Aims

Posterior column plating through the single anterior approach reduces the morbidity in acetabular fractures that require stabilization of both the columns. The aim of this study is to assess the effectiveness of posterior column plating through the anterior intrapelvic approach (AIP) in the management of acetabular fractures.

Aims

Acetabular fractures in older adults lead to a high risk of mortality and morbidity. However, only limited data have been published documenting functional outcomes in such patients. The aims of this study were to describe outcomes in patients aged 60 years and older with operatively managed acetabular fractures, and to establish predictors of conversion to total hip arthroplasty (THA).

Aims

Complex displaced osteoporotic acetabular fractures in the elderly are associated with high levels of morbidity and mortality. Surgical options include either open reduction and internal fixation alone, or combined with total hip arthroplasty (THA). There remains a cohort of severely comorbid patients who are deemed unfit for extensive surgical reconstruction and are treated conservatively. We describe the results of a coned hemipelvis reconstruction and THA inserted via a posterior approach to the hip as the primary treatment for this severely high-risk cohort.

In the time since Letournel popularised the surgical treatment of acetabular fractures, more than 25 years ago, there have been many changes within the field, related to patients, surgical technique, implants and post-operative care. However, the long-term outcomes appear largely unchanged. Does this represent stasis or have the advances been mitigated by other negative factors? In this article we have attempted to document the recent changes within the surgery of patients with a fracture involving the acetabulum, outline contemporary management, and identify the major problem areas where further research is most needed.

Cite this article: Bone Joint J 2017;99-B:1125–31

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded.

A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans.

There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001).

These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach.

This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns.

Cite this article: Bone Joint J 2015;97-B:1271-8.

Stoppa approach has recently been adapted for pelvic surgery as it allows direct intra-pelvic reduction and fixation of the quadrilateral plate and anterior column. We report our early experience, indications and complications with this exposure introduced in 2010 in our tertiary unit. A Retrospective review of all Stoppa approaches in pelvic-acetabular fixations was performed from a prospectively maintained database. Of the 25 patients, mean age 40 years (range 15–76), who underwent pelvic-acetabular fixation using Stoppa approach, 21 patients had mean follow up of 7.3 months (1–48 months). All except 24% of patients had one or more additional systemic injury some requiring additional surgery. There were 6 acetabular fractures, 13 pelvic ring injuries and 6 combined fractures. Mean injury-surgery interval was 9 days (range 3–20). 8 patients had an isolated Stoppa approach whilst the remaining others also had an additional approach. Mean surgical time was 239 minutes. Anatomical reduction was achieved in 96% (24/25) cases. There was 1 minor intra-operative vascular injury, repaired immediately successfully, and no late wound infections, or other visceral complications. One patient reported new onset sensory numbness which resolved after the first review. Two patients reported erectile dysfunction thought to be caused by the initial injury. One patient had asymptomatic plate loosening. None required revision surgery. Despite the obvious learning curve, we found this approach safe and it did not compromise accuracy of reduction in well selected patients, but early surgery within 10–14 days is recommended to aid optimal reduction

The increasing prevalence of osteoporosis in an ageing population has contributed to older patients becoming the fastest-growing group presenting with acetabular fractures. We performed a systematic review of the literature involving a number of databases to identify studies that included the treatment outcome of acetabular fractures in patients aged > 55 years. An initial search identified 61 studies; after exclusion by two independent reviewers, 15 studies were considered to meet the inclusion criteria. All were case series. The mean Coleman score for methodological quality assessment was 37 (25 to 49). There were 415 fractures in 414 patients. Pooled analysis revealed a mean age of 71.8 years (55 to 96) and a mean follow-up of 47.3 months (1 to 210). In seven studies the results of open reduction and internal fixation (ORIF) were presented: this was combined with simultaneous hip replacement (THR) in four, and one study had a mixture of these strategies. The results of percutaneous fixation were presented in two studies, and a single study revealed the results of non-operative treatment.

With fixation of the fracture, the overall mean rate of conversion to THR was 23.1% (0% to 45.5%). The mean rate of non-fatal complications was 39.8% (0% to 64%), and the mean mortality rate was 19.1% (5% to 50%) at a mean of 64 months (95% confidence interval 59.4 to 68.6; range 12 to 143). Further data dealing with the classification of the fracture, the surgical approach used, operative time, blood loss, functional and radiological outcomes were also analysed.

This study highlights that, of the many forms of treatment available for this group of patients, there is a trend to higher complication rates and the need for further surgery compared with the results of the treatment of acetabular fractures in younger patients.

Cite this article: Bone Joint J 2014;96-B:157–63.

The December 2013 Trauma Roundup³⁶⁰ looks at: Re-operation for intertrochanteric hip fractures; Are twin incisions better than one round the acetabulum?; Salvage osteotomy for calcaneal fractures; Posterior dislocation; Should MRSA be covered in open fractures?; Characterising the saline load test; Has it healed: hip fractures under the spotlight; and stem cells present in atrophic non-union.

Operative approaches to the acetabulum are generally classified into anterior, posterior, extensile or combined approaches. The choice of approach depends upon the fracture pattern and the amount of relative displacement affecting the anterior and posterior bony structures. Occasionally, extensile or combined surgical approaches are indicated for the treatment of complex fracture patterns with extensive involvement of both the anterior and posterior acetabular anatomy. However, it is believed that these approaches may be associated with higher complication rates than more limited surgical approaches. The ilioinguinal approach described by Letournel is routinely employed in the treatment of anterior column, anterior wall, anterior column/posterior hemi- transverse and certain associated both-columns, transverse and T-type fractures. The utility of this approach is sometimes limited by difficulty in visualising, reducing and applying instrumentation to the quadrilateral plate and posterior column components of these fractures. A surgical approach described by Stoppa in 1989—and later extended to acetabular indications by Cole and Bolhofner—can be used, often in combination with the lateral window of the standard ilioinguinal approach, to effectively treat the same range of fractures as an ilioinguinal approach. Access to the quadrilateral plate and certain displaced posterior column fracture lines is enhanced by this approach—possibly eliminating the need for combined or extensile approaches in certain cases. A retrospective study undertaken at our institution demonstrated that anatomic articular reduction was achieved in 14 of 17 complex acetabular fractures treated via a Stoppa approach. All fractures in the study had at least 5 mm of posterior column displacement preoperatively

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five ‘windows’ for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called ‘Pararectus’ approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues.

In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

Purpose: The age of patients presenting with acetabular fracture has increased over the last ten years. Older patients tend to have patterns involving the anterior column with comminution of the quadrilateral plate. Our goal was to investigate the appropriateness of open reduction and internal fixation using the modified Stoppa approach for geriatric acetabular fractures. Method: A retrospective review of patients over the age of 60 having presented to an academic level I trauma center over the course of four years. Twenty patients were identified and treated using the modified Stoppa approach with plating of the quadrilateral surface. Patients were evaluated clinically using both SF-36 and Harris Hip Score. Records and radiographs (using criteria described by Matta) were reviewed retrospectively. Results: All patients were followed for a minimum of two years with no lost at follow-up. Mean age for patients at time of intervention was 68 years. Average blood lost was 800cc and surgical time was 130 minutes (range, 55–210). There was one traumatic injury to the obturator nerve and two patients were noted to have temporary weakness of the hip adductors postoperatively. Average Harris Hip Score and the SF-36 were improved significantly (p< 0.05). Significant lost of reduction was seen in two patients and was correlated to superior dome impaction (p < 0.0001). Three patients required re-intervention with a Total Hip Arthroplasty. Conclusion: Internal fixation using the modified Stoppa approach to buttress the quadrilateral plate should be considered a viable alternative to total hip arthroplasty for the initial treatment of acetabular fractures of the anterior column in the elderly

We report the outcome of 161 of 257 surgically fixed acetabular fractures. The operations were undertaken between 1989 and 1998 and the patients were followed for a minimum of ten years. Anthropometric data, fracture pattern, time to surgery, associated injuries, surgical approach, complications and outcome were recorded. Modified Merle D’Aubigné score and Matta radiological scoring systems were used as outcome measures. We observed simple fractures in 108 patients (42%) and associated fractures in 149 (58%).

The result was excellent in 75 patients (47%), good in 41 (25%), fair in 12 (7%) and poor in 33 (20%). Poor prognostic factors included increasing age, delay to surgery, quality of reduction and some fracture patterns. Complications were common in the medium- to long-term and functional outcome was variable. The gold-standard treatment for displaced acetabular fractures remains open reduction and internal fixation performed in dedicated units by specialist surgeons as soon as possible.

Surgical dislocation of the hip in the treatment of acetabular fractures allows the femoral head to be safely displaced from the acetabulum. This permits full intra-articular acetabular and femoral inspection for the evaluation and potential treatment of cartilage lesions of the labrum and femoral head, reduction of the fracture under direct vision and avoidance of intra-articular penetration with hardware. We report 60 patients with selected types of acetabular fracture who were treated using this approach. Six were lost to follow-up and the remaining 54 were available for clinical and radiological review at a mean follow-up of 4.4 years (2 to 9).

Substantial damage to the intra-articular cartilage was found in the anteromedial portion of the femoral head and the posterosuperior aspect of the acetabulum. Labral lesions were predominantly seen in the posterior acetabular area. Anatomical reduction was achieved in 50 hips (93%) which was considerably higher than that seen in previous reports. There were no cases of avascular necrosis. Four patients subsequently required total hip replacement. Good or excellent results were achieved in 44 hips (81.5%). The cumulative eight-year survivorship was 89.0% (95% confidence interval 84.5 to 94.1). Significant predictors of poor outcome were involvement of the acetabular dome and lesions of the femoral cartilage greater than grade 2. The functional mid-term results were better than those of previous reports.

Surgical dislocation of the hip allows accurate reduction and a predictable mid-term outcome in the management of these difficult injuries without the risk of the development of avascular necrosis.

Background: Surgical approaches to the acetabular fracture present a challenge for most surgeons. The ilioinguinal approach by Letournel has fundamentally contributed to the successful treatment of such fractures. The current tendency is to minimize the approach while maintaining a proper visual field that allows inspection of fracture fragments and the ability to reduce them. The Stoppa approach is a less invasive anterior intra-pelvic approach that could be combined with a lateral window of the ilioinguinal approach, especially helpful in facilitating the approach to the quadrilateral plate. Aim: To evaluate the efficacy and safety of the Stoppa approach for the treatment of different types of acetabular fractures. Patients: Between the years 2004 and 2006, 45 patients with acetabular fractures were operated on using the Stoppa approach. Their age ranged between 14 and 73 (average 42). There were 33 males and 12 females whose fractures were classified as anterior column fractures (21) associated both columns (11) transverse (6), T-shape and other various types. They were consecutively operated in two level 1 trauma centers; in 13 the Stoppa approach was used solely and in the others a combination of the Stoppa approach with an iliac window was employed. Patients were followed for an average of 11.4 months (range 2–36 months), and assessed using the Merle d’Aubigné score. Results: Visualization of the fracture, reduction and fixation were all feasible through the Stoppa approach. The average length of surgery was 4 hours and an average of intraoperative bleeding was 1086 cc. We were able to achieve excellent reduction in 37 patients and a good reduction in the rest of the cases. Clinical outcomes were good to excellent in 90% of the patients. 3 patients underwent hip arthroplasty due to post traumatic osteoarthritis. Conclusions: The Stoppa approach in combination with an iliac window offers superb visualization of the quadrilateral plate, anterior column and in some cases the posterior column as well and enables excellent reduction. It is a reasonable replacement for the iliuinguinal approach offering less tissue dissection

Using finely reconstructed helical pelvis CT scans of ninety-three cases and image analysis software, we define the “Safe Zone” for the extra-articular placement of screws during internal fixation of the acetabulum, using a Stoppa approach. Screws should be at most: 11mm from the top of the Sciatic notch, 23mm from the tip of the Ischial Spine, and at most 5mm posterior to the top of the Obturator canal, along the pelvic brim. The purpose of this study was to identify a “safe zone” in the inner pelvis, to allow extra-articular screw placement using the Stoppa approach. Acetabulum internal fixation screws can safely (extra-articular position) be placed through the Stoppa approach using three identifiable landmarks. Surgeons can use these identifiable anatomic landmarks for the safe placement of screws along the inner aspect of the acetabulum. Study Population: males:females 47%:53%, mean age: 51,3yrs (18–88). Reference measurements (means): Femoral Head (FH): 45,5mm (36–6), Inter-SI joint:177,9mm (102–34). Safe distance to joint: 1) from Sciatic notch: 11mm; 2) from Ischial Spine: 23mm; 3) from Obturator roof: 5mm. The Ischial Spine Distance (ISD) showed clustering (p< 0.05) into two groups according to Femoral Head diameter: FH< 47mm: Safe ISD=23mm ; FH≥47mm: Safe IS=28mm. Ninety-three Helical Pelvis CT scans with fine reconstruction were done between July 1, 1999-June 30, 2000. Axial images were analyzed using GE Vox Tool® v.3.0.3 image analysis software. The femoral head diameter and the Inter-SI joint distance were used as reference. The distance between three identifiable bony landmarks and the point which would allow the placement of a 4mm screw outside the hip joint were measured. Inter and Intra-observer reliability study showed a difference < 1mm in > 90% of cases. Surgical approaches which avoid extensive dissection and manipulation of the gluteal musculature are gaining in popularity. The Stoppa is such an approach which gives access to the medial acetabular wall and to the inner pelvis from the SI joint to the symphysis along the pelvic brim. This blind approach does not allow visualisation of the joint and confirmation of screw placement. The present paper offers surgeons these reference points

The Stoppa approach was originally conceived to deal with difficult abdominal hernia surgery. Its use has been modified to deal with Acetabular and Pelvic surgery. We report on our use of the Stoppa approach in 26 cases from 1998–2003 to fix Pelvic, Acetabular, and combined Pelvic/Acetabular fractures. The Stoppa approach was used in combination with other approaches to afford the best access for fixation. 11 of the cases were Acetabular fractures with no pelvic ring disruption (42.3%), 4 cases (15.3%) were pelvic ring disruptions without an Acetabular component. The other 11 cases (42.3%) were combined Pelvic and Ace-tabular fractures where this approach came into its own. In particular it is to be noted that the Corona Mortis was easily identifiable in 5 (19.2%) of the cases to allow its safe ligation. The anatomy of the approach and the access afforded are considered, along with the plating techniques that can be achieved because of its use. Patients were followed up for an average of 17.39 months with one lost to follow up. Clinical results were excellent in 20 cases, good in 2, fair in 2, and poor in 1. Complications were lateral femoral cutaneous nerve palsy in 11 patients, 1 bladder rupture, 2 superficial wound infections, one lateral incisional hernia related to an ilioinguinal approach, and 1 deep vein thrombosis. Heterotopic Ossification occurred in 3 patients in whom the Kocher-Langenbeck approach was used. One revision for screw proximity to the joint was undertaken. The Stoppa approach allows safe access and ease of reduction and fixation in these complex fractures, in combination with other approaches, particularly in combined pelvic and Acetabular fractures. We outline our recommendations for its use in this paper and outline a series of fracture patterns where it is most helpful

There have been multiple approaches described for internal fixation of acetabular fractures. We discuss the results of acetabular fractures treated in our institution via a Stoppa intrapelvic approach. Between July 1997 to October 2002, the senior author surgically treated 14 acetabular fractures using this approach. Indications for utilizing this approach include displaced anterior column fractures, transverse fractures, T shaped fractures, both column fractures and anterior column or wall fractures associated with a posterior hemi transverse component. The fractures were classified according to Letournel and Judet. There were 10 males, 4 females with a mean age of 34 years (20–57 years). Patients were followed up for an average of 26 months (8–60 months). All fractures went on to union at an average of 12 weeks. There was one superficial wound infection, which was successfully treated with antibiotics. No patients suffered loss of fixation. There were no nerve or visceral injury in our series. Clinical results evaluated were based on the Harris Hip Score (out of 100). Our results show 13 patients had good to excellent results (Score 80–100), whereas one patient had a fair result. The Stoppa intrapelvic approach offers improved reduction and fixation techniques with a decrease in complications associated with extensile approaches