The pararectus approach for internal fixation of acetabular fractures involving the anterior column: evaluating the functional outcome

Abstract

Introduction: Aim of this retrospective analysis of prospectively collected data was to evaluate the functional mid-term outcome two years after open reduction and internal fixation of acetabular fractures involving the anterior column with affection of the quadrilateral plate using the pararectus approach on a large cohort.

Method: Fifty-two patients (12 female, 40 male) with a median age of 55 (range 18-90) years and displaced acetabular fractures involving the anterior column were surgically treated in a single level I trauma centre between July 2012 and February 2016 using the pararectus approach. Thirty-four patients (8 female and 26 male) with a median age of 58 (range 20-85) years were available for complete clinical follow-up at regular intervals, finally 24 months post-operatively. Functional outcome was evaluated according to modified Merle d'Aubigné score, Lower Extremity Functional Scale, WOMAC, and SF-36.

Results: Range of time between trauma and surgical treatment was three (range 0-19) days. Operation time was 140 (range 60-240) minutes, and duration of hospital treatment was 19 (range 7-38) days. Functional results in 34 patients available for final follow-up demonstrated 68 points (median; range 39-80) according to the Lower Extremity Functional Scale, 6% according to the WOMAC (mean; SD ± 14.5%), and 69% (mean; SD ± 20.1%) according to the SF-36. The modified Merle d'Aubigné score was excellent in 22 patients, good in eight patients, and fair in four patients.

Discussion/conclusion: Based on the good to excellent functional mid-term follow-up results of this study, the pararectus approach can be recommended as sufficient alternative single access to address displaced acetabular fractures involving the anterior column, independent of patients' age.

Keywords: Acetabular fracture; Ilioinguinal approach; Lower extremity functional scale; Merle d’Aubigné; Outcome; Pararectus approach; Quadrilateral plate; SF-36; Stoppa approach; WOMAC.

Fig. 1

Both column acetabular fracture with dislocation of the quadrilateral plate and impaction of the acetabular dome

Fig. 2

Surgical access using the pararectus approach: the incision (dotted line) starts cranially at the junction of the lateral and middle thirds of the line connecting the umbilicus with the anterior superior iliac spine. The incision ends at the border between the middle and medial thirds of the line connecting the anterior superior iliac spine with the symphysis. If necessary, an extension of the incision is possible (extended dotted line)

Fig. 3

Retraction of mobilized external iliac vessels (A) provides optimal visualization of the pelvic brim and the quadrilateral plate (B). The direct intraoperative view into the fracture gap (C) facilitates anatomical fracture reduction

Fig. 4

Post-operative X-ray demonstrates the fracture reduced anatomically using a small fragment plate (Stryker PRO system, Stryker Corp., Kalamazoo, MI, USA) on the pelvic brim and quadrilateral plate without any step or gap