APACHE-Anterior Plating of the Acetabulum in Hemi-Endoscopic Technique: An Alternative Method for Internal Fixation of the Acetabulum

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.

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.

Fig 2

Schematic 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 3

Anterior 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).

Fig 4

Intraoperative 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).