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Fukuoka S, Yorimitsu M, Uehara T, Naniwa S, Hata T, Sato K, Noda T, Sato T, Ozaki T. Ideal insertion point and projection of the infra-acetabular screw in acetabular fracture surgery. Injury 2024; 55:111264. [PMID: 38105150 DOI: 10.1016/j.injury.2023.111264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 11/27/2023] [Accepted: 11/30/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND In acetabular fracture surgery, an infra-acetabular screw (IAS) is inserted from the anterior to the posterior column through the infra-acetabular corridor to stabilize both columns. Although the IAS is useful for increasing fixation strength, proper placement requires proficiency and often results in extraosseous screw penetration. The complex anatomy of the infra-acetabular corridor and difficult intraoperative detection of the ideal insertion point and angle make proper placement of the IAS challenging. This study aimed to detect the ideal insertion point and angle of the IAS based on anatomical landmarks that can be directly identified intraoperatively. METHODS We retrospectively reviewed the pelvic CT of 50 adults who underwent serial slice CT imaging. The pelvic inlet plane (PIP), which contains the anterior border of both the sacroiliac joint and posterior superior edge of the pubic symphysis, was used as the reference plane for the pelvic coordinate system to simulate the ideal insertion of IAS. The distance from the posterior superior edge of the pubic symphysis to the ideal insertion point of the IAS (IAS distance) and the angle and length of the IAS that could be inserted from the ideal insertion point were measured. RESULTS The mean IAS distance was 61.0 ± 5.7 mm (57.6 ± 4.3 mm in men and 64.4 ± 4.9 mm in women). The mean angle between ideal IAS and yz-plane on the outlet view (α-angle) was 8.4 ± 6.6 ° (6.4 ± 5.6° in men and 10.5 ± 7.0° in women). The mean angle between ideal IAS and y-axis on the yz-plane (β-angle) was 86.5 ± 10.6 ° (86.0 ± 10.3° in men and 87.0 ± 10.9° in women). The length of IAS was 97.1 ± 4.7 mm in men and 89.2 ± 3.6 mm in women. CONCLUSION The IAS ideal insertion point detected as a distance from the pubic symphysis may aid in the proper insertion of the IAS during surgery. The insertion angle was parallel or tilted 10 ° laterally to the longitudinal axis in the pelvic outlet plane and almost perpendicular to the PIP in the sagittal plane when inserted from the ideal insertion point.
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Affiliation(s)
- Shiro Fukuoka
- Department of Orthopedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kitaku, Okayama City, Okayama, 700-8558 Japan
| | - Masanori Yorimitsu
- Department of Musculoskeletal Traumatology, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata, Kitaku, Okayama City, Okayama, 700-8558 Japan.
| | - Takenori Uehara
- Department of Emergency Health Care and Disaster Medicine, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata, Kitaku, Okayama City, Okayama, 700-8558 Japan
| | - Shuichi Naniwa
- Department of Orthopedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kitaku, Okayama City, Okayama, 700-8558 Japan
| | - Toshiaki Hata
- Department of Orthopedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kitaku, Okayama City, Okayama, 700-8558 Japan
| | - Kohei Sato
- Department of Orthopedic Surgery, Science of Functional Recovery and Reconstruction, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kitaku, Okayama City, Okayama, 700-8558 Japan
| | - Tomoyuki Noda
- Department of Orthopedic Surgery, Kawasaki Medical School General Medical Center, 2-6-1 Nakasange, Kitaku, Okayama City, Okayama, 700-8505 Japan
| | - Toru Sato
- Department of Orthopedic Surgery, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kitaku, Okayama City, Okayama, 701-1192 Japan
| | - Toshifumi Ozaki
- Department of Orthopedic Surgery, Science of Functional Recovery and Reconstruction, Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, 2-5-1 Shikata, Kitaku, Okayama City, Okayama, 700-8558 Japan
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Hinz N, Baumeister D, Dehoust J, Münch M, Frosch KH, Augat P, Hartel MJ. The infraacetabular screw versus the antegrade posterior column screw in acetabulum fractures with posterior column involvement: a biomechanical comparison. Arch Orthop Trauma Surg 2024:10.1007/s00402-024-05324-3. [PMID: 38676740 DOI: 10.1007/s00402-024-05324-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/12/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Traditionally, plate osteosynthesis of the anterior column combined with an antegrade posterior column screw is used for fixation of anterior column plus posterior hemitransverse (ACPHT) acetabulum fractures. Replacing the posterior column screw with an infraacetabular screw could improve the straightforwardness of acetabulum surgery, as it can be inserted using less invasive approaches, such as the AIP/Stoppa approach, which is a well-established standard approach. However, the biomechanical stability of a plate osteosynthesis combined with an infraacetabular screw instead of an antegrade posterior column screw is unknown. MATERIAL AND METHODS Two osteosynthesis constructs were compared in a synthetic hemipelvis model with an ACPHT fracture: Suprapectineal plate + antegrade posterior column screw (APCS group) vs. suprapectineal plate + infraacetabular screw (IAS group). A single-leg stance test protocol with an additional passive muscle force and a cyclic loading of 32,000 cycles with a maximum effective load of 2400 N was applied. Interfragmentary motion and rotation of the three main fracture lines were measured. RESULTS At the posterior hemitransverse fracture line, interfragmentary motion perpendicular to the fracture line (p < 0.001) and shear motion (p < 0.001) and at the high anterior column fracture line, interfragmentary motion longitudinal to the fracture line (p = 0.017) were significantly higher in the IAS group than in the APCS group. On the other hand, interfragmentary motion perpendicular (p = 0.004), longitudinal (p < 0.001) and horizontal to the fracture line (p = 0.004) and shear motion (p < 0.001) were significantly increased at the low anterior column fracture line in the APCS group compared to the IAS group. CONCLUSIONS Replacing the antegrade posterior column screw with an infraacetabular screw is not recommendable as it results in an increased interfragmentary motion, especially at the posterior hemitransverse component of an ACPHT fracture.
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Affiliation(s)
- Nico Hinz
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany.
| | - Dirk Baumeister
- Institute for Biomechanics, BG Unfallklinik Murnau, Professor-Kuentscher-Strasse 8, 82418, Murnau am Staffelsee, Germany
| | - Julius Dehoust
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
| | - Matthias Münch
- Laboratory for Biomechanics, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
| | - Peter Augat
- Institute for Biomechanics, BG Unfallklinik Murnau, Professor-Kuentscher-Strasse 8, 82418, Murnau am Staffelsee, Germany
| | - Maximilian J Hartel
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
- Department of Trauma Surgery, Orthopaedics and Sports Traumatology, BG Klinikum Hamburg, Bergedorfer Strasse 10, 21033, Hamburg, Germany
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Yu YH, Chen IJ, Lai CY, Hsu YH, Chou YC. Does a simultaneous ventral/dorsal approach provide better reduction quality in treating acetabular fracture involving both columns with displaced posterior wall? Arch Orthop Trauma Surg 2024; 144:1547-1556. [PMID: 38386063 PMCID: PMC10965567 DOI: 10.1007/s00402-024-05224-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/15/2024] [Indexed: 02/23/2024]
Abstract
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.
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Affiliation(s)
- Yi-Hsun Yu
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Fu-Hsin St. Kweishan, Taoyuan, 33302, Taiwan.
| | - I-Jung Chen
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Fu-Hsin St. Kweishan, Taoyuan, 33302, Taiwan
| | - Chih-Yang Lai
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Fu-Hsin St. Kweishan, Taoyuan, 33302, Taiwan
| | - Yung-Heng Hsu
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Fu-Hsin St. Kweishan, Taoyuan, 33302, Taiwan
| | - Ying-Chao Chou
- Department of Orthopaedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Fu-Hsin St. Kweishan, Taoyuan, 33302, Taiwan
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Rajnish RK, Elhence A, Srivastava A, Yadav SK, Kantiwal P, Gupta S. Does the pararectus approach have better outcomes and fewer complications than the modified Stoppa approach for the fixation of acetabular fractures in adults: A systematic review and meta-analysis? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024:10.1007/s00590-024-03885-y. [PMID: 38451336 DOI: 10.1007/s00590-024-03885-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND The pararectus approach is a minimally invasive surgical approach for anterior acetabulum fracture, with an advantage of the medial window of the modified Stoppa approach (MSA). However, it is unclear whether the pararectus approach is superior to MSA. We aimed this systematic review and meta-analysis to compare the outcomes and complications of pararectus and MSA. METHODS We performed a data search by conducting an electronic search across databases of PubMed, Embase, Scopus, Cinahl, CNKI, and Cochrane Library and included seven comparative studies for analysis. Statistical analysis was performed using the RevMan software 5.4.1. The risk of bias was evaluated using the Cochrane Collaboration's risk of bias tool for RCTs and the MINORS tool for non-RCTs. RESULTS Two randomized control trials (RCTs), one prospective study, and four retrospective studies were included. Meta-analysis revealed a better Matta's reduction quality [OR 1.58, 95% CI 1.06, 2.37; p = 0.03] and radiological outcome [OR 2.18, 95% CI 1.03, 4.60; p = 0.04] in MSA than in pararectus approach. However, the pararectus approach has less intraoperative blood loss [MD - 9.79 (95% CI - 176.75, - 6.83; p = 0.03)] and a shorter hospital stay [MD - 2.61 (95% CI - 5.03, - .18; p = 0.04)] than MSA. Both approaches have failed to show a difference concerning overall complication rates [OR 0.66 (95% CI 0.28, 1.55; p = 0.34)], postoperative infection, DVT, duration of surgery [MD - 15.09 (95% CI - 35.38, 5.20; p = 0.15)], functional outcome, and incision length. CONCLUSION The pararectus approach offers an advantage with lesser operative blood loss and shorter hospital stay, whilst MSA stands out with better reduction quality and radiological outcomes. Nevertheless, both approaches exhibit no difference in complication rates, duration of surgery, incision length, and functional outcome. Hence, the pararectus approach can be considered an alternative to MSA; however, the existing literature fails to demonstrate a distinct advantage over MSA.
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Affiliation(s)
- Rajesh Kumar Rajnish
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
| | - Abhay Elhence
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
| | - Amit Srivastava
- Department of Orthopaedics, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Sandeep Kumar Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India.
| | - Prabodh Kantiwal
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
| | - Saurabh Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
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Davalos RA, Mourafetis L, Tompane T, Wheatley BM. Are methods to quantify osseous exposure in orthopedic surgery reliable? Injury 2024; 55:111231. [PMID: 38043145 DOI: 10.1016/j.injury.2023.111231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/09/2023] [Accepted: 11/19/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Our study examined if there were any limitations when using various measurement techniques in the literature to quantify osseous exposure. Additionally, we also examined if surface contour had any influence on obtained measurements, which no previous study has attempted. MATERIALS AND METHODS Three methods used to quantify osseous exposure area were identified, one in which involves manually applying mesh over exposure area. The other two use digital image capture software (ImageJ, Bethesda, MD). We simulated flat, convex, and mixed surface types using synthetic bone analogs. We assessed the degree of variability between mean values using an ANOVA or Kruskal-Wallis equality of populations rank test. Cronbach's alpha test of internal reliability was used to assess the internal reliability of measurement technique. RESULTS ANOVA test for difference in measurement techniques on all three surface types was statistically significant (p < 0.05). Cronbach's alpha test of internal reliability for each technique on the convex surface did not obtain adequate significance (alpha >0.70). Only the mesh method obtained adequate alpha value for significance when applied to the flat and mixed surface types. DISCUSSION Each of the three measurement techniques tested demonstrated poor internal reliability. We suggest taking care when comparing studies that use different quantification techniques when calculating osseous exposure for different surgical approaches. Future studies should explore alternative methods of osseous exposure quantification.
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Affiliation(s)
- Raul A Davalos
- Uniformed University of the Health Sciences School of Medicine, Bethesda, MD 20814, USA
| | - Laura Mourafetis
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, CA 92134, USA
| | - Trevor Tompane
- Department of Orthopaedic Surgery, Naval Hospital Camp Pendleton, CA 92055, USA
| | - Benjamin M Wheatley
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, CA 92134, USA.
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Rajnish RK, Srivastava A, Elhence A, Yadav SK, Rathor K, Gupta S. A systemic review and meta-analysis of pararectus versus ilioinguinal approach for the management of acetabular fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:549-560. [PMID: 37646876 DOI: 10.1007/s00590-023-03700-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE The complex anatomy of acetabular fracture needs a surgical approach that can achieve anatomical reduction with fewer complications for the fixation of these fractures. Current literature suggests that both Pararectus (PR) approach and Ilioinguinal (IL) approach can be used for the fixation of these fractures safely. However, superiority of the PR approach over the IL approach is not established. Hence, this meta-analysis aimed to compare the PR versus IL approach. METHODOLOGY A literature search was performed on five databases Medline/PubMed, Scopus Embase, Cinhal, and Cochrane Library, from the inception to January 14, 2023. A qualitative and quantitative analysis was done for the five eligible studies from the literature search. Individual study characteristics data and outcomes were extracted, and Software version 5.4.1 of Review Manager was used for statistical analysis. RESULTS Five articles, one Randomized trial (RCT), and four retrospective articles were included and analyzed in this meta-analysis. PR approach has a shorter surgical time [mean difference (MD) -48.4 with 95% CI -74.49, -22.30; p = 0.0003], less intraoperative blood loss (MD -123.22 with 95% CI -212.28, -34.15; p = 0.007), and smaller surgical incision (MD -9.87 with 95% CI -15.21, -4.52; p = 0.0003) than the IL approach. However, the meta-analysis failed to show a difference between the two surgical approaches concerning the quality of reduction, overall complications, nerve injury, vascular injury, heterotopic ossification, deep vein thrombosis, and pulmonary embolism. CONCLUSION The PR approach has a shorter surgical duration, less blood loss, and a smaller surgical incision than the IL approach. However, both surgical approaches have equivocal results regarding fracture reduction quality, complication rates, and functional outcomes for acetabular fracture fixation. Hence, for acetabular fractures fixation, PR approach can be considered a safe and feasible alternative to the IL approach.
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Affiliation(s)
- Rajesh Kumar Rajnish
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
| | - Amit Srivastava
- Department of Orthopaedics, University College of Medical Sciences and GTB Hospital, Delhi, India
| | - Abhay Elhence
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
| | - Sandeep Kumar Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India.
| | - Kuldeep Rathor
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
| | - Saurabh Gupta
- Department of Orthopaedics, All India Institute of Medical Sciences, Jodhpur, India
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Pagano S, Müller K, Alt V, Maderbacher G, Holzapfel DE, Baumann F, Freigang V. [Navigated or conventional acetabular surgery : Comparison of positional accuracy exemplified by the infra-acetabular screw]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:44-53. [PMID: 36929038 PMCID: PMC10786994 DOI: 10.1007/s00113-023-01304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND The principle of joint-preserving treatment of acetabular fractures is the anatomic reduction of joint-bearing elements and internal osteosynthesis. For stabilization of the anterior and posterior columns against each other, the infra-acetabular screw (IAS) is regularly used in the clinical routine. OBJECTIVE The aim of this study was to compare the position of the IAS in the infra-acetabular corridor after navigated placement and after freehand placement. MATERIAL AND METHOD The position of the screw was evaluated in 42 patients using multiplanar reconstructions. The screw was placed freehand in 30 patients and using image-guided navigation in 12 patients. In addition to measurement of the position of the screw, demographic data, operating time, radiation exposure and blood loss were recorded. RESULTS The vast majority of the patients were male (86%), the median age was 67 years and the median body mass index (BMI) was 25 kg/m2. The median operating time was 166 min and the median blood loss was 900 ml. The adjusted values in the whole sample considering the position of the screw were: distance of screw to cartilage mean value (m) = 3.8 mm, distance of screw to corridor center m = 3.5 mm and angle of screw to corridor m = 1.4°. There were no differences between the groups in the demographic parameters and the accuracy of positioning of the screw (p-value > 0.05). There was a longer irradiation time and a higher radiation dose in the navigated group compared to the group without navigation (p-value < 0.001). CONCLUSION With appropriate experience both procedures are comparable taking into account the accuracy. Taking into consideration other perioperative parameters, such as radiation exposure and planned operating time, patient-related factors should be taken into consideration.
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Affiliation(s)
- Stefano Pagano
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Karolina Müller
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Günther Maderbacher
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Dominik E Holzapfel
- Orthopädische Klinik für die Universität Regensburg, Asklepios Klinikum Bad Abbach, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Deutschland
| | - Florian Baumann
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Viola Freigang
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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Wood MJ, Al-Jabri T, Zaghloul A, Lanting B, Giannoudis PV, Hart AJ. Periprosthetic acetabular fractures as a complication of total hip arthroplasty. Injury 2023; 54:111058. [PMID: 37748235 DOI: 10.1016/j.injury.2023.111058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Periprosthetic acetabular fractures are rare but potentially devastating complications of total hip arthroplasty. As the number of total hip arthroplasties performed annually increases, so has the incidence of periprosthetic fractures, with the topic being spotlighted more frequently in the orthopaedic community. There is a particular sparsity of literature regarding periprosthetic acetabular fractures, with periprosthetic femoral fractures after total hip arthroplasty being traditionally far more commonly reported. This article aims to provide an up-to-date review of the epidemiology, risk factors, diagnostic challenges, classifications, and management strategies for periprosthetic acetabular fractures after total hip arthroplasty.
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Affiliation(s)
- Matthew J Wood
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, United Kingdom
| | - Talal Al-Jabri
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, United Kingdom; Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada.
| | - Ahmed Zaghloul
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, United Kingdom
| | - Brent Lanting
- Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
| | - Alister James Hart
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, United Kingdom; Institute of Orthopaedics and Musculoskeletal Science, University College London, Stanmore, HA7 4LP, United Kingdom
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Shigemura T, Yamamoto Y, Maruyama J, Kitamura T, Nakane R, Kawaguchi H, Iida D, Murata Y. Efficacy and safety of pararectus approach for the treatment of acetabular fractures: A systematic review and meta-analysis. Orthop Traumatol Surg Res 2023; 109:103498. [PMID: 36460292 DOI: 10.1016/j.otsr.2022.103498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 08/31/2022] [Accepted: 10/04/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND The pararectus (PR) approach combines the advantages of the second window of the ilioinguinal approach and the medial view of the modified Stoppa approach. However, it is unclear whether the PR approach is more effective or safer than the other approaches, as few clinical studies have compared the PR approach with the other approaches. The aim of this study was to provide a systematic review and meta-analysis comparing the PR approach with the other approaches for the treatment of acetabular fractures and to answer the following question: Are the results of the PR approach superior to those of the other approaches in terms of reduction quality, operative time, operative blood loss, complications, and clinical outcomes for treatment of acetabular fractures? PATIENTS AND METHODS A systematic literature review was conducted using relevant original studies from various databases. Pooling of data was performed using RevMan software (version 5.3, Cochrane Collaboration, Oxford, UK). A p-value<0.05 was considered to be significant. We calculated the mean differences for continuous data and odds ratio for dichotomous data with 95% confidence intervals for each outcome. Statistical heterogeneity was assessed based on I2 using the standard χ2 test. RESULTS Five studies were included in this meta-analysis. The findings demonstrated that operative blood loss was significantly lower in the PR approach than in the other approaches (p=0.04). There was no significant difference in the rate of anatomical reduction, the operative time, the rate of complications, and the rate of excellent or good clinical score between the PR approach and the other approaches. DISCUSSION The PR approach provided lower operative blood loss, although there was no significant difference in reduction quality, operative time, complications, and excellent or good clinical score between the PR approach and the other approaches. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Tomonori Shigemura
- Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan.
| | - Yohei Yamamoto
- Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan
| | - Juntaro Maruyama
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Takaki Kitamura
- Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan
| | - Ryo Nakane
- Department of Orthopaedic Surgery, Kumagaya General Hospital, 4-5-1 Nakanishi, Kumagaya, Saitama 360-8567, Japan
| | - Hiroki Kawaguchi
- Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan
| | - Daisuke Iida
- Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan
| | - Yasuaki Murata
- Department of Orthopaedic Surgery, Teikyo University Chiba Medical Center, 3426-3 Anesaki, Ichihara, Chiba 299-0111, Japan
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Lippross S, Wehrenpfennig C, Wedel T, Seekamp A, Osmonov D, Moradi B, Fitschen-Oestern S, Finn J, Klueter T, Kurz B, Alkatout I. The anterior transmuscular intrapelvic approach for the treatment of acetabular fractures-a new anterior surgical strategy. BMC Musculoskelet Disord 2023; 24:638. [PMID: 37559078 PMCID: PMC10411011 DOI: 10.1186/s12891-023-06775-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/03/2023] [Indexed: 08/11/2023] Open
Abstract
The anterior ilioinguinal and the posterior Kocher-Langenbeck approach have long been the standard surgical approaches to the acetabulum. The last decade has witnessed the development of so-called intrapelvic approaches for anterior pathologies because they provide better exposure of the quadrilateral plate. Currently, the modified Stoppa approach and the pararectus approach are frequently used by surgeons for the treatment of acetabular fractures. We investigated an even more direct access to the entire anterior column and the quadrilateral plate via the abdominal wall muscles, between the incisions for the ilioinguinal and the pararectus approach.After intensive study of anatomic specimens, a cadaver dissection was performed prior to clinical application. The approach was then used in 20 patients who were assessed retrospectively.Postoperative CT scans showed that, according to the Matta scoring system, the quality of fracture reduction was "anatomical" (≤ 1 mm) in 12 (60%), "imperfect" (2-3 mm) in four (20%), and "poor" (> 3 mm) in four (20%) patients. Numerous minor complications were observed; the majority of these had resolved at the time of discharge.In conclusion, the anterior transmuscular intrapelvic approach (ATI) is a safe and effective alternative to the ilioinguinal and pararectal approaches, and may be regarded as an evolutionary advancement of traditional procedures.
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Affiliation(s)
- Sebastian Lippross
- Department of Trauma and Orthopaedic Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany.
| | - Clara Wehrenpfennig
- Department of Trauma and Orthopaedic Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Thilo Wedel
- Institute of Anatomy, Christian-Albrecht University, Kiel, Germany
| | - Andreas Seekamp
- Department of Trauma and Orthopaedic Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Daniar Osmonov
- Department of Urology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Babak Moradi
- Department of Trauma and Orthopaedic Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Stefanie Fitschen-Oestern
- Department of Trauma and Orthopaedic Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Joerg Finn
- Department of Trauma and Orthopaedic Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Tim Klueter
- Department of Trauma and Orthopaedic Surgery, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Bodo Kurz
- Institute of Anatomy, Christian-Albrecht University, Kiel, Germany
| | - Ibrahim Alkatout
- Department of Gynaecology, University Medical Center of Schleswig-Holstein, Campus Kiel, Kiel, Germany
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11
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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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Pararectus Approach in Acetabular Fractures in Patients Older Than 65 years. Is it Possible to Improve the Technique? J Orthop Trauma 2023; 37:109-115. [PMID: 36155367 DOI: 10.1097/bot.0000000000002489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/14/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Review clinical results of the treatment for acetabular fractures using the pararectus approach and analyze surgical variations of the traditional approach. DESIGN Retrospective. SETTING Tertiary referral hospital. PATIENTS 46 patients over 65 years of age who sustained an acetabular fracture and underwent surgery using the pararectus approach. INTERVENTION Fractures were treated using a pararectus approach. Three variations of the original technique were performed: (1) Ligature of the deep iliac circumflex artery and vein, (2) separation of the psoas and iliacus muscles, and (3) isolation of the spermatic cord in men and round ligament in women together with the iliac and epigastric vessels. MAIN OUTCOME MEASUREMENTS Outcomes measures included surgical, demographic, and clinical data, and information related to follow-up. RESULTS Duration of surgery, 125 minutes (95-210). Quality of reduction on postoperative computed tomography (CT) scan; anatomic in 22 patients (47.8%), incomplete in 16 (34.8%), and poor in 8 (17.4%). In patients in whom the hip was preserved (n = 41), functional status was excellent in 15 patients (36.5%), good in 17 (41.4%), fair in 6 (14.7%), and poor in 3 (7.4%), with mean functional score of 16 points (7-18). Seven patients (15.2%) developed posttraumatic osteoarthritis and 4 of these patients underwent total hip replacement. CONCLUSIONS This study reports positive outcomes in fracture reduction and clinical outcomes with low complications in older patients who suffered acetabular fractures and were treated using a pararectus approach. Small variations in the technique, such as those proposed in this study, may help to widen access to the surgical site and simplify the technique. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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13
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[Osteosynthesis of geriatric acetabular fractures]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2023; 126:100-108. [PMID: 36607406 DOI: 10.1007/s00113-022-01276-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 01/07/2023]
Abstract
The aim of the treatment of acetabular fractures is principally an anatomical reconstruction of the joint surface to avoid posttraumatic arthritis. The increasing number of geriatric patients with acetabular fractures of the anterior column type resulting from simple falls on the side and substantial patient-related inherited comorbidities, represent particular challenges for the surgical approach and osteosynthesis due to the osteoporotic bone quality. Due to the establishment of minimally invasive lateral pelvic accesses to the acetabulum and the adaptation of the osteosynthesis technique and material to these approaches, it appears that even in very old patients with acetabular fractures mobility can be better and more rapidly restored and sequelae caused by immobility can be prevented.
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Wang Z, Wang Z, Chen G, Gao M, Zhu R, Yang H. Clinical application of the anterior pelvic wall locking plate (APWLP) in acetabular fractures involving the quadrilateral surface. J Orthop Surg Res 2023; 18:76. [PMID: 36721227 PMCID: PMC9887884 DOI: 10.1186/s13018-022-03392-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 11/06/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The management of acetabular quadrilateral surface fractures remains challenging for surgeons, and the treatment options for such fractures remain controversial. Quadrilateral surface surgery is a complex procedure involving combined approaches, and the quality of fracture reduction closely depends upon the surgical procedure, as well as the skill and experience of the surgeon. This study aimed to explore the clinical effects of applying an anterior pelvic wall locking plate (APWLP) through the lateral-rectus approach for treating acetabular fractures involving the quadrilateral surface. METHODS This retrospective analysis was comprised of 35 patients with acetabular fractures involving the quadrilateral surface who were treated with an APWLP in our hospital between June 2016 and December 2020. The patients included 25 males and ten females, with an average age of 52.45 years. All the patients were exposed through the lateral-rectus approach, six patients were exposed with an additional iliac fossa approach, and the fractures were fixed by combining an APWLP with a reconstruction plate. The Matta imaging standard was used to assess the quality of the fracture reduction, and the final follow-up clinical outcome was classified as excellent (18 points), good (15-17), fair (13-14), or poor (< 13) according to the modified Merle d'Aubigné-Postel scoring standard. RESULTS All patients successfully completed the operation, and there was no blood vessel or nerve injury during any of the operations. The average follow-up period was 26.11 months. The mean time of resuming full-weight-bearing activities was 12.88 weeks. Hip flexion and extension and internal and external rotation ranges of motion significantly increased over time. At the last follow-up, Matta's imaging evaluation showed that 24 cases were anatomically reduced, seven cases were satisfactory, and four cases were unsatisfactory. The satisfaction rate was 88.6% (31/35). According to the modified Merle d'Aubigné-Postel scoring standard, the hip function was excellent, good, fair, and poor in 23, 6, 4, and 2 cases, respectively. The excellent and good rates represented 82.9% of the total cases (29/35). CONCLUSION The findings suggest that the APWLP for acetabulum quadrilateral surface fracture achieve good to excellent clinical and radiological outcomes, and an APWLP may be a new treatment option for these fractures involving the quadrilateral surface.
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Affiliation(s)
- ZhiDong Wang
- grid.429222.d0000 0004 1798 0228Department of Orthopaedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 China
| | - ZhenHeng Wang
- grid.429222.d0000 0004 1798 0228Department of Orthopaedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 China
| | - GuangDong Chen
- grid.429222.d0000 0004 1798 0228Department of Orthopaedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 China
| | - MaoFeng Gao
- grid.429222.d0000 0004 1798 0228Department of Orthopaedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 China
| | - RuoFu Zhu
- grid.429222.d0000 0004 1798 0228Department of Orthopaedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 China
| | - HuiLin Yang
- grid.429222.d0000 0004 1798 0228Department of Orthopaedics, The First Affiliated Hospital of Soochow University, 899 Pinghai Road, Suzhou, 215006 China
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Wang T, Hou X, Zhou Z, Liu J, Zhang S, Ge S, Jia S, Zheng L. Treatment of acetabular fracture involving anterior and posterior columns using a single pararectus approach: surgical experience and preliminary results. INTERNATIONAL ORTHOPAEDICS 2023; 47:233-240. [PMID: 36194283 DOI: 10.1007/s00264-022-05587-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 09/18/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE This study aims to evaluate the efficacy of single pararectus approach in patients confirmed with acetabular fracture involving anterior and posterior columns. METHODS A total of 58 patients confirmed with acetabular fracture involving anterior and posterior columns and treated at our hospital between January 2015 and January 2020 were retrospectively analyzed. A single pararectus approach was applied for all patients. Routine X-rays were performed at follow-up of one, three, six, 12, and 18 months, and three-dimensional CT scans were added at six and 18 months. Fracture reduction quality was assessed using the Matta score system, and functional assessment used the Modified Merle D'Aubigné and Postel score system. Post-operative complications, including fat liquefaction and deep vein thrombosis, were recorded and analyzed. RESULTS The median operation time was 186 min while the intra-operative blood loss was 421 mL. The rate of good-to-excellent reduction was 94.8%, and the rate of good-to-excellent hip function score reached 93.1%. Seven patients presented with post-operative complications, including three intra-operative small vascular injuries, two peritoneal small perforations, one fat liquefaction, and one deep vein thrombosis. CONCLUSION Using a single pararectus approach is convenient and effective for treating acetabular fracture involving anterior and posterior columns, especially those involving the quadrilateral area. TRIAL REGISTRATION ChiCTR, ChiCTR2100054604. Registered 21 December 2022. Retrospectively registered, http://www.chictr.org.cn/showproj.aspx?proj=144783 .
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Affiliation(s)
- Tianlong Wang
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Xiaodong Hou
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Zifei Zhou
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Junfeng Liu
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Shaodi Zhang
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Shuo Ge
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Shaohua Jia
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China
| | - Longpo Zheng
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China. .,Shanghai Trauma Emergency Center, Shanghai, 200072, China. .,Orthopedic Intelligent Minimally Invasive Diagnosis & Treatment Center, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200072, China.
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16
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The difference in the corridor of the antegrade posterior column screw according to the presence of pelvic dysmorphism. Injury 2022; 53:3774-3780. [PMID: 36045030 DOI: 10.1016/j.injury.2022.08.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/23/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Antegrade posterior column screw (aPCS) fixation via the anterior approach has been widely used for separated the posterior columns in acetabular fracture treatment. Although the relationship between pelvic dysmorphism and sacroiliac screws has been widely studied, no studies have reported on the clinical impact of pelvic dysmorphism on acetabular fractures. This study aimed to reveal the difference in the insertion angle and entry point of aPCS between the dysmorphic and normal pelvises. METHODS Patients diagnosed with unilateral acetabular fractures and who underwent pelvic computed tomography scans between 2013 and 2019 in two institutes were enrolled in this study. Patients were divided into the dysmorphic and control groups according to the sacral dysmorphic score, which predicts the presence of pelvic dysmorphism, and each group enrolled 130 patients. The semitransparent 3D hemipelvis model was reconstructed using a 3D reconstruction program. The sagittal and coronal angles of a virtual cylinder that fill the safe corridor of the column screw the most were measured. The surface area of the safe corridor and distance of the optimal entry point from the anterior border of the sacroiliac joint were analyzed. The measurements were compared between the dysmorphic and control groups. RESULTS The average sacral dysmorphic score in the normal and dysmorphic pelvis groups was 56.1 and 81.0, respectively. There were no significant differences in demographic data, including age, sex, height, weight, and body mass index, between the dysmorphic and control groups. There was a significant difference in the average sagittal insertion angle of PCs, which was 38.3° in the control group and 27.2° in the dysmorphic group (P < 0.001). The coronal insertion angles were not significantly different. The dysmorphic group presented longer straight distances (25.9 vs 24.8 mm, P = 0.026) and had a smaller aPCS surface area (685 vs 757 mm2, P < 0.001) than the control group. CONCLUSION The present study describes a difference in the corridor of aPCS between the dysmorphic and normal pelvis. Insertion of aPCS in the dysmorphic pelvis requires a more acute angular trajectory in the sagittal plane than that in the normal pelvis.
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Atlihan D, Aydin M, Capkin S, Surucu S, Gunaydin F, Acar HI. A new modified pararectus approach and visualization: an anatomical study. Arch Orthop Trauma Surg 2022; 143:2493-2501. [PMID: 35648218 DOI: 10.1007/s00402-022-04478-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/12/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The aim of our study was to visualize all the windows used in the pararectus approach with detailed cadaver images to facilitate better understanding of orthopedic surgeons and, in addition, was to modify the incision used in the pararectus approach to a more cosmetic bikini incision. MATERIALS AND METHODS In total, 20 cadavers fixed in 10% formalin were used in this study. Of these cadavers, 14 were male and six were female, with a mean age at death of 57 (42-82 years). The four windows were defined as follows in all the cadavers: pubic, quadrilateral, sacroiliac, and iliac windows. RESULTS The most important structure at risk in the pubic window was the corona mortis, as it was observed in 12 (60%) cadavers. In men, the spermatic cord was an important structure at risk in the pubic window. The obturator vessels and nerves were the structures at most risk in the quadrilateral window due to their close location with the quadrilateral surface. The obturator nerve on the medial side and at the entrance of the pelvis through the linea terminalis and lumbosacral truncus were the structures at most risk close to the sacroiliac joint in the sacroiliac window. CONCLUSION This anatomical study includes highly instructive visual shapes and cadaver images for the acetabulum and pelvis, whose anatomical structures are quite complex. We have found that this modified pararectus approach provides excellent access to the internal pelvic rim. CLINICAL RELEVANCE The anatomical data regarding the modified pararectus approach in this study will assist orthopedic surgeons in the surgical management of acetabular and pelvic fractures.
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Affiliation(s)
- Dogan Atlihan
- Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, Istanbul, Turkey.
| | - Mahmud Aydin
- Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Sercan Capkin
- Department of Orthopedics and Traumatology, Aksaray University Education Research Hospital, Aksaray, Turkey
| | - Serkan Surucu
- Department of Orthopedics and Traumatology, University of Missouri Kansas City, Kansas City, USA
| | - Fatih Gunaydin
- Mersin City Training and Research Hospital, Mersin, Turkey
| | - Halil Ibrahim Acar
- Department of Anatomy, Faculty of Medicine, Ankara University, Ankara, Turkey
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Küper MA, Röhm B, Audretsch C, Stöckle U, Höch A, Histing T, Stuby FM, Trulson A, Herath SC. Pararectus approach vs. Stoppa approach for the treatment of acetabular fractures - a comparison of approach-related complications and operative outcome parameters from the German Pelvic Registry. Orthop Traumatol Surg Res 2022; 108:103275. [PMID: 35331921 DOI: 10.1016/j.otsr.2022.103275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/12/2021] [Accepted: 01/28/2022] [Indexed: 02/03/2023]
Abstract
PURPOSE The Pararectus approach has been introduced as an alternative anterior approach to the Stoppa approach in acetabular surgery. There is no evidence which approach should be preferred, especially regarding approach-related complications. Therefore, aim of this registry study was to compare the Pararectus approach to the Stoppa approach regarding complications and quality of reduction. METHODS Patients from the German Pelvic Registry with a surgically treated acetabular fracture, either through the Pararectus approach or the Stoppa approach, were analyzed or compared regarding demographic, clinical and operative parameters. RESULTS In total, 384 patients with an acetabular fracture received a surgical procedure with either the Pararectus approach (n=120) or the Stoppa approach (n=264). There were no differences between the two groups regarding demographic parameters and fracture pattern. The overall complication rate (35.0% vs. 31.4%), the mortality rate (5.0% vs. 3.0%) and the osteosynthesis-associated complication rate (5.8% vs. 4.2%) tended to be higher in the Pararectus group with no statistical significance. There were significantly more anatomical reductions in the Pararectus group (56% vs. 43%; p=0.01). However, operation time was significantly longer in the Pararectus group (255±125 vs. 205±103 minutes; p<0.001). CONCLUSION Despite a longer operation time, the Pararectus approach and the Stoppa approach are equivalently applicable for the treatment of acetabular fractures regarding complication rates and quality of reduction. LEVEL OF EVIDENCE III, retrospective comparative study.
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Affiliation(s)
- Markus A Küper
- Department for Traumatology and Reconstructive Surgery, BG Trauma Center, University of Tübingen, Tübingen, Germany.
| | - Björn Röhm
- Department for General and Visceral Surgery, Havelland Hospitals GmbH, Nauen, Germany
| | - Christof Audretsch
- Department for Traumatology and Reconstructive Surgery, BG Trauma Center, University of Tübingen, Tübingen, Germany
| | - Ulrich Stöckle
- Center for Musculoskeletal Surgery, Charité University Medicine Berlin, Berlin, Germany
| | - Andreas Höch
- Department of Orthopedics, Trauma and Plastic Surgery, University of Leipzig, Leipzig, Germany
| | - Tina Histing
- Department for Traumatology and Reconstructive Surgery, BG Trauma Center, University of Tübingen, Tübingen, Germany
| | - Fabian M Stuby
- Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany
| | - Alexander Trulson
- Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany
| | - Steven C Herath
- Department for Traumatology and Reconstructive Surgery, BG Trauma Center, University of Tübingen, Tübingen, Germany
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Abstract
OBJECTIVES To characterize the location and frequency of the fracture lines and comminution zones of both-column fractures using fracture mapping. METHODS Both-column fractures were retrospectively reviewed in 4 Level 1 trauma centers. Mimics software was used to reconstruct the both-column fractures and simulate the fracture reduction. Then, the fracture lines and the intra-articular and extra-articular comminution zones were drawn on a 3-dimensional innominate bone template. The distribution of fracture lines and fracture fragments were also mapped on the two-dimensional template of the acetabulum. All the included patients were divided into low-variety group and high-variety group according to the anterior column fracture line above or below the anterior superior spine. The anatomical characteristics of the posterior wall fragment were also analyzed in these 2 groups. RESULTS Seventy-eight patients with both-column fracture were included. The T type or inverted Y type main fracture lines divided the innominate bone into low-variety (n = 11) and high-variety (n = 67) both-column fractures. The extra-articular comminution zones are usually distributed between the posterior iliac fragment and anterior column fragment. High-variety type both-column fractures are usually combined with high and sharp posterior wall fragments, whereas low-variety type both-column fractures are usually accompanied by low and flat posterior wall fragments. The comminution zones in the acetabulum are mostly concentrated in the anterior and inferior parts of the acetabulum. CONCLUSIONS The innominate bone is divided into 3 major parts in the both-column fracture, and the fracture center is located at the proximal of the acetabular dome. The both-column fractures are divided into low-variety and high-variety patterns. The location of the anterior column fracture determined the characteristics of the posterior wall fragment.
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Acetabular Peri-Prosthetic Fractures—A Narrative Review. Medicina (B Aires) 2022; 58:medicina58050630. [PMID: 35630047 PMCID: PMC9143047 DOI: 10.3390/medicina58050630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 12/15/2022] Open
Abstract
Acetabular peri-prosthetic fractures are rare but their incidence is rising due to the increased prevalence of total hip arthroplasty, the increasing life expectancy and the growing functional demand of an ageing population, the incidence of primary total hip arthroplasty is increasing. They are either intra-operative or post-operative and have various aetiologies. Several factors such as implant stability, bone loss, remaining bone stock, fracture pattern, timing, age and co-morbidities of the patients must be considered for adequate treatment. To date, the literature on this subject has been sparse and no universally recognized treatment algorithm exists. Their rarity makes them a little-known entity and their surgical management represents a challenge for most orthopaedic surgeons. This review aims to present an update on epidemiology, the diagnostic work up, existing classification systems, surgical approaches and therapeutic options for acetabular peri-prosthetic fractures.
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Liu G, Chen J, Liang C, Zhang C, Li X, Hu Y. The Pararectus approach in acetabular fractures treatment: functional and radiologcial results. BMC Musculoskelet Disord 2022; 23:370. [PMID: 35443641 PMCID: PMC9022322 DOI: 10.1186/s12891-022-05275-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The surgical treatment of complex acetabular fractures is one of the most challenging procedures for orthopedic surgeons. The Pararectus approach, as a reasonable alternative to the existing surgical procedures, was performed for the treatment of acetabular fractures involving the anterior column. This study aimed to evaluate outcome using the Pararectus approach for acetabular fractures involving anterior columns. METHODS Thirty-seven with displaced acetabular fractures involving anterior columns were treated between July 2016 and October 2019 using the Pararectus approach. The functional outcomes (using the Merle d Aubigné and Postel scoring system, WOMAC and modified Harris scoring), the quality of surgical reduction (using the Matta criteria), and postoperative complications were assessed during approximately 26 months follow-up period. RESULTS Thirty-seven patients (mean age 53 years, range: 30-71; 28 male) underwent surgery. Mean intraoperative blood loss was 840 ml (rang: 400-2000 ml) and mean operating time was 210 min (rang: 140-500 min). The modified Merle d Aubigné score was excellent and good in 27 cases (73%), fair in 6 cases (16%), and poor in 3 cases (11%). The mean score was 88.5 (range:77-96) for the modified Harris Hip scores, and 22 (range:7-35) for the WOMAC scores after operation. Postoperative functional outcomes were significantly improved compared with preoperative outcomes (P < 0.0001). The quality of reduction was anatomical in 21 cases (57%), satisfactory in 9 cases (24%), and unsatisfactory in 7 cases (19%). At follow-up, four patients developed a DVT, and heterotopic bone formation was observed in one patient. The hip osteoarthritis was not observed. CONCLUSION The Pararectus approach achieved good functional outcomes and anatomical reduction in the treatment of acetabular fractures involving anterior column with minimal access morbidity.
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Affiliation(s)
- Guoming Liu
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Jinli Chen
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Chengzhi Liang
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Chengdong Zhang
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Xuwen Li
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. China
| | - Yanling Hu
- Department of Orthopedics, Affiliated Hospital of Qingdao University, Qingdao, Shandong, 266003, P.R. 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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Zhou XF, Gu SC, Zhu WB, Yang JZ, Xu L, Fang SY. Quadrilateral plate fractures of the acetabulum: Classification, approach, implant therapy and related research progress. World J Clin Cases 2022; 10:412-425. [PMID: 35097066 PMCID: PMC8771372 DOI: 10.12998/wjcc.v10.i2.412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/29/2021] [Accepted: 12/02/2021] [Indexed: 02/06/2023] Open
Abstract
The quadrilateral plate (QP) is an essential structure of the inner wall of the acetabulum, an important weight-bearing joint of the human body, which is often involved in acetabular fractures. The operative exposure, reduction and fixation of QP fractures have always been the difficulties in orthopedics due to the special morphological structure and anatomical features of the QP. Fortunately, there have been many effective methods and instruments developed for QP exposure, reduction and fixation by virtue of the combined efforts of numerous orthopedists. At the same time, each method presents with its own advantages and disadvantages, resulting in different prognoses. It is necessary to have a thorough understanding of the anatomy, radiology and fixation techniques of the QP in terms of patient prognosis optimization. In this paper, the anatomical features, definition and classification of QP, operative approach selection, implant internal fixation methods and efficacy were reviewed.
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Affiliation(s)
- Xue-Feng Zhou
- Department of Orthopedics, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230000, Anhui Province, China
- Graduate School, Wannan Medical College, Wuhu 241000, Anhui Province, China
| | - Si-Chao Gu
- Department of Orthopedics, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230000, Anhui Province, China
| | - Wan-Bo Zhu
- Department of Orthopedics, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230000, Anhui Province, China
| | - Jia-Zhao Yang
- Department of Orthopedics, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230000, Anhui Province, China
| | - Lei Xu
- Department of Traumatic Orthopedics, The First Affiliated Hospital of USTC, Hefei 230001, Anhui Province, China
| | - Shi-Yuan Fang
- Department of Orthopedics, The First Affiliated Hospital of University of Science and Technology of China, Hefei 230000, Anhui Province, China
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Management of anterior associated types of acetabular fractures utilizing the modified Stoppa and the pararectus approaches: a prospective cohort study and early experience from a level one Egyptian trauma centre. INTERNATIONAL ORTHOPAEDICS 2022; 46:897-909. [PMID: 34994817 DOI: 10.1007/s00264-021-05293-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This study aimed to report the early experience (radiographic, functional, and complications outcomes) from an Egyptian (North African) level one trauma centre after utilizing the modified Stoppa and the pararectus approaches to manage anterior-associated types of acetabular fractures. PATIENTS AND METHODS Between January 2014 and April 2018, 63 patients (40 males and 23 females) with a mean age of 33 ± 11.5 were included, 45 patients were treated through the modified Stoppa (group A), and 18 through the pararectus approach (group B). RESULTS At a mean follow-up of 32.11 ± 15.36 months (range 12 to 64), 56 patients (43 group A and 13 group B) were evaluated. The post-operative anatomical reduction was achieved in 44 (78.6%) patients. At the last follow-up, Matta radiological outcome grades were excellent and good in 50 (89.2%) patients, fair and poor in six (10.8%). The mean Harris Hip Score (HHS) was 92.6 ± 7.6; the mean modified Merle D'Aubigné (MMD) score was 16.5 ± 1.5. Excellent functional outcome was reported in 42 (75.0%) and 25 (44.6%) patients according to HHS and MMD scores, respectively. There are four (7.1%) intra-operative iatrogenic complications (two in each approach), three (5.3%) vascular injuries (two in group B and one in group A), and one (1.8%) bladder injury in group A. CONCLUSION Employing less-invasive anterior approaches for managing anterior associated types of acetabular fractures proved efficiency and safety. Good to excellent radiological and functional outcomes were achieved, with no significant difference between both approaches.
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Comparison of Therapeutic Outcomes of Transabdominal Pararectus Approach and Modified Stoppa Approach in Treating Pelvic and Acetabular Fractures. Indian J Orthop 2022; 56:829-836. [PMID: 35542317 PMCID: PMC9043044 DOI: 10.1007/s43465-021-00585-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 11/29/2021] [Indexed: 02/04/2023]
Abstract
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.
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Küper MA, Ateschrang A, Hirt B, Stöckle U, Stuby FM, Trulson A. Laparoscopic Acetabular Surgery (LASY) - vision or illusion? Orthop Traumatol Surg Res 2021; 107:102964. [PMID: 34033917 DOI: 10.1016/j.otsr.2021.102964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 12/02/2020] [Accepted: 01/13/2021] [Indexed: 02/03/2023]
Abstract
Displaced acetabular fractures usually require open surgical approaches. Aim of this cadaver study was to evaluate a laparoscopic approach to prepare the anterior acetabular column and the quadrilateral plate in analogy to the laparoscopic pelvic lymphadenectomy. The laparoscopic preparation and anatomy is presented and illustrated step by step in a human cadaver followed by a modular plate osteosynthesis of the anterior column involving the quadrilateral plate is performed via a minimally invasive approach using standard laparoscopic instruments. In conclusion we could demonstrate that the laparoscopic preperitoneal preparation of the acetabulum according to the laparoscopic pelvic lymphadenectomy provides more free range for the surgical instruments compared to a previously described total extraperitoneal approach. The development of specific reduction tools and implants is under investigation. Until then, at least the laparoscopic preparation could be introduced in the clinical setting in the near future. TYPE OF STUDY: Technical note - Cadaver study.
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Affiliation(s)
- Markus Alexander Küper
- BG Trauma Center, Department for Traumatology and Reconstructive Surgery, Eberhard Karls University, Tübingen, Germany.
| | - Atesch Ateschrang
- Ev. Stift St. Martin, Department for Orthopedics and Traumatology, Koblenz, Germany
| | - Bernhard Hirt
- Institute of Clinical Anatomy and Cell Analysis, Eberhard Karls University, Tübingen, Germany
| | - Ulrich Stöckle
- Charité University Medicine Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Fabian Maria Stuby
- BG Trauma Center, Department for Traumatology, Orthopedics and Surgery, Murnau am Staffelsee, Germany
| | - Alexander Trulson
- BG Trauma Center, Department for Traumatology, Orthopedics and Surgery, Murnau am Staffelsee, Germany
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Huang H, Xing W, Zeng C, Huang W. Pararectus approach combined with three-dimensional printing for anterior plate fixation of sacral fractures. Injury 2021; 52:2719-2724. [PMID: 32430192 DOI: 10.1016/j.injury.2020.03.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/26/2020] [Accepted: 03/29/2020] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Huajun Huang
- The Third Affiliated Hospital of Southern Medical University(Academy of Orthopedics·Guangdong Province), Guangzhou, Guangdong, 510630, China; Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde), Shunde, Guangdong, 528308, China
| | - Weirong Xing
- Musculoskeletal Disease Center, Jerry L. Pettis Memorial VA Medical Center, Research Service, 11201 Benton St, Loma Linda, CA 92357, USA
| | - Canjun Zeng
- The Third Affiliated Hospital of Southern Medical University(Academy of Orthopedics·Guangdong Province), Guangzhou, Guangdong, 510630, China.
| | - Wenhua Huang
- The Third Affiliated Hospital of Southern Medical University(Academy of Orthopedics·Guangdong Province), Guangzhou, Guangdong, 510630, China; National Key Discipline of Human Anatomy, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510515, China; Guangdong Provincial Key Laboratory of Medical Biomechanics, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510515, China; Guangdong Engineering Research Center for Translation of Medical 3D Printing Application, Guangzhou, Guangdong, 510515, China.
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28
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Yao S, Chen K, Zhu F, Liu J, Wang Y, Zeng L, Wan Y, Qu Y, Yang L, Guo X, Yang X. Internal fixation of anterior acetabular fractures with a limited pararectus approach and the anatomical plates: preliminary results. BMC Musculoskelet Disord 2021; 22:203. [PMID: 33602187 PMCID: PMC7891165 DOI: 10.1186/s12891-021-04034-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/31/2021] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
- Sheng Yao
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Kaifang Chen
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fengzhao Zhu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Liu
- Department of Radiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yulong Wang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lian Zeng
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yizhou Wan
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanzhen Qu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liang Yang
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaodong Guo
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xu Yang
- Department of Orthopaedics, Suizhou Hospital, Hubei university of medicine, Suizhou, China.
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The Quadrilateral Plate in Acetabular Fracture Surgery: What Is It and When Should It Be Addressed? J Am Acad Orthop Surg 2021; 29:e109-e115. [PMID: 33405487 DOI: 10.5435/jaaos-d-20-00080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
The quadrilateral plate (QP) is the relatively flat surface of bone in the true pelvis lying directly medial to the acetabulum. This surface is frequently involved in acetabular fractures. Elderly individuals, in particular, commonly sustain anterior column fractures with incomplete or complete posterior hemitransverse fracture lines with associated QP comminution. If QP fracture lines propagate through the superior weight-bearing surface of the acetabulum, the femoral head may displace medially, leading to poor outcomes if not addressed. Fortunately, the collective work of many orthopaedic surgeons has resulted in numerous effective methods for approaching, reducing, and stabilizing the QP and the diverse family of fractures which affect it. A thorough understanding of the QP, its anatomy, radiology, and techniques for fixation, is required to optimize patient outcomes.
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30
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Khalifa AA. Letter to the editor: Modified Stoppa as an alternative surgical approach for fixation of anterior fracture acetabulum: a randomized control clinical trial. J Orthop Surg Res 2021; 16:96. [PMID: 33514377 PMCID: PMC7847153 DOI: 10.1186/s13018-021-02231-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 01/14/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Ahmed A Khalifa
- Orthopaedic and Traumatolgy Department, Qena Faculty of Medicine and University Hospital, South Valley University, Qena, Egypt.
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31
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Risk of Injury to the Neurovascular Structures in the Pararectus Approach Used in Acetabular Fractures: A Cadaver Study. J Orthop Trauma 2021; 35:e13-e17. [PMID: 32502059 DOI: 10.1097/bot.0000000000001856] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Complex acetabular fractures involving the quadrilateral plate may necessitate infrapectineal buttress plating, which can be performed through the pararectus approach. The aim of this cadaveric study was to identify the anatomical guide points to protect neurovascular structures at the risk of injury during the pararectus approach. METHODS Six fresh frozen cadavers (12 hemipelves) were dissected in this study. Location of the inferior epigastric artery (IEA), obturator nerve and corona mortis (CM) was measured using common anatomic landmarks, namely, anterior superior iliac spine, symphysis pubis (SP), and sacroiliac (SI) joint. RESULTS In the superficial dissection of the abdominal wall, the mean distance between the IEA and anterior superior iliac spine was 106.7 ± 5.2 (range, 99.2-116.4) mm, and the mean distance between IEA and SP was 77.9 ± 3.5 (range, 70.6-82.2) mm. In deep dissection, the mean distance between the SI joint and the SP was 133.1 ± 5.7 (range, 126.0-142.0) mm. The mean distance between the SI joint and ON was 37.3 ± 2.8 (range, 31.0-41.0) mm. The CM was unable to be detected in 2 cadavers, 1 on the right and 1 on the left hemipelves. The mean distance between the CM and SP was 47.7 ± 3.9 (range, 43.0-55.0) mm. CONCLUSIONS A pararectus approach is a useful approach which allows infrapectineal plating in the treatment of complex acetabular fractures; however, the preservation of critical neurovascular structures is essential during dissection. This study is helpful to identify the structures at risk according to commonly used anatomic landmarks. These data might be a necessary guideline for hip and trauma surgeons.
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Pohlemann T, Herath SC, Braun BJ, Rollmann MF, Histing T, Pizanis A. Anterior approaches to the acetabulum: which one to choose? EFORT Open Rev 2020; 5:707-712. [PMID: 33204514 PMCID: PMC7608571 DOI: 10.1302/2058-5241.5.190061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Surgical treatment of acetabular fractures remains challenging even for experienced surgeons. Whilst the ilioinguinal and the Kocher-Langenbeck approach remain the standard procedures to expose the anterior or posterior aspects of the acetabulum, some modified anterior approaches for the stabilization of the acetabulum have been introduced. This article will provide an overview of approaches to the anterior aspect of the acetabulum and explain the efforts that have been made to improve the surgeon’s options for certain fracture modifications, such as fractures with separation of the quadrilateral surface.
Cite this article: EFORT Open Rev 2020;5:707-712. DOI: 10.1302/2058-5241.5.190061
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Affiliation(s)
- Tim Pohlemann
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Steven C Herath
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Benedikt J Braun
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Mika F Rollmann
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Tina Histing
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
| | - Antonius Pizanis
- Department of Trauma, Hand and Reconstructive Surgery, Saarland University Hospital, Homburg, Germany
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Zou R, Wu M, Guan J, Xiao Y, Chen X. Therapeutic Effect of Acetabular Fractures Using the Pararectus Approach Combined with 3D Printing Technique. Orthop Surg 2020; 12:1854-1858. [PMID: 33112031 PMCID: PMC7767683 DOI: 10.1111/os.12738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/09/2020] [Accepted: 06/03/2020] [Indexed: 11/28/2022] Open
Abstract
Objective To explore the clinical efficacy of pararectus approach combined with 3D printing technique for the surgical treatment of partial acetabular fractures. Methods We retrospectively evaluated 33 (20 males and 13 females) patients with acetabular fractures in the period of June 2017 to December 2018. According to Judet and Letournel classification: 11 cases were of anterior column fracture, 10 cases were of double column fracture, seven fractures were of the anterior column with posterior half transverse, three fractures were of transverse fracture, and two cases were of “T” fracture. For all cases, 3D printing is used to print the acetabular model. Pre‐bent reconstruction plates from the model were placed to fixate fractures via the pararectus approach. Results Thirty‐three patients (mean age 48 years; range, 35–63 years), included 20 men and 13 women, were treated successfully with open reduction and internal fixation by the pararectus approach. Surgery duration was 203 min on average (range: 135–245 min), and intra‐operative bleeding was 1030 mL on average (range: 450–1400 mL). All patients were followed‐up for 12–18 months (average,14 months); two patients (6.0%) developed postoperative ossifying myositis, and there are no obvious symptoms at present; one patient (3.0%) developed postoperative wound infection, and the wound completely improved by secretion culture, enhanced dressing, and effective antibiotics; all the acetabular fractures united after 12 to 16 weeks (average,13 weeks). According to the modified Merle d'Aubigne and Postel scoring system to assess the hip function: excellent in 22 cases (66.7%), good in seven cases (21.2%), and fair in four cases (12.1%). Conclusions In the treatment of partial acetabular fractures, the pararectus approach combined with 3D printing technique can achieve effective reduction and fixation, decrease intraoperative hemorrhage, shorten operation time, and the internal fixation position can be properly adjusted during the operation by looking directly at the model.
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Affiliation(s)
- Ruyi Zou
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Min Wu
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Jianzhong Guan
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yuzhou Xiao
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Xiaotian Chen
- Department of Orthopaedics, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
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Bastian JD, Näf DR, Cullmann JL, Keel MJ, Giannoudis PV. Does increased acetabular depth affect safe infra-acetabular screw placement in acetabular fracture fixation? Eur J Trauma Emerg Surg 2020; 47:1319-1326. [PMID: 32728900 PMCID: PMC8476395 DOI: 10.1007/s00068-020-01455-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 07/21/2020] [Indexed: 11/24/2022]
Abstract
Background Infra-acetabular screws enhance the fixation strength in acetabular fractures with separation of both columns. Placement without iatrogenic femoral head violation is challenging. Purpose To assess the impact of the acetabular configuration, the patients’ age and gender on safe infra-acetabulum screw insertion. Methods In 112 patients (69 females; mean age: 34 years, range 17–88; n = 200 hips), the lateral center–edge angle (LCE) was measured on radiographs. Using corresponding axial CT scans the residual distance from (the lateral border) of the screw to (the medial border of) the femoral head (“Screw-to-Femoral Head distance”; “RD_SFH”) was determined. Statistical analysis was carried out using linear regression, multiple linear regression and normal distribution estimation. Results The mean (range) LCE angle was 30° (7°–51°) and the mean (range) “RD_SFH” was 5 mm (1–14 mm). The linear regression model shows a significant linear relation between LCE and “RD_SFH” with a slope parameter of − 0.15 (p value < 0.0001), the Pearson correlation between LCE and “RD_SFH” is − 0.56 (CI [− 0.71, [− 0.40]). Age did not have a significant impact on the relation between LCE and “RD_SFH” (p value 0.85). Compared to male patients, in females, the intercept is 4.62 mm (p value 0.0005) less, the slope parameter is 0.09 (p value 0.029) larger. Conclusion The virtual possibility to place an infra-acetabular screw was given in all patients. An increasing depth of the acetabulum correlated with a decrease in residual distances. As hip joint cartilage thickness was not considered in measurements, intraoperative rule-out of screw mispositioning especially in deep acetabular sockets and females is still of utmost importance.
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Affiliation(s)
- Johannes Dominik Bastian
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland.
| | - David Riccardo Näf
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Jennifer Larissa Cullmann
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Bern, Switzerland
| | - Marius Johann Keel
- Department of Orthopaedic Surgery and Traumatology, Inselspital Bern, Bern University Hospital, University of Bern, Freiburgstrasse 18, 3010, Bern, Switzerland
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Leeds, Leeds, UK
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Küper MA, Konrads C, Trulson A, Bahrs C, Stöckle U, Stuby FM. Complications of surgical approaches for osteosynthesis treatment of acetabular fractures: Analysis of pitfalls and how to avoid them. Injury 2020; 51:984-990. [PMID: 32113739 DOI: 10.1016/j.injury.2020.02.100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 02/19/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Fractures of the acetabulum are rare injuries. The indication for surgical stabilization depends on the grade of instability and dislocation. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of anatomical structures and possible risks of the different approaches, are important. METHODS Over a period of 15 years, we analyzed all patients with acetabular fractures, treated in our Level I Trauma Center with special interest in surgical and approach-related complications. Based on our complication rates, we describe the used different surgical approaches and the accessible anatomical structures respectively. Finally, we focus on strategies to reduce the risk of approach-related complications in acetabular surgery. RESULTS Between January 2003 and December 2017, 523 patients with an acetabular fracture were treated in our Tertiary Referral Hospital. Of these, 101 patients had at least one complication, resulting in an overall complication rate of 19.3%. 296 patients underwent surgical treatment of the acetabular fracture, while 227 patients were treated non-operatively. Surgically treated patients had a significantly higher complication rate of 21.2% (63/296) compared to conservatively treated patients with a complication rate of 16.7% (38/227). Neurovascular and thromboembolic adverse events were the most often complications. CONCLUSIONS Patients with acetabular fractures are at a high risk for different kind of complications. The most common risks are neuro-vascular and thromboembolic incidents. The risk of getting a complication is increased in surgically treated patients, therefore both the indication for surgical treatment and the surgical approach should be carried out carefully, including individual patient parameters and fracture types as well as the surgeons expertise.
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Affiliation(s)
- Markus A Küper
- BG Trauma Center, Department for Traumatology and Reconstructive Surgery, University of Tübingen, Tübingen, Germany.
| | - Christian Konrads
- BG Trauma Center, Department for Traumatology and Reconstructive Surgery, University of Tübingen, Tübingen, Germany
| | - Alexander Trulson
- Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany
| | - Christian Bahrs
- BG Trauma Center, Department for Traumatology and Reconstructive Surgery, University of Tübingen, Tübingen, Germany
| | - Ulrich Stöckle
- Charité University Medicine Berlin, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Fabian M Stuby
- Department of Trauma Surgery, BG Trauma Centre Murnau, Murnau am Staffelsee, Germany
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Küper MA, Trulson A, Minarski C, Stuby F, Stöckle U, Konrads C. Risks and Strategies to Avoid Approach-Related Complications During Operative Treatment of Pelvic Ring or Acetabular Fractures. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 159:144-152. [PMID: 31797336 DOI: 10.1055/a-1023-4756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Injuries of the pelvic ring or the acetabulum are either to be found in young patients with high energy trauma mechanisms or in geriatric patients after simple falls with very low impact energy. The indication for surgical stabilization is given by the grade of instability. Exact knowledge of the different possible surgical approaches is essential for the planning of the surgical treatment. Both, knowledge of reachable anatomical structures and possible risks of the different approaches are important. In this review, we summarize the standard surgical approaches to the pelvic ring and to the acetabulum. We describe the reachable anatomical structures for each approach, approach-related pitfalls, and we focus on strategies to reduce approach-related complications.
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Affiliation(s)
| | - Alexander Trulson
- Department for Trauma and Orthopaedic Surgery, BG Trauma Hospital Murnau
| | | | - Fabian Stuby
- Department for Trauma and Orthopaedic Surgery, BG Trauma Hospital Murnau
| | - Ulrich Stöckle
- Centre for Musculoskeletal Surgery, Charité University Medicine Berlin
| | - Christian Konrads
- Department for Trauma and Reconstructive Surgery, BG Hospital Tubingen
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Soni A, Gupta R, Sen R. Modified Stoppa Approach for Acetabulum Fracture: A Review. Rev Bras Ortop 2019; 54:109-117. [PMID: 31363255 PMCID: PMC6510579 DOI: 10.1016/j.rboe.2017.09.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 09/28/2018] [Indexed: 01/22/2023] Open
Abstract
Fracture acetabulum is a grave injury and a challenge for orthopedic surgeons. Anterior and posterior approaches have been described for fixation of acetabulum fractures. The modified Stoppa approach is considered an alternate to anterior approach, which provides access to pelvis from inside the cavity. The purpose of this article is to review the available literature on use of the modified Stoppa approach in acetabulum fractures. The available data suggest that modified Stoppa approach is useful in anterior acetabulum fractures and some posterior acetabulum fractures, especially where buttressing of medial wall is required.
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Affiliation(s)
- Ashwani Soni
- Departmento de Ortopedia, Government Medical College and Hospital, Chandigarh, India
| | - Ravi Gupta
- Departmento de Ortopedia, Government Medical College and Hospital, Chandigarh, India
| | - Ramesh Sen
- Departmento de Ortopedia, Fortis Hospital Mohali, Sahibzada Ajit Singh Nagar, India
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Kurze C, Keel MJB, Kollár A, Siebenrock KA, Klenke FM. The pararectus approach-a versatile option in pelvic musculoskeletal tumor surgery. J Orthop Surg Res 2019; 14:232. [PMID: 31337419 PMCID: PMC6651940 DOI: 10.1186/s13018-019-1275-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 07/10/2019] [Indexed: 11/21/2022] Open
Abstract
Background Pelvic tumors are usually resected through the utilitarian pelvic incision, an extended ilioinguinal/iliofemoral approach. The pararectus approach, an intrapelvic anatomical approach with extraperitoneal access to the pelvis, has been established previously for the treatment of pelvic and acetabular fractures. However, it has not been used to address pelvic tumors. The study aimed at investigating the feasibility of this approach for pelvic tumor surgery and the possibilities of combining this approach with standard approaches to the hip joint. Methods Thirteen patients that underwent pelvic tumor resections were retrospectively reviewed. Tumor resections were performed through the pararectus (n = 10) or extended pararectus approach (n = 3). In six of those cases, the pararectus approach was combined with extrapelvic approaches including the modified Gibson (n = 4), the Kocher-Langenbeck (n = 1), and the trochanteric flip approach (n = 1). The mean follow-up was 32.6 ± 9.1 months. Results In all cases, the tumor resections were carried out according to the preoperative plan. In seven of 13 cases, wide resections were performed; six of 13 cases were planned close resections. Four cases of major complications were observed (vascular injury, deep infection, iliac vein thrombosis, total hip arthroplasty dislocation). Minor complications were observed in two cases. One tumor recurred locally. At the final follow-up, 10 patients were alive, eight of those without evidence of disease. Conclusion The study demonstrated the suitability of the pararectus approach for pelvic tumor resections. The possibility to combine the approach with standard approaches to the hip joint allowed for single-stage reconstructions of the pelvis and the hip joint without sacrificing surgical margins and function. The pararectus approach is a versatile option adding to the established approaches for musculoskeletal tumor surgery of the pelvis.
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Affiliation(s)
- Christophe Kurze
- Department of Orthopedic Surgery, Inselspital, Bern University Hospital, CH-3010, Bern, Switzerland
| | | | - Attila Kollár
- Department of Medical Oncology, Inselspital, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Klaus Arno Siebenrock
- Department of Orthopedic Surgery, Inselspital, Bern University Hospital, CH-3010, Bern, Switzerland
| | - Frank Michael Klenke
- Department of Orthopedic Surgery, Inselspital, Bern University Hospital, CH-3010, Bern, Switzerland.
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Zhang R, Yin Y, Li S, Jin L, Guo J, Hou Z, Zhang Y. Fixation of Displaced Acetabular Fractures With an Anatomic Quadrilateral Surface Plate Through the Stoppa Approach. Orthopedics 2019; 42:e180-e186. [PMID: 30602047 DOI: 10.3928/01477447-20181227-03] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 08/09/2018] [Indexed: 02/03/2023]
Abstract
Satisfactory fixation for displaced acetabular fractures involving the quadrilateral surface remains difficult to obtain with conventional reconstruction plates. To achieve minimally invasive management of fractures of the quadrilateral surface, the authors designed a type of anatomic quadrilateral surface plate (AQSP). A retrospective study to assess the therapeutic results of the AQSP was performed at their institution. A total of 26 patients with quadrilateral surface fractures fixed with an AQSP through the Stoppa approach from February 2014 to February 2015 were included in this study. There were 16 men and 10 women with a mean age of 37.5 years. The patients were followed for a mean of 28.81 months (range, 24-36 months). The mean operative time was 98.85±16.08 minutes, and the mean intraoperative blood loss was 353.85±124.84 mL. Postoperative radiographs and computed tomography scans showed that anatomic and good reductions were obtained in 88.46% (23 patients) and 11.54% (3 patients) of the patients, respectively. Screw loosening was not observed. All of the fractures healed well at a mean of 3.54 months. Two cases of obturator nerve injury and 1 case of corona mortis rupture were observed. However, permanent complications were not observed. The mean Merle d'Aubigné score at final follow-up was 16.38±1.33 points. The authors conclude that satisfactory fixation with the AQSP system can be achieved through the Stoppa approach. [Orthopedics. 2019; 42(2):e180-e186.].
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Tannast M, Keel MJB, Siebenrock KA, Bastian JD. Open Reduction and Internal Fixation of Acetabular Fractures Using the Modified Stoppa Approach. JBJS Essent Surg Tech 2019; 9:e3. [PMID: 31086721 DOI: 10.2106/jbjs.st.18.00034] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Background The modified Stoppa approach is performed for safe and efficient management of acetabular fractures involving the anterior column. This approach avoids dissection of the inguinal canal, the femoral nerve, and the external iliac vessels as seen in the "second window" of the ilioinguinal approach and has thus been shown to be less invasive than the ilioinguinal approach1. As an intrapelvic approach, it facilitates the management of medial displacement fracture patterns involving the quadrilateral plate and dome impaction that typically occur in the elderly2,3. The reduced morbidity of this approach is of particular relevance for elderly patients who must respond to the stresses of injury and surgery with diminished physiological reserves. Description The specific surgical steps include preoperative planning, patient positioning and setup, a Pfannenstiel incision, superficial and deep dissection, development of the Retzius space and retraction of the bladder, exposure of the superior pubic ramus and iliopectineal eminence, dissection and ligation of a potential corona mortis, exposure of the obturator nerve and vessels, subperiosteal preparation of the pubic ramus with retraction of the external iliac vessels, subperiosteal exposure of the quadrilateral plate with detachment of the internal obturator muscle and exposure of the posterior column, assessment of residual displacement by fluoroscopic views, longitudinal soft-tissue or lateral skeletal traction (optional) for reduction of medial displacement of the femoral head, disimpaction of the acetabular dome fragment and grafting of the supra-acetabular void (optional) under fluoroscopic and arthroscopic (optional) control, and reduction and fixation of extra-articular components (iliac wing posteriorly and pubic ramus anteriorly), the posterior column (infra-acetabular screw), and the quadrilateral plate (buttress plate). Before wound closure, the urine output is checked for occurrence of hematuria, an indication of bladder penetration. The anterior lamina of the rectus sheath is then sutured, and a layered closure performed. Alternatives The ilioinguinal approach might be used instead. Rationale The modified Stoppa approach avoids dissection within the inguinal canal, the second window of the ilioinguinal approach. Therefore, this approach is less invasive and might be an alternative for joint-preserving surgery, especially in the elderly.
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Affiliation(s)
- Moritz Tannast
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Marius J B Keel
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland.,Trauma Center Hirslanden, Clinic Hirslanden, Zürich, Switzerland
| | - Klaus-Arno Siebenrock
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes D Bastian
- Department of Orthopaedic and Trauma Surgery, Inselspital, University of Bern, Bern, Switzerland
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Wang C, Liu H, Lin X, Chen J, Li T, Mai Q, Fan S. A Single Lateral Rectus Abdominis Approach for the Surgical Treatment of Complicated Acetabular Fractures: A Clinical Evaluation Study of 59 Patients. Med Sci Monit 2018; 24:7285-7294. [PMID: 30311603 PMCID: PMC6195786 DOI: 10.12659/msm.911009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background This study aimed to evaluate outcome following a single lateral rectus abdominis surgical approach for complicated acetabular fractures, involving anterior and posterior columns. Material/Methods From January 2012 to March 2016, 59 patients, including 36 anterior column hemitransverse fractures, 18 two-column fractures, and five T-type complicated acetabular fractures, were treated with a single lateral rectus abdominis approach and fixed by plates and cannulated lag screws. Anterior column fractures were fixed with 3.5 mm reconstruction plates; posterior column fractures were fixed with 6.5 mm cannulated lag screws. The quality of surgical reduction (using the Matta criteria), functional outcome (using the modified Merle d’Aubigné and Postel scoring system), and postoperative complications were assessed with 24-month follow-up. Results Fifty-nine patients (mean age, 45 years; range, 18–64 years) including 39 men and 20 women underwent surgery. Mean intraoperative blood loss was 514.6 ml (range, 150–830 ml) and mean operating time was 86.3 min (range, 42–145 min). Anatomical reduction was good in 40 cases (67.8%), fair in 15 cases (25.4%), and poor in four cases (6.8%). The modified Merle d’Aubigné score was excellent in 39 cases (66.1%), good in 14 cases (23.7%), fair in five cases (8.5%), and poor in one case (1.7%). At follow-up, there were five cases of peritoneal damage, eight cases of obturator nerve dysfunction, and four cases of postoperative traumatic arthritis. Conclusions The single lateral rectus abdominis surgical approach for the treatment of complicated acetabular fractures was minimally invasive with good anatomical exposure and good outcomes.
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Affiliation(s)
- Canbin Wang
- Department of Traumatic Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Han Liu
- Department of Traumatic Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Xuezhi Lin
- Department of Traumatic Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Jiahui Chen
- Department of Traumatic Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Tao Li
- Department of Traumatic Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Qiguang Mai
- Department of Traumatic Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China (mainland)
| | - Shicai Fan
- Department of Traumatic Orthopaedics, The Third Affiliated Hospital of Southern Medical University, Guangzhou, Guangdong, China (mainland)
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von Rüden C, Wenzel L, Becker J, Thannheimer A, Augat P, Woltmann A, Bühren V, Perl M. The pararectus approach for internal fixation of acetabular fractures involving the anterior column: evaluating the functional outcome. INTERNATIONAL ORTHOPAEDICS 2018; 43:1487-1493. [PMID: 30215099 PMCID: PMC6525136 DOI: 10.1007/s00264-018-4148-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 09/06/2018] [Indexed: 12/21/2022]
Abstract
Introduction Aim of this retrospective analysis of prospectively collected data was to evaluate the functional mid-term outcome two years after open reduction and internal fixation of acetabular fractures involving the anterior column with affection of the quadrilateral plate using the pararectus approach on a large cohort. Method Fifty-two patients (12 female, 40 male) with a median age of 55 (range 18–90) years and displaced acetabular fractures involving the anterior column were surgically treated in a single level I trauma centre between July 2012 and February 2016 using the pararectus approach. Thirty-four patients (8 female and 26 male) with a median age of 58 (range 20–85) years were available for complete clinical follow-up at regular intervals, finally 24 months post-operatively. Functional outcome was evaluated according to modified Merle d’Aubigné score, Lower Extremity Functional Scale, WOMAC, and SF-36. Results Range of time between trauma and surgical treatment was three (range 0–19) days. Operation time was 140 (range 60–240) minutes, and duration of hospital treatment was 19 (range 7–38) days. Functional results in 34 patients available for final follow-up demonstrated 68 points (median; range 39–80) according to the Lower Extremity Functional Scale, 6% according to the WOMAC (mean; SD ± 14.5%), and 69% (mean; SD ± 20.1%) according to the SF-36. The modified Merle d’Aubigné score was excellent in 22 patients, good in eight patients, and fair in four patients. Discussion/conclusion Based on the good to excellent functional mid-term follow-up results of this study, the pararectus approach can be recommended as sufficient alternative single access to address displaced acetabular fractures involving the anterior column, independent of patients’ age.
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Affiliation(s)
- Christian von Rüden
- Department of Trauma Surgery, BG Trauma Centre Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany. .,Institute of Biomechanics, BG Trauma Centre Murnau, Murnau, Germany. .,Institute of Biomechanics, Paracelsus Medical University, Salzburg, Austria.
| | - Lisa Wenzel
- Department of Trauma Surgery, BG Trauma Centre Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Johannes Becker
- Department of Trauma Surgery, BG Trauma Centre Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Andreas Thannheimer
- Department of Trauma Surgery, BG Trauma Centre Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Peter Augat
- Institute of Biomechanics, BG Trauma Centre Murnau, Murnau, Germany.,Institute of Biomechanics, Paracelsus Medical University, Salzburg, Austria
| | - Alexander Woltmann
- Department of Trauma Surgery, BG Trauma Centre Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Volker Bühren
- Department of Trauma Surgery, BG Trauma Centre Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
| | - Mario Perl
- Department of Trauma Surgery, BG Trauma Centre Murnau, Professor Küntscher Str. 8, 82418, Murnau, Germany
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Abstract
Background Even 50 years after the introduction of the extrapelvic ilioinguinal approach for open reduction and internal fixation of acetabular fractures involving predominantly the anterior column, this approach is still acknowledged as being the so-called gold standard1. The pattern of acetabular fractures has changed within the last 10 to 20 years2,3, with a greater prevalence of quadrilateral plate fractures that is due in part to the increase in elderly trauma. The intrapelvic approach, also called the modified Stoppa approach4-6, was introduced as a less invasive alternative to the extrapelvic ilioinguinal approach, mostly combined with the first window of the ilioinguinal approach. The Pararectus approach also offers intrapelvic surgical access and has demonstrated safe surgical dissection with enhanced exposure and favorable outcome compared with the Stoppa approach7-10. Description The skin incision runs along the lateral border of the rectus abdominis muscle to develop the anterior rectus sheath. The retroperitoneal space lateral to the rectus abdominis muscle is entered and the inferior epigastric vessels and the round ligament in females or the spermatic cord in males are identified. The superior pubic ramus and the iliopectineal eminence are exposed. If the corona mortis vessels (a vascular anastomosis between the obturator vessels and the external iliac artery) are present, they are ligated. The obturator nerve and vessels are exposed. The dissection is then directed posteriorly under retraction of the external iliac vessels with further subperiosteal exposure of the pubic ramus, the quadrilateral plate, and the posterior column. Any nonessential iliolumbar vessels are ligated. Residual displacement is assessed with fluoroscopic views. For reduction of a medially displaced femoral head, longitudinal extremity soft tissue or lateral skeletal traction (optional), with a Schanz pin in the greater trochanter, is used. For disimpaction of acetabular dome fragments and grafting of a supra-acetabular void (optional), a fluoroscopy unit is used to assess reduction and identify the void; in addition, arthroscopy can be used. The scope is introduced through the fracture gap to check for reduction without any water or specific setup. For reduction and fixation of extra-articular components (iliac wing posteriorly and superior pubic ramus anteriorly), the posterior column, and the quadrilateral plate, the fluoroscopy unit is used. The anterior lamina of the rectus sheath is sutured, and a layered closure performed. Alternatives The ilioinguinal or modified Stoppa approach might be used instead. Rationale The Pararectus approach combines the advantages of the ilioinguinal approach and the Stoppa approach. The Pararectus approach facilitates surgical access directly above the hip joint, which is comparable with the access obtained through the second window of the ilioinguinal approach, but without dissection of the inguinal canal. Moreover, the Pararectus approach provides intrapelvic visualization that is at least equivalent to that offered by the Stoppa approach but without losing any direct access to the hip joint.
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Affiliation(s)
- Marius J B Keel
- Department of Orthopaedic and Trauma Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Trauma Center Hirslanden, Clinic Hirslanden, Zürich, Switzerland
| | - Klaus-Arno Siebenrock
- Department of Orthopaedic and Trauma Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Moritz Tannast
- Department of Orthopaedic and Trauma Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes D Bastian
- Department of Orthopaedic and Trauma Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Baumann F, Schmitz P, Mahr D, Kerschbaum M, Gänsslen A, Nerlich M, Worlicek M. A guideline for placement of an infra-acetabular screw based on anatomic landmarks via an intra-pelvic approach. J Orthop Surg Res 2018; 13:77. [PMID: 29631637 PMCID: PMC5892032 DOI: 10.1186/s13018-018-0786-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 03/25/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Due to demographic changes, more and more fracture patterns involving anterior acetabular structures occur. The infra-acetabular screw is seen a useful tool to increase stability in fixation of the acetabular cup. However, the exact position of this screw in relation to anatomic landmarks which are intra-operatively palpable via an intra-pelvic approach has not yet been determined. METHODS This biomorphometric experimental study references the ideal screw position of an infra-acetabular screw to anatomic landmarks palpable via an intra-pelvic approach. Therefore, we created a computer tomography-based 3D-model of 40 patients (20 women, 20 men) who received a computer tomography (CT) scan of the pelvis for any other reason than an acetabular fracture. RESULTS The entry point of an ideal infra-acetabular was of high constancy. At mean, this point was 10.2 mm caudal and 10.4 mm medial of the ilio-pubic/ilio-pectineal eminence. This reference is independent of age, gender, or physical dimensions. However, we found gender-dependent differences for the angulation and the length of the screw. CONCLUSIONS This study provides a comprehensive guideline to determine the ideal entry point for an infra-acetabular screw via an intra-pelvic approach. The entry point is located 10.2 mm caudal and 10.4 mm medial of the ilio-pubic/ilio-pectineal eminence. TRIAL REGISTRATION Clinical Trial Registry University of Regensburg Z-2017-0930-1 . Registered 04. Dec 2017.
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Affiliation(s)
- Florian Baumann
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany.
| | - Paul Schmitz
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Daniel Mahr
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Axel Gänsslen
- Clinic for Trauma Surgery, Orthopedics and Hand Surgery, Klinikum Wolfsburg, Wolfsburg, Germany
| | - Michael Nerlich
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
| | - Michael Worlicek
- Department of Trauma Surgery, Regensburg University Medical Center, 93042, Regensburg, Germany
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Chana-Rodríguez F, Cuervas-Mons M, Rojo-Manaute J, Mora F, Arnal J, Vaquero-Martín J. Ultrasound-guided supra-acetabular pin placement in pelvic external fixation: description of a surgical technique and results. Injury 2017; 48 Suppl 6:S66-S74. [PMID: 29162245 DOI: 10.1016/s0020-1383(17)30797-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Pelvic fracture in trauma patients can lead to hemodynamic instability. External fixation is a treatment capable of stabilizing these injuries in the context of damage control surgery. Supra-acetabular pin offers the greater biomechanical stability but requires the use of intraoperative fluoroscopy. The aim of this study was to analyze our results for an ultrasound-guided supra-acetabular pinning. MATERIAL AND METHODS Cross-sectional study with cadaveric specimens. Ultrasound-guided pin placement assessed by fluoroscopy and dissection. RESULTS Fourteen ultrasound-guided supra-acetabular pins were placed in seven cadaveric specimens. Excellent placement in all cases, evaluated with radiological control. Good qualitative bone fixation after dissection. One femoral cutaneous nerve was not found during anatomic dissection and was assumed injured. CONCLUSION Ultrasound-guided supra-acetabular pin placement is a feasible and effective technique. Our study indicates that pin placement without intraoperative fluoroscopy is feasible without compromising the reliability of its placement.
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Affiliation(s)
- Francisco Chana-Rodríguez
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain.
| | - Manuel Cuervas-Mons
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - José Rojo-Manaute
- Department of Traumatology and Orthopaedic Surgery, Medcare Orthopaedics and Spine Hospital, Dubai, United Arab Emirates
| | - Félix Mora
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Juan Arnal
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Javier Vaquero-Martín
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, C/Doctor Esquerdo, 46, 28007, Madrid, Spain
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Tosounidis T, Aderinto J, Giannoudis PV. Pipkin Type-III fractures of the femoral head: Fix it or replace it? Injury 2017; 48:2375-2378. [PMID: 29061440 DOI: 10.1016/j.injury.2017.10.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Affiliation(s)
- Theodoros Tosounidis
- Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds, UK
| | - Joseph Aderinto
- Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedics, Floor D, Clarendon Wing, LGI, University of Leeds, Leeds, UK; NIHR Leeds Biomedical Research Center, Chapel Allerton Hospital, Leeds, UK.
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Dumont CE, Keel MJ, Djonov V, Haefeli PC, Schmid T, Olariu R, Cullmann JL, Bastian JD. The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest. Injury 2017; 48:2169-2173. [PMID: 28823386 DOI: 10.1016/j.injury.2017.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/05/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The feasibility of harvesting a vascularized iliac crest utilizing the Pararectus approach was assessed in cadavers and then this new technique was implemented in a clinical case. METHODS Bilaterally in five cadavers the branches of both external iliac arteries were injected with colored silicone to assess their position to each other and to harvest a bone graft vascularized by the deep circumflex iliac artery (DCIA) through the Pararectus approach. This technique was implemented in a 68-years-old female patient, initially admitted to a level-I-trauma center after sustaining multiple injuries by falling from great height. For definitive treatment of a severely contaminated medially open (Gustilo-Anderson Type 3A) calcaneal luxation fracture (Sanders type IIIBC) in this patient a vascularized iliac crest autograft harvest by the Pararectus approach was used for reconstructive surgery. RESULTS The DCIA and the deep inferior epigastric vessels (DIEV: vascularizing the rectus abdominis muscle and main pedicle of the inferiorly based rectus abdominis myocutaneous flap) are very close on the lateral and medial border of the external iliac artery, respectively. As a consequence, the retrograde dissection of the DIEV towards the DCIA through the Pararectus approach made the dissection of the vascularized iliac crest more amenable, preserving both the lateral femoral cutaneous and the genitofemoral nerves. Four months after the surgery the patient was able to fully weight-bear in orthopedic shoes. Radiographs and CT scans showed correct hind foot alignment and bony integration of the vascularized iliac crest graft into the residual calcaneal body. CONCLUSION The Pararectus approach allowed for secure collection of large vascularized iliac grafts. The presented technique was successful as a salvage procedure in a clinical case with substantial bone loss after an open calcaneal fracture.
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Affiliation(s)
- C E Dumont
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - M J Keel
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - V Djonov
- Institute of Anatomy, University of Bern, Switzerland
| | - P C Haefeli
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - T Schmid
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland
| | - R Olariu
- Department of Plastic and Hand Surgery, University of Bern, Inselspital, Switzerland
| | - J L Cullmann
- Department of Diagnostic, Interventional and Paediatric Radiology, University of Bern, Inselspital, Switzerland
| | - J D Bastian
- Department of Orthopaedic and Trauma Surgery, University of Bern, Inselspital, Bern, Switzerland.
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Secure Screw Placement in Management of Acetabular Fractures Using the Suprapectineal Quadrilateral Buttress Plate. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8231301. [PMID: 28698880 PMCID: PMC5494112 DOI: 10.1155/2017/8231301] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/21/2017] [Indexed: 11/30/2022]
Abstract
Acetabular fractures involving predominantly the anterior column associated with a disruption of the quadrilateral surface can be treated with instrumentation implementing the stabilization of the quadrilateral surface. The recently introduced suprapectineal quadrilateral buttress plate is specifically designed to prevent secondary medial subluxation of the femoral head, especially in elderly patients with reduced ability for partial weight bearing. Whereas there are guidelines available for safe screw fixation for the anterior and posterior columns, there might be a concern for intra-articular placement of screws placed through the infrapectineal part of the quadrilateral buttress plate. Within this report we analyzed retrospectively screw placement in 30 plates in postoperative CT scans using algorithms for metal artifact reduction. None of the screws of the buttress plate penetrated the hip joint. We describe the placement, length, and spatial orientation of the screws used for fracture fixation and suggest that the use of intraoperative image intensifiers with a combined inlet-obturator view of 30–45° best projects the screws and the hip joint. Preoperative knowledge of approximate screw placement and information for accurate intraoperative imaging may contribute to safe acetabular fracture fixation and may reduce operating time and limit radiation exposure to the patient and the personnel. This trial is registered with KEK-BE: 266/2014.
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Abstract
The effective management of articular impacted fractures requires the successful elevation of the osteochondral fragment to eliminate joint incongruency and the stable fixation of the fragments providing structural support to the articular surface.The anatomical restoration of the joint can be performed either with elevation through a cortical window, through balloon-guided osteoplasty or direct visualisation of the articular surface.Structural support of the void created in the subchondral area can be achieved through the use of bone graft materials (autologous tricortical bone), or synthetic bone graft substitutes.In the present study, we describe the available techniques and materials that can be used in treating impacted osteochondral fragments with special consideration of their epidemiology and treatment options. Cite this article: EFORT Open Rev 2017;2. DOI: 10.1302/2058-5241.2.160072. Originally published online at www.efortopenreviews.org.
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Affiliation(s)
- Ippokratis Pountos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK
| | - Peter V. Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, and NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, LS7 4SA Leeds, West Yorkshire, Leeds, UK
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