The Pararectus approach for anterior intrapelvic management of acetabular fractures

Abstract

A new anterior intrapelvic approach for the surgical management of displaced acetabular fractures involving predominantly the anterior column and the quadrilateral plate is described. In order to establish five 'windows' for instrumentation, the extraperitoneal space is entered along the lateral border of the rectus abdominis muscle. This is the so-called 'Pararectus' approach. The feasibility of safe dissection and optimal instrumentation of the pelvis was assessed in five cadavers (ten hemipelves) before implementation in a series of 20 patients with a mean age of 59 years (17 to 90), of whom 17 were male. The clinical evaluation was undertaken between December 2009 and December 2010. The quality of reduction was assessed with post-operative CT scans and the occurrence of intra-operative complications was noted. In cadavers, sufficient extraperitoneal access and safe instrumentation of the pelvis were accomplished. In the patients, there was a statistically significant improvement in the reduction of the fracture (pre- versus post-operative: mean step-off 3.3 mm (sd 2.6) vs 0.1 mm (sd 0.3), p < 0.001; and mean gap 11.5 mm (sd 6.5) vs 0.8 mm (sd 1.3), p < 0.001). Lesions to the peritoneum were noted in two patients and minor vascular damage was noted in a further two patients. Multi-directional screw placement and various plate configurations were feasible in cadavers without significant retraction of soft tissues. In the treatment of acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach allowed anatomical restoration with minimal morbidity related to the surgical access.

Quadrilateral plate fractures of the acetabulum: An update

“…2,6,11,17,25,[30][31][32][33][34][35][36][37][38][39][40] They report on 353 acetabular fractures of which 213 were treated non-operatively (Table 1) and 140 treated operatively (Table 2). Various radiographic scoring techniques have been used to describe the quality of reduction 18,[41][42][43][44][45] and osteoarthritic changes.…”

“…3,29,42,47 More recently alternative approaches, advantageous to the reduction and fixation of the quadrilateral plate have been described, including the Stoppa approach. 3,29,42,45,47 Keel et al 39 have recently described the pararectus surgical approach. Five windows are utilised, via the extraperitoneal space along the lateral border of rectus abdominis.…”

“…These refer to 140 different cases as reported in 12 studies 6,11,17,25,31,[34][35][36][37][38][39][40] published between the years 1956 and 2012 (Table 2).…”

“…Keel et al 39 in 2012 have recently described their results using the pararectus approach for fractures involving the anterior column and quadrilateral plate. Twenty patients were included in the study with an average age of 59 years.…”

What Is the Frequency of Nerve Injuries Associated With Acetabular Fractures?

“…According to the registry data, this approach is not popular in German hospitals with only 0.1% of all approaches. Regardless of which approach is used, particular attention should be paid to retraction [9] as well as to avoid trapping of the nerve during reduction of fracture fragments [2,4,12,13,16,20].…”