Citation Information :
Patil A, Attarde DS, Haphiz A, Sancheti P, Shyam A. A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients. 2021; 16 (3):152-160.
Aim and objective: To study the radiological and functional outcomes as well as complications in the management of fractures involving both columns of the acetabulum using a single surgical approach.
Design: Type IV, prospective clinical study.
Setting: Level I trauma centre.
Materials and methods: Inclusion criteria were as follows: (a) patients over 20 year of age and (b) patients suffering from acetabular fractures involving both columns as per Letournel and Judet classification, namely transverse, transverse + posterior wall, T type, anterior column posterior hemi-transverse (ACPHT) and associated both columns. Exclusion criteria were as follows: (a) patient suffering from isolated anterior column, posterior column, anterior wall, posterior wall and posterior wall + column fractures; (b) patient who have undergone surgical procedures of the hip prior to trauma; and (c) compound acetabular fractures. A total of 23 patients having both column acetabulum fractures were included prospectively from June 2016 to December 2018 and followed up till 1 year postoperatively. Open reduction and internal fixation were performed through one of three described approaches, i.e., iliofemoral, Kocher-Langenbeck, and anterior intrapelvic or ilioinguinal.
Results: Our study population consisted of 30.4% transverse, 39.1% associated both columns, 21.7% T type and 8.7% anterior column + posterior hemi-transverse. Of these, 65.2% were operated using the Kocher-Langenbeck approach, while 30.4% of patients required the anterior intrapelvic approach. The remaining 4.3% of patients were operated by the iliofemoral approach. Anatomic reduction was achieved in 100% of our study population with remaining displacement less than or equal to 1°mm. At 1-year follow-up, all fractures showed a satisfactory union with an excellent Matta index in 100% study subjects. Complications at 1 year included one case of foot drop, which was present preoperatively but failed to improve and one case of post-traumatic arthritis. Average Harris Hip score (HHS) and mean Merle D\'Aubigne (MDA) scores suggested good clinical outcomes in the study population.
Conclusions: A single approach can be used to achieve good functional and radiological outcomes in carefully selected bicolumnar fractures of the acetabulum, with less approach-related morbidity.
Clinical significance: Traditionally, multiple approaches are used for acetabulum fractures involving both columns, but with proper patient selection, single approach can be used with good functional and surgical outcomes.
Peter RE. Open reduction and internal fixation of osteoporotic acetabular fractures through the ilio-inguinal approach: use of buttress plates to control medial displacement of the quadrilateral surface. Injury 2015;46(Suppl 1):S2–S7. DOI: 10.1016/S0020-1383(15)70003-3.
Khoury A, Weill Y, Mosheiff R. The Stoppa approach for acetabular fracture. Oper Orthop Traumatol 2012;24(4–5):439–448. DOI: 10.1007/s00064-011-0093-z.
Letournel E. Diagnosis and treatment of nonunions and malunions of acetabular fractures. Orthop Clin North Am 1990;21(4):769–788. PMID: 2216407.
Hesp WL, Goris RJ. Conservative treatment of fractures of the acetabulum. Results after longtime follow-up. Acta Chir Belg 1988;88(1):27–32. PMID: 3376664.
Matta JM, Mehne DK, Roffi RA. Fractures of the acetabulum. Early results of a prospective study. Clin Orthop Relat Res 1986;(205):241–250. PMID: 3698383.
Mcmurtry R, Walton D, Dickinson D, et al. Pelvic disruption in the polytraumatized patient: a management protocol. Clin Orthop Relat Res 1980;(151):22–30. PMID: 7418309.
Culemann U, Holstein JH, Köhler D, et al. Different stabilisation techniques for typical acetabular fractures in the elderly—a biomechanical assessment. Injury 2010;41(4):405–410. DOI: 10.1016/j.injury.2009.12.001.
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 2012;94(3):405–411. DOI: 10.1302/0301-620X.94B3.27801.
Märdian S, Schaser KD, Hinz P, et al. Fixation of acetabular fractures via the ilioinguinal versus pararectus approach: a direct comparison. Bone Joint J 2015;97-B(9):1271–1278. DOI: 10.1302/0301-620X.97B9.35403.
Hammad AS, El-Khadrawe TA. Accuracy of reduction and early clinical outcome in acetabular fractures treated by the standard ilio-inguinal versus the Stoppa/iliac approaches. Injury 2015;46(2):320–326. DOI: 10.1016/j.injury.2014.10.053.
Jakob M, Droeser R, Zobrist R, et al. A less invasive anterior intrapelvic approach for the treatment of acetabular fractures and pelvic ring injuries. J Trauma 2006;60(6):1364–1370. DOI: 10.1097/01.ta.0000208139.97474.f7.
Probe RO, Reeve RO, Lindsey RW. Femoral artery thrombosis after open reduction of an acetabular fracture. Clin Orthop Relat Res 1992(283):258–260. PMID: 1395255.
Hirvensalo E, Lindahl J, Kiljunen V. Modified and new approaches for pelvic and acetabular surgery. Injury 2007;38(4):431–441. DOI: 10.1016/j.injury.2007.01.020.
Guy P. Evolution of the anterior intrapelvic (Stoppa) approach for acetabular fracture surgery. J Orthop Trauma 2015;29(Suppl. 2):S1–S5. DOI: 10.1097/BOT.0000000000000269.
Ansari M. Is single Ilioinguinal approach the solution for treating all types of acetabular fractures-a prospective study of 54 patients. IOSR-JDMS 2013;8(5):26–34. DOI: 10.9790/0853-0852634.
Isaacson MJ, Taylor BC, French BG, et al. Treatment of acetabulum fractures through the modified Stoppa approach: strategies and outcomes. Clin Orthop Rel Res 2014;472(11):3345–3352. DOI: 10.1007/s11999-014-3460-x.
Xue Z, Qin H, Ding H, et al. A novel approach for treatment of acetabular fractures. Med Sci Monit 2016;22:3680–3688. DOI: 10.12659/msm.898887.
Chen K, Ji Y, Huang Z, et al. Single modified ilioinguinal approach for the treatment of acetabular fractures involving both columns. J Orthop Trauma 2018;32(11):e428–e434. DOI: 10.1097/BOT.0000000000001303.
Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach: a 10-year perspective. J Orthop Trauma 2006;20(1):S20–S29. PMID: 16385203.
Prevezas N. Evolution of pelvic and acetabular surgery from ancient to modern times. Injury 2007;38(4):397–409. DOI: 10.1016/j.injury.2007.01.035.
Hue AG, Gauthé R, Tobenas-Dujardin AC, et al. Complex fractures of the acetabulum: should the enlarged iliofemoral approach be abandoned? Results at 20 years’ follow-up. Orthop Traumatol Surg Res 2018;104(4):465–468. DOI: 10.1016/j.otsr.2018.02.005.
Moroni A, Caja VL, Sabato C, et al. Surgical treatment of both-column fractures by staged combined ilioinguinal and Kocher-Langenbeck approaches. Injury 1995;26(4):219–224. DOI: 10.1016/0020-1383(95)00007-v.
Zhang R, Yin Y, Li S, et al. Minimally invasive treatment of both-column acetabular fractures through the Stoppa combined with iliac fossa approach. Scientific Rep 2017;7(1):1–9. DOI: 10.1038/s41598-017-08724-1.
Suzuki T, Smith WR, Hak DJ, et al. Combined injuries of the pelvis and acetabulum: nature of a devastating dyad. J Orthop Trauma 2010;24(5):303–308. DOI: 10.1097/BOT.0b013e3181ca32af.
Osgood GM, Manson TT, O'Toole RV, et al. Combined pelvic ring disruption and acetabular fracture: associated injury patterns in 40 patients. J Orthop Trauma 2013;27(5):243–247. DOI: 10.1097/BOT.0b013e31826c2751.
Chin FY, Lo WH, Chen TH, et al. Fractures of posterior wall of acetabulum. Arch Orthop Trauma Surg 1996;115(5):273–275. DOI: 10.1007/BF00439052.
Iqbal F, Taufiq I, Najjad MK, et al. Functional and radiological outcome of surgical management of acetabular fractures in tertiary care hospital. Hip Pelvis 2016;28(4):217–224. DOI: 10.5371/hp.2016. 28.4.217.
Paksoy AE, Topal M, Aydin A, et al. Outcomes of surgical management of acetabular fractures treated with anterior approaches. Eurasian J Med 2019;51(3):257–261. DOI: 10.5152/eurasianjmed. 2019.0241.
Jindal K, Aggarwal S, Kumar P, et al. Complications in patients of acetabular fractures and the factors affecting the quality of reduction in surgically treated cases. J Clin Orthop Trauma 2019;10(5):884–889. DOI: 10.1016/j.jcot.2019.02.012.
Çağlar Ö, Kamacı S, Bekmez Ş, et al. Mid-term results of displaced acetabulum fractures surgically treated using anterior intra-pelvic approach (modified Stoppa). Ulus Travma Acil Cerrahi Derg 2020;26(1):130–136. DOI: 10.14744/tjtes.2019.03835.
Kizkapan TB, Misir A, Uzun E, et al. Comparison of acetabulum posterior wall fractures and fracture dislocations: dislocation does not affect clinical and radiological outcomes. Acta Orthop Belg 2018;84:117–122. PMID: 30462593.
Letournel E, Judet R. Fractures of the acetabulum. Springer Science & Business Media; 2012.