MODIFIED STOPPA APPROACH FOR PELVIC AND ACETABULAR FRACTURE TREATMENT

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.

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.

Iatrogenic Bladder Rupture Resulting From the Modified Stoppa Approach for Acetabular Fracture: A Case Report

Iatrogenic bladder rupture is a rare yet serious complication associated with orthopedic surgical procedures, particularly those involving the modified Stoppa (MS) approach for acetabular fractures. We present a case of a 65-year-old patient who experienced iatrogenic bladder rupture during surgery for acetabular fracture fixation using the MS approach. Despite the challenges posed by this complication, prompt diagnosis and repair during the same surgical intervention led to favorable outcomes. Our case underscores the importance of perioperative vigilance in detecting and managing such injuries to mitigate the risk of urinary tract complications and late infections. Understanding the anatomical nuances and employing meticulous surgical techniques are essential for minimizing the risks associated with the MS approach.

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

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

Design and Application of an Acetabular Integrative Anatomic Plate: A Retrospective Study of 178 Cases with Complex Acetabular Fractures

OBJECTIVE

As conventional plates require repeated pre-bending during surgery with poor matching, this study aimed to explore the design and application of an acetabular integrative anatomical plate (AIAP) via the lateral-rectus approach (LRA) in fresh complex acetabular fractures for the good reduction and fixation.

METHODS

We designed an AIAP based on the anatomical morphology of the Chinese people. From March 2016 to September 2021, 178 patients with fresh complex acetabular fractures treated with an AIAP via the LRA were retrospectively analyzed. All patients were treated by the LRA under general anesthesia in a supine position. The fragments were well reduced and fixed by AIAPs. The operation time and intraoperative blood loss were recorded. All patients underwent reexamination of pelvic X-rays and CT scans and were followed up for over 1 year postoperatively. The reduction quality of fracture was evaluated according to the Matta criteria. The postoperative functional recovery was evaluated by modified Merle d'Aubigne-Postel scoring system. Statistics were analyzed by SPSS 25.0 (SPSS Inc., Chicago, IL, USA).

RESULTS

All 178 patients went through the operation successfully. The time from injury to operation ranged from 5 to 21 days (8.7 ± 2.6 days). The operation time ranged from 35 to 150 min (75 ± 29 min). The intraoperative blood loss was from 250 to 1400 ml (440 ± 153 ml). According to the Matta score, the fracture reduction was evaluated as excellent in 131 cases, good in 31 cases, and poor in 16 cases, with an overall excellent and good rate of 91%. Four patients suffered wound fat liquefaction and healed after fresh dressing. All patients were followed up for 1 to 5 years without wound infection. All fractures were healed. At the last follow-up, the modified Merle d'Aubigne-Postel score results were evaluated as excellent in 125 cases, good in 26 cases, and fair in 27 cases, with an overall excellent and good rate of 84.8%. Postoperative complications included six cases of traumatic arthritis of the hips and two cases of femoral head necrosis.

CONCLUSION

The LRA with an AIAP can help expose, reduce, and fix anterior and posterior columns as well as the quadrilateral area of the acetabulum, which is capable of improving the reduction quality of complex acetabular fractures and shortening surgical time and blood loss, thus reaching a good clinical efficacy.

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.

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.

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. 

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.