Surgical Discussion

Patient positioning:  Supine position on a radiolucent table to facilitate intraoperative imaging and access to both anterior and posterior columns.

Anatomical surgical approach:  A combined ilioinguinal and modified Stoppa approach was utilized. A midline Pfannenstiel incision was made to access the modified Stoppa window, allowing preperitoneal dissection to expose the quadrilateral plate, medial wall, and posterior column from the internal pelvis. The bladder was retracted inferiorly, and the corona mortis vessels were identified and ligated to prevent bleeding. Next, an ilioinguinal approach was performed through a standard oblique incision parallel to the inguinal ligament. Dissection was carried through the external oblique aponeurosis. The femoral neurovascular bundle and iliopsoas muscle were mobilized to allow access to the pelvic brim and anterior column through the lateral and middle windows. Careful manipulation was required around the keystone fragment, which was closely related to the internal iliac vessels, necessitating meticulous dissection and protection.

The surgeon noted that the anterior column required derotation using a spiked pusher, followed by clamping with a goose clamp and bulldog clamp. The posterior column was reduced and clamped with a goose clamp over the pelvic brim. Despite a wide inferior aspect, fixation was deemed stable without additional screws in the symphysis or sacroiliac joint. A postoperative CT scan confirmed adequate fixation of the posterior column with three screws from the anterior column plate.

Postoperative protocol:   Postoperative rehabilitation included protected weight-bearing for 6 weeks, followed by gradual progression to full weight-bearing as tolerated. Range of motion exercises were initiated early to prevent joint stiffness.

Follow up:   Not specified.

Orthopaedic implants used:   Orthopaedic implants used included a reconstruction plate for the anterior column and three screws for posterior column fixation from the anterior approach.