Acetabular fractures are usually caused by high-energy trauma, have an incidence of ∼3 out of every 100,000 patients per year, and are one of the most difficult fractures to manage in orthopedic surgery (1, 2). Because it is an intraarticular fracture, displaced acetabular fracture patients usually need surgical treatment (3). Many surgical approaches have been used to treat acetabular fractures, such as the iliofemoral, ilioinguinal, Kocher–Langenbeck, combined anterior/posterior, modified Stoppa, and extended iliofemoral approaches (4–6). The modified Stoppa approach was proposed by Cole and Bolhofner in 1994 and has been widely used in recent years (7). It is an ideal surgical fixation method for the majority of acetabular fractures, because it not only results in good exposure of the fracture area but also achieves a good reduction of fracture fragments, especially those involving the anterior column, anterior wall, and posterior hemitransverse, transverse, T-type, and both columns with predominately anterior displacement (2, 4, 8, 9).

In clinical applications, closed suction drainage (CSD) is often used as a preventive strategy to eliminate dead space and reduce the occurrence of postoperative wound complications, including hematoma formation, redness, infection, pain, and incisional hernia (10, 11). The application of CSD in open wound or infectious surgeries can play a role in draining pus and necrotic tissue debris, and its use in these cases was previously beyond doubt (11). However, there is little published evidence to support its routine use after surgery. Some literature suggests that the use of CSD may be associated with increased postoperative blood transfusion rates, days in hospital, and incision pain (10, 12). In addition, some have argued that CSD, as a foreign body, may become a potential source of infection, allowing external pathogens to enter deep wounds and increasing the chances of infection (13–15). Similar debates have been reported in the orthopedic spine and trauma literature (16, 17).

To prevent the formation of wound hematomas and enhance postoperative recovery, many orthopedic surgeons still routinely use CSD after using a modified Stoppa approach to treat acetabular fractures. However, we have found that the use of CSD will not provide any benefit to patients with acetabular fractures repaired using a modified Stoppa approach. Therefore, the aim of this study was to compare the clinical efficacy of CSD with no-CSD after a modified Stoppa approach in the surgical fixation of acetabular fractures.

To our knowledge, our study is the first to evaluate whether using CSD has an impact on the clinical outcome of acetabular fractures treated by a modified Stoppa approach. Previous studies have suggested that CSD could be used as a preventive treatment to decrease the likelihood of surgical site infection and incision-related complications in high-risk patients after orthopedic surgery (10, 19). However, according to our study results, compared to the patients in the no-CSD group, the patients with CSD for acetabular fractures repaired by a modified Stoppa approach were associated with a higher risk of postoperative blood transfusion and pain, with no impact on clinical outcomes and incision-related complications.

Acetabular fracture is one of the most difficult fractures to manage in orthopedic surgery. An ideal surgical approach for acetabular fractures is invaluable. It not only facilitates good exposure of the surgical field and effective reduction of the fracture but also causes as few complications as possible (2). The modified Stoppa approach is only appropriate in specific surgical indications and does not often allow for posterior column access if needed. This approach has many advantages, including large areas of visualization, less chance of damaging major nerves and vessels, short operation time, and less trauma (4, 20).

Traditionally, CSD has been successfully used in the management of acute and chronic open wounds to decrease the incidence of hematomas and infection by reducing the accumulation of blood and exudate in the incision cavity (10, 21, 22). In recent years, researchers have tried to apply CSD to closed incisions for acetabular fractures to prevent surgical site infection and wound complications after surgery (19). A retrospective study by Reddix et al. (23) showed that the use of CSD in patients with acetabular fracture may significantly reduce the incidence of deep infections. Although certain high-risk patients with acetabular fractures, such as obese patients, may benefit from treatment with CSD, the use of CSD remains controversial. For example, the results published by Boissonneault et al. (24) show that, in their study, the use of CSD after the surgical fixation of acetabular fractures via the Kocher–Langenbeck approach significantly increased postoperative blood transfusion rates and days in hospital, but wound complications and incision infection rates did not differ.

Similarly, in the current study, the patients in the CSD group showed higher postoperative transfusion volumes (259.25 ml vs. 127.27 ml, P = 0.034) and transfusion rates (55.55% vs. 27.27%, P = 0.027) than those in the no-CSD group. Some scholars believe that 24–48 h after surgery is the stage of maximum bleeding and seepage of surgical sites (25). Negative pressure suction caused the exudate to continue to drain outside the body and disrupted the self-coagulation mechanism, which were the main reasons for the increase in postoperative blood transfusion (25). In fact, prophylactic CSD after acetabular fractures remains controversial. The use of CSD is almost always determined by the surgeon after surgery based on the quality of intraoperative hemostasis, magnitude of the surgical procedure, and experience (17, 26).

Several authors have reported that the advantages of using CSD after acetabular fracture surgery were controlling postoperative wound drainage and preventing local accumulation of hematomas (27). However, Kim et al. (28) found that routine use of CSD not only failed to prevent or reduce postoperative morbidities but also may have led to prolonged postoperative pain. Some published studies confirmed that the application of CSD may produce undesired results, such as an increased risk of infection and pain and an increased length of hospital stay after surgery. In addition, some studies suggested that compared with the CSD group, the VAS scores of the patients in the no-CSD group decreased by 50%, especially on postoperative Day 2 (26).

In our study, we found that there was no increase in the frequency of incision-related complications in the no-CSD group. A total of three patients (11.11%) developed hematomas and five (18.52%) developed superficial infections in the CSD group, which were no significant difference from those in the no-CSD group. Theoretically, the use of CSD is beneficial to reduce the incidence of pain and fever. However, our findings were the opposite, with the patients in the CSD group having higher VAS scores on postoperative Day 1 (CSD group, 4.14 ± 1.43 vs. no-CSD group, 3.00 ± 0.93; P = 0.002) and 3 (CSD group, 2.48 ± 1.08 vs. no-CSD group, 1.73 ± 0.94; P = 0.013) and higher temperatures on postoperative Day 2 (CSD group, 37.34 ± 0.69°C vs. no-CSD group, 36.97 ± 0.51°C; P = 0.035) than the patients in the no-CSD group. We believed that the drain itself, similar to a foreign body, increased discomfort and anxiety. In addition, active pulling and removal can also increase patient pain, and the absorption of residual exudate in the cavity after removal of the drain can cause fever.

This study has several potential limitations, including the retrospective design with the associated bias. The small sample size from a single institution was also a main limitation. In addition, the retrospective evaluation of intra and postoperative blood loss from medical records may lead to concerns about the reliability of this study. We only compared and analyzed a few perioperative laboratory indicators, while other indicators, such as white blood cell count and platelet count, were not addressed. Furthermore, we only compared the placement of drains after treating acetabular fractures via a modified Stoppa approach and did not include other approaches or the number of drains. Finally, although it is an important evaluation indicator in the perioperative period of hip fracture, the incidence of deep vein thrombosis was not included due to incomplete data. We will conduct further research in the future.

It is unnecessary to use CSD routinely after treating acetabular fractures via a modified Stoppa approach, because the application of CSD will not effectively reduce the incidence of postoperative incision-related complications and will increase the risk of increased postoperative blood transfusion rate and pain.