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Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them
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Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them Markus A. Küper a,∗, Christian Konrads a,1, Alexander Trulson b, Christian Bahrs a, Ulrich Stöckle c, Fabian M. Stuby b a b c
BG Trauma Center, Department for Traumatology and Reconstructive Surgery, University of Tübingen, Tübingen, Germany Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany Charité University Medicine Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
a r t i c l e
i n f o
Article history: Accepted 19 February 2020 Available online xxx Keywords: Hip joint Pelvis Pelvic ring fracture Approach-related complications
a b s t r a c t Background: Fractures of the acetabulum are rare injuries. The indication for surgical stabilization depends on the grade of instability and dislocation. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of anatomical structures and possible risks of the different approaches, are important. Methods: Over a period of 15 years, we analyzed all patients with acetabular fractures, treated in our Level I Trauma Center with special interest in surgical and approach-related complications. Based on our complication rates, we describe the used different surgical approaches and the accessible anatomical structures respectively. Finally, we focus on strategies to reduce the risk of approach-related complications in acetabular surgery. Results: Between January 2003 and December 2017, 523 patients with an acetabular fracture were treated in our Tertiary Referral Hospital. Of these, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. 296 patients underwent surgical treatment of the acetabular fracture, while 227 patients were treated non-operatively. Surgically treated patients had a significantly higher complication rate of 21.2% (63/296) compared to conservatively treated patients with a complication rate of 16.7% (38/227). Neurovascular and thromboembolic adverse events were the most often complications. Conclusions: Patients with acetabular fractures are at a high risk for different kind of complications. The most common risks are neuro-vascular and thromboembolic incidents. The risk of getting a complication is increased in surgically treated patients, therefore both the indication for surgical treatment and the surgical approach should be carried out carefully, including individual patient parameters and fracture types as well as the surgeons expertise. © 2020 Elsevier Ltd. All rights reserved.
Introduction Fractures of the acetabulum and the pelvic ring are rare injuries which make up about 3–8% of all fractures. They occur with two frequency peaks regarding patient age. The first peak occurs in younger patients around the 2nd to 3rd decade of life and the second peak occurs around the 7th to 8th decade [1]. While the main reason for pelvic fractures in the younger patient is usually a high energy trauma (like motor vehicle accidents or fall from
∗
Corresponding author. E-mail address: [email protected] (M.A. Küper). 1 Markus Alexander Küper and Christian Konrads contributed equally to this publication.
great height), elderly patients acquire pelvic injuries by a low energy trauma (e.g. fall from the stand or out of bed). Due to the demographic development, the frequency of those age-associated pelvic injuries has increased over the past years [2]. From both, the anatomical and biomechanical point of view, the acetabulum consists of two columns. The anterior column reaches from the tip of the iliac crest along the anterior superior iliac spine (ASIS), the superior pubic ramus onto the middle of the inferior pubic ramus. The posterior column reaches from the upper crest of the greater sciatic notch along the entire ischial bone also to the middle of the inferior pubic ramus. Biomechanically, the posterior column is far more important than the anterior column because it transmits the forces from the torso via the iliosacral joints to the proximal femur.
https://doi.org/10.1016/j.injury.2020.02.100 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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M.A. Küper, C. Konrads and A. Trulson et al. / Injury xxx (xxxx) xxx Table 1 Posterior surgical approach to the acetabulum (Kocher-Langenbeck approach) [17,18]. Indications
Possible complications
Avoid complications
Fracture of posterior column,Fracture of posterior wall,Transverse fracture, Combined fractures with main pathology of posterior column or wall
Injury of sciatic nerve
Bend knee (nerve relaxed),Upholster nerve with short external rotator muscles Blunt dissection of gluteus maximus muscle Identify vessel at quadratus femoris muscle
Injury of inferior gluteal nerve Injury of femoral circumflex artery
Usually, acetabular fractures are classified according to Letournel/Judet into ten different fracture types [3-5]. Depending on the fracture morphology and the needed exposition, mainly the following posterior and anterior standard approaches are used for the surgical treatment of acetabular fractures: • • •
•
The Kocher-Langenbeck approach (posterior) The Ilioinguinal approach according to Letournel (anterior) The anterior intrapelvic approach (AIP, modified Stoppa approach), often in combination with the first window of the ilioinguinal approach The Pararectus approach according to Keel (anterior)
To make the decision whether or not to stabilize an acetabular fracture with an osteosynthesis, it is necessary to assess the potential benefits and the risks of the surgical procedure. Besides the primary stability of the fracture, the patient’s general condition and concomitant diseases as well as the activity level prior to the accident leading to the fracture, the own expertise should play a crucial role in the surgeon’s decision making. Regarding the risks of the surgical procedure, especially the different surgical approaches and the approach-related morbidity are of major interest for the surgeon [6]. This means that the knowledge of the different approaches to the acetabulum and their pitfalls is essential for the pelvic trauma surgeon and his decision. We analyzed our complications in acetabular fracture surgery. Based on our data and experience over the last 15 years, we present an overview of the most common open surgical approaches to the acetabulum with a brief description of the surgical technique together with approach-specific risks and suggestions how to avoid approach-related complications.
• • • • • •
Length of hospital stay (in days) Fracture type according to Judet/Letournel Number of osteosynthetic operations Surgical approach Overall complication rate Mortality The following complications were recorded:
• • • • • • • • •
Bleeding Thromboembolic events Surgical site infection Neurologic complications Pulmonary complications Abdominal complications Implant loosening / failure Secondary dislocation Others
Association between surgical approach and approach-related complications Bleeding, neurologic complications, bladder injuries, or incisional hernias were defined as approach-related complications. Patients were grouped according to the surgical approach: Kocher-Langenbeck approach (KL), ilioinguinal approach, anterior intrapelvic approach (AIP, modified Stoppa approach), Pararectus approach, and others. We then associated each approach-related complication to the respective surgical approach and finally compared different surgical approaches regarding their approached-related complication rates. Results
Patients and methods Study population Between January 2003 and December 2017, 1.848 consecutive patients with a pelvic fracture were registered at our institution, a tertiary trauma center. The data from the patients with an acetabular fracture were analyzed retrospectively for this study. The local Ethics Committee of the Eberhard-Karls-University in Tübingen, Germany, approved the study. The patients were divided in two groups: (1) Patients with a surgically treated acetabular fracture and (2) patients with a conservatively treated acetabular fracture. Analyzed parameters The following demographic parameters were analyzed: • •
Age Gender
Of the 1.848 patients with a pelvic fracture, 523 patients had an acetabular fracture. Of these, 366 patients had a unilateral acetabular fracture, 16 patients had a bilateral acetabular fracture, and 141 patients had combined fractures of the acetabulum and the pelvic ring. Demographics and fracture distribution The mean age of the patients was 56.9 ± 21.1 years (range 11– 98 years). The gender distribution was 70% male (366 patients) to 30% female (157 patients). The mean length of hospital stay was 24.5 ± 26.1 days (range 0–251 days). The fracture types were distributed as follows: • • • • •
57 posterior wall fractures 14 posterior column fractures 43 anterior wall fractures 97 anterior column fractures 49 transverse fractures
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Table 2 Anterior surgical approaches to the acetabulum.
Approach
Indications
Ilioinguinal approach (Letournel) [14] Anterior intrapelvic approach (modified Stoppa) + 1st window of ilioinguinal approach [10]
Fracture of anterior column, Fracture of anterior wall, Fracture of anterior column and posterior hemitransverse, Combined fractures with main pathology anterior column, anterior wall, or quadrilateral plate
Pararectus approach (Keel) [19]
• • • • • • •
13 posterior column + posterior wall fractures 45 transverse + posterior wall fractures 23 T-type fractures 102 anterior column + posterior hemi transverse fractures 78 two-column fractures 7 unclassified fractures 11 unclassifiable fractures
Surgical treatment and surgical approaches Of the 523 patients with an acetabular fracture, 296 patients were operated and the acetabulum was stabilized. The following surgical approaches were used: 101 KL approaches, 67 Ilioinguinal approaches, 59 patients AIP approaches (modified Stoppa approach) and 30 Pararectus approaches. In 39 patients an operation was performed with a surgical approach that was different from the standard approaches.
Possible complications
Avoid complications
1st window preparation: stay lateral of anterior superior iliac spine 2nd window preparation: stay 2 cm from anterior superior iliac spine Injury of Truncus 1st window lumbosacralis preparation: stop dissection at the anterior sacrum 15 mm medial of the sacroiliac joint Injury of bladder Place urinary catheter preoperatively, Blunt dissection of retrosymphyseal space Injury of Corona 2nd window mortis preparation: identification in the middle of the upper pubic bone and ligation Injury of spermatic 2nd window cord preparation: dissect abdominal muscles from inguinal ligament Injury of vasa Subperiosteal obturatoria dissection underneath the obturator internus muscle Injury of obturator Subperiosteal nerve dissection underneath the obturator internus muscle Injury of sciatic Avoid deep nerve dissection along quadrilateral plate Incisional hernia Refixation of oblique abdominal muscles to iliac crest and inguinal ligament Injury of the lateral cutaneous femoral nerve
Complications Of the 523 patients with an acetabular fracture, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. Surgically treated patients had a higher complication rate of 21.2% (63/296) compared to the group of conservatively treated patients with a complication rate of 16.7% (38/227). In the group of the surgically treated patients, the following complications occurred: • • • • • • •
5 neurological complications (1.7%) 16 bleeding complications (5.4%) 14 thromboembolic events (4.7%) 8 surgical site infections (2.7%) 5 abdominal complications (1.7%) 7 pulmonary complications (2.4%) 9 other complications (3.0%) Bladder injuries or incisional hernias were not registered.
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Approach-related complications occurred in 3.3% (Pararectus approach), 6.9% (KL approach), 7.5% (ilioinguinal approach) and 10.2% (AIP approach), respectively. An association of the surgical approaches with the respective approach-related complications is presented in Table 1. Discussion As other studies showed before, our results demonstrate rather high complication rates in both conservatively and surgically treated patients with acetabular fractures [7]. Acetabular fractures accompanied with associated injuries lead to longer hospital stays and prolonged remobilization of the patients [8]. Percutaneous osteosynthesis techniques might reduce approach-related complications, but they only can be used, if the fracture is not severely dislocated, as the reduction of dislocated fractures is not possible through a percutaneous approach. Therefore, the quality of reduction is limited compared to open approaches [9]. In Tables 2 and 3, a summary of the different open surgical approaches to the acetabulum is provided. Beside the fracture types, which can be treated with the respective approach, special approach-related risks and strategies to prevent complications during preparation of the surgical approaches are described. Posterior approach to the acetabulum (Kocher-Langenbeck approach)
Fig. 1. Posterior approach to the acetabulum (Kocher-Langenbeck). A: Skin incision of the Kocher-Langenbeck-approach with the patient in prone position. B: Position of the sciatic nerve in relation to the external rotator muscles. C: View after detaching the short external rotator muscles from the greater trochanter. ∗ : Sciatic nerve. +: short external rotator muscles. °: quadratus femoris muscle. #: gluteus medius muscle. ~: Joint capsule.
The term Kocher-Langenbeck approach for the dorsal standard approach to treat acetabular fractures has been used since 1980. However, first descriptions of this approach were presented in 1874 by Bernhard von Langenbeck [10]. In 1911, Theodor Kocher presented a caudal extension of this approach [11] and since 1954, Letournel and Judet have used this surgical approach to address and treat acetabular fractures. For a long time, this approach was the most commonly used approach in the treatment of acetabular fractures until it was increasingly replaced by the anterior approaches over the last two decades. Nowadays, the Kocher-Langenbeck approach is mainly used for the treatment of acetabular fractures with the main pathology of the posterior column or for isolated posterior wall fractures [12]. In prone or lateral position, the skin incision starts distally to the major trochanter and is performed in a curved way over the major trochanter up to the posterior superior iliac spine (Fig. 1a). After incising the fascia lata, the gluteus maximus muscle is bluntly dissected until the short outer rotator muscles appear (Fig. 1b). These muscles are transected from the major trochanter with strict conservation of the circumflex femoral artery. The sciatic nerve is protected dorsally by the muscle bellies of the short outer rotators (Fig. 1c). Now, the fracture can be exposed or, if necessary, the approach can be extended either by incising the joint capsule or through a surgical hip dislocation by trochanter osteotomy. Special risks of the Kocher-Langenbeck approach include iatrogenic neurovascular injuries with a frequency of up to 10% [1315]. Strategies to avoid complications related with this approach are listed in Table 2. Ilioinguinal approach according to Letournel In the 1960s, Emile Letournel described the Ilioinguinal approach for the treatment of acetabular fractures with main dislocation of the anterior column [16]. Despite the development of less invasive anterior approaches (e. g. modified Stoppa + 1st window of the Pararectus approach), the Ilioinguinal approach is still a commonly used anterior approach in the treatment of acetabular fractures around the world [17].
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Table 3 Surgical approaches and the related complication rates. Surgical approach
n
Overall complications (%)
Approach-related complications (%)
None (conservative treatment) Kocher-Langenbeck Ilioinguinal approach Anterior intrapelvic approach (modified Stoppa) Pararectus Other
227 101 67 59 30 39
16.7% 24.8% 22.4% 16.9% 20.0% 17.9%
– 6.9% (7/101) 7.5% (5/67) 10.2% (6/59) 3.3% (1/30) 5.1% (2/39)
(38/227) (25/101) (15/67) (10/59) (6/30) (7/39)
Approach related complications: neurovascular complications, bladder injuries, incisional hernias.
Fig. 2. Ilioinguinal approach (Letournel). A: Skin incision of the Ilioinguinal approach with the patient in supine position. B: View of the 3 windows of the Ilioinguinal approach. ∗ : Lateral cutaneous femoris nerve. +: Psoas muscle. °: Inguinal ligament. #: 1st window. ~: 2nd window (lateral of the femoral vessels). §: 3rd window (medial of the femoral vessels).
The operation is performed in supine position. The skin incision reaches from the middle of the iliac crest along the ASIS and the inguinal ligament as far as 2 cm cranial of the symphysis (Fig. 2a). Now, three windows can be developed to expose the entire anterior part of the acetabulum [18,12] (Fig. 2b). Through the 1st window the iliac wing and the iliosacral joint can be exposed. For the development of the 2nd window, the oblique abdominal muscles and the dorsal parts of the inguinal canal (the transverse fascia and the caudal parts of the internal oblique abdominal muscle) must be transected from the inguinal ligament. After preparation of the vascular and muscular lacunae by sectioning the iliopectineal arc, the iliopectineal line of the acetabulum can be exposed by retracting the femoral neurovascular bundle. By preparation and dissec-
tion of the internal obturator muscle subperiosteally to the dorsal side, the quadrilateral surface can be reached indirectly up to the sciatic spine. The 3rd window is located medially to the femoral vessels and provides visualization of the superior pubic ramus. If the skin incision is extended analogue to the Stoppa approach or the Pfannenstiel approach over the midline to the opposing side, it is called the 4th window of the Ilioinguinal approach [19]. Approach-related complications of the ilioinguinal-approach include neurovascular injuries as well as injuries to the structures of the inguinal canal or injuries to the bladder or peritoneum (Table 3). These complications can have a frequency of up to 27% [20].
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Fig. 3. Anterior intrapelvic approach (Modified Stoppa approach). A: View of the situs after doing the Pfannenstiel incision. B: View on the quadrilateral plate after ligating and dividing the corona mortis vessel. ∗ : Transection of one pyramid muscle from the superior pubic ramus. +: Quadrilateral plate. °: divided corona mortis vessel.
Anterior intrapelvic approach (AIP, modified Stoppa approach) The original Stoppa approach was presented in 1973 by René Stoppa for the preperitoneal mesh-repair of bilateral groin hernias [21]. Technically, it is an extended Pfannenstiel approach. Through the modified Stoppa approach (anterior intrapelvic approach) the entire anterior pelvic ring can be exposed except for the ischial rami [22]. Together with the 1st window of the Ilioinguinal approach, the AIP approach can be used for the osteosynthesis of acetabular fractures with dislocation of the anterior column or the quadrilateral surface [23]. Analogue to the Pfannenstiel approach, the skin is incised transversely about 2 cm proximal to the symphysis over a distance of about 10 cm. After preparation down to the rectus sheath the midline of the fascia is incised longitudinally. However, contrary to the Pfannenstiel approach, the transection of one pyramid muscle from the superior pubic ramus is absolutely necessary to get an adequate vision of the lateral structures (Fig. 3a). Along the pubic rami, the periosteum is dissected to the lateral side. In case of an existing corona mortis vessel, this anastomosis between the inferior epigastric artery and the obturator artery should be ligated and divided. Now, the quadrilateral surface of the acetabulum can be prepared along the internal obturator muscle down to the ischial spine (Fig. 3b). During this phase of preparation, the obturator vessels and the obturator nerve must be preserved. By further dorsal preparation of the periosteum, the ventral part of the sacroiliac (SI) joint can be exposed. In a systematic review, the overall complication rate of the AIP approach was rated as high as 17.5% [20]. The specific risks of the AIP approach are actually the same like in the Ilioinguinal approach and they are presented in Table 3. AIP approach + 1st window of the Ilioinguinal approach As a result of up to 27% approach-related complications for the Ilioinguinal approach, many less-invasive variants of this approach were developed. The most commonly used variant is the combination of the AIP approach with the 1st window of the Ilioinguinal approach [23]. The approach is carried out as a combination of the mentioned two approaches. The preparation along the iliopectineal
line is performed as a rendezvous maneuver between the two incisions below the femoral neurovascular bundle. One advantage of this approach is the fact that the transection of the oblique abdominal muscles from the inguinal ligament is not necessary, which results in lower rates of incisional hernias and injuries to the spermatic cord. A possible disadvantage could be the worse visualization of the iliopectineal line and the quadrilateral plate which reduces the options for fracture reduction. Approach-specific complications occur in about 20% [20,24,25]. Strategies to avoid complications by surgical dissection are presented in Table 3. Pararectus approach according to Keel In 2012, Keel first presented a limited invasive anterior approach to the acetabulum which combined the advantages of the extensive intrapelvine approach (good options to reduce dislocations of the quadrilateral plate) with the advantages of the Ilioinguinal approach (good visualization of the entire pelvic entry) [26]. Since then, this approach has seen increasing popularity for the treatment of acetabular fractures [27,28]. Moreover, in patients who underwent a preperitoneal mesh repair of inguinal hernias the Pararectus approach allows for an easier dissection due to less adhesions compared to the Ilioinguinal approach. The skin is incised over a length of 10–12 cm laterally to the rectal sheath (=pararectal, Fig. 4a) and the dissection is continued until the peritoneal sac which is then bluntly shoved to the medial side analogue to the extraperitoneal preparation for the extraanatomical kidney transplantation (Fig. 4b). Like in the Ilioinguinal approach, the development of the three (respectively four) windows can be prepared from the iliosacral joint up to the symphysis (Fig. 4c). The excellent visualization of the quadrilateral plate is called the 5th window of the Pararectus approach. The approach-related risks of the Pararectus approach are the same as in the Ilioinguinal approach (Table 3). While the risk of injuries to the obturator vessels or the obturator nerve is reduced through the excellent visualization of the quadrilateral plate, the risk of intraoperative bleeding is increased with a rate of up to 9% [27,29,30]. Despite the increased risk of injuries to the peritoneum, usually this is without any consequences if it is an isolated peritoneal injury without involvement of intraabdominal organs.
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Acknowledgments We sincerely thank Mrs. Catharina Scheuermann-Poley for editing this manuscript in the English language. References
Fig. 4. Pararectus approach (Keel). A: Pararectal skin incision (red line). B: Preparation between the oblique abdominal muscles and the peritoneum. C: View on the quadrilateral plate and the obturator neurovascular bundle. ∗ : Peritoneum. +: Rectus abdominis muscle. #: Oblique abdominal muscles. °: Femoral vessels. §: Obturator neurovascular bundle. ~: Quadrilateral plate.
Conclusions Patients with acetabular fractures are at risk for complications. Operatively treated patients had an insignificantly higher complication rate than conservatively treated patients. The most common risks are neuro-vascular complications. For surgical treatment, indication and approach should be set carefully, including individual patient parameters and fracture types. Declaration of Competing Interest
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The authors declare that they have no conflict of interest. Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Contents lists available at ScienceDirect
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Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them Markus A. Küper a,∗, Christian Konrads a,1, Alexander Trulson b, Christian Bahrs a, Ulrich Stöckle c, Fabian M. Stuby b a b c
BG Trauma Center, Department for Traumatology and Reconstructive Surgery, University of Tübingen, Tübingen, Germany Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany Charité University Medicine Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
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Article history: Accepted 19 February 2020 Available online xxx Keywords: Hip joint Pelvis Pelvic ring fracture Approach-related complications
a b s t r a c t Background: Fractures of the acetabulum are rare injuries. The indication for surgical stabilization depends on the grade of instability and dislocation. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of anatomical structures and possible risks of the different approaches, are important. Methods: Over a period of 15 years, we analyzed all patients with acetabular fractures, treated in our Level I Trauma Center with special interest in surgical and approach-related complications. Based on our complication rates, we describe the used different surgical approaches and the accessible anatomical structures respectively. Finally, we focus on strategies to reduce the risk of approach-related complications in acetabular surgery. Results: Between January 2003 and December 2017, 523 patients with an acetabular fracture were treated in our Tertiary Referral Hospital. Of these, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. 296 patients underwent surgical treatment of the acetabular fracture, while 227 patients were treated non-operatively. Surgically treated patients had a significantly higher complication rate of 21.2% (63/296) compared to conservatively treated patients with a complication rate of 16.7% (38/227). Neurovascular and thromboembolic adverse events were the most often complications. Conclusions: Patients with acetabular fractures are at a high risk for different kind of complications. The most common risks are neuro-vascular and thromboembolic incidents. The risk of getting a complication is increased in surgically treated patients, therefore both the indication for surgical treatment and the surgical approach should be carried out carefully, including individual patient parameters and fracture types as well as the surgeons expertise. © 2020 Elsevier Ltd. All rights reserved.
Introduction Fractures of the acetabulum and the pelvic ring are rare injuries which make up about 3–8% of all fractures. They occur with two frequency peaks regarding patient age. The first peak occurs in younger patients around the 2nd to 3rd decade of life and the second peak occurs around the 7th to 8th decade [1]. While the main reason for pelvic fractures in the younger patient is usually a high energy trauma (like motor vehicle accidents or fall from
∗
Corresponding author. E-mail address: [email protected] (M.A. Küper). 1 Markus Alexander Küper and Christian Konrads contributed equally to this publication.
great height), elderly patients acquire pelvic injuries by a low energy trauma (e.g. fall from the stand or out of bed). Due to the demographic development, the frequency of those age-associated pelvic injuries has increased over the past years [2]. From both, the anatomical and biomechanical point of view, the acetabulum consists of two columns. The anterior column reaches from the tip of the iliac crest along the anterior superior iliac spine (ASIS), the superior pubic ramus onto the middle of the inferior pubic ramus. The posterior column reaches from the upper crest of the greater sciatic notch along the entire ischial bone also to the middle of the inferior pubic ramus. Biomechanically, the posterior column is far more important than the anterior column because it transmits the forces from the torso via the iliosacral joints to the proximal femur.
https://doi.org/10.1016/j.injury.2020.02.100 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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M.A. Küper, C. Konrads and A. Trulson et al. / Injury xxx (xxxx) xxx Table 1 Posterior surgical approach to the acetabulum (Kocher-Langenbeck approach) [17,18]. Indications
Possible complications
Avoid complications
Fracture of posterior column,Fracture of posterior wall,Transverse fracture, Combined fractures with main pathology of posterior column or wall
Injury of sciatic nerve
Bend knee (nerve relaxed),Upholster nerve with short external rotator muscles Blunt dissection of gluteus maximus muscle Identify vessel at quadratus femoris muscle
Injury of inferior gluteal nerve Injury of femoral circumflex artery
Usually, acetabular fractures are classified according to Letournel/Judet into ten different fracture types [3-5]. Depending on the fracture morphology and the needed exposition, mainly the following posterior and anterior standard approaches are used for the surgical treatment of acetabular fractures: • • •
•
The Kocher-Langenbeck approach (posterior) The Ilioinguinal approach according to Letournel (anterior) The anterior intrapelvic approach (AIP, modified Stoppa approach), often in combination with the first window of the ilioinguinal approach The Pararectus approach according to Keel (anterior)
To make the decision whether or not to stabilize an acetabular fracture with an osteosynthesis, it is necessary to assess the potential benefits and the risks of the surgical procedure. Besides the primary stability of the fracture, the patient’s general condition and concomitant diseases as well as the activity level prior to the accident leading to the fracture, the own expertise should play a crucial role in the surgeon’s decision making. Regarding the risks of the surgical procedure, especially the different surgical approaches and the approach-related morbidity are of major interest for the surgeon [6]. This means that the knowledge of the different approaches to the acetabulum and their pitfalls is essential for the pelvic trauma surgeon and his decision. We analyzed our complications in acetabular fracture surgery. Based on our data and experience over the last 15 years, we present an overview of the most common open surgical approaches to the acetabulum with a brief description of the surgical technique together with approach-specific risks and suggestions how to avoid approach-related complications.
• • • • • •
Length of hospital stay (in days) Fracture type according to Judet/Letournel Number of osteosynthetic operations Surgical approach Overall complication rate Mortality The following complications were recorded:
• • • • • • • • •
Bleeding Thromboembolic events Surgical site infection Neurologic complications Pulmonary complications Abdominal complications Implant loosening / failure Secondary dislocation Others
Association between surgical approach and approach-related complications Bleeding, neurologic complications, bladder injuries, or incisional hernias were defined as approach-related complications. Patients were grouped according to the surgical approach: Kocher-Langenbeck approach (KL), ilioinguinal approach, anterior intrapelvic approach (AIP, modified Stoppa approach), Pararectus approach, and others. We then associated each approach-related complication to the respective surgical approach and finally compared different surgical approaches regarding their approached-related complication rates. Results
Patients and methods Study population Between January 2003 and December 2017, 1.848 consecutive patients with a pelvic fracture were registered at our institution, a tertiary trauma center. The data from the patients with an acetabular fracture were analyzed retrospectively for this study. The local Ethics Committee of the Eberhard-Karls-University in Tübingen, Germany, approved the study. The patients were divided in two groups: (1) Patients with a surgically treated acetabular fracture and (2) patients with a conservatively treated acetabular fracture. Analyzed parameters The following demographic parameters were analyzed: • •
Age Gender
Of the 1.848 patients with a pelvic fracture, 523 patients had an acetabular fracture. Of these, 366 patients had a unilateral acetabular fracture, 16 patients had a bilateral acetabular fracture, and 141 patients had combined fractures of the acetabulum and the pelvic ring. Demographics and fracture distribution The mean age of the patients was 56.9 ± 21.1 years (range 11– 98 years). The gender distribution was 70% male (366 patients) to 30% female (157 patients). The mean length of hospital stay was 24.5 ± 26.1 days (range 0–251 days). The fracture types were distributed as follows: • • • • •
57 posterior wall fractures 14 posterior column fractures 43 anterior wall fractures 97 anterior column fractures 49 transverse fractures
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Table 2 Anterior surgical approaches to the acetabulum.
Approach
Indications
Ilioinguinal approach (Letournel) [14] Anterior intrapelvic approach (modified Stoppa) + 1st window of ilioinguinal approach [10]
Fracture of anterior column, Fracture of anterior wall, Fracture of anterior column and posterior hemitransverse, Combined fractures with main pathology anterior column, anterior wall, or quadrilateral plate
Pararectus approach (Keel) [19]
• • • • • • •
13 posterior column + posterior wall fractures 45 transverse + posterior wall fractures 23 T-type fractures 102 anterior column + posterior hemi transverse fractures 78 two-column fractures 7 unclassified fractures 11 unclassifiable fractures
Surgical treatment and surgical approaches Of the 523 patients with an acetabular fracture, 296 patients were operated and the acetabulum was stabilized. The following surgical approaches were used: 101 KL approaches, 67 Ilioinguinal approaches, 59 patients AIP approaches (modified Stoppa approach) and 30 Pararectus approaches. In 39 patients an operation was performed with a surgical approach that was different from the standard approaches.
Possible complications
Avoid complications
1st window preparation: stay lateral of anterior superior iliac spine 2nd window preparation: stay 2 cm from anterior superior iliac spine Injury of Truncus 1st window lumbosacralis preparation: stop dissection at the anterior sacrum 15 mm medial of the sacroiliac joint Injury of bladder Place urinary catheter preoperatively, Blunt dissection of retrosymphyseal space Injury of Corona 2nd window mortis preparation: identification in the middle of the upper pubic bone and ligation Injury of spermatic 2nd window cord preparation: dissect abdominal muscles from inguinal ligament Injury of vasa Subperiosteal obturatoria dissection underneath the obturator internus muscle Injury of obturator Subperiosteal nerve dissection underneath the obturator internus muscle Injury of sciatic Avoid deep nerve dissection along quadrilateral plate Incisional hernia Refixation of oblique abdominal muscles to iliac crest and inguinal ligament Injury of the lateral cutaneous femoral nerve
Complications Of the 523 patients with an acetabular fracture, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. Surgically treated patients had a higher complication rate of 21.2% (63/296) compared to the group of conservatively treated patients with a complication rate of 16.7% (38/227). In the group of the surgically treated patients, the following complications occurred: • • • • • • •
5 neurological complications (1.7%) 16 bleeding complications (5.4%) 14 thromboembolic events (4.7%) 8 surgical site infections (2.7%) 5 abdominal complications (1.7%) 7 pulmonary complications (2.4%) 9 other complications (3.0%) Bladder injuries or incisional hernias were not registered.
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Approach-related complications occurred in 3.3% (Pararectus approach), 6.9% (KL approach), 7.5% (ilioinguinal approach) and 10.2% (AIP approach), respectively. An association of the surgical approaches with the respective approach-related complications is presented in Table 1. Discussion As other studies showed before, our results demonstrate rather high complication rates in both conservatively and surgically treated patients with acetabular fractures [7]. Acetabular fractures accompanied with associated injuries lead to longer hospital stays and prolonged remobilization of the patients [8]. Percutaneous osteosynthesis techniques might reduce approach-related complications, but they only can be used, if the fracture is not severely dislocated, as the reduction of dislocated fractures is not possible through a percutaneous approach. Therefore, the quality of reduction is limited compared to open approaches [9]. In Tables 2 and 3, a summary of the different open surgical approaches to the acetabulum is provided. Beside the fracture types, which can be treated with the respective approach, special approach-related risks and strategies to prevent complications during preparation of the surgical approaches are described. Posterior approach to the acetabulum (Kocher-Langenbeck approach)
Fig. 1. Posterior approach to the acetabulum (Kocher-Langenbeck). A: Skin incision of the Kocher-Langenbeck-approach with the patient in prone position. B: Position of the sciatic nerve in relation to the external rotator muscles. C: View after detaching the short external rotator muscles from the greater trochanter. ∗ : Sciatic nerve. +: short external rotator muscles. °: quadratus femoris muscle. #: gluteus medius muscle. ~: Joint capsule.
The term Kocher-Langenbeck approach for the dorsal standard approach to treat acetabular fractures has been used since 1980. However, first descriptions of this approach were presented in 1874 by Bernhard von Langenbeck [10]. In 1911, Theodor Kocher presented a caudal extension of this approach [11] and since 1954, Letournel and Judet have used this surgical approach to address and treat acetabular fractures. For a long time, this approach was the most commonly used approach in the treatment of acetabular fractures until it was increasingly replaced by the anterior approaches over the last two decades. Nowadays, the Kocher-Langenbeck approach is mainly used for the treatment of acetabular fractures with the main pathology of the posterior column or for isolated posterior wall fractures [12]. In prone or lateral position, the skin incision starts distally to the major trochanter and is performed in a curved way over the major trochanter up to the posterior superior iliac spine (Fig. 1a). After incising the fascia lata, the gluteus maximus muscle is bluntly dissected until the short outer rotator muscles appear (Fig. 1b). These muscles are transected from the major trochanter with strict conservation of the circumflex femoral artery. The sciatic nerve is protected dorsally by the muscle bellies of the short outer rotators (Fig. 1c). Now, the fracture can be exposed or, if necessary, the approach can be extended either by incising the joint capsule or through a surgical hip dislocation by trochanter osteotomy. Special risks of the Kocher-Langenbeck approach include iatrogenic neurovascular injuries with a frequency of up to 10% [1315]. Strategies to avoid complications related with this approach are listed in Table 2. Ilioinguinal approach according to Letournel In the 1960s, Emile Letournel described the Ilioinguinal approach for the treatment of acetabular fractures with main dislocation of the anterior column [16]. Despite the development of less invasive anterior approaches (e. g. modified Stoppa + 1st window of the Pararectus approach), the Ilioinguinal approach is still a commonly used anterior approach in the treatment of acetabular fractures around the world [17].
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Table 3 Surgical approaches and the related complication rates. Surgical approach
n
Overall complications (%)
Approach-related complications (%)
None (conservative treatment) Kocher-Langenbeck Ilioinguinal approach Anterior intrapelvic approach (modified Stoppa) Pararectus Other
227 101 67 59 30 39
16.7% 24.8% 22.4% 16.9% 20.0% 17.9%
– 6.9% (7/101) 7.5% (5/67) 10.2% (6/59) 3.3% (1/30) 5.1% (2/39)
(38/227) (25/101) (15/67) (10/59) (6/30) (7/39)
Approach related complications: neurovascular complications, bladder injuries, incisional hernias.
Fig. 2. Ilioinguinal approach (Letournel). A: Skin incision of the Ilioinguinal approach with the patient in supine position. B: View of the 3 windows of the Ilioinguinal approach. ∗ : Lateral cutaneous femoris nerve. +: Psoas muscle. °: Inguinal ligament. #: 1st window. ~: 2nd window (lateral of the femoral vessels). §: 3rd window (medial of the femoral vessels).
The operation is performed in supine position. The skin incision reaches from the middle of the iliac crest along the ASIS and the inguinal ligament as far as 2 cm cranial of the symphysis (Fig. 2a). Now, three windows can be developed to expose the entire anterior part of the acetabulum [18,12] (Fig. 2b). Through the 1st window the iliac wing and the iliosacral joint can be exposed. For the development of the 2nd window, the oblique abdominal muscles and the dorsal parts of the inguinal canal (the transverse fascia and the caudal parts of the internal oblique abdominal muscle) must be transected from the inguinal ligament. After preparation of the vascular and muscular lacunae by sectioning the iliopectineal arc, the iliopectineal line of the acetabulum can be exposed by retracting the femoral neurovascular bundle. By preparation and dissec-
tion of the internal obturator muscle subperiosteally to the dorsal side, the quadrilateral surface can be reached indirectly up to the sciatic spine. The 3rd window is located medially to the femoral vessels and provides visualization of the superior pubic ramus. If the skin incision is extended analogue to the Stoppa approach or the Pfannenstiel approach over the midline to the opposing side, it is called the 4th window of the Ilioinguinal approach [19]. Approach-related complications of the ilioinguinal-approach include neurovascular injuries as well as injuries to the structures of the inguinal canal or injuries to the bladder or peritoneum (Table 3). These complications can have a frequency of up to 27% [20].
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Fig. 3. Anterior intrapelvic approach (Modified Stoppa approach). A: View of the situs after doing the Pfannenstiel incision. B: View on the quadrilateral plate after ligating and dividing the corona mortis vessel. ∗ : Transection of one pyramid muscle from the superior pubic ramus. +: Quadrilateral plate. °: divided corona mortis vessel.
Anterior intrapelvic approach (AIP, modified Stoppa approach) The original Stoppa approach was presented in 1973 by René Stoppa for the preperitoneal mesh-repair of bilateral groin hernias [21]. Technically, it is an extended Pfannenstiel approach. Through the modified Stoppa approach (anterior intrapelvic approach) the entire anterior pelvic ring can be exposed except for the ischial rami [22]. Together with the 1st window of the Ilioinguinal approach, the AIP approach can be used for the osteosynthesis of acetabular fractures with dislocation of the anterior column or the quadrilateral surface [23]. Analogue to the Pfannenstiel approach, the skin is incised transversely about 2 cm proximal to the symphysis over a distance of about 10 cm. After preparation down to the rectus sheath the midline of the fascia is incised longitudinally. However, contrary to the Pfannenstiel approach, the transection of one pyramid muscle from the superior pubic ramus is absolutely necessary to get an adequate vision of the lateral structures (Fig. 3a). Along the pubic rami, the periosteum is dissected to the lateral side. In case of an existing corona mortis vessel, this anastomosis between the inferior epigastric artery and the obturator artery should be ligated and divided. Now, the quadrilateral surface of the acetabulum can be prepared along the internal obturator muscle down to the ischial spine (Fig. 3b). During this phase of preparation, the obturator vessels and the obturator nerve must be preserved. By further dorsal preparation of the periosteum, the ventral part of the sacroiliac (SI) joint can be exposed. In a systematic review, the overall complication rate of the AIP approach was rated as high as 17.5% [20]. The specific risks of the AIP approach are actually the same like in the Ilioinguinal approach and they are presented in Table 3. AIP approach + 1st window of the Ilioinguinal approach As a result of up to 27% approach-related complications for the Ilioinguinal approach, many less-invasive variants of this approach were developed. The most commonly used variant is the combination of the AIP approach with the 1st window of the Ilioinguinal approach [23]. The approach is carried out as a combination of the mentioned two approaches. The preparation along the iliopectineal
line is performed as a rendezvous maneuver between the two incisions below the femoral neurovascular bundle. One advantage of this approach is the fact that the transection of the oblique abdominal muscles from the inguinal ligament is not necessary, which results in lower rates of incisional hernias and injuries to the spermatic cord. A possible disadvantage could be the worse visualization of the iliopectineal line and the quadrilateral plate which reduces the options for fracture reduction. Approach-specific complications occur in about 20% [20,24,25]. Strategies to avoid complications by surgical dissection are presented in Table 3. Pararectus approach according to Keel In 2012, Keel first presented a limited invasive anterior approach to the acetabulum which combined the advantages of the extensive intrapelvine approach (good options to reduce dislocations of the quadrilateral plate) with the advantages of the Ilioinguinal approach (good visualization of the entire pelvic entry) [26]. Since then, this approach has seen increasing popularity for the treatment of acetabular fractures [27,28]. Moreover, in patients who underwent a preperitoneal mesh repair of inguinal hernias the Pararectus approach allows for an easier dissection due to less adhesions compared to the Ilioinguinal approach. The skin is incised over a length of 10–12 cm laterally to the rectal sheath (=pararectal, Fig. 4a) and the dissection is continued until the peritoneal sac which is then bluntly shoved to the medial side analogue to the extraperitoneal preparation for the extraanatomical kidney transplantation (Fig. 4b). Like in the Ilioinguinal approach, the development of the three (respectively four) windows can be prepared from the iliosacral joint up to the symphysis (Fig. 4c). The excellent visualization of the quadrilateral plate is called the 5th window of the Pararectus approach. The approach-related risks of the Pararectus approach are the same as in the Ilioinguinal approach (Table 3). While the risk of injuries to the obturator vessels or the obturator nerve is reduced through the excellent visualization of the quadrilateral plate, the risk of intraoperative bleeding is increased with a rate of up to 9% [27,29,30]. Despite the increased risk of injuries to the peritoneum, usually this is without any consequences if it is an isolated peritoneal injury without involvement of intraabdominal organs.
Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100
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Acknowledgments We sincerely thank Mrs. Catharina Scheuermann-Poley for editing this manuscript in the English language. References
Fig. 4. Pararectus approach (Keel). A: Pararectal skin incision (red line). B: Preparation between the oblique abdominal muscles and the peritoneum. C: View on the quadrilateral plate and the obturator neurovascular bundle. ∗ : Peritoneum. +: Rectus abdominis muscle. #: Oblique abdominal muscles. °: Femoral vessels. §: Obturator neurovascular bundle. ~: Quadrilateral plate.
Conclusions Patients with acetabular fractures are at risk for complications. Operatively treated patients had an insignificantly higher complication rate than conservatively treated patients. The most common risks are neuro-vascular complications. For surgical treatment, indication and approach should be set carefully, including individual patient parameters and fracture types. Declaration of Competing Interest
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The authors declare that they have no conflict of interest. Please cite this article as: M.A. Küper, C. Konrads and A. Trulson et al., Complications of surgical approaches for osteosynthetic treatment of acetabular fractures: Analysis of pitfalls and how to avoid them, Injury, https://doi.org/10.1016/j.injury.2020.02.100