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The Stoppa Combined with Iliac Fossa Approach for the Treatment of Both-Column Acetabular Fractures Yun Yang†, Chang Zou† and Yue Fang*

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The Stoppa Combined with Iliac Fossa Approach for the Treatment of Both-Column Acetabular Fractures Yun Yang†, Chang Zou† and Yue Fang* Yang et al. Journal of Orthopaedic Surgery and Research (2020) 15:588 https://doi.org/10.1186/s13018-020-02133-3 RESEARCH ARTICLE Open Access The Stoppa combined with iliac fossa approach for the treatment of both-column acetabular fractures Yun Yang†, Chang Zou† and Yue Fang* Abstract Background: At present, the choice of surgical approach for both-column fractures is still controversial. The purpose of this study was to explore the efficacy of the Stoppa combined with iliac fossa (S+IF) approach in the treatment of both-column fractures. Methods: In this retrospective case series, 76 patients were included in the study from 2014 to 2018. They were divided into two groups according to the surgical approaches. The differences of intraoperative blood loss, operative time, quality of reduction, clinical outcome, and perioperative complications were compared between the two groups. Results: All patients had undergone the IL approach or the S+IF approach. The average operative time was 156.2 min (110~210 min) in group I and 126.5 min (80~180 min) in group II (P < 0.001). The average blood loss in group I was 784.1 ml, while the average blood loss in group II was 625.3 ml (P = 0.007). According to Matta’s criteria, 28 cases obtained anatomic reduction and 12 cases got imperfect reduction in group I; 21 cases obtained anatomic reduction and 7 cases got imperfect reduction in group II (P > 0.05). The clinical outcome (excellent to good) was 66% in group I versus 69% in group II (P > 0.05). The complication rates were 18.2% in group I and 12.5% in group II (P > 0.05). Conclusions: As a minimally invasive surgical approach, the S+IF approach is a valuable alternative to the IL approach for the treatment of both-column acetabular fractures if these two anterior approaches can achieve fracture exposure, reduction, and fixation. Keywords: Acetabular fracture, Both columns, Stoppa approach, Iliac fossa approach, Ilioinguinal approach, Internal fixation Background anatomical reduction and rigid internal fixation are very Both-column fractures account for about 20% of the critical to obtain a good outcome [3–6]. In order to total number of acetabular fractures, which are charac- achieve accurate reduction and minimize complications, terized by no articular fragment in connection with the it is necessary to choose the appropriate surgical axial skeleton and fracture lines involving multiple approach. planes [1–3]. In the treatment of acetabular fractures, The choice of surgical approach for both-column frac- tures is still controversial. The IL approach is the stand- ard anatomic approach for most both-column fractures * Correspondence: [email protected] †Yun Yang and Chang Zou contributed equally to this work. [7] and enables direct visualization of the anterior col- Department of Orthopaedics, West China Hospital, Sichuan University, umn up to the symphysis pubis. The exposure of the Chengdu, Sichuan, People’s Republic of China © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Yang et al. Journal of Orthopaedic Surgery and Research (2020) 15:588 Page 2 of 7 quadrilateral plate via the IL approach can only be Surgical technique achieved by palpation of the endopelvic finger. Some IL approach scholars actively explore a single approach to treat this The incision of the IL approach began at the middle of complex injury [8–11]. Others are skeptical that neither iliac crest and was anteriorly and distally extending to the IL nor the Kocher-Langenbeck (KL) approach alone the anterior superior iliac spine (ASIS) and the pubic tu- can expose all of the fragments [12–14]. However, ex- bercle (Fig. 1). The IL approach was divided into three tensile approaches are associated with higher rates of windows by lacuna vasorum and lacuna musculorum. complications [13–15]. Therefore, limited exposure is The lateral window could be exposed by subperiosteal necessary to optimize treatment and reduce complica- dissection of the abdominal muscle and iliac muscle. tions. The Stoppa approach, as a midline approach, can The aponeurosis of the external oblique was carved to provide direct exposure of the area from the sacroiliac identify and dissociate the external ring of inguinal canal joint to the pubic symphysis (including the quadrilateral and expose the medial window. The aponeurosis of the plate) [6, 16]. However, it does not expose the iliac wing internal oblique was incised, followed by a wide drainage and is sometimes combined with the lateral window of film to free and protect the femoral vessels, femoral the IL approach to treat complex acetabular fractures nerve, lymphatic vessels, and conjunctive tendon. Finally, [17, 18]. the iliopubic fascia was separated and cut to expose the To overcome the respective limitations of the IL and middle window. After satisfactory reduction was accom- Stoppa approaches, we have treated complex acetabular plished, a prebent plate was placed for fixation. fractures through the S+IF approach in recent years. Moreover, there is little literature on the treatment of S+IF approach both-column fractures by S+IF approach. Therefore, the The patient who received the S+IF approach (Fig. 2) was aim of this study was to investigate the clinical efficacy placed in the supine position. The incision of the Stoppa of the S+IF approach in the treatment of both-column approach was performed in the region 1~2 cm above the fractures by comparing with the IL approach. pubic symphysis. The bladder was protected, and the rectus abdominis was retracted to expose the pubic sym- Materials and methods physis and the superior ramus of the pubis. The rectus Materials abdominis and neurovascular bundle were then retracted From January 2014 to January 2018, we retrospectively laterally to protect them. If corona mortis was encoun- studied 98 patients with acetabular fractures. Inclusion tered, ligation should be performed. The iliopubic fascia criteria were (1) acute both-column fracture and (2) and obturator fascia were incisively dissected from the fractures treated with the S+IF or IL surgical approach. front to the back to expose the true pelvic rim, the quad- The exclusion criteria were (1) fractures treated via the rilateral plate, and the posterior column of the acetabu- combined anterior and posterior approaches, (2) pre- lum. The ischial support band and the back of the pelvic operative range of motion (ROM) deficiency of the hip, rim could be better exposed by stripping the psoas (3) open fractures, (4) less than 1 year of follow-up, (5) muscle. The IF approach (the lateral window of the IL conservative treatment, and patients with a history of approach) began at the middle of the iliac crest to the bladder surgery, hysterectomy, cesarean section, or pros- ASIS. The exposure of the iliac wing could be achieved tatectomy. Overall, 76 patients met the criteria for inclu- by retracting the iliac muscle and iliac vessels, and the sion. Data were collected through an anonymous way exposure could be improved by flexion, rotation, adduc- because the patients’ identifiers such as name and tion, and abduction of the affected hip. Reduction tech- unique identity were erased. This study was approved by niques included the use of a ball-spiked pusher to the Ethics Committee and Institutional Review Board of provide an outward force, the insertion of a Hohmann West China Hospital. lever at the greater sciatic notch to pry out the posterior All patients were studied with X-rays (anteroposterior column and femoral traction, or the use of traction bed and Judet oblique views) and CT scan with 3D recon- for longitudinal traction. struction for classification of acetabular fractures. Pre- operative skeletal traction was conducted on the affected Follow-up and evaluation criteria side to guard against further injury to the femoral head. The patients’ charts were surveyed for intraoperative All patients were treated by the same medical team. blood loss, operative time, quality of reduction, clinical These patients were divided into two groups according outcome, and perioperative complications. The quality to the surgical approaches. The first group included 44 of the reduction was evaluated based on the immediately patients treated by the IL approach (group I), while the postoperative radiographs. It was graded as anatomic, second group of 32 patients were treated by the S+IF imperfect, and poor according to the scoring system approach (group II). published by Matta [4]. Yang et al. Journal of Orthopaedic Surgery and Research (2020) 15:588 Page 3 of 7 Fig. 1 Surgical incision of the IL approach Follow-up was performed at 1, 2, and 3 months and 1 presented as the mean ± standard deviation. The com- year after surgery and yearly thereafter. Clinical out- plication rates of two groups were determined by chi- comes were measured using the Matta modification of square test.
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