International Journal of Advanced Joint Reconstruction ISSN 2385-7900

Introduction

Since Judet and Letournel presented their works (1,2) the surgical treatment of displaced acetabular fractures has been considered as Gold Standard, with the ilioinguinal approach2 being widely considered as the elected approach for the reduction and fixation of fractures involving the anterior wall and column (3,4). In 1989, Stoppa described an approach intended for the surgical treatment of inguinal hernias using a Dacron mesh (5). This approach was modified by Hivensalo et al. (6) and afterwards by Cole and Bolhofner (7) as an alternative to the

traditional ilioinguinal approach. It consists in an intra-pelvic, extra-peritoneal approach, that has the potential benefit of avoid complications associated with ilioinguinal approach (8), such vascular injuries of the iliac vessels. It also allows direct access to the quadrilateral plate allowing its reduction and fixation, achieving a level of primary mechanical stability that hardly can be achieved through the ilioinguinal approach (8,9-11,31,32,34). We present the results obtained in the treatment of acetabular fractures with the modified Stoppa approach in our center, analyzing functional outcomes and complications. In

Modified Stoppa approach in acetabular fractures in 32 patients. Results and introduction of an alternative technique for fractures

associating dome comminution. Diranzo-García J, Estrems-Díaz V, Hernández-Ferrando L, Vilatela-Gómez A, Zarzuela-Sánchez V,

Castillo-Ruiperez L, Bru Pomer A. Unidad de Cadera y Pelvis. Servicio de Cirugía Ortopédica y Traumatología.

Consorcio Hospital General Universitario de Valencia, Avenida Tres Cruces 2, 46014 Valencia, Spain

Abstract Objective: To evaluate the results achieved in the treatment of acetabular fractures using the modified Stoppa approach in our center. Methods: We performed a retrospective descriptive analysis of 32 acetabular fractures in 32 patients with a mean age of 58,4 yo. We used the Judet and Letournel criteria in order to classify the acetabular fractures; 10 cases (31%) were simple patterns and 22 (69%) were complex patterns. We found that the most frequent fracture pattern found in our series was the two columns fracture with medial displacement of the quadrilateral plate (34%). Twelve cases (38%) showed acetabular dome comminution. The average follow-up of these patients was 31 months. Results: We achieved anatomical reduction in 22 cases (69%). The average score in the Merle d’Aubigné functional score was 15.9 points, obtaining good or excellent results in 80% of the cases. Better functional results (p<0,05) were obtained in those patients with simple fracture patterns and in those that showed an anatomical reduction. Five patients (16%) developed osteoarthritis progression following surgery. Three of them required prosthetic hip replacement. Three patients (9%) suffered complications: one laceration of the superior gluteus artery, one bladder laceration and an obturator nerve neuroapraxia. Conclusion: The modified Stoppa approach is a useful technique for the treatment of acetabular fractures affecting the anterior column and wall, which associate medial displacement of the quadrilateral plate. The possibility of obtaining direct visualization of the dome comminution area will help the reduction of the impacted tectum fragments, allowing the restoration of the joint congruency obtaining good results.

Keywords Acetabulum Surgery, Fractures, Bone, Pelvis, Dome Comminution.

ORIGINAL

JFV EM B

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addition, we describe a technical modification regarding the original approach allowing reduction and fixation of complex acetabular fractures with tectum comminution. The effect of tectum comminution in the functional outcomes was also measured.

Material and Methods

Between March 2014 and May 2019, 32 acetabular fractures were treated in our hospital using the modified Stoppa approach. We analyzed in a descriptive and retrospective fashion, the clinical and radiological outcomes of those 32 patients as well as the complications. All the data was gathered thorough direct patient evaluation along with data available from their clinical reports. The consent form was duly signed by all the patients. Demographic data and fracture pattern is shown in Table 1. Seven out of 32 patients were females and 25 were males; with an average age of 58.4 years-old (range 22-79). The fracture mechanism was low-energy trauma in seven cases (22%) (all of them falls from standing height), and high-energy trauma in 25 cases (78%): eight bicycle crashes with direct trauma over the trochanteric region, five falls from height, six road accidents and six hits by a vehicle. The right acetabulum was damaged in 17 cases (53%) and the left one in 15 (47%). Fractures were classified according to Judet and Letournel criteria (1) using standard x-ray projections and CT scan images. Ten fractures (31%) were classified as elemental or simple and 22 (69%) as complex. The most frequent pattern of fracture was both columns fractures (11 cases, 34%), followed by 9 cases (28%) of associated anterior plus posterior hemitransverse fractures, five cases (16%) of transverse with medial displacement of the quadrilateral plate, four cases affecting anterior column, two cases of T shaped fractures, and one case of anterior wall fracture. Furthermore, all fractures were classified according to the tectum comminution, considering that those which presented three or more fragments affecting the weight-bearing area of the acetabulum in the median-sagittal CT plane met criteria to be considered comminuted fractures (12), resulting in 12 comminuted (38%) and 20 non-comminuted fractures (62%).

Surgical indications and technique Surgery was indicated in fractures with articular displacement greater than 2mm and fractures affecting the weight bearing surface (13,14). The average time elapsed from the injury until surgery was 8 days (3-22 days). 7 patients underwent surgery after 15 days of hospitalization, since their medical conditions involved a higher risk of complications that contraindicated surgery. All the surgeries were performed by the same surgical team following the technique described by Stoppa (5), modified by Hirvensalo (6), Cole and Bolhofner (7). With the hip in 30-45° of flexion and the surgeon sitting on the contralateral side of the lesion, an 8-10-centimeter-long horizontal incision is made two centimeters above the pubic symphysis. The

Table 1. Patient demographics, surgical details and functional results in 32 patients

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Figure 1. Intraoperative image. Exposure of the quadrilateral plate (star) and obturator nerve (arrow).

Figure 2. Intraoperative image. Bone defect created with the mobilization of the impacted dome. Through this bone defect, the underlaying femoral head can be seen (arrow).

Figure 3. Intraoperative image. Reduction of the fracture and stabilisation using supra and infrapectineal osteosynthesis plates. Arrow: obturator nerve.

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linea alba is opened in a craniocaudal direction and the rectus femoris on the same side of the fracture is subperiosteally detached, exposing the pubic symphysis and the superior pubic ramus. Subsequently, the Retzius space can be accessed after reflecting the bladder to protect it from injury. From 4 to 9 cm lateral to the pubic symphysis, 50-84% of patients present with a so-called corona mortis (15-17), a vascular anastomosis between the obturator and the external iliac artery. This structure must be either ligated or cauterized as it is a potentially dangerous source of bleeding. In our study, the corona mortis was identified in 25 cases (78%). The iliopectineal fascia is subsequently detached at the level of the supero-lateral pubic ramus and Hohmann retractors are placed along the anterior column, at the level of the linea terminalis, from the anterior pubic ramus to the anterior sacroiliac joint. These retractors are aimed at protecting the external iliac vessels, the iliac psoas and the femoral nerve during the procedure. From that moment onwards, the fracture can be exposed in the mid-pelvic area (Figure 1). Lateral to the fracture, the obturator neurovascular bundle follows an oblique path, from superior-posterior to anterior-inferior, before it enters the obturator foramen. The bundle and the bladder must be protected by placing a blunt Hohmann retractor at the level of the greater sciatic notch. Placement of this retractor makes it posible to expose the posterior column up to the anterior sacroiliac joint, which will

be the posterior fixation point of the osteosynthesis used. At that moment, full exposure of the fracture will have been achieved. As a technical enhancement (29), in cases where the dome has been impacted, the fractured quadrilateral plate can be further medialized with the help of a Cobb periosteal elevator. At the same time, lateral traction is applied to the proximal femur using a Schanz screw inserted in the lesser trochanter. This technical maneuver allows direct visualization of the impacted area. Disimpaction of the dome fracture is performed at the subcondral level, using a 10 mm scope or a Cobb periosteal elevator. Mobilization of the impacted dome creates a larger bone defect (Figure 2), which requires application of bone grafting to provide robust structural support to the dome area and prevent the dome from shifting back to the original position. The fracture can now be reduced and stabilized by means of an infra-pectineal plate (Figure 3) (3.5 mm Low Profile Pelvic System, Synthes USA, Paoli, PA) supported directly on the quadrilateral plate. The fixation screws must be placed into the two posterior-most screw-holes, located in front of the anterior sacroiliac joint and into the two or three anterior screw-holes, located at iliac-pubic level. In Figure 4, we show a case of a patient with a transverse acetabular fracture before and after being operated by a modified Stoppa approach. In 25 cases (78%) we combined the modified Stoppa approach with the lateral window of the ilioinguinal approach

Figure 4: Anatomical reduction of a transverse fracture with medial displacement of the quadrilateral plate. No progression of the degree of osteoarthritis and good functional results at 30 months.

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in order to fix high anterior column fractures. In seven cases (22%) we associated a Kocher-Langenbeck approach, to fix posterior column fractures. In five cases (16%) cancellous bone allograft was necessary to fill the defect behind weight bearing area. We used bone allografts, given that we have a bone allograft bank in our institution. For the rest of the patients, we achieved a proper reduction without requiring the use of any allograft. The average surgical time was 164 minutes (120-220 minutes) and 17 patients (53%) required blood transfusion during the surgery or in the immediate postoperative period. All patients received antibiotic prophylaxis following the antibiotic prophylaxis guides of our section: Cefazolin 2 gr e.v. 30 minutes before surgery. Patients were provided another antibiotic dose of 2 gr of e.v. Cefazolin besides 240 mg of e.v. Gentamicin at the en of the surgical procedure. Afterwards, at the hospital ward, all patients were provided 2gr of e.v. Cefazolin each 6 hours during 4 days. The average postoperative stay was seven days (4-21 days). Articular mobilization and sitting were started after 48 hours from the surgical intervention, and walking was allowed with progressive weight-bearing from the 12th week onward, subjected to the radiographic consolidation of the fracture. All patients were prescribed Celecoxib 200mg p.o. daily for 3 weeks, in order to avoid heterotopic ossifications.

Postoperative evaluation and statistical analysis Patients were assessed clinically and radiographically at 4 weeks, 12 weeks, 6 months, and therefore annually. The score obtained in the last patient assessment was used as reference for the study purpose. The average follow-up was 31 months (6-58 months). The standard evaluation in each appointment included the Merle d’Aubigné functional score (18), with the patients asked about their degree of satisfaction with the surgical procedure. The radiological evaluation included standard projections for acetabulum described by Judet and Letournel: AP pelvic film and internal and external 45° obliques (Judet views). The quality of the reduction achieved was classified into three categories according to the criteria proposed by Matta (13): anatomical reduction (0-1mm displacement), imperfect

reduction (2-3mm displacement) and poor reduction (displacement greater than 3mm). We evaluated the progression to osteoarthritis of the hip according to the Tönnis classification (19). The radiological assessment was performed by the same surgical team that performed the surgical interventions, but avoiding the main surgeon in each patient’s radiological assessment. The postoperative classification was carried out by the same team of surgeons. The analysis of the data was performed using the statistical-data processing software SPSS 22 for MAC OS (version 22; SPSS, Chicago, IL). The Chi-square and Mann-Whitney U non-parametric test were used for independent data, to analyze the hypothetical relationship between variables. A p<0.05 value was considered as statistically significant.

Results

Imaging results Anatomical reduction of the fracture was achieved in 22 cases (69%), imperfect reduction in nine (28%) and poor reduction in one case (3%) (Table 2). Three patients with imperfect reduction and two on which we achieved anatomic reduction, showed progression of the degree of osteoarthritis. Three patients underwent prosthetic replacement of the hip. None of the patients developed heterotopic ossifications.

Clinical results According to Merle d’Aubigné functional score, the results obtained were excellent in three patients (9%), good in 23 (71%), acceptable in five (17%) and poor in one (3%), with an average score of 15.9 points out of 18 (range 13-18) (Table 2). Better results were achieved in those patients on which surgery took place in the first 15 days following the injury (16.1 points) compared to those on which surgery was performed later (15.4 points) (p=0.041). Patients with complex fractures presented worse functional outcomes than those with simple fractures, with 15.5 and 16.6 points (p=0.031) respectively. Likewise, better functional results were achieved in patients with an anatomical reduction of the articular surface (16.3 points), compared to those with an imperfect or poor reduction (15.2 points) (p=0.024). In

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contrast, patients with fractures showing tectum comminution (15.8 points), showed functional outcomes that were comparable to patients who had no comminution in the dome area (16 points) (p=0.89). By the end of the follow-up, 72% of the patients were satisfied with the surgery results.

Complications Two intraoperative complications were observed: a superior gluteal artery injury while placing a Hohmmann retractor into the greater sciatic notch, which required vascular repair; and bladder laceration in a patient who had underwent pelvic irradiation due to a bladder adenocarcinoma, which was treated by direct suture. Regarding postoperative complications, one patient presented postoperative neuropraxia of the obturator nerve with complete recovery six weeks after the intervention.

Discussion

The ilioinguinal approach has been considered the approach of choice since it was described by Judet and Letournel (1,2) for the treatment of fractures compromising the acetabular wall and the anterior column. However, this approach offers a limited vision of the quadrilateral plate and roof area, allowing only an indirect reduction of the medial area. This limited medial exposure of the ilioinguinal approach does not allow the creation of stable osteosynthesis on the quadrilateral plate and, therefore, could be associated to further medial displacement of the acetabular fracture. Additionally, it is a technically demanding approach, with

prolonged surgery time and with potential severe complications described like femoral nerve lesions, surgical wound infections and high risk of bleeding, especially from the external iliac vessels (9-10,31-32). The minimally invasive, intra-pelvic and extra-peritoneal Stoppa approach allows a direct visualization of the medial zone of the anterior column, quadrilateral plate and the medial zone of the most inferior part of the posterior column (11,34). Thereby, the approach gives access to the sacroiliac joint, ischial spine, and the lesser and greater sciatic notches and allows direct reduction and fixation of most acetabular fractures (anterior column fractures, anterior wall fractures, anterior column associated to hemi-transversal posterior fractures, transverse fractures, “T-shaped” fractures and some affecting both columns). Previous studies have shown that the modified Stoppa approach is particularly effective for the treatment of fractures of the quadrilateral plate with medial displacement and tectum impaction (8-11, 20,30). In our series, we obtained an anatomical reduction of the fracture in 69% of the cases, an imperfect reduction in 28% and a poor reduction in 3%, with good or excellent results in 80% of patients in Merle d’Aubigné functional score. Our radiological and clinical results are comparable to those presented by other authors (8,11,12,21,33,35) (Table 2). As it has been reported in other studies (12,22,23), we found a close relationship between the radiological and the clinical outcomes, which was also evidenced in our series, with a better functional prognosis in those patients with simple or elemental fractures (p=0.031) and an anatomical reduction of the fracture (p=0.024).

Table 2. Radiological and functional results of the modified Stoppa group in the current study in comparison to literature data.

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The reconstruction of the acetabular weight bearing area is key to achieve outstanding clinical outcomes. The presence of the radiographic “Gull Sign” described by Anglen et al. (24), is synonym of tectum impaction, and is a sign of poor prognosis. Lafflame et al. (25), correlated this tectum comminution with a worse quality of the reduction (p=0.02) and with the progression to total hip arthroplasty (p=0.02). Kim et al. (12), described worse reduction of those fractures with three or more bone fragments in the acetabular tectum area (p=0.03) and therefore worse functional outcomes. Notwithstanding, in our series, we did not find worse results in patients with tectum comminution compared to those who presented this area unbroken, with a score of 15.8 and 15.9 points respectively in the Merle d’Aubigné functional score (p=0.89). Therefore, with the reconstruction that can be achieved using our modified Stoppa approach, we can minimize the negative impact associated with the presence of tectum comminution in the patient’s clinical outcome. The technical modification introduced in this paper improves the reconstruction of comminuted and impacted fractures in the acetabular tectum area, with subsequent better clinical results. Patients on which surgery took place after 15 days of hospitalization, scored worse in the functional scales (p=0.041), which was related with the higher complexity in order to perform the surgical approach due to higher tissue fibrosis and the difficulty to achieve a proper fracture reduction. Therefore, alternative techniques as total hip replacement should be consider an alternative in those patients. Among the patient’s complications we counted a superior gluteal artery laceration, bladder laceration and an obturator nerve neurapraxia, nevertheless the overall complications rate was similar to that is reported in other series with similar characteristics (8,11,12,21,33,35). Obturator nerve neurapraxia is a frequently shown complication, with incidences up to 26% (5-7), often produced by traction of the nerve when it lies over a plate which has not been perfectly molded onto the lesser pelvis. We have not found any reported cases of bladder laceration, being the one that we reported a patient that had previously underwent radiotherapy. Therefore, we consider that previous radiotherapy should be considered as a contraindication for

the modified Stoppa approach, making those patients more suitable for other approaches. In five cases, there was a progression on the degree of hip osteoarthritis and three cases required a rescue treatment with total hip arthroplasty. There was no relation found between: fracture pattern, dome comminution and quality of the reduction obtained (p>0.05) and the progression to osteoarthritis on the affected hip. We believe this complication could increase with a longer follow-up, especially in those patients who suffered high-energy trauma causing irreversible chondral damage, even after having achieved anatomical reductions, as described by other authors (26-28). We have not reported any cases of heterotopic ossifications, implementing a prophylactic treatment in all cases, however it is possible that with longer monitoring some patients could develop this condition. Regarding the limitations of our study, it is a retrospective case-series study and therefore it is subject to the limitations related to this type of study design. The follow-up period is relatively short and there is a great heterogeneity among patients, which does not allow us to report on long-term progress. Additionally, we have not performed any comparative study with another surgical technique nor with non-surgical management for this type of fractures.

Conclusion

We consider the modified Stoppa approach to be a useful technique for the treatment of acetabular fractures affecting the anterior column and wall, which associate medial displacement of the quadrilateral plate. According to the results, we consider that the medial exposure of the acetabular fracture and the possibility of obtaining direct visualization of the dome comminution area will help the reduction of the impacted tectum fragments, allowing the restoration of the joint congruency and the eventual use of subchondral bone grafts, that could prevent further impaction of the fragments, thus obtaining good results. However, this is a technically demanding surgical approach, and therefore extreme care must be taken to avoid injuring nearby neurovascular and visceral structures.

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Copyright

Copyright © 2020 Diranzo-García J et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Conflicts of interest statement

The authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.

How to cite

Diranzo-García J, Estrems-Díaz V, Hernández-Ferrando L, Vilatela-Gómez A, Zarzuela-Sánchez V, Castillo-Ruiperez L, Bru Pomer A. Modified Stoppa approach in acetabular fractures in 32 patients. Results and introduction of an alternative technique for fractures associating dome comminution. Int J Adv Jt Reconstr. 2020; 7(2):31-39.

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