Fractures of the pelvis are uncommon fractures, with bimodal distribution in the population, caused by high-energy trauma in the young, like motor vehicle collision, and by low-energy trauma in the elderly, as falling on the same level. In recent decades there has been a rise in the incidence of these fractures, thanks to the increase in the survival rates of the most critical patients and to the improvement of emergency care [1, 2].
In older age there is an increase of specific patterns of fracture involving the anterior acetabular structures: anterior column, quadrilateral lamina fracture, medial dislocation of the femoral head, and roof impaction (with the specific Gull sign), differ from those in younger patients [20, 21].
The anterior column is formed from a combination of the ilium and pubic bones. Anterior column fracture is an elementary fracture according to the Judet and Letournel classification that could be isolated or involved in an associated pattern of fractures with posterior hemitransverse, T-type, and both columns, that require a specific fixation technique .
A traditional fixation method of these fractures uses lag screws over a suprapectineal plate through the ilioinguinal approach described by Letournel. In addition, an infrapectineal plate could be used to provide a buttress effect against the protrusion of the femur into the pelvis. The combination of a standard pelvic brim plate with lag screws and an infrapectineal plate supporting the quadrilateral lamina resulted in a better fixation construct and provide better stability with the advantages in the prevention of construct failure in situations in which significant lateral to medial force is applied, such as patient falls on homolateral hip [23,24,25,26].
In recent years, new alternative hardware has been introduced for the treatment of anterior acetabular fractures, the suprapectineal QLS plate, which is an anatomic preshaped plate, that represents a valid alternative to the infrapectineal plates, providing a better dynamic buttress effect to the comminuted fragments of the quadrilateral lamina, and preventing the medial subluxation of the femoral head. This hardware allows the simultaneous fixation of the anterior column, with the suprapectinal portion of the plate, and the quadrilateral lamina, with the infrapectineal portion; so are useful in the treatment of different fracture patterns: anterior column, anterior column with posterior hemitransverse, T- type and both columns. They have been specifically designed to prevent secondary medial subluxation of the femoral head, especially in elderly patients with reduced partial load capacity; moreover, screws placed in the quadrilateral lamina extension were not in danger for intraarticular placement as demonstrated in CT scans [4, 27, 28].
In the literature is reported a great variability of osteosynthesis for the treatment of fractures of the anterior column of the acetabulum with the involvement of the quadrilateral surface, without consensus in the choices.
Boni G et al. use a suprapectineal plate with the addition of a stainless-steel locking calcaneal plate, through the modified Stoppa approach, to fix quadrilateral lamina; while Farid YR et al. proposed a cerclage wire-plate composite fixation with an extraosseous cerclage and a reconstruction plate over the pelvic brim [29, 30].
Another possible treatment uses a 3.5 mm or 4.5 mm reconstruction plate on the pelvic brim partially protruding medially into the true pelvis and in addiction one or more buttress screws inserted through the plate holes, on the outside surface of the quadrilateral surface close to the edge of the pelvic brim .
Kulkarni et al. described the treatment of comminuted quadrilateral plate fractures of the acetabulum using a modified Stoppa approach and a spring buttressing plate with good scores in clinical and radiological outcome at 1 year follow up .
In our experience, the AIP approach is associated with the suprapectineal QLS plates. In some cases, if the fracture of the anterior column is high or very displaced can be combined with the first window, the lateral one, of the ilioinguinal approach described by Letournel [4, 5, 33].
In our series, we were able to achieve an anatomical reduction with a postoperative displacement < 1 mm in 26 of 34 cases.
Our clinical and radiographic results are comparable to those obtained by other authors. Archdeacon et al., using a combination of suprapectineal and infrapectineal plates, found an average MAP score of 16 and an excellent MRSS in 15, good in 3, poor in 3; while Tosounidis et al., using a quadrilateral plate reconstruction with a buttress plate through the ilioinguinal approach obtain in 30 patients an MRSS excellent in 11, good in 9, fair in 5 and poor in 5; while the overall functional score was excellent in 17, good in 4, fair in 6 and poor in 3 cases [23, 26].
This shows that the QLS plate in combination with the AIP approach makes it possible to obtain a valid endopelvic exposure of the fracture that allows for a good reduction and consequently a stable fixation.
At the last clinical follow-up examination, all patients reported a good functional restore with no or mild pain and no or slight hip stiffness not particularly affecting their quality of life, but those with an anatomical reduction had an excellent clinical outcome.
The AIP approach utilizing the anatomical-preshaped suprapectineal plate allows anatomic or at least imperfect fracture reduction, according to Matta’s radiological criteria, in 97% of cases of our study.
In our experience, the plates have shown an excellent anti-protrusion effect of the femoral head and quadrilateral lamina, without a record of delayed union or malunion.
This procedure with the combination of a specific anesthesiology technique as the supra-inguinal fascia iliaca compartment block has become the standard procedure in our departments for the fracture of the acetabulum that involves the anterior column .
The strength of our study is that to our knowledge there is no case series in the literature of patients treated with the combined use of the AIP approach and QLS plate.
Limitations of the study are the small number of cases, different follow-up times, lack of a case-control treatment with an alternative fixation method and short-term follow-up.
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