Quadrilateral surface fractures often involve the anterior and posterior acetabulum columns, and the traditional anterior and posterior approach using reconstruction plate fixation is unsatisfactory [6, 7]. There are various new steel plates for treating acetabular fractures involving the quadrilateral surface, with satisfactory clinical results [8–10]. This study used the Weigao anterior pelvic wall locking plate to expose and fix the quadrilateral surface fracture through the lateral rectus approach. The postoperative Matta imaging evaluation of patients showed an 88.6% (31/35) satisfaction rate, according to the modified Merled’Aubigné-Postel scoring standard. The excellent and good rates of hip joint function were 82.9% (29/35). At the last follow-up, all fractures were healed. The belief is that the anterior pelvic wall locking plate has the following advantages:
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Quadrilateral surface fractures often involve the anterior and posterior columns of the acetabulum. When fractures occur, the quadrilateral surface bones tend to shift to the medial side. The anterior pelvic wall plate has a J-shaped design, which is placed on the inside of the ilium, on the arcuate edge, the pubic branch, and the bone is displaced inward. This approach provides a blocking effect from the inside to the outside required to fix the fracture.
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For comminuted fractures in the quadrilateral surface or a bone that is not well blocked, the J-shaped design allows a locking screw to be inserted through the fixation hole on the front wall, providing a fence and blocking the bone in the quadrilateral surface. Therefore, the block is shifted to the inside. Clinical studies and biomechanical experiments have shown that the steel plate placed on the inside of the arcuate edge has good fixation effects on the bone masses involved in the quadrilateral surface of the acetabular fracture and effectively prevents the bone mass from outside shifting to the medial side [11, 12]. In this study, the anterior pelvic wall plate was placed on the inner side of the arcuate edge. After follow-up, there were no displacements of the quadrilateral surface to the medial side, and the fixation effect was satisfactory.
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The steel plate is easily placed. The arcuate edge of the acetabulum, the iliac pubic bulge, and the anatomical structure of the suprapubic branch are uneven. If the steel plate is placed here, it is difficult to shape and attach during surgery. Moreover, the acetabular anterior, the posterior column, and the quadrilateral surface bone blocks become limited at fixation [13].
The iliac arteries and veins and the femoral nerves are close to the iliac pubic tuberosity and the superior pubic branch. Therefore, the ilioinguinal approach requires the anatomy of the inguinal ligament, pubic ligament, and other structures to expose the blood vessels, nerves, and bone surface before the plate can be easily placed. This process increases the difficulty of operation [14].
This research employed the lateral rectus approach. After separating the second and third windows, the steel plate was inserted from the third window. The steel plate was placed on the inside part of the iliac bone through the field of view exposed by the second and third windows, arcuate edge, suprapubic branch, and the J-shaped structure inside the quadrilateral surface, properly fixing the bone in the quadrilateral surface.
The reduction quality of acetabular fractures of the quadrilateral surface is closely related to surgical exposure [15]. However, quadrilateral surface exposure is a difficult procedure in the intraoperative treatment of acetabular fractures involving the quadrilateral surface.
Several methods are applied to expose the quadrilateral surface. Letournel first reported the traditional ilioinguinal approach in 1993 for treating acetabular, anterior column fractures [15]. The surgical approach shows the pubic branch, arcuate edge, sacroiliac joint, iliac fossa, etc., and indirectly exposes the quadrilateral surface of the acetabulum.
The modified Stoppa approach [16, 17] reveals 79% of the inner true pelvis, 80% of the square area, 2cm above the true pelvic rim, and 5cm below it. This approach is suitable for the exposure and fixation of quadrilateral surface fractures, but not in severely obese patients and has developed abdominal muscles. It is difficult to expose and fix the fracture in patients with bladder injury or surgery using this approach. The method should be combined with the iliac fossa approach if an ipsilateral iliac bone fracture accompanies the fracture.
Keel [18] first reported in 2012 that the pararectus approach was used for treating acetabular fractures. It suitably treated the anterior column with square fractures. This approach is characterized by small surgical trauma and minimal invasiveness. Presently, this single approach can treat patients suitable for the Letournel-Judet classification and does not involve posterior wall fractures.
In this study, the lateral rectus approach was used to expose the square bone mass, the anterior wall of the acetabulum, the arcuate edge, the sacroiliac joint, and the medial edge of the iliac bone. The window was exposed during the operation. At this point, it was necessary to identify the arteries and veins under the abdominal wall, ligate them as a breakthrough, and then dissect the surgical window. The 35 patients in this study were exposed to the quadrilateral plate through the lateral rectus approach. The operator needed to be familiar with the anatomy, gentle intraoperative movements to avoid breaking the peritoneum, and familiar with separating the inferior abdominal arteries and veins for ligation.
The second window required gentle separation of the iliac blood vessels and femoral nerves to avoid damaging the vascular and nerve tissues. Simultaneously, a clear vision is required when inserting steel plates and screws to avoid damaging the blood vessels when inserting nails.
The choice of internal fixation is critical for maintaining the quality of acetabular fracture reduction. The key to surgical treatment is to prevent inward and downward displacement of the bone in the quadrilateral surface. Presently, there are numerous methods for internal fixation when treating fractures in the quadrilateral surface. They include: wire cerclage combined with nail plate system [19], percutaneous screw technology [20], reconstruction plate combined with square area steel plate elastic fixation [21], quadrilateral surface titanium plate and screws that are directly fixed, anatomical type, and 3D printed quadrilateral plates [22]. However, no internal fixation device can solve all the fracture problems involving the quadrilateral plate.
In this study, a locking plate on the anterior pelvic wall was adopted to treat the acetabular fracture involving the quadrilateral surface through the lateral rectus approach. The follow-up results were satisfactory, and the hip joint function was good. Therefore, the fracture can be exposed from a single approach and well fixed. This study is preliminary with a small number of cases and can only be discussed from clinical follow-up. This study showed that the anterior pelvic wall plate fixes acetabular fractures and fractures involving the quadrilateral surface from the inside-out with satisfactory reduction and good hip joint function. The clinical follow-up shows that the clinical effect of using the anterior pelvic wall plate to treat fractures involving the quadrilateral surface is satisfactory. However, the internal fixation lacks biomechanical experiments.