This study showed that the solely anterior plating via modified Stoppa approach achieved clinically satisfactory mid-term outcomes for complex acetabular fractures with posterior column detachments. Preoperative fracture type identification based on the novel three-column classification is facilitative to identify the appropriate candidates for such a simplified approach.
The modified Stoppa approach with the lateral window of the classic ilioinguinal approach is practically convenient to access fracture fragments of posterior column effectively with advantages of less blood loss, shorter operation time, and fewer complications than other traditional approaches. The average intraoperative blood loss in our cohorts was 320 mL, which was significantly less than blood loss with a single ilioinguinal approach ranging from 760 mL to 1170 [26, 29] or simultaneous anterior (Stoppa/iliac window approach) and Kocher-Langenbeck approach ranging from 586 ml to 1252 ml [30–32]. Similarly, the average operative time in our cohorts (2.1 hours) is considerably shorter than the single ilioinguinal approach (2.6–4.3 hours) [26, 33] and the simultaneous anterior modified ilioinguinal/Stoppa approach (2.1–4.4 hours) [30, 31, 34–36]. Moreover, no heterotopic ossification and only two obturator nerve injury (recovered within 3 months postop) was observed in our cohorts, which are also significantly less than the rates of heterotopic ossification (25.6%), traumatic nerve palsy (16.4%), and iatrogenic nerve palsy (8.0%) in 3670 patients reported by a recent meta-analysis [37].
Previous biomechanical experiments demonstrated that a single locking plating of the anterior column provided less stability than a traditional treatment with posterior column plating and anterior column screwing [38], however, the anterior fixation with multiple spring plates, especially the ilioischial plate, practically allows for a direct buttressing of posterior column fractures and provides clinically comparable stability as a posterior plating. The additional lag screws positioned from anterior to posterior direction can fix the fragments of the posterior columns and achieve a rigid fixation [39, 40]. Here, all patients achieved radiographic bone healing at 3 months postoperatively with good or excellent fracture abduction and fixation in 90% cases, which are in good agreement with a previous study reporting congruent reduction in 89% cases treated with either single (anterior or posterior) approach or simultaneous anterior-posterior approach [41]. Similarly, 85% of our cases achieved good or excellent hip function at average 17-month postoperatively, consistent with a prior investigation reporting satisfactory hip function in 85.2% cases treated via simultaneous ilioinguinal and Kocher-Langenbeck approaches over 4-year postoperatively [42].
The newly established three-column classification is practical to identify the pattern of complex acetabular fracture and provides an instrumental guide to select corresponding most favorable interventions. Based on this novel classification, the indications of such a simplified approach are proposed as follows: (1) type B1.1, intact roof-anterior column fractures; (2) type B1.2, separated roof-anterior column fractures; (3) type B1.3, complicated roof-anterior column fractures; (4) type B2.1, intact anterior-posterior column fractures; (5) type B2.2, separated anterior-posterior column fractures; (6) type B2.3, complicated anterior-posterior column fractures without posterior wall fractures; (7) type C1, elementary 3-column fractures; (8) and type C3, complicated 3-column fractures. Preoperative evaluation of patient status, fracture type, extent of the displacement, the surgeon’s experience is crucial [34]. For patients with obesity or history of previous low abdominal surgeries with possible local adhesions, other approaches might be favorable. Moreover, imprudent manipulation with limited exposure might cause extensive soft tissue damages and hinder the satisfactorily reduction of fractures, possibly influencing the long-term prognosis [11, 43, 44]. Therefore, surgeons are recommended to start using this modified Stoppa approach after mastering the ilioinguinal approach to avoid possible iatrogenic injuries of the perifracture structures.
Several limitations exist in this study. The sample size of our cohorts was relatively small, and the follow-up is also relatively short, which might not allow to draw firm conclusions about ultimate efficacy of the anterior plating for complex acetabular fracture with posterior column detachments. Secondly, the retrospective analysis cannot allow for a detailed investigation of characteristics of our cohorts and a comparison with a possible control group. Moreover, long-term comparisons with traditional treatments are required to confirm the possible benefits of this procedure. Strengths of this investigation include the establishment of the indications of such a simplified approach based on the novel three-column classification and the representation of its corresponding mid-term outcomes.