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Structures at risk from medially placed acetabular screws
EM Keating, MA Ritter and PM Faris
J Bone Joint Surg Am. 1990;72:509-511.
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Publisher Information
The Journal of Bone and Joint Surgery
20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org
Copyright
1990
by The Journal
of Bone
Structures
Medially
BY
E.
MICHAEL
at
Placed
KEATING,
M.D.t,
and Joint
Risk
From
The
ABSTRACT:
fourteen
acetabula
the Department
MERRILL
the
Centerfor
of Orthopaedic
anatomical
were
studied
structures
to identify
Incorporated
from
Acetabular
A.
RITTER,
MOORESVILLE,
and
Surgery,
Hip
adjacent
to
structures
M.D.t,
AND
PHILIP
M.
FARIS,
M.D.t,
INDIANA
and
Surgery,
Screws*
Knee
Surgery,
Louisiana
State
screws;
vascular
Mooresville,
University,
Shreveport,
many manufacturers
complications
that
Louisiana
now sell such components.
have been reported
usually
The
have
that are at risk from acetabular
screws.
There
were six
embalmed
acetabula,
four acetabula
from two fresh autopsy
specimens,
and four acetabula
that were studied
been related to intrapelvic
extrusion
of cement or to damage
to the common
iliac vein during reaming’3.
Little attention
during
when
two
gynecological
operations.
Models
screws
can
penetrated
structed
to show where
these
dially
placed
screws
either
were
penetrate.
or came
conMedan-
has been
paid,
however,
to the risk
to anatomical
structures
a drill-bit or screw penetrates
the second cortex.
Although
orthopaedic
surgeons
are very familiar
with
the structures
that are anterior,
superior,
and posterior
to
ACETABULAR COMPONENT
IN RIGHT
_/
ACETABULUM
SYMPHYSIS
1
FIG.
Fig.
Fig.
possible
1: Drawing
2: Drawing
placement
of the right pelvic
of the right pelvic
of the screws.
brim.
brim,
FIG. 2
showing
placement
of the
gerously
close
to the external
iliac vein; the obturator
artery,
nerve,
and vein; and tributaries
of the internal
iliac vein.
To avoid
injury
to the medial
vascular
structures,
screws
should
not be placed
in the anterosuperior
quadrant of the acetabulum.
acetabular
cup,
interest
has developed
in the use of porouscomponents
that are fixed with cancellous
holes
the acetabulum,
that lie medial
tation in 1986.
drilled
in the
pelvis
and
pins
used
many are not as well acquainted
to it. Our interest
was piqued
After a revision
hip arthroplasty,
penetration
of a branch
by selective
prompted
us to study
acetabulum
of an internal
arteriography.
the structures
to determine
iliac
The
the danger
to demonstrate
with those
by a consulthis patient
had a retroperitoneal
hematoma,
anuria,
and
infection
about the implant;
the patient
eventually
mined
Substantial
coated
acetabular
with
a secondary
died from
artery,
case
as deter-
of this
patient
that lie adjacent
of penetration
to the
by a drill-
bit or screw.
*
No benefits
in any
form
have
been
received
or will be received
a commercial
party related
directly
or indirectly
to the subject
No funds were received
in support
of this study.
t Center
for Hip and Knee Surgery,
1 199 Hadley
Road,
Indiana
46158.
VOL.
72-A,
NO.
4, APRIL
1990
ofthis
from
Materials
article.
Mooresville,
Three
embalmed
types
acetabula
and
of anatomical
and four
Methods
subjects
fresh
autopsy
were
studied;
specimens
six
were
509
510
E.
M.
KEATING,
M.
PJT. ILIAC
EXT.
ILIAC
A.
A. & V.
V.
RITTER,
AND
P.
M.
FARIS
joined
the external
thus did not course
iliac vein as it entered
the pelvis
and
along the surface
ofthe
internal
obturator
muscle with the obturator
nerve. The sciatic nerve, as it left
the pelvis,
lay directly
against the osseous
surface of the
sciatic notch adjacent
to the internal iliac vein. In the acetabula that were studied
during the gynecological
opera-
OBTURATOR
tions,
surface
the
external
iliac
of the arcuate
vein
line,
lay
and
directly
thus
it was
on
the
osseous
not protected
by
the iliopsoas
and iliacus muscles as it appeared
to be in the
cadavera.
The external
iliac artery, however,
coursed along
the iliopsoas
muscle
and tendon
and thus was relatively
protected
by the thickness
of the
muscle.
In the models and the cadaver
specimens,
screws that
were inserted into the anterior part of the rim and the depths
of the acetabular
cup either penetrated
or came dangerously
close
to the external
iliac
vein;
the obturator
artery,
nerve,
FIG. 3
Drawing
of the right pelvic
brim,
showing
penetration
of the external
iliac vein, obturator
vein, and tributaries
of the internal
iliac vein by holes
drilled
in the anterosuperior
portion
of the acetabulum.
The arrows
indicate
the areas of penetration
marked
by fixation
pins that were used to secure
the acetabular
component.
dissected,
of two
and four
additional
hysterectomies.
and porous-coated
overly
sional
acetabula
Six cadaver
were
as part
studied
acetabula
were
reamed,
acetabular
components
were secured
We
constructed
four
long screws.
models.
then
with
AREA
three-dimen-
Results
In our dissections,
the internal obturator
muscle was
only two to four millimeters
thick and provided
minimum
protection
for the adjacent vascular structures.
The obturator
artery,
vein,
of the
pelvis
inferior
to the obturator
that
included
internal
iliac
and
nerve
on
the
the
pudendal
vein2
(Fig.
coursed
way
medially
to the
foramen
the
arcus
below
superior
and
vein,
and other
branches
tributaries
of the internal
1). The
tendineus
was
the rim
foramen.
was a large plexus
inferior
were found two to three millimeters
wall of the pelvis, with no strong
since
just
obturator
vesicular
of veins
veins,
(the
arcus
iliac
vein
medial
barrier,
tendineus
is the lateral origin of the levator ani muscle,
which forms
the abdominal
floor).
The intra-abdominal
tributaries
of the internal
iliac
vein, especially
the superior and inferior vesicular
veins and
the uterine plexus, were extremely
variable; they really were
a plexus
of veins
usually formed a
and on the inferior
obturator
muscle.
In two of the
were replaced
by
rather
than
a single
vein.
These
the obturator
pubic vein
4
acetabulum.
The shaded
of intrapelvic
structures
area represents
by a screw
the danger
or drill-bit.
and vein; and tributaries
of the internal iliac vein (Figs. 2
and 3). Any screws that were placed in the superior
portion
of the acetabulum
and penetrated
the medial wall were close
to the external iliac vein and the internal iliac venous plexus.
The bladder
and rectum were relatively
safe. Neither
the
screws
that
were
placed
vein and artery
and artery that
posterior
tabulum nor those placed distal
transverse
acetabular
ligament
dangerous
position
(Fig. 4).
to the midline
of the ace-
to the anterior border of the
penetrated
the pelvis in a
Discussion
vessels
plexus that lay on the levator ani muscle
portion ofthe exposed part of the internal
specimens,
an enlarged
FIG.
Drawing
of the right
zone for the penetration
the
of the internal
from the osseous
protecting
fascial
inferior
Just
The sciatic nerve lies against the posterior
wall of the
acetabulum
as it leaves the pelvis at the greater sciatic notch.
This nerve may be identified
and protected
by palpation
of
the posterior
part of the wall of the acetabulum
during
drilling and the insertion
of screws; thus, screws that are placed
ThE
JOURNAL
OF BONE
AND
JOINT
SURGERY
STRUCTURES
in the posterior
inferior
the
portion
anterior
part
of the wall
of the
acetabulum,
attachment
ment,
is relatively
longer
artery,
near the medial
and vein are
pelvis,
by the
The
tributaries
viously;
of
safe,
the
since
iliopsoas
and
that
posterior
transverse
iliacus
artery
it has
safe.
and
to
is no
The femoral
nerve,
as they leave the
is replaced
inferior
epigastric
noted,
replaced
by an enlarged
stated that the obturator
by an enlarged
small
pubic
in 30 per
number
anatomical
that we have described
cent
from
the
population4.
ofdissections
variations
are present
branch
of the
in our study,
other
than
in the area
the ones
medial
to the
acetabulum.
Screws
been reported
preand venous
system
that
511
SCREWS
artery
In view ofthe
it is possible
tendons.
as already
ACETABULAR
artery
liga-
cavity
and
PLACED
The
distal
in the intra-abdominal
vein has
arterial
were
been
MEDIALLY
acetabular
muscles
In two of our dissections,
the obturator
vein and
pubic vein and artery;
FROM
the abdominal
we found
of the internal
iliac
this is the most variable
RISK
are relatively
wall of the pelvis.
protected
laterally,
variability
in the body4.
AT
that are inserted
in the anterosuperior
of the acetabulum,
a pie-shaped
arc drawn
from the mid-portion
quadrant
area that is bounded
of the superior
dome
anterior border of the transverse
acetabular
ligament,
the most dangerous
area because
of the thinness
acetabulum
dially.
and the intra-abdominal
vascular
by an
to the
are in
of the
structures
me-
References
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BERGQVIST,
163,
2.
3.
4.
VOL.
A.
S.; and ERICSSON,
B. F.: Vascular
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Edited
by Roger
Warwick
and P. L. Williams.
British
ed. 35, pp. 668-708.
Philadelphia,
W.
T. H. : Rupture
of the Common
Iliac Vein from Reaming
the Acetabulum
during Total Hip Replacement.
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276-277,
March
1972.
R. T.: Essentials
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Ed. 6, pp. 500-505,
511, 536. New York,
Oxford
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