CEM YALIN KILINÇ, Ahmet Emrah ACAN, EMRE GÜLTAÇ, RABİA MİHRİBAN KILINÇ, ONUR HAPA, NEVRES HÜRRİYET AYDOĞAN

Treatment results for acetabulum fractures using the modiﬁed Stoppa approach

Objectives: The aim of this study was to evaluate the clinical and radiological results of the surgical treatment of acetabular fractures using modiﬁed Stoppa approach. Methods: A total of 57 patients (mean age 37.8 years; range 15e84) who underwent surgical treatment for acetabular fracture with modiﬁed Stoppa approach from February 2013 to June 2016 were included into the study. The mean follow-up time was 28.1 months (range 24e35). The records were reviewed for fracture patterns, time to surgery, operative time, blood loss, reduction quality, and perioperative complications. Reduction quality was graded as anatomic, imperfect, or poor. The Harris Hip Score (HHS) and Merle d'Aubigne score were used for functional evaluation. Results: Among the 63 acetabulum fractures of the 57patients, 27 wereassociated with bothcolumns,12 were T-type fractures, 10 were transverse, 7 were anterior column/posterior hemitransverse, 5 were anterior column, and 2 were anterior wall fracture. A single surgeon performed all operations. Pfannenstiel incision was used in the ﬁrst 19 cases while vertical midline incision in the remaining 38 cases. Average time to operation was 5.5 days, and supplemental lateral windows were used in 17 (29.8%) patients. Average blood loss and operation times were 660 mL and 152 min, respectively. Radiological outcomes were anatomic, imperfect, and poor in 52 (82.5%), 9 (14.2%), and 2 (3.2%) of the acetabulum fractures, respectively. Clinical outcomes at 2 years with HHS and Merle d’Aubigne scores were mean 86.6 (range 66e96) (Excellent in 27, good in 23, fair in 4, poor in 3 patient) and 16.7 (range 10e18) (Excellent in 25, very good in 18, good in 6, fair in 5, poor in 3 patient), respectively. There was a signiﬁcant relation between the reduction quality and clinical outcome (p < 0.001), while there was no signiﬁcant relation between the clinical outcome and the fracture type (p > 0.05). Iatrogenic externaliliac vein damage was noted in 2 patients. Obturator nerve palsy was noted in 3 patients, who recovered spontaneously at mean time of 3.7 months (range 3e5). Rectus abdominus paralysis was noted in 2 of the 19 (10.5%) Pfannenstiel-incision patients but not in the vertical-incision patients. Conclusion: Our experience in 57 patients shows that satisfactory results can be obtained, even in bilateral fractures with vertical midline incision.

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Briffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture ﬁxation with ten years' follow-up. J Bone Joint Surg Br. 2011;93(2):229e236. https:// doi.org/10.1302/0301-620X.93B2.24056.

Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Br. 2012;94(17):1559e1567. https://doi.org/10.2106/JBJS.K.00444.

Arazi M, Kutlu A, Eristi Y, €Ogün TC, Kapıcıoglu MIS. Open reduction and internal ﬁxation of the displaced fractures of the acetabulum with single-nonextensile approaches. J Bone Joint Surg Br. 2001;83(suppl 2):118. Issn Print: 0301-620X.

Bray TJ, Esser M, Fulkerson L. Osteotomy of the trochanter in open reduction and internal ﬁxation of acetabular fractures. J Bone Joint Surg. 1987;69(5): 711e717. PMID:3597472.

Goulet JA, Bray TJ. Complex acetabular fractures. Clin Orthop Relat Res. 1989;240:9e20. PMID: 2492912.

Helfet DL, Schmeling GJ. Management of complex acetabular fractures through single nonextensile exposures. Clin Orthop Relat Res. 1994;305:58e68. PMID: 8050248.

Kebaish AS, Roy A, Rennie W. Displaced acetabular fractures: long-term followup. J Trauma. 1991;31(11):1539e1542. https://doi.org/10.1097/00005373199111000-00014.

Kloen P, Siebenrock KA, Ganz R. Modiﬁcation of the ilioinguinal approach. J Orthop Trauma. 2002;16(8):586e593. PMID: 12352568.

Letournel E. Acetabulum fractures: classiﬁcation and management. Clin Orthop Relat Res. 1980;151:81e106. PMID: 7418327.

Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. J Orthop Trauma. 2006;20(suppl 1):20e29. https://doi.org/10.1097/01.bot.0000202389.40246.c0.

Routt ML, Swiontkowski MF. Operative treatment of complex acetabular fractures: combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am. 1990;72(6):897e904. PMID: 2114408.

Sagi HC, Dziadosz D, Mir H, Virani N, Olson C. Obesity, leukocytosis, embolization, and injury severity increase the risk for deep postoperative wound infection after pelvic and acetabular surgery. J Orthop Trauma. 2013;27(1): 6e10. https://doi.org/10.1097/BOT.0b013e31825cf382.

Cole JD, Bolhofner BR. Acetabular fracture ﬁxation via a modiﬁed Stoppa limited intrapelvic approach: description of operative technique and preliminary treatment results. Clin Orthop Relat Res. 1994;305:112e123. PMID: 8050220.

Khoury A, Weill Y, Mosheiff R. The Stoppa approach for acetabular fracture. Oper Orthop Traumatol. 2012;24(4e5):439e448. https://doi.org/10.1007/ s00064-011-0093-z.

Ma K, Luan F, Wang X, et al. Randomized, controlled trial of the modiﬁed Stoppa versus ilioinguinal approach for acetabular fractures. Orthopedics. 2013;36(10):1307e1315. https://doi.org/10.3928/01477447-20130920-25.

Liu Y, Yang H, Li X, Yang SH, Lin JH. Newly modiﬁed Stoppa approach for acetabular fractures. Int Orthop. 2013;37(7):1347e1353. https://doi.org/ 10.1007/s00264-013-1920-7.

Shazar N, Eshed I, Ackshota N, Hershkovich O, Khazanov A, Herman A. Comparisonofacetabularfracturereductionquality by the ilioinguinalorthe anterior intrapelvic (modiﬁed Rives-Stoppa) surgical approaches. J Orthop Trauma. 2014;28(6):313e319. https://doi.org/10.1097/01.bot.0000435627.56658.53.

Sagi HC, Afsari A, Dziadosz D. The anterior intra-pelvic (modiﬁed Rives-Stoppa) approach for ﬁxation of acetabular fractures. J Orthop Trauma. 2010;24(5): 263e270. https://doi.org/10.1097/BOT.0b013e3181dd0b84.

Matta JM. Fractures of the acetabulum: accuracy of reduction and clinical results in patients managed operatively within three weeks after the injury. J Bone Joint Surg Am. 1996;78(11):1632e1645. PMID: 8934477.

Haddad RJ, Cook SD, Brinker MR. A comparison of three varieties of noncemented porous-coated hip replacement. J Bone Joint Surg Br. 1990;72(1):2e8. PMID: 2298788.

Kavanagh BF, Fitzgerald JRH. Clinical and roentgenographic assessment of total hip arthroplasty: a new hip score. Clin Orthop Relat Res. 1985;13:3e40.

Bose P, Regan F, Brown SP. Improving the accuracy of estimated blood loss at obstetric hemorrhage using clinical reconstructions. Int J Obstetrics Gynaecol. 2006;113(8):919e924. https://doi.org/10.1111/j.1471-0528.2006.01018.x.

Ponsen KJ, Joosse P, Schigt A, Goslings CJ, Luitse SK. Internal fracture ﬁxation using the Stoppa approach in pelvic ring and acetabular fractures: technical aspects and operative results. J Trauma. 2006;61(3):662e667. https://doi.org/ 10.1097/01.ta.0000219693.95873.24.

Hirvensalo E,Lindahl J,Kiljunen V.Modiﬁed and new approachesfor pelvic and acetabular surgery. Injury. 2007;38(4):431e441. https://doi.org/10.1016/ j.injury.2007.01.020.

Isaacson MJ, Taylor BC, French BG, Poka A. Treatment of acetabulum fractures throughthemodiﬁedStoppaapproach:strategiesandoutcomes.ClinOrthopRelat Res. 2014;472(11):3345e3352.https://doi.org/10.1007/s11999-014-3460-x.

Elmadag M, Guzel Y, Aksoy Y, Arazi M. Surgical treatment of displaced acetabular fractures using a modiﬁed Stoppa approach. Orthopedics. 2016;39(2):340e345. https://doi.org/10.3928/01477447-20160222-07.

Laﬂamme GY, Hebert-Davies J, Rouleau D, Benoit B, Leduc S. Internal ﬁxation of osteopenic acetabular fractures involving the quadrilateral plate. Injury. 2011;42(10):1130e1134. https://doi.org/10.1016/j.injury.2010.11.060.

Bastian JD, Tannast M, Siebenrock KA, Keel MJB. Mid-term results in relation to age and analysis of predictive factors after ﬁxation of acetabular fractures using the modiﬁed Stoppa approach. Injury. 2013;44(12):1793e1798. https:// doi.org/10.1016/j.injury.2013.08.009.

Andersen RC, O'Toole RV, Nascone JW, Sciadini MF, Frisch HM, Turen CW. Modiﬁed Stoppa approach for acetabular fractures with anterior and posterior column displacement: quantiﬁcation of radiographic reduction and analysis of interobserver variability. J Orthop Trauma. 2010;24(5):271e278. https:// doi.org/10.1097/BOT.0b013e3181b2b4ca.

Jakob M, Droeser R, Zobrist R, Messmer P, Regazzoni P. A less invasive anterior intrapelvic approach for the treatment of acetabular fractures and pelvic ring injuries. J Trauma. 2006;60(6):1364e1370. https://doi.org/ 10.1097/01.ta.0000208139.97474.f7.

May C, Egloff M, Butscher A, et al. Comparison of ﬁxation techniques for acetabular fractures involving the anterior column with disruption of the quadrilateral plate: a biomechanical study. J Bone Joint Surg Am. 2018;100(12): 1047e1054. https://doi.org/10.2106/JBJS.17.00295.

TanoğluO,AlemdaroğluKB, _IltarS, ÖzmeriçA,DemirT,ErbayFK.Biomechanical comparison of three different ﬁxation techniques for anterior column posterior hemitransverse acetabular fractures using anteriorintrapelvic approach. Injury. 2018;49(8):1513e1519. https://doi.org/10.1016/j.injury.2018.06.020.