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

Comparison of Two Surgical Approaches for Periacetabular Osteotomy: A Retrospective Study of Patients with Developmental Dysplasia of the Hip

OBJECTIVE

Given the intricate challenges and potential complications associated with periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH). Our study aimed to compare the clinical and imaging benefits and drawbacks of two surgical approaches, the modified Stoppa combined iliac spine approach and the modified Smith-Peterson approach, for treating PAO and to provide guidance for selecting clinical approaches.

METHODS

A retrospective analysis of 56 patients with 62 DDHs was conducted from June 2018 to January 2022. The experimental group underwent surgery via the modified Stoppa combined iliac spine approach, while the control group underwent surgery via the modified Smith-Peterson approach for periacetabular osteotomy and internal fixation. Basic statistical parameters, including age, sex, BMI, and preoperative imaging data, were analyzed. Differences in surgical time, intraoperative blood loss, and postoperative imaging data were compared, as were differences in preoperative and postoperative imaging data between the two groups.

RESULTS

There were 28 hips in the experimental group and 34 in the control group. Moreover, there was no significant difference in the basic parameters between the experimental and control groups. Before and after the operation, for the LCE angle, ACE angle, and Tonnis angle, there was no significant difference in acetabular coverage (p > 0.05). However, there were significant differences between the two groups in terms of the above four indicators before and after the operation (p < 0.05). After the operation, the experimental group exhibited significant increases in both lateral and anterior acetabular coverage of the femoral head. However, the experimental group had longer operation times and greater bleeding volumes than did the control group. Despite this, the experimental group demonstrated significant advantages in protecting the lateral femoral cutaneous nerve compared to the control group.

CONCLUSION

The modified Stoppa combined iliac spine approach can be considered a practical approach for PAO and is more suitable for patients with DDH who plan to be treated by one operation than the classic modified Smith-Peterson approach for PAO.

Does the pararectus approach have better outcomes and fewer complications than the modified Stoppa approach for the fixation of acetabular fractures in adults: A systematic review and meta-analysis?

BACKGROUND

The pararectus approach is a minimally invasive surgical approach for anterior acetabulum fracture, with an advantage of the medial window of the modified Stoppa approach (MSA). However, it is unclear whether the pararectus approach is superior to MSA. We aimed this systematic review and meta-analysis to compare the outcomes and complications of pararectus and MSA.

METHODS

We performed a data search by conducting an electronic search across databases of PubMed, Embase, Scopus, Cinahl, CNKI, and Cochrane Library and included seven comparative studies for analysis. Statistical analysis was performed using the RevMan software 5.4.1. The risk of bias was evaluated using the Cochrane Collaboration's risk of bias tool for RCTs and the MINORS tool for non-RCTs.

RESULTS

Two randomized control trials (RCTs), one prospective study, and four retrospective studies were included. Meta-analysis revealed a better Matta's reduction quality [OR 1.58, 95% CI 1.06, 2.37; p = 0.03] and radiological outcome [OR 2.18, 95% CI 1.03, 4.60; p = 0.04] in MSA than in pararectus approach. However, the pararectus approach has less intraoperative blood loss [MD - 9.79 (95% CI - 176.75, - 6.83; p = 0.03)] and a shorter hospital stay [MD - 2.61 (95% CI - 5.03, - .18; p = 0.04)] than MSA. Both approaches have failed to show a difference concerning overall complication rates [OR 0.66 (95% CI 0.28, 1.55; p = 0.34)], postoperative infection, DVT, duration of surgery [MD - 15.09 (95% CI - 35.38, 5.20; p = 0.15)], functional outcome, and incision length.

CONCLUSION

The pararectus approach offers an advantage with lesser operative blood loss and shorter hospital stay, whilst MSA stands out with better reduction quality and radiological outcomes. Nevertheless, both approaches exhibit no difference in complication rates, duration of surgery, incision length, and functional outcome. Hence, the pararectus approach can be considered an alternative to MSA; however, the existing literature fails to demonstrate a distinct advantage over MSA.

Vertical Versus Pfannenstiel Incision-Modified Stoppa Approach in the Treatment of Acetabular Fractures

OBJECTIVES

The aims of this study were to compare the patient and fracture characteristics, radiological, functional, and quality of life outcomes; the need for a lateral window approach and requirement of total hip arthroplasty; and complications in patients with simple and complex acetabular fractures who underwent a modified Stoppa approach through vertical and Pfannenstiel incisions.

METHODS

DESIGN

This was a retrospective comparison study.

SETTING

Level 1 trauma center.

PATIENT SELECTION CRITERIA

Patients with acetabular fractures (A-O-/-O-T-A type 62A-B-C) treated with vertical (group V) or Pfannenstiel (group P) incision-modified Stoppa approach between 2010 and 2020 were included.

OUTCOME MEASURES AND COMPARISONS

Patient characteristics, radiological evaluations (reduction quality and posttraumatic osteoarthritis), patient functional outcomes [12-item Short-Form Survey (SF-12) physical component score, SF-12 mental component score, Harris Hip Score, and Merle d'Aubigné-Postel], approach modifications and stratification by fracture type and complications were compared between those treated with vertical or Pfannenstiel incisions.

RESULTS

One hundred four patients (mean age of 38.5 ± 14.3 years) were included. There was no significant difference between the Pfannenstiel or vertical groups regarding patient and fracture characteristics (P = 0.137), postoperative reduction quality (P = 0.130), or the mean functional and quality of life outcome scores at the last follow-up (P = 0.483 for the Harris Hip Score, P = 0.717 for the Merle d'Aubigné-Postel score, P = 0.682 for the SF-12 physical component score, and P = 0.781 for the SF-12 mental component score). In group P, significantly more patients needed additional lateral incisions (40.8% vs. 10.9%; P 0.001) and total hip replacement procedures (12.2% vs. 1.8%; P = 0.049). The total, early, and late complication rates were significantly higher in group P (P 0.001, P = 0.034, and P = 0.049, respectively).

CONCLUSIONS

Pfannenstiel incision was associated with higher complication rates than vertical incision in acetabular fractures treated through a modified Stoppa approach. Fracture complexity is associated with the need for a lateral window approach and total hip arthroplasty, as well as a worse functional and radiological outcome regardless of incision type. However, it was not associated with the development of intraoperative or postoperative complications.

LEVEL OF EVIDENCE

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

Anterior approaches in acetabular fractures: a true learning curve analysis

Today, acetabular surgeons in training have to learn ilioinguinal and anterior intrapelvic approaches (AIP). The aim of this study was to describe the 5-years learning curve of a surgeon. Objective was to assess clinical and radiological results; and to assess factors which could influence this learning curve. Between November 2015 and May 2020, patients with an acetabular fracture operated by the surgeon during the 5-years learning curve with an anterior approach were included in this single-center retrospective study based on a prospective database. Epidemiological, operative, clinical, radiological and complications data's were collected. To assess learning-curve effect the series was divided into two groups: first 2.5-years and last 2-years. Subgroup analysis were performed according to the surgical approach, to the reduction quality and the prognostic factors. In total, 46 patients were included, 23 in period 1 and 23 in period 2. 16 patients (35%) had ilioinguinal approach and 30 patients (65%) had modified Stoppa-Cole approach. At mean follow-up of 24 months, 38 patients (83%) were reviewed. Anatomical reduction (< 1 mm) was achieved in 28 patients (60.9%) with a 9% rate of perioperative complications and 37% rate of post-operative complications. In conclusion, this study gives a realistic overview of the learning curve of anterior approaches in acetabular fractures surgery. Our results should encourage surgeons, while keeping in mind how much this surgery can be challenging, with high rate of complications and difficulty to obtain a systematic anatomical reduction.

A Comparative Analysis of Commonly Used Surgical Approaches for Anterior Acetabular Fractures

Introduction Fractures of the acetabulum are inherently complex due to the anatomy of the innominate bones and also the presence of several vital neurovascular structures in the vicinity. Thus, the treatment of pelvic ring and acetabulum fractures is riddled with complexities and is considered among the most challenging surgeries for an orthopedic surgeon. When anterior access is necessary, such as in the anterior column, both columns, anterior column posterior hemitransverse, transverse, and T-type fractures, both the ilioinguinal and the anterior intrapelvic (AIP) or modified Rives-Stoppa methods are employed. The aim of this study is to compare the results from acetabular fractures treated with a modified Stoppa and ilioinguinal technique. Materials and methods We conducted a prospective cohort study to compare the outcomes of anterior acetabular fracture fixation using the modified Stoppa approach and the ilioinguinal approach. The outcomes measured were the amount of intraoperative bleeding, surgery duration, postoperative quality of fracture reduction, postoperative drain collection, and postoperative neurovascular status. The functional outcome was measured at three, six, and 12 months using the Merle d'Aubigné score. The radiological outcome was measured using the Matta scoring system. Results A significant difference was noticed in the two groups in the average blood loss and surgical duration, where the mean blood loss was 911.67 ± 143.05 ml in the ilioinguinal approach and 748.33 ± 165.30 ml in the modified Stoppa approach. While the ilioinguinal approach had a mean surgical duration of 190.33 ± 29.42 minutes, the modified Stoppa approach had 151.33 ± 23 minutes. The difference in postoperative fracture reduction in both groups was insignificant. The lateral femoral cutaneous nerve was compromised in 8.33% of cases in group A. The obturator nerve was compromised in 6.67% of cases in group B. The postoperative functional outcome was assessed by the modified Merle d'Aubigné score, and the radiological outcome was evaluated by the Matta score. The results obtained in both our study arms were comparable. Conclusion Based on our results, we can safely advocate the superiority of the Stoppa approach over a more extensive ilioinguinal approach. By virtue of being shorter in surgical duration and causing lesser blood loss, the Stoppa approach seems to be a better alternative, especially in elderly or polytrauma patients. As no difference was noted in the postoperative outcomes both clinically and radiologically, no approach showed superiority over the other in terms of patients' eventual functional outcomes.

Pararectus Approach in Acetabular Fractures in Patients Older Than 65 years. Is it Possible to Improve the Technique?

OBJECTIVES

Review clinical results of the treatment for acetabular fractures using the pararectus approach and analyze surgical variations of the traditional approach.

DESIGN

Retrospective.

SETTING

Tertiary referral hospital.

PATIENTS

46 patients over 65 years of age who sustained an acetabular fracture and underwent surgery using the pararectus approach.

INTERVENTION

Fractures were treated using a pararectus approach. Three variations of the original technique were performed: (1) Ligature of the deep iliac circumflex artery and vein, (2) separation of the psoas and iliacus muscles, and (3) isolation of the spermatic cord in men and round ligament in women together with the iliac and epigastric vessels.

MAIN OUTCOME MEASUREMENTS

Outcomes measures included surgical, demographic, and clinical data, and information related to follow-up.

RESULTS

Duration of surgery, 125 minutes (95-210). Quality of reduction on postoperative computed tomography (CT) scan; anatomic in 22 patients (47.8%), incomplete in 16 (34.8%), and poor in 8 (17.4%). In patients in whom the hip was preserved (n = 41), functional status was excellent in 15 patients (36.5%), good in 17 (41.4%), fair in 6 (14.7%), and poor in 3 (7.4%), with mean functional score of 16 points (7-18). Seven patients (15.2%) developed posttraumatic osteoarthritis and 4 of these patients underwent total hip replacement.

CONCLUSIONS

This study reports positive outcomes in fracture reduction and clinical outcomes with low complications in older patients who suffered acetabular fractures and were treated using a pararectus approach. Small variations in the technique, such as those proposed in this study, may help to widen access to the surgical site and simplify the technique.

LEVEL OF EVIDENCE

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

Ilioinguinal versus modified Stoppa approach for open reduction and internal fixation of displaced acetabular fractures: a systematic review and meta-analysis of 717 patients across ten studies

BACKGROUND

Acetabulum fracture is one of the most challenging fractures to manage and operate for orthopaedic surgeons; anatomical reduction of fractures and reconstruction of the joint is of utmost importance. These factors in turn are dependent on the appropriate surgical approach used to improve the clinical outcomes and reduce associated complications. Hence, this meta-analysis aims to compare the outcomes of ilioinguinal versus modified Stoppa approach for open reduction and internal fixation (ORIF) of displaced acetabular fractures.

METHODS

Medline (PubMed), Embase, Scopus, and Cochrane Library databases were searched from their inception to 10th of June 2021 for both randomized clinical trials (RCTs) and or non-randomized studies comparing the outcomes of ilioinguinal approach and modified Stoppa approach for the ORIF of acetabular fractures. The estimates of treatment effects were described by mean difference (MD) for continuous variables and odds ratio (OR) for dichotomous variables with corresponding 95% confidence (95% CI) intervals. The risk of bias was assessed by MINORS tool for the non-randomized, and the Cochrane Collaboration's risk of bias tool for RCTs.

RESULT

A total of ten studies (717 patients), three RCTs and seven retrospective studies, were included. Modified Stoppa approach showed shorter mean duration of surgery (MD 47.13, 95% CI: 27.30-66.96), lesser number of overall complications (OR 2.14, 95% CI: 1.46-3.13), less intraoperative blood loss (MD 259.65, 95% CI: 152.66-366.64), and lower rates of infection (OR 2.17, 95% CI: 1.14-4.15). However, ilioinguinal approach showed a better quality of fracture reduction (OR 0.59, 95% CI: 0.42-0.82). Results were equivocal in terms of vascular injuries (OR 1.88 (95% CI: 0.86-4.09), nerve injuries (OR 1.77, 95% CI: 0.99-3.17), heterotopic ossification (OR1.74, 95% CI: 0.63-4.82), and clinical outcome (OR 0.81, 95% CI: 0.45-1.47) between the two groups.

CONCLUSION

Modified Stoppa approach carries a lesser duration of surgery, lesser intraoperative blood loss, fewer overall complications, and lesser postoperative infection rates compared to ilioinguinal approach. Although a better anatomical reduction is achieved by ilioinguinal approach, however, this does not translate into better clinic functional outcomes which remain comparable between the two approaches. So overall, modified Stoppa approach seems a better alternative for managing these fractures.

Simultaneous reduction and fixation using an anatomical suprapectineal quadrilateral surface plate through modified Stoppa approach in superomedially displaced acetabular fractures

Treatment of superomedially displaced acetabular fractures including a quadrilateral surface (QLS) is challenging. We present a surgical technique using an anatomical suprapectineal QLS plate through the modified Stoppa approach and report the availability of this plate to treat this fracture type along with the surgical outcomes. Sixteen consecutive patients (14 men and 2 women) who underwent surgical treatment using an anatomical suprapectineal QLS plate through a modified Stoppa approach for superomedially displaced acetabular fractures between June 2018 and June 2020, were enrolled retrospectively. These fractures included 11 both-column fractures and 5 anterior-column and posterior hemitransverse fractures, which were confirmed on preoperative 3-dimensional computed tomography. Surgical outcomes were clinically assessed using the Postel Merle d’Aubigné (PMA) score and visual analog scale (VAS) score at the final follow-up, and radiological evaluations were performed immediately after the operation and at the final follow-up. For comparative analysis, 23 patients who underwent internal fixation with the conventional reconstruction plate through modified ilioinguinal approach between February 2010 and May 2018, were selected. This control group was composed of 18 both-column fractures and 5 anterior-column and posterior hemitransverse fractures. The follow-up period was at least 1 year in all patients. The mean operation time and blood loss was 109 min, and 853 ml, respectively, whereas 236 min, and 1843 ml in control group. Anatomical reduction was achieved in 14 (87.5%) patients, while imperfect reduction was achieved in the remaining 2 patients. At the final follow-up, radiographic grades were excellent, fair, and poor in 14 patients (87.5%), one, and one, respectively. The mean PMA score was 16.1 (range 13–18) and the mean VAS score was 1.0 (range 0–3). No secondary reduction loss or implant loosening was observed. However, 2 patients underwent conversion to total hip arthroplasty (THA) due to post-traumatic arthritis and subsequent joint pain. No other complications were observed. In the comparative analysis, radiological outcome showed a significant relationship with the conversion to THA (p = 0.013). Shorter operation time and less blood loss were significantly observed in the QLS plate fixation group through the modified Stoppa approach compared with the conventional reconstruction plate fixation group through modified ilioinguinal approach (p < 0.001, respectively). Simultaneous reduction and fixation using an anatomical suprapectineal QLS plate through the modified Stoppa approach may be a viable technique in superomedially displaced acetabular fractures along with shorter operation time and less blood loss.

Subcutaneous anterior pelvic bridge — an innovative technique for fixation of selective acetabular fracture: a case series and literature review

Introduction

The aim of the study was to introduce an innovative technique involving the use of a subcutaneous anterior pelvic bridge (SAPB) in the treatment of selective acetabular fractures.

Methods

We performed a retrospective study of 21 patients with acetabular fracture who were treated with SAPB between January 2016 and March 2021. The patients’ data were retrieved from electronic charts. Radiological results were evaluated according to the Matta system to assess the quality of the reduction and time of union. Functional outcomes were assessed in line with the d’Aubigné and Postel scoring system. Post-operative complications were also recorded.

Results

SAPB required around 60 minutes, with minimal blood loss and short learning curve. Matta score revealed excellent radiological outcomes in seventeen displaced fractures with seven excellent outcomes and nine good outcomes. Functional outcomes were excellent in twelve hips, good in seven hips, and fair in two hips. Six patients had transient lateral femoral cutaneous nerve palsy.

Discussion

The innovative SAPB method for the treatment of selective acetabular fracture is proven to be a feasible method with promising outcomes. SAPB is a minimally invasive technique and strengthens the stability of fixation, with less blood loss and fewer intra-operative/post-operative complications.

Oblique-ilioischial plate technique: a novel method for acetabular fractures involving low posterior column

Background

Complex acetabular fractures involving the anterior and posterior columns are an intractable clinical challenge. The study investigated the safety and efficacy of oblique-ilioischial plate technique for acetabular fractures involving low posterior column.

Methods

A retrospective analysis of 18 patients operated with the oblique-ilioischial plate technique by the modified Stoppa approach (or combined with iliac fossa approach) between August 2016 and July 2021 for low posterior column acetabular fractures was conducted. The anterior column was fixed with a reconstructed plate from the iliac wing along the iliopectineal line to the pubis. The low posterior column was fixed with the novel oblique-ilioischial plate running from the ilium to the ischial ramus. Operative time, intraoperative blood loss, reduction quality, and postoperative hip function were recorded.

Results

Out of the 18 patients, 10 were male and 8 were female. The mean age was 48.6±10.2 years (range: 45–62 years); The mean interval from injury to operation was 7.2±1.4 days (range: 5–19 days); The mean operative time was 2.1±0.3 h (range: 1.0–3.2 hours); The mean intraoperative blood loss was 300±58.4 mL (range: 200–500 mL). Postoperative reduction (Matta’s criteria) was deemed as excellent (n = 9), good (n = 4), and fair (n = 5). At the final follow-up, the hip function (modified Merle d’Aubigne-Postel scale) was deemed as excellent (n = 11), good (n = 3), and fair (n = 4). The mean union time was 4.5±1.8 months (range: 3–6 months). No implant failure, infection, heterotopic ossification, or neurovascular injury were reported.

Conclusion

The oblique-ilioischial plate technique via anterior approach for acetabular fractures involving low posterior column offers reliable fixation, limited invasion, little intraoperative bleeding, and fewer complications. However, larger multicenter control studies are warranted.

Pararectus approach vs. Stoppa approach for the treatment of acetabular fractures - a comparison of approach-related complications and operative outcome parameters from the German Pelvic Registry

PURPOSE

The Pararectus approach has been introduced as an alternative anterior approach to the Stoppa approach in acetabular surgery. There is no evidence which approach should be preferred, especially regarding approach-related complications. Therefore, aim of this registry study was to compare the Pararectus approach to the Stoppa approach regarding complications and quality of reduction.

METHODS

Patients from the German Pelvic Registry with a surgically treated acetabular fracture, either through the Pararectus approach or the Stoppa approach, were analyzed or compared regarding demographic, clinical and operative parameters.

RESULTS

In total, 384 patients with an acetabular fracture received a surgical procedure with either the Pararectus approach (n=120) or the Stoppa approach (n=264). There were no differences between the two groups regarding demographic parameters and fracture pattern. The overall complication rate (35.0% vs. 31.4%), the mortality rate (5.0% vs. 3.0%) and the osteosynthesis-associated complication rate (5.8% vs. 4.2%) tended to be higher in the Pararectus group with no statistical significance. There were significantly more anatomical reductions in the Pararectus group (56% vs. 43%; p=0.01). However, operation time was significantly longer in the Pararectus group (255±125 vs. 205±103 minutes; p<0.001).

CONCLUSION

Despite a longer operation time, the Pararectus approach and the Stoppa approach are equivalently applicable for the treatment of acetabular fractures regarding complication rates and quality of reduction.

LEVEL OF EVIDENCE

III, retrospective comparative study.

The Pararectus approach in acetabular fractures treatment: functional and radiologcial results

BACKGROUND

The surgical treatment of complex acetabular fractures is one of the most challenging procedures for orthopedic surgeons. The Pararectus approach, as a reasonable alternative to the existing surgical procedures, was performed for the treatment of acetabular fractures involving the anterior column. This study aimed to evaluate outcome using the Pararectus approach for acetabular fractures involving anterior columns.

METHODS

Thirty-seven with displaced acetabular fractures involving anterior columns were treated between July 2016 and October 2019 using the Pararectus approach. The functional outcomes (using the Merle d Aubigné and Postel scoring system, WOMAC and modified Harris scoring), the quality of surgical reduction (using the Matta criteria), and postoperative complications were assessed during approximately 26 months follow-up period.

RESULTS

Thirty-seven patients (mean age 53 years, range: 30-71; 28 male) underwent surgery. Mean intraoperative blood loss was 840 ml (rang: 400-2000 ml) and mean operating time was 210 min (rang: 140-500 min). The modified Merle d Aubigné score was excellent and good in 27 cases (73%), fair in 6 cases (16%), and poor in 3 cases (11%). The mean score was 88.5 (range:77-96) for the modified Harris Hip scores, and 22 (range:7-35) for the WOMAC scores after operation. Postoperative functional outcomes were significantly improved compared with preoperative outcomes (P < 0.0001). The quality of reduction was anatomical in 21 cases (57%), satisfactory in 9 cases (24%), and unsatisfactory in 7 cases (19%). At follow-up, four patients developed a DVT, and heterotopic bone formation was observed in one patient. The hip osteoarthritis was not observed.

CONCLUSION

The Pararectus approach achieved good functional outcomes and anatomical reduction in the treatment of acetabular fractures involving anterior column with minimal access morbidity.

Treatment of acetabular fractures with quadrilateral plate injury - a comparison of two commonly used methods

BACKGROUND

Acetabular fractures with quadrilateral plate (QLP) involvement have traditionally been treated by buttress plates applied through an Ilio-inguinal approach. Recently, many surgeons prefer the application of infra-pectineal plates through the modified Stoppa approach for this purpose. Whether one method can be preferred over the other is a matter of investigation.

HYPOTHESIS

The research question was whether an infra pectineal plate applied through the modified Stoppa approach for acetabular fractures with QLP involvement would result in an equivalent or better outcome than a buttress plate applied through an ilioinguinal approach.

PATIENTS AND METHODS

This was a retrospective study of patients with QLP fractures operated by either of the two methods and who had completed at least one year follow up. Demographic and surgical details and the radiological and clinical outcomes at the last follow-up visit were obtained from patient records.

RESULTS

A total of 41 patients were treated with a buttress plate applied through an ilioinguinal approach (group A), and 49 patients were treated with an infra-pectineal plate by the modified Stoppa approach (group B). Duration of surgery and intra-operative blood loss was significantly less in group B patients. Radiological and clinical outcomes were better in group B patients than group A patients. Implant loosening was more frequent in group A patients. Injury to the obturator vessels were more common in group B patients.

CONCLUSION

With a comparatively lesser surgical duration and blood loss, better clinical and radiological outcomes at least one year after the surgery, an infra-pectineal plate applied through the modified Stoppa approach can be considered the preferred treatment for most acetabular fractures with QLP involvement.

LEVEL OF EVIDENCE

III.

Comparison between ilioinguinal approach and modified Stoppa approach for the treatment of acetabular fractures: An updated systematic review and meta-analysis

BACKGROUND

The modified Stoppa (MS) approach is an alternative to the ilioinguinal (IL) approach and three meta-analyses comparing these two approaches for the treatment of acetabular fractures were published previously. The aim of this study was to provide an updated systematic review and meta-analysis comparing the MS approach with the IL approach for the treatment of acetabular fractures and to answer the following question: are the results of the MS approach superior to those of the IL approach in terms of reduction quality, operative time, operative blood loss, complications, and clinical outcomes for treatment of acetabular fractures?

PATIENTS AND METHODS

An updated systematic literature review was conducted using relevant original studies from various databases (PubMed, Web of Science and the Cochrane Library). Pooling of data was performed using RevMan software (version 5.3, Cochrane Collaboration, Oxford, UK). A p-value of<0.05 was considered to be significant. We calculated the mean differences (MDs) for continuous data and odds ratio (OR) for dichotomous data with 95% confidence intervals (CIs) for each outcome. Statistical heterogeneity was assessed based on I² using the standard Chi² test. When I²>50%, significant heterogeneity was assumed and a random-effects model was applied for the meta-analysis. A fixed-effects model was applied in the absence of significant heterogeneity.

RESULTS

Six studies were included in this meta-analysis. The findings demonstrated that the rate of anatomical reduction was significantly higher in the MS approach than in the IL approach (I²=0%, OR=1.75, 95% CI: 1.13-2.69, p=0.01), the operative time was significantly shorter in the MS approach than in the IL approach (I²=88%, MD=-63.60, 95% CI: -93.01 - (-34.20), p<0.0001) and operative blood loss was significantly lower in the MS approach than in the IL approach (I²=75%, MD=-350.51, 95% CI: -523.45 - (-177.58), p<0.0001). There was no significant difference in the rate of nerve injury (I²=0%, OR=0.47, 95% CI: 0.16-1.39, p=0.17), the rate of vascular injury (I²=0%, OR=0.51, 95% CI: 0.17-1.49, p=0.22), the rate of infection (I²=0%, OR=0.53, 95% CI: 0.25-1.12, p=0.10), the rate of heterotopic ossification (I²=45%, OR=0.63, 95% CI: 0.22-1.85, p=0.40), and the rate of excellent or good clinical score (I²=21%, OR=1.15, 95% CI: 0.56-2.38, p=0.70) between the two approaches.

DISCUSSION

The MS approach provided better reduction quality, shorter operative time, lower operative blood loss, although there were no significant differences in the rate of complications, and excellent or good clinical score between the two approaches.

LEVEL OF EVIDENCE

III.

Management of anterior associated types of acetabular fractures utilizing the modified Stoppa and the pararectus approaches: a prospective cohort study and early experience from a level one Egyptian trauma centre

PURPOSE

This study aimed to report the early experience (radiographic, functional, and complications outcomes) from an Egyptian (North African) level one trauma centre after utilizing the modified Stoppa and the pararectus approaches to manage anterior-associated types of acetabular fractures.

PATIENTS AND METHODS

Between January 2014 and April 2018, 63 patients (40 males and 23 females) with a mean age of 33 ± 11.5 were included, 45 patients were treated through the modified Stoppa (group A), and 18 through the pararectus approach (group B).

RESULTS

At a mean follow-up of 32.11 ± 15.36 months (range 12 to 64), 56 patients (43 group A and 13 group B) were evaluated. The post-operative anatomical reduction was achieved in 44 (78.6%) patients. At the last follow-up, Matta radiological outcome grades were excellent and good in 50 (89.2%) patients, fair and poor in six (10.8%). The mean Harris Hip Score (HHS) was 92.6 ± 7.6; the mean modified Merle D'Aubigné (MMD) score was 16.5 ± 1.5. Excellent functional outcome was reported in 42 (75.0%) and 25 (44.6%) patients according to HHS and MMD scores, respectively. There are four (7.1%) intra-operative iatrogenic complications (two in each approach), three (5.3%) vascular injuries (two in group B and one in group A), and one (1.8%) bladder injury in group A.

CONCLUSION

Employing less-invasive anterior approaches for managing anterior associated types of acetabular fractures proved efficiency and safety. Good to excellent radiological and functional outcomes were achieved, with no significant difference between both approaches.

Comparison of Therapeutic Outcomes of Transabdominal Pararectus Approach and Modified Stoppa Approach in Treating Pelvic and Acetabular Fractures

OBJECTIVE

Pelvic and acetabular fractures are common orthopedic diseases, and this research was to investigate the therapeutic effects of pararectus and Stoppa approaches in treating complex pelvic acetabular fractures.

METHODS

The clinical information of patients with pelvic and acetabular fractures treated surgically in Lu'an Hospital of Chinese medicine, China from January 2016 to April 2020 was analyzed. There were 30 cases each in the transabdominal pararectus approach and modified Stoppa approach groups. The operation time, incision length, blood loss, and postoperative complications of both groups were recorded according to the Merle d'Aubigné-Postel hip score. The recovery of hip function was evaluated 6 months after surgery, and the clinical and therapeutic efficacies of the two groups were compared.

RESULTS

The patients were followed up for 6-7 months (average, 6.5 months). The average operation time, incision length, and blood loss in the pararectus and Stoppa approach groups were 180 ± 41.105 min, 8.667 ± 1.373 cm, 259.667 ± 382 mL and 202.667 ± 32.793 min, 11.600 ± 1.958 cm, and 353.667 ± 590 mL, respectively. The satisfactory rate of fracture reduction, excellent and good rate of hip function score, and incidence of complications were 28/30, 27/30, 1/30 and 25/30, 25/30, 3/30, respectively. There were significant differences in operation time, incision length, and blood loss between the two groups (p < 0.05). However, there was no significant difference in the excellent and good rate of hip function score, fracture reduction satisfaction, and complication rate between both groups (p > 0.05).

CONCLUSIONS

The pararectus approach can reveal the better anatomical structure of the pelvis and acetabulum, such as the corona mortis and quadrilateral plate, for conducive fracture reduction and fixation. It can also effectively shorten the length of the incision, reduce operative blood loss, and shorten the operation time. It is a better choice for the clinical treatment of complex pelvic and acetabular fractures.

The influence of bone quality on radiological outcome in 50 consecutive acetabular fractures treated with a pre-contoured anatomic suprapectineal plate

PURPOSE

To investigate the range of indications of an anatomical-preshaped three-dimensional suprapectineal plate and to assess the impact of the bone mass density on radiologic outcomes in different types of acetabular fractures.

PATIENTS AND METHODS

A consecutive case series of 50 acetabular fractures (patient age 69 ± 23 years) treated with suprapectineal anatomic plates were analyzed in a retrospective study. The analysis included: Mechanism of injury, fracture pattern, surgical approach, need for additional total hip arthroplasty, intra- or postoperative complications, as well as bone mass density and radiological outcome on postoperative computed tomography.

RESULTS

Most frequently, anterior column fracture patterns with and without hemitransverse components as well as associated two column fractures were encountered. The anterior intrapelvic approach (AIP) was used in 98% (49/50) of the cases as primary approach with additional utilization of the first window of the ilioinguinal approach in 13/50 cases (26%). Determination of bone density revealed impaired bone quality in 70% (31/44). Postoperative steps and gaps were significantly greater in this subgroup (p < 0.05). Fracture reduction quality for postoperative steps revealed anatomic results in 92% if the bone quality was normal and in 46% if impaired (p < 0.05). In seven cases (14%), the plate was utilized in combination with acute primary arthroplasty.

CONCLUSION

A preshaped suprapectineal plate provides good radiological outcomes in a variety of indications in a predominantly geriatric cohort. Impaired bone quality has a significantly higher risk of poor reduction results. In cases with extensive joint destruction, the combination with total hip arthroplasty was a valuable option.

A Modified Levine Approach for Exposure of the Anterior Column, Anterior Wall, and Sacroiliac Joint: A Surgical Technique and a Case Series

Surgical exposure of the anterior column, anterior wall, pelvic brim, and sacroiliac joint is accessible through the lateral window of the ilioinguinal approach. Residual attachment of the abdominal muscles and inguinal ligament to the anterior superior iliac spine (ASIS) is often a limiting factor to expanded distal and medial exposure, especially in patients with a large abdomen that hangs over the pelvis. An ASIS osteotomy has been described to improve exposure, particularly of the distal anterior wall and joint capsule, pubic ramus, and anterior quadrilateral plate. However, an ASIS osteotomy can be troublesome to reattach. In this study, we introduce a soft tissue release technique to mobilize the abdominal muscles and inguinal ligament to allow expanded surgical access to the distal anterior column/wall and sacroiliac joint and to create a working space for fracture reduction and fixation.

[Research progress of different surgical approaches in treatment of acetabular both-column fractures]

Objective

To review the research progress of different surgical approaches in the treatment of acetabular both-column fractures.

Methods

The domestic and foreign related research literature on surgical approaches for acetabular both-column fractures was extensively consulted. The anatomical characteristics, exposure ranges, advantages, disadvantages, and indications of various common surgical approaches for both-column fractures were mainly summarized.

Results

The ilioinguinal approach is more suitable for both-column fractures if the anterior column fracture is complicated or combined with the anterior wall fracture while the posterior column fracture is simple and stable. The modified Stoppa approach or the lateral (para) rectus abdominal approach is the preferred choice when both-column fractures are combined with a quadrilateral fracture or femoral head dislocation. What's more, the Kocher-Langenbeck approach is required when the posterior column fractures are complicated or combined with posterior wall fractures. In addition, the simultaneous ilioinguinal and Kocher-Langenbeck approaches are the first choices when the both-column fractures possessing extremely severe and obvious displacement.

Conclusion

The reasonable choice of surgical approach is extremely important for acetabular both-column fractures. Each surgical approach has its advantages and limitations. It is necessary to take the precise reposition of the acetabular joint surface as the principle, and comprehensively judge the fracture types and severity of anterior column, posterior column, and square area, and then select the optimal surgical approach for surgical treatment.

Internal fixation of anterior acetabular fractures with a limited pararectus approach and the anatomical plates: preliminary results

Background

The surgical treatment of acetabular fracture has adverse outcomes and high risk, and minimally invasive method is a good way to reduce complications and improve hip joint function. This study is to investigate the treatment of certain acetabular fractures primarily involving the anterior column and quadrilateral plate using a limited pararectus approach and the anatomical plates.

Methods

A consecutive cohort of 17 patients with anterior displaced acetabular fractures were managed operatively with a limited approach and the anatomical plates. Ten patients had anterior column fractures, 1 patient had anterior wall fracture, 4 patients had transverse fractures and 2 patients had anterior column with posterior hemi-transverse fractures. The inferior half of the pararectus approach was adopted to open the medial window and to access the anterior column and the quadrilateral plate. The anatomical plates were used for internal fixation. Residual displacements were assessed on the postoperative CT scans using a standardized digital method. The surgical details, hip functional outcomes, and complications were noted.

Results

All of the patients were operated using the limited pararectus approach and the anatomical plates successfully. The mean operative time and blood loss were 90.9 min and 334.1 ml, respectively. The average postoperative residual gap and step displacement on CT were 2.9 mm and 0.7 mm, respectively. The radiological outcome was estimated according to the Matta score, ten of the cases were graded anatomical, six were graded imperfect, and one was graded poor. Follow up averaged 15 months. Functional outcomes were excellent for nine, good for six, and fair for two. It was noted that one case of peritoneal injury was repaired intraoperatively.

Conclusions

The limited pararectus approach with the advantages of less trauma, direct exposure to the anterior column and quadrilateral plate. The anatomical plates can fit with the surface of the acetabulum, which saves the time of remodeling plates during operation and facilitate fracture reduction. The combination approach can be a good choice for limited surgery of displaced anterior acetabular fractures especially involving the quadrilateral plate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04034-w.

Comparative study of anatomical locking plate and reconstruction plate in treating acetabular fractures

PURPOSE

This study aims to compare the effectiveness of anatomic locking plate and reconstruction plate used in treating acetabular fractures.

METHODS

From January 2009 to January 2016, patients with acetabular fractures were included in this retrospective study. We grouped the patients into two groups based on the internal fixation: reconstruction plate group (RPG) and anatomic locking plate group (ALPG). The operation time, blood loss, intra-operative screw penetration, and plate breakage were compared between the two groups. The intra-operative fluoroscopic images were used to evaluate the fixation location. The quality of reduction and radiological grading were assessed according to the criteria developed by Matta. The clinical assessment was based on the Merle d'Aubigne-Postel score.

RESULTS

Eighty-three patients were included in this study and were followed up for an average of 35 months (range, 25 to 42 months). Thirty-five patients were treated with the anatomical locking plate, and 48 patients were treated with the reconstruction plate. The mean surgical time was significantly shorter (P < 0.0001) in ALPG patients than in RPG patients, and the intra-operative blood loss was significantly lower (P = 0.008). The rates of intra-operative screw penetration or plate breakage in the ALPG (0/35) are significantly lower than that in the RPG (7/48) (P = 0.018). Post-operative Matta score (P = 0.905), Merle d'Aubigne-Postel score (P = 0.957), and overall complication rates (P = 0.391) were not significantly different among the groups.

CONCLUSION

Patients treated by anatomical locking plate had shorter operation time, less bleeding, and lower rate screw perforation compared to patients treated by reconstruction plate. Anatomical locking plate is a better choice for acetabulum fractures, especially complicated fractures.

The Stoppa combined with iliac fossa approach for the treatment of both-column acetabular fractures

Background

At present, the choice of surgical approach for both-column fractures is still controversial. The purpose of this study was to explore the efficacy of the Stoppa combined with iliac fossa (S+IF) approach in the treatment of both-column fractures.

Methods

In this retrospective case series, 76 patients were included in the study from 2014 to 2018. They were divided into two groups according to the surgical approaches. The differences of intraoperative blood loss, operative time, quality of reduction, clinical outcome, and perioperative complications were compared between the two groups.

Results

All patients had undergone the IL approach or the S+IF approach. The average operative time was 156.2 min (110~210 min) in group I and 126.5 min (80~180 min) in group II (P < 0.001). The average blood loss in group I was 784.1 ml, while the average blood loss in group II was 625.3 ml (P = 0.007). According to Matta’s criteria, 28 cases obtained anatomic reduction and 12 cases got imperfect reduction in group I; 21 cases obtained anatomic reduction and 7 cases got imperfect reduction in group II (P > 0.05). The clinical outcome (excellent to good) was 66% in group I versus 69% in group II (P > 0.05). The complication rates were 18.2% in group I and 12.5% in group II (P > 0.05).

Conclusions

As a minimally invasive surgical approach, the S+IF approach is a valuable alternative to the IL approach for the treatment of both-column acetabular fractures if these two anterior approaches can achieve fracture exposure, reduction, and fixation.

Therapeutic Effect of Acetabular Fractures Using the Pararectus Approach Combined with 3D Printing Technique

Objective

To explore the clinical efficacy of pararectus approach combined with 3D printing technique for the surgical treatment of partial acetabular fractures.

Methods

We retrospectively evaluated 33 (20 males and 13 females) patients with acetabular fractures in the period of June 2017 to December 2018. According to Judet and Letournel classification: 11 cases were of anterior column fracture, 10 cases were of double column fracture, seven fractures were of the anterior column with posterior half transverse, three fractures were of transverse fracture, and two cases were of “T” fracture. For all cases, 3D printing is used to print the acetabular model. Pre‐bent reconstruction plates from the model were placed to fixate fractures via the pararectus approach.

Results

Thirty‐three patients (mean age 48 years; range, 35–63 years), included 20 men and 13 women, were treated successfully with open reduction and internal fixation by the pararectus approach. Surgery duration was 203 min on average (range: 135–245 min), and intra‐operative bleeding was 1030 mL on average (range: 450–1400 mL). All patients were followed‐up for 12–18 months (average,14 months); two patients (6.0%) developed postoperative ossifying myositis, and there are no obvious symptoms at present; one patient (3.0%) developed postoperative wound infection, and the wound completely improved by secretion culture, enhanced dressing, and effective antibiotics; all the acetabular fractures united after 12 to 16 weeks (average,13 weeks). According to the modified Merle d'Aubigne and Postel scoring system to assess the hip function: excellent in 22 cases (66.7%), good in seven cases (21.2%), and fair in four cases (12.1%).

Conclusions

In the treatment of partial acetabular fractures, the pararectus approach combined with 3D printing technique can achieve effective reduction and fixation, decrease intraoperative hemorrhage, shorten operation time, and the internal fixation position can be properly adjusted during the operation by looking directly at the model.

Modified Stoppa as an alternative surgical approach for fixation of anterior fracture acetabulum: a randomized control clinical trial

Background

Fracture acetabulum is a challenging, difficult to treat orthopedic injury due to its location and associated concomitant injuries. The modified Stoppa approach for reduction of fracture acetabulum improves access to quadrilateral surface and posterior column and is considered to be advantageous in many facets of the surgery.

Methods

A randomized controlled clinical study was conducted to provide an update on our experience with modified Stoppa as a favorable surgical approach in acetabular fractures. In the period between 2015 and 2017; 18 patients with acetabular fractures operated by the classical ilioinguinal approach were retrospectively reviewed through their medical records as a controlled group and selected 20 patients with acetabular fractures were operated in the period between 2017 and 2019 using the modified Stoppa approach, as a clinical case group. The two groups were compared regarding operative data and postoperative clinical data, complications, and follow up. Cases were operated in Al Zahraa University Hospital and Nasr City Insurance Hospital by the same surgeon and one of the co-authors.

Results

(Group A) those operated by ilioinguinal approach and (Group B) those operated using Stoppa approach. The whole study included 25 males (66%); mean age was 41.8 ± 8.42 (range 18-65) years. The mean follow-up period was 18.5 months with 5 patients lost to follow-up. Both column fractures were observed in most of the patients (45%). We observed anatomical reduction, excellent clinical outcome scores in 75% of patients of group B (p = 0.030), and less complications.

Conclusion

Our findings indicated that the modified Stoppa approach is the most convenient approach when surgery is required and achieved favorable results in the treatment of anterior acetabular fractures because it improves visualization in lateral compression injuries and allows treatment of both column fractures with single incision. Hence, it is recommended as an alternative to ilioinguinal approach in developing countries. Further, larger-scale comparative studies of the two surgical modalities for different acetabular fracture types and long-term complications are recommended.

Trial registration

A retrospective registration is proceeding through Clinicaltrials.gov.

Level of evidence

Level III, therapeutic clinical study

Meta-analysis of modified Stoppa approach and ilioinguinal approach in anterior pelvic ring and acetabular fractures

BACKGROUND

The purpose of this meta-analysis was to compare the efficacy of the modified Stoppa approach (MSA) and ilioinguinal approach (IA) in the treatment of anterior pelvic ring and acetabular fractures.

METHODS

A literature search was conducted using PubMed, Embase, and Cochrane database for articles that compared MSA and IA in the treatment of anterior pelvic ring and acetabular fractures. All the included articles were evaluated by 2 trained reviewers in accordance with the Cochrane Collaboration Handbook for potential risk. The Jadad decision algorithm and Downs and Black scores were also used to assess the quality of the included studies. The extracted data included operative time, intraoperative blood loss, reduction quality, clinical outcome, and complications.

RESULTS

Five articles were included in this meta-analysis, with 186 patients in the MSA group and 219 patients in the IA group. Compared with IA, MSA significantly shortened the operative time (P = .0002), decreased intraoperative blood loss (P = .002), and provided better reduction quality (P = .03). Meanwhile, this meta-analysis suggests no significant difference between MSA and IA regarding clinical outcomes (P = .63) and complications (P = .34). The subgroup analysis of complications also showed no statistically significant difference between the 2 groups (including infection, and vascular and nerve injuries).

CONCLUSION

According to this meta-analysis, the currently available evidence suggests that MSA can significantly shorten operative time, decrease intraoperative blood loss, and provide better reduction quality than IA in the treatment of anterior pelvic ring and acetabular fractures. In addition, in terms of clinical outcomes and complications, no significant differences were found between the 2 groups.

LEVEL OF EVIDENCE

Level IV, meta-analysis.

Short-term results of surgical treatment of acetabular fractures using the modified Stoppa approach

BACKGROUND

As the more commonly used ilioinguinal approach is extensive and associated with complications arising from the dissection along the inguinal canal, we attempt to evaluate the efficacy of the modified Stoppa approach as an alternative in the operative management of acetabular fractures.

METHODS

Twenty-three patients with acetabular fractures, were operated by the modified Stoppa approach. Fractures were classified; operative time and blood loss were recorded; the radiological and clinical outcomes were prospectively analysed. We analysed the radiological results according to the criteria of Matta and the clinical results by the Merle d'Aubigne and Postel score with a mean follow up of 15.13 months.

RESULTS

The clinical outcomes were excellent or good in nineteen cases, fair and poor in two patients each. In eighteen of our cases the reduction was anatomic, imperfect in two cases, and poor in three cases. The mean pre-operative displacements on axial, sagittal and coronal NCCT sections were 3.8, 3.1 and 3.6 mm, respectively; and mean post-operative displacements were 0.2, 0.3 and 0.2 mm, respectively. The mean pre-operative and post-operative fracture gap were 12.8 mm and 1.1 mm respectively.

CONCLUSIONS

Minimizing perioperative morbidity and simultaneously allowing access for anatomical reduction are the major benefits of the approach. The modified Stoppa approach can substitute the ilioinguinal approach for the surgical fixation of acetabular fractures.

Supra-ilioinguinal versus modified Stoppa approach in the treatment of acetabular fractures: reduction quality and early clinical results of a retrospective study

Background

To compare the efficacy of the operative techniques, complications, reduction quality and hip functional recovery by using the supra-ilioinguinal approach and the modified Stoppa approach for the management of acetabular fractures.

Methods

A consecutive cohort of 60 patients from September 2014 to October 2017 with displaced acetabular fractures involving the quadrilateral plate were treated operatively with supra-ilioinguinal approach (group A) and modified Stoppa approach (group B), respectively. There were 36 patients in group A and 24 patients in group B. The surgical details, complications, radiographic and clinical results were recorded. The quality of reduction was assessed by measuring the residual step and gap displacement of postoperative CT with a standardized digital method.

Results

The complications, reduction quality (gaps and steps) and hip function recovery had no significant statistical difference in approaches. The mean operative time was shorter and the mean intraoperative haemorrhage was less in group A. There were statistical differences in the operative time (P = 0.025) and intraoperative haemorrhage (P = 0.003) between the supra-ilioinguinal approach and the modified Stoppa approach.

Conclusion

Compared to the modified Stoppa approach, the supra-ilioinguinal approach provides a closer visualization to the quadrilateral plate, the operative time was shorter and the intraoperative haemorrhage was clearly less. It is at least equal to or could be a better choice to deal with complicated acetabular fractures especially involving the quadrilateral plate and the anterior one third of the iliac bone.

Retrospective study of 16 acetabular fractures with involvement of the quadrilateral plate treated with an anterior intrapelvic modified Rives-Stoppa approach

GOAL

To report our experience with the use of Stoppa approach for fractures of the acetabulum with quadrilateral plate involvement.

MATERIAL AND METHOD

Retrospective study; level iv. All patients were operated in a third level trauma center. The surgical team was experienced in the management of pelvic fractures. Data about patients, injuries, treatment features and clinical and radiological results were collected. We performed a statistical analysis; both descriptive and analytical.

RESULT

16 patients integrated the sample. 15 suffered associated fracture patterns. Anatomical plates were used in 15. Four required extended approaches. Reduction was anatomical in 9. 7 suffered some complication, needing the additional surgical procedures in 4. The surgical site infection rate was particularly high, appearing in 3.

DISCUSSION

Radiological results were within the previously reported. We had a high complication rate, particularly infection. This outcome may be influenced by the special complexity of our cases and the adaptation process to a new technique.

CONCLUSSION

Using the Stoppa approach we achieved lots of good or anatomical reductions. However, is an exigent and not without complications technique.

Management of anteromedially displaced acetabular fractures using a collinear reduction clamp through modified ilioinguinal approach

The authors present a surgical technique using a collinear reduction clamp through the modified ilioinguinal approach (MIA) for anteromedially displaced acetabular fractures along with the surgical outcomes. Between October 2010 and June 2015, 15 patients underwent surgical treatment for anteromedially displaced acetabular fractures; 10 both-column fractures and 5 anterior column and posterior hemitransverse fractures. Anteriorly displaced anterior column fragment and medially displaced quadrilateral plate fragment were simultaneously reduced using a collinear clamp and fixed with a 3.5mm-reconstruction plate through MIA. Postoperatively, anatomical reduction was achieved in 12 patients, while imperfect reduction was achieved in 3. At a mean follow-up of 49.0 months (range, 24-93 months), the mean Postel Merle d'Aubigné score were 16.3 and the mean VAS score was 0.9. Final radiographic grades according to Matta system were excellent in 13 patients and good in 2. Surgical technique using a collinear reduction clamp through the MIA can provide satisfactory outcomes in anteromedially displaced acetabular fractures.

Modified Stoppa Approach for Acetabulum Fracture: A Review

Fracture acetabulum is a grave injury and a challenge for orthopedic surgeons. Anterior and posterior approaches have been described for fixation of acetabulum fractures. The modified Stoppa approach is considered an alternate to anterior approach, which provides access to pelvis from inside the cavity. The purpose of this article is to review the available literature on use of the modified Stoppa approach in acetabulum fractures. The available data suggest that modified Stoppa approach is useful in anterior acetabulum fractures and some posterior acetabulum fractures, especially where buttressing of medial wall is required.

Fixation of Displaced Acetabular Fractures With an Anatomic Quadrilateral Surface Plate Through the Stoppa Approach

Satisfactory fixation for displaced acetabular fractures involving the quadrilateral surface remains difficult to obtain with conventional reconstruction plates. To achieve minimally invasive management of fractures of the quadrilateral surface, the authors designed a type of anatomic quadrilateral surface plate (AQSP). A retrospective study to assess the therapeutic results of the AQSP was performed at their institution. A total of 26 patients with quadrilateral surface fractures fixed with an AQSP through the Stoppa approach from February 2014 to February 2015 were included in this study. There were 16 men and 10 women with a mean age of 37.5 years. The patients were followed for a mean of 28.81 months (range, 24-36 months). The mean operative time was 98.85±16.08 minutes, and the mean intraoperative blood loss was 353.85±124.84 mL. Postoperative radiographs and computed tomography scans showed that anatomic and good reductions were obtained in 88.46% (23 patients) and 11.54% (3 patients) of the patients, respectively. Screw loosening was not observed. All of the fractures healed well at a mean of 3.54 months. Two cases of obturator nerve injury and 1 case of corona mortis rupture were observed. However, permanent complications were not observed. The mean Merle d'Aubigné score at final follow-up was 16.38±1.33 points. The authors conclude that satisfactory fixation with the AQSP system can be achieved through the Stoppa approach. [Orthopedics. 2019; 42(2):e180-e186.].

Open Reduction and Internal Fixation of Acetabular Fractures Using the Modified Stoppa Approach

Background

The modified Stoppa approach is performed for safe and efficient management of acetabular fractures involving the anterior column. This approach avoids dissection of the inguinal canal, the femoral nerve, and the external iliac vessels as seen in the "second window" of the ilioinguinal approach and has thus been shown to be less invasive than the ilioinguinal approach¹. As an intrapelvic approach, it facilitates the management of medial displacement fracture patterns involving the quadrilateral plate and dome impaction that typically occur in the elderly^2,3. The reduced morbidity of this approach is of particular relevance for elderly patients who must respond to the stresses of injury and surgery with diminished physiological reserves.

Description

The specific surgical steps include preoperative planning, patient positioning and setup, a Pfannenstiel incision, superficial and deep dissection, development of the Retzius space and retraction of the bladder, exposure of the superior pubic ramus and iliopectineal eminence, dissection and ligation of a potential corona mortis, exposure of the obturator nerve and vessels, subperiosteal preparation of the pubic ramus with retraction of the external iliac vessels, subperiosteal exposure of the quadrilateral plate with detachment of the internal obturator muscle and exposure of the posterior column, assessment of residual displacement by fluoroscopic views, longitudinal soft-tissue or lateral skeletal traction (optional) for reduction of medial displacement of the femoral head, disimpaction of the acetabular dome fragment and grafting of the supra-acetabular void (optional) under fluoroscopic and arthroscopic (optional) control, and reduction and fixation of extra-articular components (iliac wing posteriorly and pubic ramus anteriorly), the posterior column (infra-acetabular screw), and the quadrilateral plate (buttress plate). Before wound closure, the urine output is checked for occurrence of hematuria, an indication of bladder penetration. The anterior lamina of the rectus sheath is then sutured, and a layered closure performed.

Alternatives

The ilioinguinal approach might be used instead.

Rationale

The modified Stoppa approach avoids dissection within the inguinal canal, the second window of the ilioinguinal approach. Therefore, this approach is less invasive and might be an alternative for joint-preserving surgery, especially in the elderly.

Treatment results for acetabulum fractures using the modified Stoppa approach

Objectives

The aim of this study was to evaluate the clinical and radiological results of the surgical treatment of acetabular fractures using modified Stoppa approach.

Methods

A total of 57 patients (mean age 37.8 years; range 15–84) who underwent surgical treatment for acetabular fracture with modified Stoppa approach from February 2013 to June 2016 were included into the study. The mean follow-up time was 28.1 months (range 24–35). The records were reviewed for fracture patterns, time to surgery, operative time, blood loss, reduction quality, and perioperative complications. Reduction quality was graded as anatomic, imperfect, or poor. The Harris Hip Score (HHS) and Merle d'Aubigné score were used for functional evaluation.

Results

Among the 63 acetabulum fractures of the 57 patients, 27 were associated with both columns, 12 were T-type fractures, 10 were transverse, 7 were anterior column/posterior hemitransverse, 5 were anterior column, and 2 were anterior wall fracture. A single surgeon performed all operations. Pfannenstiel incision was used in the first 19 cases while vertical midline incision in the remaining 38 cases. Average time to operation was 5.5 days, and supplemental lateral windows were used in 17 (29.8%) patients. Average blood loss and operation times were 660 mL and 152 min, respectively. Radiological outcomes were anatomic, imperfect, and poor in 52 (82.5%), 9 (14.2%), and 2 (3.2%) of the acetabulum fractures, respectively. Clinical outcomes at 2 years with HHS and Merle d’Aubigné scores were mean 86.6 (range 66–96) (Excellent in 27, good in 23, fair in 4, poor in 3 patient) and 16.7 (range 10–18) (Excellent in 25, very good in 18, good in 6, fair in 5, poor in 3 patient), respectively. There was a significant relation between the reduction quality and clinical outcome (p < 0.001), while there was no significant relation between the clinical outcome and the fracture type (p > 0.05). Iatrogenic external iliac vein damage was noted in 2 patients. Obturator nerve palsy was noted in 3 patients, who recovered spontaneously at mean time of 3.7 months (range 3–5). Rectus abdominus paralysis was noted in 2 of the 19 (10.5%) Pfannenstiel-incision patients but not in the vertical-incision patients.

Conclusion

Our experience in 57 patients shows that satisfactory results can be obtained, even in bilateral fractures with vertical midline incision.

Level of evidence

Level IV Therapeutic Study

A Single Lateral Rectus Abdominis Approach for the Surgical Treatment of Complicated Acetabular Fractures: A Clinical Evaluation Study of 59 Patients

Background

This study aimed to evaluate outcome following a single lateral rectus abdominis surgical approach for complicated acetabular fractures, involving anterior and posterior columns.

Material/Methods

From January 2012 to March 2016, 59 patients, including 36 anterior column hemitransverse fractures, 18 two-column fractures, and five T-type complicated acetabular fractures, were treated with a single lateral rectus abdominis approach and fixed by plates and cannulated lag screws. Anterior column fractures were fixed with 3.5 mm reconstruction plates; posterior column fractures were fixed with 6.5 mm cannulated lag screws. The quality of surgical reduction (using the Matta criteria), functional outcome (using the modified Merle d’Aubigné and Postel scoring system), and postoperative complications were assessed with 24-month follow-up.

Results

Fifty-nine patients (mean age, 45 years; range, 18–64 years) including 39 men and 20 women underwent surgery. Mean intraoperative blood loss was 514.6 ml (range, 150–830 ml) and mean operating time was 86.3 min (range, 42–145 min). Anatomical reduction was good in 40 cases (67.8%), fair in 15 cases (25.4%), and poor in four cases (6.8%). The modified Merle d’Aubigné score was excellent in 39 cases (66.1%), good in 14 cases (23.7%), fair in five cases (8.5%), and poor in one case (1.7%). At follow-up, there were five cases of peritoneal damage, eight cases of obturator nerve dysfunction, and four cases of postoperative traumatic arthritis.

Conclusions

The single lateral rectus abdominis surgical approach for the treatment of complicated acetabular fractures was minimally invasive with good anatomical exposure and good outcomes.

Less Invasive Anterior Iliac Approach and Compression Osteosynthesis for the Treatment of High Anterior Column Fractures of the Acetabulum

Background

Displaced anterior column fractures have increasingly been treated surgically by the ilioinguinal approach and fixation with lag screws and a buttress plate on the pelvic brim. However, a major disadvantage of the ilioinguinal approach is possible damage to the neurovascular bundle and the lymphatic structures in the intermediate part of the approach. This study aims to present a novel surgical technique of the less invasive anterior iliac approach and compression osteosynthesis for high anterior column fractures of the acetabulum.

Methods

In this retrospective case series, 19 patients treated operatively for isolated high anterior column fractures using the less invasive anterior iliac approach and compression osteosynthesis were included. Patient demographics, the cause of injury, associated injuries, time to surgical reconstruction, and operation time were collected from the medical records. The quality of reduction was assessed by postoperative standard radiographic views and computed tomography scans and graded according to Matta's criteria. Clinical and radiographic grades were assessed according to Matta's criteria at the last follow-up.

Results

This less invasive surgical technique was successful for reduction and fixation in all high anterior column fractures and provided sufficient stability to allow immediate mobilization of the patients after surgery. Twelve fractures were combined with the quadrilateral plate fracture and seven fractures did not involve the quadrilateral plate. According to Matta's criteria, anatomical reduction was obtained in 17 patients and imperfect reduction in two patients. Clinical results were excellent in 17 patients and good in two patients. Radiographic results were excellent in 17 patients and good in two patients. Ten patients had neurapraxia of the lateral femoral cutaneous nerve related to the approach, which was resolved completely in seven. One patient had deep vein thrombosis.

Conclusions

Our less invasive surgical technique of the anterior iliac approach and compression osteosynthesis is a useful addition to the existing techniques in the treatment of high anterior column fractures of the acetabulum. Despite being a limited approach and fixation, this technique provides sufficient exposure for reducing and fixing the fracture and adequate stability to allow immediate mobilization of the patient after surgery.

Biomechanical comparison of three different fixation techniques for anterior column posterior hemitransverse acetabular fractures using anterior intrapelvic approach

OBJECTIVES

The aim of this study was to biomechanically compare three different fixation methods for the fixation of anterior column posterior hemitransverse type acetabular fracture (ACPHT).

METHODS

ACPHT fracture models were created on twenty-four foam cortical shell artificial hemipelvis models. Three fixation methods were assessed - Group 1: posterior column lag screws over a suprapectineal plate; Group 2: Posterior column lag screws over a suprapectineal plate and an infrapectineal plate; Group 3: A suprapectineal plate and a vertical infrapectineal plate. Stiffness and displacement amounts of fixation methods under dynamic and static axial loading conditions were measured.

RESULTS

In the dynamic and static tests, Group 3 showed the less stable fixation compared to Group 2. There was no statistically significant difference between the stiffness values of the fixation groups. In the static tests, there was no statistically significant difference between Group 1 and 2, although less displacements were obtained in Group 2.

CONCLUSIONS

A combination of posterior lag screws over a suprapectineal plate and an infrapectineal plate supporting the pelvic brim along both sides of the linea terminalis resulted in a better fixation construct than a suprapectineal plate accompanying with a vertical infrapectineal plate provide better stability with less fracture displacement.

Modified Stoppa approach for operative treatment of acetabular fractures: 10-year experience and mid-term follow-up

INTRODUCTION

The (modified) Stoppa approach for acetabular fracture surgery has gained significant popularity and early results have been encouraging but clinical outcome at extensive follow-up is scarce. The purpose of this study is to provide an update on our experience with this approach for operative treatment of acetabular fractures and to assess clinical outcome at mid-term follow-up.

METHODS

In this retrospective study, all patients treated operatively for an acetabular fracture using the Stoppa approach over a 10-year period were included. Surgery details were reviewed and patients were contacted and requested to return for follow-up. Primary outcome was native hip survivorship, secondary outcome measures included; functional outcome (Merle d'Aubiginé, Harris hip) scores, health-related quality of life (short-form 36) and radiographic outcome (heterotopic ossification, hip osteoarthritis).

RESULTS

Forty-five patients received operative fixation for 47 acetabular fractures using the Stoppa approach. Complications requiring surgical intervention were found in one patient (with a vascular lesion) intra-operatively and 3 patients (with wound infections (2) and diffuse bleeding (1)) post-operatively. Follow-up was 83% and 29/39 (74%) native hips survived at mean 59 months (SD 49) postoperatively. Excellent-good functional scores were found in 88% (Merle d'Aubiginé) and 76% (Harris hip) of patients who had retained their native hip. Most (6/8) short-form 36 indices in these patients were comparable to population norms. Of 29 native hips with radiographic follow-up (mean 59 months (SD 49), 4 (86%) had no-minimal radiographic abnormalities.

CONCLUSION

This study confirms that the Stoppa approach is a safe and effective technique for acetabular fracture fixation. Moreover, at mid-term follow-up, this approach is associated with satisfactory results in terms of hip survivorship as well as functional and radiographic outcome. As such, our findings reinforce the notion that this less invasive technique presents a valuable alternative to the ilioinguinal approach for the surgical treatment of acetabular fractures.

EASY (endoscopic approach to the symphysis): a new minimally invasive approach for the plate osteosynthesis of the symphysis and the anterior pelvic ring-a cadaver study and first clinical results

BACKGROUND

Minimally invasive surgical approaches to reduce approach-associated morbidity are an interdisciplinary goal in surgery. In principle, the endoscopic approach for the extraperitoneal repair of groin hernias is the minimally invasive variant of the modified Stoppa-approach, which is used for the treatment of pelvic ring injuries in traumatology.

METHOD

Anatomical feasibility study regarding the plate osteosynthesis of the anterior pelvic ring via a minimally invasive variant of the modified Stoppa-approach.

RESULTS

We present the minimally invasive variant of the modified Stoppa-approach in a human cadaver step by step, both photographically and radiologically. Feasibility of the plate osteosynthesis of the symphysis is presented in a patient with open book injury via the minimally invasive approach using standard laparoscopic instruments.

CONCLUSION

The plate osteosynthesis of the anterior pelvic ring via the minimally invasive variant of the modified Stoppa-approach is feasible with existing standard laparoscopic instruments.

Learning Curve for Surgical Treatment of Acetabular Fractures: A Retrospective Clinical Study of a Practical and Theoretical Training Course

Background

Surgical treatment of acetabular fracture and the anatomic reconstruction of the hip joint are difficult to achieve due to the complex pelvic anatomy, and surgical training requires a prolonged and steep learning curve. The aim of this study was to evaluate the effects of an applied training course, including cadaveric dissection, for the surgical treatment of acetabular fractures.

Material/Methods

This retrospective study included 35 patients who underwent surgical treatment for acetabulum fractures between 2012–2016. Patients were divided into three groups during two training courses, for the first two years and second two years. The surgical treatment was performed through single or combined standard approaches, according to the fracture pattern. The radiological outcome was evaluated using Matta’s criteria to grade postoperative reduction and final radiological outcome and the restoration of the hip joint center (HJC). The clinical outcome was evaluated using the modified the Merle d’Aubigné-Postel (DAP) hip score.

Results

Both post-course groups had statistically better functional and radiological outcomes compared with the pre-course group. Depending on the learning curve, the mean duration of surgery decreased from 153 minutes to 82.3 minutes. Although there was no statistical difference between groups in the vertical shift of the HJC, there was a statistically significant in the amount of horizontal shift of the HJC in the second two years of training, compared with the other groups.

Conclusions

Functional and radiological outcome of surgical treatment of acetabular fracture may be improved with increased training, depending on the learning curve.

Ilioinguinal approach versus Stoppa approach for open reduction and internal fixation in the treatment of displaced acetabular fractures: A systematic review and meta-analysis

PURPOSE

To compare the efficacy and safety of open reduction and internal fixation through ilioinguinal approach and Stoppa approach for the treatment of displaced acetabular fractures.

METHODS

Case-controlled trials (CCTs) published from January 2010 to August 2015 that compared the ilioinguinal approach and Stoppa approach in the management of displaced acetabular fractures were retrieved from the databases of Cochrane Library, Pubmed, CNKI, and so on. Methodological quality of the trials was critically assessed. Statistical software RevMan 5.0 was used for data analysis.

RESULTS

Eight articles were included in the meta-analysis. Through comparing the efficacy and safety of ilioinguinal approach and Stoppa approach in the treatment of displaced acetabular fracture, statistical significance was found in the average operation time [WMD = 68.29, 95% CI (10.52, 126.05), p < 0.05] and the median intraoperative blood loss [WMD = 142.26, 95% CI (9.30, 275.23), p < 0.05]. However, there existed no statistical significance in the fracture end reset satisfaction rate [RR = 0.63, 95% CI (0.17, 2.37), p > 0.05], the early complications rate [RR = 0.89, 95% CI (0.33, 2.40), p > 0.05], the late complications rate [RR = 0.91, 95% CI (0.27, 3.01), p > 0.05], and Harris hip score good function rate [RR = 0.52, 95% CI (0.25, 1.10), p > 0.05].

CONCLUSION

Though both techniques can obtain satisfactory clinical functions in the treatment of displaced acetabular fractures, Stoppa approach is superior to the ilioinguinal approach in terms of operation time and intraoperative blood loss.

The Anterior Intrapelvic Approach for Acetabular Fractures Using Approach-Specific Instruments and an Anatomical-Preshaped 3-Dimensional Suprapectineal Plate

OBJECTIVES

Anatomical acetabular plates the anterior intrapelvic approach (AIP) were recently introduced to fix acetabular fractures through the intrapelvic approach. Therefore, we asked the following: (1) Does the preshaped 3-dimensional suprapectineal plate interfere with or even impair the fracture reduction quality? (2) How often does the AIP approach need to be extended by the first (lateral) window of the ilioinguinal approach?

DESIGN

Observational case series.

SETTING

Two Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Patients with unstable acetabular fractures in 2014.

INTERVENTION

Fracture fixation with anatomical-preshaped, 3-dimensional suprapectineal plates through the AIP approach ± the first window of the ilioinguinal approach.

OUTCOME MEASUREMENTS

Fracture reduction results were measured in computed tomography scans and graded according to the Matta quality of reduction. Intraoperative parameters and perioperative complications were recorded. Radiological results (according to Matta) and functional outcome (modified Merle d'Aubigné score) were evaluated at 1-year follow-up.

RESULTS

Thirty patients (9 women + 21 men; mean age ± SE: 64 ± 8 years) were included. The intrapelvic approach was solely used in 19 cases, and in 11 cases, an additional extension with the first window of the ilioinguinal approach (preferential for 2-column fractures) was performed. The mean operating time was 202 ± 59 minutes; the fluoroscopic time was 66 ± 48 seconds. Fracture gaps and steps in preoperative versus postoperative computed tomography scans were 12.4 ± 9.8 versus 2.0 ± 1.5 and 6.0 ± 5.5 versus 1.3 ± 1.7 mm, respectively. At 13.4 ± 2.9 months follow-up, the Matta grading was excellent in 50%, good in 25%, fair in 11%, and poor in 14% of cases. The modified Merle d'Aubigné score was excellent in 17%, good in 37%, fair in 33%, and poor in 13% of cases.

CONCLUSION

The AIP approach using approach-specific instruments and an anatomical-preshaped, 3-dimensional suprapectineal plate became the standard procedure in our departments. Radiological and functional early results justify joint preserving surgery in most cases.

LEVEL OF EVIDENCE

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

Effects of the acetabular fracture index and other factors of posterior wall acetabular fracture on functional outcome

Objective To analyze the effects of the acetabular fracture index (AFI) and other factors on the functional outcome of patients with acetabular fractures involving the posterior wall. Methods Forty-eight patients who underwent surgery in our department were reviewed. According to the AFI, which indicates the percentage of remaining intact posterior acetabular arc, the patients were divided into Group A (AFI ≤ 25%, 11 patients), Group B (25% < AFI ≤ 50%, 23 patients), Group C (50% < AFI ≤ 75%, 7 patients), and Group D (75% < AFI ≤ 100%, 7 patients). The AFI was measured with a computed tomography picture archiving and communication system or calculated with the cosine theorem. A nonparametric test and ordinal regression were used to determine the role of the AFI and other factors on the functional outcome. Perioperative information, including demographic and fracture-related data, reduction quality, physical therapy duration, association with a lower limb fracture and avascular necrosis of the femoral head were prospectively gathered. Results The mean AFIs of A, B, C, and D groups were 14.3%, 35.9%, 59.5%, and 81.2%, respectively. No statistically significant differences were observed among the groups for demographic and fracture-related data. A better reduction quality (OR = 4.21, 95%CI 1.42 ∼ 12.43, χ2 = 6.781, P = 0.009) and a larger value of AFI (OR = 2.56, 95%CI 1.18 ∼ 5.55, χ2 = 5.648, P = 0.017) result in a higher functional score. The functional outcome of a physical therapy duration of more than 12 months (OR = 0.15, 95%CI 0.02 ∼ 0.90, χ2 = 4.324, P = 0.038) was better than that of less than 12 months. Lower limb fracture (OR = 0.13, 95%CI 0.02 ∼ 0.74, χ2 = 5.235, P = 0.022) and avascular necrosis of femoral head (OR = 0.02, 95%CI 0.00 ∼ 0.87, χ2 = 4.127, P = 0.042) were found to correlate with a lower functional score. Conclusion With a greater of AFI, the functional outcome score would be better. Other factors, including reduction quality, physical therapy duration, association with a lower limb fracture, and avascular necrosis of the femoral head, most likely also affect hip functional recovery.

Internal fixation of acetabular fractures in an older population using the TIMI approach - Midterm results of a prospective study

INTRODUCTION

The incidence of geriatric acetabular fractures continues to increase due to demographic changes. In the elderly, anterior column fractures are common, and standard approaches are associated with a considerable risk for surgery-associated complications. Therefore, a minimally invasive approach was developed in our department. The aim of this study was to examine early and mid-term results regarding the use of this novel two-incision minimally invasive (TIMI) approach in patients aged over 55 years with acetabular fractures.

METHODS

From July 2007 to April 2014, 47 patients aged over 55 years were treated via the TIMI approach; these patients were included in the present prospective study. The patients' characteristics, data, and early phase of care were assessed during acute care. A radiological evaluation comprised pre- and postoperative CT scans and x-rays, including Judet views at follow-up. Follow-up examinations were performed after 6 and 24 months and comprised a clinical and radiological examination and an evaluation of hip function (Harris Hip Score) and health-related quality of life (EQ-5D).

RESULTS

The mean age of the patients was 74±11years, with a gender ratio of 35/12 (m/f). The average operation time was 93±30min, and perioperative blood loss amounted to 858±463ml. In total, five (11%) complications associated with the operative procedure occurred, and revision surgery was necessary in three patients. We observed no wound infections, abdominal wall hernias or cases of heterotopic ossification in our sample. The Harris Hip Score at six months after surgery was 81, and it slightly improved to 84 after 24 months. The mean EQ5D index was 0.91 at six months after surgery and 0.92 at 24 months after surgery.

CONCLUSION

The TIMI approach represents a valuable alternative to the ilioinguinal and modified Stoppa approach for the treatment of acetabular fractures located in the anterior column, which are often observed in geriatric patients.

LEVEL OF EVIDENCE

Therapeutic Level II (Prospective cohort study).

Surgical Treatment of Displaced Acetabular Fractures Using a Modified Stoppa Approach

A retrospective evaluation was performed of 36 patients (25 males and 11 females; average age, 44 years) with displaced acetabular fractures who were treated with a modified Stoppa approach. Fractures included 18 anterior columns, 2 both columns, 8 anterior columns with posterior hemitransverse, 6 transverse, and 2 T-type, according to the Judet and Letournel classification. Range of motion, Harris Hip Scores, and Merle d'Aubigné scores were evaluated. Pre- and postoperative measurements taken included displacements and gaps on axial, coronal, and sagittal computed tomography (CT) images and postreduction quality assessed radiologically. Mean follow-up was 14.7 months. Mean perioperative bleeding was 970 cc (range, 800-1250 cc). Mean Harris Hip Score was 77.9, mean Merle d'Aubigné score was 16.4, mean flexion was 105.2°, and mean extension was 16.9°. Anatomical reduction of the acetabular fracture was achieved in 29 (80.5%) patients; it was satisfactory in 5 (13.8%) and poor in 2 (5%). Mean preoperative displacements on axial, coronal, and sagittal sections were 4.1, 3.6, and 3.1 mm, respectively, and mean postoperative displacements were 0.2, 0.3, and 0.2 mm, respectively. Mean preoperative gap distance was 14.5 mm, and mean postoperative gap distance was 1.1 mm. Postoperative foot drop was observed in 2 patients, obturator nerve damage in 1, partial iliac vein damage in 1, and avascular necrosis of the femoral head in 1. Despite a steep learning curve, the modified Stoppa approach is a good alternative to the ilioinguinal approach. It can be used to treat many complex acetabular fractures.

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.