Anatomy Study Of Acetabular Posterior Column And Analysis Of Clinical Therapuetic Effect In Modified Stoppa Approach

BackgroundModified Stoppa approach and ilioinguinal approach are intrapelvic approaches of acetabulum.Since the first application by Hirvensalo and Cole to treat acetabular fractures,it has been more than 20 years.Most of surgeons consider modified Stoppa approach has more advantages than iliac abdomen approach.Firstly,the anatomical structure is simple,sparing the dissection of inguinal canal to access to the pelvic cavity.Secondly,provide the direct vision of intrapelvic area,especially of quadrilateral plate and posterior column.Thirdly,surgeons can apply infrapectineal plate to fix anterior column and buttress the quadrilateral plate.Fourthly,relatively less traumatic,easier to distinguish corona mortis.Cole apllied the infrapectioneal plate to the treatment of anterior column fractures by modified stoppa approach.The infrapectineal plate extends from the stable sciatic buttress vicinity of the pubic symphysis.Later scholars inspired by infrapectineal plate,applied the reconstruction plate to fix the posterior fractures through modified Stoppa approach.The plate situated the the front of greater sciatic notch,extended from ilium,cross the sciatic buttress,deep into the above level of the sciatic spine.This kind of fixation of the plate has not a fixed name,in terms of the situation in pelvic,we can call it the ilioischial plate fixation in this paper.Compared with traditional plate fixation,ilioischial plate fixation can be only applied through the modified Stoppa approach in the front of greater sciatic notch,which make it the one of the important anatomical marks.The procedures of reduction and fixation may cause damage to the adjacent anatomic structures.Yet there is not any research specially focus on the adjacent anatomic structures of posterior column through the modified Stoppa approach.The first part of this article is about the adjacent anatomic structures of posterior column through the modified Stoppa approach,the second part is comparison of the modified Stoppa reduction and ilioinguinal approach with the reduction,clinical results and complications.Objective1?Dissection through eight the pelvis specimens,measure and record anatomical parameters of the anatomical structures adjacent to the greater sciatic notch.For clinical application of the modified Stoppa approach and ilioischial plate technique provide a reference basis.2?Search and collect the published literature about the modified stoppa approach and statistical analyze the data to explore and compare the therapeutic effect of the modified Stoppa approach and the ilioinguinal approach.Materials and Methods1.The pelvic specimenAnatomy department of Southern Medical University provides eight pelvic(6 male 2 female)specimens2.Start from linea alba of rectus into the pelvis,perform subperiosteal dissection from the pubic symphysis,along the pelvis brim,to the front of sacroiliac joint,expose quadrilateral plate,posterior column,greater sciatic notch.Identify and measure the anatomy parameters of obturator neurovascular bundle,superior neurovascular bundle,sciatic nerve,pudendal nerve neurovascular bundle,etc.3.Statistical calculation and analysis by SPSSThe second part1.Search and collect of literature In PUBMED,Keywords:(("Stoppa Approach"OR" AnteriorApproach"))AND "Acetabular" AND(ilioinguinal approach)2.The inclusion criteria as follows:1.The patients older than 15 years old generally,less than 65 years old,not including acetabular fractures of children and the elderly t;2.Documents for case analysis data,comparative index involves operation time and blood loss,reduction rate,complications,etc.;3.exclude the treatment of pelvic fractures;4.Treatments exclude the special fracture pattern;5.Literature in English.3.Summarize and analyze the results.Result1.Anatomic structures adjacent posterior column in modified stappa approach1.1 The corona mortis and aberrant obturator vessels:6 specimens were visible single corona mortis,are the vein type,originating from the inferior epigastric vein.1 specimen is absent either corona mortis or aberrant obturator vessels.1 specimen is absent corona mortis,but aberrant obturator vessels instead.The distant of corona mortisto the pubic symphysis is 48 ± 5.5 mm.Aberrant obturator vessels consist of single and single vein,originating from the iliac vessels,almost vertically downward,and accompany with obturator nerve into the obturator canal.Aberrant obturator artery diameter is 3.2 mm,aberrant obturator vein is 6.3 mm,and the distance of the pubic symphysis is 45 mm,and 48 mm,respectively.1.2 Obturator neurovascular bundle:in resting situation,the distance between the obturator nerve and pelvic brim is 14.6±2.4 mm,the obturator artery is 19.3 ± 1.5 mm,obturator vein is 25.6 ± 1.7 mm.Under distraction at lesser sciatic notch,the distance between the obturator nerve and pelvic brim 19.5±1.8 mm,the obturator artery is 30.1± 2.6 mm,obturator vein is 39.2±3.8 mm.1.3 Superior gluteal neurovascular bundle:they situate behind the top of greater sciatic notch.In7 specimens,superior gluteal artery are lie behind superior glutealnerve.In 1 specimen,the superior gluteal artery is located in the front of the superior glutealnerve.The distance between the top of greater sciatic notch and superior gluteal neurovascular bundle is 8.6 ± 2.2 mm,superior glutea artery diameter is 4.3 ± 0.6 mm.1.4The sciatic nerve to greater sciatic notch edge projection points on the vertex distance 15.4 ± 2.5 mm,on the edge of the sciatic nerve projection point and ischial spine 5.6±3.5 mm,after sciatic nerve point to the sciatic notch margin of 3.4± 1.2 mm.1.5The distance beween internal pudendal arteryand greater sciatic notch is 3.6±1.5 mm,internal pudendal artery diameter is 2.3 ±0.8 mm.2.Comparison clinical result between modified stoppa approach and ilioinguinal approach1.According to search keywords(Stoppa Approach)OR(AnteriorApproach))AND(Acetabular Fracture),theinitial search result is 204,according to the inclusion criteria,,finally achieve 11 articles,including 4 articlescomparative analysis of clinical cases.Conclusion1.Theobturator neurovascular bundle can be retracted at thelesser sciatic notch,provide the operation space,but need to pay attention to the retracting tension.2.There is safe zone between superior gluteal neurovascular bundle and sciatic nerve at the greater sciatic notch.It can be the fulcrum for revealing and reduction..3.Distance exists between sciatic never and the greater sciatic notch.Surgeons should reduce operation at this position as possible.Extendinghipcan reduce tension of sciatic nerve.4.Atthe level of ischial spine,internal pudendal artery is very close to greater sciatic notch which should be protected carefully.5.Modified Stoppa approach provide wider vision,more reasonable plate fixation and could achieve better clinical results than other approaches.Anatomical structure is simple There is short-term learning curve for orthopaedic surgeons because of anatomical structures is less complex.But for experienced orthopaedic surgeons can achieve the same advantages in ilioinguinal approach.