Integrated spine trauma team protocol: Combined neurosurgical and orthopedic experience for the management of traumatic spinal injuries.

Objectives: During the last decades, spine surgery has grown exponentially. In spite of that, it remains a surgical specialty without a well-defined own certification. It is usually carried out, separately, by neurosurgeons and orthopedic surgeons, even if there is an overlapping of competence and skills. Materials and Methods: In our hospital, from January 2019, a systematic protocol called integrated spine trauma team protocol (ISTTP) was implemented to improve the management of traumatic spinal injuries in a multidisciplinary way. It is characterized by a specific algorithm from diagnosis to postoperative care. According to the new protocol, orthopedic spinal surgeons and neurosurgeons work together as an integrated spine trauma team. The authors analyzed, retrospectively, the results obtained by comparing patients treated before and after the application of the ISTTP. Results: The new protocol allowed a statistically significant reduction in waiting time before surgery and complication rate. Moreover, early discharge of patients was recorded. To the best of our knowledge, this is the first study that described a specific algorithm for a standardized multidisciplinary management of the spinal trauma with combined orthopedic and neurosurgeon expertise. Conclusion: Our preliminary results suggest that the application of our ISTTP leads to better results for treating traumatic spinal injury (TSI).

Floating hip in polytraumatized patients: complications, mechanism of injury, and surgical strategy.

PURPOSE: Floating hip fractures are severe and rare injuries with high complication rate and lack of standard management. The purpose of this retrospective study was to review the outcomes of a case series of polytraumatized patients with floating hip injuries, in order to describe the relationship between complication rate and floating hip injury type, the pathomechanism of injury, and the surgical treatment strategy. METHODS: Forty-five patients with floating hip injuries were analyzed. Complication rate, mechanism of injury, and surgical strategy (damage control orthopedics, stages of internal fixation) were recorded. Fractures were classified using the Mueller system for floating hips and AO/OTA system for the other fractures. RESULTS: Of the 45 patients with floating hip injuries, 23 (51.1%) developed complications. The results revealed that the complication rate was associated with the instability and type of the pelvic or acetabular fracture (61-C AO/OTA pelvic fracture [73.3%; p = 0.04], 62-B AO/OTA acetabular fracture [88.8%; p = 0.03]). Vertical shear (VS) pelvic fractures were related to middle-distal femoral fractures and lateral compression/anteroposterior compression (LC/APC) pelvic lesions were associated to proximal femoral fractures (p = 0.012). CONCLUSIONS: Complications were associated with the severity and instability of the pelvic and acetabular type of fractures. The pathomechanism causing Mueller type B and C floating hip injuries was illustrated. A two-stage "femur first" surgical approach was the preferred one for definite internal fixation of fractures.

Italian Consensus Conference on Guidelines for preoperative treatment in acetabular fractures.

Preoperative management of acetabular fracture is a major problem and no consensus has been reached in literature on the optimal treatment of this problem. We present the results of the First Italian Consensus Conference on Acetabular fracture. An extensive review of the literature has been undertaken by the organizing committee and forwarded to the panel. Members were appointed by surgical experience with acetabular fractures. From November 2017 to January 2018, the organizing committee undertook the critical revision and prepared the presentation to the Panel on the day of the Conference. Then 11 recommendations were presented according to the 11 submitted questions. The Panel voted the recommendations after discussion and amendments with the audience. Later on, a second debate took place in September 2018 to reach a unanimous consent. We present results of the following questions: does hip dislocation require reduction? Should hip reduction be performed as soon as possible? In case of unsuccessful reduction of the dislocation after attempts in the emergency department, how should it be treated? If there is any tendency toward renewed dislocation, how should it be treated? Should Computed Tomography (CT) scan be performed before reduction? Should traction be used? How can we treat the pain? Is preoperative ultrasound exam to rule out vein thrombosis always necessary? Is tranexamic acid intravenous (IV) preoperatively recommended? Which antibiotic prophylactic protocols should be used? Is any preoperative heterotopic ossification prophylaxis suggested? In this article we present the indications of the First Italian Consensus Conference: a hip dislocation should be reduced as soon as possible. If unsuccessful, surgeon may repeat the attempts optimizing the technique. Preoperative CT scan is not mandatory before reduction. Skeletal traction is not indicated in most of the acetabular fracture. Standard pain and antibiotic prophylactic protocols for trauma patient should be used. Preoperative ultrasound exam is not recommended in all acetabular fracture. Tranexamic acid should be preoperatively used. There is no indication for preoperative heterotopic ossification.

Mortality and morbidity in COVID-19 orthopedic trauma patients: is early surgery the keystone?

In the pandemic disease caused by SARS-CoV-2 virus, trauma surgery continued the management of patients with fractures. The purpose of the study is to evaluate mortality and morbidity in orthopedic trauma patients surgically treated with a diagnosis of COVID-19 infection, comparing them to a control group of COVID-19 negative. We retrospectively identified patients admitted to our Emergency Room from March 8th to May 4th 2020 (time frame corresponding to the first wave of the pandemic peak, one of the most severe in the world at that time) with a diagnosis of fracture that were subsequently surgically treated. We applied a dedicated pathway for the management of COVID-19 trauma patients allowed to perform an early surgery and short hospitalization. For each patient included demographics, clinical, laboratory, radiological data and type of treatment for COVID-19 infection were collected. Sixty-five (65) patients were identified. Of those, 17 (6 women and 11 men, mean age 63.41 years old, mean ASA grade 2.35) were COVID-19 positive (study group), while the others were control group (mean age 56.58 years old, mean ASA grade 2.21). In the study group, the preoperative laboratory tests showed leukocytosis in six and lymphopenia in 15 cases. Fourteen patients had a high level of C-reactive protein. Fifteen patients had an abnormal level of D-dimer. The mortality recorded was 5.8% and 4.1% in the study and control group respectively. Perioperative adverse events were registered in 5 cases (29.4%) in the study group and in 8 (16.6%) in the control group (p>0.05). Dedicated COVID-19 trauma pathway with the aim of an early surgery could be key for a better result in terms of mortality and morbidity. Age and ASA grade could represent independent risk factors for perioperative complications.

Orthopedic injuries in patients with multiple injuries: Results of the 11th trauma update international consensus conference Milan, December 11, 2017.

BACKGROUND: In blunt trauma, orthopedic injuries are often associated with cerebral and torso injuries. The optimal timing for definitive care is a concern. The aim of the study was to develop evidence-based guidelines for damage-control orthopedic (DCO) and early total care (ETC) of pelvic and long-bone fractures, closed or open, and mangled extremities in adult trauma patients with and without associated injuries. METHODS: The literature since 2000 to 2016 was systematically screened according to Preferred Reporting Items for Systematic Reviews and meta-analyses protocol. One hundred twenty-four articles were reviewed by a panel of experts to assign grade of recommendation and level of evidence using the Grading of recommendations Assessment, Development, and Evaluation system, and an International Consensus Conference, endorsed by several scientific societies was held. RESULTS: The choice between DCO and ETC depends on the patient's physiology, as well as associated injuries. In hemodynamically unstable pelvic fracture patient, extraperitoneal pelvic packing, angioembolization, external fixation, C-clamp, and resuscitative endovascular balloon occlusion of the aorta are not mutually exclusive. Definitive reconstruction should be deferred until recovery of physiological stability. In long bone fractures, DCO is performed by external fixation, while ETC should be preferred in fully resuscitated patients because of better outcomes. In open fractures early debridement within 24 hours should be recommended and early closure of most grade I, II, IIIa performed. In mangled extremities, limb salvage should be considered for non-life-threatening injuries, mostly of upper limb. CONCLUSION: Orthopedic priorities may be: to save a life: control hemorrhage by stabilizing the pelvis and femur fractures; to save a limb: treat soft tissue and vascular injuries associated with fractures, stabilize fractures, recognize, and prevent compartmental syndrome; to save functionality: treat dislocations, articular fractures, distal fractures. While DCO is the best initial treatment to reduce surgical load, ETC should be applied in stable or stabilized patients to accelerate the recovery of normal functions. LEVEL OF EVIDENCE: Systematic review of predominantly level II studies, level II.

48 h for femur fracture treatment: are we choosing the wrong quality index?

BACKGROUND: In the last 10 years, the rate of femur fractures treated within 48 h from trauma has been introduced as a performance index for hospital management in Italy. Literature showed a significant indirect correlation between early treatment and mortality/comorbidity. The aims of early treatment are pain management and reduction of time to ambulation. The purpose of this study is to evaluate whether early treatment has reduced time to ambulation in femur fracture. MATERIALS AND METHODS: All patients admitted to two level I trauma centers with proximal femoral fracture between 1/1/2017 and 31/12/2017 were included in this study. Exclusion criteria were patient age younger than 65 years, death before surgery, and nonsurgical treatment. The following data were collected: age, gender, date and time of admission to emergency department, height, weight, body mass index (BMI), type and side of fracture, American Society of Anesthesiologists (ASA) score, date and time of surgery, surgical time, length of hospitalization, death during hospitalization, time from surgery to physiotherapy start, and time from surgery to first walking day. RESULTS: The study sample resulted in 660 patients. Mean age was 82 years, 64 % were female, mean BMI was 24 kg/m2, mean ASA score was 2.7, and 42 % were medial fractures. Mean time from admission to surgery was 95 h; 49.8 % were treated within the first 48 h. Mean time from surgery to physiotherapy start was 2 days, 21 % were not able to walk during hospitalization, time from surgery to first walking day was 5 days, and mean hospitalization time was 15 days. Early surgery was significantly (p = 0.008) associated with the probability of ambulation recovery during hospitalization. No association (p = 0.513) was found between early surgery and time in bed without walking. CONCLUSIONS: Early surgery in femur fracture became a priority in the health system. However, according to our data, although 51 % of patients were treated within the first 48 h, time from surgery to physiotherapy start (2 days) was still too long. Furthermore, time from surgery to first walking day was 6 days, longer than in most published papers. These data suggest that the performance index (rate of femur fractures treated within 48 h) may be improved by changing it to rate of femur fractures surgically treated with return to walking in 96 h. LEVEL OF EVIDENCE: Level 4 (retrospective study).

Mid-term results with a neck-preserving femoral stem for total hip arthroplasty.

INTRODUCTION:: This prospective study aims to evaluate the mid-term clinical and radiological performance of a new short, neck-preserving femoral stem in total hip arthroplasty (THA). PATIENTS AND METHODS:: 178 consecutive patients (190 hips) underwent THA from November 2008 to July 2016. Mean follow-up is 62.4 months. Women make up 41% of the cohort at a mean age of 50 ± 4 years, with primary hip osteoarthritis as the main complaint. All patients underwent radiological evaluation using the modified Gruen method, and clinical assessment via the Harris Hip Score (HHS), preoperatively and at 1, 6, 12, 24, 60, 80 and 106 months post-op. RESULTS:: A mean HHS increase (from 50 ± 12 points preoperatively to 96 ± 4 at 62 months), together with painless articular improvement, was present at 6 months postoperatively indicating early functional recovery. Effective osteointegration and primary stability were present on radiographic analysis, without evidence of stress shielding or stem mal-positioning: subsidence amounting to <1 mm was present in 40% of implants immediately after surgery, with subsequent stabilisation within 6 months in all cases. Metaphyseal trabecular re-orientation in absence of symptomatic cortical hypertrophy or progressive radiolucency indicates physiological load transfer in the proximal femur. Stem-related revision surgery was necessary for 1.05% of all implants due to fracture and infection. No loosening, dislocations or mechanical failures were reported. CONCLUSIONS:: All patients show excellent functional recovery and clinical outcomes at 62 months, demonstrating the role optimal primary stability and physiological joint reconstruction play in ensuring stable secondary fixation and long-term survival of a short, neck-preserving stem.

A new bioinspired collagen-hydroxyapatite bone graft substitute in adult scoliosis surgery: results at 3-year follow-up.

BACKGROUND: Spinal fusion is a common procedure used for surgical treatment of spinal deformity. In recent years, many bone graft substitutes (BGS) have been developed to provide good arthrodesis when the available autologous bone harvested from the patient is not enough. The aim of this study was to analyze the use of a new-generation composite material (RegenOss) made of Mg-hydroxyapatite nanoparticles nucleated on type I collagen to obtain long posterolateral fusion in adult scoliosis surgery. METHODS: A total of 41 patients who underwent spinal fusion for the treatment of adult scoliosis were retrospectively analyzed. According to Lenke classification, visual analog scale (VAS) score and Oswestry Disability Index (ODI) score, radiographic rates of bone union were evaluated before surgery and at 6, 12 and 36 months of follow-up. Fusion was considered to be successful when criteria for Lenke grade A or B were satisfied. Patient-related risk factors were considered for the evaluation of the final outcome. RESULTS: At 36-month follow-up, radiographic evidence of spinal fusion was present in the majority of patients (95.1%). A time-dependent statistically significant improvement was evidenced after surgery for all clinical outcomes evaluated. Based on the demographic data collected, there were no statistically significant factors determining fusion. The correction of deformity was maintained at different time points. No intraoperative or postoperative complications were recorded. CONCLUSIONS: The present study demonstrated that RegenOss can safely be used to achieve good arthrodesis when associated with autologous bone graft to obtain long spinal fusion in the treatment of adult scoliosis.

Distraction osteogenesis for tibial nonunion with bone loss using combined Ilizarov and Taylor spatial frames versus a conventional circular frame.

This retrospective review assesses 55 tibial nonunions with bone loss to compare union achieved with combined Ilizarov and Taylor spatial frames (I-TSF) versus a conventional circular frame with the standard Ilizarov procedure. Seventeen (31 %) of the 55 nonunions were infected. Thirty patients treated with I-TSF were compared with 25 patients treated with a conventional circular frame. In the I-TSF group, an average of 7.6 cm of bone was resected and the lengthening index (treatment time in months divided by lengthening amount in centimeters) was 1.97. In the conventional circular frame group, a mean of 6.5 cm was resected and the lengthening index was 2.1. Consolidation at the docking site and at the regenerate bone occurred in 49 (89 %) of 55 cases after the first procedure. No statistically significant difference was shown between the two groups. Superiority of one modality of treatment over the other cannot be concluded from our data. Application of combined Ilizarov and Taylor spatial frames for bone transport is useful for treatment of tibial nonunion with bone loss. Level of evidence Case series, Level III.

Evaluation of an endoscopic procedure for the treatment of docking site nonunion.

OBJECTIVE: To determine the effectiveness of an endoscopic docking site surgery during the use of a classic bone transport technique for dealing with bone loss. DESIGN: Retrospective comparative study. SETTING: Level I trauma center. PATIENTS: Nine patients treated with endoscopic docking site surgery (group 1) were compared with 18 patients treated with standard open grafting of the docking site (group 2). All 27 bone transports with distraction osteogenesis were performed for the treatment of segmental tibial bone defects. INTERVENTION: In group 1, 6 tibial and 3 tibiotalar docking sites were endoscopically treated. Anteromedial (instrumentation) and anterolateral (visualization) portals were used without a tourniquet, using a 30-degree arthroscope and a motorized 5-mm shaver/abrader. Fibrous tissue was removed, bone ends abraded, and the bone canal cleaned with bone grafting. MAIN OUTCOME MEASURE: Clinical and radiographic. RESULTS: Bone transport lengthening was 9.7 and 9.1 cm in groups 1 and 2, respectively. Consolidation at the docking site occurred in 8 patients (89%) in group 1. The docking site consolidation time and index lengthening were lower in group 1 (18 vs. 20 weeks for group 2 and 1.59 vs. 1.82 mo/cm in group 1 vs. group 2). Time in the external fixator was similar between the 2 groups (461 vs. 466 days in group 1 vs. group 2). Normal alignment was observed in both groups. CONCLUSIONS: This study provides evidence that minimally invasive endoscopic docking site treatment during bone transport is a safe and viable technique using a common arthroscopic instrumentation.

Taylor spatial frame fixation in patients with multiple traumatic injuries: study of 57 long-bone fractures.

OBJECTIVE: To evaluate the Taylor spatial frame (TSF) for primary and definitive fixation of lower limb long-bone fractures in patients with multiple traumatic injuries. DESIGN: Retrospective. SETTING: Level I trauma center. PATIENTS: Consecutive series of 52 patients, 57 fractures (25 femoral and 32 tibial), treated between 2005 and 2009. Forty-nine fractures (86%) were open. Injury Severity Score ≥16 for all patients. INTERVENTION: Fifty-four fractures (95%) underwent definitive fixation with the TSF and 3 were treated primarily within 48 hours of injury. In 22 cases (39%), fractures were acutely reduced with the TSF, fixed to bone and the struts in sliding mode without further adjustment, and in 35 cases (61%), the total residual deformity correction program was undertaken. MAIN OUTCOME MEASURE: Clinical and radiological. RESULTS: Complete union was obtained in 52 fractures (91%) without additional surgery at an average of 29 weeks. Four nonunions and 1 delayed union occurred. Results based on Association for the Study and Application of the Method of Ilizarov criteria: 74% excellent, 16% good, 4% fair, and 7% poor for bone outcomes and 35% excellent, 47% good, and 18% fair for functional outcomes. Eighty-eight percent of patients returned to preinjury work activities. CONCLUSIONS: Primary and definitive fixation with the TSF is effective. Advantages include continuity of device until union, reduced risk of infection, early mobilization, restoration of primary defect caused by bone loss, easy and accurate application, convertibility and versatility compared with a monolateral fixator, and improved union rate and range of motion for lower extremity long-bone fractures in patients with multiple traumatic injuries.

Clinical reliability of closed techniques and comparison with open strategies to achieve union at the docking site.

PURPOSE: This retrospective review follows 31 tibial nonunions to compare union at the docking site using closed versus open strategies. In this cohort of patients, all but five were infected nonunions. METHODS: Thirteen patients initially treated with single compression were compared with 18 patients treated by open revision of the docking site. In the single compression group, an average of 6.5 cm of bone was resected and index lengthening was 2.04. In the open revision group, a mean of 9.4 cm was resected and the index lengthening was 1.73. RESULTS: Consolidation at the docking site occurred in all subjects in both groups. There was no statistical difference between the two groups. Conclusive evidence of superiority of one modality of treatment over the other cannot be drawn from our data. CONCLUSIONS: The simple compression procedure requires less invasive surgery and is probably less demanding and more cost-effective in short transports.

Efficacy of unipedicular baloon kyphoplasty for treatment of multiple myeloma vertebral lesions.

STUDY DESIGN: A retrospective cohort study. PURPOSE: To analyze differences in between the unipedicular vs. bipedicular balloon kyphoplasty for the treatment of multiple myeloma lesions. OVERVIEW OF LITERATURE: Both vertebroplasty and kyphoplasty are reported to be effective for the treatment of vertebral compression fractures in multiple myeloma patients. Kyphoplasty is often performed with a bipedicular approach while vertebroplasty with a monopedicular approach. Monopedicular kyphoplasty is investigated as a viable surgical technique alternatively in comparison with the bipedicular method. METHODS: We performed 37 vertebral body augmentation procedures, 18 vertebroplasty (group A) and 19 kyphoplasty, 9 unipedicular approaches (group B1) and 10 bipedicular approaches (group B2), on 14 patients affected by multiple myeloma with a mean clinical and radiographic follow up of more than 12 months. RESULTS: Both kyphoplasty techniques lead to a better postoperative improvement of the vertebral height and kyphotic deformity if compared with the vertebroplasty, with a statistical significance for the body height restoration only (p = 0.0066). The unipedicular and the bipedicular kyphoplasty have similar results in term of kyphotic deformity correction and height restoration. The 85.7% (12/14) of the patients had an immediate improvement of the pain and no difference between the vertebroplasty and kyphoplasty groups were observed regarding the pain. We observed a 24.3% of cement leakage in all groups with no clinical symptoms and noticed that the risk of extravasations was higher in multilevel treatment, in bipedicular kyphoplasty procedures and in patients not treated previously with a bone marrow transplant. CONCLUSIONS: Both vertebroplasty and kyphoplasty are effective in treating vertebral compression fracture due to multiple myeloma. Unipedicular kyphoplasty could give equivalent results as with bipedicular kyphoplasty in multilevel disease, aiming only to restore the sagittal alignment of the spine and the height of the vertebral body especially at the thoracolumbar spinal segment.

Bone transport for postinfectious segmental tibial bone defects with a combined ilizarov/taylor spatial frame technique.

OBJECTIVE: To assess and compare the results of trifocal (two-level bone lengthening with compression at the nonunion site) and bifocal (one-level bone lengthening with compression at the nonunion site) bone transport using the Taylor Spatial Frame (TSF; Smith and Nephew, Inc, Memphis, TN) for postinfectious segmental tibial bone defects. DESIGN: Retrospective study of 12 patients with atrophic tibial nonunions. These patients were treated with resection of the nonunion followed by bone transport using the TSF for the segmental tibial bone defects. All patients were treated by the same surgeon (F.S.). SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Twelve consecutive patients treated for postinfectious segmental tibial bone defects between November 2004 and September 2007. INTERVENTION: All patients were treated using the TSF for a trifocal or bifocal technique of bone transport along with associated soft tissue reconstructive surgeries. All patients were additionally treated with 45 days of culture-specific antibiotics. OUTCOME MEASUREMENT: All patients were evaluated by the guidelines of the Association for the Study of the Method of Ilizarov. RESULTS AND CONCLUSION: All patients achieved complete union and eradication of infection. The results were evaluated according to Association for the Study of the Method of Ilizarov criteria: 83% were excellent and 17% were good in terms of bony outcomes; functional results were excellent in 50%, good in 42%, and fair in 8%. Combined Ilizarov/TSF trifocal and bifocal techniques for the treatment of segmental tibial bone defects achieve union without malalignment of the mechanical axis.

Sequential reconstruction of complex femoral fractures with circular hybrid Sheffield frame in polytrauma patients.

The timing of definitive fixation for major fractures in polytrauma patients is controversial. We investigated the outcome of the Sheffield hybrid system (SHF) as a solution in the role of primary and definitive fixator for patient with open femoral fractures in whom definitive osteosynthesis with intramedullary nail can be associated with higher rate of complications. Eleven patients (7 men and 4 women), mean age of 40.4 years (range 14-75 years) with previous injury severity score (ISS) greater than or equal to 16 were treated from a damage control orthopedics perspective. Time in the fixator averaged 28 weeks (range 10-64 weeks). Mean follow-up was 3 years (2-4.5). All fractures united. Paley functional and bone results in most cases were good to excellent. Final mean knee range of motion was 113 degrees. We found that SHF for complex fractures of the femur combine maximum support for the bone and preservation of soft tissues. SHF is an effective technique compared to internal nails and earlier external fixator devices, attributable to its advantages such as continuity of frame till union, preventing any second-hit phenomenon, early mobilization, and restoration of primary defect due to bone loss by differential distraction osteogenesis without additional surgery.

Versatility of Taylor Spatial Frame in Gustilo-Anderson III C femoral fractures: report of three cases.

Taylor Spatial Frame (TSF) combines a multiplanar external fixator and software accuracy for reduction of acute long-bone fractures. The frame gives stability, soft-tissue preservation, adjustability and functionality allowing bone to realize its full osteogenic potential. Three patients with multiple injuries and femoral Gustilo-Anderson type III C have been treated in our center. Initial surgery was performed within 6 h of injury with help of vascular surgeon. We used TSF as definitive fixation method. The results were assessed using the functional and radiological scoring system described by Paley and Maar. Fracture union occurred in all limbs and average fixation time was 151.6 days. All three patients had excellent outcome in terms of bony and functional ASAMI criteria. The TSF is a valuable tool. It is a definitive method of femoral Gustilo-Anderson type III C fracture care using external fixation with several advantages over previously used devices.

Alternative fixation method for open femoral fractures from a damage control orthopaedics perspective.

A decision for immediate versus delayed fixation in a polytrauma patient mainly in cases of open femoral fracture depends upon time elapsed since injury, duration of stay in intensive care, soft tissue status, probable intra-operative difficulties and presence of systemic complication. We studied the outcome of the Taylor Spatial Frame (TSF) as a solution in the role of primary and definitive fixator for patients in whom definitive osteosynthesis with intramedullary nailing (IMN) can be associated with higher rate of complications. In view of damage control orthopaedics (DCO), we found that TSF is an effective technique compared to internal nails and earlier external fixator devices, attributable to its advantages such as continuity of frame till union, preventing any second-hit phenomenon, early mobilisation and restoration of primary defect due to bone loss by differential distraction osteogenesis without additional surgery. According to the Paley and Maar's evaluation criteria, 11 patients had an excellent result with clinical and radiological union; the functional result was excellent in three patients, good in five, fair in two and poor in one.

Minimal-invasive posterior approach in the treatment of the posterior wall fractures of the acetabulum.

We examined patients affected by a posterior wall fracture of the acetabulum treated with a minimally invasive posterior approach (from 12 to 18 cm). During 2004-2006 19 patients were treated by this approach. 4 patients had a combined surgery by the ileo-inguinal approach. Fracture fixation was performed using reconstruction plates and screws. All the patients were studied with typical X-rays projection for pelvis and iliac oblique view and obturator oblique view (Judet view) and CT scan with 3D reconstruction. After 3 months a CT scan was performed on about 30% of our patients, which demonstrated the perfect healing of the fractures. The most important advantages we observed using this approach were a lesser split of the gluteus maximus and no risk of damage for the superior gluteal nerve. In the early post-operative rehabilitation we examined the trophism of the gluteus maximus, which was found to be better than in patients treated with the typical Kocher-Langenbeck approach. The only absolute contraindication for this technique is in obese patients. The post-operative complications include one case of heterotypic ossification of the gluteus minimus and one case of peroneal-nerve palsy with the spontaneous and complete recovery within 6 months. According to our experience this kind of approach could be used for posterior wall fracture of the pelvis and it can be extended to transverse fractures. In the post-operative period the greatest advantage is the lesser muscle damage and therefore a most effective rehabilitation.