Anterior Approach for the Acetabular Fractures

Jae Youn Yoon; Jae-Woo Cho; Ji Wan Kim

doi:10.12671/jkfs.2019.32.3.157

Journal List > J Korean Fract Soc > v.32(3) > 1130295

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Yoon, Cho, and Kim: Anterior Approach for the Acetabular Fractures

Original Article

J Korean Fract Soc 2019;32(3):157-164.

Published online: 10 January 2019

DOI: https://doi.org/10.12671/jkfs.2019.32.3.157

Anterior Approach for the Acetabular Fractures

Jae Youn Yoon, M.D., Jae-Woo Cho, M.D., Ji Wan Kim, M.D., Ph.D.

Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Department of Orthopaedic Surgery, Korea University Guro Hospital, Korea University College of Medicine*, Seoul, Korea

Correspondence to: Ji Wan Kim, M.D., Ph.D. Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3530 Fax: +82-2-488-7877 E-mail: bakpaker@hanmail.net

Received 25 June 2019 Revised 25 June 2019 Accepted 25 June 2019

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

In the surgical treatment of acetabular fractures, the anterior approach is used widely for anterior column fractures with or without posterior column fractures. This paper reviews the anterior approach for the anatomical reduction and rigid fixation of acetabular fractures: traditional ilioinguinal approach, modified Stoppa approach, and new Pararectal approach.

Keywords: Acetabulum, Acetabular fracture, Approach

References

1. Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res. 292:62–76. 1993.

2. 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. 305:112–123. 1994.

3. 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. 24:271–278. 2010.

4. Archdeacon MT, Kazemi N, Guy P, Sagi HC. The modified Stoppa approach for acetabular fracture. J Am Acad Orthop Surg. 19:170–175. 2011.

5. Hirvensalo E, Lindahl J, Kiljunen V. Modified and new approaches for pelvic and acetabular surgery. Injury. 38:431–441. 2007.

6. Kim JW, Kim YC. Modified Stoppa approach in acetabular fractures. J Korean Fract Soc. 27:274–280. 2014.

7. Keel MJ, Ecker TM, Cullmann JL, et al. The Pararectus approach for anterior intrapelvic management of acetabular fractures: an anatomical study and clinical evaluation. J Bone Joint Surg Br. 94:405–411. 2012.

8. Tosounidis TH, Giannoudis VP, Kanakaris NK, Giannoudis PV. The Ilioinguinal approach: state of the art. JBJS Essent Surg Tech. 8:e19. 2018.

9. Elmadağ M, Güzel Y, Acar MA, Uzer G, Arazi M. The Stoppa approach versus the ilioinguinal approach for anterior acetabular fractures: a case control study assessing blood loss complications and function outcomes. Orthop Traumatol Surg Res. 100:675–680. 2014.

10. Ruchholtz S, Buecking B, Delschen A, et al. The two-incision, minimally invasive approach in the treatment of acetabular fractures. J Orthop Trauma. 27:248–255. 2013.

11. Jimenez ML, Tile M, Schenk RS. Total hip replacement after acetabular fracture. Orthop Clin North Am. 28:435–446. 1997.

12. Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. J Orthop Trauma. 20:S20–S29. 2006.

13. Stoppa RE, Rives JL, Warlaumont CR, Palot JP, Verhaeghe PJ, Delattre JF. The use of Dacron in the repair of hernias of the groin. Surg Clin North Am. 64:269–285. 1984.

14. Kim JW, Seo YM, Jang HS. Reduction technique of dome impaction using the modified Stoppa approach – a technical note. J Korean Fract Soc. 30:131–136. 2017.

15. Tannast M, Keel MJB, Siebenrock KA, Bastian JD. Open reduction and internal fixation of acetabular fractures using the modified Stoppa approach. JBJS Essent Surg Tech. 9:e3. 2019.

17. Keel MJ, Bastian JD, Büchler L, Siebenrock KA. [Anterior approaches to the acetabulum]. Unfallchirurg. 116:213–220. 2013; German.

18. Kloen P, Siebenrock KA, Ganz R. Modification of the ilioinguinal approach. J Orthop Trauma. 16:586–593. 2002.

19. Laflamme GY, Hebert-Davies J, Rouleau D, Benoit B, Leduc S. Internal fixation of osteopenic acetabular fractures involving the quadrilateral plate. Injury. 42:1130–1134. 2011.

20. Keel MJB, Siebenrock KA, Tannast M, Bastian JD. The Pararectus approach: a new concept. JBJS Essent Surg Tech. 8:e21. 2018.

21. Bastian JD, Savic M, Cullmann JL, Zech WD, Djonov V, Keel MJ. Surgical exposures and options for instrumentation in acetabular fracture fixation: Pararectus approach versus the modified Stoppa. Injury. 47:695–701. 2016.

22. Märdian S, Schaser KD, Hinz P, Wittenberg S, Haas NP, Schwabe P. Fixation of acetabular fractures via the ilioinguinal versus pararectus approach: a direct comparison. Bone Joint J. 97:1271–1278. 2015.

23. Keel MJ, Tomagra S, Bonel HM, Siebenrock KA, Bastian JD. Clinical results of acetabular fracture management with the Pararectus approach. Injury. 45:1900–1907. 2014.

24. Bastian JD, Tannast M, Siebenrock KA, Keel MJ. Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach. Injury. 44:1793–1798. 2013.

25. Isaacson MJ, Taylor BC, French BG, Poka A. Treatment of acetabulum fractures through the modified Stoppa approach: strategies and outcomes. Clin Orthop Relat Res. 472:3345–3352. 2014.

26. Ma K, Luan F, Wang X, et al. Randomized, controlled trial of the modified Stoppa versus the ilioinguinal approach for acetabular fractures. Orthopedics. 36:e1307–e1315. 2013.

27. Shazar N, Eshed I, Ackshota N, Hershkovich O, Khazanov A, Herman A. Comparison of acetabular fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified Rives-Stoppa) surgical approaches. J Orthop Trauma. 28:313–319. 2014.

28. Hammad AS, El-Khadrawe TA. Accuracy of reduction and early clinical outcome in acetabular fractures treated by the standard ilioinguinal versus the Stoppa/iliac approaches. Injury. 46:320–326. 2015.

Fig. 1.

Ilioinguinal approach. (A) Skin incision from the symphysis pubis to the iliac crest. (B) Incision of the inguinal ligament. (C) Iliopectineal fascia. (D) Exposure of the lateral window (white arrow: lateral femoral cutaneous nerve, black arrow: iliopectineal fascia). (E) Exposure of the ilium and anterior sacroiliac joint through the lateral window. (F) Three windows (1: lateral window, 2: middle window, 3: medial window, m: lacuna musculorum, v: lacuna vasorum, s: spermatic cord).

Fig. 2.

Modified Stoppa approach. (A) Skin incision-like Pfannelstiel incision; 10 cm transverse incision 2 cm above the symphysis pubis. (B) Subcutaneous dissection. (C) Incision of the fascia (linea alba) of the rectus abdominis. (D) Deep blunt dissection along the superior pubic ramus. (E) Identification of the obturator nerve. (F) Exposure of the quadrilateral surface.

Fig. 3.

Modified Stoppa approach for a bilateral pelvis ring injury and right acetabular fracture. (A) Initial pelvis X-ray showing the right acetabular anterior column fracture with the right sacral alar fracture and left pubic fracture. (B, C) Three-dimensional reconstruction images. (D) Postoperative pelvis anteroposterior.

Fig. 4.

Pararectal approach. (A) Skin incision. (B) Exposure of the deep fascia. (C) Incision of the rectus sheath. (D) Exposure of the lateral border of the rectus abdominis and retroperitoneal fat. (E) Schematic diagrams of the approach for the retroperitoneal space. (F) Exposure of the anterior column. (G) Reduction of the anterior and posterior column with a Collinear clamp.

Fig. 5.

Number of journals published worldwide related to each anterior pelvic approach in acetabular fractures.

Fig. 6.

Illustrated images on the range of surgical exposure, according to the type of anterior pelvic approach. (A) Ilioinguinal approach. (B) Modified Stoppa approach. (C) Pararectal approach.

Table 1.

Comparison of the Anterior Approach

	Ilioinguinal approach	Modified Stoppa approach	Pararectus approach
Advantage	· Most commonly used surgical approach. · Wide surgical exposure of both inner and outer pelvic spaces is possible. · Favorable clinical outcomes, compared to other surgical approaches.	· Exposure and direct visualization of medially displaced quadrilateral surface are available. · Easy to insert a buttress plate into the inferior pelvic brim and directly reduce the medially displaced quadrilateral surface. · Either side of the pelvis can be exposed using a single surgical approach. · Direct reduction of upwardly impacted acetabular dome is possible.	· Approach from the higher level of the pelvis. · Exposure and direct visualization of a medially displaced quadrilateral surface is available. · Both surgical exposure of Stoppa and ilioinguinal approach can be achieved. · Reduced risk of ilioinguinal hernia. · Incision wound is relatively small. · Less need for an additional lateral window.
Disadvantage	· External iliac neurovascular bundle can be injured during the approach. · Inguinal canal needs to be opened. · Access to the 2nd window is limited. · Access to the posterior column and inferior quadrilateral surface is limited, and can only be manipulated indirectly. · Direct exposure and visualization of the articular surface is not possible.	· Obturator nerve may be injured during exposure of the quadrilateral surface. · Additional lateral incision is frequently required (55%-93%). · The screw insertion angle is limited in posterior column fractures. · Hernia may occur postoperatively. · Lateral femoral cutaneous nerve of the thigh and femoral nerve can be injured during traction.	· May be limited in obese patients or those with abdominal distension or bowel obstruction. · An additional lateral window maybe required in comminuted high level anterior column fractures. · Surgical dissection and exposure of the 2nd window maybe limited in delayed surgery due to intrapelvic adhesions. · The lateral femoral cutaneous nerve of the thigh and femoral nerve can be injured during traction.

TOOLS

Similar articles