is the hematoma that is formed in the lateral window of
IIA, and we are aware that very often (40-60%) of AIPA is followed with the opening of this lateral window.
IIA
Letournel E.
Judet R.15
within 3 weeks
Matta J. 41
No.pt.
Operative time
Blood loss
569
(158 IIA)
NR
62 cases well recorded:
1 case: less than 0.5l
13 cases: 0.5-1l
11 cases: 1-2l
17 cases: 2-3l
20 cases: more than 3 l
Superficial
wound
infections
6 (3.79%)
Deep wound
infection
3(1.89%)+
1(0.63%)late
* Without AB
7/22 op = 31.8%(before 1990)
* With good AB cover
2/146 op = 1.4%
116
3.7h
1500cc
3
0
Hirvensalo et
al.30
164
0
17
Pelvis B-type 760ml
Pelvis C-type 1540ml (ant.
+post. Approach)
IIA for acetabular fr. NR
1063ml
2
Andersen R. et
al.22
Cole et al.27
Wolf H. et al. 31
Sagi et al.26
Ponsen et al. 32
* Pelvis B-type 112min
Pelvis C-type 1h 43 min
(IIA, without post app.)
* IIA for acetabular fr. NR
4.7 hours
1
1
55
23
57
25
?
NR
263 min (4h 23min)
195 (3h 15min)
?
NR
690ml
2000
AIPA
1
1
1
1
Table 5 Operative time, blood loss and Infection rate
8|Page
Results
Although there is an impression that there is no big difference in the presented radiographic and clinical result between both
approaches, our conclusion is that the results in the presented series are impossible precisely to compare and precisely to
conclude. Some of them lack of important information but the most important thing is that in different papers are used
different criteria/scales to present the results of their studies. Also the results are influenced from other factors that are not
controlled in different studies including details of operation that are not standardized, also the postoperative protocol and
other details.
This confirms the need for a prospective multicentric controlled study to get comparable results and also the complication rate
between IIA and AIPA.
IIA
Matta J. 41
116
88
74
%
16
16
%
12
10
%
30
37
%
11
%
7.3
%
6.1
%
38
Poor
Fair
Good
intermediate
62.4%
Good
149
26.27%
Exellent
418
73.72%
Unsatisfactory
>3mm
158 IIA
Clinical results
Very good
Letournel E.
Judet R.15
within 3
weeks
Satisfactory
2-3mm
Reduction criteria
Anatomic
0-1mm
No.pt.
47
%
11
14
%
13.2%
2
2%
AIPA
Hirvensalo
et al.30
164
0-2 mm
138
Andersen R.
et al.22
Cole et al.27
84
%
82
%
17
14
55
Excellent
3-5mm
15
3
Good
64
%
Sagi et al.26
57
35
Ponsen et al.
25
11
32
9
%
18
%
14
0
7
37
%
8
%
0%
Fair+poor
25
%
4
58
%
HHS 2
>80
106 75
>5mm
1
11
%
8
%
5
%
47
%
23
46
%
21
HHS
60-79
22
%
16
%
42
%
9
%
42
%
1
2
%
HHS
<60
13
9
%
2
%
5
10
%
Table 6 Radiografic and clinical results
Conclusion
One must understood that there is no ideal and easy approach for treatment of acetabular fractures. It is always labour and
risky surgery.
The IIA is an approach is used widely also in our country to approach acetabulum from anterior. In our country unfortunately
we still have not implemented the AIPA.
According to some authors AIPA has advantages comparing to IIA. Wide surgical field and easier access to the medial wall of the
innominate bone, much easier and biomechanically reasonable infrapectineal plating 40 especially when dealing with osteopenic
bone, easily postoperative rehabilitation, less invasive dissection with evitation to open the inguinal canal without
2
Harris Hip Score
9|Page
compromitation of the inguinal floor, no dissection around the femoral blood and lymphatic vessels, direct visualization of the
entire pelvic brim, direct visualization and easier access for ligation of the “corona mortis”, direct visualization of the posterior
column22,26, make this approach superior to the IIA.
Will AIPA replace IIA also in our country? There is a lack of controlled prospective study that should be multicentric because of
the low incidence of acetabular fractures to compare the final results, complication rate and other parameters that will lead us
to conclude about the superiority of one or other approach. But according to the presented facts in this review regarding
anatomical and biomechanical advantages, the approach has to be implemented in our everyday practice and we are
comfortable to prefer it, especially because of the fact that comparing the complication rate there is no significant difference
between the both approaches. Based on the low incidence of complication we can consider this approach relatively safe, but
we must know the fact that the approach is technically demanding and it can be considered as a safe one only in hands of
experienced general surgeon30.
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