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The Stoppa approach for acetabular fracture

Der Stoppa-Zugang bei Azetabulumfrakturen

  • Operative Techniken
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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

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.

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Conflict of interest

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

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Authors and Affiliations

  1. Department of Kerem, Hadassah-Hebrew University Medical Center, PO Box 12000, 91120, Jerusalem, Israel

    A. Khoury, Y. Weill & R. Mosheiff

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  1. A. Khoury
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  2. Y. Weill
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  3. R. Mosheiff
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Correspondence to A. Khoury.

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Khoury, A., Weill, Y. & Mosheiff, R. The Stoppa approach for acetabular fracture. Oper Orthop Traumatol 24, 439–448 (2012). https://doi.org/10.1007/s00064-011-0093-z

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