The Pararectus approach for anterior intrapelvic management of acetabular fractures: an anatomical study and clinical evaluation.

University of Bern, Department of Orthopaedic and Trauma Surgery, Inselspital, Bern 3010, Switzerland.
The Bone & Joint Journal (Impact Factor: 2.8). 03/2012; 94(3):405-11. DOI: 10.1302/0301-620X.94B3.27801
Source: PubMed

ABSTRACT A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five 'windows' for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called 'Pararectus' approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

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    ABSTRACT: Introduction To present the accuracy of reduction, complications and results two years after open reduction and internal fixation of displaced acetabular fractures involving the anterior column (AC) through the Pararectus approach. Frequencies for conversion to total hip replacement in the early follow up, the clinical outcome in preserved hips, and the need for an extension of the approach (1st window of the ilioinguinal approach) are compared to the literature about the modified Stoppa approach. Methods Forty-eight patients (mean age 62 years, range: 16-98; 41 male) with displaced acetabular fractures involving the AC (AC: n = 9; transverse fracture: n = 2; AC and hemitransverse: n = 24; both column: n = 13) were treated between 12/2009 and 12/2011 using the Pararectus approach. Surgical data and accuracy of reduction (using computed tomography) were assessed. Patients were routinely followed up at eight weeks, six, twelve and 24 months postoperatively. Failure was defined as the need for total hip arthroplasty. Twenty-four months postoperatively the outcome was rated according to Matta. Results In four patients there were four intraoperative complications (minor vascular damage in two, small perforations of the peritoneum in two) which were managed intraoperatively. Fracture reduction showed statistically significant decreases (mean ± SD, pre- vs. postoperative, in mm) in “step-offs”: 2.6 ± 1.9 vs. 0.1 ± 0.3, p < 0.001 and “gaps”: 11.2 ± 6.8 vs. 0.7 ± 0.9, p < 0.001. Accuracy of reduction was “anatomical” in 45, “imperfect” in three. Five (13%) from 38 available patients required a total hip arthroplasty. Of 33 patients with a preserved hip the clinical outcome was graded as “excellent” in 13 or “good” in 20; radiographically, 27 were graded as “excellent”, four as “good” and two as “fair”. An extension of the approach was infrequently used (1st window ilioinguinal approach in 2%, mini-incision at the iliac crest in 21%). Conclusion In the treatment of acetabular fractures involving the anterior column the Pararectus approach allowed for anatomic restoration with minimal access morbidity. Results obtained by means of the Pararectus approach after two years at least parallel those reported after utilization of the modified Stoppa approaches. In contrast to the modified Stoppa approach, a relevant extension of the Pararectus approach was almost not necessary.
    Injury 10/2014; 45(12). DOI:10.1016/j.injury.2014.10.040 · 2.46 Impact Factor
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    ABSTRACT: Background The modified Stoppa approach was introduced to manage fracture of the anterior column instead of the ilioinguinal approach to reduce morbidity. However there is no clinical evidence to confirm its efficiency. Therefore this study was designed to ascertain: (1) if the Stoppa approach versus ilioinguinal allows less blood loss, (2) if functional and radiological results are superior to that of the ilioinguinal approach, (3) if the rate of complication was different. Hypothesis The modified Stoppa approach allows less blood loss than the ilioinguinal in management of fractures of the anterior column of the acetabulum. Patients and methods Nineteen patients who were treated with the ilioinguinal approach (Group A) at a mean follow-up of 33 months and 17 patients who were treated with the modified Stoppa approach (Group B) at a mean follow-up of 28.9 months were retrospectively reviewed. Patients were called to the final follow-up examination, mean follow-up durations were set and the functional evaluation of patients was made with measurement of range of motion, Harris Hip Scores (HHS), and Merle D’Aubigné score. Results Average blood loss was determined at a mean 1170 mL (range, 750–2150 mL) in Group A and at a mean 1110 mL (range, 450–2000 mL) in Group B (P = 0.168). The mean HHS (group A = 89.4 [73–99] and group B = 88.4 [75–97]) and Merle D’Aubigné scores (group A = 16.8 [13–18] and group B = 16.5 [13–18]) showed no significant difference between the groups (P = 0.169). At the final follow-up, the mean hip flexion was found to be 106.83 ± 12.47 and the hip extension was 10.33 ± 6.12 in Group A, while these values were 103.71 ± 14.32 and 10.69 ± 8.17 in Group B (NS between groups regarding flexion [P = 0.678] and extension [P = 0.445]). The complication rate was 31% in Group A (6 patients) and 23% in Group B (4 patients) (P > 0.05). Discussion Both surgical approaches give successful results in the treatment of acetabular fractures. Contrary to expectations, there was no difference in the amount of bleeding at the wound site from the Stoppa technique, even though it is minimally invasive, compared to the ilioinguinal approach. Level of evidence Level III retrospective case control study.
    Orthopaedics & Traumatology Surgery & Research 10/2014; 101(1). DOI:10.1016/j.otsr.2014.05.020 · 1.17 Impact Factor
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    ABSTRACT: Acetabular fractures and surgical interventions used to treat them can result in nerve injuries. To date, only small case studies have tried to explore the frequency of nerve injuries and their association with patient and treatment characteristics. High-quality data on the risk of traumatic and iatrogenic nerve lesions and their epidemiology in relation to different fracture types and surgical approaches are lacking.
    Clinical Orthopaedics and Related Research 08/2014; 472(11). DOI:10.1007/s11999-014-3838-9 · 2.88 Impact Factor