Pararectus approach to the AO B2.2 pelvic fracture: early functional and radiological outcomes

Clinical efficacy and psychological influence of lateral rectus approach for treating pelvic fracture with lumbosacral plexus injury

BACKGROUND

The surgical treatment of pelvic fractures is challenging, particularly after lumbosacral plexus injuries. Such impairments affect a patient's physiological function and can cause significant mental health problems. In recent years, the new transrectus lateral approach has favorably treated pelvic fractures and possibly preserved patients' physiological and psychological conditions. Therefore, investigating its clinical efficacy for treating pelvic fractures plus lumbosacral plexus injuries is of great clinical significance.

AIM

To investigate the clinical effect of the transrectus lateral approach on pelvic fractures complicated by lumbosacral plexus injuries as well as anxiety and depression.

METHODS

Data of 136 patients with pelvic fractures complicated by lumbosacral plexus injuries treated by the transrectus lateral approach (January 2011 to May 2024) were retrospectively analyzed. The patients' general data were collected via questionnaire. The Self-rating Anxiety Scale (SAS) and Self-rating Depression Scale (SDS) were used to assess anxiety and depression, respectively. We adopted a numerical rating scale (NRS) to evaluate pain degree, the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, and Medical Research Council (MRC) Scale for Muscle Strength to evaluate treatment efficacy and complications.

RESULTS

The 136 included patients (92 male, 44 female) were a mean 48.02 ± 15.72 years old. The mean SAS score was 66.36 ± 5.15 preoperatively vs 42.15 ± 4.36 postoperatively, while the mean SDS score was 65.61 ± 5.02 preoperatively vs 43.83 ± 4.54 postoperatively, showing statistically significant differences (P < 0.05). The mean NRS and PSQI scores were significantly lower pre- vs postoperatively (P < 0.05). Postoperatively, 67 patients with fresh pelvic fractures plus nerve injuries achieved an MRC of M5, 22 achieved an M1-M4, and four achieved an M0. Postoperative motor function improved by a mean 4.20 grades (scale, 0-5). Among the patients with old pelvic fractures and nerve injuries, 19 achieved an M5, 16 achieved an M1-M4, and eight achieved an M0. Motor function improved significantly by a mean 3.30 grades (scale, 0-5; P < 0.05). No serious postoperative complications occurred.

CONCLUSION

The transrectus lateral approach to treating pelvic fractures plus lumbosacral plexus injuries can safely alleviate anxiety and depression, relieve pain, improve sleep quality, reduce intraoperative blood loss, and improve postoperative recovery.

The para-rectus approach for extraction of intra-pelvic migrated acetabular implants

Primary and revision total hip arthroplasty can be complicated by intrapelvic migration of the acetabular components. This complication constitutes an evolutionary turning point in the history of this prosthesis since it could lead to compression or invasion of noble intra-pelvic structures. The second problem lies in the extraction of these implants in this anatomically dangerous region. We report the case of a patient who was operated on for a septic loosening of her total hip arthroplasty with protrusion of the acetabular components (Kerboull cross-plate and the cup) intrapelvicly via the para-rectus approach which allowed safe removal of these implants. This is an intra-pelvis approach lateral to the rectus abdominis muscle, initially described in acetabular fractures, with few studies reporting its use in this type of complex situations.

Iatrogenic nerve injury following pelvic ring injury: a network meta-analysis

BACKGROUND

Pelvic ring injuries are common in multi-trauma patients and can be life-threatening, necessitating prompt surgical intervention to improve outcomes. However, surgery can lead to complications such as iatrogenic nerve injury. This network meta-analysis aimed to improve outcomes in multi-trauma patients with pelvic ring injuries by evaluating the incidence of iatrogenic nerve injuries, identifying vulnerable nerves, and comparing different fixation methods.

MATERIALS AND METHODS

A systematic search of MEDLINE, EMBASE, and Scopus from inception to 5 December 2023 revealed 29 comparative studies on the incidence of iatrogenic nerve injury in 1561 adult patients with pelvic ring injuries. Data were extracted on study and patient characteristics, iatrogenic nerve injury incidences, and specific nerve injuries. A random-effects model assessed treatment effects, with subgroup analysis and meta-regression. The main outcomes included odds ratios (ORs) and confidence intervals (CIs) for iatrogenic nerve injuries.

RESULTS

Compared with closed reduction internal fixation, robotic-assisted techniques had the highest, and open reduction internal fixation had the lowest ORs for iatrogenic nerve injuries. The robotic-assisted approach ranked best with an OR of 0.22 (95% CI: 0.02-2.16), while closed reduction internal fixation with the anterior approach (OR: 0.71; 95% CI: 0.21-2.48) and open reduction internal fixation with the anterior approach performed the worst. The lateral femoral cutaneous nerve was injured in all open reduction internal fixation with anterior approach procedures and in 66.7% of open reduction internal fixation with posterior approach procedures. Meta-regression showed a significantly lower OR for iatrogenic nerve injuries in patients aged >41.4 years in the open reduction internal fixation with the anterior approach group (OR: 0.02; 95% CI: 0.001-0.63; P  = 0.026) compared with younger patients.

CONCLUSION

The robotic-assisted technique may result in the fewest iatrogenic nerve injuries during the treatment of pelvic ring injuries. The posterior approach may also reduce the risk of iatrogenic nerve injuries.

Does a simultaneous ventral/dorsal approach provide better reduction quality in treating acetabular fracture involving both columns with displaced posterior wall?

INTRODUCTION

Various surgical techniques have been proposed to manage acetabular fractures involving both columns with posterior wall displacement. However, the optimal surgical approach to achieve satisfactory reduction quality remains controversial.

MATERIALS AND METHODS

This retrospective study evaluated 34 patients with fractures who were treated at a single medical institution. The patients were divided into two groups according to the ventral/dorsal surgical approach employed: simultaneous (SI) and sequential (SE). Perioperative parameters, as well as radiological and functional outcomes, were analyzed and compared between the two groups.

RESULTS

The SI and SE groups comprised 9 and 23 out of the 34 patients, respectively. The SI group exhibited a significantly shorter surgical time and lower estimated blood loss than the SE group (p = 0.04 and 0.03, respectively). The quality of reductions of the anterior and posterior columns was similar between the two groups; however, superior reduction in the fracture gap of the posterior wall was observed in the SI group, as revealed by axial and coronal computed tomography scans.

CONCLUSIONS

A simultaneous ventral and dorsal approach through the pararectus and the modified Gibson approach confer clinical advantages in reducing the fracture gap, surgical time, and intraoperative blood loss when managing acetabular fractures involving both columns and a displaced posterior wall. Therefore, these surgical approaches may be considered to be optimal for achieving satisfactory reduction quality in such fractures.

Simultaneous reduction and fixation of concomitant acetabular fracture and ipsilateral sacroiliac joint injury through the pararectus approach: a technical report and early radiological outcome

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.