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

Stoppa Intrapelvic Approach Provides Good Functional Clinical Outcomes: Prospective Study with a Minimum Follow-up of One Year and Comparison with the Literature

Objective  To describe the clinical and radiographic outcomes of a cohort of patients with acetabular fractures treated with the modified Stoppa approach. Methods  We conducted a prospective analysis of adult patients with acetabular fractures treated using the modified Stoppa approach from June 2020 to June 2021, with a minimum follow-up period of 12 months. The analysis included demographic, epidemiological, and perioperative data, as well as postoperative radiographic and functional outcomes. Results  The study included 15 cases, with 14 men (93.3%) and 1 woman (6.67%). A postoperative tomographic evaluation revealed an anatomical reduction in 50%, an imperfect reduction in 13.6%, and a poor reduction in 36.4% of the subjects. Regarding the functional scores, the Harris Hip Score ranged from 56 to 100, with a mean value of 92.5. The Majeed Pelvic Score classified the functional outcome as excellent in 36.5%, good in 40.6%, moderate in 18.7%, and poor in 4.2% of the cases. Conclusion  The present case series study demonstrated positive statistical relevance between reduction quality and functional outcomes and between the time until surgery and the reduction quality. The functional outcomes at a one-year of follow-up demonstrate that this approach can be an excellent alternative for anterior acetabulum fractures.

Single pararectus approach combined with three-dimensional guidance for the treatment of acetabular fracture

Background

Surgery for acetabular fractures involving both columns is difficult and traumatic, making it necessary to explore a minimally invasive and accurate surgical method.

Methods

This retrospective case-control study analyzed the clinical data of 34 patients and divided them into two groups: a control group (9 males and 8 females) and a research group (11 males and 6 females) with acetabular fractures involving the anterior and posterior columns. All patients were placed in the supine position via the pararectus approach. A three-dimensional (3D) guide was placed at the position where the posterior column screw was inserted in the second window, and a posterior column screw was placed percutaneously on the medial side of the iliac spine in the research group. The operation time, intraoperative blood loss, and fracture union time of the two groups were recorded. Pelvic radiographs and computed tomography (CT) scans were routinely performed before and after surgery to evaluate reduction and fixation. Residual gap and step displacement were measured using a standardized CT-based method after the surgery. Hip mobility was assessed according to the modified Merle, d'Aubigné, and Postel criteria.

Results

All patients were followed up for 6-30 (16.941±6.571) months. The operation times of the two groups were 126 [interquartile range (IQR), 95-133] min (control group) and 110 (IQR, 85-124) min (research group), the intraoperative blood losses were 430 (IQR, 290-550) mL (control group) and 380 (IQR, 260-500) mL (research group). All patients achieved bone healing, with a union time of 15 (IQR, 12-17) weeks (control group) and 13 (IQR, 11.5-15) weeks (research group). According to the standardized CT-based method, the reduction after surgery was acceptable in 13 (control group) and 14 (research group) of these patients (defined as a gap <5 mm or a step-off <1 mm), and the anatomical reduction rates were 76.47% and 82.35%, respectively.

Conclusions

The use of a single pararectus approach combined with 3D guide-assisted percutaneous anterograde posterior column screws can shorten the operation time and place effective posterior column screws precisely with minimal invasiveness. At the same time, the acetabular reduction and functional recovery are satisfactory, and there are fewer postoperative complications, which makes this procedure an ideal surgical option.

Hip Function after Surgically Treated Isolated Traumatic Acetabular Fracture: A Prospective Series of Consecutive Cases

Purpose

Isolated acetabular fractures can occur as a result of a high energy impact on the hip joint. Surgery is required for most patients with an isolated acetabular fracture in order to alleviate pain, restore joint stability, and regain hip function. This study was conducted in order to examine the course of hip function in patients after surgical treatment of an isolated traumatic acetabular fracture.

Materials and Methods

This prospective series of consecutive cases included patients who underwent surgery for treatment of an isolated acetabular fracture in a European level one trauma center between 2016 and 2020. Patients with relevant concomitant injuries were excluded. Scoring of hip function was performed by a trauma surgeon using the Modified Merle d'Aubigné and Postel score at six-week, 12-week, six-month, and one-year follow-up. Scores between 3-11 indicate poor, 12-14 fair, 15-17 good, and 18 excellent hip function.

Results

Data on 46 patients were included. The mean score for hip function was 10 (95% confidence interval [CI] 7.09-12.91) at six-week follow-up (23 patients), 13.75 (95% CI 10.74-16.76) at 12-week follow-up (28 patients), 16 (95% CI 13.40-18.60) at six-month follow-up (25 patients), and 15.50 (95% CI 10.55-20.45) at one-year follow-up (17 patients). After one-year follow-up, the scores reflected an excellent outcome in 11 patients, good in five patients, and poor in one patient.

Conclusion

This study reports on the course of hip function in patients who have undergone surgical treatment for isolated acetabular fractures. Restoration of excellent hip function takes six months.

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.

The use of suprapectineal plate in acetabular fractures via ilioinguinal approach with Stoppa window

Objective

The aim of the study was to investigate the clinical results of open reduction and internal fixation using a suprapectineal buttress plate for specific acetabular fractures.

Methods

We conducted a retrospective study involving thirty-three patients with specific acetabular fractures in an academic level 2 trauma center. We performed the ilioinguinal approach with Stoppa window for buttress plating of the quadrilateral surface. Clinical examination, radiographs and computed tomography were done using criteria described by Matta. Functional outcome was evaluated by visual analog scale (VAS), WOMAC, Harris Hip score modified, Hip disability and Osteoarthritis Outcome Score (HOOS) and modified Merle d’Aubignè scoring system.

Results

Average follow-up was 40.4 months with a minimum of 24 months. Mean age was 59.09 years. The 82% of patients were treated with a suprapectineal plate using ilioinguinal approach with Stoppa window. The 18% of patients required a Kocher-Langenbeck approach in order to get anatomic reduction of posterior wall or column. The 91% of patients were satisfied of their condition during activity of day living and only a small cohort reported walking aids. The worst clinical results were obtained in patients characterized by highest step displacement. Deep infection of surgical wound was observed in 6% of patients. In 3% of patients, one vascular injury occurred during surgery.

Conclusion

Internal fixation using ilioinguinal approach with Stoppa window and a suprapectineal plate to buttress the quadrilateral plate should be considered a viable treatment of some acetabular fractures. Patients can expect a good functional outcome with a low complication rate.

Team Approach: Management of Geriatric Acetabular Fractures

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Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase.

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An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention.

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Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.

Novel Utilization of Anterior Intrapelvic (Stoppa) Approach for Periacetabular Ganz Osteotomy: A Report of 2 Cases

CASE

The Ganz periacetabular osteotomy (PAO) is widely used to correct developmental hip dysplasia in the adolescent and young adult population. The aim of this case study was to examine the novel utility and safety of Stoppa approach for the Ganz PAO in a 15-year-old girl and 25-year-old man. The Stoppa approach is traditionally used for acetabular fractures, and its use for a Ganz PAO is relatively novel.

CONCLUSION

The Stoppa approach allows surgeons to successfully perform the Ganz PAO while simultaneously providing direct visualization for all osteotomies and vital structures.

Articular disimpaction in acetabular fractures

Acetabular impaction fractures when not adequately addressed leads to early arthritis. Dome impaction injuries and marginal impaction injuries have to be properly planned pre-operatively with respect to surgical approach, disimpaction techniques and fixation strategies. CT scan is the best modality to analyse the site, extent of impaction and plan strategies to reduce. Emphasis of early mobilisation should not drive the surgeon towards the motive of rigid fixation of columns alone, as the inadequate reduction of acetabular impaction leads to loss of mechanical support on weight bearing and thereby cause loss of reduction. Bone grafting either by auto or allograft or graft substitutes in the void after disimpaction helps in reducing anatomically and provide mechanical support adequately. In cases of severe comminution, reconstruction of the wall defect with autologous graft is a better treatment option. In this article we reviewed the characteristics of impaction injuries of acetabulum exploring surgical procedures, approaches and techniques for achieving open reduction and internal fixation.