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

Clinical efficacy and psychological influence of lateral rectus approach for treating pelvic fracture with lumbosacral plexus injury

BACKGROUND

The surgical treatment of pelvic fractures is challenging, particularly after lumbosacral plexus injuries. Such impairments affect a patient's physiological function and can cause significant mental health problems. In recent years, the new transrectus lateral approach has favorably treated pelvic fractures and possibly preserved patients' physiological and psychological conditions. Therefore, investigating its clinical efficacy for treating pelvic fractures plus lumbosacral plexus injuries is of great clinical significance.

AIM

To investigate the clinical effect of the transrectus lateral approach on pelvic fractures complicated by lumbosacral plexus injuries as well as anxiety and depression.

METHODS

Data of 136 patients with pelvic fractures complicated by lumbosacral plexus injuries treated by the transrectus lateral approach (January 2011 to May 2024) were retrospectively analyzed. The patients' general data were collected via questionnaire. The Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) were used to assess anxiety and depression, respectively. We adopted a numerical rating scale (NRS) to evaluate pain degree, the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, and Medical Research Council (MRC) Scale for Muscle Strength to evaluate treatment efficacy and complications.

RESULTS

The 136 included patients (92 male, 44 female) were a mean 48.02 ± 15.72 years old. The mean SAS score was 66.36 ± 5.15 preoperatively vs 42.15 ± 4.36 postoperatively, while the mean SDS score was 65.61 ± 5.02 preoperatively vs 43.83 ± 4.54 postoperatively, showing statistically significant differences (P < 0.05). The mean NRS and PSQI scores were significantly lower pre- vs postoperatively (P < 0.05). Postoperatively, 67 patients with fresh pelvic fractures plus nerve injuries achieved an MRC of M5, 22 achieved an M1-M4, and four achieved an M0. Postoperative motor function improved by a mean 4.20 grades (scale, 0-5). Among the patients with old pelvic fractures and nerve injuries, 19 achieved an M5, 16 achieved an M1-M4, and eight achieved an M0. Motor function improved significantly by a mean 3.30 grades (scale, 0-5; P < 0.05). No serious postoperative complications occurred.

CONCLUSION

The transrectus lateral approach to treating pelvic fractures plus lumbosacral plexus injuries can safely alleviate anxiety and depression, relieve pain, improve sleep quality, reduce intraoperative blood loss, and improve postoperative recovery.

Developing a core outcome set for acetabular fractures: a systematic review (part I)

BACKGROUND

There are indications that clinical studies investigating the surgical treatment of acetabular fractures assess different outcomes. This heterogeneity reduces the comparability of study results and, thus, limits the knowledge generated from research. Core outcome sets (COS) contain a minimum set of outcomes that should be measured in studies investigating a specific disease or injury. A COS for surgically treated acetabular fractures does not yet exist. Therefore, the aim of this study is to identify the reported outcomes in studies investigating the surgical treatment of acetabular fractures.

METHODS

Studies including skeletally mature individuals (≥ 16 years) with isolated acetabular fractures treated surgically were included. Studies with polytrauma patients, pathological fractures, additional pelvic fractures, exclusively non-surgical treatment, or juvenile individuals were excluded. Three databases and two clinical trial registries were searched on 15 November 2022. The identified outcomes were grouped and subsequently categorized according to the Core Outcome Measures in Effectiveness Trials Guidelines.

RESULTS

A total of 193 studies were included, which reported a cumulative total of 2581 outcomes. After grouping, 266 unique outcomes were identified. No outcome was examined in all studies. Pain, ability to walk independently, range of motion, quality of reduction, and heterotopic ossification were the most reported unique outcomes and assessed in at least 60% of included studies. A total of 105 outcomes were only assessed in one of the included studies. Outcomes of all five core areas and 25 outcome domains of the Core Outcome Measures in Effectiveness Trials taxonomy were examined. Furthermore, outcomes were named and defined differently, measured at different time points, and assessed using a variety of measurement instruments.

CONCLUSION

Overall, this systematic review shows that a wide range of outcomes are measured in studies examining surgical treatment of acetabular fractures. The results of this systematic review will be used in a subsequent study to develop the COS for surgically treated acetabular fractures by using the Delphi method.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022357644; COMET: 2123.

Comparative evaluation and ranking of anterior surgical approaches for acetabular fractures: A systematic review and network meta-analysis

BACKGROUND

To compare the outcome of pararectus, ilioinguinal, and intrapelvic approaches in patients with acetabular fracture and to rank the best, second best, and third best surgical approach.

METHODS

A literature search was conducted in PubMed, Epistemonikos, and Embase up to 30 November 2024. A network meta-analyses was conducted to assess the outcomes of pararectus, ilioinguinal, and intrapelvic surgical approaches. Random-effects models with mean differences (MDs) and odds ratios (ORs) were calculated for continuous and binary variables, respectively, all with 95 % confidence intervals (CIs).

RESULTS

A total of 30 primary studies (2,348 patients) were included. There was no statistically significant difference between the pararectus and intrapelvic approach in overall complications (OR 0.86, 95 % CI 0.47 to 1.58). The pararectus approach had 0.51 lower odds for overall complications compared with the ilioinguinal approach (OR 0.51, 95 % CI 0.28 to 0.94). The intrapelvic approach had 0.59 lower odds for overall complications compared with the ilioinguinal approach (OR 0.59, 95 % CI 0.37 to 0.94). There was no statistically significant difference between the pararectus and intrapelvic approach in reduction quality (OR 1.32, 95 % CI 0.89 to 1.95). The pararectus approach had 2.02 higher odds for reduction quality compared with the ilioinguinal approach (OR 2.02, 95 % CI 1.30 to 3.15). The intrapelvic approach had 1.53 higher odds for reduction quality compared with the ilioinguinal approach (OR 1.53, 95 % CI 1.12 to 2.10). There was no statistically significant difference between the pararectus and intrapelvic approach in intraoperative blood loss (MD -31.38, 95 % CI -105.62 to 42.85). The pararectus approach had a 207.35 mL lower intraoperative blood loss compared with the ilioinguinal approach (MD -207.35, 95 % CI -288.52 to -126.18). The intrapelvic approach had a 175.97 mL lower intraoperative blood loss compared with the ilioinguinal approach (MD -175.97, 95 % CI -233.51 to -118.42).

CONCLUSION

This is the first study to rank the three anterior surgical approaches for acetabular fractures. The findings establish that while the pararectus and intrapelvic approaches are comparable, the ilioinguinal approach ranks third. The superior outcomes of the pararectus and intrapelvic approaches in complications, operative efficiency, and reduction quality highlight their importance in surgical practice.

Comparative analysis of surgical approaches in acetabular fractures: Blood loss and procedural efficiency

Background

Acetabulum fractures pose significant challenges in orthopedic trauma due to anatomical complexity and the potential for iatrogenic injury to surrounding structures. The study aims to compare the outcomes of two surgical approaches, the ilioinguinal approach (IA) and the modified Stoppa approach (MSA), in managing acetabular fractures.

Methods

A retrospective cohort study was conducted on 50 patients with anterior acetabular fractures. Demographic characteristics and perioperative data were collected, and the patients were categorized based on the applied surgical approach, either IA or MSA. Statistical tests were used for data analysis.

Results

The MSA group showed significantly lower intraoperative blood loss compared to IA (MSA: 404.36 ± 151.94 ml, IA: 650.92 ± 136.33 ml, Δ = 246.56 ml, P < 0.001). The mean procedure duration for MSA was 141.88 ± 27.12 min, compared to 172.24 ± 32.69 min for IA (P = 0.37). The incidence of soft tissue infection (MSA: 8 %, IA: 8 %) and sciatic nerve injury (both 0 %) exhibited no significant differences (P > 0.99). Postoperative assessments, Harris Hip Scores (MSA: 90.08 ± 6.26, IA: 89.29 ± 6.64, P = 0.66) and Modified Merle d'Aubigné Scores (MSA: 14.86 ± 1.37, IA: 15.23 ± 1.16, P = 0.40), showed no substantial variance between groups.

Conclusion

The study suggests that the MSA approach demonstrated superiority, particularly due to significantly less intraoperative blood loss. Further comprehensive studies are recommended to validate and generalize these findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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".

Decellularization of various tissues and organs through chemical methods

Due to the increase in demand for donor organs and tissues during the past 20 years, new approaches have been created. These methods include, for example, tissue engineering in vitro and the production of regenerative biomaterials for transplantation. Applying the natural extracellular matrix (ECM) as a bioactive biomaterial for clinical applications is a unique approach known as decellularization technology. Decellularization is the process of eliminating cells from an extracellular matrix while preserving its natural components including its structural and functional proteins and glycosaminoglycan. This can be achieved by physical, chemical, or biological processes. A naturally formed three-dimensional structure with a biocompatible and regenerative structure is the result of the decellularization process. Decreasing the biological factors and antigens at the transplant site reduces the risk of adverse effects including inflammatory responses and immunological rejection. Regenerative medicine and tissue engineering applications can benefit from the use of decellularization, a promising approach that provides a biomaterial that preserves its extracellular matrix.

Comparison of the MIPPO technique and the modified Stoppa approach in the treatment of unstable anterior pelvic ring injuries: a retrospective cohort study

BACKGROUND

Anterior pelvic ring injuries have gradually become common. Using a minimally invasive technique to treat this injury may be feasible if the reduction and stability can be effectively achieved. We describe a percutaneous technique, minimally invasive percutaneous plate osteosynthesis (MIPPO), to fixate the anterior pelvis via establishing a subperiosteal tunnel between two limited incisions over the iliac crest(s) and pubic ramus in this research.

METHODS

A retrospective cohort study comparing the MIPPO technique (n = 60) versus the modified Stoppa approach (n = 53) for anterior pelvic ring injuries with posterior ring instability was performed from September 2016 to January 2023. The relative surgery variables, follow-up function evaluation, and complications were compared in two groups. The reduction quality of fracture was assessed according to the Matta criterion, and the functional score was evaluated using the Majeed score.

RESULTS

All patients completed follow-up, with an average interval of 39.90 ± 17.53 months (range 12-78). In the MIPPO technique group, the surgery interval and blood losses were lower compared to the modified Stoppa approach group (P<0.05). The mean procedure times and intraoperative blood losses were 69.56 ± 14.04 min/side (range 50-110) and 156.23 ± 49.75 mL/side (range 90-250) for unilateral anterior ring MIPPO fixation separately. All patients got a satisfactory reduction of the fracture. In the follow-up, earlier ambulation, shorter postoperative hospital stays, and lower complication rates were observed for patients using the MIPPO technique compared to the modified Stoppa approach (P<0.05). However, there is no statistical difference in these indicators including fracture union interval, full load time, the Majeed score, patient satisfaction level, and return to pre-injured work rate between the two groups.

CONCLUSION

This clinical experience gives support for the use of the MIPPO technique to stabilize the anterior pelvis. This minimally invasive technique was an effective and safe surgery method and could obtain satisfactory function results, particularly fitting to part of patients with resistance using the modified Stoppa approach.

Quadrilateral plate classification program of acetabular fractures based on three-column classification: a three-dimensional fracture mapping study

BACKGROUND

A new classification system for acetabular fractures has been proposed in recent years, which is called the 3-column classification. However, this system does not provide information regarding quadrilateral plate fractures. To address this issue, we utilized three-dimensional (3D) fracture line mapping and heat map to analyze the link between the 3-column classification and quadrilateral plate fractures.

METHODS

We collected CT scan data from 177 patients who had been diagnosed with acetabular fractures. Additionally, we utilized a CT scan of a healthy adult to generate a standard acetabular model. We utilized the collected CT data of the fracture to create a 3D model and subsequently reduced it. We then matched each acetabular fracture model with the standard acetabular model and mapped all of the fracture lines to the standard model. 3D fracture lines and heat maps were created by overlapping all fracture lines. Fracture characteristics were then summarized using these maps.

RESULTS

This study analyzed a total of 221 acetabular fractures. The most frequently observed fracture type, based on the three-column classification, was A1.2, which corresponds to fractures of the anterior column. In contrast, the least common type of fracture was A4, which represents fractures of the central wall. It was noted that quadrilateral plate fractures were frequently observed in fractures classified as type B and C according to the three-column classification.

CONCLUSIONS

Among the three-column classification, the QLP fractures are commonly observed in type B and C. It is important to carefully identify these fractures during the diagnostic process. Therefore, based on the three-column classification, we have amalgamated quadrilateral plate fractures and formulated a classification program for acetabular fractures.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical and Radiological Outcomes of Patients With Anterior Acetabulum Fractures Treated by the Modified Stoppa Approach

Introduction Acetabular fractures are intra-articular fractures involving the lower extremity's weight-bearing dome. These fractures require an anatomical reduction of the fracture fragments. This aim can be accomplished by the selection of an appropriate surgical approach. This study aimed to analyze the clinical and radiological outcomes of patients with fractures in the anterior part of the acetabulum who were treated by the modified Stoppa approach. Methods This prospective observational study was conducted from April 2022 to September 2023. The inclusion criteria were: (i) age between 18 and 70 years, (ii) displaced acetabular fracture (displacement > 3 mm), (iii) within three weeks of trauma (iv) acetabular fractures with involvement of anterior column. Exclusion criteria included: (i) patients with visceral injuries requiring colostomy, (ii) pathological fracture, (iii) open fractures of the acetabulum, and (iv) neglected fracture (more than three weeks). Intraoperative data regarding surgical time, amount of blood loss, and incidence of intraoperative complications were recorded. In the postoperative period, anteroposterior X-ray and Judet views of the pelvis X-ray were obtained. Matta criteria were used to judge the quality of Fracture reduction and fixation. All the patients to be included in this study had undergone a minimum follow-up duration of six months. At the last follow-up, an assessment of the functional outcome of the affected hip by Merle d'Aubigné Hip Score and Harris Hip Score was done. Results Twenty-four patients were included in the study. The mean patient age was 36.08±11.65 years. Eighteen patients were male (75%) and six patients were female in this study. All acetabular fractures were due to high-energy trauma: road traffic accidents in 22 cases (91%) and fall from height in two cases (9%). According to Judet & Letournel's classification, there were 13 T-type fractures, five transverse fractures, and six associated both column fractures. The mean duration of surgery was 152.08 ±29.19 minutes, and the mean intraoperative blood loss was 277.08±85.95 ml. Intraoperatively one unit of blood transfusion was done in most cases. There were intraoperative complications of rent in the external iliac vein in two patients. Postoperative X-rays showed anatomical reduction in 17 cases, imperfect reduction in five cases, and poor reduction in two cases. Functional outcome of the hip by Merle d'Aubigné Hip Score was very good in 15, good in four, fair in three, and poor in two patients. Similar functional outcomes were obtained with the Harris Hip Score. Conclusion The results of the current study demonstrated that the modified Stoppa approach allows good visualization of the pelvic brim, quadrilateral surface, and posterior column. Lesser experienced orthopedic surgeons should utilize this approach to get good radiological and functional outcomes.

Comparison of clinical effects of two surgical approaches in the treatment of acetabular fractures

Objective

To determine the clinical effect of lateral rectus abdominis approach and modified Stoppa approach for the surgical treatment of acetabular fractures.

Methods

A retrospective analysis was performed on the case data of 30 patients with acetabular fractures admitted to the Department of Orthopaedics of Hengshui City People's Hospital from June 2017 to June 2021. According to the surgical methods, the enrolled patients were divided into the lateral rectus abdominis approach group (observation group) and the modified Stoppa approach group (control group), with 15 patients in each group. Further comparison was made on the incision length, operation time, intraoperative blood loss, length of stay in the hospital, fracture reduction, hip joint function, neurological recovery, and postoperative complications between the two groups.

Results

There was no significant difference between the two groups in the length of stay in the hospital, hip joint function score, fracture reduction quality, and excellent-to-good rate of hip joint function (p>0.05). There were significant differences in incision length, intraoperative blood loss, operation time, postoperative motor and touch function scores, and postoperative complication rate between the observation group and the control group (p<0.05).

Conclusion

The clinical effect of the lateral rectus abdominis approach is close to that of the modified Stoppa approach for the surgical treatment of acetabular fracture patients. However, and importantly, surgery through the lateral rectus abdominis approach has less trauma, shorter operation time, lower surgical complications, and good postoperative functional recovery.

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

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

Drain vs. no-drain for acetabular fractures after treatment via a modified stoppa approach: A retrospective study

OBJECTIVE

The aim of this study was to compare the clinical efficacy of close suction drainage (CSD) and no-CSD after a modified Stoppa approach for the surgical fixation of acetabular fractures.

METHODS

This retrospective study included 49 consecutive acetabular fracture patients, who presented to a single level I trauma center for surgical fixation, using a modified Stoppa approach from January 2018 to January 2021. All surgeries were performed by a senior surgeon using the same approach, and the patients were divided into two groups based on whether CSD was used after the operation. Details of the patient demographics, fracture characteristics, intraoperative indicators, reduction quality, intra and postoperative blood transfusion, clinical outcomes, and incision-related complications were collected.

RESULTS

No significant differences were found in the demographics, fracture characteristics, intraoperative indicators, reduction quality, clinical outcomes, and incision-related complications between the two groups (P > 0.05). The use of CSD was associated with a significantly higher postoperative blood transfusion volume (P = 0.034) and postoperative blood transfusion rate (P = 0.027). In addition, there was a significant difference in postoperative temperatures, especially on postoperative Day 2 (no-CSD 36.97 ± 0.51°C vs. CSD 37.34 ± 0.69°C, P = 0.035), and higher visual analogue scale (VAS) scores, especially on postoperative Day 1 (no-CSD 3.00 ± 0.93 vs. CSD 4.14 ± 1.43, P = 0.002) and 3 (no-CSD 1.73 ± 0.94 vs. CSD 2.48 ± 1.08, P = 0.013).

CONCLUSION

The results of this study suggest that routine use of CSD should not be recommended for patients with acetabular fractures after surgical fixation using a modified Stoppa approach.

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.

Sciatic nerve injury after acetabular fractures: a meta-analysis of incidence and outcomes

PURPOSE

To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated.

METHODS

PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted.

RESULTS

Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively.

CONCLUSION

A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve.

Clinical Outcomes of the Modified Stoppa Combined with Iliac Fossa Approach for Complex Acetabular Fractures: A Medium- and Long-term Retrospective Study

Objective

The modified Stoppa combined with iliac fossa approach has gained increasing popularity. Although early clinical outcomes have been satisfactory, extensive long‐term clinical outcomes are relatively scarce. The purpose of this study was to evaluate the medium‐ and long‐term outcomes of this approach for complex acetabular fractures.

Methods

This was a retrospective study involving 57 patients with complex acetabular fractures from January 2009 to January 2016. All fractures were treated with the modified Stoppa combined with iliac fossa approach. Follow‐up was at least 5 years. Primary outcome measures, including quality of reduction and clinical outcomes, were recorded by an independent observer. Secondary outcome measures included time to surgery, surgical time, intraoperative blood loss, and perioperative complications.

Results

Fifty‐seven patients (range, 18–80 years) included 46 males and 11 females. There were 32 cases on the left side and 25 cases on the right side. The most common associated injury was pulmonary contusion. According to the Judet–Letournel classification, there were 27 both‐column fractures, 16 anterior column with posterior hemitransverse fractures and 14 T‐type fractures. The average time from injury to surgery was 7.3 days. The average intraoperative blood loss and transfusion were 750.9 ml and 564.3 ml, respectively. All fractures healed within 6 months after surgery. The average follow‐up time was 7.7 years, and there was no loss of follow‐up. The quality of reduction was graded as anatomical in 23 cases (40.4%), imperfect in 22 cases (38.6%), and poor in 12 cases (21.0%). According to grading system of Merle d’ Aubigne and Postel, clinical outcomes at 1 year follow‐up were excellent in 17 cases (29.8%), good in 25 cases (43.9%), fair in four cases (7.0%), and poor in 11 cases (19.3%). The excellent and good rate was 73.7% and the difference was not statistically significant compared with the clinical outcomes at the last follow‐up. Intraoperative complications included four cases of obturator nerve injury and two cases of vascular injury. Postoperative complications included one case of wound delayed healing, two cases of deep vein thrombosis, two cases of avascular necrosis of femoral head, three cases of heterotopic ossification and five cases of post‐traumatic arthritis. Only one of these patients underwent reoperation for femoral head necrosis.

Conclusions

The modified Stoppa combined with iliac fossa approach can achieve satisfactory reduction quality and hip function. It might be a valuable alternative to the ilioinguinal approach for the surgical management of acetabular fractures.

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

BACKGROUND

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION

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

LEVEL OF EVIDENCE

III.

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

Objective

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

Methods

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

Results

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

Conclusion

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

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.