Modified ilioinguinal approach to the acetabulum and pelvis from beneath the inguinal ligament: a subinguinal approach

A comparison between ilioinguinal and modified Stoppa approach in anterior column acetabular fractures

INTRODUCTION

Pelvis fractures are among the most difficult fractures to manage and treat for Orthopedic surgeons. Anatomic reduction is the main goal to reach in the acetabular fractures' treatment. The following study compares clinical outcomes and complications of Ilioinguinal versus modified Stoppa approach in Open Reduction and Internal Fixation (ORIF) of anterior column acetabulum fractures.

MATERIALS AND METHODS

A comparative analysis on 90 patients undergoing ORIF on acetabular fracture has been performed. Patients have been divided into two groups. The first group was treated by Ilioinguinal approach (n = 48), the second group by modified Stoppa approach (n = 42). The following parameters have been compareted: quality of fragment reduction; operative time; peri‑ and post-operative blood loss; complications; clinical and radiographic outcomes.

RESULTS

The modified Stoppa approach has shown a shorter mean operative time (146 min vs 175 min), fewer complications (14/48 vs 6/42), less blood loss both in the perio-operative phase (0.8 Hb pt vs 1.3 Hb pt) than in postoperative one (1.1 Hb pt vs 1.5 Hb pt), a lower rate of nerve, infections and critical complications. On the other hand, the ilioinguinal approach has showed better results in terms of quality of fracture reduction (43/48 patiens with anatomical or near anatomical reduction vs. 37/42). No significant differences concerning vascular lesions, clinical and functional outcomes have been found between the two groups.

CONCLUSIONS

The modified Stoppa approach results in shorter operative time, less intra-operative blood loss and fewer complications than the ilioinguinal one. Greater anatomic reduction is achieved by Ilioinguinal approach; however, this does not necessarily translate into better clinical and functional outcomes which, overall, are comparable in the two analysed approaches. In conclusion, the modified Stoppa approach is deemed to be a better alternative in treating these fractures.

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.

Safety Precautions for the Corona Mortis using Minimally Invasive Ilioinguinal Approach in Treatment of Anterior Pelvic Ring Fracture

Objective

To explore the safety of the corona mortis of the minimally invasive plate insertion in treatment of the anterior pelvic ring fracture by studying the relationship between the vessel and the position of plate.

Method

The corona mortis was dissected out of eight adult cadavers and were simulated for the insertion of the anterior ring minimally invasive plate, and the presence of the anastomotic branch (the corona mortis) in the suprapubic branch area was observed. After the Corona mortis stripped off, the data was measured, such as the length, vessel diameter, distance from the pubic tubercle, and the maximum vertical distance between the corona mortis and the pubis. The measured data and the previous literatures were analyzed to study the morphology of the corona mortis and the position relation between the corona mortis and the placement of subperiosteal tunnel through the minimally invasive ilioinguinal approach.

Results

Out of the 16 unilateral pelvises, the corona mortis were observed on 12 unilateral pelvises with an incidence rate of 75%. Amongst them, there were seven cases of vein anastomosis (incidence of 43.75%), three cases of arterial anastomosis (incidence of 18.75%), and two cases of both arterial anastomosis and vein anastomosis (incidence of 12.5%). The corona mortis length ranged between 24.5 and 37.5 mm (average of 30.7 ± 3.6 mm); the diameter ranged between 1.6 and 3.5 mm (average of 2.5 ± 0.5 mm) and the distance between the vessels and the pubic tubercle was between 53.9 and 65.2 mm (average of 59.0 ± 3.6 mm). Above the pubis, the corona mortis originated from the iliac or the inferior epigastric vessel. It crossed the pubic branch to the dorsal side of the pubis and proceeded downward to anastomize with the obturator vessels near the obturator. Toothless tweezers were used to peel and lift up the corona mortis from the pubic bone. The maximum vertical distance between the corona mortis and the pubis ranged between 8.8 and 18.3 mm (average of 12.6 ± 3.0 mm).

Conclusion

The corona mortis have a high rate of incidence, with a large number of differences in the type and shape of blood vessels among patients. Following peeling, the movement between the corona mortis and pubic bone is limited. Nevertheless, the plate and bone exfoliator still passed safely. Therefore, when surgeons use the minimally invasive ilioinguinal approach to establish channels, the process of subperiosteal stripping must be performed to avoid any accidental injury.

[Comparison of effectiveness between two combined anterior and posterior approaches for complicated acetabular fractures]

Objective

To compare the effectiveness between modified ilioinguinal approach combined with Kocher-Langenbeck (K-L) approach and Stoppa approach combined with K-L approach for the treatment of complicated acetabular fractures.

Methods

Between May 2011 and May 2016, Sixty-two patients with complicated acetabular fractures were treated with operation via combined anterior and posterior approaches. Thirty-four cases (group A) were treated with modified ilioinguinal approach combined with K-L approach, and 28 cases (group B) were treated with Stoppa approach combined with K-L approach. There was no significant difference in gender, age, injury causes, the type of fracture, time from injury to operation, and associated injury between 2 groups ( P>0.05). The operation time, intraoperative blood loss, and hospitalization time were recorded. X-ray film was performed to evaluate the fracture reduction according to the Matta reduction criteria and observe the fracture healing, osteoarthritis, and heterotopic ossification. Clinical results were evaluated according to the grading system of modified d'Aubigne and Postel.

Results

There was no significant difference in operation time, intraoperative blood loss, and hospitalization time between 2 groups ( P>0.05). Postoperative incision fat liquefaction occurred in 2 cases in group A and group B respectively, and deep vein thrombosis of lower extremity occurred in 1 case in group A. No iatrogenic injury was found in 2 groups. Fifty-six patients were followed up after operation. Thirty patients in group A were followed up 12-48 months (mean, 31.8 months). Twenty-six patients in group B were followed up 12-46 months (mean, 30.2 months). At 12 months after operation, according to the grading system of modified d'Aubigne and Postel, the hip function was rated as excellent in 9 cases, good in 16 cases, fair in 3 cases, and poor in 2 cases, with the excellent and good rate of 83.3% in group A; the hip function was rated as excellent in 7 cases, good in 14 cases, fair in 2 cases, and poor in 3 cases, with the excellent and good rate of 80.8% in group B. There was no significant difference in the hip function between 2 groups ( Z=0.353, P=0.724). The X-ray films showed that there were 23 cases of anatomical reduction, 6 cases of satisfactory reduction, and 1 case of unsatisfactory reduction in group A, and 20 cases, 5 cases, and 1 case in group B, respectively. There was no significant difference in the results of fracture reduction between 2 groups ( Z=0.011, P=0.991). Fracture healing was observed in both groups. There was no significant difference in fracture healing time between 2 groups ( t=0.775, P=0.106). During follow-up, 5 cases of osteoarthritis changes, 2 cases of heterotopic ossification, and 2 cases of avascular necrosis of femoral head occurred in group A, and 4 cases, 2 cases, and 1 case in group B, respectively. The difference between 2 groups was not significant ( P>0.05).

Conclusion

According to the location and type of fracture, making a choice between the modified anterior approach and Stoppa approach, and then combined with K-L approach for treatment of complicated acetabular fracture, can obtain satisfactory effectiveness.

A Novel Approach for Treatment of Acetabular Fractures

Background

There is no single approach that provides adequate exposure for treatment of all types of acetabular fractures. We describe our experience with an easier, relatively less invasive pubic symphysis approach (PSA) for the treatment of acetabular fractures.

Material/Methods

Between March 2011 and March 2012, fifteen patients with acetabular fracture underwent surgery using the PSA technique. Fracture reduction and treatment outcomes were assessed by clinical and radiological examination. Operation time, intraoperative blood loss and postoperative complications were documented.

Results

Mean operative time was 222±78 minutes. Average blood loss was 993±361 mL. Anatomical reduction was achieved in all patients. Minimum follow-up period was 31 months. Postoperative hypoesthesia in the area of innervation of the lateral femoral cutaneous nerve was reported in one patient, with spontaneous recovery at one month after surgery. No complications were reported during the follow-up period. At the most recent follow up, clinical outcomes were graded as “excellent” in six patients, “good” in eight patients and “fair” in one patient based on the modified Merle d’Aubigné-Postel score.

Conclusions

PSA appears to be a timesaving and safe approach for treatment of acetabular fractures that affords good visual access and allows for excellent fracture reduction. Our preliminary results revealed a much lower incidence of complications than traditional approaches, suggesting PSA is an alternative for treatment of acetabular fractures.

Cerclage wiring in displaced associated anterior column and posterior hemi-transverse acetabular fractures

PURPOSE

The effects of cerclage wiring in the open reduction and internal fixation of displaced associated anterior column and posterior hemi-transverse acetabular fractures were evaluated.

METHODS

This is a retrospectively clinical study of such cases where the main surgical strategy was open reduction and internal fixation with cerclage wire and reconstruction plates. Data on 12 cases treated between 1992 and 2011 were collected. The mean follow-up period was 32 (12-132) months.

RESULTS

Reduction with a fracture gap of less than 2 mm without articular stepping and solid union was achieved in all 12 cases. Postoperative complication developed in one case of symptomatic arthritis. Excluding the case with symptomatic arthritis, the other cases had good to excellent final D'Aubigne and Postel functional results.

CONCLUSIONS

Cerclage wiring is very useful and effective in the reduction and fixation of displaced associated anterior column and posterior hemi-transverse acetabular fractures, and supplemental fixation with reconstruction plates and screws is necessary.