Modified and new approaches for pelvic and acetabular surgery

Surgical treatment of acetabular fractures: a comparative cohort study comparing orthogonal double plating to suprapectineal quadrilateral surface (QLS) plate osteosynthesis

BACKGROUND

Acetabular fractures often require stabilization. Fractures involving the quadrilateral plate (QP) remain challenging due to complex anatomy and minimal bone stock. Treatment options include orthogonal double plate fixation or anatomically preformed suprapectineal quadrilateral surface (QLS) plates. The purpose of this study was to evaluate a series of buttress plating of acetabular fractures (OTA/AO 62) comparing orthogonal double plate and QLS plate osteosynthesis regarding surgical procedure, complications, and outcome.

METHODS

At one level I trauma center, 109 patients underwent internal fixation either by orthogonal double plate osteosynthesis or by preshaped QLS plate. Surgical approach was performed via the first and third windows of the ilioinguinal approach. Reduction quality and osteosynthesis material were checked using CT. Groups were retrospectively evaluated regarding demographic factors, classification, and trauma mechanism. Clinical outcome was assessed utilizing the modified Harris Hip Score (mHHS). Follow-up was 25 months.

RESULTS

Fractures were stabilized using orthogonal double plate osteosynthesis (56%) and QLS plates (44%). Following OTA/AO classification, 16 type A (14.7%), 69 type B (63.3%), and 24 type C (22.0%) fractures underwent treatment. Groups did not differ regarding fracture types, age, or BMI. The majority was male (75%). High-energy trauma accounted for 39.4%. Surgery averaged 187.43 min for orthogonal double plates and 163.13 min for the QLS plate (p = 0.012). No differences were found regarding hospital stay or complications. Neither postoperative osteoarthritis nor mHHS was related to plate type. Patients with high-energy trauma had better mHHS outcomes. Preexisting osteoarthritis resulted in reduced outcome.

DISCUSSION

Acetabular fracture stabilization is challenging due to extensive approaches, minimal bone stock of the QP, and difficult plate placement. Our analysis confirms that orthogonal double plate fixation and QLS plates provide secure stabilization for acetabular fractures. According to our findings, utilization of the QLS plate may result in reduced OR time due to its anatomically tailored shape.

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".

Quadrilateral plate fractures

During the last two decades, extended scientific interest focused on quadrilateral plate (QLP) fractures as part of common acetabular fractures. The QLP corresponds to the medial wall of the acetabulum, and different fracture pattern of Letournel´s fracture types are associated with concomitant QLP fractures. Except anterior and posterior wall fractures, all other fracture types may be associated with QLP fractures. QLP fracture features include simple fracture lines up to highly comminuted fractures. A detailed preoperative analysis of these fractures is important to get a better understanding of intraoperative decision making. No consensus exists regarding the optimal classification and treatment of QLP fractures. Various operative approaches and treatment concepts exists depending on the specific QLP fracture type and the acetabular fracture type. Several new implants were development for optimal but often individual stabilization concepts. The gold-standard is still some medial buttressing during internal fixation predominantly using plates, but also screw fixation is considered an option. Additional dome impactions must be considered as an integral part in any QLP fracture analysis and stabilization.

Articular impactions in acetabular fractures

Impactions of the articular surface are relevant prognostic parameters in the treatment of acetabular fractures. Posterior marginal impactions and acetabular dome impactions may occur depending on the direction of the force vectors during trauma. Posterior marginal impactions are mainly observed in posterior fracture dislocations, while acetabular dome impactions are frequently seen in the elderly with the hip joint in extension during trauma. Femoral head impactions are also frequently associated with acetabular fractures, mainly in fracture dislocations and transverse acetabular fractures. CT scans using thin slices are mandatory in order to preoperatively identify acetabular and femoral head impactions. Intraoperatively, the reduction techniques depend on the type of marginal impaction. Posterior impactions are usually addressed via a posterior approach by applying femoral traction under direct visualization or even by performing surgical hip dislocation. Acetabular dome impactions may be reduced using the fracture lines or by creating a cortical window. Reduction is followed by filling the void with bone or bone substitutes supported by raft screws. No clear treatment recommendations for femoral head impactions are given in the literature.

Intrapelvic suprapectineal acetabular plates interfere with the quality of reduction evaluations on postoperative X-rays. A retrospective case series

INTRODUCTION

Intrapelvic suprapectineal plates play an important role in acetabular fracture fixation. However, the shape of these implants may interfere with the quality of reduction evaluations using plain X-rays. We sought to evaluate this artifact and its relationship with CT findings.

MATERIALS AND METHODS

In a retrospective, single-center series of 22 acetabular fractures, postoperative AP, alar and obturator X-ray views and CT images were evaluated by three independent observers. Cohen's kappa was used to examine interrater reliability.

RESULTS

Suprapectineal plates interfered with the evaluation of the weight-bearing surface in 75.3%, and with all three oblique views in 43.9% of cases. The central segment was most consistently interfered with, corresponding to the area where the greatest malreduction was in 46.9% coronal and 42.4% of sagittal CT views.

CONCLUSIONS

Since the quality of reduction has prognostic value and is a necessary guide for the surgical team, that CT may be considered for the postoperative examination of the most challenging acetabular fracture cases.

Clinical and radiographic results of internal fixation of quadrilateral plate fractures of acetabulum

INTRODUCTION

Quadrilateral plate (QLP) is a relatively thin bony structure located below the pelvic brim proximal to the hip joint, so management of its fractures is challenging.

OBJECTIVES

Evaluation of the functional and radiological outcomes of internal fixation of quadrilateral plate acetabular fractures; comparison of two methods of fracture fixation.

PATIENTS AND METHODS

A prospective multicentric study including 30 patients who underwent open reduction and internal fixation of QLP fractures through modified Stoppa approach. Patients were divided into two groups according to the method of fixation (anatomical QLP plate vs suprapectineal and infrapectineal plates). Post-operative quality of reduction was evaluated using Matta score. Radiographical assessment according Matta's grading criteria and clinical outcome assessment using the Harris Hip Score (HHS) were repeated at follow-up and at one year to assess displacement.

RESULTS

Mean age of patients was 34.9 ± 12.1 years. After one year follow-up, clinically mean HHS was 88. ± 5.74. Radiologically post-operative reduction quality was anatomical in 21 (70%) patients, satisfactory in eight (26.7%) patients and unsatisfactory in one (3.3%) patient. Matta's grading at the last follow-up was excellent in 21 (70%) patients, good in six (20%), fair in two (6.7%) patients and poor in one (3.3%) patient. No significant difference was recorded between the two groups in terms of radiographical and clinical results and rate of complications.

CONCLUSION

Accurate reduction of quadrilateral plate fracture with secure fixation through modified Stoppa approach provides good and reproducible outcomes with few complications regardless the type of the implant.

The Pararectus approach: a preferred surgical approach for fixation of acetabular fractures predominantly involving the anterior column - a narrative review

Beginning in France in the 1960s, the management of acetabular fractures has increasingly evolved toward surgical treatment strategies. The basic principles established by the pioneers of acetabular surgery, Letournel and Judet - anatomical reconstruction of the joint and stable osteosynthesis - remain unchanged. Modern advancements in surgical techniques aim to reduce access-related trauma and minimize complications. The notable rise in acetabular fractures among the elderly, which predominantly affect the anterior aspects of the acetabulum, has driven the development of less invasive, soft tissue-sparing anterior approaches. This evolution began with the ilio-inguinal approach in the 1960s, progressed to the modified Stoppa approach in the 2000s and, most recently, the Pararectus approach in the 2010s. Each of these approaches upholds the fundamental principles of effective acetabular fracture care, while offering distinct advantages and disadvantages. In this review, we examine the merits and limitations of the Pararectus approach, specifically focusing on its utility in the surgical treatment of anterior column posterior hemitransverse acetabular fractures. Ultimately, the success of the individual patient's outcome is less dependent on the chosen approach and more on the surgeon's experience and expertise. Ideally, surgeons should be proficient in all these approaches to tailor the surgical strategy to the individual patient's requirements, thereby ensuring optimal outcomes.

Fluroscopy-assisted transiliac antegrade lag screw placement technique in both columns of acetabulum: A novel procedure

The use of pelvic osseous fixation corridors and lag screw fixation in acetabular and pelvic surgery has gained popularity, especially with the recent development of intraoperative imaging and navigation techniques. However, advanced intraoperative imaging and navigation techniques require technical equipment and are costly. Therefore, traditional fluoroscopic techniques still maintain their importance. In this article, we describe a novel pelvic osseous fixation corridor that traverses both columns of the acetabulum, along with the detailed methodology of its fluoroscopic imaging and the techniques for fluoroscopy-assisted screw placement. The technique of placing screws in this current fixation corridor is only under fluoroscopy assistance, without using any specially produced guide or navigation device. LEVEL OF PROOF: IV.

Combining Innovative Techniques: Total Extraperitoneal Approach in Orthopedic Surgery (O-TEP) and Percutaneous Both Column Screw (BCS) Fixation Technique in a Geriatric Acetabular Fracture Case

The concepts of both column fixation corridor (BCFC) and both column screws (BCS) along with the orthopedic total extraperitoneal approach (O-TEP) are highly innovative approaches in orthopedic surgery. However, the orthopedic literature lacks sufficient studies on these topics, indicating a significant gap. This case report aims to highlight how combining these innovative techniques can facilitate the use of BCFC and BCS in the treatment of acetabular fractures with O-TEP, thereby enhancing the feasibility of endoscopic techniques. Furthermore, we aim to discuss the potential advantages of BCFC and BCS concepts when used in O-TEP.For this purpose, we present a case of a 74-year-old geriatric patient with a transverse acetabular fracture involving the posterior column. The quadrilateral surface was exposed using the O-TEP approach, and the fracture was reduced using a fully endoscopic approach. The fixation was achieved using BCS and a Magic screw through percutaneous screw placement.The patient's clinical condition was followed for at least 13 months. The clinical outcomes demonstrated the effectiveness of combining these innovative techniques in the treatment of acetabular fractures, with satisfactory healing and functional recovery observed.This case report illustrates that combining BCFC and BCS with the O-TEP approach can facilitate the treatment of acetabular fractures with minimally invasive techniques and enhance the feasibility of endoscopic procedures. These findings suggest potential advantages of using BCFC and BCS concepts in O-TEP, warranting further investigation and study.

Comparison of 2 different fixation techniques of comminuted acetabular quadrilateral surface fractures using square bracket-shaped tubular plate or interfragmentary screws in addition to supra/infrapectineal plate fixation: An observational study

The management of comminuted quadrilateral fractures remains challenging, and treatment options are constantly evolving. The purpose of the present study was to examine the outcomes of 2 different fixation techniques in the management of comminuted quadrilateral fractures. Twenty-two patients with comminuted quadrilateral acetabular fractures were surgically treated with interfragmentary lag screw (group 1) and square bracket-shaped tubular (SBST) plate technique (group 2), in addition to suprapectineal and infrapectineal pelvic reconstruction plate fixation between January 2016 and July 2019 at our clinic. 2 years follow-up control data of each group were compared in terms of radiological and functional results, and complications. According to the functional score comparison, the mean Merle d'Aubigne Postel scoring system (MAP) score was 15.2/15.6 (P = .632), and the mean Harris hip scoring (HHS) system score was 74.65/77.3 (P = .664) in groups 1 and 2, respectively. Radiological comparison was performed according to matta radiological criteria (MRC), and 2 excellent, 6 good, 2 poor, 4 excellent, 4 good, and 4 poor radiological results were observed in groups 1 and 2, respectively. intraarticular screw penetration was detected in 3 patients in group 1, while there was no articular implant penetration in group 2 (P = .001). We believe that satisfactory results can be obtained with the SBST plate technique, offering functional and clinical outcomes that are similar to those of the interfragmentary screw technique. The SBST plate technique is superior in terms of avoiding intraarticular screw penetration and related revision surgery.

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

OBJECTIVES

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

METHODS

DESIGN

This was a retrospective comparison study.

SETTING

Level 1 trauma center.

PATIENT SELECTION CRITERIA

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

OUTCOME MEASURES AND COMPARISONS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Is the Direct Fixation of Displaced Quadrilateral Plates in Acetabular Fractures Necessary?

Quadrilateral plate fractures represent a heterogeneous group of acetabular fractures. Accurate reduction is required to prevent post-traumatic arthritis. The purpose of this study is to determine the reduction effect of the direct fixation of quadrilateral plates in acetabular fractures, and to evaluate the strength of direct fixation compared to indirect fixation. Between 2005 and 2021, 49 patients underwent surgery for open reduction and internal fixation in acetabular fractures with severely displaced quadrilateral plates. Twenty-nine patients comprised the indirect fixation group, and twenty patients comprised the direct fixation group. In a comparison of primary outcome between two groups, 10 out of 29 indirect-group patients and 1 out of 20 direct-group patients developed post-traumatic osteoarthritis, wherein the difference between the two groups is statistically significant. In the assessment of postoperative Matta's radiological reduction status, 19 out of 20 patients in the direct group had achieved anatomical and congruent reduction. The treatment using a direct reduction and internal fixation improved the reduction quality of articular displacement and offered a better survivorship of the affected hip joint.

The value of digital 3D models in evaluating surgical outcomes using the uninjured contralateral acetabulum after acetabular fracture repair

BACKGROUND

Currently, assessment of acetabular fracture reduction is mainly performed by evaluating 2D slices of 3D CT scans. This subjective method can potentially be improved by using 3D models and objective analysis tools. In order to evaluate the potential value of digital 3D reconstructed models in the assessment of acetabular fracture reduction, 3D reconstructions of the fractured acetabulum were compared to the mirrored healthy contralateral side for both the pre-, and post-surgical setting.

METHODS

Thirteen patients with one-sided acetabular fractures were included in the study. All patients received a pre-, and postoperative CT scan. The similarity between the healthy acetabulum and the contralateral fractured acetabulum was determined by two observers for both the pre-, and postoperative setting by completing the following four steps; (1) mirroring of the fractured acetabulum, (2) initial manual alignment of this mirrored 3D model to the contralateral version, (3) surface-based matching (iterative closest point registration) using the acetabular cartilage surface, and (4) calculating the surface distances between affected and healthy acetabular 3D models. Descriptive statistics showed the surface distance between pre-, and post-surgical reduction, as well as the interobserver variability.

RESULTS

A total of 13 patients with an acetabular fracture were included; 11 males and 2 females with a mean ± SD age of 55.6 ± 14.7 years. Digital mirroring of the fractured acetabula to the healthy acetabula was successful for both preoperative and postoperative situations in all patients. The median distance between both fractured and mirrored healthy contralateral acetabula was significantly larger (p<0.01) for the preoperative group (2.21 mm (interquartile range (IQR): 1.30 mm)) compared to the postoperative group (0.93 mm (IQR: 0.59 mm)). The median distance deviation was not significantly different (p = 0.96) between observers.

CONCLUSIONS

The results of comparing 3D model of fractured acetabula with the contra-lateral healthy acetabula before, and after surgical repair indicate that this method can be a suitable tool to objectively assess acetabular fracture reduction. Further research is needed to confirm the usefulness to predict future arthrosis after surgical repair.

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

OBJECTIVES

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

DESIGN

Retrospective.

SETTING

Tertiary referral hospital.

PATIENTS

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

INTERVENTION

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

MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

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

BACKGROUND

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

METHODS

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

RESULT

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

CONCLUSION

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

Management of Complex Acetabular Fractures by Using 3D Printed Models

Background and Objectives: Using 3D printed models in orthopaedics and traumatology contributes to a better understanding of injury patterns regarding surgical approaches, reduction techniques, and fracture fixation methods. The aim of this study is to evaluate the effectiveness of a novel technique implementing 3D printed models to facilitate the optimal preoperative planning of the surgical treatment of complex acetabular fractures. Materials and Methods: Patients with complex acetabular fractures were assigned to two groups: (1) conventional group (n = 12) and (2) 3D printed group (n = 10). Both groups included participants with either a posterior column plus posterior wall fracture, a transverse plus posterior wall fracture, or a both-column acetabular fracture. Datasets from CT scanning were segmented and converted to STL format, with separated bones and fragments for 3D printing in different colors. Comparison between the two groups was performed in terms of quality of fracture reduction (good: equal to, or less than 2 mm displacement, and fair: larger than 2 mm displacement), functional assessment, operative time, blood loss, and number of intraoperative x-rays. Results: A significant decrease in operative time, blood loss, and number of intraoperative x-rays was registered in the 3D printed group versus the conventional one (p < 0.01), with 80% of the patients in the former having good fracture reduction and 20% having fair reduction. In contrast, 50% of the patients in the conventional group had good reduction and 50% had fair reduction. The functional score at 18-month follow-up was better for patients in the 3D printed group. Conclusions: The 3D printing technique can be considered a highly efficient and patient-specific approach for management of complex acetabular fractures, helping to restore patient′s individual anatomy after surgery.

A new modified pararectus approach and visualization: an anatomical study

INTRODUCTION

The aim of our study was to visualize all the windows used in the pararectus approach with detailed cadaver images to facilitate better understanding of orthopedic surgeons and, in addition, was to modify the incision used in the pararectus approach to a more cosmetic bikini incision.

MATERIALS AND METHODS

In total, 20 cadavers fixed in 10% formalin were used in this study. Of these cadavers, 14 were male and six were female, with a mean age at death of 57 (42-82 years). The four windows were defined as follows in all the cadavers: pubic, quadrilateral, sacroiliac, and iliac windows.

RESULTS

The most important structure at risk in the pubic window was the corona mortis, as it was observed in 12 (60%) cadavers. In men, the spermatic cord was an important structure at risk in the pubic window. The obturator vessels and nerves were the structures at most risk in the quadrilateral window due to their close location with the quadrilateral surface. The obturator nerve on the medial side and at the entrance of the pelvis through the linea terminalis and lumbosacral truncus were the structures at most risk close to the sacroiliac joint in the sacroiliac window.

CONCLUSION

This anatomical study includes highly instructive visual shapes and cadaver images for the acetabulum and pelvis, whose anatomical structures are quite complex. We have found that this modified pararectus approach provides excellent access to the internal pelvic rim.

CLINICAL RELEVANCE

The anatomical data regarding the modified pararectus approach in this study will assist orthopedic surgeons in the surgical management of acetabular and pelvic fractures.

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.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Role of 3D printing in the management of complex acetabular fractures: a comparative study

PURPOSE

The aim of this study is to assess the role of 3D printing of actual size pelvis in the management and outcome of acetabular fractures.

METHODS

Retrospective study with inclusion of acetabular fractures which were divided into two groups (traditional and 3D printing) was done over a 1 year period. The indices for comparison of both groups in this study were (a) operative time (from skin incision to suture), (b) intraoperative blood loss (noted from the anaesthetist notes), (c) times of intraoperative fluoroscopy, (d) postoperative complications, (e) quality of fracture reduction (good =  < 2 mm displacement, fair =  > 2 mm displacement) and (f) Harris hip score at final follow-up.

RESULTS

27 cases (traditional group = 15, 3D printing group = 12) meeting the study criteria were included in the study with a mean follow-up of 26.3 ± 11.2 months. There was a significant difference in the operative time, intraoperative blood loss and number of intraoperative fluoroscopy images. The mean operative time was shorter in the 3D printing group by 62 min. No difference was noted in the quality of reduction in either of the groups (p > 0.05).

CONCLUSION

3D imaging and printing helps in better understanding of the anatomy of acetabular fractures. It leads to reduced operative time, blood loss as well as exposure to radiation intraoperatively. There is no difference in functional outcome at final follow-up between 3D printing and traditional groups.

Omega plate for the treatment of acetabular fractures involving the quadrilateral plate

This retrospective study aimed to assess the outcome of a modified Stoppa approach using an anatomically precontoured plate for the treatment of acetabular fractures. In total, 30 patients (mean age 50.3 years; 25 men and 5 women) with acetabular fractures were treated between January 1, 2018 and December 31, 2019. In all 30 cases, fracture reduction was performed through a modified Stoppa approach and fixed with the omega plate. In specific fracture patterns, additional approaches were needed (lateral window in 4 cases and posterior Kocher-Langenbeck approach in 7 cases). Patients were assessed for restoration of the hip joint congruency, complications, and overall fracture reduction. Quality of reduction was categorized based on Matta's radiological principles and to assess functional outcome the Merle d'Aubigné-Postel and Harris hip score was used. The average anesthesia time was 253.6 min, the mean intraoperative blood lost was 266.6 ml and the mean intraoperative fluoroscopy dose was 3.21 mGy. According to Matta criteria for reduction quality, anatomical reduction was recorded in 22 cases, imperfect reduction in 6 cases and 2 cases had poor reduction. The average follow-up was 22.5 months. Malunion, loss of reduction or implant loosening were not recorded. Late complications included one case of avascular necrosis of the femoral head and post-traumatic arthritis changes in 5 cases. At the final follow-up, a mean Merle d'Aubigné-Postel score of 13.26±4.46 and a mean Harris score of 86.03±13.37 were recorded. The possibility of an anatomically precontoured plate with subsequent lower operative time combined with stable fixation of the primary acetabular fracture fragments and the quadrilateral plate makes the omega plate a viable option for treating acetabular fractures with a very low complication rate and good to excellent results in 89% of the cases.

Surgical Drill Guide for Insertion of an Infra-Acetabular Screw Based on an Anatomically Precontoured Plate System: A Cadaveric Study

PURPOSE

Due to the anatomic structure of the pelvis, free-hand placement of screws in the acetabular fracture management can be difficult. Infra-acetabular screw fixation increases acetabular stability by distal fixation of the cup. Aim of this cadaveric study is to investigate if a plate-referenced drill guide can provide save placement of an infra-acetabular screw over a precontoured suprapectineal quadrilateral buttress plate (SQBP).

METHODS

We constructed a drill guide for an infra-acetabular screw based on the surface of an anatomically precontoured SQBP. A total of 12 adult cadaveric acetabular specimens were used for drill guide-assisted placement of the infra-acetabular screw. The drill guide contains a radiopaque spiral to allow longitudinal fine adjustment of the SQBP along the pelvic brim to assure correct position of the plate-drill-guide construct in relation to the Koehler's teardrop. After screw placement, we conducted a computed tomography (CT) scan of all specimens to assess the actual position of the screw in relation of the infra-acetabular corridor and the acetabular joint surface.

RESULTS

The position of the screw was within the infra-acetabular corridor in all cases. We did not see any intra-articular or intrapelvic screw penetration. The mean distance of the centerline of the screw to the medial border of the infra-acetabular corridor was 3.35 mm. The secure distance to the virtual surface of the femoral head to was 7.3 mm.

CONCLUSIONS

A plate-referenced drill guide can provide safe placement of an infra-acetabular screw for treatment of acetabular fractures. Radiographic fine adjustment is necessary to access the optimal entry point.

Modified Stoppa Approach: Beyond Acetabular Fractures: A Report of 2 Cases

CASES

We used the modified Stoppa approach in a 17-year-old man with a retained bullet in his acetabular fossa. The acetabular hole was used to irrigate the hip joint. We also used this approach in a 29-year-old woman with right hip pain and limping to remove an isolated tenosynovial giant cell tumor ("localized pigmented villonodular synovitis") in the acetabular fossa expanding through the acetabulum.

DISCUSSION

We believe that this approach should become more familiar because it offers a simple alternative for treating acetabular pathologies mainly involving the acetabular fossa, sparing patients the hazards of capsulotomy, trochanteric osteotomy, dislocation, and traction and fluid pressure in hip arthroscopy.

Outcomes of Direct Infrapectineal Buttress Plate for Quadrilateral Surface Fractures of Acetabulum Using an Anterior Intrapelvic Approach

Purpose

Reduction and stable fixation of the quadrilateral plate are challenging primarily due to its location in the true pelvis, limited bone stock, juxta-articular nature, and its comminution. The current study aimed to investigate the quality of reduction and functional outcomes after open reduction and internal fixation (ORIF) with infrapectineal buttress plating of the quadrilateral surface via an anterior intrapelvic approach.

Materials and Methods

We conducted a retrospective review of twenty-one patients with acetabular fractures involving quadrilateral plate operated at Ghurki Trust Teaching Hospital between January 2017 and December 2018. Radiological assessment of the quality of reduction was conducted using criteria described by Matta. Functional outcomes were evaluated using a modified Postel Merle d'Aubigné score.

Results

The current study included 15 males and 6 females with a mean age of 40.67±12.17 years (range, 22–62 years). The most common fracture pattern was anterior column and posterior hemi-transverse in eight patients followed by true bicolumn and T-type fractures in seven and four patients respectively. Both transverse fractures were transtectal. The quality of reduction according to Matta criteria was anatomical in 14 patients, imperfect in five and poor in two. Functional outcomes were excellent in 47.6% cases, good in 42.9%, and fair in 9.5% cases. Both patients with fair outcomes had non-anatomical reduction, and one required total hip arthroplasty at a later time.

Conclusion

Quadrilateral plate reconstruction with an infrapectineal buttress plate applied though an anterior intrapelvic approach provides high rates of anatomical reduction and yields good functional outcomes.

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.

Digital anatomical study and clinical application of screw placement for quadrilateral plate fractures in the danger zone

BACKGROUND

Direct screw placement for quadrilateral plate fractures in the danger zone of the acetabulum is very difficult. This study was performed to simulate the surgical procedure and try to obtain effective and safe screw angles through the middle window of the ilioinguinal approach in Chinese patients.

METHODS

We randomly collected the pelvic computed tomography (CT) scans of 100 adults. DICOM-formatted CT-scan images were imported into Mimics software. The three-dimensional reconstruction (3D) digital model of the semi-pelvis was established. A 3.5 mm cylinder was used to simulate the pathway of the screw from the designated insertion point. The angles of insertion and intersex differences were explored by statistical analyses.

RESULTS

The screws could be inserted via three angles: medial inclination, anterior inclination and posterior inclination. The mean minimum medial inclination angle (MIMIA) of insertion point A was 4.96° ± 1.11° in males and 8.66° ± 3.40° in females, and the intersex difference was significant. The mean minimum medial inclination angle (MIMIA) of insertion point B was - 5.31° ± 3.69° in males and 1.75° ± 8.95° in females, and the intersex difference was significant. There were no differences between any of the angles for males and females at insertion point O.

CONCLUSIONS

Preoperative measurement and calculation by digital tools before screw placement for quadrilateral plate fractures of the acetabulum are feasible. Double cortical screws could be placed safely in the danger zone through the middle window of the ilioinguinal approach to increase the stability of the acetabulum.

Which Anterior Acetabular Fracture Surgical Approach is Preferred? A Survey of the Orthopaedic Trauma Association Active Membership

OBJECTIVE

The goal of this survey was to determine the current surgeon-preferred anterior surgical approach for the treatment of acetabular fractures in North America.

DESIGN

Web-based survey; PARTICIPANTS:: Orthopaedic Trauma Association (OTA) members.

METHODS

Active members of the OTA were solicited to participate in an OTA-sponsored survey asking for their preferred standard anterior surgical approach to the acetabulum, along with some general demographic data. The approach choices were: the classic ilioinguinal as described by Letournel, a modified ilioinguinal, the modified Stoppa (Anterior Intrapelvic) with or without a lateral window, the pararectus, and an alternative to be specified by the survey taker.

RESULTS

Of the 675 total active OTA membership, 214 (32%) satisfactorily completed the survey. Of the 214 active members, only 32 (15%) prefer the classic ilioinguinal approach and 60 (28%) prefer some type of modified ilioinguinal approach. More than half of the active member respondents (121; 56.5%) prefer the modified Stoppa approach. Statistical analysis of the respondents' demographic data revealed only years in practice to be significantly different among treatment options (P < 0.01) with those with the least time in practice preferring the modified Stoppa.

CONCLUSIONS

It seems that the modified Stoppa has become the preferred anterior acetabular fracture surgical approach in North America, being especially favored by those more recently in practice. The exact reasons for this change cannot be determined from this survey and are most likely multifactorial. However, training experience may play an important role.

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.

3D printing of implants for patient-specific acetabular fracture fixation: an experimental study

PURPOSE

To test the effect of 3D printed implants, designed according to surgeon's individual plan, on the accuracy of reduction of an acetabular fracture model.

METHODS

Seven identical standardized plastic bone models of an anterior column/posterior hemi-transverse acetabular fracture were used. A CT of one plastic fracture model was made. Using preoperative planning software, three surgeons independently planned the reduction and fixation procedure and designed implants and drill guides. The designed implants and guides were then 3D printed. Each surgeon first executed his plan using his 3D printed plates and guides on one fracture model and then performed another procedure on an identical model with standard implants and instrumentation. Displacement of the fragments at the weight-bearing fracture lines in the acetabulum was measured after fixation. Linear mixed effect models were used to evaluate the effect of different solutions to the same fracture pattern.

RESULTS

Mean (SD) displacement of the fracture line between the ischium and stable fragment was 1.1 (0.9) mm for the standard implant and 0.8 (0.6) mm for the 3D printed implant, while the displacements of the fracture line between the stable fragment and anterior column were 0.6 (0.6) and 0.3 (0.3) for the standard and 3D printed methods, respectively (p < 0.001). Mean (SD) fracture line step-off at any fracture line for the standard implant was 1.2 (0.9) mm and 0.4 (0.4) mm for the 3D printed implant (p = 0.022).

CONCLUSIONS

Patient-specific 3D printed plates and drill guides may facilitate retaining accurate reduction and fixation of select acetabular fracture patterns.

MODIFIED STOPPA APPROACH FOR PELVIC AND ACETABULAR FRACTURE TREATMENT

OBJECTIVE

A retrospective review aims to investigate the operative methods and therapeutic effects of the modified Stoppa approach for treating pelvic and acetabular fractures.

METHODS

18 patients with acetabular fracture of the anterior column and pelvic anterior ring fracture underwent surgical treatment using the modified Stoppa approach. Some of the treatment was combined with the iliac fossa approach or rear K-L approach. Fracture reduction and postoperative function were evaluated using the Matta scoring standard and the Majeed scoring system. The Oxford Centre for Evidence-Based Medicine system was used to grade the literature review and create graded B recommendations.

RESULTS

Incision length was 6-12 cm (mean, 10 cm), operative duration was 50-150 minutes (mean, 85 minutes), and intraoperative blood loss volume was 400-1,000 ml (mean, 500 ml). 18 patients were followed up for 12-36 months post-operation. In the results of X-ray films, 12 cases were anatomical reductions and the remaining cases were satisfactory reductions. According to Majeed standard, 13 patients were excellent and five patients were good.

CONCLUSIONS

Treatment using the modified Stoppa approach was suitable for anterior approaches, in which pelvic and acetabular fractures were sufficiently exposed, the fracture was conveniently reduced, less complications occurred, and curative effect was satisfactory. Level of evidence III, Retrospective comparative study.

The value of 3D reconstructions in determining post-operative reduction in acetabular fractures: a pilot study

Background

In patients with acetabular fractures, the reconstructed three-dimensional (3D) model of the contralateral acetabulum could be used as a mirrored template for the anatomical configuration of the affected joint. This has not been validated.

Objective

To investigate whether the right and left acetabula, as reconstructed 3D models, are valid mirrored duplicates that can be used as a reference model for the contralateral side.

Methods

CT scans of twenty patients with unaffected acetabula were used. The symmetry of the generated 3D models was evaluated through: (1) mirroring of the acetabulum; (2) initial rough matching; (3) automatic optimisation of the matching via surface-based matching; (4) calculation of distances between surfaces by evaluating the Euclidean (straight-line) error distance between the closest points between left and right. The percentages of surface points of the left and right acetabulum with a distance smaller than 0.5, 1.0, 1.5 and 2.0 mm were calculated and evaluated, in relation to Matta’s criteria, for acetabular fracture reductions.

Results

The mean distance deviation was less than 0.75 mm in all 40 comparisons. The calculated distances in 90.7% of the surface points of the left and right acetabulum were below the tolerance threshold of 1.0 mm, based on Matta’s anatomical reduction criteria, and 98.7% of the surface points scored below Matta’s imperfect tolerance threshold of 2.0 mm.

Conclusion

This study demonstrates 3D reconstructed models of healthy left and right acetabula are highly similar and could potentially be used as mirrored duplicates. The next step will be to investigate these results in patients with reduced acetabular fractures.

AYDOĞAN N. A comparative biomechanical analysis of suprapectineal and infrapectineal fixation on acetabular anterior column fracture by finite element modeling

Background/aim

The aim of this study is to compare the stability and implant stresses of suprapectineal plate with infrapectineal plate in three subconfigurations of the screw types.

Materials and methods

The stabilities of different fixation methods were compared by finite element analysis on six models. Three infrapectineal and three suprapectineal models each with locked, unlocked, or combined screws were employed. Three-dimensional finite element stress analysis was performed by using isotropic materials with a load of 2.3 kN applied at standing positions. Motion at the fracture line was measured on four different points located on the pubic and iliac sides of the fracture line.

Results

Infrapectineal plate fixation with unlocked screws was found to be the most stable fixation method with 0.006 mm displacement of fragments in all axes at standing positions. The suprapectineal unlocked method was found to be the most unstable in standing positions with maximum displacement values of 0.46 mm vertical shear movement in the x-axis, –0.14 mm displacement in the y-axis, and –0.33 mm lateral shear in the z-axis.

Conclusion

The infrapectineal unlocked plate supplies the most stable fixation with the least implant stress, contrary to the suprapectineal unlocked plate, which has the lowest stability and highest implant stresses.

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

Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base?

Background

Little attention in the literature appears to have been paid to the issue of postoperative weight-bearing protocols for different injury patterns after pelvic fracture surgery. The primary aim of this study is to review the currently available literature to define the level of available evidence used to inform surgical decisions on weight-bearing after pelvic fracture surgery. Secondary aims are to assess the published methods of fracture classification, surgical management, and assessment or reporting of patient outcomes.

Methods

A systematic review of the English language literature from 1990 to 2016 was undertaken. Eligible papers were all papers reporting minimum 6-month outcomes following surgery for pelvic fractures in adults. Exclusion criteria included pathological fractures or those resulting from penetrating injury, solely osteoporotic fractures, or series with less than 6 months of follow-up data.

Results

There is very little published scientific data to inform the treating surgeon on postoperative weight-bearing protocols after pelvic fracture surgery, with no randomized trials and only 1 paper out of 122 stating this as a primary aim. More than half of the papers published did not state what postoperative protocol was employed. There is no standardization of outcome measures, with less than 20% of papers using the most common validated outcome scoring system; in contrast, there is good agreement on the use of either the Tile (75%) or Burgess and Young (20%) classification.

Limitations

Due to the lack of published studies looking at the topic of postoperative weight-bearing after pelvic fractures, no specific recommendations are possible. As large numbers of papers were included, they were not individually assessed for bias.

Conclusion

A review of postoperative weight-bearing regimes reveals a nonexistent scientific evidence base from which to make recommendations, although a consensus strategy has been identified. Future research needs to be directed at this topic, as has already been the case in numerous other fracture areas, since the advantages of early mobility are potentially significant. The reported methodology for assessing and reporting patient outcomes after pelvic fracture surgery reveals no consistent standards, and the majority of papers use no specific outcome scoring system.

How to cite this article

Rickman M, Link B-C, Solomon LB. Patient Weight-bearing after Pelvic Fracture Surgery-A Systematic Review of the Literature: What is the Modern Evidence Base? Strategies Trauma Limb Reconstr 2019;14(1):45-52.

Single Modified Ilioinguinal Approach for the Treatment of Acetabular Fractures Involving Both Columns

OBJECTIVES

To report the technical aspects, radiographic results, and complications of a modified ilioinguinal approach for the treatment of bicolumnar acetabular fractures, especially involving the quadrilateral plate.

DESIGN

Retrospective review.

SETTING

Level I Trauma Center, Wuhan Union Hospital, China.

PATIENTS/PARTICIPANTS

Data from all acetabular fractures (n = 96) treated surgically were collected between January 2012 and June 2015. According to the exclusion criteria, 22 patients who had undergone a single supra-ilioinguinal approach with a minimum of 1-year follow-up were included in the study.

INTERVENTION

The supra-ilioinguinal approach was used to treat bicolumnar acetabular fractures by modifying the ilioinguinal approach, using the navel, anterior superior iliac spine, and the symphysis pubis as landmarks.

MAIN OUTCOME MEASUREMENTS

The surgical exposure and reduction of fractures is expected to become more direct and convenient, with shorter surgical time, less blood loss, and fewer complications.

RESULTS

Of the 22 consecutive patients, 5 were anterior column with posterior hemi-transverse, 11 were associated both column, 3 were transverse and 3 were T-type patterns. Average length of incision, operative time, and intraoperative blood loss were 10.7 ± 1.1 cm, 182 ± 40 minutes, and 793 ± 228 mL, respectively. Seventeen cases of the reductions were graded excellent; 4, good; and 1, poor. In the last follow-up, the Merle d 'Aubigné scores showed that 14 cases were excellent; 6, good; and 2, poor. Postoperative deep vein thrombosis occurred in 1 patient and lateral femoral cutaneous nerve injury in 3 patients.

CONCLUSIONS

For the treatment of bicolumnar acetabular fractures, the supra-ilioinguinal approach provides direct visualization and convenient access to the quadrilateral plate, and allows for appropriate reduction and fixation with few complications.

LEVEL OF EVIDENCE

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

The pararectus approach for internal fixation of acetabular fractures involving the anterior column: evaluating the functional outcome

Introduction

Aim of this retrospective analysis of prospectively collected data was to evaluate the functional mid-term outcome two years after open reduction and internal fixation of acetabular fractures involving the anterior column with affection of the quadrilateral plate using the pararectus approach on a large cohort.

Method

Fifty-two patients (12 female, 40 male) with a median age of 55 (range 18–90) years and displaced acetabular fractures involving the anterior column were surgically treated in a single level I trauma centre between July 2012 and February 2016 using the pararectus approach. Thirty-four patients (8 female and 26 male) with a median age of 58 (range 20–85) years were available for complete clinical follow-up at regular intervals, finally 24 months post-operatively. Functional outcome was evaluated according to modified Merle d’Aubigné score, Lower Extremity Functional Scale, WOMAC, and SF-36.

Results

Range of time between trauma and surgical treatment was three (range 0–19) days. Operation time was 140 (range 60–240) minutes, and duration of hospital treatment was 19 (range 7–38) days. Functional results in 34 patients available for final follow-up demonstrated 68 points (median; range 39–80) according to the Lower Extremity Functional Scale, 6% according to the WOMAC (mean; SD ± 14.5%), and 69% (mean; SD ± 20.1%) according to the SF-36. The modified Merle d’Aubigné score was excellent in 22 patients, good in eight patients, and fair in four patients.

Discussion/conclusion

Based on the good to excellent functional mid-term follow-up results of this study, the pararectus approach can be recommended as sufficient alternative single access to address displaced acetabular fractures involving the anterior column, independent of patients’ age.

Establishment of fluoroscopy views and standardized procedure of percutaneous magic screw insertion for acetabulum fractures

Background

To place the magic screw more simply, we established a set of reproducible fluoroscopic views and a standardized procedure of magic screw insertion.

Materials and methods

This study on the magic screw tunnel uses a three-dimensional reconstruction model and a skeleton projection. The 3D model of the pelvis was made to be transparent and it was rotated to the place where the ischial spine was just sheltered by the posterior wall of the acetabulum. The angles of this view projection were recorded in the transverse plane and coronal plane. Six cadaveric pelvises (three males, three female) were used to validate the proper projection angle of the C-arm fluoroscopy. The skeleton specimens were all positioned latericumbent on a radiolucent table.

Result

In all pelvis 3D models, all magic cylinders with a 7.3 mm diameter were successfully inserted along the bone structure tunnel in 30 3D pelvic models. The average angle of the transverse view rotated by the C-arm fluoroscopy was 162° in males and 157° in females, the angle of the coronal plane was 22° in males and 24° in females. The average distance between the front wheel of the C-arm machine and the middle axial line of the radiolucent bed was 43 cm in males and 43 cm in females. In skeleton pelvis research, all the screws were safely inserted using this method.

Conclusion

The magic screw technique could be a good choice for the treatment of acetabular fractures, especially quadrilateral plate fractures. If the proper fluoroscopy view technique is used properly, the magic screw can be inserted rapidly and safely.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of Fixation Techniques for Acetabular Fractures Involving the Anterior Column with Disruption of the Quadrilateral Plate: A Biomechanical Study

BACKGROUND

In elderly patients who have sustained an acetabular fracture involving disruption of the quadrilateral plate (QLP), postoperative loading of the joint beyond the level of partial weight-bearing can result in medial redisplacement of the QLP. The purpose of this biomechanical study was to compare the performances of 4 different fixation constructs intended to prevent medial redisplacement of the QLP.

METHODS

Anterior column posterior hemitransverse (ACPHT) fractures with disruption of the QLP were created on synthetic hemipelves (fourth-generation Sawbones models) and subsequently stabilized with (1) a 12-hole plate bridging the QLP (Group 1), (2) the plate with added periarticular screws along the QLP (Group 2), (3) the plate combined with an infrapectineal buttress plate (Group 3), or (4) the plate with the added periarticular screws as well as the buttress plate (Group 4). The point of load application on the acetabulum was defined to be the same as the point of application of maximum vertical hip contact force during normal walking. Loads were applied to simulate either partial weight-bearing (20 cycles, from 35 to 350 N) or inadvertent supraphysiologic loads (linearly increasing loads until the onset of failure, defined as fragment displacement of >3 mm). A universal testing machine was synchronized with a digital image correlation system to optically track redisplacement at the QLP. The level of significance was set at p < 0.05.

RESULTS

During experimental simulation of partial weight-bearing, maximum fracture step openings never exceeded 2 mm. During simulation of inadvertent supraphysiologic load, the median load to failure was higher (p < 0.05) in Group 2 (962 N; range, 798 to 1,000 N) and Group 4 (985 N; range, 887 to 1,000 N) compared with Group 1 (445 N; range, 377 to 583 N) and Group 3 (671 N; range, 447 to 720 N).

CONCLUSIONS

All 4 fixation constructs performed in an acceptable manner on testing with simulated partial weight-bearing. Only additional periarticular screws along the QLP increased the fixation strength.

CLINICAL RELEVANCE

Redisplacement of the QLP resulting in an incongruency of the hip joint has been associated with poor long-term outcomes. Within the constraints of this study, periarticular long screws were superior to infrapectineal buttress plates in preventing medial redisplacement of the QLP.

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.