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von Rüden C, Brand A, Perl M. [The pararectus approach: surgical procedure for acetabular fractures]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023; 35:110-120. [PMID: 36928712 PMCID: PMC10076372 DOI: 10.1007/s00064-023-00800-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 09/09/2022] [Accepted: 09/10/2022] [Indexed: 03/18/2023]
Abstract
OBJECTIVE The pararectus approach was rediscovered several years ago for pelvic surgery and described as an alternative approach especially for the treatment of acetabular fractures of the anterior column involving the quadrilateral plate. INDICATIONS For optimal visualization of acetabular fractures involving the quadrilateral plate, fractures of the anterior wall and anterior column, anterior column/posterior hemitransverse fractures, and fractures with central impression of dome fragments, the pararectus approach has proven to be a useful access. CONTRAINDICATIONS The pararectus approach is not used for posterior column fractures, posterior wall fractures, combined posterior wall and posterior column fractures, transverse fractures with displaced posterior column or in combination with posterior wall fractures, and T‑fractures with displaced posterior column or in combination with posterior wall fractures. SURGICAL TECHNIQUE The entire pelvic ring, including the quadrilateral plate, can be accessed via the pararectus approach. The choice of the correct surgical window depends on the fracture location and the requirements of fracture reduction. POSTOPERATIVE MANAGEMENT In general, partial weight-bearing should be maintained for 6 weeks, although earlier weight-bearing release may be possible if necessary, depending on fracture pattern and osteosynthesis. Particularly in geriatric patients, partial weight-bearing is often not possible, so that early and often relatively uncontrolled full weight-bearing has to be accepted. RESULTS In a comparative gait analysis between patients following surgical stabilization of an isolated unilateral acetabular fracture through the pararectus approach and healthy subjects, sufficient stability and motion function of the pelvis and hip during walking was already evident in the early postoperative phase.
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Affiliation(s)
- Christian von Rüden
- Abteilung Unfallchirurgie, BG Unfallklinik Murnau, Murnau, Deutschland.,Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Andreas Brand
- Universitätsinstitut für Biomechanik, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Mario Perl
- Unfallchirurgische und Orthopädische Klinik, Universitätsklinikum Erlangen, Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), Krankenhausstr. 12, 91054, Erlangen, Deutschland.
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Häckel S, Christen S, Vögelin E, Keel MJB. Exposure of the Lumbosacral Plexus by Using the Pararectus Approach: A Technical Note. Oper Neurosurg (Hagerstown) 2023; 24:e1-e9. [PMID: 36227214 DOI: 10.1227/ons.0000000000000418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/06/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Surgical exploration of the lumbosacral plexus is challenging. Previously described approaches reach from invasive open techniques with osteotomy of the ilium to laparoscopic techniques. OBJECTIVE To describe a novel surgical technique to explore lumbosacral plexopathies such as benign nerve tumors or iatrogenic lesions of the lumbosacral plexus in 4 case examples. METHODS We retrospectively evaluated 4 patients suffering from pathologies or injuries of the lumbosacral plexus between 2017 and 2019. The mean follow-up period after surgery was 23.5 (range 11-52) months. All patients underwent neurolysis of the lumbosacral plexus using the single incision, intrapelvic, extraperitoneal pararectus approach. RESULTS In all patients, the pathology of the lumbosacral plexus was successfully visualized, proving feasibility of the extraperitoneal pararectus approach for this indication. There were no major complications, and all patients recovered well. CONCLUSION The pararectus approach allows excellent visualization of the lumbar plexus and intrapelvic lesions of the femoral and sciatic nerves.
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Affiliation(s)
- Sonja Häckel
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital Bern, University Bern, Bern, Switzerland
| | - Samuel Christen
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital Bern, University Bern, Bern, Switzerland
- Department of Hand, Plastic and Reconstructive Surgery, Cantonal Hospital, St. Gallen, Switzerland
| | - Esther Vögelin
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital Bern, University Bern, Bern, Switzerland
| | - Marius J B Keel
- Department of Orthopaedic Surgery and Traumatology, Inselspital, University Hospital Bern, University Bern, Bern, Switzerland
- Hand and Plastic Surgery and Surgery of Peripheral Nerves, Inselspital, University Hospital Bern, University Bern, Bern, Switzerland; Trauma Center Hirslanden, Clinic Hirslanden, Zurich, Switzerland
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Yu YH, Tsai PJ, Liu CH, Chen IJ, Hsu YH, Chou YC. Simultaneous reduction and fixation of concomitant acetabular fracture and ipsilateral sacroiliac joint injury through the pararectus approach: a technical report and early radiological outcome. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03367-z. [PMID: 35994114 DOI: 10.1007/s00590-022-03367-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/10/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE Osteosynthesis for acetabular fractures with ipsilateral sacroiliac joint (SIJ) injuries remains challenging for orthopedic surgeons, despite the evolution of surgical approaches, such as the pararectus approach, and treatment sequences. The study aimed to describe the details of the treatment of acetabular fracture with ipsilateral SIJ injury by the pararectus approach and to report its surgical outcomes. METHODS We retrospectively assessed patients with acetabular fractures and ipsilateral SIJ injuries undergoing osteosynthesis by the pararectus approach over a three-year period. Evaluation parameters of the quality of reduction of both acetabulum and pelvis injuries were, among others, Matta's criteria, Lefaivre's criteria, inlet/outlet ratios, and maximal gap measured on computed tomography (CT) scans. RESULTS Ten patients (seven men and three women) were enrolled. Pelvic ring injuries classified as AO B2.3 and acetabular fractures involving two columns were the most common fractures, accounting for 70% and 60%, respectively. Radiological evaluation for pelvic ring injury revealed three excellent and seven good results according to Matta's criteria, as well as five excellent, three good, and one fair results according to Lefaivre's criteria. Inlet and outlet ratios were between 0.84-1.06 and 0.93-1.60, respectively. The distance of the sacroiliac joints significantly improved postoperatively in both axial and coronal views (P = 0.002). Further, the maximal articular gap and step-off of acetabular fractures on axial, coronal, and sagittal view CT scans showed statistically significant improvements after osteosynthesis. CONCLUSION Simultaneous reduction and fixation of acetabular fractures with ipsilateral SIJ injuries using the pararectus approach achieved satisfactory radiological outcomes. LEVEL OF EVIDENCE IV. TRIAL REGISTRATION Retrospectively registered.
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Affiliation(s)
- Yi-Hsun Yu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan.
| | - Ping-Jui Tsai
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Chang-Heng Liu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - I-Jung Chen
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
| | - Ying-Chao Chou
- Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital and Chang Gung University, 5, Fu-Hsin St. Kweishan, 33302, Tao-Yuan, Taiwan
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Li J, Yu XK, Tian W, Dong XM, Guo L, Li XF. The clinical value of using magnetic resonance contrast-enhanced three-dimensional nerve view in the diagnosis and management of sacral fracture accompanied by sacral plexus injury. Technol Health Care 2022; 30:1407-1415. [PMID: 35661030 DOI: 10.3233/thc-213543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The treatment of sacral fractures accompanied by nerve injury is complex and often leads to an unsatisfactory prognosis and poor quality of life in patients. OBJECTIVE The present study aimed to investigate the clinical value of using 3.0T magnetic resonance contrast-enhanced three-dimensional (MR CE-3D) nerve view magnetic resonance neurography (MRN) in the diagnosis and management of a sacral fracture accompanied by a sacral plexus injury. METHODS Thirty-two patients with a sacral fracture accompanied by a sacral plexus injury, including 24 cases of Denis spinal trauma type II and 8 cases of type III, were enrolled in the study. All patients had symptoms or signs of lumbosacral nerve injury, and an MRN examination was performed to clarify the location and severity of the sacral nerve injury. Segmental localization of the sacral plexus was done to indicate the site of the injury as being intra-spinal (IS), intra-foraminal (IF), or extra-foraminal (EF), and the severity of the nerve injury was determined as being mild, moderate, or severe. Surgical nerve exploration was then conducted in six patients with severe nerve injury. The location and severity of the nerve injury were recorded using intra-operative direct vision, and the results were statistically compared with the MRN examination results. RESULTS MRN showed that 81 segments had mild sacral plexus injuries (8 segments of IS, 20 segments of IF, 53 segments of EF), 78 segments had moderate sacral plexus injuries (8 segments of IS, 37 segments of IF, and 33 segments of EF), and 19 segments had severe sacral plexus injuries (7 segments of IS, 9 segments of IF, and 3 segments of EF). The six patients who underwent surgery had the following intra-operative direct vision results: 3 segments of moderate injury (IF) and 20 segments of severe injury (7 segments of IS, 10 segments of IF, 3 segments of EF). There was no statistically significant difference in the results between the intra-operative direct vision and those of the MRN examination (p> 0.05). CONCLUSION MR CE-3D nerve view can clearly and accurately demonstrate the location and severity of sacral nerve injury accompanied by a sacral fracture, and has the potential for being the first choice of examination method for this kind of injury, which would be of important clinical value.
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Affiliation(s)
- Jian Li
- Department of Radiology, Tianjin Hospital, Tianjin, China.,Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Xiao-Kun Yu
- Department of Radiology, The Fifth Centre Hospital of Tianjin City, Tianjin, China.,Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Wei Tian
- Department of Traumatic Orthopaedics, Tianjin Hospital, Tianjin, China
| | - Xiao-Man Dong
- Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Lin Guo
- Department of Radiology, Tianjin Hospital, Tianjin, China
| | - Xiao-Feng Li
- Department of Radiology, Tianjin Hospital, Tianjin, China
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Pararectus approach to the AO B2.2 pelvic fracture: early functional and radiological outcomes. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:829-836. [PMID: 35122136 PMCID: PMC10126065 DOI: 10.1007/s00590-022-03216-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE The pararectus approach is used to treat acetabular fractures; however, it remains unclear whether it can be used to treat pelvic fractures. This study aimed to examine the outcomes of patients with a pelvic ring fracture treated with this approach. METHODS Seven patients with AO B2.2 pelvic fractures treated with the pararectus approach were included. Patients' pain was assessed pre- and postoperatively with a numerical rating scale. Radiological evaluations included inlet and outlet ratios and pelvic symmetry. Functional outcomes, including Merle d'Aubigné and Majeed scores, were also recorded for 12 months. RESULTS One patient experienced obturator nerve neuropraxia. Pain scores ranged from 2.3-8.0 to 2.0-3.1 points before and after surgery, respectively. Radiological findings revealed satisfactory outcomes. The maximal gap of the affected ilium reduced from 8.6-20.2 to 0-3.4 mm, from 6.8-17.9 to 0-4.4 mm, and from 3.7-20.3 to 0-3.2 mm in the axial, sagittal, and coronal views, respectively. Based on multiple evaluations, functional outcomes were improved for all patients. CONCLUSION The pararectus approach can be used safely and satisfactorily to treat AO B 2.2 pelvic fractures.
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Shimauchi-Ohtaki H, Takahashi T, Kanematsu R, Miyasaka K, Minami M, Sakaguchi N, Honda F, Hanakita J. Full-endoscopic decompression for fifth lumbar radiculopathy due to a fragility sacral fracture associated with far-lateral L5/S1 disc herniation: A technical note. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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