Minimal invasive para-rectus approach for limited open reduction and percutaneous fixation of displaced acetabular fractures

[Imaging examination procedures, navigation and minimally invasive procedures in acetabular surgery]

Acetabular fractures still pose a special challenge even today. Considering the increasing case numbers, especially in the geriatric patient group, modern imaging examination procedures represent an essential pillar of the diagnostics. Especially in this vulnerable patient group, minimally invasive methods are necessary, which can be guaranteed by intraoperative navigation; however, the choice of surgical access and implants is also made based on the existing morphological characteristics of fractures, which highlights the importance of an imaging modality that is as detailed as possible. Last but not least, new developments concerning the surgical treatment of these injuries are also based on this. This article summarizes the current state of the techniques and the available literature.

Comparison of Therapeutic Outcomes of Transabdominal Pararectus Approach and Modified Stoppa Approach in Treating Pelvic and Acetabular Fractures

OBJECTIVE

Pelvic and acetabular fractures are common orthopedic diseases, and this research was to investigate the therapeutic effects of pararectus and Stoppa approaches in treating complex pelvic acetabular fractures.

METHODS

The clinical information of patients with pelvic and acetabular fractures treated surgically in Lu'an Hospital of Chinese medicine, China from January 2016 to April 2020 was analyzed. There were 30 cases each in the transabdominal pararectus approach and modified Stoppa approach groups. The operation time, incision length, blood loss, and postoperative complications of both groups were recorded according to the Merle d'Aubigné-Postel hip score. The recovery of hip function was evaluated 6 months after surgery, and the clinical and therapeutic efficacies of the two groups were compared.

RESULTS

The patients were followed up for 6-7 months (average, 6.5 months). The average operation time, incision length, and blood loss in the pararectus and Stoppa approach groups were 180 ± 41.105 min, 8.667 ± 1.373 cm, 259.667 ± 382 mL and 202.667 ± 32.793 min, 11.600 ± 1.958 cm, and 353.667 ± 590 mL, respectively. The satisfactory rate of fracture reduction, excellent and good rate of hip function score, and incidence of complications were 28/30, 27/30, 1/30 and 25/30, 25/30, 3/30, respectively. There were significant differences in operation time, incision length, and blood loss between the two groups (p < 0.05). However, there was no significant difference in the excellent and good rate of hip function score, fracture reduction satisfaction, and complication rate between both groups (p > 0.05).

CONCLUSIONS

The pararectus approach can reveal the better anatomical structure of the pelvis and acetabulum, such as the corona mortis and quadrilateral plate, for conducive fracture reduction and fixation. It can also effectively shorten the length of the incision, reduce operative blood loss, and shorten the operation time. It is a better choice for the clinical treatment of complex pelvic and acetabular fractures.

Pararectus approach combined with three-dimensional printing for anterior plate fixation of sacral fractures

BACKGROUND

Surgical treatment of sacral fractures is difficult, both for reduction and stabilization. Traditional surgical reduction and internal fixation require a long duration of operation leading to extra blood loss, extensive tissue damage, and increased risk of post-operation complications. The purpose of this study was to evaluate the feasibility of a minimally invasive technique that could be more effective, more tissue sparing, and lead to less bleeding. We hypothesized that a Pararectus approach for anterior fixation of unstable sacral fractures would be reliable and more advantageous and significantly improve the outcome of sacral fracture repair.

METHODS

Twelve patients with unstable sacral fractures were recruited and examined by CT scanning. A 3D model of each sacral fracture was reconstructed. The computer-assisted 3D image of the reduced pelvis was 3D printed for surgery simulation and plate pre-bending. All cases were treated operatively with the anterior anatomical reduction and internal fixation via a minimally invasive Pararectus approach. VAS, Matta, and Majeed scores were used to evaluate outcomes of the operation.

RESULTS

Pre-operations were consistent with the actual surgeries in all cases. The pre-bent plates had an anatomical shape specifically fit to the individual pelvis without further adjustment at the time of surgery, and fracture reductions were significantly improved with little invasive tissue damage. The average operation time was 110 min. The intraoperative blood loss and incision length averaged 695 ml and 6.7 cm, respectively. A high percentage of all cases achieved a diaplasis with an excellent or good score according to the Matta and Majeed standards (83.33% and 91.67%, respectively).All patients achieved clinical healing with an average healing time of 8 weeks.

CONCLUSION

3D printing-assisted anterior fixation of unstable sacral fractures via a minimally invasive Pararectus approach is feasible. This new surgical strategy minimizes trauma damage and bleeding and produces satisfactory reduction and therapeutic efficacy.

Internal fixation of anterior acetabular fractures with a limited pararectus approach and the anatomical plates: preliminary results

Background

The surgical treatment of acetabular fracture has adverse outcomes and high risk, and minimally invasive method is a good way to reduce complications and improve hip joint function. This study is to investigate the treatment of certain acetabular fractures primarily involving the anterior column and quadrilateral plate using a limited pararectus approach and the anatomical plates.

Methods

A consecutive cohort of 17 patients with anterior displaced acetabular fractures were managed operatively with a limited approach and the anatomical plates. Ten patients had anterior column fractures, 1 patient had anterior wall fracture, 4 patients had transverse fractures and 2 patients had anterior column with posterior hemi-transverse fractures. The inferior half of the pararectus approach was adopted to open the medial window and to access the anterior column and the quadrilateral plate. The anatomical plates were used for internal fixation. Residual displacements were assessed on the postoperative CT scans using a standardized digital method. The surgical details, hip functional outcomes, and complications were noted.

Results

All of the patients were operated using the limited pararectus approach and the anatomical plates successfully. The mean operative time and blood loss were 90.9 min and 334.1 ml, respectively. The average postoperative residual gap and step displacement on CT were 2.9 mm and 0.7 mm, respectively. The radiological outcome was estimated according to the Matta score, ten of the cases were graded anatomical, six were graded imperfect, and one was graded poor. Follow up averaged 15 months. Functional outcomes were excellent for nine, good for six, and fair for two. It was noted that one case of peritoneal injury was repaired intraoperatively.

Conclusions

The limited pararectus approach with the advantages of less trauma, direct exposure to the anterior column and quadrilateral plate. The anatomical plates can fit with the surface of the acetabulum, which saves the time of remodeling plates during operation and facilitate fracture reduction. The combination approach can be a good choice for limited surgery of displaced anterior acetabular fractures especially involving the quadrilateral plate.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04034-w.

A retrospective comparison of the conventional versus three-dimensional printed model-assisted surgery in the treatment of acetabular fractures

OBJECTIVE

The aim of this study was to compare the clinical and radiological outcomes of the conventional versus individualized three-dimensional (3D) printing model-assisted pre-contoured plate fixation in the treatment of patients with acetabular fractures.

METHODS

The data from 18 consecutive patients who underwent surgery for the acetabular fractures were retrospectively analyzed. The patients were divided into two groups (9 in each): conventional and 3D printed model-assisted. The groups were then compared in terms of the duration of surgery, time of instrumentation, time of intraoperative fluoroscopy, and volume of blood loss. The quality of the fracture reduction was also evaluated postoperatively by radiography and computed tomography in both the groups. The quality of the fracture reduction was defined as good (<2 mm) or fair (>2 mm) based on the amount of displacement in the acetabulum.

RESULTS

The conventional group included 9 patients (9 males; mean age=41.7 years; age range=16-70) with a mean follow-up of 11.9 months (range=8-15); the 3D printed model-assisted group consisted of 9 patients (9 males; mean age=46.2 years; age range=30-66) with a mean follow-up of 10.33 months (range=7-17). The average duration of surgery, mean time of instrumentation, time of intraoperative fluoroscopy, and mean volume of blood loss were 180.5±9 minutes, 36.2±3.6 minutes, 6±1 times, and 403.3±52.7 mL in the 3D printed model-assisted group, and 220±15.6 minutes, 57.4±10.65 minutes, 10.4±2.2 times, and 606.6±52.7 mL in the conventional group, respectively. Procedurally, the average duration of surgery, mean time of instrumentation, and mean time of fluoroscopy were significantly shorter, and the mean volume of blood loss was significantly lower in the 3D printed model-assisted group (p<0.05). The quality of the fracture reduction was good in 7 patients (78%) in the conventional group and 8 patients (89%) in the 3D printed model-assisted group.

CONCLUSION

As compared with the conventional surgery, the 3D printing model-assisted pre-contoured plate fixation technique can improve the clinical and radiological outcomes of the acetabular fractures, with shorter surgery, instrumentation, intraoperative fluoroscopy times, and blood loss.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Technical Considerations and Fluoroscopy in Percutaneous Fixation of the Pelvis and Acetabulum

Surgical treatment of the pelvic ring and acetabulum continues to evolve. Improved imaging technology and means for closed reduction have meant that percutaneous techniques have gained popularity in the treatment of the pelvic ring and, more recently, in the acetabulum. Potential benefits include decreased soft-tissue dissection, blood loss, and surgical time. However, these are technically demanding procedures that require substantial expertise from both the surgeon and the radiographer. This article details the necessary fluoroscopic views and general methods used in percutaneous techniques around the pelvis and acetabulum. Despite most studies reporting good-to-excellent clinical and radiographic results, further work is needed to facilitate standardization and optimization of these outcomes.

Short-column acetabular fracture fixation through a mini-pararectus approach in anteriorly displaced acetabular fractures: A case series

Background:

A mini-pararectus approach has been described as a minimally invasive approach for stabilizing acetabular fractures. This approach allows a direct view of anteriorly displaced acetabular fractures. In this preliminary study, we report the outcomes of short-column plating, using either a pelvic-brim plate or a spring plate to stabilize anteriorly and medially displaced fractures.

Methods:

Nine patients were included in this report, which was conducted between June 2015 and October 2016 in Assiut University Hospital, which is a level 1 trauma center in Upper Egypt. Eight patients had a transverse fracture of the acetabulum, and a single patient had a posterior hemi-transverse fracture of the anterior column. After the mini-pararectus approach through which anatomical reduction of the fracture was achieved, short-column plating, either a pelvic-brim plate or spring plate was introduced through this 3-5 cm incision. Outcomes were assessed.

Results:

The mean operative time was 88.8 min (range, 60-120 min). The mean blood loss was 78.8 mL (range, 50-150 mL). The maximal fracture displacement mean was 7 mm (range, 4–18 mm) preoperatively. According to the Radiologic Matta score, anatomical reduction of the fracture (0–1 mm displacement) was achieved in all patients. No complications of metal failure or secondary fracture displacement were encountered.

Conclusions:

Short-column plating through a mini-pararectus approach can be an alternative option for stabilizing acetabular fractures in a minimally invasive way in selected patients.

Level of Evidence:

Level IV.

Percutaneous fixation of acetabular fractures

The objective of surgery for acetabular fractures is to achieve precise reduction to restore joint congruence, fix internal bone fragments, avoid displacement of the fracture and allow rapid rehabilitation.Open reduction and internal fixation is the benchmark method for displaced acetabular fractures, but open reductions can increase morbidity, causing neurovascular injury, blood loss, heterotopic bone formation, infection and poor wound healing.An anatomical reduction with a gap of 2 mm or less is a predictor of good joint function and reduced risk of post-traumatic osteoarthritis.The percutaneous approach is associated with fewer complications than open techniques, but acetabular geometry makes percutaneous screw insertion a challenging procedure.The percutaneous technique is recommended for non-displaced or slightly displaced fractures, and in obese, osteoporotic and elderly patients who cannot receive total joint arthroplasty.We recommend the use of intramedullary cannulated screws.Fracture reductions are achieved by manual traction of the affected bones. If some fracture displacement remains, accessory windows can be used to introduce a ball spike pusher, a hook or a Steinmann pin which can be used as a joystick to rotate the fracture.In this paper, we describe the accessory windows for the anterior column, the quadrilateral plate and the posterior column. We detail the position, direction and kind of screws used to stabilize the anterior and posterior columns. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170054.

Treatment of Transverse with or without Posterior Wall Fractures of Acetabulum Using a Modified Smith-Petersen Combined with Kocher-Langenbeck Approach

BACKGROUND The aim of this study was to explore the surgical treatment of transverse with or without posterior wall fractures of the acetabulum. MATERIAL AND METHODS We surgically treated 21 consecutive cases of pure transverse (7 cases) and with posterior wall (14 cases) fractures of the acetabulum. The anterior column fractures were firstly reduced, temporarily fixed through a modified Smith-Petersen small incision, and finally fixed after the fixation of the posterior column and wall fractures, which were reduced and fixed through a Kocher-Langenbeck approach. The operative time, intra-operative blood loss, quality of reduction (Matta criteria), perioperative complications, osseous union, subsequent complications, and hip function evaluation were recorded. RESULTS The mean operative time was 198.1 min and the mean intra-operative blood loss was 938.1 ml. Anatomic reduction of the anterior column was obtained in 20 cases and was imperfect in 1 case. All posterior column and wall fractures were anatomically reduced. We followed up 18 cases for a mean duration of 16.3 (8-30) months. All the fractures achieved osseous union. The mean Harris score was 85.1 points, with an excellent result in 7 cases, good in 8, fair in 2, and poor in 1. According to modified Merle d' Aubigne and Postel score system, the results were excellent in 2 cases, good in 15, and poor in 1. Avascular necrosis of the femoral head occurred in 1 case, heterotopic ossification in 3 cases, and numbness of the anterolateral thigh in 6 cases. CONCLUSIONS For transverse with or without posterior wall fractures of the acetabulum, reduction and fixation of anterior and posterior column should be done in sequence, and a modified Smith-Petersen small incision might be a good choice in reduction and fixation of the anterior column because it possesses advantages of direct visualization and minimal invasion.

Rationale for more consistent choice of surgical approaches for acetabular fractures

OBJECTIVES

All acetabular fractures are difficult to treat surgically, but there are four types involving two columns that are particularly challenging. The choice of surgical approach is crucial. The purpose of the study was to determine and evaluate the factors influencing the choice of surgical approach for two-column acetabular fractures. We hypothesised that more accurate preoperative planning, sophisticated technical capabilities, and evolution of surgeon experience will result in more consistent use of non-extensile single surgical approaches. We also evaluated the outcomes of surgical treatment and the correlation with the surgical approach used.

DESIGN

Retrospective cohort study.

PATIENTS AND METHODS

A total of 156 patients with 157 acetabular fractures involving two columns (Letournel T-types and both-column) treated surgically in a 25-year period (1988-2013) were included in the study. The acetabular fractures in this study were divided into two groups according to the date of surgery: 81 in Group 1 (1998-2002) and 76 in Group 2 (2003-2013). All fractures were classified preoperatively according to the Judet and Letournel classification system and Matta's categorisation of surgical approach. Four surgical approaches were used: single Kocher-Langenbeck (KL), single ilioinguinal (II), combined Kocher-Langenbeck and ilioinguinal (KL+II), and extended iliofemoral (EIF). The efficacy of the surgical approach utilised was assessed using three parameters: anatomical reduction, surgical time and intraoperative complications.

RESULTS

There was no statistical difference between Group 1 and Group 2 in the distribution of T-type (p=0.424) and both-column (p=0.425) fractures. In Group 2 more acetabular fractures were treated through single non-extensile approaches compared with Group 1 (90.8% vs. 54.3%, p<0.001). Increase in single approach surgery resulted in shorter mean surgical time (p<0.001) and significant increase in anatomical reduction (p=0.039). The frequency of intraoperative complications was not statistically different (p=0.07) between the two groups, but there was a trend to fewer complications in Group 2.

CONCLUSIONS

The surgical approaches chosen for acetabular fractures that involve two columns (Letournel T-types and both-column) should become more consistent. The results of this study indicate that the majority of such acetabular fractures can be treated successfully through single surgical approaches.

Comparison of reconstruction plate screw fixation and percutaneous cannulated screw fixation in treatment of Tile B1 type pubic symphysis diastasis: a finite element analysis and 10-year clinical experience

Objective

The objective of this study is to compare the biomechanical properties and clinical outcomes of Tile B1 type pubic symphysis diastasis (PSD) treated by percutaneous cannulated screw fixation (PCSF) and reconstruction plate screw fixation (RPSF).

Materials and Methods

Finite element analysis (FEA) was used to compare the biomechanical properties between PCSF and RPSF. CT scan data of one PSD patient were used for three-dimensional reconstructions. After a validated pelvic finite element model was established, both PCSF and RPSF were simulated, and a vertical downward load of 600 N was loaded. The distance of pubic symphysis and stress were tested. Then, 51 Tile type B1 PSD patients (24 in the PCSF group; 27 in the RPSF group) were reviewed. Intra-operative blood loss, operative time, and the length of the skin scar were recorded. The distance of pubic symphysis was measured, and complications of infection, implant failure, and revision surgery were recorded. The Majeed scoring system was also evaluated.

Results

The maximum displacement of the pubic symphysis was 0.408 and 0.643 mm in the RPSF and PCSF models, respectively. The maximum stress of the plate in RPSF was 1846 MPa and that of the cannulated screw in PCSF was 30.92 MPa. All 51 patients received follow-up at least 18 months post-surgery (range 18–54 months). Intra-operative blood loss, operative time, and the length of the skin scar in the PCSF group were significantly different than those in the RPSF group. No significant differences were found in wound infection, implant failure, rate of revision surgery, distance of pubic symphysis, and Majeed score.

Conclusion

PCSF can provide comparable biomechanical properties to RPSF in the treatment of Tile B1 type PSD. Meanwhile, PCSF and RPSF have similar clinical and radiographic outcomes. Furthermore, PCSF also has the advantages of being minimally invasive, has less blood loss, and has shorter operative time and skin scar.