Stoppa Approach For Acetabular Fractures Research Articles

Traitement des fractures de l’acetabulum atteignant la lame quadrilatère : comparaison des voies ilio-inguinales et de Stoppa

BackgroundAcetabular fractures with quadrilateral plate (QLP) involvement have traditionally been treated by buttress plates applied through an Ilio-inguinal approach. Recently, many surgeons prefer the application of infra-pectineal plates through the modified Stoppa approach for this purpose. Whether one method can be preferred over the other is a matter of investigation. HypothesisThe research question was whether an infra pectineal plate applied through the modified Stoppa approach for acetabular fractures with QLP involvement would result in an equivalent or better outcome than a buttress plate applied through an ilioinguinal approach. Patients and methodsThis was a retrospective study of patients with QLP fractures operated by either of the two methods and who had completed at least one year follow up. Demographic and surgical details and the radiological and clinical outcomes at the last follow-up visit were obtained from patient records. ResultsForty one patients were treated with a buttress plate applied through an ilioinguinal approach (group A), and 49 patients were treated with an infra-pectineal plate by the modified Stoppa approach (group B). Duration of surgery and intra-operative blood loss was significantly less in group B patients. Radiological and clinical outcomes were better in group B patients than group A patients. Implant loosening was more frequent in group A patients. Injury to the obturator vessels were more common in group B patients. ConclusionWith a comparatively lesser surgical duration and blood loss, better clinical and radiological outcomes at least one year after the surgery, an infra-pectineal plate applied through the modified Stoppa approach can be considered the preferred treatment for most acetabular fractures with QLP involvement. Level of evidenceIII.

Treatment of acetabular fractures with quadrilateral plate injury – a comparison of two commonly used methods

BackgroundAcetabular fractures with quadrilateral plate (QLP) involvement have traditionally been treated by buttress plates applied through an Ilio-inguinal approach. Recently, many surgeons prefer the application of infra-pectineal plates through the modified Stoppa approach for this purpose. Whether one method can be preferred over the other is a matter of investigation. HypothesisThe research question was whether an infra pectineal plate applied through the modified Stoppa approach for acetabular fractures with QLP involvement would result in an equivalent or better outcome than a buttress plate applied through an ilioinguinal approach. Patients and MethodsThis was a retrospective study of patients with QLP fractures operated by either of the two methods and who had completed at least one year follow up. Demographic and surgical details and the radiological and clinical outcomes at the last follow-up visit were obtained from patient records. ResultsA total of 41 patients were treated with a buttress plate applied through an ilioinguinal approach (group A), and 49 patients were treated with an infra-pectineal plate by the modified Stoppa approach (group B). Duration of surgery and intra-operative blood loss was significantly less in group B patients. Radiological and clinical outcomes were better in group B patients than group A patients. Implant loosening was more frequent in group A patients. Injury to the obturator vessels were more common in group B patients. ConclusionWith a comparatively lesser surgical duration and blood loss, better clinical and radiological outcomes at least one year after the surgery, an infra-pectineal plate applied through the modified Stoppa approach can be considered the preferred treatment for most acetabular fractures with QLP involvement. Level of evidenceIII.

Lésion du nerf obturateur dans la voie d’abord de Stoppa modifiée pour fracture de l’acetabulum

IntroductionThe modified Stoppa approach for acetabular fractures has become popular. However, the possibility of injury to the obturator nerve with this approach has not been sufficiently considered. We have experienced a case of nerve entrapment in severely displaced fractures. Therefore, we performed a retrospective study to: (1) evaluate the incidence of obturator nerve injury in the modified Stoppa approach for acetabular fractures, (2) analyze the relationship between the extent of displacement of the quadrilateral plate and injury to the obturator nerve. HypothesisWe hypothesized that obturator nerve injury would be related to a marked medial displacement of the quadrilateral plate. Patients and methodsWe conducted a retrospective cohort study of 22 patients with acetabular fractures that were surgically treated with the modified Stoppa approach. The medial displacement of the quadrilateral plate was measured on a three-dimensional reconstruction image with the inlet view. Postoperative electrodiagnostic tests were performed based on clinical suspicion of neurological injury. Nerve injuries were divided into initial trauma or postoperative complication, and recovery of nerve function was evaluated. We identified the incidence of obturator nerve injury and analyzed the relationship between obturator nerve injury and medial displacement of the quadrilateral plate. ResultsThe incidence of obturator nerve injury was 2/22 (9.1%), and all injuries resulted from the initial trauma. The average displacement of the quadrilateral plate was 15.9±13.4mm. Patients were divided into two groups, using a displacement of 24mm as a cutoff point, identified using a receiver operating characteristic curve analysis. There were 16 patients in group 1 (<24mm) and 6 patients in group 2 (≥24mm). The incidence of obturator nerve injury from trauma was 0/16 (0%) in group 1 and 2/6 (33.3%) in group 2 (P=0.018). ConclusionsNo cases of postoperative obturator nerve injury were identified. Preoperative obturator nerve injury was more common in patients with a displacement of the quadrilateral plate≥24mm. Level of evidenceIV, retrospective study.

Advancement in the Stoppa approach in acetabular fractures

The acetabular fractures are technically challenging due to the deep location in the pelvis and low degree of exposure. Although the classic ilioinguinal approach could treat most anterior acetabulum fractures, the limited surgical field and difficulty in exposure is the main obstacle surgeons should overcome. Various approaches including extended approaches and combined anterior and posterior approaches ensure adequate exposure, but high rate of complications impede it from clinical use. The Stoppa approach has been favored by the orthopedic surgeons in recent years for the minimized surgical dissection and good exposure. It allows for extensive visualization of the pelvic brim and direct manipulation of quadrilateral plate. This approach is indicated in all anterior column and wall fractures, combined anterior column and posterior hemi-transverse fractures, selected both-column fractures, transverse and T-fractures. The utilization of the Stoppa approach developed along with the evolution of the relevant theory of acetabular fractures in the past years. The development such as the precise measurement of safe zone and the application of new apparatus could do great help in decreasing the complications and improving the surgical results. This article summarizes the relevant literatures and provides a review of the advances in the Stoppa approach in acetabular fractures.

Injury of the obturator nerve in the modified Stoppa approach for acetabular fractures

IntroductionThe modified Stoppa approach for acetabular fractures has become popular. However, the possibility of injury to the obturator nerve with this approach has not been sufficiently considered. We have experienced a case of nerve entrapment in severely displaced fractures. Therefore, we performed a retrospective study to: (1) evaluate the incidence of obturator nerve injury in the modified Stoppa approach for acetabular fractures; (2) analyze the relationship between the extent of displacement of the quadrilateral plate and injury to the obturator nerve. HypothesisWe hypothesized that obturator nerve injury would be related to a marked medial displacement of the quadrilateral plate. Patients and methodsWe conducted a retrospective cohort study of 22 patients with acetabular fractures that were surgically treated with the modified Stoppa approach. The medial displacement of the quadrilateral plate was measured on a three-dimensional reconstruction image with the inlet view. Postoperative electrodiagnostic tests were performed based on clinical suspicion of neurological injury. Nerve injuries were divided into initial trauma or postoperative complication, and recovery of nerve function was evaluated. We identified the incidence of obturator nerve injury and analyzed the relationship between obturator nerve injury and medial displacement of the quadrilateral plate. ResultsThe incidence of obturator nerve injury was 2/22 (9.1%), and all injuries resulted from the initial trauma. The average displacement of the quadrilateral plate was 15.9±13.4mm. Patients were divided into two groups, using a displacement of 24mm as a cutoff point, identified using a receiver operating characteristic curve analysis. There were 16 patients in group 1 (<24mm) and 6 patients in group 2 (≥24mm). The incidence of obturator nerve injury from trauma was 0/16 (0%) in group 1 and 2/6 (33.3%) in group 2 (P=0.018). ConclusionsNo cases of postoperative obturator nerve injury were identified. Preoperative obturator nerve injury was more common in patients with a displacement of the quadrilateral plate≥24mm. Level of evidenceIV, retrospective study.

Modified Stoppa Approach in Acetabular Fractures

Modified Stoppa Approach in Acetabular Fractures

Newly modified Stoppa approach for acetabular fractures

We present our experience of using a newly modified Stoppa approach combined with a lateral approach to the iliac crest in patients with acetabular fractures in reference to fracture reduction and fixation, technical aspects, and the incidence of complications. We used a consecutive group of 29 adult patients with acetabular fractures treated operatively with a newly modified Stoppa approach between 2009 and 2011. The newly modified Stoppa approach was performed to fix the acetabular fractures with main anterior displacement and the anterior and lateral parts of the pelvis. This approach was combined with a lateral approach on the iliac crest for fractures of the iliac wing. All the patients were followed up for at least 1.5 years. Of the 29 patients, ten anterior column, two associated both column, seven anterior column with posterior hemi-transverse, four transverse, and six T-type fractures. The average blood loss was 950 mL, and average operative time was 155 minutes. Anatomic or satisfactory reduction was achieved in 96 % of the acetabular fractures. Two patients had mild symptoms of the lateral femoral cutaneous nerve and improved within three months. The newly modified Stoppa approach provides excellent visualization to the anterior column, quadrilateral surface and permits good postoperative results for treatment of acetabular fractures. We considered this technique as a viable alternative for the ilioinguinal approach when exposure of the anterior acetabulum is needed.

Applying Stoppa approach in acetabular fractures

Objective To report the preliminary results and surgical technique of Stoppa approach used in treatment of acetabular fracture.Methods From May 2005 to May 2010,23 patients with acetabular fracture were treated using modified Stoppa approach.The mean age was 37 years old (range,21-71years old).According to Letournel classification,there were 7 cases in anterior column fracture,6 cases in anterior column with posterior hemitransverse fracture,6 cases in transverse fracture,4 cases in associated with both column fractures.All patients in the study were operated under general anesthesia on a radiolucent table in a supine position and underwent Stoppa approach.Fracture reduction was evaluated by Matta's score system.The clinical outcome was judged by modified Merle d' Aubigne and Postel score system.Four cases of associated both column fractures,4 cases of anterior column with posterior hemitransverse fracture required the use of the lateral window.Results The mean surgical time was 166 min (range,110-320 min).The mean blood lose was 647 ml (range,300-2500 ml).Blood transfusion was 3.3 unites (0-12 unites).All the factures healed in 3 months.The fracture reduction was evaluated according to the Matta's score system:an excellent reduction was obtained in 15 patients(65％),a good reduction was obtained in 5 patients (22％),and three (13％) were considered poor.Clinical results were excellent in 11 patients (48％),good in 7 patients (30％),fair in 3 patient (13％),and poor in 2 patients (9％).Superficial wound infection happened in 1 case.It healed after debridment.One patient noted to have significant weakness of the hip adductors (obturator nerve palsy) after surgery.It reached grade Ⅳ one year later.No sciatic nerve,femoral nerve and vascular injury happened in this study.Conclusion For the selected acetabualar fracture,Stoppa approach can get satisfied exposure and fixation of the fracture,especially in the patient with central dislocation of the femoral head as well as medial displacement of quadrilateral plate. Key words: Acetabulum, Fractures, bone; Surgical procedures, operative

Modified Stoppa Approach for Acetabular Fractures With Anterior and Posterior Column Displacement: Quantification of Radiographic Reduction and Analysis of Interobserver Variability

To quantify the reduction of acetabular fractures with displacement of the anterior and posterior column by using only a single anterior approach that combines the modified Stoppa approach with the lateral window of the classic ilioinguinal approach. The second objective was to evaluate the interobserver variability of our technique for radiographic evaluation of the reduction. Level I trauma referral center. A consecutive cohort of 17 patients with displaced acetabular fractures treated operatively with use of only an anterior approach that combined the modified Stoppa approach with the lateral window of the ilioinguinal approach. To be included in the study, patients had to have at least 5 mm of posterior column displacement and had to have undergone no other approaches. Primary outcome was radiographic evidence of reduction as measured by a technique that evaluates five parameters of postoperative reduction. Interobserver variability was evaluated with interclass correlation. Secondary outcomes included operative time, blood loss, and complications. Anatomic reduction of the articular surface was obtained in 14 (82%) patients, imperfect radiographic reduction in three (18%), and poor radiographic reduction in none (0%). Average anterior column displacement improved from 17.5 mm preoperatively to 0.5 mm postoperatively. Average posterior column displacement improved from 13.0 mm to 1.2 mm. Average femoral head medialization improved from 12.5 mm to 1.0 mm. Average quadrilateral surface medialization improved from 15.2 mm to 0.6 mm. Four complications occurred in three patients, including one deep infection, one seroma, and two instances of symptoms in the lateral femoral cutaneous nerve. Our technique for grading the radiographic outcome yielded relatively high interobserver reliability preoperatively with interclass correlation values ranging from 0.72 to 0.96 for the five measured parameters. Postoperative reliability was worse. Anatomic or imperfect reduction of certain acetabular fractures involving displacement of both the anterior and posterior columns, even with significant (greater than 5 mm) displacement of the posterior column, can be obtained through the modified Stoppa window and the lateral window of the ilioinguinal approach. The method for evaluating preoperative displacement had excellent reliability.