Abstract
Background
Acetabulum fractures pose significant challenges in orthopedic trauma due to anatomical complexity and the potential for iatrogenic injury to surrounding structures. The study aims to compare the outcomes of two surgical approaches, the ilioinguinal approach (IA) and the modified Stoppa approach (MSA), in managing acetabular fractures.
Methods
A retrospective cohort study was conducted on 50 patients with anterior acetabular fractures. Demographic characteristics and perioperative data were collected, and the patients were categorized based on the applied surgical approach, either IA or MSA. Statistical tests were used for data analysis.
Results
The MSA group showed significantly lower intraoperative blood loss compared to IA (MSA: 404.36 ± 151.94 ml, IA: 650.92 ± 136.33 ml, Δ = 246.56 ml, P < 0.001). The mean procedure duration for MSA was 141.88 ± 27.12 min, compared to 172.24 ± 32.69 min for IA (P = 0.37). The incidence of soft tissue infection (MSA: 8 %, IA: 8 %) and sciatic nerve injury (both 0 %) exhibited no significant differences (P > 0.99). Postoperative assessments, Harris Hip Scores (MSA: 90.08 ± 6.26, IA: 89.29 ± 6.64, P = 0.66) and Modified Merle d’Aubigné Scores (MSA: 14.86 ± 1.37, IA: 15.23 ± 1.16, P = 0.40), showed no substantial variance between groups.
Conclusion
The study suggests that the MSA approach demonstrated superiority, particularly due to significantly less intraoperative blood loss. Further comprehensive studies are recommended to validate and generalize these findings.
1. Introduction
Acetabular fractures are one the most arduous issues in orthopedics traumatology whereas the body of evidence shows a rapidly increasing trend in the incidence of these fractures.1 This difficulty is fundamentally due to the anatomical complexity of the pelvic region considering various aspects including the spatial imagination and interpretation, its proximity to the important vascular and nervous structures, and the hardship of accessing the region.2 Accordingly, most surgeons have remarkable challenges in decision-making to surgically approach the acetabular fractures including anatomical reduction of the fractures and joint reconstruction, appropriately.3 The critical nature of this issue becomes apparent when considering the potential inadvertent harm to nearby nerves and blood vessels, as well as damage to pelvic organs.4
Given that, diverse approaches have been introduced; however, the response to the question “What is the superior surgical approach to acetabular fractures with the best outcomes and the least complications?” remained vague.
The ilioinguinal approach (IA) was first introduced by Letournel which has been numerously used to treat pelvic ring and acetabular fractures.5 The positive points of IA include a wide and appropriate view of the acetabular fractures, low probability of injuring sciatic nerve, lack of requirement for abductor muscle separation, making negligible postoperative scar that can be easily hidden, and rapid return to daily life.6 Previous investigations have reported a rate of 45–74 % for successful anatomical reduction following IA(7). In spite of its benefits, this method is associated with drawbacks like recurrent stress on the lateral femoral cutaneous nerve, femoral nerve, and peripheral blood vessels in the eye socket, potentially resulting in issues such as nerve paralysis, restricted blood flow, and blood clot formation within veins.7, 8, 9
By 1993, Hrvensalo et al. proposed a new procedural strategy for pelvic and acetabular fractures, known as the modified Stoppa approach (MSA).10 In addition to the fact that MSA was useful for all types of pelvic fractures and therefore, could be applied in all the conditions that IA was routinely used, MSA has other advantages such as proper visualization of the fractured area, the ability to reduce and fix the medially displaced fractures and unremarkable surgical trauma. Based on the literature, the anatomical reduction following MSA accounts for 59–82 %.11, 12, 13
Since then, scientists have been searching for the best approach to manage acetabular fractures; however, the response to this issue remains unclear and inconclusive. Given that, the current study aims to investigate the outcomes of IA versus MSA in patients with acetabular fractures.
2. Methods
2.1. Study population
A retrospective cohort study was conducted on 50 patients with acetabular fractures who underwent either Interventional Approach (IA) or Modified Surgical Approach (MSA) surgeries at hospitals affiliated with the university between April 2019 and December 2021. The study protocol was developed in accordance with the Helsinki Declaration and received approval from the Ethics Committee of the university. Patients or their legal representatives were briefed on the potential use of their medical data for research, assured of data confidentiality, and provided written consent for participation.
Individuals over 18 years with acetabular fractures, including anterior column fracture or other types (such as anterior column-posterior hemitransverse, T-type, anterior column-T transverse, and both columns fractures), necessitating an anterior surgical approach within four weeks of fracture onset, were eligible. Exclusion criteria comprised conservative fracture management, isolated posterior column fractures, pathologic or open fractures, contraindications for general anesthesia, and hip joint osteoarthritis. Patient selection was done through convenience sampling from eligible candidates based on archived hospital records, ensuring an equal representation of IA and MSA cases.
2.2. Interventional approach
The patients’ medical records were recruited and categorized according to the applied surgical approach, AI(5) versus MSA(10).
The Ilioinguinal Approach involves positioning the patient supine and making a precise incision above the symphysis pubis that extends towards the ASIS, allowing for thorough exposure of the surgical site. Delicate dissection separates abdominal muscles from the iliac crest, enabling successful access to the inner table. By incising the external oblique aponeurosis, surgeons gain clear visualization of the underlying anatomy and safeguard vital structures like the spermatic cord. Careful dissection of the inguinal ligament while protecting the external iliac vessels and femoral cutaneous nerve is essential. This approach involves meticulous division of the iliopectineal fascia to create three distinct windows for comprehensive access during surgery.
In contrast, the Modified Stoppa Approach maintains the supine position with knee support to relax the iliopsoas muscle. The surgical process includes a transverse incision above the symphysis pubis, followed by incision of the linea alba and division of the ipsilateral rectus abdominis muscle to access the pelvic region accurately. Ligation of any encountered corona mortis and precise dissection along the pelvic brim are key steps. Detachment of the iliopectineal fascia and strategic retractor placement optimize exposure of the quadrilateral surface. The insertion of a blunt Hohmann retractor between the surface and the internal obturator muscle enhances visualization, with a lateral window aiding in the reduction and fixation of iliac crest fractures.
2.3. Data collection
A comprehensive set of data encompassing demographic, perioperative, and postoperative parameters was meticulously gathered. Pertaining to demographics, details such as patients' age, gender, smoking status, and body mass index (BMI) were meticulously documented. Additionally, details on the type of acetabular fracture, preoperative blood loss, and the time interval between fracture occurrence and surgical intervention were meticulously recorded. Perioperative data involved the estimation of intraoperative blood loss, surgical duration, and the incidence of postoperative complications, including but not limited to surgical site infections, requirement for reoperation, screw implantations, sciatic nerve injuries, and occurrences of deep venous thrombosis. Patients were subject to a follow-up period of one year post-intervention, allowing for a reevaluation of outcomes. Joint reduction quality was meticulously evaluated using hip joint anterior-posterior radiography, with the application of Matta's criteria during the 12-month postoperative assessment to categorize reductions as either anatomic, imperfect, or poor based on displacement criteria.14
Furthermore, the necessity for total hip arthroplasty (THA) was methodically recorded. Postoperative functional assessments were carried out utilizing Merle Score and Harris Hip Score (HHS) at baseline and subsequently at the 12-month post-intervention evaluation.
2.4. Measurement instruments
The Harris Hip Scale: The Harris Hip Scale evaluates patient hip function through a self-reported questionnaire known as the Harris Hip Score (HHS). This questionnaire covers aspects like hip pain, walking ability, use of walking aids, distance walked, challenges in sitting, putting on shoes and socks, and stair climbing. It assesses patient function without the need for physical examination or range of motion tests. The scoring on this scale ranges from 100 for excellent function to less than 70 for poor hip function.15
Modified Merle d’Aubigné Score: The Modified Merle d'Aubigné Score serves as a system for evaluating post-fracture status across three dimensions: pain, ambulation, and range of motion (ROM), with separate scoring in the range of 0–6 for each subcategory. The final score is derived from the combined scores of these three dimensions, categorizing outcomes as excellent,18 good,15, 16, 17 fair,13, 14 or poor (less than 13). Detailed scoring criteria are outlined in Table 1 for reference.
Table 1.
Modified Merle d’Aubigné Score16.
| Grade | Pain Description | Walking Ability | Range of Motion |
|---|---|---|---|
| 0 | Intense and permanent pain | Unable to walk | Ankylosis with bad hip position |
| 1 | Severe pain, even at night | Can walk with crutches | No movement or slight deformity |
| 2 | Severe pain when walking, prevents activity | Can walk with canes | Flexion under 40° |
| 3 | Tolerable pain with limited activity | Can walk with 1 cane for less than 1 h, very difficult | Flexion between 40 and 60° |
| 4 | Mild pain when walking, disappears with rest | Can walk a long time with a cane, short time without cane and with limp | Flexion between 60 and 80°; can reach foot |
| 5 | Mild and inconstant pain; normal activity | Can walk without cane, slight limp | Flexion between 80 and 90°; abduction of at least 15° |
| 6 | No pain | Normal walking | Flexion more than 90°; abduction to 30° |
2.5. Statistical analysis
The obtained data were inputted into the Statistical Package for Social Sciences (SPSS Inc. PASW statistics for Windows, Chicago) version 24. Categorical variables were reported as absolute numbers and percentages, while continuous variables were presented as mean ± standard deviation. Statistical comparisons for categorical data utilized Chi-square or Fisher's exact tests, whereas independent t-tests were employed for continuous variables. A significance level of less than 0.05 was considered statistically significant. The study's power was analyzed using G∗Power version 3.1.9.7.
3. Results
The study enrolled 50 individuals with acetabular fractures, divided into groups receiving either IA or MSA management. Demographically, the participants showed statistical similarity in various characteristics, including age (P-value = 0.47), gender distribution (P-value = 0.48), BMI (P-value = 0.76), smoking status (P-value = 0.73), and history of addiction (P-value >0.99). Additionally, baseline clinical features such as the time interval between fracture occurrence and surgery (P-value = 0.43), fracture type (P-value = 0.78), and concurrent pelvic ring fractures (P-value = 0.73) were comparable across the groups. Further detailed information can be found in Table 2.
Table 2.
Demographic and baseline clinical characteristics.
| Variable | Illioinguinal approach (n = 25) | Modified Stoppa approach (n = 25) | P-value |
|---|---|---|---|
| Demographic characteristics | |||
| Age (year), mean±standard deviation | 40 ± 12.40 | 35.84 ± 11.52 | 0.47b |
| Gender (male), n (%) | 21 (84) | 19 (76) | 0.48a |
| Body mass index (kg/m2), mean±standard deviation | 25.27 ± 1.80 | 24.71 ± 2.06 | 0.76b |
| Smoking (yes), n (%) | 624 | 520 | 0.73a |
| Addiction (yes), n (%) | 312 | 416 | >0.99c |
| Clinical data | |||
| The interval between fracture incidence and surgical procedure (week), mean±standard deviation | 3.13 ± 1.08 | 3.29 ± 1.36 | 0.43b |
| Type of fracture, n (%) | |||
| Anterior column | 11 (44) | 14 (56) | 0.78c |
| Anterior column-posterior hemitransverse | 312 | 416 | |
| Transverse | 520 | 28 | |
| T-type | 416 | 312 | |
| Both columns fractures | 28 | 28 | |
| Pelvic ring injury, n (%) | 520 | 624 | 0.73a |
Chi-square test.
Independent t-test.
Fisher exact test.
Table 3 presents the outcomes associated with the surgical methods in both in-hospital and follow-up settings for the two groups. The MSA-treated group exhibited significantly lower intraoperative blood loss compared to the IA-treated group (P-value <0.001). However, parameters such as procedure duration (P-value = 0.37), sciatic nerve injury (P-value >0.99), occurrence of soft tissue infections (P-value >0.99), deep vein thrombosis (DVT) incidence (P-value = 0.63), screw penetration (P-value = 0.68), heterotopic ossification (P-value >0.99), quality of acetabular reduction (P-value = 0.79), need for reoperation (P-value = 0.5555), and requirement for total hip arthroplasty (THA) in the first year after the fracture surgery (P-value = 0.55) did not exhibit significant differences between the two groups. Furthermore, tools assessing postoperative pain and function demonstrated no significant variances between the IA and MSA groups (P-value >0.05).
Table 3.
The outcomes of the surgical procedures.
| Variable | Illioinguinal approach (n = 25) | Modified Stoppa approach (n = 25) | P-value |
|---|---|---|---|
| In-hospital data | |||
| The operation duration (minute), mean±standard deviation | 172.24 ± 32.69 | 141.88 ± 27.12 | 0.37b |
| Intraoperative blood loss (ml), mean±standard deviation | 650.92 ± 136.33 | 404.36 ± 151.94 | <0.001b |
| Injury to the sciatic nerve, n (%) | 0 (0) | 0 (0) | >0.99a |
| Follow-up data | |||
| Soft tissue infection, n (%) | 28 | 28 | >0.99a |
| Deep venous thromboembolism, n (%) | 312 | 28 | 0.63a |
| Screw penetration, n (%) | 0 (0) | 0 (0) | >0.99a |
| Heterotopic ossification, n (%) | 312 | 416 | 0.68a |
| Reoperation requirement, n (%) | 28 | 14 | 0.55a |
| Early total hip arthroplasty(within first year), n (%) | 28 | 14 | 0.55a |
| Reduction outcomes | |||
| Anatomic | 14 (56) | 16 (64) | 0.79a |
| Imperfect | 728 | 624 | |
| Poor | 416 | 312 | |
| Harris Hip Score (within a year), mean±standard deviation | 89.29 ± 6.64 | 90.08 ± 6.26 | 0.66b |
| Modified Merle d’Aubigné Score (within a year), mean±standard deviation | 15.23 ± 1.16 | 14.86 ± 1.37 | 0.40c |
Chi-square test.
Independent t-test.
Mann-Whitney U test.
The study power was calculated which revealed 94 % for the primary outcome (operation duration) and less than 80 % for the other measures.
4. Discussion
The management of acetabular fractures poses significant challenges due to their complexity and functional importance. Despite numerous studies investigating various surgical approaches in an attempt to optimize outcomes, the optimal approach for treating acetabular fractures remains a debated topic. In light of this, our study sought to compare the outcomes of two prominent surgical techniques for acetabular fractures:, IA versus MSA(17).
The study encompassed two patient groups matched in terms of demographic and baseline clinical characteristics, thus attributing the outcomes primarily to the surgical methods with minimal influence from potential confounding factors. Our findings indicated that, apart from significantly higher intraoperative blood loss in the IA group, outcomes between IA and MSA did not exhibit substantial differences, both during the in-hospital stay and at follow-up. Instruments such as the Harris Hip Score (HHS) and Modified Merle d'Aubigné Score were utilized to evaluate postoperative pain and joint function, showing no discernible variance.
Surfing the literature shows several studies comparing these two techniques where the major body of the studies are in agreement with us regarding the significantly higher amounts of blood loss in the IA compared with MSA(18–20). The volume of blood loss might even increase to ranges above 1200 ml in IA.18 Reduction quality was similar in the current study. Although Aziz and colleagues reported confirmatory outcomes to use regarding the reduction status of their patients18; the other studies mostly insisted on the superiority of MSA over IA regarding the appropriateness of anatomical reduction.4,19,21 The length of the surgical procedure was less in MSA; however, this difference was not statistically different. This finding is in agreement with the other investigations and is one of the perspectives making MSA more preferred over AI.4,17,22 Postoperative complications including neurovascular injury, soft tissue infection, DVT incidence, screw penetration, heterotopic ossification and requirement for reoperation or THA were negligible and also similar between the approaches. Other comparative studies assessing the postoperative complications in IA versus MSA reported comparable data in with our outcomes.11,23,24 Besides, the meta-analysis conducted by Shigemura et al. confirmed our findings17
We applied HHS and Merle scores in order to assess postoperative function of the patients undergoing IA versus MSA revealing insignificant differences. Consistently, Aziz et al. reported no difference between the Merele scores of IA and MSA-treated individuals. Besides, the majority of the patients represented scores between 14 and 16 compatible with good state.18 Rommens and colleagues reported comparable postoperative Merle scores comparing the approaches for two years.25 In line with the other investigations, Scrivano et al. who applied both HHS and Merele represented similar outcomes of the two approaches.19
IA, a widely used method for treating acetabular fractures, has been in practice for quite some time.2 Its versatility in addressing various anterior acetabular fractures is a notable advantage. However, factors like time consumption, the risk of nerve damage, and increased intraoperative blood loss may raise concerns about its utilization.8,23,26 On the other hand, Modified Stoppa Approach (MSA) has emerged as an alternative technique for acetabular fractures. This method offers distinct benefits such as safeguarding the lateral femoral cutaneous nerve and femoral vessels from surgical injury, along with providing clear visibility of the pelvis and acetabulum's front and inner aspects.2 Nonetheless, MSA necessitates exposure of the corona mortis, requiring orthopedists to possess a thorough understanding of nearby anatomical structures. Despite its advantages, drawbacks such as obturator nerve damage, peritoneal penetration, and rectus abdominis muscle atrophy have been documented post-MSA procedure.2,27,28
In summary, making decision regarding the favored approach to fix acetabular fractures is complex and various factors should be taken into account; however, the majority of the studies preferred MSA over IA. Nevertheless, further studies in order to generalize this notion are strongly recommended.
5. Limitations
The small sample population and short period of follow-up are the most significant limitations of the current study. Besides, a study with randomized clinical trial design might improve the generalizability of the data. Another limitation is the short duration of post-total hip replacement (THR) follow-up. Although we are concerned about this limitation that restricts the generalizability of our data, it is worth noting that the majority of post-acetabular fracture total hip replacements occur within the first year following surgery.29
6. Conclusion
The results of the current study suggest a slight superiority of the Modified Surgical Approach (MSA) over the Interventional Approach (IA), primarily attributed to its lower intraoperative blood loss. While other postoperative radiological, clinical, and functional factors displayed relatively improved outcomes with MSA, these differences did not reach statistical significance. Consequently, further investigations are warranted to delve deeper into the comparative efficacy of these surgical approaches in managing acetabular fractures.
Ethics approval and informed consent
This retrospective cohort study was approved by the Ethics Committee of the Medical University of Isfahan under ethical code IR.MUI.MED.REC.1401.136. The procedures followed in this study were in accordance with the ethical standards outlined by the institutional ethics committee and were in compliance with the principles of the Helsinki Declaration of 1975, as revised in 2000. Additionally, for studies involving human participants, informed consent was obtained from all adult research participants. The age threshold for assent in this region adheres to regional and national guidelines. Confidentiality of subjects was strictly maintained, with no participants' names, initials, or hospital numbers included in any illustrative material. Patients or their legal representatives were briefed on the potential use of their medical data for research, ensured about data confidentiality, and provided written consent for participation.
Funding
This research was funded by the Medical University of Isfahan and did not receive support from any additional specific grant provided by a public, commercial, or not-for-profit funding source.
CRediT authorship contribution statement
Hadi Ravanbod: Supervision, Project administration, Funding acquisition, review & editing, Conceptualization, Investigation, Writing – original draft, Writing – review & editing. Behnam Alikhani: Data collection, Formal analysis, Writing – original draft, Writing – review & editing, Methodology. Mojtaba Baniasadi: Data collection, Methodology, Writing – original draft, Writing – review & editing. Hosein Masoumi: Writing – original draft, Writing – review & editing, Investigation.
Declaration of competing interest
There are no conflicting interests that might influence the impartiality of the research documented.
Acknowledgement
We express our sincere gratitude to the members of the orthopedics department who generously provided their cases. Their willingness to share valuable clinical data and insights has substantially enriched the scope and depth of our study. We truly appreciate their valuable contribution to advancing knowledge in the field of orthopedic trauma surgery.
References
- 1.Melhem E., Riouallon G., Habboubi K., Gabbas M., Jouffroy P. Epidemiology of pelvic and acetabular fractures in France. J Orthop Traumatol: Surgery & Research. 2020;106(5):831–839. doi: 10.1016/j.otsr.2019.11.019. [DOI] [PubMed] [Google Scholar]
- 2.Ma K., Luan F., Wang X., et al. Randomized, controlled trial of the modified Stoppa versus the ilioinguinal approach for acetabular fractures. Orthopedics. 2013;36(10):e1307–e1315. doi: 10.3928/01477447-20130920-25. [DOI] [PubMed] [Google Scholar]
- 3.Guo H.-Z., He Y.-F., He W.-Q. Modified stoppa approach for pelvic and acetabular fracture treatment. Acta Ortopédica Bras. 2019;27:216–219. doi: 10.1590/1413-785220192704188933. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Wu H., Zhang L., Guo X., Jiang X. Meta-analysis of modified Stoppa approach and ilioinguinal approach in anterior pelvic ring and acetabular fractures. Medicine. 2020;99(4) doi: 10.1097/MD.0000000000018395. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Letournel E. Acetabulum fractures: classification and management. Clin Orthop Relat Res. 1980;151:81–106. [PubMed] [Google Scholar]
- 6.Tosounidis T.H., Giannoudis V.P., Kanakaris N.K., Giannoudis P.V. The ilioinguinal approach: state of the art. JBJS essential surgical techniques. 2018;8(2) doi: 10.2106/JBJS.ST.16.00101. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Fensky F., Lehmann W., Ruecker A., Rueger J.M. Ilioinguinal approach: indication and technique. J Orthop Trauma. 2018;32:S12–S13. doi: 10.1097/BOT.0000000000001194. [DOI] [PubMed] [Google Scholar]
- 8.Park K., Chan C., Lee G., Ahn H., Yoon T. Outcome of alternative approach to displaced acetabular fractures. Injury. 2017;48(2):388–393. doi: 10.1016/j.injury.2016.11.029. [DOI] [PubMed] [Google Scholar]
- 9.Gänsslen A., Grechenig S., Nerlich M., Müller M., Grechenig W. Standard approaches to the acetabulum part 2: ilioinguinal approach. Acta Chir Orthop Traumatol Cech. 2016;83(4):217–222. [PubMed] [Google Scholar]
- 10.Hirvensalo E., Lindahl J., BösTMAN O. A new approach to the internal fixation of unstable pelvic fractures. Clin Orthop Relat Res. 1993;297:28–32. [PubMed] [Google Scholar]
- 11.Shazar N., Eshed I., Ackshota N., Hershkovich O., Khazanov A., Herman A. Comparison of acetabular fracture reduction quality by the ilioinguinal or the anterior intrapelvic (modified rives–Stoppa) surgical approaches. J Orthop Trauma. 2014;28(6):313–319. doi: 10.1097/01.bot.0000435627.56658.53. [DOI] [PubMed] [Google Scholar]
- 12.Archdeacon M.T., Kazemi N., Guy P., Sagi H.C. The modified Stoppa approach for acetabular fracture. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2011;19(3):170–175. doi: 10.5435/00124635-201103000-00006. [DOI] [PubMed] [Google Scholar]
- 13.Jain M., Kumar P., Tripathy S.K., Behera I.I.S., Rana R., Das S. Clinico-radiological outcomes of using Modified Stoppa approach for treating acetabular fractures: an Institutional Review. Cureus. 2020;12(4) doi: 10.7759/cureus.7821. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Wenzel L., von Rüden C., Thannheimer A., et al. The Pararectus approach in acetabular surgery: radiological and clinical outcome. J Orthop Trauma. 2020;34(2):82. doi: 10.1097/BOT.0000000000001636. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Weaver M.J., Smith R.M., Lhowe D.W., Vrahas M.S. Does total hip arthroplasty reduce the risk of secondary surgery following the treatment of displaced acetabular fractures in the elderly compared to open reduction internal fixation? A pilot study. J Orthop Trauma. 2018;32:S40–S45. doi: 10.1097/BOT.0000000000001088. [DOI] [PubMed] [Google Scholar]
- 16.Kovalenko B., Bremjit P., Fernando N. Classifications in brief: Tönnis classification of hip osteoarthritis. Clin Orthop Relat Res. 2018;476(8):1680. doi: 10.1097/01.blo.0000534679.75870.5f. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Shigemura T., Murata Y., Yamamoto Y., Shiratani Y., Hamano H., Wada Y. Comparison between ilioinguinal approach and modified Stoppa approach for the treatment of acetabular fractures: an updated systematic review and meta-analysis. J Orthop Traumatol: Surgery & Research. 2022;108(2) doi: 10.1016/j.otsr.2022.103204. [DOI] [PubMed] [Google Scholar]
- 18.Aziz A.M.A., Sonkawade V.D., Santpure S. Comparative study of modified Stoppa approach and ilioinguinal approach for pelviacetabular fractures. International Journal of Research in Orthopaedics. 2020;6(5):1070. [Google Scholar]
- 19.Scrivano M., Vadalà A., Fedeli G., et al. A comparison between Ilioinguinal and modified Stoppa approach in anterior column acetabular fractures. Injury. 2023 doi: 10.1016/j.injury.2023.111166. [DOI] [PubMed] [Google Scholar]
- 20.Fan L., Jin Y.-J., He L., Lü Z., Fan H.-H. Modified Stoppa approach in treatment of pelvic and acetabular fractures. Zhongguo gu shang= China journal of orthopaedics and traumatology. 2012;25(10):810–812. [PubMed] [Google Scholar]
- 21.Yang Y., Zou C., Fang Y. The Stoppa combined with iliac fossa approach for the treatment of both-column acetabular fractures. J Orthop Surg Res. 2020;15(1):1–7. doi: 10.1186/s13018-020-02133-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Elmadağ M., Güzel Y., Acar M., Uzer G., Arazi M. The Stoppa approach versus the ilioinguinal approach for anterior acetabular fractures: a case control study assessing blood loss complications and function outcomes. J Orthop Traumatol: Surgery & Research. 2014;100(6):675–680. doi: 10.1016/j.otsr.2014.05.020. [DOI] [PubMed] [Google Scholar]
- 23.Ismail H.D., Djaja Y.P., Fiolin J. Minimally invasive plate osteosynthesis on anterior pelvic ring injury and anterior column acetabular fracture. Journal of Clinical Orthopaedics and Trauma. 2017;8(3):232–240. doi: 10.1016/j.jcot.2017.06.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Al Adawy AS., Aziz A.H.A., El Sherief F.A., Mahmoud W.S., Mabrook M., Hassan Y.E.-S. Modified Stoppa as an alternative surgical approach for fixation of anterior fracture acetabulum: a randomized control clinical trial. J Orthop Surg Res. 2020;15(1):1–12. doi: 10.1186/s13018-020-01660-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Rommens P., Broos P., Vanderschot P. Preparation and technique for surgical treatment of 225 acetabulum fractures. 2 year results of 175 cases. Unfallchirurg. 1997;100(5):338–348. doi: 10.1007/s001130050128. [DOI] [PubMed] [Google Scholar]
- 26.Kacra B.K., Arazi M., Cicekcibasi A.E., Büyükmumcu M., Demirci S. Modified medial Stoppa approach for acetabular fractures: an anatomic study. J Trauma Acute Care Surg. 2011;71(5):1340–1344. doi: 10.1097/TA.0b013e3182092e8b. [DOI] [PubMed] [Google Scholar]
- 27.Kim J., Shon H., Park J. Injury of the obturator nerve in the modified Stoppa approach for acetabular fractures. J Orthop Traumatol: Surgery & Research. 2017;103(5):639–644. doi: 10.1016/j.otsr.2017.03.005. [DOI] [PubMed] [Google Scholar]
- 28.Rocca G., Spina M., Mazzi M. Anterior Combined Endopelvic (ACE) approach for the treatment of acetabular and pelvic ring fractures: a new proposal. Injury. 2014;45:S9–S15. doi: 10.1016/j.injury.2014.10.016. [DOI] [PubMed] [Google Scholar]
- 29.Chung T.C., Chen T.S., Hsu Y.C., Kao F.C., Tu Y.K., Liu P.H. Long-term total hip arthroplasty rates in patients with acetabular and pelvic fractures after surgery: a population-based cohort study. PLoS One. 2020;15(4) doi: 10.1371/journal.pone.0231092. [DOI] [PMC free article] [PubMed] [Google Scholar]