Minimally invasive plate osteosynthesis on anterior pelvic ring injury and anterior column acetabular fracture

Abstract

Introduction: In performing surgery for fractures of the pelvis and acetabulum, various surgical approaches have been introduced with their own advantages and drawbacks. The extensile nature of ilioinguinal approach gives excellent exposure but was related to wound healing problems. Modified stoppa has a higher difficulty and poses a risk for neurovascular injury. In this study, we elaborate our experience using the Modified Stoppa approach with additional lateral window while adding few modifications to simplify the procedure and facilitate future implant removal.

Methods: A prospective-retrospective cohort involving 30 anterior pelvic ring and/or anterior column acetabulum fracture patients were conducted from 2012-2016. Fifteen cases were prospectively treated using the modified approach since 2014, while the remaining fifteen cases that were treated using Ilioinguinal approach were retrospectively reviewed. Intraoperative parameters such as blood loss, duration of surgery, quality of reduction (Matta) and postoperative functional outcome (Majeed and Hannover score) at 12 months period were recorded and evaluated by a blinded reviewer.

Result: There were no significant differences between the two groups in mean age, sex and fracture type. The mean blood loss in the MIPO group were 325 ± 225 mL versus 710.67 ± 384.51 mL in the control group (p = 0.002). Duration of surgery were 149.33 ± 91.92 minutes in MIPO group versus 235.71 ± 65.79 minutes in ilioinguinal group (p = 0.014). There were no significant differences noted between the two groups in the quality of reduction and postoperative functional outcome, either by using Majeed or Hannover pelvic score. No complications were found after a 12-months follow up period. Two modified cases already had their implant removed and during the procedure, fibrotic tissue were minimal making the implant removal was less complicated and easier.

Conclusions: Modified stoppa and lateral window technique can be used as a safe and effective alternative approach for anterior pelvic ring fracture and/or anterior column acetabulum fracture. This approach decreased the duration of surgery and blood loss without compromising the quality of reduction and functional outcome in patients.

Keywords: Acetabular fracture; Anterior column; MIPO; Modified stoppa and lateral window; Pelvic fracture.

Fig. 1

A 36 years old male with unstable pelvic fracture, MT C3 Type right anterior column (a) Preoperative anteroposterior pelvic radiograph showing fracture of right superior and inferior pubic rami, left anterior column acetabular fracture, left sacral fracture and vertical instability of left hemipelvis; (b) 3D reconstruction CT Scan showing clearer image of the fracture pattern. (c) Modified Stoppa and lateral ilioinguinal approach, showing the extent of incision while leaving the second (middle) window intact; (d) Blunt finger dissection subperiosteally connecting the tunnel from both incisions; (e) postoperative anteroposterior pelvic radiograph showing satisfactory reduction of pelvic fracture and anatomical reduction of left anterior acetabular column.

Fig. 2

Indirect reduction using reduction tools. (a), Pelvic reduction clamp (b) ball and spike pusher (c) Post-fixation-illustration showing the modified Stoppa approach and final fixation of the reconstruction plate after indirect reduction.

Fig. 3

A 21 years old female with pelvic and acetabular fracture. (a) The anteroposterior radiograph showed that left acetabular anterior column fracture, superior and inferior right ramus pubis fracture, left iliac wing fracture. (b) Three dimensional CT reconstruction image shows the configuration of acetabular fracture and iliac wing more clearly; (c) Postoperative pelvis anteroposterior radiograph showing satisfactory reduction achieved in left acetabular fracture and satisfactory reduction on right superior pubic rami fracture using modified Stoppa and lateral window approach.

Fig. 4

A 47 years old male with pelvic Tile A fracture and urethra rupture. (a) Pelvic anteroposterior radiograph showing fracture at bilateral superior and inferior pubic rami, (b) Postoperative pelvic anteroposterior radiograph showing anatomical reduction of the fracture and symphisiolysis using modified Stoppa and lateral window approach (c) Follow-up after 1 year, showing a complete union at both of his pubic ramus. (d) Removal of the implant, second window was necessary to be opened, no fibrosis was found. (e) Post removal x-ray.