00:00:08
so when we make our fan and steel
00:00:10
incision we're going to come down onto
00:00:14
the rectus fascia and as we expose the
00:00:18
rectus fascia we're going to try to come
00:00:22
as far distantly not just on
00:00:26
top of the pubic body but we're actually
00:00:30
going to want to come down over the
00:00:34
front of the pubic body anteriorly here
00:00:38
like this so that we see the rectus
00:00:42
fascia coming down inserting on the
00:00:44
anterior aspect as well as the superior
00:00:47
aspect of the pubic bodies you have to
00:00:50
keep in mind that
00:00:53
the rectus fascia has a very broad Apon
00:00:57
neotic sort of insertion on the pubic
00:01:01
it's not just superiorly it goes all the
00:01:04
way down the front of the pubic body so
00:01:06
here's rectus fasha we'll just expose
00:01:09
that a little bit
00:01:19
more so here we have the rectus fascia
00:01:23
exposed anly remember that above the
00:01:27
umbilicus there is a posterior and an
00:01:30
anterior rectus fascia but below the
00:01:32
umus here there's really only an
00:01:34
anterior rectus fascia on the posterior
00:01:38
surface of the rectus there's only one
00:01:40
thin layer of transversalis
00:01:42
fascia so the midline generally can be
00:01:47
found by looking for the decoation or
00:01:50
crossing of the rectus fibers here and
00:01:53
here and remember we want to come down
00:01:56
as anterior as we possibly can so here's
00:01:59
the decoation or crossing of the
00:02:00
anterior rectus fibers sometimes you can
00:02:03
actually palpate the linear
00:02:05
Alba but we're going to come right
00:02:08
through
00:02:10
here and it's important to remember that
00:02:14
we want to try and split the rectus as
00:02:17
high proximally as we
00:02:21
can the thing that makes people the most
00:02:24
nervous about doing this is that they
00:02:26
inadvertently get into the perial cavity
00:02:29
if you do get into the peral cavity all
00:02:32
we have to do from that
00:02:34
standpoint is take a little bit of
00:02:36
chromic and just close it up so if we
00:02:40
look here we can see that the division
00:02:43
between the two halves so the two heads
00:02:45
of the rectus is going to be right in
00:02:47
here we'll come right through there and
00:02:49
we're going to elevate this portion of
00:02:52
rectus away from the left side
00:03:00
and then you'll see that posteriorly
00:03:02
here we're going to have that one very
00:03:05
thin layer of transversalis fascia which
00:03:08
is right here so we've found the
00:03:12
interval between the right and the left
00:03:15
half of the rectus gone through the
00:03:16
linear
00:03:17
Alba and now we've split our rectus nice
00:03:21
and high a good at least a good 10 cm up
00:03:25
from the the pubic
00:03:28
symphysis and this this fine layer of
00:03:32
fascia is the transversalis fascia here
00:03:34
posterior to the rectus and we haven't
00:03:36
gone through it yet we're just
00:03:38
mobilizing the right rectus and taking
00:03:40
it over to the
00:03:41
contralateral
00:03:43
side now we're going to relax on this
00:03:46
retractor and we're going to put it
00:03:50
distally so that we can see down the
00:03:53
front of the pubic body now and I'm
00:03:56
going to take the knife and we're going
00:03:59
to now release the
00:04:01
rectus off of the
00:04:04
superior and then the anterior aspect to
00:04:08
the pubic bodies here it's important to
00:04:11
recognize that if we just were to
00:04:14
release only the superior portion
00:04:17
attachment right here in the pubic body
00:04:18
and leave all of this part still
00:04:21
attached we're not going to be able to
00:04:23
mobilize the rectus like we want to so
00:04:26
we're going to come down the front of
00:04:29
the pubic body like this we're not going
00:04:32
to dissect or release the symos ligament
00:04:34
but we are going to take the rectus off
00:04:38
of the front of the pubic body like this
00:04:42
so that's a sleeve of rectus right there
00:04:44
that we're bringing up off of the
00:04:46
anterior aspect of the pubic body and
00:04:49
I'm going to keep doing this keep coming
00:04:51
out laterally
00:04:54
here like that there's still the rectus
00:04:57
is still inserted distantly in the pubic
00:04:59
body and still inserted laterally on the
00:05:01
pubic body but I'm just taking the more
00:05:03
medial and
00:05:04
anterior portion of it off coming this
00:05:08
way underneath it and we're going to get
00:05:09
out to the pubic
00:05:13
tubic you can see that we still have our
00:05:15
transversalis fascia intact right here
00:05:17
and we're going to address that in a
00:05:19
second so as I get to this point here
00:05:22
you can see that I've taken this whole
00:05:24
sleeve of rectus and now we're laying it
00:05:27
over and the final part really is just
00:05:30
going to be getting out right here right
00:05:33
to that point right there which is now
00:05:35
lateral to the pubic
00:05:42
Tule and this is where we're going to
00:05:44
put in retractor number one so retractor
00:05:48
number one remember it goes right in
00:05:51
that spot right there which is just
00:05:52
anterior the medial aspect of the
00:05:55
superior pubic Ramis just lateral to the
00:05:57
pubic Tule so this retractor number one
00:06:01
is going to come in here and we're going
00:06:03
to just slide it just anterior to the
00:06:06
superior pubic Ramis and then we're
00:06:08
going to take a
00:06:10
stabilizing kwire and put it through the
00:06:13
retractor to hold it in
00:06:21
place so now we have the distal aspect
00:06:24
of the rectus out of the way and the
00:06:26
next part here is going to be coming
00:06:27
through this fine layer of transversalis
00:06:30
fascia and a lot of times you can do
00:06:33
that just by finger dissection and you
00:06:35
come into the retropubic space of Rus
00:06:37
here which is between the bladder and
00:06:39
the posterior aspect of the pubic body
00:06:43
so here's pubic symphysis
00:06:47
midline and here is all of that
00:06:50
transversalis fascia and then we're just
00:06:52
going to take your finger and we're just
00:06:54
going to split the transversalis fascia
00:06:56
approximately like this
00:06:59
now when you come through that layer of
00:07:01
transversalis fascia you're going to
00:07:03
notice that there
00:07:05
are
00:07:08
adhesions between the bladder which is
00:07:11
here and the unders surface of the
00:07:14
rectus so the first thing you're going
00:07:16
to do is with finger dissection you're
00:07:17
just going to sweep your finger on the
00:07:19
under surface of the
00:07:21
rectus to break down and get rid of all
00:07:24
of those little fascial adhesions
00:07:27
between the bladder and and the rectus
00:07:30
because as we move the rectus in this
00:07:32
direction we want the bladder to stay on
00:07:35
the side of the surgeon not the side of
00:07:37
the fracture if we if we don't take
00:07:39
those adhesions down as we retract the
00:07:42
rectus towards the side of the fracture
00:07:44
we're going to pull the bladder with it
00:07:46
and we're not going to be able to
00:07:48
visualize as well so we need to break
00:07:51
down those adhesions between bladder and
00:07:53
under surface of rectus once we got that
00:07:56
now we can start working along the uh
00:07:59
Superior pubic Ramis in the anterior
00:08:01
column well the next phase of this
00:08:04
operation is going to be dissecting
00:08:06
along the superior pubic Ramis which is
00:08:10
right here pubic body and the pubic
00:08:12
symphysis is right here this is superior
00:08:15
Ramis here's the pubic
00:08:17
tubic and the retractor number one is
00:08:19
just lateral to the pubic tubic come
00:08:22
along the superior pubic Ramis here all
00:08:25
right we have the bladder is being
00:08:27
retracted away from us so it's falling
00:08:29
away from the anterior column and the
00:08:31
superior pubic Ramis and in this fascia
00:08:35
here is where we're going to encounter
00:08:38
an
00:08:39
anastomosis between the external iliac
00:08:41
vessels which are behind this retractor
00:08:44
and the operator vessels which are down
00:08:46
here you can just start to see a hint of
00:08:49
the arbitrator nerve coursing right here
00:08:52
coming towards the operator Framing and
00:08:55
exiting there so this vessel that's
00:08:57
coming down here is coming from from the
00:09:00
external iliac down over the superior
00:09:02
Ramis into the operator frame into
00:09:05
Anastos between the external and the
00:09:06
internal iliac
00:09:08
system so depending on the size of this
00:09:11
vessel it can either be cauterized or
00:09:16
might need to be ligated if it's a
00:09:18
little bit larger this one in this case
00:09:20
is a little bit larger and we' probably
00:09:22
elect to put a hemoclip or ligate
00:09:25
instead of just cauterizing it but that
00:09:28
vessel has to
00:09:30
be
00:09:32
ligated Bovi something has to be out of
00:09:35
the way in order that we can continue
00:09:38
with the dissection along the superior
00:09:41
pubic Ramis and the anterior column
00:09:44
here because the next tissue that we're
00:09:47
going to encounter is going to be the
00:09:50
iliopectineal fascia which is this
00:09:53
reflection of fascia right here coming
00:09:55
from the superior pubic Ramis up all
00:09:59
right
00:10:01
now an important thing to remember
00:10:04
although people tend to want to try to
00:10:07
contrast the IL wiell to the anterior
00:10:11
intrapelvic in
00:10:14
actuality the surgery is the
00:10:17
same and the general philosophy is the
00:10:20
same and that is is that in order to do
00:10:25
a good anterior approach to the pelvis
00:10:27
or the acetabulum we need to be able to
00:10:33
connect the false pelvis which is the
00:10:36
internal iliac fossa over there
00:10:38
laterally and the true pelvis down here
00:10:41
where the bladder is everything below
00:10:43
the brim so the only way to do that the
00:10:46
only way to connect those two cavities
00:10:48
or those two spaces is to release the IL
00:10:52
optinal fasia which is right here off
00:10:55
the superior pubic Ramos so in an
00:10:57
ilioinguinal approach through through
00:11:00
window number two or the middle
00:11:02
window we would come through we start
00:11:04
from the false pelvis we would release
00:11:06
the IL optinal fascia come down to the
00:11:09
brim and that would connect us to the
00:11:11
true pelvis if we're doing an anterior
00:11:14
intrapelvic approach or an
00:11:16
AIP we're starting in the true pelvis
00:11:19
we're going to release the IL optinal
00:11:21
fascia and that's going to allow us to
00:11:24
get access up into
00:11:27
the false pelvis above the brim here we
00:11:31
can
00:11:31
see the external iliac vein coming from
00:11:36
above here above the brim down into the
00:11:39
pelvis so as we do this we're going to
00:11:42
place this retractor which can be a dver
00:11:45
or anything else underneath the external
00:11:47
iliac vein to protect it and keep it out
00:11:49
of the way so that we just expose the
00:11:51
whole pelvic brim for us this is not a
00:11:55
vein this is the iliacus muscle this
00:11:58
little purple
00:12:00
uh bit of tissue right here so first
00:12:03
order business is going to be to release
00:12:04
the IL optinal fascia so we're going to
00:12:08
take our knife and here's the superior
00:12:09
pubic ramus we're going to come right
00:12:11
along the brim we're going to run our
00:12:13
knife right on bone and we're going to
00:12:16
release that iliopectineal fascia
00:12:19
underneath that is going to be some
00:12:20
pectineus
00:12:26
muscle and we stay right on bone and
00:12:29
we're safe the whole time the external
00:12:31
iliac vein is above us the arbitrator
00:12:34
neurovascular bundle is down well below
00:12:37
us along the quadrilateral surface so
00:12:39
there's there are no structures at risk
00:12:41
here and we have the hip
00:12:45
flexed so once we've released the fascia
00:12:48
off of the superior pubic Ramis the IL
00:12:51
optinal fascia we're going to come with
00:12:53
an elevator and now this is going to
00:12:55
allow us to slowly get in underneath
00:12:59
the ilos soos muscle and tendon over the
00:13:02
front of
00:13:05
the superior pubic
00:13:08
Ramis and you'll recognize that the
00:13:12
anterior column or the anterior part of
00:13:14
the pelvic ring is really just a series
00:13:16
of Hills and Valleys the pubic body is a
00:13:20
hill and then as you come down lateral
00:13:23
to the pubic Tule you get into a valley
00:13:25
which is a superior pubic Ramis as we
00:13:27
come out farther laterally the pubic
00:13:29
root is another Hill that we Elevate up
00:13:31
over top of and then on the other side
00:13:34
of the pubic root is the so's Gutter and
00:13:37
we're going to want to get into the so's
00:13:40
gutter with a retractor so that we
00:13:43
because we're going to actually want to
00:13:47
elevate the tissues off of the superior
00:13:49
pubic Ram so that we can see the
00:13:51
entirety of the superior pubic Rus out
00:13:53
to the pubic root like this and then
00:13:57
eventually over into the se's
00:14:00
gutter we can't put in retractor number
00:14:02
two yet until we get out as far as the
00:14:06
so's gutter in the anterior wall so we
00:14:08
can take a sharp Homan and just put it
00:14:11
over the front of the superior pubic
00:14:14
Ramis so now you can see we have
00:14:17
Superior pubic Ramis this is the
00:14:19
beginning or the medial aspect of the
00:14:21
pubic root right here and then we're
00:14:23
coming in underneath the iliacus muscle
00:14:26
here and so as as we come in we're going
00:14:30
to just stay on bone and stay underneath
00:14:33
the iliacus
00:14:35
muscle generally taking it away from its
00:14:38
origin on the pelvic brim coming in
00:14:41
underneath it and then that will now
00:14:43
allow us to get out as far lateral as
00:14:46
The soas
00:14:47
Gutter and the base or the beginning of
00:14:50
the anterior wall of the
00:14:54
acetabulum up to this point our entire
00:14:57
dissection is staying above the pelvic
00:15:00
brim sucal and into the internal iliac
00:15:04
fossa once we have all of that iliacus
00:15:07
and ilos soos
00:15:10
mobilized we can take retractor number
00:15:16
two and then we're going to run it
00:15:19
underneath the iliacus and ilos muscle
00:15:22
tenant out into the so's Gutter and out
00:15:26
towards the base of the and interior
00:15:29
wall so we can take this home and out so
00:15:32
now we can see Superior pubic Ramis
00:15:37
coming out and we can see all of the
00:15:39
pubic root here and then now this is
00:15:42
getting up into the internal iliac fausa
00:15:44
there while we're still above the pelvic
00:15:49
brim and in the internal iliac fausa it
00:15:51
is important that we recognize where the
00:15:55
arbitrator nerve is and we can take with
00:15:59
either finger dissection through this
00:16:00
loose areola and fatty tissue or with a
00:16:04
pair of Mets and bound scissors
00:16:06
something but just to mobilize it and
00:16:10
see where it runs as it runs proximately
00:16:13
just over the sacr iliac joint up
00:16:16
towards the lumbo sacral plexus
00:16:19
because there is still right here you
00:16:22
can see and now my my uh Mets right now
00:16:26
are just at the anterior aspect of the S
00:16:28
really joint and you can see that
00:16:30
there's still a band of fascia here just
00:16:33
lateral to the obturator nerve which is
00:16:35
here so there's this band of fascia
00:16:38
right here that still is tethering the
00:16:40
iliacus and the iloo
00:16:43
muscle so we come in with a BBY or an
00:16:47
elevator and we just want to release
00:16:49
that
00:16:51
fascia so that it's released and we get
00:16:54
in much more and that will allow us to
00:16:56
mobilize the iliacus and ilos soos
00:16:59
muscle much more out of the way and'll
00:17:02
facilitate getting in retractor number
00:17:04
three substantially so really you're
00:17:06
really want to get a good idea of where
00:17:08
that OB trator nerve is is running is
00:17:10
running and where it is and and not only
00:17:13
that but having the obrador nerve
00:17:15
dissected and mobilizing this is going
00:17:17
to help us a lot with the second aspect
00:17:20
or the second half of this exposure
00:17:21
which is getting down onto the
00:17:23
quadrilateral surface and the posterior
00:17:25
column down here so we're going to take
00:17:29
retractor number three now and we're
00:17:32
going to put it right here underneath
00:17:35
the
00:17:36
iliakis and then we're going to just run
00:17:39
this up and lateral to the sacroiliac
00:17:42
joint all right and if you look in there
00:17:45
you can see where the arbitrator nerve
00:17:47
is you can see that this retractor is
00:17:50
just lateral to the cilc joint and
00:17:52
lateral to where
00:17:56
the uh arator nerve is running
00:18:00
now this this retractor here has two
00:18:05
kwire stabilization points in it one
00:18:08
that's more medial and one that's more
00:18:10
lateral we're going to choose to put a
00:18:12
stabilization pin into the more lateral
00:18:15
of the two holes so that it will
00:18:21
stay out of the
00:18:24
way of our anterior column buttress
00:18:26
plate when it comes time we only want
00:18:29
one point of fixation so that we can
00:18:31
rotate it because we want to keep this
00:18:34
retractor parallel to the axis that
00:18:39
the that the uh external iliac vein and
00:18:42
artery are running in so that they
00:18:46
don't get tented over the edge of the
00:18:50
retractor all right so
00:18:53
now we can see
00:18:57
the internal the lower part of the
00:19:00
internal iliac fossa all the way back to
00:19:02
the SI joint which is right here there's
00:19:06
OB trator nerve running up just over the
00:19:09
anterior aspect of the SI joint coming
00:19:11
down towards the operator
00:19:13
foramen this is all pelvic brim from SI
00:19:16
joint pelvic brim pelvic brim coming up
00:19:20
here Superior pubic Ramis and then
00:19:24
finally back to pubic body and pubic
00:19:26
tubal right here so really with this
00:19:29
exposure so far what we've done just by
00:19:32
mobilizing the ilos soos and the rectus
00:19:35
we can see the entire aspect of the
00:19:37
lower portion of the anterior column as
00:19:39
well as the internal probably the lower
00:19:41
half of the internal iliac fosser right
00:19:44
to the Celiac joint here all right next
00:19:48
part of this is going to be coming down
00:19:51
the quadrilateral surface in the postor
00:19:53
column so again we have our arbitrator
00:19:55
nerve mobilized and it's important to
00:19:57
mobilize the OB at nerve because we're
00:20:00
going to have to eventually work on both
00:20:03
sides of it up here and down here
00:20:05
underneath it but the lower we get down
00:20:07
onto the posterior column we can't
00:20:11
continue to retract the med operator
00:20:13
nerve medially so we're going to have to
00:20:15
start working below it down
00:20:17
here all
00:20:19
right so by way of
00:20:22
orientation looking at the quad upper
00:20:24
portion of the quadrilateral surface in
00:20:26
the posterior column this is the OB
00:20:28
internis muscle and a lot of times in
00:20:31
the fracture scenario this muscle is
00:20:33
already going to be disrupted and torn
00:20:36
some cases it's not and you have to
00:20:38
release its fascia away from the pelvic
00:20:41
brim here so that we can start to
00:20:43
release it and mobilize it away from the
00:20:46
posterior column and the operator or the
00:20:49
posterior column and the quadrilateral
00:20:50
surface so we're going to start above
00:20:52
the nerve here and we're just going to
00:20:54
start releasing and
00:20:56
mobilizing the obit trator internis
00:20:59
muscle now you can start to see here
00:21:01
below the brim you can start to see the
00:21:05
bone and the surface of the posterior
00:21:07
column and the quadrilateral surface so
00:21:10
we're just going to keep releasing and
00:21:13
sometimes this muscle is disrupted or
00:21:16
badly damaged and if that's the case you
00:21:18
can take some of it out debride some of
00:21:20
it with a round jure but now as I'm
00:21:23
coming further down the quadrilateral
00:21:25
surface and the posterior CM I'm going
00:21:27
to come in here underneath
00:21:29
the arbitrator nerve and
00:21:33
continue to mobilize the arbitrator
00:21:35
internis muscle and this way I'm not
00:21:38
putting any
00:21:40
tension on the obit terator nerve and
00:21:43
avoiding the
00:21:45
weariness of the obturator nerve that
00:21:48
some people
00:21:49
are can be concerned about which is
00:21:53
clearly an issue we don't want to cause
00:21:55
any iatrogenic injury to the obit
00:21:58
terator nerve a point uh of
00:22:02
consideration here during this
00:22:03
dissection and and another uh endorsment
00:22:06
of lateral femal traction is that with a
00:22:09
lot of these fractures where there's a
00:22:11
lot of displacement of the quadrilateral
00:22:13
surface and the posterior column into
00:22:16
the pelvis because of the femoral head
00:22:18
what that does is it puts a lot of
00:22:20
tension on the opor nerve and an obit
00:22:23
trator nerve here will be will be tented
00:22:27
or stretched
00:22:29
over that fracture fragment of the
00:22:32
quadral surface in the posterior column
00:22:34
it'll be in like this so getting the
00:22:36
femal head out and with ligamentotaxis
00:22:39
or capsula taxis pulling that quadral
00:22:43
surface in the in the postor column back
00:22:45
laterally it takes tension off of the
00:22:47
operator nerve and it makes the
00:22:49
dissection actually quite a bit
00:22:52
easier so I'm going to continue to just
00:22:55
peel OB trator and turnus off of the
00:22:59
posterior column here in this situation
00:23:02
since this is a cadaver and it's not
00:23:03
fractured you can see right here the
00:23:06
obor vein is still intact as is the
00:23:08
artery that runs with it and in the
00:23:11
fracture scenario that's
00:23:14
often torn so as we continue to take off
00:23:19
the operator internis muscle from the
00:23:22
posterior column and quadrilateral
00:23:24
surface we'll get to a point where we
00:23:27
come into the greater sciatic Notch
00:23:29
which is right here so the cob is coming
00:23:33
down posterior column and now it's into
00:23:35
the greater sciatic Notch here and you
00:23:36
can see I'm working below the arbitrator
00:23:39
nerve so as we do this we have to keep
00:23:44
in mind that to facilitate this
00:23:46
reduction what we've done is we've
00:23:49
flexed the hip so that we can relax the
00:23:53
ILO soos but by doing that we put a
00:23:57
little bit more tension
00:23:58
onto the sciatic nerve just like we
00:24:01
would if we were doing an ilioinguinal
00:24:03
so anytime we do any dissection down
00:24:06
here along the posterior border of the
00:24:09
medial surface of the posterior column
00:24:11
which is right here we have to be
00:24:13
careful as we come into the greater not
00:24:15
so we don't do any plunging because
00:24:17
that's going to put some pressure onto
00:24:19
the stic nerve and potentially injure
00:24:21
the stic nerve so keep in mind that the
00:24:23
satic nerve even though this is an
00:24:24
anterior exposure that the satic nerve
00:24:27
is something that in our operative field
00:24:29
but this cob here is now on
00:24:32
the posterior border of the posterior
00:24:34
column right in the greater sciatic
00:24:36
Notch now and this dissection will be
00:24:38
carried down dist in this fashion all
00:24:41
the way here onto the iscal spine and
00:24:45
this cob right here this tissue here is
00:24:49
the iscal spine and the distal insertion
00:24:52
of the sacrospinous ligament right there
00:24:54
so this is all from here to here this is
00:24:57
all greater static frame in a greater
00:24:59
Notch coming down and then onto iscal
00:25:02
spine right there so we have essentially
00:25:06
the entire medial surface of the
00:25:08
posterior column from the lateral to the
00:25:11
sac joint the pelvic brim the whole
00:25:14
surface of the posterior column all the
00:25:16
way down to the iscal spine exposed as
00:25:20
well as the quadrilateral surface which
00:25:23
is right in this whole area right here
00:25:26
it's all quadrilateral surface so we
00:25:29
have that whole bit of of acetum now
00:25:32
exposed so we can control manipulate and
00:25:35
even fixate the posterior column from
00:25:38
its medial aspect here have access to
00:25:41
the quadrilateral
00:25:44
surface pelvic brim from the SI joint
00:25:48
all the way to the pubic body and the
00:25:51
lower half of the internal iliac fausa
00:25:55
and here along the anterior column over
00:25:57
the pubic root and this is so's gutter
00:26:00
right here so we have all this exposure
00:26:04
through this anterior inter pelvic
00:26:07
window right here the final retractor
00:26:11
the suction
00:26:13
retractor is used at the base of the
00:26:16
wound once we finally dissected along
00:26:18
the quadral surface and into the
00:26:20
posterior column and greater static
00:26:22
framing so this portion the blunt
00:26:25
portion of this retractor is going to be
00:26:26
placed right onto either the posterior
00:26:30
column or into the greater sciatic Notch
00:26:33
carefully so
00:26:36
that the bladder can be pushed out of
00:26:40
the way like this and so this retractor
00:26:44
is going to help to it's going to come
00:26:46
in underneath the obturator nerve which
00:26:48
is right here remember it's medial to
00:26:51
the nerve so the nerves not being
00:26:52
retracted with the suction
00:26:54
retractor the tip of the retractor goes
00:26:56
into just the beginning part part of the
00:26:58
greater satic framan and levers on that
00:27:01
posterior aspect of the posterior column
00:27:03
and then this portion of the retractor
00:27:05
here is pushing the bladder out of the
00:27:07
way so that it improves our
00:27:09
visualization down here into the pelvis
00:27:12
so now we see that whole pelvic brim we
00:27:13
see the quadrilateral surface and we see
00:27:15
the posterior column and then here's the
00:27:18
iscal
00:27:19
spine all right at the same time the
00:27:23
suction is evacuating any of the fluids
00:27:25
that are corre collecting down here at
00:27:27
the base of the
00:27:33
wound this is the Sprite screw inserter
00:27:36
we'll just demonstrate the use of it and
00:27:39
sometimes uh what we'll we'll assume
00:27:41
that we have our reduction clamps in
00:27:43
place and now we're putting in screws
00:27:47
to replace reduction clamps with either
00:27:50
position screws or lag
00:27:53
screws canula for the drill is in place
00:28:01
the calibrated drill bit comes in and
00:28:03
we're going to drill from the brim out
00:28:05
towards the suas toab our bone
00:28:08
posteriorly in this
00:28:10
situation and when I feel that we've
00:28:12
come to that far
00:28:17
CeX we're going to measure the depth off
00:28:19
the calibration with the
00:28:22
sleeve then the
00:28:25
drill the inner canula would be be
00:28:30
removed and then we will take a
00:28:34
screw and place it
00:28:37
in and then we'll follow with
00:28:41
the screw
00:28:47
driver until the screw is seated
00:28:59
it's important to remember where the
00:29:01
arbitrator nerve is and
00:29:04
where the retractor number three is
00:29:06
remember that this this plate is going
00:29:11
to come to
00:29:13
lie lateral to the obturator nerve and
00:29:17
you can see where it's sitting now just
00:29:20
lateral to the sck reallya Joint
00:29:23
proximally up here it has to be medial
00:29:28
to the stabilization pin in retractor
00:29:30
number three here so that's why we try
00:29:32
to use the more lateral of the two pin
00:29:34
slots so that our anterior column
00:29:37
buttress plate can come up and lay down
00:29:39
nicely just lateral to the Celiac joint
00:29:42
which is right here that's the sac joint
00:29:45
there's our obturator nerve so our plate
00:29:47
has come in along the quadrilateral
00:29:50
surface just lateral to the obturator
00:29:53
nerve
00:29:54
now like we've discussed in the past the
00:29:58
this is a buttress
00:29:59
plate that has to buttress both the
00:30:02
anterior column and the quadrilateral
00:30:05
surface the plate itself is not a
00:30:07
reduction tool we should have the
00:30:09
posterior column the anterior column
00:30:11
everything reduced before replacing our
00:30:14
neutralization plate
00:30:15
here now in order to ensure that this
00:30:19
plate is going to be snug up against the
00:30:23
quadrilateral surface to to provide a
00:30:24
good buttress to the quadrilateral
00:30:26
surface in the posterior column
00:30:28
as well as being down for the anterior
00:30:31
column
00:30:32
portion the easiest way to accomplish
00:30:35
that is we're going to use the handle
00:30:37
for the plate
00:30:39
insertion to lateralize the plate and
00:30:42
push against the quadr lateral
00:30:45
surface then what we're going to do is
00:30:49
we're going to follow with a screw in
00:30:51
the plate right around the posterior arm
00:30:54
here so into this
00:30:56
hole or the one just posterior to it but
00:31:00
we're going to drill that screw as
00:31:02
eccentrically as possible and the
00:31:04
lateral side of the hole so that as the
00:31:07
plate is pushed down onto the bone by
00:31:11
the screw head in the supercanal region
00:31:14
it also continues to lateralize and want
00:31:16
to push the plate more lateral so again
00:31:20
that first screw that comes in is going
00:31:22
to be this screw back here by the
00:31:25
posterior arm drilled in an eent Centric
00:31:28
fashion to pull the plate laterally as
00:31:30
it brings it down onto the anterior
00:31:34
column or the supercanal
00:31:38
bone by lateralizing and pushing the
00:31:41
plate against the posterior column and
00:31:43
quadrilateral surface we're going to
00:31:46
drill
00:31:51
eccentrically and once the plate is down
00:31:54
and secured in position
00:31:58
the plate insertion handle can be
00:32:04
removed check to ensure that the
00:32:06
operator nerve is hanging
00:32:09
freely and
00:32:11
then we can take another reduction Force
00:32:14
up I'm going to put this reduction Force
00:32:17
up on the anterior aspect of the plate
00:32:21
to bring it down onto the pubic body
00:32:25
next we'll come back and re verify that
00:32:28
the plate is flush on both the anterior
00:32:33
column and the quadrilateral surface as
00:32:37
well as posterior column right
00:32:40
there we'll continue on with securing
00:32:44
the quadrilateral surface portion of the
00:32:46
plate or into the posterior
00:32:51
column with screws into the posterior
00:32:54
column just posterior to the acet Tulum
00:32:59
in this particular plate there are three
00:33:01
holes in the posterior limb one just
00:33:05
above the iscal
00:33:09
spine one Midway and a third final one
00:33:13
that's up here just above the greater
00:33:16
sciatic
00:33:19
Notch at the level of the stic buttress
00:33:23
depending on the fracture pattern and
00:33:25
the location of the fracture line the
00:33:27
surgent has to choose which one of these
00:33:31
screw holes and screw positions is going
00:33:33
to be optimal in this
00:33:36
situation we'll put a screw into the
00:33:38
middle hole of the plate directed into
00:33:41
the posterior
00:33:51
column we'll measure it again with the
00:33:54
calibration
00:33:58
and that's about a 28 so a 30 will be
00:34:08
fine we'll put the screw into the handle
00:34:11
of the plate screw
00:34:13
inserter and insert the screw and
00:34:22
driver and then remember with the plate
00:34:25
screw inserter as the yellow line line
00:34:28
on the screwdriver approaches the handle
00:34:31
we have to then bring the handle back
00:34:33
slightly so that the screw head does not
00:34:36
capture the
00:34:37
sleeve in the screw hole of the
00:34:43
plate we then back it up all the way
00:34:46
verify the screw position and we can see
00:34:49
that the screw is now in the posterior
00:34:51
column of the
00:34:56
plate so this screw is now behind the
00:34:58
acetabulum or posterior to the
00:35:00
acetabulum which is over here directed
00:35:03
in the posterior column of the plate
00:35:06
posterior to the
00:35:08
acetabulum so you'll then follow with
00:35:11
another screw closer to the curc Joint
00:35:14
the most posterior aspect of the plate
00:35:17
and then gradually work your way along
00:35:20
the anterior column with screw fixation
00:35:23
into the pubic body and the superior
00:35:25
pubic
00:35:26
Ramis for
