Modified Stoppa Approach Alone or in Combination with a Lateral Window for Acetabular Fractures Involving Both Columns

Introduction Acetabular fractures are intra-articular fractures involving the lower extremity's weight-bearing dome. These fractures require an anatomical reduction of the fracture fragments. This aim can be accomplished by the selection of an appropriate surgical approach. This study aimed to analyze the clinical and radiological outcomes of patients with fractures in the anterior part of the acetabulum who were treated by the modified Stoppa approach. Methods This prospective observational study was conducted from April 2022 to September 2023. The inclusion criteria were: (i) age between 18 and 70 years, (ii) displaced acetabular fracture (displacement > 3 mm), (iii) within three weeks of trauma (iv) acetabular fractures with involvement of anterior column. Exclusion criteria included: (i) patients with visceral injuries requiring colostomy, (ii) pathological fracture, (iii) open fractures of the acetabulum, and (iv) neglected fracture (more than three weeks). Intraoperative data regarding surgical time, amount of blood loss, and incidence of intraoperative complications were recorded. In the postoperative period, anteroposterior X-ray and Judet views of the pelvis X-ray were obtained. Matta criteria were used to judge the quality of Fracture reduction and fixation. All the patients to be included in this study had undergone a minimum follow-up duration of six months. At the last follow-up, an assessment of the functional outcome of the affected hip by Merle d'Aubigné Hip Score and Harris Hip Score was done. Results Twenty-four patients were included in the study. The mean patient age was 36.08±11.65 years. Eighteen patients were male (75%) and six patients were female in this study. All acetabular fractures were due to high-energy trauma: road traffic accidents in 22 cases (91%) and fall from height in two cases (9%). According to Judet & Letournel's classification, there were 13 T-type fractures, five transverse fractures, and six associated both column fractures. The mean duration of surgery was 152.08 ±29.19 minutes, and the mean intraoperative blood loss was 277.08±85.95 ml. Intraoperatively one unit of blood transfusion was done in most cases. There were intraoperative complications of rent in the external iliac vein in two patients. Postoperative X-rays showed anatomical reduction in 17 cases, imperfect reduction in five cases, and poor reduction in two cases. Functional outcome of the hip by Merle d'Aubigné Hip Score was very good in 15, good in four, fair in three, and poor in two patients. Similar functional outcomes were obtained with the Harris Hip Score. Conclusion The results of the current study demonstrated that the modified Stoppa approach allows good visualization of the pelvic brim, quadrilateral surface, and posterior column. Lesser experienced orthopedic surgeons should utilize this approach to get good radiological and functional outcomes.

: Acetabular fractures are commonly caused by high-velocity injuries that can result from falls from heights or motor vehicle accidents. Surgical fixation has been found to result in improved clinical outcomes such as reduced pain, improved range of motion, and improved alignment and stability of the joint. Patients with pelvic injuries often have associated multiple systemic injuries, adding to the overall morbidity and mortality. Treating fractures in the pelvic area involving the acetabulum can be complicated, significantly when displaced. Proper exposure of the acetabulum and rigid internal fixation is necessary to achieve the main goals of treatment, which are to reconstruct the articular surface and promote early mobilization. Closed methods make it nearly impossible to restore the articular surfaces completely and obtain enough stability for early hip motion.: This study assesses the functional outcome of open surgical fixation of acetabulum fractures involving single or both columns. : Our study looked at patients over 18 years old with displaced fractures, and we treated them using only two approaches: the Kocher Langenbeck approach and the Modified Stoppa approach. Radiological and functional examinations were performed monthly for the first six months. Postoperative radiological assessments were graded using Matta's criteria, and functional outcomes were assessed using modified Merle d' Aubigné and Postel Hip Score.: We treated displaced acetabular fractures using only two non-extensile approaches: the Kocher Langenbeck approach and the Modified Stoppa approach. In most cases (67%), we used only one method, except in 7 patients. Our treatment achieved an impressive 85% rate of good to excellent outcomes (18 out of 21). Our study found that the delay in surgery time significantly impacted Merle d' Aubigne scores (P<0.05), leading to complications and lower functional outcomes in complicated cases. The functional and radiological outcomes were also significantly affected by the mechanism of injury, time between injury and surgery, initial degree of displacement, and quality of reduction. Surgical fixation of displaced acetabular fractures can yield better results with good imaging facilities, experienced surgeons, better instrumentation, and good perioperative care. However, further studies with an adequate sample size are needed to validate our findings. A study on the outcome of acetabular fractures treated surgically found that early surgical intervention and good perioperative care can lead to satisfactory functional outcomes. The study used only two non-extensile approaches and achieved an 85% rate of suitable to excellent outcomes. The study also observed that the mechanism of injury, time between injury and surgery, initial degree of displacement, and reduction quality significantly affected functional and radiological outcomes. However, further studies are needed to validate the findings.

Introduction: Pelvis is important bony structure of body that provide main weight bearing surface for the hip joint in form of acetabulum, with the advancement of the high speed transportations, pelvic trauma has been raised in numbers so as acetabular fractures. Stable acetabular fractures fixation with accurate anatomic reduction always has been a big challenge for orthopaedic surgeons. Acetabular fractures fixation has risen step ahead after evolution of modified stoppa approach, as this approach allow minimum soft tissue handling, easy accessibility and provide adequate exposure to intrapelvic structures. Recently modified stoppa approach has evolved as primary approach for acetabular fractures fixation. AIM: To perform acetabulum fracture fixation through an optimum surgical exposure “modified stoppa approach” Materials And Method: this study conducted on 20 patients who presented with acetabular fractures after an RTA or fall from height or due to other various cause. Fracture fixation done through modified stoppa approach for those who met in our inclusion criteria ,to provide pelvic and hip joint stability. Patients demographics, location, duration from injury to surgical interventions, duration of hospital stay, if any complication occurred during surgery were recorded. Result: Out of total 20 patients 17 were male and 3 patients were female, average age 39year[Range from 18 to 60 yr], 12 patients having isolated unilateral acetabulum fracture present, 2 having bilateral acetabular fracture and 4 having associated pelvic bone fracture along with unilateral acetabulum fracture, 2 patients having long bone of lower limb fracture along with acetabular injury. All the fixation done through modified stoppa approach. Intraoperatively in all the patients easy accessibility and wide exposure obtain for intrapelvic structures. All the neurovascular structures easily identified and protected over the surgical site. Intraoperatively no clinical and radiological complication were observed in all patients. Post operatively all the patients were able to bear weight, within the 12±4 week,. Conclusion: We got a conclusion that the modified stoppa approach is anterior intrapelvic approach which provides an excellent view to the acetabular[anterior column, quadrilateral plate, posterior hemitransverse] and other intrapelvic structures, with minimal soft tissue handling, easy accessibility to preserve neurovascular structures. This approach provides direct access to the pubis, the posterior surface of the ramus, the quadrilateral surface, the pubic eminence, and the infrapectineal surface, as well as the sciatic buttress, sciatic notch, and the anterior sacroiliac joint. It can be used in most of the acetabular fractures fixation, the only downside is being the steep learning curve and familiarity of the structures while addressing these fractures. Keywords: Acetabulum, Acetabular fracture, Modified stoppa approach, quadrilateral plate.

IntroductionFractures of the acetabulum are inherently complex due to the anatomy of the innominate bones and also the presence of several vital neurovascular structures in the vicinity. Thus, the treatment of pelvic ring and acetabulum fractures is riddled with complexities and is considered among the most challenging surgeries for an orthopedic surgeon.When anterior access is necessary, such as in the anterior column, both columns, anterior column posterior hemitransverse, transverse, and T-type fractures, both the ilioinguinal and the anterior intrapelvic (AIP) or modified Rives-Stoppa methods are employed. The aim of this study is to compare the results from acetabular fractures treated with a modified Stoppa and ilioinguinal technique.Materials and methodsWe conducted a prospective cohort study to compare the outcomes of anterior acetabular fracture fixation using the modified Stoppa approach and the ilioinguinal approach. The outcomes measured were the amount of intraoperative bleeding, surgery duration, postoperative quality of fracture reduction, postoperative drain collection, and postoperative neurovascular status.The functional outcome was measured at three, six, and 12 months using the Merle d'Aubigné score. The radiological outcome was measured using the Matta scoring system.ResultsA significant difference was noticed in the two groups in the average blood loss and surgical duration, where the mean blood loss was 911.67 ± 143.05 ml in the ilioinguinal approach and 748.33 ± 165.30 ml in the modified Stoppa approach. While the ilioinguinal approach had a mean surgical duration of 190.33 ± 29.42 minutes, the modified Stoppa approach had 151.33 ± 23 minutes. The difference in postoperative fracture reduction in both groups was insignificant. The lateral femoral cutaneous nerve was compromised in 8.33% of cases in group A. The obturator nerve was compromised in 6.67% of cases in group B. The postoperative functional outcome was assessed by the modified Merle d’Aubigné score, and the radiological outcome was evaluated by the Matta score. The results obtained in both our study arms were comparable.ConclusionBased on our results, we can safely advocate the superiority of the Stoppa approach over a more extensive ilioinguinal approach. By virtue of being shorter in surgical duration and causing lesser blood loss, the Stoppa approach seems to be a better alternative, especially in elderly or polytrauma patients.As no difference was noted in the postoperative outcomes both clinically and radiologically, no approach showed superiority over the other in terms of patients’ eventual functional outcomes.

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. 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. 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. Merle d'Aubigne hip scores were very good in 55% (12 of 22), good in 9% (two of 22), medium in 18% (four of 22), fair in 5% (one of 22), and poor in 14% (three of 22), and 70% (23 of 33) of patients were able to ambulate without any assistive devices. Complications included one superficial infection and three deep infections, two patients with temporary lateral thigh numbness, no obturator nerve palsies, and one inguinal hernia. Three deaths in the cohort were seen in followup as a result of unrelated causes. Radiographic grading of fracture reductions after surgery revealed that 27 (75%) were anatomic, six (17%) were satisfactory, and three (8%) were unsatisfactory. A total of 94% of the fractures united. In agreement with prior published data, our results show good functional outcomes with minimal complications using the modified Stoppa approach for a variety of acetabular fractures. Our results highlight the difficulty but feasibility in treating posterior column displacement through an anterior approach. Consideration for dual approaches with posterior column involvement may be warranted to optimize fracture reduction and functional outcomes. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

IntroductionAcetabular 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 methodsPatients 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.ConclusionAdoption 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.

The aims of this study were to compare the patient and fracture characteristics, radiological, functional, and quality of life outcomes; the need for a lateral window approach and requirement of total hip arthroplasty; and complications in patients with simple and complex acetabular fractures who underwent a modified Stoppa approach through vertical and Pfannenstiel incisions. This was a retrospective comparison study. Level 1 trauma center. Patients with acetabular fractures (A-O-/-O-T-A type 62A-B-C) treated with vertical (group V) or Pfannenstiel (group P) incision-modified Stoppa approach between 2010 and 2020 were included. Patient characteristics, radiological evaluations (reduction quality and posttraumatic osteoarthritis), patient functional outcomes [12-item Short-Form Survey (SF-12) physical component score, SF-12 mental component score, Harris Hip Score, and Merle d'Aubigné-Postel], approach modifications and stratification by fracture type and complications were compared between those treated with vertical or Pfannenstiel incisions. One hundred four patients (mean age of 38.5 ± 14.3 years) were included. There was no significant difference between the Pfannenstiel or vertical groups regarding patient and fracture characteristics (P = 0.137), postoperative reduction quality (P = 0.130), or the mean functional and quality of life outcome scores at the last follow-up (P = 0.483 for the Harris Hip Score, P = 0.717 for the Merle d'Aubigné-Postel score, P = 0.682 for the SF-12 physical component score, and P = 0.781 for the SF-12 mental component score). In group P, significantly more patients needed additional lateral incisions (40.8% vs. 10.9%; P 0.001) and total hip replacement procedures (12.2% vs. 1.8%; P = 0.049). The total, early, and late complication rates were significantly higher in group P (P 0.001, P = 0.034, and P = 0.049, respectively). Pfannenstiel incision was associated with higher complication rates than vertical incision in acetabular fractures treated through a modified Stoppa approach. Fracture complexity is associated with the need for a lateral window approach and total hip arthroplasty, as well as a worse functional and radiological outcome regardless of incision type. However, it was not associated with the development of intraoperative or postoperative complications. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective To investigate the effectiveness of anterior fixation with an oblique-ilioischial plate for acetabular fractures of lower posterior column. Methods A consecutive series of 7 patients were retrospectively reviewed who had been treated operatively from August 2016 to July 2017 for acetabular fractures of lower posterior column. They were 4 men and 3 women, aged from 45 to 62 years (average, 48.6 years). The injury was caused by a traffic accident in 4 cases and by falling from a height in 3. By the Letournel-Judet classification, there were one case of transverse fracture, 3 cases of T-shaped fracture, 2 cases of anterior+posterior hemitransverse fracture and one case of associated both column fracture. The intervals from injury to operation ranged from 6 to 19 days (average, 7 days). All of them were treated by the modified Stoppa approach (or combined with an iliac fossa approach). The anterior column was stabilized with a reconstruction plate for the iliac wing along the iliopectineal line to the pubis in all cases. The lower posterior column was fixated with a newly developed oblique-ilioischial plate running from the ilium to the ischial ramus. Operative time, intraoperative blood loss, reduction quality and postoperative function of the affected hip were recorded. Results The operative time for this cohort ranged from 1.0 to 3.2 h (average, 2.1 h) and the intraoperative blood loss from 200 to 500 mL (average, 300 mL). The postoperative reduction was rated by the Matta's criteria as excellent in 5 cases, as good in one and as fair in one. This cohort was followed up for 7 months (from 6 to 9 months). At the final follow-up, the hip function was rated by the modified Merle d'Aubigne-Postel scale as excellent in 5 cases, as good in one and as fair in one. Fracture healing was achieved in all the patients after 3 to 6 months (average, 4.5 months). No implant failure, infection, heterotopic ossification or neurovascular injury occurred during the follow-up. Conclusion Anterior fixation with an oblique-ilioischial plate via the modified Stoppa approach or combined with an iliac fossa approach is a good treatment for acetabular fractures involving the lower column, due to its advantages of reliable fixation, limited invasion, little intraoperative bleeding and few complications. Key words: Acetabulum; Fractures, bone; Bone plates; Fracture fixation, internal; Surgical approach

Surgical management of an acetabular fracture in type- I osteogenesis imperfecta through a modified Stoppa approach - A case report and literature review

Treatment of superomedially displaced acetabular fractures including a quadrilateral surface (QLS) is challenging. We present a surgical technique using an anatomical suprapectineal QLS plate through the modified Stoppa approach and report the availability of this plate to treat this fracture type along with the surgical outcomes. Sixteen consecutive patients (14 men and 2 women) who underwent surgical treatment using an anatomical suprapectineal QLS plate through a modified Stoppa approach for superomedially displaced acetabular fractures between June 2018 and June 2020, were enrolled retrospectively. These fractures included 11 both-column fractures and 5 anterior-column and posterior hemitransverse fractures, which were confirmed on preoperative 3-dimensional computed tomography. Surgical outcomes were clinically assessed using the Postel Merle d’Aubigné (PMA) score and visual analog scale (VAS) score at the final follow-up, and radiological evaluations were performed immediately after the operation and at the final follow-up. For comparative analysis, 23 patients who underwent internal fixation with the conventional reconstruction plate through modified ilioinguinal approach between February 2010 and May 2018, were selected. This control group was composed of 18 both-column fractures and 5 anterior-column and posterior hemitransverse fractures. The follow-up period was at least 1 year in all patients. The mean operation time and blood loss was 109 min, and 853 ml, respectively, whereas 236 min, and 1843 ml in control group. Anatomical reduction was achieved in 14 (87.5%) patients, while imperfect reduction was achieved in the remaining 2 patients. At the final follow-up, radiographic grades were excellent, fair, and poor in 14 patients (87.5%), one, and one, respectively. The mean PMA score was 16.1 (range 13–18) and the mean VAS score was 1.0 (range 0–3). No secondary reduction loss or implant loosening was observed. However, 2 patients underwent conversion to total hip arthroplasty (THA) due to post-traumatic arthritis and subsequent joint pain. No other complications were observed. In the comparative analysis, radiological outcome showed a significant relationship with the conversion to THA (p = 0.013). Shorter operation time and less blood loss were significantly observed in the QLS plate fixation group through the modified Stoppa approach compared with the conventional reconstruction plate fixation group through modified ilioinguinal approach (p < 0.001, respectively). Simultaneous reduction and fixation using an anatomical suprapectineal QLS plate through the modified Stoppa approach may be a viable technique in superomedially displaced acetabular fractures along with shorter operation time and less blood loss.

Acetabular fractures with quadrilateral plate involvement form a heterogeneous group of fractures which are not specifically defined by any current classification system. Surgical treatment of these fractures poses a challenge to Orthopaedic surgeons. The aim of this study was to evaluate the efficacy, safety and outcomes of the fixation technique by using IRBP for acetabular fractures with quadrilateral plate involvement via single modified Stoppa approach.A total of 30 patients with acetabular quadrilateral plate fracture, selected between January 2016 to June 2019, were managed by IRBP via modified Stoppa approach. This was a prospective study and all patients were followed up to a minimum of 2 years. The primary outcome measures were reduction quality and functional outcome which were evaluated according to Matta’s radiological criteria and modified Merle d’Aubigné and Postel score respectively. Secondary outcomes were intra-operative conditions such as operative time and blood loss and post-operative complications.Anatomic reduction was obtained in 22 (73.3%), Imperfect in 6 (20%), and Poor in 2 (6.7%) cases. The modified Merle d’Aubigné and Postel score outcomes were Excellent to Good in 25 (83.3%) patients, Fair in 3 (10%), and Poor in 2 (6.7%) with the mean score being 16.07 ± 2.68. 21 (70%) patients did not have any complications. None of the cases had quadrilateral screws entering the hip joint.The use of IRBP system is an effective and safe choice for acetabular fractures with quadrilateral plate involvement done via modified Stoppa approach as it has low rate of complications, addresses multiple fractures of acetabulum through a single approach and provides good functional and radiological outcomes over long term.

IntroductionPelvis fractures are among the most difficult fractures to manage and treat for Orthopedic surgeons. Anatomic reduction is the main goal to reach in the acetabular fractures’ treatment. The following study compares clinical outcomes and complications of Ilioinguinal versus modified Stoppa approach in Open Reduction and Internal Fixation (ORIF) of anterior column acetabulum fractures. Materials and methodsA comparative analysis on 90 patients undergoing ORIF on acetabular fracture has been performed. Patients have been divided into two groups. The first group was treated by Ilioinguinal approach (n = 48), the second group by modified Stoppa approach (n = 42). The following parameters have been compareted: quality of fragment reduction; operative time; peri‑ and post-operative blood loss; complications; clinical and radiographic outcomes. ResultsThe modified Stoppa approach has shown a shorter mean operative time (146 min vs 175 min), fewer complications (14/48 vs 6/42), less blood loss both in the perio-operative phase (0.8 Hb pt vs 1.3 Hb pt) than in postoperative one (1.1 Hb pt vs 1.5 Hb pt), a lower rate of nerve, infections and critical complications. On the other hand, the ilioinguinal approach has showed better results in terms of quality of fracture reduction (43/48 patiens with anatomical or near anatomical reduction vs. 37/42). No significant differences concerning vascular lesions, clinical and functional outcomes have been found between the two groups. ConclusionsThe modified Stoppa approach results in shorter operative time, less intra-operative blood loss and fewer complications than the ilioinguinal one. Greater anatomic reduction is achieved by Ilioinguinal approach; however, this does not necessarily translate into better clinical and functional outcomes which, overall, are comparable in the two analysed approaches. In conclusion, the modified Stoppa approach is deemed to be a better alternative in treating these fractures.

Objective To evaluate the modified Stoppa approach in treatment of patients with pelvic and acetabular fractures. Methods We analyzed the outcomes of 26 consecutive patients with fractures of the pelvic ring and 9 patients with acetabular fractures who had been treated between March 2008 and December 2009 by open reduction and internal fixation through the modified Stoppa approach. The modified Stoppa approach was made through a low midline incision to fix the pelvis and acetabular fractures. By Tile classification, the 26 pelvic fractures included 2 cases of B1, 4 of B2, 7 of B3, 4 of C1-1, 2 of C1-2, 4 of C1-3, and 3 of C2. By Letournel classification, the 9 acetabular fractures included one case of anterior column, 3 transverse cases, 2 T type cases, one anterior column plus posterior transverse case, and 2 cases of both columns. For pelvic fractures, the modified Stoppa approach was used exclusively in 10 cases, in combination with the iliac fossa approach in 15 cases, and in combination with the posterior approach in one case. For acetabular fractures, the modified Stoppa approach was used exclusively in 3 cases, in combination with the Kocher-Langenbeck approach in 4 cases, and in combination with the Kocher-Langenbeck and iliac fossa approaches in 2 cases of both columns. Results The average operation time was 90 min (65 to 135 min)and the blood loss averaged 320 mL(150 to 1200 mL) in all but one patient with obsolete fracture of both columns. The reductions of the pelvic and acetabular fractures were all excellent and good. Twenty-two patients with pelvic fracture were accessible for an average follow-up of 4 months. Among them, one case of plate breakage and one case of screw loosening were found. Seven patients with acetabular fracture were accessible for an average follow-up of 4 months. One case of mild hip flexion and one case of ectopic ossification were found in them but there was no femoral head necrosis. Satisfactory functional results were achieved in the 29 cases that had been followed up. Conclusion The modified Stoppa approach may be used exclusively or in combination with other approaches to treat pelvic and acetabular fractures effectively, providing advantages of easy manipulation and a low complication rate. Key words: Pelvis; Acetabulum; Fracture; Surgical approach

Acetabular fractures pose a great surgical challenge for orthopedic trauma surgeons. We believe that the Stoppa approach with an iliac window extension, previously described as a modified Stoppa approach is adequate for the majority of acetabular fractures excluding those with predominant posterior wall involvement. In this paper we will present our experience in using the Stoppa approach, its indications, preparations, the detailed surgical approach, complications and the different tips used in this relatively modern approach. All simple and combined fracture types that involve the anterior column of the pelvis including the quadrilateral plate. Posterior wall or extensive posterior column involvement. Transverse and T-fractures with mainly posterior displacement. Suprapubic, intrapelvic approach, extending from the symphysis pubis anteriorly to the sacroiliac joint posteriorly. Superficial landmarks are identical to the Pfannenstiel approach, the rectus abdominis muscles are longitudinally dissected, the symphysis pubis is exposed and a sub-periosteal deep surgical dissection is carried out along the anterior column and the quadrilateral plate, and posteriorly toward the greater sciatic notch and the sacroiliac joint. In a 5-year review of 60 acetabular fractures that underwent open reduction and internal fixation using the modified Stoppa approach, there were 36% anterior column fractures, 28% both-column fractures, the rest being anterior column with posterior hemi transverse fractures, transverse and T-fractures. Any extension of the fracture to the iliac wing necessitated an additional lateral window (93% of cases). In cases with posterior displacement, an additional approach was utilized to address a posterior wall fracture. All fractures healed within 12weeks. Mean Merle d'Aubigné score was 15.22. Postoperative radiological evaluation revealed anatomical reduction in 54% of the patients, satisfactory in 43%, and unsatisfactory in 3% of the patients. Overall there were 15minor and major complications.

Introduction: Since acetabular fractures are intra-articular, accurate anatomic reduction is essential to achieve a good functional outcome. Among the various surgical approaches, ilioinguinal and modified Stoppa approaches are the only available intra-pelvic approaches. Even though ilioinguinal approach is more commonly used, modified Stoppa approach is becoming more popular due to the possibility of visualising and reducing quadrilateral plate fragments as well as fixation of posterior column through anterior approach. The aim of our study was to assess the efficacy of various reduction tools/ techniques for reduction and fixation of fractures operated using modified Stoppa approach. Materials and Methods: We have operated on 16 patients with acetabular fractures through modified Stoppa approach in the age group of 19 years to 70 years (mean 42 years) with male female ratio of 13:3. In patients requiring combined approach, the anterior approach was done first. In all the patients, modified Stoppa was combined with a lateral window. We have used various reduction techniques including transtrochanteric Schanz pin, intra-focal elevators, ball spike, bone hook, iliac crest Schanz pin, Farabeuf forceps, undercontoured plate, etc. Results: Matta’s radiographic reduction criteria showed anatomic reduction in 10 cases. Clinical assessment using Merle d’ Aubigne scoring showed excellent results in 9 cases and good results in 6 cases. Follow up was done for a maximum period of six months. Conclusion: Modified Stoppa approach provides better visualisation of quadrilateral surface and sciatic buttress when compared to the ilioinguinal approach. The use of appropriate reduction techniques helps in achieving good reduction of anterior column, at the same time provides opportunity to fix the posterior column from the anterior aspect using anterior to posterior column screws, obviating the need for a separate posterior approach. Keywords: Modified Stoppa, Acetabulum,