Advertisement

Operative Orthopädie und Traumatologie

, Volume 24, Issue 4–5, pp 439–448 | Cite as

The Stoppa approach for acetabular fracture

  • A. Khoury
  • Y. Weill
  • R. Mosheiff
Operative Techniken

Abstract

Objective

Acetabular fractures pose a great surgical challenge for orthopedic trauma surgeons. We believe that the Stoppa approach with an iliac window extension, previously described as a modified Stoppa approach is adequate for the majority of acetabular fractures excluding those with predominant posterior wall involvement. In this paper we will present our experience in using the Stoppa approach, its indications, preparations, the detailed surgical approach, complications and the different tips used in this relatively modern approach.

Indications

All simple and combined fracture types that involve the anterior column of the pelvis including the quadrilateral plate.

Contraindications

Posterior wall or extensive posterior column involvement. Transverse and T-fractures with mainly posterior displacement.

Surgical technique

Suprapubic, intrapelvic approach, extending from the symphysis pubis anteriorly to the sacroiliac joint posteriorly. Superficial landmarks are identical to the Pfannenstiel approach, the rectus abdominis muscles are longitudinally dissected, the symphysis pubis is exposed and a sub-periosteal deep surgical dissection is carried out along the anterior column and the quadrilateral plate, and posteriorly toward the greater sciatic notch and the sacroiliac joint.

Results

In a 5-year review of 60 acetabular fractures that underwent open reduction and internal fixation using the modified Stoppa approach, there were 36% anterior column fractures, 28% both-column fractures, the rest being anterior column with posterior hemi transverse fractures, transverse and T-fractures. Any extension of the fracture to the iliac wing necessitated an additional lateral window (93% of cases). In cases with posterior displacement, an additional approach was utilized to address a posterior wall fracture. All fractures healed within 12 weeks. Mean Merle d’Aubigné score was 15.22. Postoperative radiological evaluation revealed anatomical reduction in 54% of the patients, satisfactory in 43%, and unsatisfactory in 3% of the patients. Overall there were 15 minor and major complications

Keywords

Stoppa approach Acetabular fractures Quadrilateral plate Surgical approach to acetabulum Osteosynthesis 

Der Stoppa-Zugang bei Azetabulumfrakturen

Zusammenfassung

Operationsziel

Azetabulumfrakturen stellen eine große chirurgische Herausforderung für Orthopäden und Unfallchirurgen dar. Unserer Meinung nach ist der Stoppa-Zugang mit Erweiterung durch ein iliakales Fenster, zuvor als modifizierter Stoppa-Zugang beschrieben, für die Mehrzahl der Azetabulumfrakturen geeignet, außer bei vorherrschender Beteiligung der hinteren Wand. In diesem Artikel präsentieren wir unsere Erfahrungen mit dem Zugang nach Stoppa, seine Indikationen, Präparationsverfahren, das detaillierte chirurgische Vorgehen, Komplikationen und verschiedene Tipps, die bei diesem relativ neuen Ansatz zum Einsatz kommen.

Indikationen

Sämtliche einfachen und kombinierten Frakturtypen, an denen der vordere Pfeiler des Beckens einschließlich der quadrilateralen Fläche beteiligt ist.

Kontraindikationen

Beteiligung der Hinterwand oder ausgedehnte Beteiligung des hinteren Pfeilers. Quer- und T-Frakturen mit überwiegend hinterer Dislokation.

Operationstechnik

Suprapubischer, intrapelviner Zugang, der sich vorn von der Symphyse bis hinten zum Sakroiliakalgelenk erstreckt. Orientierungspunkte an der Oberfläche identisch wie beim Pfannenstiel-Zugang, Längsdurchtrennung der Fasern des M. rectus abdominis, Darstellung der Symphyse und tiefe subperiostale chirurgische Dissektion entlang des vorderen Pfeilers und der quadrilateralen Fläche sowie hinten in Richtung Incisura ischiadica major und Sakroiliakalgelenk.

Ergebnisse

In einer 5-Jahres-Übersicht über 60 Azetabulumfrakturen mit offener Reposition und interner Osteosynthese über einen modifizierten Stoppa-Zugang lagen in 36% der Fälle Frakturen des vorderen Pfeilers vor, in 28% 2-Pfeiler-Frakturen, in den übrigen Fällen Frakturen des vorderen Pfeilers mit hinterer Hemiquerfraktur, Quer- und T-Frakturen. Bei Ausdehnung der Fraktur bis zur Darmbeinschaufel war ein zusätzliches laterales Fenster erforderlich (93% der Fälle). In Fällen mit hinterer Dislokation wurde ein zusätzlicher Zugang zur Versorgung einer Hinterwandfraktur verwendet. Alle Frakturen heilten innerhalb von 12 Wochen. Der Score nach Merle d’Aubigné lag im Mittel bei 15,22. Die postoperative radiologische Evaluation ergab bei 54% der Patienten eine anatomische Reposition, zufriedenstellend war die Reposition bei 43% und nicht zufriedenstellend bei 3%. Insgesamt gab es 15 kleinere und größere Komplikationen.

Schlüsselwörter

Stoppa-Zugang Azetabulumfrakturen Quadrilaterale Fläche Chirurgischer Zugang zum Azetabulum Osteosynthese 

Notes

Conflict of interest

On behalf of all authors, the corresponding author states that there are no conflicts of interest.

References

  1. 1.
    Anderson RC, O’Toole RV, Nascone JW et al (2010) Modified Stoppa approach for acetabular fractures with anterior and posterior column displacement: quantification of radiographic reduction and analysis of interobserver variability. J Orthop Trauma 24:271–278CrossRefGoogle Scholar
  2. 2.
    Bray TJ, Esser M, Fulkenson L (1987) Osteotomy of the trochanter in open reduction an internal fixation of acetabular fractures. J Bone Joint Surg 69:711–717PubMedGoogle Scholar
  3. 3.
    Cole JD, Bolhofner BR (1994) Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop 305:112–123PubMedGoogle Scholar
  4. 4.
    Darmanis S, Lewis A, Mansoor A (2007) Bircher M. Corona mortis: an anatomical study with clinical implications in approaches to the pelvis and acetabulum. Clin Anat 20:433–439PubMedCrossRefGoogle Scholar
  5. 5.
    Fishmann AJ, Greeno RA, Brooks LR, Matta JM (1994) Prevention of deep vein thrombosis and pulmonary embolism in the acetabular and pelvic fracture surgery. Clin Orthop Relat Res 305:133–137PubMedCrossRefGoogle Scholar
  6. 6.
    Goulet JA, Bray TJ (1989) Complex acetabular fractures. Clin Orthop Relat Res 240:9–20PubMedGoogle Scholar
  7. 7.
    Helfet DL, Borrelli J, DiPasquale T, Sanders R (1992) Stabilization of acetabular fractures in elderly patients. J Bone Joint Surg Am 74:753–765PubMedGoogle Scholar
  8. 8.
    Guy P, Al-Otaibi M, Harvey E, Helmy N (2010) The ‘safe zone’ for extra-articular screw placement during intra-pelvic acetabular surgery. J Orthop Trauma 24:279–283PubMedCrossRefGoogle Scholar
  9. 9.
    Helfet DL, Schmeling GJ (1994) Management of the complex acetabular fractures through single nonextensile exposures. Clin Orthop Relat Res 305:58–68 (Review)PubMedCrossRefGoogle Scholar
  10. 10.
    Jakob M, Droeser R, Zobrist R et al (2006) A less invasive anterior intrapelvic approach for the treatment of acetabular fractures and pelvic ring injuries. J Trauma 60:1364–1370PubMedCrossRefGoogle Scholar
  11. 11.
    Johnson EE, Eckardt JJ, Letournel E (1987) Extrinsic femoral artery occlusion following internal fixation of an acetabular fracture: a case report. Clin Orthop Relat Res 217:209–213PubMedGoogle Scholar
  12. 12.
    Judet R, Judet J, Letournel E (1964) Fractures of the acetabulum: classification and surgical approaches for open reduction. Preliminary report. J Bone Joint Surg Am 46:1615–1646PubMedGoogle Scholar
  13. 13.
    Kebaish AS, Roy A, Rennie W (1991) Displaced acetabular fractures. Long-term follow-up. J Trauma 31:1539–1542PubMedCrossRefGoogle Scholar
  14. 14.
    Kloen P, Siebenrock KA, Ganz R (2002) Modification of the ilioinguinal approach. J Orthop Trauma 16:586–593PubMedCrossRefGoogle Scholar
  15. 15.
    Letournel E (1961) Les fractures du cotyle, etude d’une serie de 75 cas. J de Chirurgie 82:47–87 [French]Google Scholar
  16. 16.
    Letournel E (1980) Acetabulum fractures: classification and management. Clin Orthop Relat Res 151:81–106PubMedGoogle Scholar
  17. 17.
    Letournel E (1993) The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 292:62–76 (Review)PubMedGoogle Scholar
  18. 18.
    Letournel E, Judet R (1993) Fractures of the acetabulum, 2nd. edn. Springer Verlag, New YorkGoogle Scholar
  19. 19.
    Letournel E (1994) Fractures of the acetabulum. A study of a series of 75 cases. 1961. Clin Orthop Relat Res 305:5–9PubMedCrossRefGoogle Scholar
  20. 20.
    Mast J, Jakob R, Ganz R (1989) Planning and reduction techniques in fracture surgery. Springer Verlag, BerlinGoogle Scholar
  21. 21.
    Matta JM (1994) Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. Clin Orthop Relat Res 305:10–19PubMedCrossRefGoogle Scholar
  22. 22.
    Matta JM (1986) Operative indications and choice of surgical approach for fractures of the acetabulum. Tech Orthop 1:13–22CrossRefGoogle Scholar
  23. 23.
    Matta JM (2006) Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. J Orthop Trauma 20(Suppl 1):20–29Google Scholar
  24. 24.
    Mears DC (1999) Surgical treatment of acetabular fractures in elderly patients with osteoportic bone. J Am Acad Orthop Surg 7:128–141 (Review)PubMedGoogle Scholar
  25. 25.
    Mears DC, Rubash HE (1985) Fractures of the acetabulum. Hip 1985:95–113Google Scholar
  26. 26.
    Montgomery KD, Geerts WH, Potter HG, Helfet DL (1997) Practical management of venous thromboembolism following pelvic fractures. Orthop Clin North Am 28:397–404 (Review)PubMedCrossRefGoogle Scholar
  27. 27.
    Ponsen KJ, Joosse P, Schigt A et al (2006) Internal fracture fixation using the Stoppa approach in pelvic ring and acetabular fractures: technical aspects and operative results. J Trauma 61:662–667PubMedCrossRefGoogle Scholar
  28. 28.
    Probe R, Reeve R, Lindsey RW (1992) Femoral artery thrombosis after open reduction of an acetabular fracture. Clin Orthop Relat Res 283:258–260PubMedGoogle Scholar
  29. 29.
    Qureshi AA, Archdeacon MT, Jenkins MA et al (2004) Infrapectineal plating for acetabular fractures: a technical adjunct to internal fixation. J Orthop Trauma 18:175–178PubMedCrossRefGoogle Scholar
  30. 30.
    Reinert CM, Bosse MJ, Poka A et al (1988) A modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg Am 70:329–337PubMedGoogle Scholar
  31. 31.
    Routt ML, Swiontkowski MF (1990) Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am 72:897–904PubMedGoogle Scholar
  32. 32.
    Sagi HC, Afsari A, Dziadosz D (2010) The anterior intra-pelvic (Modified Rives-Stoppa) approach for fixation of acetabular fractures. J Orthop Trauma 24:263–270PubMedCrossRefGoogle Scholar
  33. 33.
    Stoppa RE, Rives JL, Warlaumont CR et al (1984) The use of Dacron in the repair of hernias of the groin. Surg Clin North Am 64:269–285PubMedGoogle Scholar
  34. 34.
    Stoppa RE (1989) The treatment of complicated groin and incisional hernias. World J Surg 13:545–554PubMedCrossRefGoogle Scholar
  35. 35.
    Tannast M, Siebenrock KA (2009) Die operative behandlung der azetabulum-T-Fraktur über eine chirurgische Hüftluxation oder einen Stoppa-Zugang. Oper Orthop Traumatol 21:251–269PubMedCrossRefGoogle Scholar

Copyright information

© Springer Verlag 2012

Authors and Affiliations

  1. 1.Department of KeremHadassah-Hebrew University Medical CenterJerusalemIsrael

Personalised recommendations