Short-term results of surgical treatment of acetabular fractures using the modified Stoppa approach

Abstract

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.

Keywords: Acetabular fractures; Acetabulum; Anterior column; Modified stoppa approach.

Fig. 1

The intra-operative pictures, of one among our patients demonstrating. a) An arc-shaped transverse, Pfannenstiel skin incision of 5–6 inches/12–15 cm made about 2 cm proximal to the pubic symphysis. b) Superficial exposure: subcutaneous tissues, rectus fascia, rectus abdominus muscle and transfersalis facia split over the symphysis pubis. c) Deep exposure: insertion of the rectus abdominus muscle, the iliopectineal fascia and the iliopsoas muscle released and elevated for adequate exposure of the true pelvis by appropriate placement of retractors. Increased visualisation assisted by the light source from the arthroscopy unit. d) Corona mortis clipped (arrows) to allow further access to the pelvic brim and the quadrilateral surface. e) Isolation of the obturator neurovascular bundle, medial to the obturator internus, and then sheltered by a malleable retractor. f) To retract the rectus musculature, a Hohmann retractor is placed on the pubic tubercle. A Deaver retractor is positioned under the iliopsoas muscle to protect the external iliac vascular bundles. A slender malleable retractor is positioned at the sciatic notch to protect the obturator neurovascular bundle.

Fig. 2

Preoperative (Fig. 2 a, b, c) and postoperative (Fig. 2 d, e, f) radiographs demonstrating a fixation of a transverse acetabular fracture using the modified Stoppas’ approach with indirect reduction using posterior column screws from the anterior side Pre- and postoperative (Fig. 2 g, h) NCCT scans of the same patient..

Fig. 3

Preoperative (Fig. 3 a, b, c) and postoperative (Fig. 3 d, e, f) radiographs representing the reduction by double plating technique; one each, on the pelvic brim and the quadrilateral plate. Pre- and post-operative (Fig. 3 g, h) NCCT scans of the same patient.