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Surgical Approaches for Acetabulum Fracture Treatment: Analytic Review
- Authors: Kolesnik A.I.1, Donchenko S.V.2, Surikov V.V.2,3, Ivanov D.A.4, Tarasov E.P.5, Yarmamedov D.M.6, Solodilov I.M.7
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Affiliations:
- Cytoproject LLC
- Botkin City Clinical Hospital
- Russian Medical Academy of Continuing Postgraduate Education
- Lytkarino City Hospital
- Odintsovo City Hospital
- Kursk State Medical University
- Kursk City Clinical Hospital No. 4
- Issue: Vol 28, No 3 (2022)
- Pages: 106-115
- Section: Reviews
- URL: https://journal.rniito.org/jour/article/view/1747
- DOI: https://doi.org/10.17816/2311-2905-1747
- ID: 1747
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Abstract
Background. The use of classical and modified surgical approaches to acetabulum is accompanied by serious intra- and postoperative complications associated with tissues, vessels, nerves, and lymphatic structures injury. The choice of approach to acetabulum affects the surgical time and the blood loss volume.
The aim of the review was to compare the surgical time and blood loss volume using different surgical approaches to the acetabulum based on the relevant literature analysis.
Methods. The search was carried out in PubMed/MEDLINE and Scopus databases from 1964 to 2022. When conducting a search for the phrases acetabular fractures, surgical approach to the acetabulum, 4368 articles were found. As a result of the selection, 12 publications containing the most complete information on the studied indicators were included in the quantitative analysis.
Results. The data of surgical treatment of 540 patients with acetabulum fractures were analyzed. The average age of the patients was 45.2±11.6 years. Among the causes of pelvic and acetabulum fractures, road accident (70.4%) and falls from height (21.3%) largely prevailed. The blood loss depended on the use of specific approaches or their combination, and the surgical time. The shortest surgical time (101.0±27.0 min.) was required using pararectal approach, the longest (264±56.4 min.) — with the use of ilio-inguinal approach. The largest volume of blood loss was observed with Pfannenstiel approach — 1057.1±377.9 ml. No statistically significant differences were found when comparing the Kocher-Langenbeck (793±328 ml), ilio-inguinal (828±64 ml) and pararectal (798±322 ml) approach. Performing the Kocher-Langenbeck approach in the patient’s lateral position reduces the surgical time by 16.8% and reduces blood loss by 12.4% compared to the patient’s prone position.
Conclusion. Comparative clinical studies are required to determine the safest surgical approaches to the acetabulum, depending on the type of fracture, the mechanism of injury and the age of the patient.
Full Text
BACKGROUND
The problem of surgical treatment of acetabular fractures remains relevant [1, 2, 3, 4, 5, 6]. The incidence of acetabular fractures ranges from 2% to 22% with an upward trend [1, 3, 7]. Classical and modified surgical approaches to the acetabulum are accompanied by serious intra- and postoperative complications in 8-59% of cases [3]. Complications are associated primarily with the traumatization of tissues, vessels, nerves, and lymphatic structures, operative time up to ≥3 h, and significant blood loss [1, 7, 8, 9, 10, 11], which become serious deterrents to the widespread use of approaches in the acute period of injury [12, 13, 14, 15, 16].
The review aimed to compare the operative time and blood loss volume when using different surgical approaches to the acetabulum based on the literature analysis.
METHODS
The search was performed in PubMed (MEDLINE) and Scopus for the period from 1964 to 2022.
The selection criteria: full-text versions of articles and abstracts containing complete information on the most commonly used standard and modified surgical approaches to the acetabulum, age of the patients, mechanism of injury, operative time, blood loss volume, and patient’s position on the operating table. The language of publications was English.
The exclusion criteria: experimental studies, clinical cases, and literature reviews.
When searching for the keywords “acetabular fractures” and “surgical approach to the acetabulum,” 4368 articles were found, of which 12 publications that contained the most complete information on the studied parameters were selected [1, 11, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26].
Statistical analysis
Data comparison was performed using SPSS Statistics for Windows, version 11.0 (SPSS Inc., Chicago, USA). Parametric and nonparametric data were compared using unpaired Student’s t-test, Mann-Whitney U-test, and χ2 test. Differences were considered significant at p < 0.05.
RESULTS
We analyzed the results of the surgical treatment of 540 patients with acetabular fractures, whose data are presented in the 12 publications selected for analysis (Table 1).
Table 1. The use of surgical approaches and indications for surgery
Author | Observation period | Surgical approach | Number of patients | Age, years | Operative time, min. | Blood loss, ml |
Borg T. [1] | 2003–2014 | Kocher-Langenbeck | 16 | 76,5 (64–89) | 188 (175–321) | 800 (400–1700) |
Ilio-inguinal | 10 | 68,2 (50–83) | 166 (95–354) | 675 (300–2600) | ||
Harris A. [11] | 1990–1998 | Kocher-Langenbeck | 51 | 34,9 (16–64) | 320 (140–503) | 1735 (300–4000) |
Xue Z. [16] | 2011–2012 | Pfannenstiel | 7 | 37 (18–53) | 158,57±28,54 | 1057,14±377,96 |
Kocher-Langenbeck | 8 | 37 (18–53) | 278,12±62,33 | 937,50±362,28 | ||
Khira Y. [17] | 2009–2017 | Kocher-Langenbeck | 20 | 32,9 (21–58) | 135±20 (120–160) | 780±350 (500–1500) |
Li Y. [18] | 2013–2017 | Kocher-Langenbeck | 9 | 37±17,09 | 71,28±9,69 | 742,22±228,68 |
Lont T. [19] | 2000–2017 | Kocher-Langenbeck | 34 | 70 (56–92) | 169 | 1100 |
Kashyap S. [20] | 2012–2015 | Kocher-Langenbeck | 30 | 48±24 | 215±55 | 570±160 |
Salameh M. [21] | 2010–2017 | Kocher-Langenbeck (decubitus) | 47 | 36,6 (20–67) | 184,2±57,5 | 551±299 |
Kocher-Langenbeck (prone) | 26 | 34,8 (18–60) | 241,4±106,7 | 584±365 | ||
Wang C. [22] | 2016–2017 | prone | 50 | 45,1±12,6 | 170,7±40,6 | 1177,1±691,6 |
Wang P. [23] | 2013–2016 | Ilio-inguinal | 47 | 41,5±11,7 | 264,0±56,4 | 873,8±535,6 |
Yang Y. [24] | 2014–2018 | Ilio-inguinal | 44 | 41,89±14,19 | 156,18±27,54 | 784,09±277,70 |
Ilio-inguinal + Stoppa | 32 | 39,94±15,21 | 126,53±29,56 | 625,31±193,39 | ||
Ozturk A. [25] | 2017–2018 | Kocher-Langenbeck | 12 | 41,9 | 199,16±24,75 | 511,66±127,33 |
Ilio-inguinal | 5 | 46,2 | 200,00±25,49 | 488,00±111,89 |
Age of patients
The mean age of the patients in all studies was 45.2 ± 11.6 years. The youngest patients were registered in the studies by Khira et al. (32.9 [21.0-58.0] years) [17], Li et al. (32.1 ± 14.6 years) [18], and Salameh et al. (34.8 [18.0-60.0] years) [21]. Older patients were enrolled in the studies by Lont et al. (70 [56-92] years) [19] and T. Borg et al. (76.5 [64.0–89.0] years using the use of the Kocher-Langenbeck approach and 68.2 [50.0–83.0] years using the ilioinguinal approach) [1].
Mechanism of injury and surgical approaches
Most patients were injured in traffic accidents (n = 184) [1, 16, 17, 19, 20, 22, 23, 24, 25]. A fall from a height of >3 m caused a fracture in 108 patients [1, 16, 17, 19, 20, 22, 23, 24, 25], whereas a fall from a height of <3 m caused a fracture in 65 patients [1, 19, 23, 24, 25]. In 11 patients, the injury resulted from falling heavy objects [21, 23]. Sports injury has been reported in nine patients [21]. Figure 1 presents a diagram of the approach to the acetabulum, taking into account the mechanism of injury. The graph presents data from nine sources because the mechanism of injury is not mentioned in other works.
Fig. 1. The choice of approach to acetabulum depending on the mechanism of injury.
Abbreviations hereafter: KL — Kocher-Langenbeck approach; IL — iliac-inguinal approach; S — Stoppa approach; PA — pararectal approach
Classification of fractures and surgical approaches
In 11 studies, the nature of acetabular fractures was classified according to Judet-Letournel. Fracture of both columns was noted in four studies [1, 16, 22, 25]. Borg et al. and Ozturk et al. used Kocher-Langenbeck and ilioinguinal approaches [1, 25], Xue et al. used Kocher-Langenbeck and Pfannenstiel approaches [16], and Wang et al. used the pararectal approach to the anterior column [22] (Fig. 2).
Fig. 2. Classification of acetabulum fractures according to Judet-Letournel in the cited sources. Percentages indicate the proportion of acetabulum fractures types from their total number
ACWH — fractures of the anterior column and hemitransverse fracture of the acetabulum posterior column; BC — fracture of both columns; T-type — T-shaped fracture; AC — fracture of the anterior column; PC — fracture of the posterior column; PW — fracture of the posterior wall; Tr — transverse acetabulum fracture
Fractures of the anterior column in combination with a semitransverse fracture of the posterior column of the acetabulum were recorded in 65 patients [1, 16, 19, 22, 23]. Fractures of the posterior wall were detected in 56 patients [1, 16, 17, 19, 21, 25]. A transverse fracture combined with a fracture of the posterior wall was found in 45 patients [1, 17, 19, 21, 23, 25], and a T-shaped fracture was registered in 36 patients [16, 19, 21, 22, 23, 25].
Operative time and blood loss depending on the surgical approach to the acetabulum
The indicators of operative time and blood loss during surgical intervention using various approaches in patients with acetabular fractures were analyzed in all 12 publications (Fig. 3).
Fig. 3. Operative time, blood loss and the age of patients with various surgical approaches to the acetabulum
Wang et al. performed surgery on 50 patients using the pararectal approach. A comparative analysis revealed that the pararectal approach required the shortest time (101.0±27.0 min) to perform surgery [22]. The longest time to perform the surgery using the ilioinguinal approach was noted in the study by Wang et al. (264.0±56.4 min) [23].
Wang et al. recorded blood loss of 1177.1± 691.6 mL when using the pararectal approach [22]. The average blood loss volume was 844.8±368.8 mL in multiauthored publications using the Kocher-Langenbeck approach [1, 11, 16, 17, 18, 19, 20, 21]. When using the ilioinguinal approach, the average blood loss was 689.2±148.2 mL [1, 23, 24, 25].
Results of surgical treatment using the Kocher-Langenbeck approach in the prone and lateral positions
The authors of the cited sources analyzed the operative time and blood loss in 106 patients aged between 36.6 (20–67) and 47.2 (24–69) years [16, 18, 20, 21, 25] and 97 patients aged 32.9 between (21–58) and 34.9 (16–64) years [11, 18, 22] when performing the Kocher-Langenbeck surgical approach with the patients in the prone and lateral positions (Fig. 4). The surgical intervention with the patient in the lateral position allows the reduction of the operative time by 16.8% and blood loss by 12.4% in comparison with the prone position [17, 18, 19, 20, 21] (Fig. 4).
Fig. 4. Operative time, blood loss and the age of the patients during the surgery using the Kocher-Langenbeck approach in the supine position and lateral position
Results of the classic ilioinguinal and Stoppa’s ilioinguinal approaches
Several authors analyzed the results of using the classic ilioinguinal approach (n=96, 128 cases) [23, 24, 25] and Stoppa’s ilioinguinal approach (n=32) [24]. The mean age of the patients was 42.7±3.4 years (Fig. 5). The use of the modified Stoppa approach allows the reduction of the operative time by 40%. The blood loss volume was the greatest when using the classic ilioinguinal approach (828.9±63.4 mL). Less blood loss was recorded when using the modified Stoppa approach (625.3 mL).
Fig. 5. Operative time, blood loss and the age of patients during surgery through the classical iliac-inguinal approach and iliac-inguinal approach in the Stoppa modification
DISCUSSION
As noted above, the choice of approach in the surgical treatment of acetabular fractures affects the operative time, blood loss, and treatment outcomes. In turn, the choice of approach is determined by various factors, such as the patient’s age, fracture type, mechanism of injury, etc.
According to Giannoudis et al., the mean age of patients who underwent surgery for acetabular fractures was 38.6±4.6 years, with men accounting for 69.4% [26]. Goyal et al. included patients with acetabular fractures aged >55 years, with a mean age of 72.5 years [14].
Acetabular fractures with a low-energy injury mechanism mainly occur in older patients. In young patients, a high-energy mechanism of injury is noted [6, 27, 28, 29, 30, 31, 32, 33].
In all publications the authors used the classification of acetabular fractures [developed by Judet and Letournel [33, 34]. Butler et al. indicated the fundamental significance and latent potentialities of this classification [35]. Letournel, the author of the classification, highlighted that the classification of acetabular fractures can be modified in relation to older patients [33, 34]. Some authors believe that the complexity of treatment of acetabular fractures in older patients is attributed to their fracture types, namely, more frequent fractures of the anterior acetabular column, quadrangular surface, and compression of the cartilage of the articular surface [6, 36, 37]. Goyal et al. noted that fractures of both columns are the most common fractures in their patients (19.03%), fractures of the anterior column in combination with a semitransverse fracture of the posterior wall were less common (17.23%), fractures of the anterior column were registered in 541 of 3157 (17.13%) cases, and posterior wall fractures were noted in 425 of 3157 (13.46%) patients [14]. In younger patients, fractures of the posterior wall are more common, whereas transverse fractures of the acetabulum in combination with a fracture of the posterior wall and T-shaped fractures are less common [38, 39].
A literature analysis revealed that the blood loss depends on the approach, i.e., alone or in combination, and accordingly on operative time. The operative time between the Kocher-Langenbeck approach and the modified Stoppa approach was not significantly different. Moreover, the direct dependence of the blood loss on the operative time is expected as confirmed by other authors [26, 40, 41, 42].
Among 203 patients with acetabular fractures who underwent surgery using the Kocher–Langenbeck approach, surgeries were performed in 52.2% (n = 106) of cases with the patient in the lateral position, which reduced the operative time by 16.8% and blood loss by 12.4% in comparison with that in the prone position [17, 18, 20, 21]. In our opinion, the question of using the Kocher-Langenbeck approach in various positions on the operating table requires further study.
The ilioinguinal approach was used in 75% (n = 96) of cases, and the Stoppa ilioinguinal approach — in 25% (n = 32) of cases. According to the data obtained, Stoppa approach allows the reduction of operative time by 40% and blood loss by 11% compared with the classical ilioinguinal approach.
The authors of the analyzed publications used surgical approaches initially taking into account fractures of the acetabular columns (isolated and simultaneous fractures of the anterior and posterior columns) [43, 44, 45, 46]. In principle, in fractures of the anterior column and anterior wall of the acetabulum, the authors used the ilioinguinal or Stoppa approach [46, 47, 48, 49, 50, 51].
CONCLUSION
Comparative clinical studies are needed to determine the safest surgical approaches to the acetabulum depending on the fracture type, injury mechanism, and patient age.
DISCLAIMERS
Author contribution
Kolesnik A.I. — research concept and design, the collection and processing of material, writing the draft, editing.
Donchenko S.V. — research concept and design, the collection and processing of material, writing the draft, editing.
Surikov V.V. — the collection and processing of material, writing the draft, editing.
Ivanov D.A. — the collection and processing of material, writing the draft, editing.
Tarasov E.P. — the collection and processing of material, writing the draft, editing.
Yarmamedov D.M. — the collection and processing of material, writing the draft, editing.
Solodilov I.M. — the collection and processing of material, writing the draft, editing.
All authors have read and approved the final version of the manuscript of the article. All authors agree to bear responsibility for all aspects of the study to ensure proper consideration and resolution of all possible issues related to the correctness and reliability of any part of the work.
Funding source. This study was not supported by any external sources of funding.
Competing interests. The authors declare that they have no competing interests.
Ethics approval. Not applicable.
Consent for publication. Not required.
About the authors
Alexandr I. Kolesnik
Cytoproject LLC
Author for correspondence.
Email: ko-lesnik@mail.ru
ORCID iD: 0000-0003-1435-8743
Dr. Sci. (Med.), Professor
Russian Federation, MoscowSergey V. Donchenko
Botkin City Clinical Hospital
Email: Don_03@mail.ru
ORCID iD: 0000-0003-3341-7446
Cand. Sci. (Med.)
Russian Federation, MoscowVladislav V. Surikov
Botkin City Clinical Hospital; Russian Medical Academy of Continuing Postgraduate Education
Email: Airbag366@yandex.ru
ORCID iD: 0000-0003-3668-2376
Russian Federation, Moscow; Moscow
Dmitry A. Ivanov
Lytkarino City Hospital
Email: Ivanovda2001@mail.ru
ORCID iD: 0000-0002-5821-6774
Russian Federation, Lytkarino
Evgeniy P. Tarasov
Odintsovo City Hospital
Email: t.john@mail.ru
ORCID iD: 0000-0002-3960-0148
Russian Federation, Odintsovo
Dmitry M. Yarmamedov
Kursk State Medical University
Email: D-yarmamedov@mail.ru
ORCID iD: 0000-0002-4580-5502
Russian Federation, Kursk
Ivan M. Solodilov
Kursk City Clinical Hospital No. 4
Email: Ivan_s_007@mail.ru
ORCID iD: 0000-0001-8219-5582
Cand. Sci. (Med.)
Russian Federation, KurskReferences
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