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Research Paper

Fixation of Pelvic–Acetabular Fractures Using a Midline-Modified Stoppa Approach: Clinical and Operative Outcomes: 採用改進Stoppa入路以下中線切口進行盤骨髖臼骨折: 臨床和手術結果

Abstract

 

Background/Purpose

This served as the first report from our locality to evaluate the modified Stoppa approach, via a low-midline wound, for treating pelvic–acetabular fractures.

Methods

A total of 17 polytrauma patients with pelvic and/or acetabular fractures were consecutively treated using the modified Stoppa approach. They were followed up for at least 1 year postoperatively for radiographic and clinical assessments, which included the Modified Merle d’Aubigne Score, Harris Hip Score, and pain visual analogue scale.

Results

Among the 17 patients, 11 had pelvic ring fractures, two had isolated acetabular fractures, and four had a combination of both. Excellent and anatomical reduction was achieved in 73.3% of pelvic fractures and 71.4% of acetabular fractures. Functional outcomes simulated a bimodal distribution. Age of patient and Injury Severity Score were significant predictors for functional results, whereas fracture characteristics and quality of reduction were not correlated with clinical outcomes in this series. We experienced a low complication rate.

Conclusion

Excellent exposure for fracture reduction and fixation with low complication rate was achieved with the modified Stoppa approach. We were encouraged by the results of this preliminary series for treating pelvic–acetabular fractures in polytrauma patients.

中 文 摘 要
背景/目的

這是以改進Stoppa入路以下中線切口進行盤骨髖臼骨折的本地首個報告。

方法

從2010年5月至2014年5月期間,採用改進Stoppa入路連續為17位病人治療其盤骨或髖臼骨折。隨訪至少一年,並紀錄影像結果和臨床成效。臨床評估包括改良Merle d’ Aubigne評分、哈里斯髖關節評分和疼痛的視覺模擬評分。

結果

在17位病人當中,11位有盤骨骨折,2位有髖臼骨折,另外4位同時有盤骨及髖臼骨折。於73.3%的盤骨環骨折及71.4%的髖臼骨折,解剖復位達到優秀水平。而功能結果則呈現了雙峰的分佈。病人的年齡和創傷嚴重程度得分 (ISS) 能顯著地預測功能結果,而骨折特性和復位的準確度則與臨床結果沒有相關。術後的併發症比率偏低。

結論

改進Stoppa入路能做到優良的顯露,良好的骨折復位及低併發症比率。患有盤骨髖臼骨折的多發性創傷病人術後的初步成果,整體來說令人鼓舞。

Keywords
acetabulum
fracture fixation
internal
multiple trauma
orthopaedic procedures
pelvis

Introduction

Since its first description by Cole and Bolhofner1 in 1994, the modified Stoppa approach (or anterior intrapelvic approach) has gained popularity for fixation of acetabular and pelvicring fractures over the past decade. Compared to the classical ilioinguinal approach developed by Judet et al2 in the 1960s, the modified Stoppa approach offers more direct access and visualisation of the pubis, the anterior column of the ilium, and more importantly, the quadrilateral plate of the acetabulum. It also simultaneously avoids dissection of the inguinal canal, femoral nerve, and external iliac vessels.3 The advantages are more obvious in patients with bilateral injuries.

Favourable results, in terms of both radiographic and clinical outcomes, with the use of the modified Stoppa approach have been increasingly described by the literature worldwide,456 including fellow traumatologists from Mainland China and other parts of Asia.78However, there has not yet been any report from our territory evaluating the use of the anterior intrapelvic approach.

Patients with pelvic–acetabular fractures frequently suffer from hypovolaemic shock on arrival, as a result of profuse fracture bleeding into the pelvic cavity. A low-midline incision and subsequent retroperitoneal packing, with or without immediate upward extension for standard laparotomy as indicated, remains one of the standard measures to resuscitating these victims of high-energy trauma.9 As compared to the original Pfannestial-type of incision,1 reports on using this low-midline laparotomy wound to perform subsequent modified Stoppa approach for fracture fixation are limited.1011

The aim of this study was therefore to evaluate the midterm radiographic, functional outcomes and associated complications of pelvic–acetabular fractures fixed with the modified Stoppa approach, with a focus on patient demographics and fracture characteristics, as well as the need for additional surgical windows for definitive fixation. An attempt was also made to identify potential predictive factors for better clinical and operative results.

Methods

Between May 2010 and May 2014, a total of 17 consecutive patients with 18 pelvic and/or acetabular fractures (1 patient having bilateral involvement) received definitive fixation by the modified Stoppa approach. All of them were primarily admitted into a single trauma institute of the locality. A minimum follow-up period of 12 months postoperatively was required for every patient included.

Preoperative data including patient demographics, mechanism of injury, Injury Severity Score17 (ISS), and interval delay to definitive fixation surgery were recorded. Fracture pattern and characteristics were evaluated using a complete set of anteroposterior, inlet, outlet, and Judet radiographs, as well as computed tomography (CT) scans. Fracture types were first segregated into pelvic ring, acetabulum, or combined. Fractures of the pelvic ring were classified using the Tile system,12 while acetabular fractures were described according to the Judet et al2 classification.

All of our patients were polytrauma patients who suffered from high-energy injury. They all received retroperitoneal packing via a low-midline incision as part of the emergency life-saving treatment for their pelvic and/or acetabular fractures, as part of the management protocol of our institution. Subsequent definitive fixation surgery using the modified Stoppa approach was performed by one of the two senior authors. Perioperative data including operating time, blood loss, and need of additional surgical window were documented.

Postoperatively, reduction quality of the fractures was assessed by using the above-mentioned standard plain radiographs. Reduction of the pelvic ring fractures and acetabular fractures was evaluated separately using the criteria put forward by Matta14and Matta and Tornetta15 (Table 1).

Table 1
Quality of reduction for acetabular fractures:
Anatomical: 0–1 mm step
Imperfect: 2–3 mm step
Poor: > 3 mm step
Surgical secondary incongruence: acetabulum is reduced but displacement of the innominate bone alters the joint position
Quality of reduction for pelvic ring fractures:
Excellent: ≤ 4 mm step
Good: 4–10 mm step
Fair: 10–20 mm step
Poor: > 20 mm step

All patients were followed up at 6 weeks, 3 months, 6 months, and 12 months after initial surgery. The same set of standard radiographs were taken at each time point for detection of (1) loss of reduction; (2) unusual progress of fracture union; (3) implant failure; (4) heterotopic ossification; and (5) osteoarthritic change using gradings again defined by Matta.14 Clinical and functional outcomes were charted for all patients by one single author at 12 months postoperatively (Table 2). They included the patients’ mobility status, pain (using visual analogue scale of 0–10), integrity of obturator nerve in terms of hip adduction power, and light touch sensation over the medial thigh. Two functional scores were also measured, namely the Harris Hip Score16 and the Merle D’Aubigne score (MDA) modified by Matta and Tornetta.15 The MAS, a score widely used for evaluating patients with pelvic–acetabular fractures, consists of three main items: degree of pain, ambulation, and range of motion. MAS constitutes a maximum score of 18. The MAS can then be further interpreted as excellent for 17 points or 18 points, good for 15 points or 16 points, fair for 13 points or 14 points, and poor for < 13 points.

Table 2
1 Ambulatory status
3 Pain (using Visual Analogue Scale of 0–10)
4 Hip adduction power and medial thigh light touch sensation (obturator nerve integrity)
5 Harris Hip Score
6 Modified Merle d’Aubigne Score

Complications were recorded with special attention to occurrence of infection, neurovascular injury, fracture nonunion, and breakage of implant.

Statistical analysis was completed using SPSS for Windows version 21.0.0 (SPSS Inc., Chicago, IL, USA). Pearson’s χ2 test was used to delineate differences between categorical variables. The independent samples t test and one-way analysis of variance test were employed for comparison of means among two or more groups, aiming to detect outcome differences among patients of different age groups and fracture characteristics. Spearman’s correlation coefficient was used to look for correlation between quantitative variables. A p value ≤ 0.05 was considered to be statistically significant.

Operative details

All operations were performed with the patient lying supine on a flat radiolucent table, permitting fluoroscopic guidance of reduction and fixation. The entire abdomen and ipsilateral lower limb were draped mobile, with the hip and knee flexed with bumps to relax the iliopsoas muscle and external iliac vessels (Figure 1). Prophylaxis against deep vein thrombosis was provided intraoperatively by intermittent pneumatic compressionstockings. A Foley catheter was inserted for decompression of the urinary bladder. Shaving of the pubis and administration of prophylactic antibiotics were done upon induction of anaesthesia.

Figure 1
Figure 1

As all our patients had received retroperitoneal packing with low-midline approach as initial emergency management, we utilised the same incision for our modified Stoppa approach. The incision was from a point just distal to the umbilicus down to the level of pubic symphysis. The anterior rectus sheath was opened vertically in midline by incising the linea alba (Figure 2). The pubic symphysis was then reached by blunt dissection at the pre-peritoneal space. Lateral exposure was gained by upward reflection of the peritoneal sac away from the fracture side, with care taken not to breach the peritoneum. Sub-periosteal dissection was started from the superior ramus, moving laterally until the corona mortis was identified and ligated (Figure 3). The external iliac vessels and obturator nerve were identified then protected using malleable retractors placed beneath the iliopsoas and obturator internus, respectively. In cases of anterior column fracture that exited high at the iliac crest, the lateral window of the ilioinguinal approach16 was also used. The incision used was typically over the anterior two-thirds of the iliac crest, which was actually the same incision for placing the pins of the pelvic external fixator (Figure 4). The iliacus muscle was elevated sub-periosteally, exposing the internal iliac fossa. The iliopectineal fascia, which is usually breached upon injury was incised. This allowed access to the pelvis above and below the iliopectineal line, the anterior column of the acetabulum, as well as the quadrilateral plate. In case of minimally displaced posterior column fracture, antegrade posterior column screw can be inserted from the inner table of the ilium to the ischium, through the lateral window of the ilioinguinal approach. Further dissection posteriorly, with precautions to protect the internal iliac vessels, allowed access to the anterior aspect of the sacroiliac joint as well. For cases with bilateral fracture, similar dissection was performed to the contralateral side. In case of sacral fractures or disruption of the sacroiliac joint, sacroiliac screws were inserted percutaneously for fixation during the same session.

Figure 2
Figure 2
Figure 3
Figure 3
Figure 4
Figure 4

Reduction of fractures was done using reduction forceps or special pelvic clamps. Fixation of fractures was typically achieved using a 3.5-mm pelvic reconstruction plate or 6.5-mm cannulated screws. The quadrilateral plate fragment was fixed by an overbent 3.5-mm reconstruction plate that acted as a spring plate. After thorough irrigation and haemostasis, suction drains were placed at the retropubic space and the internal iliac fossa (if lateral window was used). Wounds were closed using polyfilament absorbable sutures for fascia plus subcutaneous layers, and nonabsorbable monofilament sutures for skin.

Results

Among the 17 patients in our series, there were 11 men and six women. Their detailed demographic characteristics and perioperative data are shown in Table 3. The mean age was 42.3 years (range, 21–79 years). All of them were multiple-trauma patients (ISS ≥ 15), with an average ISS of 37.6. They were all admitted with haemorrhagic shock managed by our multidisciplinary pelvic damage control protocol including pelvic external fixation, retroperitoneal packing, with or without angioembolisation. All of the fractures were the result of high-energy injury. The commonest being jump from height (64.7%), followed by road traffic accident (23.5%), and crush by heavy object (11.8%). Regarding their premorbid status, a substantial proportion (41.2%) of our patients had a history of psychiatric illness.

Table 3
Patient characteristics Range
No. of patients 17
Male 11 (64.7)
Female 6 (35.3)
Age (y) 42.3 ± 15.8 21–79
Injury Severity Score 37.6 ± 9.2 21–54
Duration of follow-up (mo) 32.4 ± 11.6 17–60
Mechanism of injury
Fall from height 11 (64.7)
Road traffic accident 4 (23.5)
Crush by heavy object 2 (11.8)
History of psychiatric illness
Yes 7 (41.2)
No 10 (58.8)
Perioperative parameter Range
Operating time (min) 179 ± 100 50–381
Delay to definite fixation (d) 6.8 ± 4.6 2–16
Intraoperative blood loss (mL) 1091 ± 870 200–3300
Use of additional surgical window
Total No. of cases 8
Lateral window of ilioinguinal 6 (75)
Lateral window + Kocher–Langenback 2 (25)

 

Data are presented as n (%) or mean ± standard deviation.

 

Two cases required addition of Kocher–Langenback approach to address posterior column involvement of acetabulum, which could not be reached by either modified Stoppa or lateral window of ilioinguinal approach.

Eleven patients had pelvic ring fractures and two patients had isolated acetabular fractures. The remaining four patients had combined pelvic ring and acetabular fractures; one of them had a pelvic ring fracture (Tile B3) plus bilateral acetabular fractures (right transverse; left anterior column), as shown in Figure 5; thus, a total of five combined pelvic–acetabular fractures were identified. The types of fractures encountered in our series were heterogeneous in terms of their variety and distribution, with details depicted in Table 4. The mean interval time between injury to surgery was 6.8 days (range, 2–16 days), which was largely determined by the patients’ general condition and stabilisation of other associated injuries. The average operating time and blood loss were 179 minutes (range, 50–381 minutes) and 1091 mL (range, 200–3300 mL), respectively.

Figure 5
Figure 5
Table 4
n
Total No. of fractures 18
Pelvic ring only 11 (61.1)
Acetabulum only 2 (11.1)
Combined 5 (27.8)
Pelvic ring fractures (Tile classification)
Total No. of pelvic ring fractures (sum of isolated pelvic ring fracture and combined) 15
B1 1 (6.7)
B2 3 (20)
B3 7 (46.7)
C1 2 (13.3)
C2 1 (6.7)
C3 1 (6.7)
Acetabulum fractures (Judet and Letournel classification)
Total No. of acetabulum fractures (sum of isolated acetabular fractures and combined) 7
Anterior column 1 (14.3)
Anterior wall 1 (14.3)
Transverse 1 (14.3)
Both columns 2 (28.6)
Anterior column posterior hemitransverse 1 (14.3)
T-shaped 1 (14.3)

 

Data are presented as n (%).

 

One patient, a 59-year-old woman, suffered from Tile’s B3 pelvic ring fracture plus bilateral acetabular fractures; she was counted as having two pelvic–acetabular fractures.

A total of eight cases required an additional surgical window during fracture reduction and fixation. Most of the patients (75%) had a lateral window of ilioinguinal approach added, while the remaining required a Kocher–Langenback approach as well for treating associated posterior column acetabular fractures. The presence of fracture involvement of the acetabulum, be it isolated or combined, strongly predicted the need for an additional window during surgery (p = 0.03).

Radiographic and functional outcomes

The radiographic results were overall satisfactory (Table 5). A substantial proportion of pelvic ring fractures (73.3%) and acetabular fractures (71.4%) achieved excellent and anatomical reduction, respectively, according to Matta’s14 and Matta and Tornetta’s15criteria. Two of seven acetabular fractures treated showed osteoarthritic change on serial postoperative radiographs; among which, one of them belonged to an advanced stage and had total hip arthroplasty done.

Table 5
Pelvic fractures (n = 15)
Excellent 11 (73.3)
Good 3 (20)
Fair 1 (6.7)
Poor 0
Acetabulum fractures (n = 7)
Anatomical 5 (71.4)
Imperfect 0
Poor 1 (14.3)
Secondary incongruence 1 (14.3)
Presence of secondary OA change (n = 7)
Normal joint 5 (71.3)
Mild OA 1 (5.9)
Intermediate OA 0
Advanced OA 1 (5.9)

 

Data are presented as n (%).

OA = osteoarthritis.

 

Most of the patients enjoyed reasonable ambulation after completion of rehabilitation. More than 70% of them were able to either walk unaided or with the help of a stick. Up to 35% managed to regain their premorbid ambulatory status. The mean score for pain using VAS of 0–10 was only 2.8. The mean modified Merle d’Aubigne score was 15.5 (standard deviation, 4.4), with 58.8% of patients attaining excellent/good clinical outcomes according to the MDA grading. Nevertheless, patients with poor MDA grade also accounted for a significant portion (29.5%). The average Harris Hip Score was 66.8.

We also tried to delineate a possible link between the preoperative characteristics, quality of reduction, and clinical outcomes of our patients (Table 6). Age of patient was an independent predictor for both MDA score and residual pain. A younger age predicted a better MDA score (Spearman’s correlation coefficient −0.58, p = 0.014) and less pain at 1 year postoperatively (Spearman’s correlation coefficient 0.48, p = 0.007). If we further segregate our patients into two groups: age < 40 years and ≥ 40 years, the younger patients would have achieved a better MDA score and Harris Hip Score (p < 0.05), as shown in Table 7.

Table 6
Spearman’s correlation coefficient (p)
Injury Severity Score
Modified Merle d’Aubigne Score −0.55 (0.023)
Harris Hip Score −0.40 (0.114)
Pain 0.23 (0.381)
Age
Modified Merle d’Aubigne Score −0.58 (0.014)
Harris Hip Score −0.39 (0.127)
Pain 0.48 (0.047)
Delay to definitive fixation
Modified Merle d’Aubigne Score −0.10 (0.703)
Harris Hip Score 0.034 (0.897)
Pain −0.011 (0.968)

Statistically significant with p < 0.05

Table 7
Mobility status
Walks unaided 6 (35.3)
Stick 6 (35.3)
Crutches 1 (5.9)
Walking frame 3 (17.6)
Wheelchair bound 1 (5.9)
Pain (VAS score of 0–10) 2.8 ± 3.0
Modified Merle d’Aubigne score 14.8 ± 4.4
Excellent (17 or 18) 4 (23.5)
Good (15 or 16) 6 (35.3)
Fair (13 or 14) 2 (11.8)
Poor (< 13) 5 (29.4)
Harris Hip Score 66.8 ± 22.0
Functional outcomes in relation to age (y) < 40 ≥ 40 p
Modified Merle d’Aubigne score (mean) 15.25 10.67 0.003*
Harris Hip Score (mean) 79.75 55.22 0.016*
Pain (VAS scale of 0–10) 1.63 4.00 0.102
*Statistically significant with p < 0.05.

 

Data are presented as n (%).

VAS = visual analogue scale.

 

Similarly, the extent and multitude of trauma suffered were also predictive of the functional outcome. A higher ISS correlated significantly with a poorer MDA score (Spearman’s correlation coefficient −0.55, p = 0.023). Nevertheless, no possible correlation could be demonstrated between the interval delay to surgery and the patient’s final functional score or residual pain. In this particular series, the quality of reduction achieved was not predictive of the functional outcomes.

Complications

The complications encountered in our series are summarized in Table 8. There was one case of postoperative wound infection, which was settled by use of antibiotics alone. No heterotrophic ossification was identified on X-rays. There was a case with delayed union of pelvic ring fracture with breakage of the anterior column plate. The patient was managed conservatively and union was finally observed after 14-months postoperative follow-up. Otherwise, there was no case of vascular injury, intraoperative violation of the peritoneumdeep vein thrombosis, and deep surgical infection requiring drainage or debridement. No patient was found to have obturator nerve palsy upon follow-up, which was defined by weakness of the hip adductor together with loss of proximal medial thigh sensation.

Table 8
n (out of 17 patients)
Infection (superficial) 1 (5.9)
Infection (deep) 0
Vascular injury 0
Obturator nerve palsy 0
Delayed union of fracture 1 (5.9)
Peritoneal violation 0
Heterotrophic ossification 0
Deep vein thrombosis 0

 

Data are presented as n (%).

 

Discussion

This serves as the first retrospective study from our locality about the use of the modified Stoppa approach for fixation of pelvic–acetabular fractures. A preliminary series of 17 patients were operated upon; all being high-energy trauma victims who incurred multiple injuries with high ISS. Our centre began to use the modified Stoppa approach in 2010. It is undeniable that a steep learning curve was initially experienced for this anterior intrapelvic approach, in terms of the technical steps of dissection as well as difficulty to manipulate and temporarily hold the reduction of the quadrilateral plate. Nevertheless, we could fully appreciate the good visibility of the pubis, supra-/infrapectineal surfaces of the ilium that this approach offers. The quadrilateral plate can be assessed with the surgeon standing on the contralateral side of the operating table. To add on, advantages reported by previous literature, including reduced risks of vascular injury1 and heterotopic ossification20 were observed (Table 8). None of our cases required conversion to the classic ilioinguinal approach. The use of an additional surgical window, namely the lateral window of ilioinguinal approach, has been described as a standard combination by certain authors,722 whereas others have reported a range of 60%4 to 93%21 regarding the need of this window. In keeping with the literature, an additional window was used in eight of our 17 cases (i.e., 47%), and the presence of acetabular fracture was an independent predictor for an additional surgical window.

In contrast to the original Pfannestial type of incision, we made use of a low-midline incision to perform the modified Stoppa approach in all our patients. If exposure to the contralateral pelvic ring was warranted, we extended the dissection to the opposite side via the same incision. This permitted our access to the entire pelvic ring except the posterior wall of the acetabulum. One of our patients, a 59-year-old pedestrian who was hit by a motor vehicle, had a Tile B3 pelvic ring injury together with bilateral acetabular fractures. We managed to fix her bilateral fractures via one single midline incision (Figure 5). She was able to walk unaided with an MDA score of 17 at 1 year postoperatively. One may be concerned about the possible compromise of soft tissue and skin as a result of vigorous wound retraction using this low-midline incision, yet only one case of superficial infection was reported in our series, while none of them had deep infection that required debridement or implant removal, bearing in mind that this surgical approach shares the same incision as the initial retroperitoneal packing. Moreover, there was no case of peritoneal perforation among our patients, as opposed to a rate of 32% as reported by Ponsen et al.11

In most of our patients, we were able to attain satisfactory to excellent fracture reduction, as presented in Table 9, which was a result comparable to other larger studies.46 Only a small proportion of our patients with acetabular fractures had osteoarthritic change in their hip joints at 1 year postoperatively (Table 5). However, this might not truly reflect the final degree of post-traumatic osteoarthritis due to the relatively short follow-up time.

Table 9
nMDA > 14 (%)% of excellent/anatomical reduction
Current study 17 58.8 70.6
Ma et al6 30 83.3 53.3
Hirvensalo et al5 164 80 (HHS > 75) 84 (step < 2 mm)
Sagi et al4 57 91 70
Shazar et al19 103 82.5

 

HHS = Harris Hip Score.

 

Regarding the clinical outcomes of our patients, we observed good results in terms of their mobility status, as > 70% of them could ambulate either unaided or just with a stick upon completion of their rehabilitation. However, for the functional scores we measured in this study, that is, the MDA and Harris Hip scores, we could see a bimodal distribution among our patients. In our series of 17 patients, 10 achieved good or excellent grades for MDA score, while five out of the remaining seven patients actually achieved a poor grade. This made the percentage of patients having MDA > 14 low as compared to those reported by Sagi et al.4 and Hirvensalo et al.5 Upon our analysis, age and ISS were found to be independent predictors of functional score gradings, especially in patients older than 40 years, which was associated with poorer MDA/Harris Hip Score. The hip range of motion was impaired among our patients in the older age group and those who suffered from severe associated injuries. This could plausibly account for their poorer functional grades, since hip range of motion was a crucial item in the MDA.

In addition, we were unable to demonstrate any correlation between the accuracy of fracture reduction and final clinical outcome in this series. This was in contrary to Matta,14who has concluded that the quality of reduction was a significant predictor for functional results.

Low complication rate was reported in our series. None of our patients developed deep vein thrombosis, despite a mean operating time of > 3 hours and no specific pharmacological measures taken for anticoagulation; this could be related to the overall lower thromboembolic risk for Asian people.23 We specifically looked into the incidence of obturator nerve palsy, as Sagi et al5 reported 25% of their patients had adductor weakness postoperatively, whereas none of our patients had such a complaint.

There were several limitations to our study: (1) the case number was low and the study design was retrospective in nature; (2) there was a lack of comparison with results using the classic ilioinguinal approach; (3) heterogeneic fracture patterns and characteristics were observed among our patients, and some of them might have had an isolated pelvic ring or acetabular injury, whereas some had a combination of both; and (4) follow-up duration was limited as only patients followed for < 1 year were excluded.

In conclusion, we experienced encouraging results with the use of the modified Stoppa approach for pelvic–acetabular fracture fixation, in terms of radiological and clinical outcomes. Instead of the classical Pfannestial incision, the use of a low-midline incision also enabled a safe and easy path for dissection during definitive fixation. The concern of deep infection using this wound packing can be minimised by meticulous dissection, stringent haemostasis, copious irrigation, use of suction drains, and appropriate antibiotic prophylaxis as demonstrated in our series. The combination of other operative windows extends its indication towards more complicated fracture patterns, including those with posterior column involvement. We hope for a larger cohort and a longer follow-up period to better examine our results for this approach. Despite the emergence of minimally invasive methods in pelvic–acetabular fracture fixation, for example, the use of three-dimensional computer navigation system, we believe that the modified Stoppa approach is still invaluable for treating fractures with significant displacement, comminution, quadrilateral plate involvement, and delayed presentation.

Declarations of conflicting interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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