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When performing an anterior intrapelvic approach to the acetabulum, ligation of the anastamoses between the obturator vessels and which of the following vessels should be performed to gain appropriate access to the true pelvis?
External iliac vessels
Internal iliac vessels
Superior gluteal vessels
Femoral cutaneous vessels
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The Stoppa, or anterior intrapelvic approach, requires ligation of the corona mortis (defined as the vascular connections between the obturator and external iliac systems) to gain visualization laterally and into the true pelvis.
The corona mortis is located behind the superior pubic ramus at a variable distance from the symphysis pubis. The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if inadvertently cut and it is difficult to achieve subsequent hemostasis.
Tornetta et al. performed a cadaveric dissection to determine the occurrence and location of the corona mortis. They found that an anastomoses between the obturator and external iliac systems occurred in 84% of the specimens. Thirty-four percent had an arterial connection, 70% had a venous connection, and 20% had both.
Archdeacon et al. discuss the indications, set-up, and technique for the Stoppa approach to the pelvis. They state that the vascular anastomoses between the external iliac and obturator vessels are encountered as the artery and vein course over the superior ramus traveling toward the obturator foramen. They state that these vessels must be ligated or clipped to advance the dissection further along the pelvic brim and quadrilateral surface.
Illustration A shows the corona mortis as an anastomoses between the obturator and external iliac vascular systems.
Answers 2-5: These do not typically anastomose with the obturator vessels.
Tornetta P, Hochwald N, Levine R
Clin. Orthop. Relat. Res.. 1996 Aug;(329):97-101. PMID: 8769440 (Link to Abstract)
Tornetta, JOT 1996
Archdeacon MT, Kazemi N, Guy P, Sagi HC.
J Am Acad Orthop Surg. 2011 Mar;19(3):170-5. PMID: 21368098 (Link to Abstract)
Archdeacon, JAAOS 2011
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A 55-year-old male involved in a motor vehicle collision sustains an acetabular fracture. Which of the following approaches would provide the best exposure for open reduction internal fixation of the displaced fragments seen on the 3-D CT image in Figure A?
Modified Stoppa approach
Medial window of the ilioinguinal
Simultaneous anterior and posterior exposure
Figure A represents an acetabular fracture pattern with medial displacement of the quadrilateral plate. Limited bone stock and anatomic access create a surgical challenge to treat these fractures. Both an ilioinguinal and modified Stoppa approach allow access to this area. However, use of the Stoppa approach often allows the middle window of the ilioinguinal approach to be avoided, resulting in minimal dissection of the inguinal canal, femoral nerve, and external iliac vessels.
Cole et al discuss their initial experience using the modified Stoppa approach for fixation of acetabular fractures. Of the 55 fractures treated, 89 % of the post operative radiographs had either an excellent or good rating.
Qureshi et al discuss their technique for infrapectineal plating that allows for stable fixation by resisting medial displacement through the quadrilateral surface.
Cole JD, Bolhofner BR
Clin. Orthop. Relat. Res.. 1994 Aug;(305):112-23. PMID: 8050220 (Link to Abstract)
Cole, CORR 1994
Qureshi AA, Archdeacon MT, Jenkins MA, Infante A, DiPasquale T, Bolhofner BR.
J Orthop Trauma. 2004 Mar;18(3):175-8. PMID: 15091273 (Link to Abstract)
Qureshi, JOT 2004
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