Surgical Discussion

Patient positioning:  The patient was positioned supine on a standard operating table without traction.

Anatomical surgical approach:  A classical ilioinguinal approach was performed, developing the lateral, middle, and medial windows. The intrapelvic interval was used to access the quadrilateral surface and posterior column. The rhomboid cortical fragment was excised to allow direct visualization and manipulation of the impacted posterior medial dome fragment. Reduction was achieved using a spiked pusher under fluoroscopic guidance. The defect was filled with morselized allograft, and the rhomboid fragment was anatomically reduced. The anterior column was stabilized with a contoured plate. Posterior column reduction was further improved using a reduction clamp applied with one tine lateral to the anterior inferior iliac spine (AIIS) and the other on the quadrilateral surface via the middle window, followed by lag screw fixation.

This case demonstrates that certain impacted dome fragments, which are otherwise inaccessible, can be directly addressed by temporarily removing overlying cortical fragments. The ilioinguinal approach, specifically through the middle window, provided unobstructed access for clamp placement and direct manipulation of both anterior and posterior column fragments. Sequential reduction and stabilization were facilitated by direct visualization and intraoperative fluoroscopy, allowing for anatomical restoration of the articular surface.

Postoperative protocol:   Postoperatively, the patient was maintained non-weight bearing on the affected limb for 8 weeks, with passive range of motion exercises initiated immediately. Progressive weight bearing was introduced at 8–10 weeks postoperatively based on radiographic evidence of healing.

Follow up:   Not specified

Orthopaedic implants used:   Contoured intrapelvic reconstruction plate, contoured anterior column plate, lag screws, morselized allograft