The Archives of Bone and Joint Surgery

The Archives of Bone and Joint Surgery

Outcomes of the Modified Stoppa Approach in Acetabular Fracture Management: Incidence of Nerve Injuries

Document Type : RESEARCH PAPER

Authors
Kamyar Khoshabi 1
Alireza Manafi Rasi 1
Reza Zandi 2
Farzad Amoozadeh Omrani 1
Reza Tavakoli Darestani 1
Mirbahador Athari 1
Sina Afzal 1
1 Department of Orthopedic Surgery, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 Department of Orthopedic Surgery, Taleghani Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
10.22038/abjs.2023.75631.3498
Abstract
Objectives: Displaced acetabular fractures are complex injuries that necessitate precise surgical 
intervention. Obturator nerve injuries occur in approximately 2% of cases. The modified Stoppa 
approach, offering enhanced exposure of the quadrilateral plate, has gained attraction as an alternative 
technique for anterior acetabular fractures. However, its proximity to the obturator nerve poses a risk 
of iatrogenic injury. This study aimed to investigate the incidence of nerve injuries and functional 
outcomes in patients undergoing the modified Stoppa approach for traumatic acetabular fractures.
Methods: This retrospective study involved 86 patients with anterior column fractures, whose data were 
prospectively collected. The fractures were treated using the modified Stoppa approach. Exclusion criteria were 
pathological fractures, alternative surgical approaches, prior nerve injuries, hip issues, refusal to participate, or 
inadequate follow-up. Data collection involved pre-operative imaging, thorough post-operative neurological 
assessments, and post-operative radiographic evaluation. Functional outcomes were assessed using the Harris Hip 
Score (HHS).
Results: Most patients were male (n=54) with a mean age of 40±17.3 years. Post-operative infection occurred in 
six cases, with resolution in four through antibiotics and two necessitating device removal. Obturator nerve damage 
was detected in 14 patients, comprising nine traumatic and five iatrogenic cases. During the follow-up, symptoms 
improved in all patients, except for the four patients with iatrogenic nerve damage.
Conclusion: Traumatic nerve injuries generally heal naturally over time. In contrast, iatrogenic injuries have a less 
optimistic prognosis, potentially resulting in lasting neurological deficits.
 Level of evidence: III
Keywords
Acetabulum
Fracture fixation
Iatrogenic disease
Nerve injury
Obturator nerve
Subjects
  1. Lehmann W, Hoffmann M, Fensky F, et al. What is the frequency of nerve injuries associated with acetabular fractures? Clin Orthop Relat Res. 2014; 472(11):3395-403. doi: 10.1007/s11999-014-3838-9.
  2. García J, Ferrando L, Díaz V, Sánchez V, Ruipérez L. Optimizing the Ana-tomic Reduction of Complex Acetabular Fractures: A Technical Enhancement to the Modified Stoppa Approach. Int Arch Orthop Surg. 2018; 1(004).
  3. Kitagawa R, Kim D, Reid N, Kline D. Surgical management of obturator nerve lesions. Neurosurgery. 2009; 65(4):A24-A28. doi:10.1227/01.Neu.0000335652.61676.Cc.
  4. Salama W, Hosny H, Mohamed MA, Noaman HH, Mousa S. Modified stoppa approach for the treatment of complex acetabular fractures. Orthopedics. 2021; 44(3):e353-e358. doi: 10.3928/01477447-20210414-06.
  5. Bible JE, Choxi AA, Kadakia RJ, Evans JM, Mir HR. Quantification of bony pelvic exposure through the modified Stoppa approach. J Orthop Trauma. 2014; 28(6):320-3. doi:10.1097/bot.0000000000000032.
  6. Kacra BK, Arazi M, Cicekcibasi AE, Büyükmumcu M, Demirci S. Modified medial Stoppa approach for acetabular fractures: an anatomic study. J Trauma. 2011; 71(5):1340-4. doi: 10.1097/TA.0b013e3182092e8.
  7. Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980; 151:81-106.
  8. Sagi HC, Afsari A, Dziadosz D. The anterior intra-pelvic (modified rives-stoppa) approach for fixation of acetabular fractures. J Orthop Trauma.2010; 24(5):263-70. doi: 10.1097/BOT.0b013e3181dd0b84.
  9. 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.
  10. Yeo DH, Oh JK, Cho JW, Kim BS. Management and outcome of Patients with acetabular fractures: associated Injuries and Prognostic factors. Journal of Trauma and Injury. 2019; 32(1):32-39.
  11. Soni A, Gupta R, Sen R. Modified Stoppa approach for acetabulum fracture: a review. Rev Bras Ortop (Sao Paulo).2019; 54(2):109-117. doi: 10.1016/j.rboe.2017.09.006.
  12. Simske NM, Krebs JC, Heimke IM, Scarcella NR, Vallier HA. Nerve injury with acetabulum fractures: incidence and factors affecting recovery. J Orthop Trauma. 2019; 33(12):628-634. doi: 10.1097/BOT.0000000000001604.
  13. Elmadag M, Guzel Y, Aksoy Y, Arazi M. Surgical treatment of displaced acetabular fractures using a modified Stoppa approach. Orthopedics. 2016; 39(2):e340-e345. doi: 10.3928/01477447-20160222-07.
  14. Kim JW, Shon HC, Park JH. Injury of the obturator nerve in the modified Stoppa approach for acetabular fractures. Orthop Traumatol Surg Res.2017; 103(5):639-644. doi: 10.1016/j.otsr.2017.03.005.
  15. Lee H, Jo S, Lee G, Cho Y. Perioperative complications of the modified Stoppa approach for the treatment of pelvic bone fractures: a single-institution review of 48 cases. Journal of Trauma and Injury. 2021; 35(1):19-24.

 

 

The Archives of Bone and Joint Surgery
Volume 12, Issue 2
February 2024
Pages 123-127

  • Receive Date 15 October 2023
  • Revise Date 25 November 2023
  • Accept Date 03 December 2023