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Internal Fracture Fixation using the Anterior Retroperitoneal Lower Laparotomy Approach in Pelvic Ring and Acetabular Fractures: the First Experience and Outcomes

Internal Fracture Fixation using the Anterior Retroperitoneal Lower Laparotomy Approach in Pelvic... DOI: 10.2478/v10163-011-0010-4 ORIGINAL ARTICLE Andris Vikmanis**, Andris Jumtins* *Riga Stradins University **Riga Eastern Clinical University Hospital, Clinics"Gailezers" Summary Introduction. The ilioinguinal approach is well established for the treatment of pelvic fractures. As an alternative, the anterior retroperitoneal lower laparatomy (modified Stoppa) approach can be used to expose pelvic and acetabular fractures. We describe our experience with this approach in polytrauma patients with pelvic ring and acetabular fractures . Aim of the Study.The aim of study was to evaluate possibilities and impossibilities of internal fixation of pelvic ring and acetabular fractures using the anterior retroperitoneal lower laparatomy approach. Materials and methods. This retrospective study describes a series of 20 consecutive patients where a modified Stoppa approach was used for pelvic or acetabular fracture fixation. Results. 10 patients with acetabular fractures, six patients with a pelvic ring injury not involving the acetabular joint and 4 patients with a combined fracture were operated through a modified Stoppa approach. Anatomic or satisfactory reduction was achieved in 92% of the acetabular fractures. Pelvic ring fractures had an anatomic (displacement <1 cm) postoperative result in 100% . Conclusions. using this approach may have good the postoperative radiological un surgical results. This is a method of choice for patients with combined trauma with internal organ damage and patients with both side pelvic bone fracture. Key words: internal fixation, pelvic and acetabular fractures, lower retroperitoneal laparotomy approach. INTRODUCTION The ilioinguinal approach is widely used for internal fracture fixation of pelvic ring and acetabular fractures. Although its value has been established in numerous reports, because of the combination of various windows, the ilioinguinal approach is a laborious exposure. In 1993, Hirvensalo(2) and later Cole(3) described an extraperitoneal ("Stoppa") approach through the rectus abdominus muscle as an alternative approach for internal fixation of fractures of the pelvic ring or acetabulum(4.5). In 2008, we started use the modified Stoppa approach through the linea alba in Latvia. The technique uses a single window for obtaining an intrapelvic overview of the operative field by manipulating the entire peritoneal sac and pelvic organs away from the fracture. We report our first experiences and outcomes with this approach in 20 patients with pelvic ring and acetabular fractures that were eligible for anterior approach. AIM OF THE STUDY The aim of the study was to evaluate the technical aspects of the procedure with its intraoperative possibilities and impossibilities, the operative results obtained, and the rate and type of complications associated with the anterior retroperitoneal lower laparotomy approach. MATERIALS AND METHODS Between October 2008 and April 2010, the Stoppa approach was used in 20 consecutive patients with pelvic, acetabular or combined fractures in which previously we would have used an ilioinguinal approach. Our patient group consisted of primary(14) and secondary(6) referred patients . Preoperatively, from radiological examinations were performed RTG ­ AP,LL,inlet,uotlet and always CT of pelvis with 3D reconstructin since most of those patients were with politrauma and as politrauma protocol CT is a must. A neurologist routinely evaluated all patients as well. Postoperatively, in all patients standard physical examination was performed by the attending trauma surgeon. The operative procedures were performed by head of trauma and orthopedic department and two assistants. The postoperative radiographic results for all fractures were classified . In the acetabular fractures, displacement of 1 mm or less was considered an anatomic reduction, 2 to 3 mm was satisfactory and more than 3 mm was unsatisfactory(1.6) . Postoperative fracture reduction of pelvic fractures was classified according to Pohlemann(7), considering a reduction within 1 cm as satisfactory. Operative Technique All patients were operated under general anesthesia on a radiolucent table in a supine position. The leg on the injured side was draped freely and both hips and knees were slightly flexed to relax the iliopsoas muscle. Prophylactic antibiotics (cefalosporin; 24 hours) and thrombosis prophylaxis (low molecular weight heparin; administered from admission until discharge) were routinely given. Through a midline incision from umbilicus to symphysis the anterior rectus sheath was opened vertically in the midline (Fig. 1). Connecting vessels between the obturator and femoral vascular system, the corona mortis, were meticulously looked for and, if detected, cut after ligation. Fig. 1. Lower abdominal midline incision The preperitoneal space was opened and bluntly dissected to the symphysis pubis. Generally the dissection is facilitated by the fracture hematoma following an anatomic dissection plane. The fibers of the transverse abdominal muscle were dissected from the peritoneal sac and subsequently the peritoneal sac was freed from its surroundings so that it could be manipulated upwards and away from the fracture side. In all cases, the common femoral artery and vein were identified, mobilized and encircled with a silastic band to facilitate manipulation if necessary; in male patients the spermatic cord was identified and retracted with a silastic band as well . Starting from the superior ramus near the symphysis, the pelvic ring was identified and exposed subperiosteally. Fig. 3. Exposure of the modified Stoppa approach Depending on the fracture type and exposure needed, after identifying the femoral nerve, the fascia of the psoas muscle was incised and the psoas muscle mobilized circumferentially if necessary (In this way, full exposure and access of the pelvic iliopectineal line and the quadrilateral plane up to the cranial and medial border of the SI joint is possible (Fig. 3). If needed, this exposure can be extended to the opposite side of the pelvic ring through the same skin incision. If any peritoneal perforation was encountered during the exposure, it was preferably closed at the time of detection with a running suture. After completion of the exposure the operative field was kept into view with blunt retractors. After the osteosynthesis was completed, a final check on hemostasis and peritoneal sac perforations was performed. A suction drain was left in the preperitoneal cavity. The rectus sheath was closed in a running fashion with a monofilament resorbable suture. The skin was closed according to the preference of the surgeon, usually with interrupted monofilament sutures. The suction drain was removed 24 to 48 hours post­operatively. RESULTS Table 1 shows the demographic characteristics of the patients. There were 14 male and 6 female patients with an average age of 40 years (range 18 to 80 years). Of these, 13 were primarily admitted to our hospital , six were referred from surrounding hospitals, and one were transferred from abroad. Ten patients had isolated acetabular fractures, six patients had pelvic ring fractures, and four patients had a combined pelvic ring and acetabular injury. According to the AO classification there were eight B type and two C type pelvic ring fractures, and according to the Letournel classification 8 both column, 4 T­shape, 1 anterior column, and 1 transverse type fractures of acetabulum. Fig. 2. Wiev of intra­operative situation .a­v.iliaca externa, b­m.rectus abdominis, c­ramus superior os pubis sin., d­corona mortis, e­peritoneum Table 1. Demographics Characteristic data Number of patients Mean age (years) Male:female ratio Type of fracture Acetabulum Number 20 40 14:6 10 (60%) Pelvic ring 6 (24%) Combined 4 (16%) Laparotomy were performed in acute stage 5 cases Median interval accident to surgery (days) 15,5 Initial treatment with external fixator 8 (cases) Fig. 5. Example of a patient with both column acetabular fractures treated by the modified Stoppa approach combined with lateral approach In the majority of patients the mechanism of injury was a road accidents (50%) and fall from a height(40%). The median time from injury to surgery was 6 days (range 0 to 57 days). This interval was mainly determined by the patients' general condition. In eight cases, temporary treatment was preceded by external fixation placement. Preoperatively in four patients, neurologic abnormalities were found: two patients had sacral plexus injuries, of which two patients had a contusion of plexus lumbaris with a paresthesia. Another two patients with traumatic brain injury. Surgical data are given in Table 2 and Table 3. The median operative time of the Stoppa­approach, defined as skin incision to skin closure, was 130 minutes (range 65 to 180 minutes). Median blood loss was 1020 ml (range 200 to 3000 ml) for all patients. All patients received packed red blood cells (PRBC) during or after the operation with a median amount of 2 units (range 1 to 6 units). For the 10 patients in whom a cell saver device was used, a median amount of 750 ml was reinfused. Iatrogenic perforation of the peritoneum was detected in two patients and after immediately closing all healed uneventfully. An anatomic result was achieved in 10 patients (71%), a satisfactory result in three patients (21%) and unsatisfactory results in one patient (8%) ­ (n_14). For pelvic ring fractures, a displacement of _1 cm on postoperative radiography was considered satisfactory. All pelvic ring fractures were anatomically reduced (n _ 10). Fig. 6. Example of patient with C type pelvic ring fracture treated by modified Stoppa approach combined with posterior approach Table 2. Surgical Data Characteristic data Operation time, minutes Blood loss, ml Blood transfusions Iatrogenic pelvic sack lesion median 130 1020 2 2 Range 65­180 200­3200 1­6 For politrauma patients (ISS greater than or equal to 16) the mean hospital stay was 34 days compared with 21 days for patients with isolated pelvic and/or acetabular injuries . Patients that were operated within 5 days after the injury had an average blood loss of 1000 ml compared with patients that were operated after 5 days who had an average blood loss of 2500 ml. Table 3. Postoperative reduction Type of fracture Number Displa­ cement Acetabulum 14 < 1 mm 1­3 mm >3 mm Pelvic ring 10 >10 mm <10 mm Result % 10 3 1 0 10 71 21 8 0 100 Fig. 4. Example of a patient with both column fractures treated by single modified Stoppa approach Complications During the retroperitoneal dissection, sever fibrosis was encountered and an injury of the peritoneal sack occurred, which was treated successfully with the stitches. There were no iatrogenic lesions of the obturator vessels, nor of the spermatic cord. Three patients had thromboembolic complications: all of these had deep venous thrombosis (DVT) at the injured side (diagnosed by duplex scanning) and one of these developed pulmonary embolism (diagnosed CT). These thromboembolic complications were detected between the 2nd and 10th week postoperatively. All were initially treated by intravenous heparinization followed by oral anticoagulation with uneventful recovery. Two patients had newly diagnosed neurologic symptoms after surgery ­ a neuropraxia of the femoral nerve which resolved spontaneously. At one year follow­up the symptoms had completely resolved. The infectious complications comprised of one urinary tract infections, one pulmonary infection and one superficial wound infection, and all resolved after antibiotic treatment. There were no deep infectious complications encountered. Table 4. Complications Complication Infection Injury of peritoneal sack Deep venozus thrombosis Neuropraxia of the femoral nerve number 3 2 3 2 DISCUSSION The treatment of both the pelvic and acetabular fractures is demanding. The operative techniques developed during the last 40 years, have been mainly for the acetabular surgery. However, development is still continuing and optimal treatment protocols are still under scientific evaluation and critical discussion, especially in the treatment of pelvic fractures. Fixation of the anterior part of the ring is still considered unnecessary in many centres although all biomechanical tests show inferior stability of a partially stabilised ring compared to a more extensive fixation of the whole ring. External fixation devices cannot restore enough stability in the unstable type C injuries to allow mobilization of the patient without risk of redisplacement of the injury sites leading to suboptimal functional results. Neither have minimal invasive, percutaneous techniques been able to guarantee good reduction or stability of the entire ring. The widely used ilioinguinal approach and especially the extended iliofemoral, transtrochanteric and triradiate exposures can be considered extensive and traumatic. The preparation of the neurovascular bundle with lymphatic vessels and funicular structures contains risks, needs extra time for meticulous preparation and always causes scar tissue formation around these important areas when using the ilioinguinal technique. All techniques directed to the joint through lateral or posterior approaches create scar formation, contain a risk of heterotopic ossification and have to be noted as a potential risk for any possible endoprosthetic solution later on. At the Department of Orthopaedics and Traumatology in Riga Eastern Clinical University Hospital the policy of internal fixation of both the acetabular and pelvic fractures was adopted simultaneously in 2008. The first operation was performed in 28.10.2008. The anterior approach was further developed as a route to achieve access to both on the entire pelvic brim and in the acetabular quadrilateral area. The external fixation frames have been used solely as temporary fixation devices to reduce the pelvic volume in open fractures and in severe bleeding when preparing the patient to angiography or internal fixation procedures. The anterior extraperitoneal approach used in the present study gives a wide view on the true pelvis and can be used in both the pelvic and acetabular fracture treatment. As an anatomical, quite short midline incision between the rectus muscles, it can be considered less invasive when compared to many other approaches on the pelvic area. The approach was combined with lateral, posterior or Kocher--Langenbec approaches depending of the fracture type in each patient. In acetabular fractures the anterior technique gives access and a direct view on the quadrilateral area, anterior wall area and even more, on the important supratectal area. Especially in those cases where the acetabular roof hides an articular fragment impacted to the weight bearing dome area, this medial window can allow the reduction of the fragments, transportation of cancellous bone and bone substitution materials and fixation of the fractures without lateral extrapelvic exposures and dislocating the joint. The anterior approach leaves the extrapelvic juxtaacetabular tissues intact which is important in possible secondary osteoarthritis and eventual joint replacement surgery. As seen in the limited number of complications this approach can be considered relatively safe, although the operation is demanding and needs good surgical skills and good knowledge of intrapelvic anatomy. The low incidence of major surgical complications, as well as deep venous thrombosis and heterotopic ossification(12) was an important finding . Although the risk of major vascular injuries is always present. Although all the patients received antithrombotic prophylaxis during the hospital stay this was an important finding, because the intrapelvic technique always includes some manipulation of the iliac vessels together with other anterior vascular structures. There were the low incidence of femoral nerve injuries which resolved spontaneusly. And there were not any lesions of the obturator nerve, although the nerve always has to be pushed down with a blunt retractor, when the lateral bony structures have to be revealed. The neurological recovery in the pelvic group with plexus injuries needs to be noted. Good recovery in both muscular and sensory deficiencies was observed especially in those patients where the reduction and fixation were successful and were in accordance with earlier studies. Moreover, by anatomical reduction the leg discrepancy could be prevented in most cases leading to normal gait. The good reduction together with proper stabilization allow early mobilization, prevent complications and thereby lead to a short hospital stay and to an early start of rehabilitation. The encouraging results with good functional recovery, the possibility of anatomical reduction with the less invasive techniques described above and the relatively low complication rate give a strong indication to continue the policy and efforts to reduce and fix both the pelvic ring and acetabular fractures in an anatomical position, whenever the general condition of the patient allows major reconstructive procedures. CONCLUSIONS Our experience with the Stoppa approach in 20 consecutive patients shows that good operative results can be obtained with this exposure. The rate of complications in this small series of seriously injured patients was considerable but the majority of these resolved with conservative treatment. We consider the Stoppa approach as a useful alternative for the ilioinguinal approach in patients with fractures in the pelvic ring or the acetabulum where open reduction and internal fixation is indicated. Furthermore, this straightforward anatomic approach offers additional advantages in bilateral fractures and combined trauma with internal organ damage. To determine its comparativeness to standard approaches with respect to functional outcome, more studies are warranted. Conflict of interest: None http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Acta Chirurgica Latviensis de Gruyter

Internal Fracture Fixation using the Anterior Retroperitoneal Lower Laparotomy Approach in Pelvic Ring and Acetabular Fractures: the First Experience and Outcomes

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Abstract

DOI: 10.2478/v10163-011-0010-4 ORIGINAL ARTICLE Andris Vikmanis**, Andris Jumtins* *Riga Stradins University **Riga Eastern Clinical University Hospital, Clinics"Gailezers" Summary Introduction. The ilioinguinal approach is well established for the treatment of pelvic fractures. As an alternative, the anterior retroperitoneal lower laparatomy (modified Stoppa) approach can be used to expose pelvic and acetabular fractures. We describe our experience with this approach in polytrauma patients with pelvic ring and acetabular fractures . Aim of the Study.The aim of study was to evaluate possibilities and impossibilities of internal fixation of pelvic ring and acetabular fractures using the anterior retroperitoneal lower laparatomy approach. Materials and methods. This retrospective study describes a series of 20 consecutive patients where a modified Stoppa approach was used for pelvic or acetabular fracture fixation. Results. 10 patients with acetabular fractures, six patients with a pelvic ring injury not involving the acetabular joint and 4 patients with a combined fracture were operated through a modified Stoppa approach. Anatomic or satisfactory reduction was achieved in 92% of the acetabular fractures. Pelvic ring fractures had an anatomic (displacement <1 cm) postoperative result in 100% . Conclusions. using this approach may have good the postoperative radiological un surgical results. This is a method of choice for patients with combined trauma with internal organ damage and patients with both side pelvic bone fracture. Key words: internal fixation, pelvic and acetabular fractures, lower retroperitoneal laparotomy approach. INTRODUCTION The ilioinguinal approach is widely used for internal fracture fixation of pelvic ring and acetabular fractures. Although its value has been established in numerous reports, because of the combination of various windows, the ilioinguinal approach is a laborious exposure. In 1993, Hirvensalo(2) and later Cole(3) described an extraperitoneal ("Stoppa") approach through the rectus abdominus muscle as an alternative approach for internal fixation of fractures of the pelvic ring or acetabulum(4.5). In 2008, we started use the modified Stoppa approach through the linea alba in Latvia. The technique uses a single window for obtaining an intrapelvic overview of the operative field by manipulating the entire peritoneal sac and pelvic organs away from the fracture. We report our first experiences and outcomes with this approach in 20 patients with pelvic ring and acetabular fractures that were eligible for anterior approach. AIM OF THE STUDY The aim of the study was to evaluate the technical aspects of the procedure with its intraoperative possibilities and impossibilities, the operative results obtained, and the rate and type of complications associated with the anterior retroperitoneal lower laparotomy approach. MATERIALS AND METHODS Between October 2008 and April 2010, the Stoppa approach was used in 20 consecutive patients with pelvic, acetabular or combined fractures in which previously we would have used an ilioinguinal approach. Our patient group consisted of primary(14) and secondary(6) referred patients . Preoperatively, from radiological examinations were performed RTG ­ AP,LL,inlet,uotlet and always CT of pelvis with 3D reconstructin since most of those patients were with politrauma and as politrauma protocol CT is a must. A neurologist routinely evaluated all patients as well. Postoperatively, in all patients standard physical examination was performed by the attending trauma surgeon. The operative procedures were performed by head of trauma and orthopedic department and two assistants. The postoperative radiographic results for all fractures were classified . In the acetabular fractures, displacement of 1 mm or less was considered an anatomic reduction, 2 to 3 mm was satisfactory and more than 3 mm was unsatisfactory(1.6) . Postoperative fracture reduction of pelvic fractures was classified according to Pohlemann(7), considering a reduction within 1 cm as satisfactory. Operative Technique All patients were operated under general anesthesia on a radiolucent table in a supine position. The leg on the injured side was draped freely and both hips and knees were slightly flexed to relax the iliopsoas muscle. Prophylactic antibiotics (cefalosporin; 24 hours) and thrombosis prophylaxis (low molecular weight heparin; administered from admission until discharge) were routinely given. Through a midline incision from umbilicus to symphysis the anterior rectus sheath was opened vertically in the midline (Fig. 1). Connecting vessels between the obturator and femoral vascular system, the corona mortis, were meticulously looked for and, if detected, cut after ligation. Fig. 1. Lower abdominal midline incision The preperitoneal space was opened and bluntly dissected to the symphysis pubis. Generally the dissection is facilitated by the fracture hematoma following an anatomic dissection plane. The fibers of the transverse abdominal muscle were dissected from the peritoneal sac and subsequently the peritoneal sac was freed from its surroundings so that it could be manipulated upwards and away from the fracture side. In all cases, the common femoral artery and vein were identified, mobilized and encircled with a silastic band to facilitate manipulation if necessary; in male patients the spermatic cord was identified and retracted with a silastic band as well . Starting from the superior ramus near the symphysis, the pelvic ring was identified and exposed subperiosteally. Fig. 3. Exposure of the modified Stoppa approach Depending on the fracture type and exposure needed, after identifying the femoral nerve, the fascia of the psoas muscle was incised and the psoas muscle mobilized circumferentially if necessary (In this way, full exposure and access of the pelvic iliopectineal line and the quadrilateral plane up to the cranial and medial border of the SI joint is possible (Fig. 3). If needed, this exposure can be extended to the opposite side of the pelvic ring through the same skin incision. If any peritoneal perforation was encountered during the exposure, it was preferably closed at the time of detection with a running suture. After completion of the exposure the operative field was kept into view with blunt retractors. After the osteosynthesis was completed, a final check on hemostasis and peritoneal sac perforations was performed. A suction drain was left in the preperitoneal cavity. The rectus sheath was closed in a running fashion with a monofilament resorbable suture. The skin was closed according to the preference of the surgeon, usually with interrupted monofilament sutures. The suction drain was removed 24 to 48 hours post­operatively. RESULTS Table 1 shows the demographic characteristics of the patients. There were 14 male and 6 female patients with an average age of 40 years (range 18 to 80 years). Of these, 13 were primarily admitted to our hospital , six were referred from surrounding hospitals, and one were transferred from abroad. Ten patients had isolated acetabular fractures, six patients had pelvic ring fractures, and four patients had a combined pelvic ring and acetabular injury. According to the AO classification there were eight B type and two C type pelvic ring fractures, and according to the Letournel classification 8 both column, 4 T­shape, 1 anterior column, and 1 transverse type fractures of acetabulum. Fig. 2. Wiev of intra­operative situation .a­v.iliaca externa, b­m.rectus abdominis, c­ramus superior os pubis sin., d­corona mortis, e­peritoneum Table 1. Demographics Characteristic data Number of patients Mean age (years) Male:female ratio Type of fracture Acetabulum Number 20 40 14:6 10 (60%) Pelvic ring 6 (24%) Combined 4 (16%) Laparotomy were performed in acute stage 5 cases Median interval accident to surgery (days) 15,5 Initial treatment with external fixator 8 (cases) Fig. 5. Example of a patient with both column acetabular fractures treated by the modified Stoppa approach combined with lateral approach In the majority of patients the mechanism of injury was a road accidents (50%) and fall from a height(40%). The median time from injury to surgery was 6 days (range 0 to 57 days). This interval was mainly determined by the patients' general condition. In eight cases, temporary treatment was preceded by external fixation placement. Preoperatively in four patients, neurologic abnormalities were found: two patients had sacral plexus injuries, of which two patients had a contusion of plexus lumbaris with a paresthesia. Another two patients with traumatic brain injury. Surgical data are given in Table 2 and Table 3. The median operative time of the Stoppa­approach, defined as skin incision to skin closure, was 130 minutes (range 65 to 180 minutes). Median blood loss was 1020 ml (range 200 to 3000 ml) for all patients. All patients received packed red blood cells (PRBC) during or after the operation with a median amount of 2 units (range 1 to 6 units). For the 10 patients in whom a cell saver device was used, a median amount of 750 ml was reinfused. Iatrogenic perforation of the peritoneum was detected in two patients and after immediately closing all healed uneventfully. An anatomic result was achieved in 10 patients (71%), a satisfactory result in three patients (21%) and unsatisfactory results in one patient (8%) ­ (n_14). For pelvic ring fractures, a displacement of _1 cm on postoperative radiography was considered satisfactory. All pelvic ring fractures were anatomically reduced (n _ 10). Fig. 6. Example of patient with C type pelvic ring fracture treated by modified Stoppa approach combined with posterior approach Table 2. Surgical Data Characteristic data Operation time, minutes Blood loss, ml Blood transfusions Iatrogenic pelvic sack lesion median 130 1020 2 2 Range 65­180 200­3200 1­6 For politrauma patients (ISS greater than or equal to 16) the mean hospital stay was 34 days compared with 21 days for patients with isolated pelvic and/or acetabular injuries . Patients that were operated within 5 days after the injury had an average blood loss of 1000 ml compared with patients that were operated after 5 days who had an average blood loss of 2500 ml. Table 3. Postoperative reduction Type of fracture Number Displa­ cement Acetabulum 14 < 1 mm 1­3 mm >3 mm Pelvic ring 10 >10 mm <10 mm Result % 10 3 1 0 10 71 21 8 0 100 Fig. 4. Example of a patient with both column fractures treated by single modified Stoppa approach Complications During the retroperitoneal dissection, sever fibrosis was encountered and an injury of the peritoneal sack occurred, which was treated successfully with the stitches. There were no iatrogenic lesions of the obturator vessels, nor of the spermatic cord. Three patients had thromboembolic complications: all of these had deep venous thrombosis (DVT) at the injured side (diagnosed by duplex scanning) and one of these developed pulmonary embolism (diagnosed CT). These thromboembolic complications were detected between the 2nd and 10th week postoperatively. All were initially treated by intravenous heparinization followed by oral anticoagulation with uneventful recovery. Two patients had newly diagnosed neurologic symptoms after surgery ­ a neuropraxia of the femoral nerve which resolved spontaneously. At one year follow­up the symptoms had completely resolved. The infectious complications comprised of one urinary tract infections, one pulmonary infection and one superficial wound infection, and all resolved after antibiotic treatment. There were no deep infectious complications encountered. Table 4. Complications Complication Infection Injury of peritoneal sack Deep venozus thrombosis Neuropraxia of the femoral nerve number 3 2 3 2 DISCUSSION The treatment of both the pelvic and acetabular fractures is demanding. The operative techniques developed during the last 40 years, have been mainly for the acetabular surgery. However, development is still continuing and optimal treatment protocols are still under scientific evaluation and critical discussion, especially in the treatment of pelvic fractures. Fixation of the anterior part of the ring is still considered unnecessary in many centres although all biomechanical tests show inferior stability of a partially stabilised ring compared to a more extensive fixation of the whole ring. External fixation devices cannot restore enough stability in the unstable type C injuries to allow mobilization of the patient without risk of redisplacement of the injury sites leading to suboptimal functional results. Neither have minimal invasive, percutaneous techniques been able to guarantee good reduction or stability of the entire ring. The widely used ilioinguinal approach and especially the extended iliofemoral, transtrochanteric and triradiate exposures can be considered extensive and traumatic. The preparation of the neurovascular bundle with lymphatic vessels and funicular structures contains risks, needs extra time for meticulous preparation and always causes scar tissue formation around these important areas when using the ilioinguinal technique. All techniques directed to the joint through lateral or posterior approaches create scar formation, contain a risk of heterotopic ossification and have to be noted as a potential risk for any possible endoprosthetic solution later on. At the Department of Orthopaedics and Traumatology in Riga Eastern Clinical University Hospital the policy of internal fixation of both the acetabular and pelvic fractures was adopted simultaneously in 2008. The first operation was performed in 28.10.2008. The anterior approach was further developed as a route to achieve access to both on the entire pelvic brim and in the acetabular quadrilateral area. The external fixation frames have been used solely as temporary fixation devices to reduce the pelvic volume in open fractures and in severe bleeding when preparing the patient to angiography or internal fixation procedures. The anterior extraperitoneal approach used in the present study gives a wide view on the true pelvis and can be used in both the pelvic and acetabular fracture treatment. As an anatomical, quite short midline incision between the rectus muscles, it can be considered less invasive when compared to many other approaches on the pelvic area. The approach was combined with lateral, posterior or Kocher--Langenbec approaches depending of the fracture type in each patient. In acetabular fractures the anterior technique gives access and a direct view on the quadrilateral area, anterior wall area and even more, on the important supratectal area. Especially in those cases where the acetabular roof hides an articular fragment impacted to the weight bearing dome area, this medial window can allow the reduction of the fragments, transportation of cancellous bone and bone substitution materials and fixation of the fractures without lateral extrapelvic exposures and dislocating the joint. The anterior approach leaves the extrapelvic juxtaacetabular tissues intact which is important in possible secondary osteoarthritis and eventual joint replacement surgery. As seen in the limited number of complications this approach can be considered relatively safe, although the operation is demanding and needs good surgical skills and good knowledge of intrapelvic anatomy. The low incidence of major surgical complications, as well as deep venous thrombosis and heterotopic ossification(12) was an important finding . Although the risk of major vascular injuries is always present. Although all the patients received antithrombotic prophylaxis during the hospital stay this was an important finding, because the intrapelvic technique always includes some manipulation of the iliac vessels together with other anterior vascular structures. There were the low incidence of femoral nerve injuries which resolved spontaneusly. And there were not any lesions of the obturator nerve, although the nerve always has to be pushed down with a blunt retractor, when the lateral bony structures have to be revealed. The neurological recovery in the pelvic group with plexus injuries needs to be noted. Good recovery in both muscular and sensory deficiencies was observed especially in those patients where the reduction and fixation were successful and were in accordance with earlier studies. Moreover, by anatomical reduction the leg discrepancy could be prevented in most cases leading to normal gait. The good reduction together with proper stabilization allow early mobilization, prevent complications and thereby lead to a short hospital stay and to an early start of rehabilitation. The encouraging results with good functional recovery, the possibility of anatomical reduction with the less invasive techniques described above and the relatively low complication rate give a strong indication to continue the policy and efforts to reduce and fix both the pelvic ring and acetabular fractures in an anatomical position, whenever the general condition of the patient allows major reconstructive procedures. CONCLUSIONS Our experience with the Stoppa approach in 20 consecutive patients shows that good operative results can be obtained with this exposure. The rate of complications in this small series of seriously injured patients was considerable but the majority of these resolved with conservative treatment. We consider the Stoppa approach as a useful alternative for the ilioinguinal approach in patients with fractures in the pelvic ring or the acetabulum where open reduction and internal fixation is indicated. Furthermore, this straightforward anatomic approach offers additional advantages in bilateral fractures and combined trauma with internal organ damage. To determine its comparativeness to standard approaches with respect to functional outcome, more studies are warranted. Conflict of interest: None

Journal

Acta Chirurgica Latviensisde Gruyter

Published: Jan 1, 2010

References