Treatment of Acetabulum Fractures Through the Modified Stoppa Approach: Strategies and Outcomes

Abstract

Background Since the original description by Letournel in 1961, the ilioinguinal approach has remained the predominant approach for anterior acetabular fixation. However, modifications of the original abdominal approach described by Stoppa have made another option available for reduction and fixation of pelvic and acetabular fractures. Questions/purposes We evaluated our results in patients with acetabulum fractures with the modified Stoppa approach in terms of (1) hip function as measured by the Merle d'Aubigne hip score; (2) complications; and (3) quality of fracture reduction and percentage of fractures that united. Methods Between September 2008 and August 2012, 289 patients with acetabular fractures were treated at our Level I trauma center. Twelve percent (36 of 289) of patients were treated operatively using the modified Stoppa approach. Ninety-seven percent (35 of 36) of our patients had fracture patterns involving displacement of the posterior column. Six (17%) were converted early to a total hip arthroplasty, and 14 (39%) were lost to final followup, leaving 22 of 36 for subjective clinical outcome analysis at a mean of 32 months (range, 9-59 months). Our general indications for this approach during the period in question were fractures of the anterior column and anterior wall, anterior column with posterior hemitransverse fractures, both column fractures, transverse fractures, and T-type fractures. Followup included regularly scheduled office visits with radiographs (AP pelvis, Judet views) that were graded by the treating surgeon and by the authors of this study (MJI, BCT) and patient outcome surveys.One of the authors (BCT) certifies that he, or a member of his immediate family, has or may receive payments or benefits, during the study period of less than USD 10,000 from DepuySynthes (DePuy Orthopaedics, Inc, Warsaw, IN, USA), Orthobullets.com for editorial staff services (Lineage Medical, LLC, Cambridge, MA, USA), and research grant support from Synthes and the Orthopaedic Trauma Association. One of the authors (BGF) certifies that he, or a member of his immediate family, has or may receive payments or benefits, during the study period of less than USD 10,000 from Biomet (Biomet, Inc, Warsaw, IN, USA) and is on the speakers' bureau for DepuySynthes. One of the authors (AP) certifies that he, or a member of his immediate family, has or may receive payments or benefits, during the study period of less than USD 10,000 from Biomet and Stryker (Kalamazoo, MI, USA). All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained. Results Merle d'Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22),...

Clinical results of acetabular fracture management with the Pararectus approach

“…In one patient, an additional significant femoral head impaction (previously identified as being a predictor of poor outcome -inter alia prosthetic replacement of the hip [3,6,7,38]) might have led to severe osteoarthritis requiring a total hip arthroplasty. The presented results agree with the literature in cases of utilisation of the modified Stoppa approach where the conversion rate to total joint replacement was reported to be in the range of 0-17% [9][10][11][12][13]15,17,19,21].…”

“…In these cases ''excellent'' or ''good'' clinical results at a minimum follow-up of one year are reported within the range of 63-89% [10][11][12][13]15,17,19,21]. The access morbidity in our series was acceptably low with only four (8%) minor intraoperative complications, one (2%) postoperative wound healing disorder and no postoperative hernias.…”

“…An extension of the approach was infrequently used (1st window ilioinguinal approach in 2%, mini-incision at the iliac crest in 21%) whereas the modified Stoppa approach was frequently used with the combination of the 1st window of the ilioinguinal approach [8] (55-93% [10,14,17,[19][20][21]) or others [9,13,15] described this combination as their standard procedure. Furthermore, the Pararectus approach allows (1) clear visualisation of the fracture without the need to change either the surgical window or the position, (2) access to the anterior wall, (3) secure access to the 2nd window, and facilitates (4) a skin incision in cases with suprapubic bladder catheters in situ (one patient in the presented series) or (5) various directions of posterior column screws without the need for an additional 1st window of the ilioinguinal approach.…”

“…However, the ilioinguinal approach might be suboptimal due to the access morbidity on account of the extended access. Therefore, others have reported the modified Stoppa approach as a less invasive alternative for the surgical access [9][10][11][12][13][14][15][16][17][18][19] Methods: Forty-eight patients (mean age 62 years, range: 16-98; 41 male) with displaced acetabular fractures involving the AC (AC: n = 9; transverse fracture: n = 2; AC and hemitransverse: n = 24; both column: n = 13) were treated between 12/2009 and 12/2011 using the Pararectus approach. Surgical data and accuracy of reduction (using computed tomography) were assessed.…”

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

“…As mentioned by Matta et al, [24] the main complication following a fracture of the acetabulum is post-traumatic osteoarthritis. The incidence of osteoarthritis in our series was 60.8%, which is considerably higher than that reported by Isaacson et al, [30] 52% and the 21.6% reported by Negrin et al, [31]. Iatrogenic nerve injury included sciatic nerve, femoral nerve and lateral cutaneous nerve of thigh are possible complication during acetabular surgery.…”