The Pararectus Approach in Acetabular Surgery: Radiological and Clinical Outcome

Abstract

Objectives: To evaluate radiological fracture reduction and clinical results using the pararectus approach in complex acetabular fractures involving the anterior column.

Design: Retrospective database analysis of prospectively collected data.

Setting: Level 1 trauma center.

Patients/participants: 61 patients (48 male and 13 female) with a median age of 55 (range 17-91) years were included. According to the chosen surgical approach, they were divided into 2 groups. The P-group included 43 patients, among them 32 male and 11 female patients with a median age of 55 (range 17-90) years. Eighteen patients [16 male, 2 female; median age: 53 (range 23-91) years] were treated through the ilioinguinal approach (I-group).

Intervention: Anterior surgical procedures through the pararectus or the ilioinguinal approach.

Main outcome measured: Reduction results were rated according to the modified Matta criteria using a measurement protocol of hip joint gaps and steps in computed tomography scans. Operation time, complications, and clinical outcomes median one year postoperatively were compared.

Results: In the pararectus group reduction was anatomical in 21 out of 40 analyzed patients (52.5%), imperfect in 11 patients (27.5%), and poor in 8 patients (20%). The mean joint step reduction was 3.7 mm, and the mean joint gap reduction was 12.1 mm. In the ilioinguinal group reduction was anatomical in 9 out of 18 patients (50%), imperfect in 4 patients (22%), and poor in 5 patients (28%). The mean joint step reduction was 1 mm, and the mean joint gap reduction was 7 mm. Operation time was significantly shorter in the P-group (mean: 49 minutes; P < 0.001).

Conclusions: This study indicates that acetabular fracture reduction using the pararectus approach is at least comparable with the ilioinguinal approach independent of patients' age. A relevant advantage of the pararectus approach was seen in a significantly shorter operation time.

Level of evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

FIGURE 1.

Postmortem surgical exposure developed through the pararectus approach lateral to the rectus abdominis muscle: mobilized peritoneum (A), external iliac vessels (B), vas deferens and inferior epigastric vessels (C), corona mortis (*), and obturator nerve and vessels (D). Editor's Note: A color image accompanies the online version of this article.

FIGURE 2.

Measurement of the hip head diameter in the transversal plane in the CT scan.

FIGURE 3.

Measurement of the largest joint gap at the tip of the acetabular dome in the transversal plane of the CT scan within a circle with the size of the hip head diameter.

FIGURE 4.

Radiographic distances in patients treated through the pararectus approach (P-group) and the ilioinguinal approach (I-group). White: preoperative gap; shaded: preoperative step; gray: postoperative gap; dotted: postoperative step.