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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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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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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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Jin L, Wang Z, Zhao K, Lian X, Chen W, Zhang Y, Hou Z. Drain vs. no-drain for acetabular fractures after treatment via a modified stoppa approach: A retrospective study. Front Surg 2023; 10:1133744. [PMID: 37009600 PMCID: PMC10063889 DOI: 10.3389/fsurg.2023.1133744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 02/23/2023] [Indexed: 03/19/2023] Open
Abstract
ObjectiveThe aim of this study was to compare the clinical efficacy of close suction drainage (CSD) and no-CSD after a modified Stoppa approach for the surgical fixation of acetabular fractures.MethodsThis retrospective study included 49 consecutive acetabular fracture patients, who presented to a single level I trauma center for surgical fixation, using a modified Stoppa approach from January 2018 to January 2021. All surgeries were performed by a senior surgeon using the same approach, and the patients were divided into two groups based on whether CSD was used after the operation. Details of the patient demographics, fracture characteristics, intraoperative indicators, reduction quality, intra and postoperative blood transfusion, clinical outcomes, and incision-related complications were collected.ResultsNo significant differences were found in the demographics, fracture characteristics, intraoperative indicators, reduction quality, clinical outcomes, and incision-related complications between the two groups (P > 0.05). The use of CSD was associated with a significantly higher postoperative blood transfusion volume (P = 0.034) and postoperative blood transfusion rate (P = 0.027). In addition, there was a significant difference in postoperative temperatures, especially on postoperative Day 2 (no-CSD 36.97 ± 0.51°C vs. CSD 37.34 ± 0.69°C, P = 0.035), and higher visual analogue scale (VAS) scores, especially on postoperative Day 1 (no-CSD 3.00 ± 0.93 vs. CSD 4.14 ± 1.43, P = 0.002) and 3 (no-CSD 1.73 ± 0.94 vs. CSD 2.48 ± 1.08, P = 0.013).ConclusionThe results of this study suggest that routine use of CSD should not be recommended for patients with acetabular fractures after surgical fixation using a modified Stoppa approach.
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Affiliation(s)
- Lin Jin
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Biomechanicsof Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhongzheng Wang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Biomechanicsof Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Kuo Zhao
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Biomechanicsof Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xiaodong Lian
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Biomechanicsof Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Chen
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Biomechanicsof Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, China
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Biomechanicsof Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, China
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Chinese Academy of Engineering, Beijing, China
| | - Zhiyong Hou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Key Laboratory of Biomechanicsof Hebei Province, Third Hospital of Hebei Medical University, Shijiazhuang, China
- NHC Key Laboratory of Intelligent Orthopaedic Equipment, Third Hospital of Hebei Medical University, Shijiazhuang, China
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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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Yang Y, Tang TT, Zou C, Fang Y. Clinical Outcomes of the Modified Stoppa Combined with Iliac Fossa Approach for Complex Acetabular Fractures: A Medium- and Long-term Retrospective Study. Orthop Surg 2022; 14:1998-2005. [PMID: 35876195 PMCID: PMC9483040 DOI: 10.1111/os.13415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 05/30/2022] [Accepted: 06/20/2022] [Indexed: 02/05/2023] Open
Abstract
Objective The modified Stoppa combined with iliac fossa approach has gained increasing popularity. Although early clinical outcomes have been satisfactory, extensive long‐term clinical outcomes are relatively scarce. The purpose of this study was to evaluate the medium‐ and long‐term outcomes of this approach for complex acetabular fractures. Methods This was a retrospective study involving 57 patients with complex acetabular fractures from January 2009 to January 2016. All fractures were treated with the modified Stoppa combined with iliac fossa approach. Follow‐up was at least 5 years. Primary outcome measures, including quality of reduction and clinical outcomes, were recorded by an independent observer. Secondary outcome measures included time to surgery, surgical time, intraoperative blood loss, and perioperative complications. Results Fifty‐seven patients (range, 18–80 years) included 46 males and 11 females. There were 32 cases on the left side and 25 cases on the right side. The most common associated injury was pulmonary contusion. According to the Judet–Letournel classification, there were 27 both‐column fractures, 16 anterior column with posterior hemitransverse fractures and 14 T‐type fractures. The average time from injury to surgery was 7.3 days. The average intraoperative blood loss and transfusion were 750.9 ml and 564.3 ml, respectively. All fractures healed within 6 months after surgery. The average follow‐up time was 7.7 years, and there was no loss of follow‐up. The quality of reduction was graded as anatomical in 23 cases (40.4%), imperfect in 22 cases (38.6%), and poor in 12 cases (21.0%). According to grading system of Merle d’ Aubigne and Postel, clinical outcomes at 1 year follow‐up were excellent in 17 cases (29.8%), good in 25 cases (43.9%), fair in four cases (7.0%), and poor in 11 cases (19.3%). The excellent and good rate was 73.7% and the difference was not statistically significant compared with the clinical outcomes at the last follow‐up. Intraoperative complications included four cases of obturator nerve injury and two cases of vascular injury. Postoperative complications included one case of wound delayed healing, two cases of deep vein thrombosis, two cases of avascular necrosis of femoral head, three cases of heterotopic ossification and five cases of post‐traumatic arthritis. Only one of these patients underwent reoperation for femoral head necrosis. Conclusions The modified Stoppa combined with iliac fossa approach can achieve satisfactory reduction quality and hip function. It might be a valuable alternative to the ilioinguinal approach for the surgical management of acetabular fractures.
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Affiliation(s)
- Yun Yang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, PR China
| | - Ting-Ting Tang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, PR China
| | - Chang Zou
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, PR China
| | - Yue Fang
- Department of Orthopaedics, West China Hospital, Sichuan University, Chengdu, PR China
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