Azetabulumchirurgie

[The pararectus approach: surgical procedure for acetabular fractures]

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.

[Osteosynthesis of geriatric acetabular fractures]

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.

[Techniques and results of primary hip arthroplasty in geriatric acetabular fractures]

As a result of demographic changes, there is an increase in geriatric acetabular fractures [1, 2]. Geriatric patients often have comorbidities, such as pre-existing coxarthritis, reduced bone quality or limited compliance, which makes injury-adapted follow-up treatment difficult [3]. As a result joint-preserving interventions often fail at an early stage, so that hip arthroplasty is necessary in the short term. The 1‑year mortality after surgically stabilized acetabular fractures is 8.1%, a significant increase by a factor of 4 compared to the age group [4]. This illustrates that differentiated criteria for the indication of joint-preserving surgery versus arthroplasty are necessary to avoid reoperations and complications. Criteria for the indications for primary arthroplasty are fracture type, pre-existing coxarthritis, poor bone quality, limited compliance and patient age (> 75 years) [5, 6].In the following article, three treatment strategies for geriatric acetabular fractures and periprosthetic acetabular fractures are presented; the 1‑stage prosthesis implantation without osteosynthesis, the 1‑stage prosthesis implantation with osteosynthesis and the 2‑stage approach with limited osteosynthesis and early total arthroplasty. The advantages and disadvantages of these options are presented based on cases and the various aspects of the treatment. The treatment of geriatric acetabular fractures is an operative challenge for the surgeon and requires a high level of expertise in both special trauma surgery and revision arthroplasty and thus represents a special interface in the fields of orthopedics and trauma surgery.