Anterior approach to the sacroiliac joint for pelvic ring fractures: Technical note

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

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

Division of the iliac vessels in the anterior intrapelvic approach to acetabular fracture

INTRODUCTION

The modified Stoppa approach is gradually becoming the gold standard in pelvic ring and acetabulum surgery. One of the potential intraoperative complications is vascular injury. The aim of this study was to identify the level of division of common iliac vessels with respect to a bone landmark, their inter-individual variability and their correlation with morphological criteria.

MATERIAL AND METHODS

This was a single-center continuous retrospective study of patients who had preoperative CT angiography for pelvic fracture between February 2017 and May 2018. The level of arterial and venous division and the angle of vein division were measured bilaterally for each patient from the most antero-inferior part of the sacroiliac joint on multiplanar reconstruction and standardized analysis. Relationships with morphological data (age, gender, BMI, height), anterior column fracture and deep venous thrombosis were analyzed.

RESULTS

The right arterial division level was 50±16mm (-2.35; 96) from the landmark and the left arterial division level 44±14mm (0; 80). The right venous division level was 30±12mm (-9; 75) and the left venous division level 30±13mm (-5; 66). The right venous bifurcation angle was 65±18° (22; 119) and the left venous bifurcation angle 68±17° (18; 117). The arterial division level was significantly higher on the right side (p=0.007). There were no significant correlations with morphological data.

CONCLUSION

The great inter-individual variability of iliac vessels should prompt analysis of their morphology on routine imaging when planning pelvic surgery using the modified Stoppa approach, in order to anticipate the risk of bleeding.

LEVEL OF EVIDENCE

IV; cases series.

Critical distance of the sacroiliac joint for open reduction using screw fixation for traumatic sacroiliac joint diastasis: a retrospective study

BACKGROUND

Osteosynthesis for sacroiliac joint (SIJ) diastasis using an iliosacral screw (ISS) and a trans-iliac-trans-sacral screw (TITSS) can be performed using a closed or an open method. However, no clear indication for open reduction has been established.

METHODS

Data on patients with unilateral traumatic SIJ diastasis who underwent ISS and TITSS fixation were retrospectively collected and separated into groups according to the reduction method: closed reduction group (C group) and open reduction group (O group). Demographic data and perioperative image assessments were compared between the groups. The critical distance of the SIJ was identified to elucidate the indication for open reduction of the diastatic SIJ.

RESULTS

Fifty-six patients met the inclusion criteria over a 3-year period. There was no significant difference in the reduction quality of pelvic ring injuries between the groups, according to Matta's and Lefaivre's criteria. The improvement in the SIJ distance was significantly greater in the O group than in the C group in the axial plane on multiplanar computed tomography (p = 0.021). This model predicted that a difference of > 3.71 mm between the injured and healthy SIJ was a recommended indication for open reduction, with an area under the curve of 0.791 (95% confidence interval 0.627-0.955, p = 0.004).

CONCLUSIONS

Open reduction for SIJ diastasis might achieve better reduction quality than does closed reduction in the axial plane in selected cases. When the difference between the injured and healthy SIJ was wider than 3.71 mm, open reduction was recommended for satisfactory radiological outcomes.

Efficacy and safety of pararectus approach for the treatment of acetabular fractures: A systematic review and meta-analysis

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.

Crescent Fracture of the Pelvis: A Case Report

Crescent fractures are a rare type of pelvic injury. They result from a lateral compression force and are rotationally unstable. The following is a case of a young male who suffered a crescent fracture on the right side of the pelvis and was treated for the same. These fractures, being rare and complex, need to be managed in accordance with other injuries sustained by the patient and also need fixation for a better functional outcome.