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

Abstract

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.

Keywords: Complex acetabular fracture; Follow-up; Iliac fossa approach; Modified Stoppa approach; Open reduction and internal fixation.

Fig. 1

Schematic diagram illustrating some key surgical steps and techniques. (A) The red line represented the incision of the mS + IF approach. (B) This diagram showed the anatomical location of the corona mortis. As soon as the corona mortis was encountered, it was ligated immediately. (C) The numbers 1, 2, and 3 represented the three main fragments, with 1 being the first to be reduced, followed by 2, and finally 3. (D) The manipulation of the critical fragments was accomplished by a number of reduction devices, such as a ball‐spiked pusher, acetabular reduction forceps

Fig. 2

(A–E) A 44‐year‐old male patient sustained a road‐traffic accident. Preoperative radiographs and three‐dimensional reconstructions showed a both‐column fracture. (F–H) Immediate postoperative radiographs showed satisfactory reduction was obtained by the mS + IF approach. (I–L) Gross appearance and postoperative radiographs at 8 years of follow‐up showed the patient had a good functional hip outcome

Fig. 3

(A–E) A 41‐year‐old female patient sustained a road‐traffic accident. Preoperative images suggested a both‐column fracture. (F–H) Immediate postoperative radiographs showed satisfactory reduction by the mS + IF approach. (I‐K) No complications such as traumatic osteoarthritis and necrosis of femoral head were found in 5 years follow‐up