Newly modified Stoppa approach for acetabular fractures

Purpose

We present our experience of using a newly modified Stoppa approach combined with a lateral approach to the iliac crest in patients with acetabular fractures in reference to fracture reduction and fixation, technical aspects, and the incidence of complications.

Methods

We used a consecutive group of 29 adult patients with acetabular fractures treated operatively with a newly modified Stoppa approach between 2009 and 2011. The newly modified Stoppa approach was performed to fix the acetabular fractures with main anterior displacement and the anterior and lateral parts of the pelvis. This approach was combined with a lateral approach on the iliac crest for fractures of the iliac wing.

Results

All the patients were followed up for at least 1.5 years. Of the 29 patients, ten anterior column, two associated both column, seven anterior column with posterior hemi-transverse, four transverse, and six T-type fractures. The average blood loss was 950 mL, and average operative time was 155 minutes. Anatomic or satisfactory reduction was achieved in 96 % of the acetabular fractures. Two patients had mild symptoms of the lateral femoral cutaneous nerve and improved within three months.

Conclusions

The newly modified Stoppa approach provides excellent visualization to the anterior column, quadrilateral surface and permits good postoperative results for treatment of acetabular fractures. We considered this technique as a viable alternative for the ilioinguinal approach when exposure of the anterior acetabulum is needed.     

The Stoppa approach for acetabular fracture

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     

Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach

Introduction

Data concerning outcome after management of acetabular fractures by anterior approaches with focus on age and fractures associated with roof impaction, central dislocation and/or quadrilateral plate displacement are rare.

Methods

Between October 2005 and April 2009 a series of 59 patients (mean age 57 years, range 13–91) with fractures involving the anterior column was treated using the modified Stoppa approach alone or for reduction of displaced iliac wing or low anterior column fractures in combination with the 1st window of the ilioinguinal approach or the modified Smith-Petersen approach, respectively. Surgical data, accuracy of reduction, clinical and radiographic outcome at mid-term and the need for endoprosthetic replacement in the postoperative course (defined as failure) were assessed; uni- and multivariate regression analysis were performed to identify independent predictive factors (e.g. age, nonanatomical reduction, acetabular roof impaction, central dislocation, quadrilateral plate displacement) for a failure. Outcome was assessed for all patients in general and in accordance to age in particular; patients were subdivided into two groups according to their age (group “<60 yrs”, group “≥60 yrs”).

Results

Forty-three of 59 patients (mean age 54 yrs, 13–89) were available for evaluation. Of these, anatomic reduction was achieved in 72% of cases. Nonanatomical reduction was identified as being the only multivariate predictor for subsequent total hip replacement (Adjusted Hazard Ratio 23.5; p < 0.01). A statistically significant higher rate of nonanatomical reduction was observed in the presence of acetabular roof impaction (p = 0.01). In 16% of all patients, total hip replacement was performed and in 69% of patients with preserved hips the clinical results were excellent or good at a mean follow up of 35 ± 10 months (range: 24–55). No statistical significant differences were observed between both groups.

Conclusion

Nonanatomical reconstruction of the articular surfaces is at risk for failure of joint-preserving management of acetabular fractures through an isolated or combined modified Stoppa approach resulting in total joint replacement at mid-term. In the elderly, joint-preserving surgery is worth considering as promising clinical and radiographic results might be obtained at mid-term.     

Rationales for the Bernese approaches in acetabular surgery

Purpose

To present two new approaches to acetabular surgery that were established in Berne, and which aim at enhanced visualization and anatomical reconstruction of acetabular fractures.

Method

The trochanteric flip osteotomy allows for surgical hip dislocation, and was introduced as a posterior approach for acetabular fracture management involving the posterior column and wall. For acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach is described.

Results

Full exposure of the hip joint, as provided by the trochanteric flip osteotomy, facilitates anatomical reduction of acetabular or femoral head fractures and safe positioning of the anterior column screw in transverse or T-shaped fractures. Additionally, the approach enables osteochondral transplantation as a salvage procedure for severe chondral femoral head damage and osteoplasty of an associated inadequate offset at the femoral head–neck junction. The Pararectus approach allows anatomical restoration with minimal access morbidity, and combines advantages of the ilioinguinal and modified Stoppa approaches.

Conclusions

Utilization of the trochanteric flip osteotomy eases visualization of the superior aspect of the acetabulum, and enables the evaluation and treatment of chondral lesions of the femoral head or acetabulum and labral tears. Displaced fractures of the anterior column with a medialized quadrilateral plate can be addressed successfully through the Pararectus approach, in which surgical access is associated with minimal morbidity. However, long-term results following the two presented Bernese approaches are needed to confirm that in the treatment of complex acetabular fractures the rate of poor results in almost one-third of all cases (as currently yielded using traditional approaches) might be reduced by the utilization of the presented novel approaches.     

Delayed Total Hip Arthroplasty for Failed Acetabular Fractures: The Influence of Initial Fracture Management on Outcome After Arthroplasty

Background

Total hip arthroplasty (THA) provides a successful salvage option for failed acetabular fractures. The complexity of arthroplasty for a failed acetabular fracture will depend on the fracture pattern and the initial management of the fracture. Our objective was to compare the midterm outcome of THA between patients who presented with failed acetabular fractures following initial surgical or nonsurgical treatment.

Longitudinal morphological change of acetabular subchondral bone cyst after total hip arthroplasty in developmental dysplasia of the hip

Purpose

The purpose of this study is to clarify morphological changes of acetabular subchondral bone cyst after total hip arthroplasty for osteoarthritis secondary to developmental dysplasia of the hip.

Methods

Two hundred and sixty-one primary cementless total hip arthroplasties of 208 patients, 18 males, 190 females, were retrospectively reviewed. Morphological changes of subchondral bone cyst were evaluated by computed tomography (CT). The mean cross-sectional area of the cyst from CT scans at 3 months postoperatively and after 7–10 years (average 8.4 years) were compared.

Results

Acetabular subchondral bone cysts were found in 49.0% of all cases in preoperative CT scans. There was no cyst which was newly recognized in CT scan performed after postoperative 7–10 years. All the cross-sectional areas of the cysts evaluated in this study were reduced postoperatively.

Conclusions

This study revealed that acetabular subchondral bone cysts do not increase or expand after total hip arthroplasty and indicated that the longitudinal morphological change of acetabular bone cysts in patients of developmental dysplasia of the hip do not influence long-term implant fixation in total hip arthroplasty.

     

Cementless total hip arthroplasty in the treatment after acetabular fractures

Introduction

The outcomes of total hip arthroplasty (THA) for the treatment of posttraumatic arthritis after acetabular fractures were inferior to those after primary non-traumatic THA.

Methods

This study was performed in academic level I trauma center. From January 2011 to December 2014, a consecutive series of 21 patients (9 females), with average age of 56.7 years (range 29–75 years) who had posttraumatic hip joint arthritis after acetabular fractures, were included in our study. All patients underwent cementless THA. The average duration of follow-up was 26 months (range 24–36 months).

Results

At the latest follow-up, all patients could walk independently, thirteen (62%) patients had excellent Harris hip score, five (24%) had good HHS, and 3 (14%) had fair score. WOMAC scale decreased from 63 (range 42–92) to 4 (range 0–19). Two patients (9.5%) had heterotopic bone formation which did not affect the activity of the patients. There were no signs of loosening of the acetabular cups or around the femoral stem.

Conclusion

Cementless THA is an ideal treatment for posttraumatic hip arthritis with anatomic restoration of the hip center to improve the functional results and decrease the incidence of complications and revision rate.

     

Auxiliäre Cerclage zur Reposition und Retention dislozierter Acetabulumfrakturen

Background

Displaced fractures of the acetabulum involving the quadrilateral plate continue to be a surgical challenge. In this study, we describe our operation technique of auxiliary acetabular cerclage-wiring combined with plate osteosynthesis and present our results as well as short-term outcome.

Patients and methods

All patients aged 18 years and older treated with auxiliary cerclage-wiring between 2007 and 2012 were included in this study. Fractures were classified according to Letournel. Cerclage wiring was used when reposition and retention of the fracture was insufficient with plates and screws alone. Short-term outcome was evaluated by the German Short Musculoskeletal Functional Assessment (SMFA-D) questionnaire.

Results

Data from 23 patients were collected. The follow-up period was 7 months (range 2–23 months). Of the 23 patients, 22 showed excellent fracture reduction and retention. One patient had to undergo revision surgery due to loss of reposition. Patients showed good functional outcome.

Conclusion

Auxiliary acetabular cerclage-wiring is a safe and effective method for fracture reduction and retention especially in displaced acetabular fractures involving the quadrilateral plate.

     

Hip arthroplasty in failed intertrochanteric fractures in elderly

Background:

Failed intertrochanteric fractures in elderly patients are surgical challenge with limited options. Hip arthroplasty is a good salvage procedure even though it involves technical issues such as implant removal, bone loss, poor bone quality, trochanteric nonunion and difficulty of surgical exposure.

Materials and Methods:

30 patients of failed intertrochanteric fractures where hip arthroplasty was done between May 2008 and December 2011 were included in study. 13 were males and 17 were females with average age of 67.3 years. There were 2 cemented bipolar arthroplasties, 19 uncemented bipolar, 4 cemented total hip arthroplasty and 5 uncemented total hip arthroplasties. 16 patients had a trochanteric nonunion, which was treated by tension band principles. Total hip was considered where there was acetabular damage due to the penetration of implant.

Results:

The average followup was 20 months (range 6-48 months). Patients were followed up from 6 to 48 months with average followup of 20 months. None of the patients were lost to followup. There was no dislocation. All patients were ambulatory at the final followup.

Conclusion:

A predictable functional outcome can be achieved by hip arthroplasty in elderly patients with failed intertrochanteric fractures. Though technically demanding, properly performed hip arthroplasty can be a good salvage option for this patient group.     

Survivorship of a Porous Tantalum Monoblock Acetabular Component in Primary Hip Arthroplasty With a Mean Follow-Up of 18 Years

Background

The use of porous tantalum for the acetabular component in primary total hip arthroplasty (THA) has demonstrated excellent short-term and midterm results. However, long-term data are scarce. The purpose of this prospective study is to report the long-term clinical and radiologic outcome following use of an uncemented porous tantalum acetabular component in primary THA with a minimum follow-up of 17.5 years, in a previously studied cohort of patients.

Use of tricortical iliac crest strut autograft in comminuted posterior wall acetabular fractures: A case series

Purpose

The results for fixation of comminuted posterior wall acetabular fractures are not very promising with reported complications in terms of osteoarthritis, nonunion and malunion which subsequently require conversion to total hip arthroplasty. The conversion to total hip arthroplasty is possible in patients over 50 years of age but not in younger patients. So this requires new methods for salvage of the native hip in young patients.

髋臼四方区复杂型骨折手术入路的选择

目的：根据复杂型髋臼四方区骨折的不同类型,探讨不同手术入路,以获得更好的手术暴露和更可靠的复住内固定。方法：自2006年1月至2011年1月共收治58例髋臼四方区骨折,男36例,女22例;年龄23～61岁,平均36．9岁。术前摄骨盆片及双斜位片,辅以CT扫描重建髋臼,按Letournel分型其中前柱15例,横形12例,T形7例,前柱伴后半横形9例,双柱骨折15例。分别采用单纯Kocher—Langenbeck（K—L）入路、髂腹股沟入路、改良的Stoppa入路手术、组合式联合手术入路,或者经改良Stoppa入路结合经皮髋臼前柱拉力螺钉固定。结果：49例患者获随访,时间2～6年,平均32个月,术后其中1例发生深部感染,经创口引流,配合有效抗生素后治愈,2例出现坐骨神经损伤,2例出现股骨头坏死。手术结果复位按Matta标准评定：解剖复位（移位〈1mm）36例,满意复位（移位1～3mm）8例,不满意复位（移位〉3ram）5例。关节功能按Merle d＇Aubigne和Postel标准评定：优32例,良12例,可4例,差1倒,总分（15．3±2．5）。结论：采用单一的手术入路只能解决一部分类型的髋臼复杂型四方区骨折,更多的需要采用联合入路,改良的Stoppa入路结合髂腹股沟前入路或者结合前柱髋臼螺钉通常是解决复杂型四方区骨折移位有效的手术入路,临床疗效满意。     

Hüftendoprothese bei Koxarthrose nach Azetabulumfrakturen

Aim

This study analyzed factors influencing prosthetic hip function after total hip replacement surgery (THR) including the initial acetabular fracture type, patient age, and the acetabular reconstruction component.

Material and method

A total of 45 patients with secondary arthritis due to acetabular fracture and THR were prospectively selected from our total hip arthroplasty register between July 1999 and December 2005. The initial acetabular fracture was classified according to the AO system and the statistical analysis of the preoperative and postoperative Harris hip score (HHS) was correlated with age, type of fracture and acetabular reconstruction component.

Results

Of the fractures 44 could be classified and 39 patients were included in the study. Median follow-up period was 15 months. HHS increased on average from 35 to 91. Only type C fractures showed statistical relevance and age had no influence on the median increase in HHS (53–55). Most important was the preoperative HHS and the restoration of proper hip anatomy and rotational alignment.

Conclusion

Patient age and injury severity influenced the preoperative function and hence the HHS after THR; however, these factors had no influence on the individual increase in the HHS.     

Treatment of periprosthetic acetabular fractures after previous hemi- or total hip arthroplasty

Objective

Treatment of displaced periprosthetic acetabular fractures in elderly patients. The goal is to stabilize an acetabular fracture independent of the fracture pattern, by inserting the custom-made roof-reinforcement plate and starting early postoperative full weight-bearing mobilization.

Indications

Acetabular fracture with or without previous hemi- or total hip arthroplasty.

Contraindications

Non-displaced acetabular fractures.

Surgical technique

Watson-Jones approach to provide accessibility to the anterior and supraacetabular part of the iliac bone. Angle-stable positioning of the roof-reinforcement plate without any fracture reduction. Cementing a polyethylene cup into the metal plate and restoring prosthetic femoral components.

Postoperative management

Full weight-bearing mobilization within the first 10 days after surgery. In cases of two column fractures, partial weight-bearing is recommended.

Results

Of 7 patients with periprosthetic acetabular fracture, 5 were available for follow-up at 3, 6, 6, 15, and 24 months postoperatively. No complications were recognized and all fractures showed bony consolidation. Early postoperative mobilization was started within the first 10 days. All patients except one reached their preinjury mobility level. This individual and novel implant is custom made for displaced acetabular and periprosthetic fractures in patients with osteopenic bone. It provides a hopeful benefit due to early full weight-bearing mobilization within the first 10 days after surgery.

Limitations

In case of largely destroyed supraacetabular bone or two-column fractures according to Letournel additional synthesis via an anterior approach might be necessary. In these cases partial weight bearing is recommended.

     

Trochanteric Fixation With a Third-Generation Cable-Plate System: An Independent Experience

Background

Greater trochanteric fracture/nonunion can be a devastating complication with significant functional impact after total hip arthroplasty, and their fixation remains a challenge because of the significant forces being transmitted as well as the poor bone quality often associated with these fractures. The objective of this study is to investigate the rates of reoperation and trochanteric nonunion using a third-generation cable-plate system at one center.

Treatment of Crowe Type-IV Hip Dysplasia Using Cementless Total Hip Arthroplasty and Double Chevron Subtrochanteric Shortening Osteotomy: A 5- to 10-Year Follow-Up Study

Background

The purpose of this study was to evaluate the functional and radiographic results of patients with Crowe type-IV hip dysplasia treated by cementless total hip arthroplasty and double chevron subtrochanteric osteotomy.

改良Stoppa入路在治疗骨盆髋臼骨折中的应用

目的:探讨改良Stoppa入路在骨盆髋臼骨折治疗中的应用疗效。方法:2010年3月至2012年5月共收治16例骨盆骨折和7例髋臼骨折患者,男18例,女5例;年龄17～65岁,平均39岁。16例骨盆骨折按Tile分型:B1型1例,B2型2例,B3型3例;C1-1型4例,C1-2型2例,Cl-3型2例,C2型2例。7例髋臼骨折按Letournel分型:前柱骨折l例,横形骨折1例,T形骨折2例,前柱伴后半横形骨折1例,双柱骨折2例。16例骨盆骨折中单独使用改良Stoppa入路9例,联合髂窝入路6例,联合后路l例。7例髋臼骨折中单独使用改良Stoppa入路4例,联合Kocher-Langenbeck入路2例,联合髂窝入路及Kocher-Langenbeck入路1例。结果:23例患者手术时间50～350min,平均130min;出血量100～1200ml,平均320ml;无手术并发症。术后根据Matta影像学评分,16例骨盆骨折均复位优;髋臼骨折复位优4例,良3例。21例患者获得随访,时间4～24个月,平均8个月,骨折均获愈合,愈合时间2.5～5个月,平均3.2个月。螺钉松动1例,l例屈髋轻度受限,无钢板断裂,无腹壁疝情况。结论:改良Stoppa入路治疗骨盆、髋臼骨折,其操作安全简捷、并发症少的优点,具有一定的应用价值。     

Infrapectineal plating for acetabular fractures: a technical adjunct to internal fixation

Acetabular fractures with medial displacement patterns, particularly medial displacement of the quadrilateral surface, may be technically challenging to treat. Minimal bone stock, limited anatomic access, and difficulty in obtaining stable internal fixation in the true pelvis contribute to the surgical challenge of open reduction and internal fixation. Applying a medial buttress plate across the quadrilateral plate below the iliopectineal line in the true pelvis can be a helpful adjunct to internal fixation in these fractures. The quadrilateral plate is approached from the opposite side of the injury through a standard ilioinguinal approach or a modified Stoppa approach. An undercontoured plate is secured posteriorly along the sciatic buttress posterior to the joint and the quadrilateral plate and anteriorly on the posterior surface of the pubic ramus. By resisting medial secondary redisplacement, this technique adds to stable fixation for acetabular fractures involving medial displacement, particularly of the quadrilateral plate.     

Structural Allograft Supporting a Trabecular Metal Cup Provides Durable Results in Complex Revision Arthroplasty

Background

Revision total hip arthroplasty (THA) is challenging specially in the presence of severe acetabular bone deficiency. We report the use of a highly porous revision shell augmented by structural allograft to provide structural support and coverage to the acetabular component.