Comparison of acetabular fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified Rives-Stoppa) surgical approaches

Achieving Anatomic Acetabular Fracture Reduction-When is the Best Time to Operate?

OBJECTIVES

We hypothesize that earlier operative intervention for acetabular fractures improves the probability of achieving an anatomic reduction.

DESIGN

Retrospective review.

SETTING

Academic level I trauma center.

PATIENTS/PARTICIPANTS

Six hundred fifty acetabular fractures treated through open reduction and internal fixation (ORIF) between September 2001 and February 2014.

INTERVENTION

Acetabular fracture ORIF.

MAIN OUTCOME MEASUREMENTS

Reduction quality was assessed through postoperative radiographs. Displacement of ≤1 mm was considered an anatomic reduction, 2-3 mm imperfect, and >3 mm poor.

RESULTS

Anatomic reductions were observed in 85% (n = 553) of cases, imperfect reductions in 11% (n = 74) of cases, and poor reductions in 4% (n = 23) of cases. Patients with anatomic reductions had significantly shorter times from injury to ORIF [odds ratio (OR) interval] (median, 3 d) when compared with either imperfect (median, 4.5 days, P = 0.02) or poor reductions (median, 7 days, P < 0.001) reductions. The OR interval of imperfect reductions was also significantly shorter than that of poor reductions (P = 0.02). Logistic regression analysis demonstrated that OR interval had an effect of -0.12, meaning that the log odds of anatomic reduction decreases by 0.12 with each day from injury to ORIF.

CONCLUSION

The interval from injury to operative fixation of acetabular fractures affects reduction quality. Earlier intervention improves the probability of achieving an anatomic reduction; therefore, ORIF should be performed as early as possible, provided the patient is optimized for surgery.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical exposures and options for instrumentation in acetabular fracture fixation: Pararectus approach versus the modified Stoppa

BACKGROUND

As an alternative to the modified Stoppa approach, the Pararectus approach is used clinically for treatment of acetabular fractures involving the anterior column. The current study assessed the surgical exposure and the options for instrumentation using both of these approaches.

METHODS

Surgical dissections were conducted on five human cadavers (all male, mean age 88 years (82-97)) using the modified Stoppa and the Pararectus approach, with the same skin incision length (10cm). Distal boundaries of the exposed bony surfaces were marked using a chisel. After removal of all soft-tissues, distances from the boundaries in the false and true pelvis were measured with reference to the pelvic brim. The exposed bone was coloured and calibrated digital images of each inner hemipelvis were taken. The amount of exposed surface using both approaches was assessed and represented as a percentage of the total bony surface of each hemipelvis. For instrumentation, a suprapectineal quadrilateral buttress plate was used. Screw lengths were documented, and three-dimensional CT reconstructions were performed to assess screw trajectories qualitatively. Wilcoxon's signed rank test for paired groups was used (level of significance: p<0.05).

RESULTS

After utilization of the Pararectus approach, the distances from the farthest boundaries of exposed bone towards the pelvic brim were significantly higher in the false but not the true pelvis, compared to the modified Stoppa approach. The percentage (mean±SD) of exposed bone accessible after utilizing the Pararectus approach was 42±8%, compared to 29±6% using the modified Stoppa (p=0.011). In cadavers exposed by the Pararectus approach, screws placed for posterior fixation and as a posterior column screw were longer by factor 1.8 and 2.1, respectively (p<0.05), and screws could be placed more posteromedial towards the posterior inferior iliac spine or in line with the posterior column directed towards the ischial tuberosity.

CONCLUSION

Compared to the modified Stoppa, the Pararectus approach facilitates a greater surgical access in the false pelvis, provides versatility for fracture fixation in the posterior pelvic ring and allows for the option to extend the approach without a new incision.

Open reduction and internal fixation aided by intraoperative 3-dimensional imaging improved the articular reduction in 72 displaced acetabular fractures

BACKGROUND AND PURPOSE

During acetabular fracture surgery, the acetabular roof is difficult to visualize with 2-dimensional fluoroscopic views. We assessed whether intraoperative 3-dimensional (3D) imaging can aid the surgeon to achieve better articular reduction and improve implant fixation.

PATIENTS AND METHODS

We operated on 72 acetabular fractures using intraoperative 3D imaging and compared the operative results, duration of surgery, and complications with those for 42 consecutive acetabular fracture operations conducted using conventional fluoroscopic imaging. Postoperative reduction was evaluated on reconstructed coronal and sagittal images of the acetabulum.

RESULTS

The fracture severity and patient characteristics were similar in the 2 groups. In the 3D group, 46 of 72 patients (0.6) had a perfect result after open reduction and internal fixation, and in the control group, 17 of 42 (0.4) had a perfect result. The mean difference in postoperative articular incongruity was 0.5 mm (95% CI: 0.4-0.7). In 29 of 72 operations, the intraoperative 3D scans led to intraoperative correction of the reduction and an improved result. The duration of surgery and infection rate were similar in the 2 groups.

INTERPRETATION

Intraoperative 3D imaging, which is not time-consuming, allowed the surgeon to correct malreductions and screw placement in 29 of 72 operations, leading to better articular reduction and more precise screw placement than in operations where conventional fluoroscopic imaging was used to control the reduction.

Fixation of acetabular fractures via the ilioinguinal versus pararectus approach

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded.

A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans.

There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001).

These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach.

This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns.

Cite this article: Bone Joint J 2015;97-B:1271-8.

The modified ilioinguinal and anterior intrapelvic approaches for acetabular fracture fixation: indications, quality of reduction, and early outcome

OBJECTIVES

Traditionally, the anterior surgical approach of choice for acetabular reconstruction was ilioinguinal. There has been an increasing usage of the midline "Stoppa" or "anterior intrapelvic approach." The aim is to report the techniques, early results (minimum 1 year), and complications of anterior approaches for acetabular reconstruction.

DESIGN

Retrospective case-note review.

SETTING

Pelvic and acetabular tertiary center.

PATIENTS

A consecutive series of acetabular fractures treated at 1 tertiary specialist unit were retrospectively reviewed. The fracture patterns, incisions used, intraoperative and postoperative complications, reduction achieved (measured on postoperative radiographs and computed tomography scans), and early postoperative results (minimum 1-year follow-up), were recorded.

MAIN OUTCOME MEASUREMENTS

Postoperative reduction (measured by postoperative plain radiographs and computed tomography).

RESULTS

Of 160 consecutive patients who underwent acetabular reconstruction, 56 (mean age, 44 years) underwent reconstruction using only anterior approaches (mean of 7 days after injury). Iatrogenic complications, postoperative infection, arthritis, and avascular necrosis rates are comparable with the literature. Overall, anatomic reduction was seen in 71% of cases and concentric reconstruction of the dome in over 90%. Thirty-six of the 56 patients (64%) were symptom-free at the latest follow-up and 34 (61%) had returned to work.

CONCLUSIONS

The results reported suggest the use of dual approaches using the lateral 2 windows, and/or a midline anterior intrapelvic approach in anterior acetabular reconstructions has a relatively low complication rate and can lead to anatomic reconstructions in 71%.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evolution of the anterior intrapelvic (Stoppa) approach for acetabular fracture surgery

With their description of an approach that took advantage of the preperitoneal/retroperitoneal space to access the posterior pelvic ring, Hirvensalo et al and Cole and Bolhofner launched a series of developments that would complement the pelvic and acetabular surgeon's armamentarium in addressing injuries in this area. From this point on, additional contributors developed clinically relevant study designs to identify safety parameters and quantify expected outcomes and prognosis. The knowledge dissemination cycle has now extended to the development of instruments and implants to assist surgeons with this approach and to better serve patients.

Reduction of the posterior column in displaced acetabulum fractures through the anterior intrapelvic approach

The anterior intrapelvic approach can be used for the reduction and fixation of displaced fractures of the acetabulum. Reduction techniques and options for placement of fixation deviate to some degree from those used with the traditional ilioinguinal approach secondary to the surgeon's perspective and available vectors. Here, we present several techniques for the application of reduction clamps, reduction techniques, and fixation options for the posterior column in displaced fractures of the acetabulum treated through the anterior intrapelvic approach.

Techniques for reduction of the quadrilateral surface and dome impaction when using the anterior intrapelvic (modified Stoppa) approach

As the anterior intrapelvic approach (AIP or modified Stoppa) has become more popular, its utility has evolved to address specific problems that are not well addressed by the ilioinguinal approach. These include anterior column (AC) fractures associated with medialization of the femoral head (protrusio) and impaction of the superomedial acetabular dome. If left unaddressed, these problems may lead to poor clinical outcomes. The AIP approach, in contrast to the ilioinguinal approach, takes a more direct path to the medial elements of the AC in the true pelvis. This exposure allows access to the impacted dome segment through the displaced AC fracture and wide visualization of the quadrilateral surface, which in turn allows direct reduction and optimal implant placement to neutralize the fracture's deforming forces. The purpose of this article is to discuss the reduction of dome impaction and the quadrilateral surface using the AIP approach.

Clinical results of acetabular fracture management with the Pararectus approach

INTRODUCTION

To present the accuracy of reduction, complications and results two years after open reduction and internal fixation of displaced acetabular fractures involving the anterior column (AC) through the Pararectus approach. Frequencies for conversion to total hip replacement in the early follow up, the clinical outcome in preserved hips, and the need for an extension of the approach (1st window of the ilioinguinal approach) are compared to the literature about the modified Stoppa approach.

METHODS

Forty-eight patients (mean age 62 years, range: 16–98; 41 male) with displaced acetabular fractures involving the AC (AC: n = 9; transverse fracture: n = 2; AC and hemitransverse: n = 24; both column: n = 13) were treated between 12/2009 and 12/2011 using the Pararectus approach. Surgical data and accuracy of reduction (using computed tomography) were assessed. Patients were routinely followed up at eight weeks, 6, 12 and 24 months postoperatively. Failure was defined as the need for total hip arthroplasty. Twenty-four months postoperatively the outcome was rated according to Matta.

RESULTS

In four patients there were four intraoperative complications (minor vascular damage in two, small perforations of the peritoneum in two) which were managed intraoperatively. Fracture reduction showed statistically significant decreases (mean ± SD, pre- vs. postoperative, in mm) in “step-offs”: 2.6 ± 1.9 vs. 0.1 ± 0.3, p < 0.001 and “gaps”: 11.2 ± 6.8 vs. 0.7 ± 0.9, p < 0.001. Accuracy of reduction was “anatomical” in 45, “imperfect” in three. Five (13%) from 38 available patients required a total hip arthroplasty. Of 33 patients with a preserved hip the clinical outcome was graded as “excellent” in 13 or “good” in 20; radiographically, 27 were graded as “excellent”, four as “good” and two as “fair”. An extension of the approach was infrequently used (1st window ilioinguinal approach in 2%, mini-incision at the iliac crest in 21%).

CONCLUSION

In the treatment of acetabular fractures involving the anterior column the Pararectus approach allowed for anatomic restoration with minimal access morbidity. Results obtained by means of the Pararectus approach after two years at least parallel those reported after utilisation of the modified Stoppa approach. In contrast to the modified Stoppa approach, a relevant extension of the Pararectus approach was almost not necessary.