Anthony P. Pohl

Posterolateral transfibular approach to tibial plateau fractures: technique, results, and rationale.

We describe a posterolateral transfibular neck approach to the proximal tibia. This approach was developed as an alternative to the anterolateral approach to the tibial plateau for the treatment of two fracture subtypes: depressed and split depressed fractures in which the comminution and depression are located in the posterior half of the lateral tibial condyle. These fractures have proved particularly difficult to reduce and adequately internally fix through an anterior or anterolateral approach. The approach described in this article exposes the posterolateral aspect of the tibial plateau between the posterior margin of the iliotibial band and the posterior cruciate ligament. The approach allows lateral buttressing of the lateral tibial plateau and may be combined with a simultaneous posteromedial and/or anteromedial approach to the tibial plateau. Critically, the proximal tibial soft tissue envelope and its blood supply are preserved. To date, we have used this approach either alone or in combination with a posteromedial approach for the successful reduction of tibial plateau fractures in eight patients. No complications related to this approach were documented, including no symptoms related to the common peroneal nerve, and all fractures and fibular neck osteotomies healed uneventfully.

The subcristal pelvic external fixator: technique, results, and rationale.

We report a new technique for pelvic external fixation that we have developed as an alternative to the anterosuperior (Slätis) and the anteroinferior (supra-acetabular) type pelvic external fixator configurations. The method principally differs from the other techniques by virtue of the subcristal positioning of the pins and offers advantages in terms of easier pin placement, less skin irritation, less pin tract infection and loosening, and less interference with hip flexion, while allowing dressing, sitting, and walking. Between 1992 and 2006, we successfully used subcristal pelvic external fixators as the definitive fixation device for 20 patients with pelvic ring disruptions. The only complications encountered were superficial pin tract infections in 4 patients (20%) who were successfully treated with wound care and antibiotics.

Surgical anatomy for pelvic external fixation

Pelvic external fixators have a high rate of reported complications, most of which relate to pin placement. In this descriptive study, we analyzed the morphology of the ilium in cadaveric specimens and compared these with the measures obtained from normal human pelvic computer tomograph scans, and how these related to each of the three basic configurations of pin positioning for the external fixation of a pelvis: anterosuperior (Slätis type), anteroinferior (supra‐acetabular), and subcristal. The irregular shape and size of the iliac wing and the abdominal wall overlying the pins insertion site could hinder accurate placement of anterosuperior pins. Potential disadvantages of the use of anteroinferior pins was found related to the deep location of the anterior inferior iliac spine, interference with the hip flexion area, risk of hip joint penetration, and the variable obliquity of the ilium. As subcristal pins are positioned between two superficial bony landmarks of the iliac crest, our findings suggest that they are more likely to have a correct placement and avoid complications. Clin. Anat. 21:674–682, 2008.