Treatment of acetabulum fractures through the modified Stoppa approach: strategies and outcomes

Functional and radiological outcomes and complications of Bernese periacetabular osteotomy through modified Stoppa approach

BACKGROUND

The Smith-Peterson approach and its modifications provide an extensive exposure and allow osteotomies through a single incision. However, the risk of complications increases when the quadrilateral surface, ischial and pubic osteotomy sites cannot be seen. This study aimed to evaluate the surgical characteristics, complications, and functional and radiological outcomes of patients with acetabular dysplasia who underwent Bernese periacetabular osteotomy (PAO) through modified Stoppa approach and plate-screw fixation.

METHODS

The study included 31 patients (41 hips) who had undergone PAO using a modified Stoppa approach. The characteristics of patients and the surgical procedure were described. The lateral centre-edge angle (LCEA) and Tönnis roof angle were evaluated in the radiological outcome evaluation. The modified Harris Hip Score (mHHS) was used to evaluate functional outcome. Furthermore, complications were described.

RESULTS

The mean age of the patients was 20.4 ± 9.0 years. Of the 31 patients, 21 underwent unilateral Bernese PAO and 10 underwent bilateral Bernese PAO. The mean follow-up period was 25.1 ± 8.8 months. Postoperatively, the mean mHHS improved significantly (68.8 ± 9.4 vs. 88.8 ± 10.0, p < 0.001). Postoperatively, the mean LCEA and Tönnis roof angle improved significantly (17.7 ± 6.0 vs. 42.2 ± 4.8, p < 0.001 for LCEA and 18.3 ± 5.5 vs. 8.0 ± 2.2, p < 0.001 for Tönnis roof angle). There was no significant correlation between preoperative to postoperative improvement in LCEA or Tönnis roof angle and improvement and mHHS (p > 0.005). 5 complications were identified: 1 transient sciatic nerve palsy, 1 external iliac vein injury, 1 infection, and 2 screw irritations of acetabulum.

CONCLUSIONS

Performing Bernese PAO through a modified Stoppa approach with plate-screw fixation results in acceptable complication rates, immediate early weight-bearing opportunity, and improved functional and radiological outcomes in patients with acetabular dysplasia.

Modified Stoppa's approach as "all fractures through one approach" for fractures of the acetabulum and pelvis

BACKGROUND

The modified Stoppa approach has gained widespread acceptance for managing acetabular fractures. This study explores its effectiveness as a comprehensive solution for a majority of acetabular, pelvic and combined injuries.

MATERIAL AND METHODS

This prospective study enrolled 27 patients [21 males, 6 females, mean age 45.4 years] with acetabular fractures and pelvic injury fulfilling the inclusion criteria. The modified Stoppa approach with a transverse incision was used in all cases. The brim plate was used to fix the anterior column, the infra-pectineal plate, hook plate and lag screws were used to fix the posterior column. Symphyseal and ramus fixation was done using a recon plate and the sacroiliac joint was fixed with illiosacral screws. The mean follow up was 3.21 years. The radiological and functional outcome was evaluated by Matta's criteria and the modified D'Aubigne and Postel criteria, respectively, for acetabular fractures and the Matta and Tornetta criteria and Majeed's score, respectively, for pelvic fractures.

RESULTS

There were 24 acetabular fractures and 4 pelvic injuries (including 1 combined injury). Average blood loss and operation times were 750 mL and 140 min, respectively. Among 24 acetabular fractures, 22 had congruent reduction and 2 had non-congruent reduction. Functional outcome was excellent in 7, good in 11, fair in 4 and poor in 2 patients. Among 4 pelvic fractures, 2 had excellent and 2 had good reduction. Majeed's score was excellent in 1 and good in 2 patients (the patient with a combined injury had an excellent functional outcome).

CONCLUSIONS

1. This study confirms the efficacy and safety of the modified Stoppa approach in treating anterior injuries of the acetabulum. 2. This study also underlines the possibility of managing the minimally displaced posterior column injuries and a good portion pelvic ring injuries through anterior approach. 3. The modified Stoppa approach may be considered a workhorse approach for treating a majority of acetabular fractures.

The intrapelvic approach to the acetabulum

The today well accepted intrapelvic approach for acetabular and pelvic ring injury fixation was first described by Hirvensalo and Lindahl in 1993 followed by a more detailed description by Cole and Bolhofner in 1994. Compared to the well-known ilioinguinal approach, described by Letournel, this approach allows an intrapelvic view to the medial acetabulum, while using the ilioinguinal approach a more superior, extrapelvic view, is dissected to the area of the acetabulum. Several names have been used to describe the new intrapelvic approach with increasing usage, mainly ilio-anterior approach, extended Pfannenstiel approach, Stoppa-approach, Rives-Stoppa approach, modified Stoppa approach and recently anterior intrapelvic approach. Especially names including "Stoppa", based on the French surgeon Rene Stoppa, an inguinal hernia surgeon, have been discussed. In contrast to the presently used intrapelvic approach, the original the Rives-Stoppa approach refers to a sublay-retromuscular technique, which places a mesh posterior to the rectus muscle and anterior to the posterior rectus sheath without dissecting along the upper pubic ramus. Thus, intrapelvic approach is not a Rives-Stoppa approach. The Cheatle-Henry approach, another inguinal hernia approach, refers best to the presently used intrapelvic approach. Discussing the anatomy and the different dissections, this approach allows anteromedial access to the anterior column and a direct view from inside the true pelvis to the quadrilateral plate and medial side of the posterior column. Thus, we favor to use the term "Intrapelvic Approach".

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.

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.

Can CT-based gap and step-off displacement predict outcome after nonoperative treatment of acetabular fractures?

Aims

The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

Methods

A multicentre cross-sectional study was performed in 170 patients who were treated nonoperatively for an acetabular fracture in three level 1 trauma centres. Using the post-injury diagnostic CT scan, the maximum gap and step-off values in the weightbearing dome were digitally measured by two trauma surgeons. Native hip survival was reported using Kaplan-Meier curves. Predictors for conversion to THA were determined using Cox regression analysis.

Results

Of 170 patients, 22 (13%) subsequently received a THA. Native hip survival in patients with a step-off ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 94% vs 70% vs 74%). Native hip survival in patients with a gap ≤ 2 mm, > 2 to 4 mm, or > 4 mm differed at five-year follow-up (respectively: 100% vs 84% vs 78%). Step-off displacement > 2 mm (> 2 to 4 mm hazard ratio (HR) 4.9, > 4 mm HR 5.6) and age > 60 years (HR 2.9) were independent predictors for conversion to THA at follow-up.

Conclusion

Patients with minimally displaced acetabular fractures who opt for nonoperative fracture treatment may be informed that fracture displacement (e.g. gap and step-off) up to 2 mm, as measured on CT images, results in limited risk on conversion to THA. Step-off ≥ 2 mm and age > 60 years are predictors for conversion to THA and can be helpful in the shared decision-making process.

The anterior transmuscular intrapelvic approach for the treatment of acetabular fractures-a new anterior surgical strategy

The anterior ilioinguinal and the posterior Kocher-Langenbeck approach have long been the standard surgical approaches to the acetabulum. The last decade has witnessed the development of so-called intrapelvic approaches for anterior pathologies because they provide better exposure of the quadrilateral plate. Currently, the modified Stoppa approach and the pararectus approach are frequently used by surgeons for the treatment of acetabular fractures. We investigated an even more direct access to the entire anterior column and the quadrilateral plate via the abdominal wall muscles, between the incisions for the ilioinguinal and the pararectus approach.After intensive study of anatomic specimens, a cadaver dissection was performed prior to clinical application. The approach was then used in 20 patients who were assessed retrospectively.Postoperative CT scans showed that, according to the Matta scoring system, the quality of fracture reduction was "anatomical" (≤ 1 mm) in 12 (60%), "imperfect" (2-3 mm) in four (20%), and "poor" (> 3 mm) in four (20%) patients. Numerous minor complications were observed; the majority of these had resolved at the time of discharge.In conclusion, the anterior transmuscular intrapelvic approach (ATI) is a safe and effective alternative to the ilioinguinal and pararectal approaches, and may be regarded as an evolutionary advancement of traditional procedures.

Severe intraoperative vascular bleeding as main complication of acetabular fractures treated with plate osteosynthesis via the modified Stoppa approach

Acetabular fractures are challenging fractures and finding the best supportive treatment is complex. Many operative treatment options exist - one of them is the plate osteosynthesis via the modified Stoppa approach gaining popularity over the last decades. The purpose of this study is to give an overview of this surgical techniques and its main complications. Patients ≥ 18 years between the years 2016 and 2022 with acetabular fractures in our department received a surgical intervention with plate fixation via the modified Stoppa approach. All protocols and documents during a patient's hospital stay were analyzed to find relevant perioperative complications concerning this operative technique. Between 01/2016 und 12/2022 75 patients with acetabular fractures were treated surgically in the author's institution with a plate osteosynthesis via the modified Stoppa approach. In 26.7 % (n = 20) of all cases, patients were confronted with one or more perioperative complications typical for this operation. Intraoperative venous bleedings were the main complication with 10.6 % (n = 8). Postoperative functional impairment of the obturator nerve and deep vein thrombosis occurred with 2.7 % (n = 2) and 9.3 % (n = 7). This retrospective study shows that plate fixation via the Stoppa approach is a good treatment option because of the excellent intraoperative overview of the fracture, but has its pitfalls and complications. Especially severe vascular bleedings must be taken into account and its management well known.

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.

Intra-articular fragment mapping in associated both-column acetabular fractures

INTRODUCTION

Associated both-column acetabular fractures (ABC-AF) are complex. A detailed description of the morphology of the articular surface of the acetabulum is not reported. This study was designed to describe the morphology of the intra-articular fragments using a fracture mapping technique to provide reference in more appropriate approach selection in surgical treatment of the fractures.

MATERIALS AND METHODS

Three-dimensional reconstruction CT images from 100 cases of ABC-AFs were retrospectively analyzed using Mimics and 3-matic software. The fractured as well as the reduced three-dimensional models were investigated, and the intra-articular fragments were identified. The distribution of the fracture lines of each main fragment and the overlapping lines of all the fragments were verified on the images.

RESULTS

The articular surface of ABC-AFS consist of three types of fragments: column fragment (CF), wall fragment (WF) and isolated fragment (IF), with the total number varying from 2 to 6. CF characterized by long fracture lines exited to periphery of innominate bone while the lines of WF were confined to the walls. IF was a free fragment found in the dome and in the quadrilateral plate. The surface was composed only by CFs in 17 cases (17%), by CFs and WFs in 59 cases (59%) and by all fragments in 24 cases (24%). The distribution of the overall fracture lines was a "dumbbell shaped" pattern, starting from the infero-anterior aspect, passing through the junction of the fossa to the anterior lunate surface and extending into the posterior region of the acetabulum.

CONCLUSIONS

The articular fragments of ABC-AFs were composed of CFs, WFs and IFs. The junction of the fossa to the anterior lunate surface and the posterior region of the rim were mostly involved. The location of the articular fragments and their connections to the periphery of the innominate may be considered in selection of approaches.

The relation between surgical approaches for pelvic ring and acetabular fractures and postoperative complications: a systematic review

Introduction

Although many articles report complications after pelvic ring and acetabular fracture surgery, a general overview of complication rates and potential risk factors is lacking. The current review provides a comprehensive summary of the complications after pelvic ring and acetabular fracture surgery in relation to the surgical approach.

Material and Methods

Pubmed and Embase databases were systematically searched using the key words: pelvic fracture, acetabular fracture, fixation, surgical approaches, complications, and their synonyms. Extracted data included patient and fracture characteristics, surgical approaches, and post-operative complications; surgical site infections (SSI), implant-related complications, malunion and non-union. Study data were summarized using descriptive statistics.

Results

Twenty-two studies (twenty-one retrospective cohort studies, of which three comparative, and one randomized controlled trial) were included in this review. The overall complication rates reported for the included surgical approaches were: 17% for the (Modified) Stoppa approach, 11% for percutaneous fixation, 5% for the Kocher–Langenbeck approach, 7% for the ilioinguinal approach and 31% for external fixation. The most frequent complications were SSI (22%) and neurological (31%) complications, which were most often reported in patients treated with an external fixator. Re-operation rates were comparable for the surgical approaches (4–8%). Two studies reported on risk factors and identified concomitant traumatic injuries, prolonged ICU stay and high body mass index as risk factors for SSI.

Conclusion

External fixation of pelvic fractures is associated with highest complications rates including SSI’s and neurological complications. Although post-operative complications are frequently reported after pelvic fracture surgery, more studies are needed that identify potential risk factors. These will assist the surgeon in (pre)operative decision making and development of preventive strategies.

Patients of Obese Representation Require Longer Operative Times: An Evaluation of Acetabular and Pelvic Ring Operative Duration

Recent literature has determined that operative times for the obese population are greater for both elective and nonelective orthopedic procedures. If time allotted for a given surgical procedure is used as a measure of procedural difficulty, then consideration can be given for using an additional coding modifier (i.e., Modifier 22) for the increased skill and effort associated with longer procedures. A retrospective chart review was conducted on all patients who underwent surgical treatment for an acute fracture about the pelvis at an urban level-1 trauma center from October 1, 2010 through October 31, 2018. After allowing for both inclusion and exclusion criteria, 102 patients with acetabular fractures and 55 patients with pelvic ring injuries were included in this investigation. The obese population within the acetabular fracture cohort demonstrated significantly longer mean times for the duration of surgery, total time in spent in the operating room, and duration under anesthesia (P values of 0.038, 0.05 and 0.035, respectively). Similar results were observed with the pelvic ring injury cohort, with significantly longer procedural times (P = 0.019), total time in the operating room (P = 0.034), and total duration under anesthesia (P = 0.0395). A trend towards a greater risk of infection was found in obese patients (7%) when compared with nonobese patients (1.6%) within the acetabular fracture subset (P = 0.093). Operative duration for acetabular fractures and pelvic ring injuries is significantly longer in the obese population. Furthermore, this indicates that a Modifier 22 may be justified for the surgical treatment of these injuries in the obese and morbidly obese patient populations.

Three-dimensional morphological analysis of quadrilateral plate fragments in associated both-column acetabular fractures

OBJECTIVE

To investigate whether the fracture morphology of quadrilateral plate (QP) fragments is associated with the anterior and posterior columns in associated both-column (ABC) fractures.

MATERIALS AND METHODS

Three-dimensional computed tomography data of 100 ABC fractures treated at our hospital from August 2016 to August 2019 were retrospectively analyzed using Mimics and 3-matic software. The distribution of fracture lines was described using the fracture mapping technique.

RESULTS

One fragment presented on the QP was confirmed in 88% of the patients. The QP fragments' fracture lines were divided into the anterior oblique (AO), superior posterior oblique (SPO), and mid-posterior oblique (MPO) lines, occurring in 100, 86, and 8 cases, respectively. AO lines were distributed along the arcuate line. SPO lines were continuations of the AO lines, which were distributed to the posterior column from the greater sciatic notch to the lesser sciatic notch. MPO lines were involved in the QP's central area. A simple fracture was found at the proximal AO and SPO lines in 80% and 86% of all displaced fractures, respectively. AO lines distal to the superior rim of the acetabula were confirmed to be comminuted fractures in 32% of all cases.

CONCLUSIONS

In ABC fractures, there was only one QP fragment in nearly 90% of all cases. The QP fractures were mainly present in the QP's peripheral area. More than 80% of the fracture patterns on the cephalic side of the QP were simple. The reduction and internal fixation of QP fractures in ABC fractures should be in the cephalic region.

Fixation of bilateral acetabular fractures using the modified Stoppa approach: Two-year clinical outcomes

OBJECTIVES

This study aims to evaluate the two-year clinical results of bilateral acetabular fractures operated via a single incision with the modified Stoppa approach.

PATIENTS AND METHODS

Between January 2013 and January 2020, a total of 22 acetabular fractures of 11 patients (7 males, 4 females; mean age: was 42.9±13.7 years; range, 19 to 62 years) who were operated via the modified Stoppa approach were retrospectively analyzed. The medical records were analyzed in terms of time to surgery, fracture patterns, Injury Severity Score (ISS), operation duration, blood loss, reduction quality, perioperative complications and concomitant injuries. Reduction quality was assessed according to Matta's criteria. The Harris Hip Score (HHS) and modified Merle d'Aubigne score (MDS) were utilized for functional assessment.

RESULTS

The mean follow-up was 49±15 (range, 30 to 79) months. The mean ISS was 28.2±7.2. The mean modified MDS was 15.90±1.57. The mean HHS was 84.27±8.85. For both sides, reduction was anatomical-anatomical (63.6%) in seven patients, anatomical-imperfect in three (27.3%) patients, and imperfectpoor in one (9.1%) patient. According to the Kellgren-Lawrence radiological evaluation at 24 months of follow-up bilaterally, Grade 0-1 osteoarthritis was observed in six (54.5%) patients, Grade 1-1 in four (36.4%) patients, and Grade 1-2 osteoarthritis in one (9.1%) patient.

CONCLUSION

The modified Stoppa approach in bilateral acetabular fractures seems to be more preferable than other approaches, as it can be performed with a single incision and provides less bleeding, shorter operation duration, and satisfactory results.

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.

Acetabular fractures treatment needs in the elderly and nonagenarians

Different treatment options for acetabular fractures in the elderly and nonagenarians exist; a consistent guideline has not been established, yet. The purpose of this study is to give an overview of how those fractures can be handled and compares two different surgical treatment methods. A total of 89 patients ≥ 18 years between 2016 and 2021 with acetabular fractures in our department received a surgical intervention with plate fixation via the Stoppa approach or a total hip arthroplasty with a Burch-Schneider ring and integrated cup. 60 patients ≥ 65 were compared in two groups, 29 patients between 65 and 79 and 31 patients ≥ 80. For comparison, data on operation times, hospitalization, complications during operation and hospital stay, blood loss and postoperative mobilization were collected. Characteristics could be found for indications for operative osteosynthesis or endoprosthetics based on the X-ray analysis. There was a tendency to treat simple fractures with osteosynthesis. Patients between 65 and 79 with an osteosynthesis had benefits in almost every comparison. Patients ≥ 80 with a plate fixation had advantages in the categories of postoperative complications, blood loss and transfusion of erythrocyte concentrates. Statistical significant differences were noticed in both groups regarding the operation time. Patients between 65 and 79 with osteosynthesis had significant benefits for postoperative complications, hospitalization, number of blood transfusions and postoperative mobilization. Finding the best supportive treatment option is difficult, and decision-making must respect fracture patterns and individual risk factors. This study shows that plate fixation via the Stoppa approach has some benefits.

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.

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.

Perioperative complications of the modified Stoppa approach for the treatment of pelvic bone fractures: a single-institution review of 48 cases

Purpose

The current study aimed to report the perioperative complications of the modified Stoppa approach for the treatment of pelvic bone fractures.

Methods

We analyzed 48 consecutive operations in 45 patients who were treated with internal fixation using the modified Stoppa approach between March 2016 and July 2018. This included three revision operations. The mean age of the patients was 54.5 years, and the patients included 35 male patients and 10 female patients. All fractures occurred as a consequence of high-energy trauma and 70.3% had associated injuries at the time of the fracture. The mean Injury Severity Score was 9.03±5.60. The perioperative complications found during and immediately after surgery were recorded and were classified into three categories: vascular injuries, nerve injuries, and other complications.

Results

Overall, 14 perioperative complications (29.2%) in 14 cases were identified. The most common complications were nerve injuries, which occurred in seven cases, all involving the obturator nerve. Uncontrollable vascular injuries occurred in six cases, which required additional incisions and support of vascular surgeons or postoperative interventions. Additionally, one case of peritoneal tearing occurred, which required help from an abdominal surgeon.

Conclusions

While the modified Stoppa approach seems to be a viable method to treat pelvic fractures, significant perioperative complications may occur, suggesting that surgeons should pay careful attention to minimize the damage to other structures and that appropriate support from other surgical departments is paramount.

A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients

Aim and objective

To study the radiological and functional outcomes as well as complications in the management of fractures involving both columns of the acetabulum using a single surgical approach.

Design

Type IV, prospective clinical study.

Setting

Level I trauma centre.

Materials and methods

Inclusion criteria were as follows: (a) patients over 20 year of age and (b) patients suffering from acetabular fractures involving both columns as per Letournel and Judet classification, namely transverse, transverse + posterior wall, T type, anterior column posterior hemi-transverse (ACPHT) and associated both columns. Exclusion criteria were as follows: (a) patient suffering from isolated anterior column, posterior column, anterior wall, posterior wall and posterior wall + column fractures; (b) patient who have undergone surgical procedures of the hip prior to trauma; and (c) compound acetabular fractures. A total of 23 patients having both column acetabulum fractures were included prospectively from June 2016 to December 2018 and followed up till 1 year postoperatively. Open reduction and internal fixation were performed through one of three described approaches, i.e., iliofemoral, Kocher-Langenbeck, and anterior intrapelvic or ilioinguinal.

Results

Our study population consisted of 30.4% transverse, 39.1% associated both columns, 21.7% T type and 8.7% anterior column + posterior hemi-transverse. Of these, 65.2% were operated using the Kocher-Langenbeck approach, while 30.4% of patients required the anterior intrapelvic approach. The remaining 4.3% of patients were operated by the iliofemoral approach. Anatomic reduction was achieved in 100% of our study population with remaining displacement less than or equal to 1°mm. At 1-year follow-up, all fractures showed a satisfactory union with an excellent Matta index in 100% study subjects. Complications at 1 year included one case of foot drop, which was present preoperatively but failed to improve and one case of post-traumatic arthritis. Average Harris Hip score (HHS) and mean Merle D'Aubigne (MDA) scores suggested good clinical outcomes in the study population.

Conclusions

A single approach can be used to achieve good functional and radiological outcomes in carefully selected bicolumnar fractures of the acetabulum, with less approach-related morbidity.

Clinical significance

Traditionally, multiple approaches are used for acetabulum fractures involving both columns, but with proper patient selection, single approach can be used with good functional and surgical outcomes.

How to cite this article

Patil A, Attarde DS, Haphiz A, et al. A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients. Strategies Trauma Limb Reconstr 2021;16(3):152–160.

Clinical application of anterior ring internal fixator system combined with sacroiliac screw fixation in Tile C pelvic fracture treatment

Background

How to perform minimally invasive surgery for Tile C pelvic fracture is a major problem in clinical practice. We performed minimally invasive surgery for Tile C pelvic fracture using anterior ring internal fixator systems combined with sacroiliac screw fixation.

Objective

To investigate the advantages and efficacy of anterior ring internal fixator systems combined with sacroiliac screw fixation in the treatment of Tile C pelvic fracture.

Methods

From May 2017 to May 2020, 27 patients with Tile C pelvic fracture who underwent anterior ring internal fixator system combined with sacroiliac screw fixation (group A) and 21 patients with Tile C pelvic fracture who underwent plate-screw system combined with sacroiliac screw fixation (group B) were retrospectively analyzed.

Results

All 48 patients were followed up for more than 12 months, all fractures healed within 3–6 months. The operative time, intraoperative bleeding volume, blood transfusion volume, incision length, hospital stay, complication rate and Majeed score were 63.5 ± 10.7 min, 48.3 ± 27.9 ml, 0 ml, 4.5 ± 0.8 cm, 10.2 ± 2.7 d, 3.7% and 89.7 ± 4.6 points, respectively, in group A and 114.8 ± 19.1 min, 375 ± 315.8 ml, 266.7 ± 326.6 ml, 9.2 ± 3.9 cm, 20.9 ± 5.7 d, 23.8% and 88.7 ± 4.9 points, respectively, in group B. Combined excellent and good rates of the Matta evaluation and Majeed score were 100% in both groups. There were no significant differences in the Matta evaluation or Majeed score between the two groups (both P > 0.05), whereas the operative time, intraoperative bleeding volume, blood transfusion volume, incision length and hospital stay were significantly less in group A (all P < 0.05).

Conclusion

An anterior ring internal fixator system combined with sacroiliac screw fixation can effectively treat Tile C pelvic fracture, and has advantages, including minimal invasiveness, simple operation, short operative time, safe and reliable features, fewer complications, short hospital stay and a good curative effect.

Acetabular Fractures with Central Hip Dislocation: A Retrospective Consecutive 50 Case Series Study Based on AO/OTA 2018 Classification in Midterm Follow-Up

Introduction

Management of acetabular fractures is challenging, especially when a medial acetabular fracture is complicated by central hip dislocation. We retrospectively investigated the clinical outcome and risk factors of secondary hip osteoarthritis requiring total hip arthroplasty after the surgical treatment of acetabular fractures with central hip dislocation.

Materials and Methods

The medical records of all patients who had acetabular medial wall fractures with central hip dislocation treated with open reduction and internal fixation by a single surgeon between January 2015 and June 2017 were reviewed. Surgical reduction was performed with the modified Stoppa with/without the Kocher-Langenbeck (KL) approach. Patients were followed for a minimum of three years, and the Majeed scoring system was used for functional evaluation. Multivariate logistic regression analysis was used to assess the association of patients' characteristics with the likelihood of advanced posttraumatic arthritis developing with conversion to total hip arthroplasty.

Results

Fifty patients were included in this study, with disease classified as AO/OTA 2018 62B/62C. Thirty-five patients (70%) had good or excellent Majeed pelvic scores. Eleven patients (22%) eventually received total hip arthroplasty because of end-stage posttraumatic arthritis. Three risk factors identified for total hip arthroplasty were male sex, initial marginal impaction, and sciatic nerve injury. Kaplan-Meier survivorship analysis estimated that the cumulative probability of free-from-end-stage arthritis was 78% (95% confidence interval, 73%–90%) at the 5-year follow-up.

Conclusion

Surgical fixation with the modified Stoppa and the KL approach for acetabular medial wall fractures with central hip dislocation is an effective approach with a satisfactory functional outcome. A prodromal factor was marginal impaction concomitant with articular damage. The trauma of high axial loading and the occupational distribution (males performing heavy manual labor and heavy lifting) with preoperative sciatic nerve injury increased the odds of developing end-stage arthritis.

Clinico-Radiological Evaluation of Modified Stoppa Approach in Treatment of Acetabulum Fractures

Background

The aim of our study was to evaluate the efficacy of Modified Stoppa approach for surgical treatment of acetabulum fractures by analyzing clinical and radiological outcomes. Also, we assess intraoperative and postoperative complications of fracture treated by using Modified Stoppa approach.

Objectives

To evaluate clinical outcomes of Modified Stoppa approach by using Merle d'Aubigne hip score. To evaluate the radiological reduction quality of Modified Stoppa approach by using the criteria of Matta, and to assess complications of Modified Stoppa approach. 

Method

Thirty-two patients participated in this study (mean age 40 years; range 18-60 years) and the male to female ratio was 4:1, patients who underwent surgical intervention for acetabular fracture by using Modified Stoppa approach from Oct 2017 to April 2019 were included. Out of 32 patients, two were lost in follow up, leaving 30 of 32 patients for clinico-radiological analysis. We classified the fracture pattern according to Judet and Letournel classification based on preoperative X-ray AP view, Judet View, and 3D-CT pelvis. Operative time, blood loss, reduction quality, and perioperative complications were assessed in each patient. Clinical outcomes were assessed by Merle d’Aubigne hip score and radiological outcomes by criteria of Matta. 

Results

Out of 30 acetabulum fractures in 30 patients, three (10%) were categorized as anterior column fracture, one (3.3%) as transverse with posterior wall, one (3.33%) as T-type, six (20%) as anterior column with posterior hemi-transverse and 19 (63.33%) as both column fractures. In our study, most patients have trauma due to road traffic accident (RTA) in 25 (83.3%) and fall from stairs in three (10%) patients. Timing of surgery after trauma was average 5.83 days (range three to 15 days), Mean surgical time determined to be 214.66 min (range 150-350 min) and mean intraoperative loss 683.33 ml (range 230-1250 ml). Clinical outcomes by Merle d’Aubigne hip score was excellent in 13 (43.33%), good in 15 (50%), fair in two (6.66%) patients whereas poor results in 0 (0%) patient (p=0.001). Quality of reduction by Matta criteria was found to be an anatomical reduction in 26 (86.6%), imperfect reduction in three (10%), and poor reduction in one patient (3.33%) (p<0.001). Radiological grading by Matta criteria was excellent in 24 (80%), good in five (16.66%), and fair in one (3.33%) patient, and no patients met criteria for poor results (p<0.001). In operative complications one patient developed an external iliac vein injury which was repaired by a vascular surgeon, one patient had a superficial infection for which debridement, regular dressing, and IV antibiotics given and resolve in one month, obturator nerve injury in one patient which was resolve in five to six months, lateral femoral cutaneous nerve injury in one patient which resolved within three months and one patient urinary bladder injury which was repaired by a general surgeon. 

Conclusion

Our experience with Modified Stoppa approach for surgical treatment of acetabulum fracture in 30 patients is excellent and effective for better visualization to anterior column, quadrilateral plate, and up to sacroiliac joint. This approach provides better visibility of the fracture site which allows for good to an excellent reduction of fracture and fixation. Although Stoppa approach is cosmetic surgery in terms of scar size, there is less complication rate than the ilioinguinal approach. 

Prospective Evaluation of Outcome of Acetabular Fractures Managed by Anterior Intrapelvic Approach

INTRODUCTION

Anterior Intrapelvic (AIP) approach has emerged, in the last two decades, as a promising approach for fixation of anterior acetabular fractures. This prospective study was conducted to analyze our results with this approach and suggest the indications for its rationale usages in a developing country.

MATERIALS AND METHODS

All patients with acetabular fractures, which required anterior fixation, were operated by AIP approach and prospectively evaluated between October 2013 and January 2018. Mechanism of injury, fracture type, operative time, blood loss, complications, radiographic, and functional outcomes were analyzed in all patients. Modified Merle D'Aubigne system was used for clinical grading, while Matta's grading was utilized for radiographic outcome.

RESULTS

Fifty eight [90.62%] patients out of the total 64 patients had good to excellent outcome on functional and radiographic results. About 93.75% patients were able to resume pre-injury activities including socially demanding tasks like ability to sit cross legged and squat. Patients operated early had better articular reductions as compared to those operated late.

CONCLUSIONS

This approach can be considered as a safe, effective and feasible alternative to traditional ilioinguinal approach for acetabulum fractures which require anterior approach. Cases which present late may have difficulty through this approach as scarring or granulation tissue may lead to inadequate visualization.

Clinico-radiological Outcomes of Using Modified Stoppa Approach for Treating Acetabular Fractures: An Institutional Review

Introduction

Acetabular fractures are complex intra-articular fractures. The extra-pelvic ilioinguinal (IL) has been the workhorse for the anterior approach and remains the gold standard. The major difference between the IL and the Stoppa approaches is that Stoppa allows for the avoidance of the middle window of the IL approach. Hence, the modified Stoppa approach (MSA) can be adopted by a comparatively less experienced surgeon with minimal complications. The purpose of this study is to evaluate the radiological and functional outcomes of patients operated on using the MSA.

Materials and methods

Patients operated on by the MSA for acetabular fractures with a minimum of one year of clinical and radiographic follow-ups were reviewed. CT scans and radiographs were evaluated for the fracture pattern, time to surgery, operative time, blood loss, quality of reduction (Matta criterion), FO [Harris hip score (HHS) and Nach Merle d'Aubigné and Postel score (NMAPS)] and complications (perioperative and follow-up). Twenty-three of 26 patients with 45 acetabular fractures operated between January 2016 and November 2018 were included. Descriptive statistics were used for demographic data, and Pearson’s chi-squared statistic was calculated for the association between radiological and functional outcomes.

Results 

Among the 23 patients, the mean age was 38.5 years (range: 15-65) with a male-to-female ratio of 18:5. The average time to surgery was 11.5 days (range: 2-32), operating time was 155 minutes (range: 90-243), and average blood loss was 650 ml (range: 500-1,250). A supplemental lateral window was used in 20 patients (87%), and three underwent the combined anterior and posterior [Kocher Langenbacks (KL)] approach. All cases were unilateral. The transverse fracture was the most common pattern (eight patients) followed by the associated both-column fracture in six and T-type, isolated anterior column fracture, and anterior column and posterior hemi-transverse fractures seen in three patients each. Iliac blade (high anterior column) fracture was seen in 14 cases and one patient had associated sacral type II fracture. Road traffic accidents accounted for 61% of the injuries and injury severity score (ISS) of >15 (polytrauma) was seen in more than 50% of the cases (associated with other organ injuries). The radiological outcome was anatomical in 52% of the cases, imperfect in 39%, and poor in 9%. The functional outcomes were good to excellent in 74% (HHS) and 79% (NMAPS) of the cases. The association and correlation between them were nonsignificant (p-value: >0.5). Two patients developed a superficial infection and three had iatrogenic obturator nerve palsy. One patient had a direct inguinal hernia, one had grade 3 bedsores, and two patients developed grade 2 arthritic changes during the follow-up. No case of vessel injury was encountered.

Conclusion

Adoption of the MSA for the treatment of acetabular fractures leads to a good-to-excellent anatomical reduction in most cases while providing direct visualization of the quadrilateral plate and posterior column. The learning curve is smaller for less-experienced surgeons in terms of complications and results. We recommend this technique as a viable alternative to the IL approach for anterior acetabular fixation.

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

Comparison of two reinforcement rings for primary total hip arthroplasty addressing displaced acetabular fractures: a biomechanical analysis

INTRODUCTION

Aim of this study was to biomechanically compare two different acetabular cup fixation constructs in terms of fracture fixation for displaced acetabular fractures involving the anterior column with hemitransverse fracture under partial and full weight-bearing conditions.

METHODS

Two different reinforcement rings designed as cages for primary THA were biomechanically tested in terms of managing a complex acetabular fracture. Single-leg stance cyclic loading was performed to assess fracture gap movement and fragment rotation. Twelve hemi pelvis Sawbones were divided into two groups: primary THA with acetabulum roof reinforcement plate (ARRP) (n = 6) and primary THA with Burch-Schneider reinforcement cage (BSRC) (n = 6).

RESULTS

During loading under partial weight-bearing (250 N) fracture gap movement tended to be larger in the BSRC group as compared to the ARRP group. Under full weight-bearing conditions, the ARRP showed 60% significantly less motion (p = 0.035) of the os ilium to os ischii gap compared to BSRC. Fracture gap movements between the os ilium and spina iliaca fragments were significantly reduced by 76% (p = 0.048) for ARRP in contrast to BSRC. The ARRP group also demonstrated significantly less movement in the fracture gaps os ischii to quadrilateral plate (62% reduction, p = 0.009) and quadrilateral plate to spina iliaca (87% reduction, p < 0.001). Significantly less rotational movement of the quadrilateral plate to the os ilium was exhibited by the ARRP group (p = 0.015).

CONCLUSIONS

The presented acetabulum roof-reinforcement plate (ARRP) provides stable conditions at the acetabular component with adequate stabilization of a displaced acetabular fracture.

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.

Posterolateral clamp placement on the pelvic brim provides optimal reduction of transtectal acetabular fractures fixed through the anterior intrapelvic approach

PURPOSE

To determine the optimal position of reduction clamps applied to reduce transtectal transverse acetabular fractures approached through the anterior intrapelvic route.

METHODS

Transtectal transverse fractures were created in sawbone hemipelvis models. Fractures were reduced and held with a large pointed reduction clamp with one tine centered on the quadrilateral plate and the other placed in one of nine various positions on the pelvic brim accessible from the anterior intrapelvic (AIP) approach. Reduction was assessed by measuring maximum gapping and step-off at the joint surface.

RESULTS

The posterolateral pelvic brim clamp position provided the most accurate reduction with the smallest articular fracture gap (mean 1.09 ± 1.05 mm) and step-off (mean 0.87 ± 1.35 mm). This clamp position, compared with the other positions as a whole, also yielded the highest proportion of perfect reductions (0 mm maximum displacement) for both step-off (83% vs 34%; RR 2.4, 95% CI 1.7-3.2) and gap (88% vs 49%; RR 1.8, 95% CI 1.4 to 2.2).

CONCLUSIONS

When clamping transtectal fractures through the AIP approach, positioning the clamp posterolaterally on the pelvic brim appears to provide the best reduction in this fracture model.

Short-column acetabular fracture fixation through a mini-pararectus approach in anteriorly displaced acetabular fractures: A case series

Background:

A mini-pararectus approach has been described as a minimally invasive approach for stabilizing acetabular fractures. This approach allows a direct view of anteriorly displaced acetabular fractures. In this preliminary study, we report the outcomes of short-column plating, using either a pelvic-brim plate or a spring plate to stabilize anteriorly and medially displaced fractures.

Methods:

Nine patients were included in this report, which was conducted between June 2015 and October 2016 in Assiut University Hospital, which is a level 1 trauma center in Upper Egypt. Eight patients had a transverse fracture of the acetabulum, and a single patient had a posterior hemi-transverse fracture of the anterior column. After the mini-pararectus approach through which anatomical reduction of the fracture was achieved, short-column plating, either a pelvic-brim plate or spring plate was introduced through this 3-5 cm incision. Outcomes were assessed.

Results:

The mean operative time was 88.8 min (range, 60-120 min). The mean blood loss was 78.8 mL (range, 50-150 mL). The maximal fracture displacement mean was 7 mm (range, 4–18 mm) preoperatively. According to the Radiologic Matta score, anatomical reduction of the fracture (0–1 mm displacement) was achieved in all patients. No complications of metal failure or secondary fracture displacement were encountered.

Conclusions:

Short-column plating through a mini-pararectus approach can be an alternative option for stabilizing acetabular fractures in a minimally invasive way in selected patients.

Level of Evidence:

Level IV.

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.

Anterior Intrapelvic Approaches: Fracture Patterns You May Want to Reconsider

The anterior intrapelvic approach with a lateral window is gaining popularity for the surgical treatment of anterior fracture patterns of the acetabulum. Certain fracture patterns and characteristics present challenges when using anterior approaches. This article aims to describe some of the fracture patterns that may be particularly difficult to address using the anterior intrapelvic approach with or without the lateral window.

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

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.

Outcome after Surgical Management of Acetabular Fractures: A 7-Year Experience

Objective

To determine the functional and radiologic results of surgical treatment in patients with acetabular fractures.

Methods

This was a retrospective cross-sectional study. We retrospectively reviewed medical records of patients operatively treated acute acetabular fractures at a level I trauma center (Shahid Rajaee) and an orthopedic center (Shahid Chamran) both in southern Iran (Shiraz) with minimally 1 year follow up over a period of 7 years from April 2009 to March 2016. Functional and radiographic outcomes, and complication were considered as main outcomes.

Results

A total number of 79 patients completed the study. Fifty-five patients were operated through Kocher-Langenbeck approach, and 18 were operated through the standard ilioinguinal approach, and 6 patients were operated through the standard ilioinguinal approach combined with Kocher-Langenbeck approach. The mean follow-up of patients was 45.6 months. The average operative time was 162.4±78.5 min, and the median blood loss was 500 ml. Functional results were excellent in 41 patients (51.9%), good in 12 (15.2%), fair in 13 (16.5%), and poor in 13 patients (16.5%). Radiologic results were excellent in 27 cases (34.2%), good in 17 cases (21.5%), fair in 18 cases (22.8%), and poor in 16 (16.5%). Osteoarthritis of hip (60.8%) and AVN of head of femur (22.8%) were two most common complications. In addition, there wasn't any significant difference between surgical approaches regarding clinical and radiographic outcomes.

Conclusion

The operative treatment for acetabular fractures gives universally satisfactory results. Thereafter, this study provides evidence that ilioinguinal approach is a good choice for anterior fractures, Kocher-Langenbeck is a good choice for posteriors fractures, and combined approach may be a good choice in the management of acetabular fractures involving two columns.

Biaxial reduction technique for the medially displaced quadrilateral surface in acetabular fracture through the modified iliofemoral approach: An observational study

Treatment of acetabular fractures is technically demanding injuries. The complex surgical approaches and special equipment have been introduced for achieving accurate anatomical reduction.The aim of the study was to present our experiences of using a newly operative technique to achieve accurate reduction of articular dome impaction and of the quadrilateral surface without special equipment or traction device in reference to fracture reduction and fixation, technical aspects, and the incidence of complications.Five acetabular fractures with involvement of the quadrilateral plate associated anterior column and posterior hemi-transverse fractures were treated with an anatomically curved reconstruction plate and 2 lag screws using a biaxial reduction technique with a modified iliofemoral approach. The impacted quadrilateral plate was reduced without special equipment with accurate reduction of the articular surface by direct digital palpation in an extensive working space.Fracture reduction was assessed by Matta radiographic scoring as anatomic (within 1 mm) or satisfactory reduction (between 1 and 3 mm) in all 5 cases. Functional outcomes, according to the Harris hip score system, were greater than 90 points in all 5 patients. No loss of reduction, joint penetration, or visceral and neurovascular injury was documented at 1-year follow-up.The biaxial reduction technique with a modified iliofemoral approach provides a versatile method for fracture fixation and greater surgical access in medial impacted dome injury with comminuted anterior AC fracture without special equipment or traction device.Observational study, level IV.

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.

Injury of the obturator nerve in the modified Stoppa approach for acetabular fractures

INTRODUCTION

The modified Stoppa approach for acetabular fractures has become popular. However, the possibility of injury to the obturator nerve with this approach has not been sufficiently considered. We have experienced a case of nerve entrapment in severely displaced fractures. Therefore, we performed a retrospective study to: (1) evaluate the incidence of obturator nerve injury in the modified Stoppa approach for acetabular fractures; (2) analyze the relationship between the extent of displacement of the quadrilateral plate and injury to the obturator nerve.

HYPOTHESIS

We hypothesized that obturator nerve injury would be related to a marked medial displacement of the quadrilateral plate.

PATIENTS AND METHODS

We conducted a retrospective cohort study of 22 patients with acetabular fractures that were surgically treated with the modified Stoppa approach. The medial displacement of the quadrilateral plate was measured on a three-dimensional reconstruction image with the inlet view. Postoperative electrodiagnostic tests were performed based on clinical suspicion of neurological injury. Nerve injuries were divided into initial trauma or postoperative complication, and recovery of nerve function was evaluated. We identified the incidence of obturator nerve injury and analyzed the relationship between obturator nerve injury and medial displacement of the quadrilateral plate.

RESULTS

The incidence of obturator nerve injury was 2/22 (9.1%), and all injuries resulted from the initial trauma. The average displacement of the quadrilateral plate was 15.9±13.4mm. Patients were divided into two groups, using a displacement of 24mm as a cutoff point, identified using a receiver operating characteristic curve analysis. There were 16 patients in group 1 (<24mm) and 6 patients in group 2 (≥24mm). The incidence of obturator nerve injury from trauma was 0/16 (0%) in group 1 and 2/6 (33.3%) in group 2 (P=0.018).

CONCLUSIONS

No cases of postoperative obturator nerve injury were identified. Preoperative obturator nerve injury was more common in patients with a displacement of the quadrilateral plate≥24mm.

LEVEL OF EVIDENCE

IV, retrospective study.

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.

Treatment of Transverse with or without Posterior Wall Fractures of Acetabulum Using a Modified Smith-Petersen Combined with Kocher-Langenbeck Approach

BACKGROUND The aim of this study was to explore the surgical treatment of transverse with or without posterior wall fractures of the acetabulum. MATERIAL AND METHODS We surgically treated 21 consecutive cases of pure transverse (7 cases) and with posterior wall (14 cases) fractures of the acetabulum. The anterior column fractures were firstly reduced, temporarily fixed through a modified Smith-Petersen small incision, and finally fixed after the fixation of the posterior column and wall fractures, which were reduced and fixed through a Kocher-Langenbeck approach. The operative time, intra-operative blood loss, quality of reduction (Matta criteria), perioperative complications, osseous union, subsequent complications, and hip function evaluation were recorded. RESULTS The mean operative time was 198.1 min and the mean intra-operative blood loss was 938.1 ml. Anatomic reduction of the anterior column was obtained in 20 cases and was imperfect in 1 case. All posterior column and wall fractures were anatomically reduced. We followed up 18 cases for a mean duration of 16.3 (8-30) months. All the fractures achieved osseous union. The mean Harris score was 85.1 points, with an excellent result in 7 cases, good in 8, fair in 2, and poor in 1. According to modified Merle d' Aubigne and Postel score system, the results were excellent in 2 cases, good in 15, and poor in 1. Avascular necrosis of the femoral head occurred in 1 case, heterotopic ossification in 3 cases, and numbness of the anterolateral thigh in 6 cases. CONCLUSIONS For transverse with or without posterior wall fractures of the acetabulum, reduction and fixation of anterior and posterior column should be done in sequence, and a modified Smith-Petersen small incision might be a good choice in reduction and fixation of the anterior column because it possesses advantages of direct visualization and minimal invasion.

A Minimally Invasive Technique Using a Modified Stoppa Approach for Periacetabular Osteotomy: A Preliminary Cadaveric Study

BACKGROUND

Developmental hip dysplasia is diagnosed when the femoral head is not sufficiently covered by the acetabulum. Anterior and lateral cover deficiency is seen, as a result a dysplastic hip joint. Various incision modifications have been developed because of the muscle dissection and wide wound scar in Smith-Peterson incision, which was originally used in Bernese osteotomy. This study evaluates applicability of the modified Stoppa approach in the performance of Bernese periacetabular osteotomy (PAO).

MATERIALS AND METHODS

Ten hemipelvises of five donor cadavers were used. The transverse Stoppa incision was made 2 cm over the symphysis pubis for quadrilateral surface exposure and pubic and ischial bone osteotomies. The second skin incision, a few centimeters lateral to the original incision, was made along the tensor fascia lata. Iliac bone osteotomy was performed starting just above the rectus femoris insertion. The displacement of the osteotomy was measured clinically and radiographically.

RESULTS

The mean anterior coverage calculated with center-edge angle was improved from 22.8° ±2.8 (range 20° min-28° max) preoperatively to 44.1° ± 3.7 (range 36° min-48° max). The displacement of the osteotomy at the iliopectineal line calculated on the iliac inlet view radiographs was 22.1 ± 3.4 mm (range 15 mm min-26 mm max). The clinical amount of the anterior displacement on the cadavers was 17.8 ± 3.35 mm (range 11 mm-21 mm) and lateral displacement was 20.3 ± 3.23 mm (range 15 mm-24 mm). The amount of the posterior intact bone enlargement at the quadrilateral surface was 5.3 ± 0.48 mm.

CONCLUSION

This less traumatic two-incision exposure is an adequate technique for Bernese PAO, allowing the bone to be cut under direct visual observation and reducing the need to use fluoroscopy.

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.

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.

Stoppa Approach for Anterior Plate Fixation in Unstable Pelvic Ring Injury

BACKGROUND

The Stoppa (intrapelvic) approach has been introduced for the treatment of pelvic-acetabular fractures; it allows easy exposure of the pelvic brim, where the bone quality is optimal for screw fixation. The purpose of our study was to investigate the surgical outcomes of unstable pelvic ring injuries treated using the Stoppa approach for stable anterior ring fixation.

METHODS

We analyzed 22 cases of unstable pelvic ring injury treated with plate fixation of the anterior ring with the Stoppa approach. We excluded cases of nondisplaced rami fracture, simple symphyseal diastasis, and parasymphyseal fractures, which can be easily treated with other techniques. The average age of the study patients was 41 years (range, 23 to 61 years). There were 10 males and 12 females. According to the Young and Burgess classification, there were 12 lateral compression, 4 anteroposterior compression, and 6 vertical shear fracture patterns. The fracture location on the anterior ring was near the iliopectineal eminence in all cases and exposure of the pelvic brim was required for plate fixation. All patients were placed in the supine position. For anterior plate fixation, all screws were applied to the anterior ramus distally and directed above the hip joint proximally. Radiologic outcomes were assessed by union time and quality of reduction by Matta method. The Merle d'Aubigne-Postel score was used to evaluate the functional results.

RESULTS

The average radiologic follow-up period was 16 months (range, 10 to 51 months). All fractures united at an average of 3.5 months (range, 3 to 5 months). According to the Matta method, the quality of reduction was classified as follows: 16 anatomical (73%) and 6 nearly anatomical (27%) reductions. There were no cases of screw or implant loosening before bone healing. The functional results were classified as 7 excellent (32%), 12 good (55%), and 3 fair (13%) by the Merle d'Aubigne-Postel score. There were no wound complications, neurovascular injuries, or other complications related to the surgical approach.

CONCLUSIONS

Stable anterior ring fixation placed via the Stoppa approach can result in excellent reduction and stable screw fixation with a low complication rate.

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.