The Pararectus Approach in Acetabular Surgery: Radiological and Clinical Outcome

Developing a core outcome set for acetabular fractures: a systematic review (part I)

BACKGROUND

There are indications that clinical studies investigating the surgical treatment of acetabular fractures assess different outcomes. This heterogeneity reduces the comparability of study results and, thus, limits the knowledge generated from research. Core outcome sets (COS) contain a minimum set of outcomes that should be measured in studies investigating a specific disease or injury. A COS for surgically treated acetabular fractures does not yet exist. Therefore, the aim of this study is to identify the reported outcomes in studies investigating the surgical treatment of acetabular fractures.

METHODS

Studies including skeletally mature individuals (≥ 16 years) with isolated acetabular fractures treated surgically were included. Studies with polytrauma patients, pathological fractures, additional pelvic fractures, exclusively non-surgical treatment, or juvenile individuals were excluded. Three databases and two clinical trial registries were searched on 15 November 2022. The identified outcomes were grouped and subsequently categorized according to the Core Outcome Measures in Effectiveness Trials Guidelines.

RESULTS

A total of 193 studies were included, which reported a cumulative total of 2581 outcomes. After grouping, 266 unique outcomes were identified. No outcome was examined in all studies. Pain, ability to walk independently, range of motion, quality of reduction, and heterotopic ossification were the most reported unique outcomes and assessed in at least 60% of included studies. A total of 105 outcomes were only assessed in one of the included studies. Outcomes of all five core areas and 25 outcome domains of the Core Outcome Measures in Effectiveness Trials taxonomy were examined. Furthermore, outcomes were named and defined differently, measured at different time points, and assessed using a variety of measurement instruments.

CONCLUSION

Overall, this systematic review shows that a wide range of outcomes are measured in studies examining surgical treatment of acetabular fractures. The results of this systematic review will be used in a subsequent study to develop the COS for surgically treated acetabular fractures by using the Delphi method.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022357644; COMET: 2123.

Comparative evaluation and ranking of anterior surgical approaches for acetabular fractures: A systematic review and network meta-analysis

BACKGROUND

To compare the outcome of pararectus, ilioinguinal, and intrapelvic approaches in patients with acetabular fracture and to rank the best, second best, and third best surgical approach.

METHODS

A literature search was conducted in PubMed, Epistemonikos, and Embase up to 30 November 2024. A network meta-analyses was conducted to assess the outcomes of pararectus, ilioinguinal, and intrapelvic surgical approaches. Random-effects models with mean differences (MDs) and odds ratios (ORs) were calculated for continuous and binary variables, respectively, all with 95 % confidence intervals (CIs).

RESULTS

A total of 30 primary studies (2,348 patients) were included. There was no statistically significant difference between the pararectus and intrapelvic approach in overall complications (OR 0.86, 95 % CI 0.47 to 1.58). The pararectus approach had 0.51 lower odds for overall complications compared with the ilioinguinal approach (OR 0.51, 95 % CI 0.28 to 0.94). The intrapelvic approach had 0.59 lower odds for overall complications compared with the ilioinguinal approach (OR 0.59, 95 % CI 0.37 to 0.94). There was no statistically significant difference between the pararectus and intrapelvic approach in reduction quality (OR 1.32, 95 % CI 0.89 to 1.95). The pararectus approach had 2.02 higher odds for reduction quality compared with the ilioinguinal approach (OR 2.02, 95 % CI 1.30 to 3.15). The intrapelvic approach had 1.53 higher odds for reduction quality compared with the ilioinguinal approach (OR 1.53, 95 % CI 1.12 to 2.10). There was no statistically significant difference between the pararectus and intrapelvic approach in intraoperative blood loss (MD -31.38, 95 % CI -105.62 to 42.85). The pararectus approach had a 207.35 mL lower intraoperative blood loss compared with the ilioinguinal approach (MD -207.35, 95 % CI -288.52 to -126.18). The intrapelvic approach had a 175.97 mL lower intraoperative blood loss compared with the ilioinguinal approach (MD -175.97, 95 % CI -233.51 to -118.42).

CONCLUSION

This is the first study to rank the three anterior surgical approaches for acetabular fractures. The findings establish that while the pararectus and intrapelvic approaches are comparable, the ilioinguinal approach ranks third. The superior outcomes of the pararectus and intrapelvic approaches in complications, operative efficiency, and reduction quality highlight their importance in surgical practice.

Comparative analysis of surgical approaches in acetabular fractures: Blood loss and procedural efficiency

Background

Acetabulum fractures pose significant challenges in orthopedic trauma due to anatomical complexity and the potential for iatrogenic injury to surrounding structures. The study aims to compare the outcomes of two surgical approaches, the ilioinguinal approach (IA) and the modified Stoppa approach (MSA), in managing acetabular fractures.

Methods

A retrospective cohort study was conducted on 50 patients with anterior acetabular fractures. Demographic characteristics and perioperative data were collected, and the patients were categorized based on the applied surgical approach, either IA or MSA. Statistical tests were used for data analysis.

Results

The MSA group showed significantly lower intraoperative blood loss compared to IA (MSA: 404.36 ± 151.94 ml, IA: 650.92 ± 136.33 ml, Δ = 246.56 ml, P < 0.001). The mean procedure duration for MSA was 141.88 ± 27.12 min, compared to 172.24 ± 32.69 min for IA (P = 0.37). The incidence of soft tissue infection (MSA: 8 %, IA: 8 %) and sciatic nerve injury (both 0 %) exhibited no significant differences (P > 0.99). Postoperative assessments, Harris Hip Scores (MSA: 90.08 ± 6.26, IA: 89.29 ± 6.64, P = 0.66) and Modified Merle d'Aubigné Scores (MSA: 14.86 ± 1.37, IA: 15.23 ± 1.16, P = 0.40), showed no substantial variance between groups.

Conclusion

The study suggests that the MSA approach demonstrated superiority, particularly due to significantly less intraoperative blood loss. Further comprehensive studies are recommended to validate and generalize these findings.

Anterior extrapelvic approaches to the acetabulum

Anterior approaches to the acetabulum can be distinguished into extrapelvic, intrapelvic and combined extrapelvic and intrapelvic approaches. Historically, the extrapelvic ilioinguinal approach was introduced in the French, English and German literature during the late 60s and became gradually the Gold-standard in treating anterior acetabular fractures. In the meantime, the intrapelvic approach, introduced by the Helsinki group, is favored by many surgeons with ongoing interest allowing direct antero-medial access to the true pelvis below the linea terminalis, to the quadrilateral plate and medial side of the posterior column. More recently, more supero-medial approaches, allowing access to the large and true pelvis have been developed, e.g. the Pararectus approach. The historical development, the value and approach-related results of the ilioinguinal approach are analyzed and discussed.

A systemic review and meta-analysis of pararectus versus ilioinguinal approach for the management of acetabular fractures

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.

[Possibilities and limits of intraoperative 2D imaging in trauma surgery]

BACKGROUND

The two-dimensional (2D) imaging represents an essential and cost-effective component of intraoperative position control in fracture stabilization, even in the era of new three-dimensional (3D) imaging capabilities.

OBJECTIVE

The aim of the present study, in addition to a current literature review, was to examine whether the intraoperative use of 2D images leads to a quality of fracture reduction comparable to postoperative computed tomographic (CT) analysis including 3D reconstructions.

MATERIAL AND METHODS

A comparative retrospective analysis of intraoperative 2D and postoperative 3D image data was performed on 21 acetabular fractures stabilized via a pararectus approach according to an established protocol using the Matta criteria.

RESULTS

The assessment of fracture reduction in intraoperative fluoroscopy compared with postoperative CT revealed a difference only in one case with respect to the categorization of the joint step reduction in the main loading zone.

CONCLUSION

In the intraoperative use of 2D imaging for fracture treatment it is important to select the correct adjustment planes taking the anatomical conditions into account in order to achieve optimum assessability. In this way, the reduction result can be adequately displayed in fluoroscopy and is also comparable to the postoperative CT control. In addition, depending on the findings, optional intraoperative dynamic fluoroscopic assessment can have a direct influence on the further surgical procedure.

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.

Treatment of Anterior Dislocation of the Sacroiliac Joint via the Lateral-rectus Approach: Surgical Techniques and Preliminary Outcomes

OBJECTIVE

Anterior dislocation of the sacroiliac joint (ADSIJ) is caused by strong violence, and because of its low morbidity, there are no standardized diagnostic and therapeutical guidelines at this moment. This study aims to explore the surgical techniques and preliminary outcomes of the lateral-rectus approach (LRA) for treating ADSIJ.

METHODS

A retrospective study was conducted of 15 patients with ADSIJ from January 2016 to January 2021. The patients' age ranged from 1.8 years old to 57 years old (37 ± 18 years old). All patients underwent open reduction and internal fixation (ORIF) through the LRA. Eight patients were combined with lumbosacral plexus injury and underwent neurolysis during operation. Patients' fracture type, mechanism of injury, associated injuries, operation time and intraoperative bleeding volume were accessed by reviewing medical history. Quality of fracture reduction was evaluated with the Matta score. At 1-year follow-up, the functional rehabilitation was evaluated by the Majeed rehabilitation criteria. For those with lumbosacral plexus injury, the neuromotor function was evaluated using muscle strength grading proposed by the British Medical Research Council (BMRC) and recovery was recorded.

RESULTS

All 15 patients underwent the operation successfully. The surgical time ranged from 70 to 220 min (126 ± 42 min), and the intraoperative blood loss ranged from 180 to 2000 mL (816 ± 560 mL). Eighty percent of the cohort (12/15) were rated as excellent and good in the Matta score for fracture reduction quality after operation without surgical incision-related complications. At 1-year follow-up, the overall excellent and good rate was 73.3% (11/15) according to the Majeed criteria, the neuromotor function recovered completely in six cases and partially in two cases according to the BMRC muscle strength grading, and the recovery of sensory function was evaluated as excellent in six cases, good in one case and poor in one case, with an overall excellent and good rate of 87.5%.

CONCLUSION

The LRA can well expose the surrounding structures of the sacroiliac joint from the front, which helps surgeons reduce and fix the anterior dislocation of the sacroiliac joint under direct vision and effectively decompress the entrapment of the lumbosacral plexus to achieve better clinical efficacy.

The anterior transmuscular intrapelvic approach for the treatment of acetabular fractures-a new anterior surgical strategy

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.

Exploration of the Extraperitoneal Approach for Single-Level Anterior Lumbar Interbody Fusion: Imaging, Anatomical and Clinical Research

Background

To explore extraperitoneal approach as an optimal option for reducing peritoneal disruption at a single-level disc in anterior lumbar interbody fusion (ALIF).

Methods

First, abdominal axial CT images obtained from 111 patients were observed to evaluate the distribution of extraperitoneal fat at L2-S1 and measure the lateral distances between the midline and the lateral borders of the rectus and the extraperitoneal fat for each disc level. Second, eight embalmed corpses were dissected along the lateral border of the rectus to expose the peritoneum, which was then separated laterally and medially to evaluate the distribution of fat and peritoneum adhesion. Finally, a total of 58 patients were selected for ALIF. For L2-L4 discs and L4-S1, the pararectus approach and the paramedian approach were utilized, respectively.

Results

Extraperitoneal fat was observed behind the rectus at the L5-S1 and the lateral distance between the fat and midline and the lateral border of the rectus gradually decreased on both sides of L2-5. On the cranial side of the arcuate line, it was easier to separate the peritoneum outward along the lateral edge of the rectus. When bluntly dissected medially, the peritoneum was closely adhered to abdominal wall. No complications such as peritoneal damage, retroperitoneal hematoma and neurological complications occurred in 58 patients undergoing the aforementioned surgical methods.

Conclusions

For L4-S1, the paramedian approach is the optimal technique to expose the disc, whereas the pararectus approach is the feasible surgical method at L2-4.

[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.

Pararectus Approach in Acetabular Fractures in Patients Older Than 65 years. Is it Possible to Improve the Technique?

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.

[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.

Treatment of Delayed Acetabular Fractures by Periacetabular Osteotomy through the Lateral-Rectus Approach

OBJECTIVE

There has been a controversy in the surgical approach for delayed acetabular fracture. The objective of the present study is to investigate the feasibility, surgical techniques, safety, and efficacy of periacetabular osteotomy using the single lateral-rectus approach (LRA) for the surgical treatment of delayed acetabular fracture.

METHODS

The retrospective study included 22 patients (16 males and six females, with an average age of 45 years) with delayed acetabular fractures from June 2012 to June 2019. For all cases, periacetabular osteotomy was performed through the single LRA. Fracture classification, mechanism of injury, associated injury, time to surgery, operation time, intraoperative blood loss, and complications were recorded and analyzed. The quality of the reduction was assessed based on Matta radiographic criteria. Potential impact factors affecting the quality of reduction were analyzed. Functional outcome was evaluated at the final follow-up according to a modified Mere D'Aubigne-Postel scoring system for each patient.

RESULTS

All patients were followed up for at least 12 months. The duration of surgery was 140 min on average (110-205 min) and the mean intraoperative blood loss was 1250 ml (500-2100 ml). According to Matta radiographic criteria, the accuracy of reduction was "anatomical" in seven patients, "imperfect" in 11 patients, and "poor" in four patients, with an excellent and good rate of 81.8%. The time to surgery in poor reduction group was significantly longer than anatomical or imperfect reduction group (p < 0.05). All the acetabular fractures united after 8-12 weeks. The average modified Merle D'Aubigne-Postel score evaluated at the final follow-up was 14.6 (6-18), and the clinical outcomes were rated as excellent in six patients, good in 10 patients, fair in four patients, and poor in two patients, with an excellent and good rate of 72.7%. There were two cases of osteonecrosis of the femoral head (9%). No other complication was found for all cases.

CONCLUSION

The LRA is an effective and minimally invasive approach in the treatment of delayed acetabular fractures excluding posterior wall fracture and posterior dislocation.

A new modified pararectus approach and visualization: an anatomical study

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.

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

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.

The Pararectus approach in acetabular fractures treatment: functional and radiologcial results

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.

Early biomechanical outcome in patients with acetabular fractures treated using the pararectus approach: a gait and stair climb analysis study

Purpose

Patients with surgically treated acetabular fractures using extensive dissection of hip muscles demonstrate an incomplete biomechanical recovery and limited joint mobility during movement. The purpose of this study was to evaluate the early biomechanical outcome in a series of patients with acetabular fractures treated using the less invasive anatomical pararectus approach.

Methods

Eight patients (48 ± 14 years, BMI 25.8 ± 3 kg/m²) were investigated 3.8 ± 1.3 months after surgery and compared to matched controls (49 ± 13 years, BMI 26 ± 2.8 kg/m²). Trunk and lower extremity kinematics and kinetics during gait and stair climb were calculated. SF-12 and the Merle d’Aubigné score were used for functional evaluation. Statistical analysis was conducted using Mann–Whitney test and Student’s t test. Effect sizes were calculated using Cohen’s d.

Results

No group differences for lower extremity kinematics during walking and stair climbing were found. During walking, patients showed significant reductions (p < 0.05) of the vertical ground reaction force (8%) and knee and hip extension moments (29 and 27%). Ipsilateral trunk lean was significantly increased by 3.1° during stair descend while reductions of vertical ground reaction force were found for stair ascend (7%) and descend (20%). Hip extension moment was significantly reduced during stair descend by 37%. Patients revealed acceptable SF-12 physical and mental component outcomes and a good rating for the Merle d’Aubigné score (15.9 ± 1.7).

Conclusion

Patients showed some biomechanical restrictions that can be related to residual deficits in weight bearing capacity and strength of the hip muscles. In contrast, an immediate recovery of mobility was achieved by preserving lower extremity and pelvic movement. Therefore, the pararectus approach can serve as a viable strategy in the surgical treatment of acetabular fractures.

Clinical trial

Trial registration number DRKS00011308, 11/14/2016, prospectively registered.

Evaluation of joint awareness after acetabular fracture: Validation of the Forgotten Joint Score according to the COSMIN checklist protocol

BACKGROUND

A fracture of the acetabulum is an uncommon, but serious injury. Established outcome tools do not reflect the patient's perspective after fracture of the hip joint. Originally designed for post-arthroplasty patients, the Forgotten Joint Score (FJS) is a patient-reported outcome measurement (PROM) tool evaluating the disease-specific health-related quality of life (HR-QoL).

AIM

To validate the FJS in patients after acetabular fracture.

METHODS

In a prospective mono-centric cohort study, we evaluated 100 patients at mean 5.2 ± 3.6 years after a fracture of the acetabulum. The validation study followed the complete COSMIN checklist protocol. For calculation of convergent validity, we used the Tegner-Activity Scale, the Western Ontario and McMaster Universities Osteoarthritis Index, the EuroQol-5D, and a subjective rating of change as an anchor variable.

RESULTS

We confirmed good internal consistency with a Cronbach's alpha of 0.95. With an intraclass correlation coefficient of 0.99 (95%CI: 0.97, 0.99), test-retest reliability of the FJS was excellent. Correlation coefficients between the questionnaires were moderate to high ranging from |0.56| to |0.83| (absolute value). No relevant floor or ceiling effects occurred. Standard error of measurement was 3.2 and smallest detectable change (SDC) was 8.8. Thus, changes greater than 8.8 points between two assessments denote a real change in FJS.

CONCLUSION

The FJS is a valid and reliable tool for evaluation of patient-reported outcome in posttraumatic condition after acetabular fracture. The SDC indicating a real clinical improvement was 8.8 points in the FJS. We could confirm responsiveness of the FJS and found no relevant floor- or ceiling effects.

Risk of Injury to the Neurovascular Structures in the Pararectus Approach Used in Acetabular Fractures: A Cadaver Study

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.