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      Der Pararectus-Zugang: operatives Vorgehen in der Acetabulumchirurgie Translated title: The pararectus approach: surgical procedure for acetabular fractures

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          Abstract

          Operationsziel

          Der Pararectus-Zugang wurde vor einigen Jahren für die Beckenchirurgie neu entdeckt und als alternativer Zugang insbesondere für die Behandlung von Acetabulumfrakturen des vorderen Pfeilers mit Beteiligung der quadrilateralen Fläche beschrieben.

          Indikationen

          Zur optimalen Darstellung von Acetabulumfrakturen mit Beteiligung der quadrilateralen Fläche, Frakturen der vorderen Wand und des vorderen Pfeilers, vorderen Pfeiler/hinteren Hemiquerfrakturen und Frakturen mit zentraler Impression von Domfragmenten hat sich der Pararectus-Zugang bewährt.

          Kontraindikationen

          Bei Frakturen des hinteren Pfeilers, der hinteren Wand, kombinierten Frakturen der hinteren Wand und des hinteren Pfeilers, Querfrakturen mit Dislokation des hinteren Pfeilers oder in Kombination mit Frakturen der hinteren Wand und bei T‑Frakturen mit Dislokation des hinteren Pfeilers oder in Kombination mit Frakturen der hinteren Wand findet der Pararectus-Zugang keine Anwendung, ebenso nicht bei Patienten mit Ileus.

          Operationstechnik

          Über den Pararectus-Zugang kann der gesamte Beckenring einschließlich der quadrilateralen Fläche erreicht werden. Die Auswahl der chirurgischen Fenster richtet sich nach der Frakturlokalisation und den Erfordernissen der Frakturreposition.

          Weiterbehandlung

          Grundsätzlich sollte eine Teilbelastung für 6 Wochen eingehalten werden, wobei Fraktur- und Osteosynthese-abhängig ggf. eine frühere Belastungsfreigabe möglich ist. Insbesondere von geriatrischen Patienten kann häufig keine Teilbelastung eingehalten werden, sodass hier die frühzeitige und oft relativ unkontrollierte Vollbelastung akzeptiert werden muss.

          Ergebnisse

          In einer vergleichenden instrumentellen Bewegungsanalyse zwischen Patienten nach operativer Stabilisierung einer isolierten unilateralen Acetabulumfraktur über den Pararectus-Zugang und gesunden Probanden zeichnete sich schon in der frühen postoperativen Phase eine suffiziente Stabilität und Bewegungsfunktion des Beckens und der Hüfte während des Gehens ab.

          Translated 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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          Most cited references28

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          The Pararectus approach for anterior intrapelvic management of acetabular fractures: an anatomical study and clinical evaluation.

          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.
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            Surgical management of acetabular fractures - A contemporary literature review.

            Surgical management of acetabular fractures is now commonplace for almost all displaced or unstable fractures. Over the last 20 years however, the patient population has aged, and there have been significant changes to safety in motor vehicles and the work-place, and people's activity types and levels have changed. The surgical specialty has also developed with time, and as a result acetabular fracture surgery today is different to 20 years ago. We have repeated a meta-analysis originally published by Giannoudis et al in 2005, to evaluate contemporary aspects of acetabular fracture patients, injury mechanisms, management, complications and functional outcomes. This paper compares data from the last 15 years to that published in 2005. We have analysed a total of 8389 fractures from 8372 patients. The mean patient age has risen from 38.6 to 45.2. A change in injury mechanisms is seen, with road traffic accidents now accounting for 66.5% of cases (previously over 80%), and a rise in the number of fractures caused by falls from 10.7 to 25.8%. There has been a marked change in the fracture types seen, with a significant rise in anterior column-based fractures (Anterior column and Anterior column posterior hemi-transverse), whilst all other fracture patterns have fallen over time. Surgery is now taking place earlier, the Kocher-Langenbeck and Ilioinguinal approaches remain the major surgical approaches used, but the Anterior Intra-Pelvic approach has become relatively common. The most significant change in complications is a substantial drop in iatrogenic nerve damage, particularly to the sciatic nerve. Post-traumatic osteoarthritis remains the major complication of this injury, with 16.9% of cases developing Matta grade III/IV changes by 44 months in this review. Heterotopic ossification also remains a common problem. Despite these changes over time, functional outcomes after acetabular fracture appear to remain similar, although there is still a lack of good quality data on medium and longer-term functional outcomes from which to assess this.
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              Surgical exposures and options for instrumentation in acetabular fracture fixation: Pararectus approach versus the modified Stoppa

              As an alternative to the modified Stoppa approach, the Pararectus approach is used clinically for treatment of acetabular fractures involving the anterior column. The current study assessed the surgical exposure and the options for instrumentation using both of these approaches.
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                Author and article information

                Contributors
                unfallchirurgie@uk-erlangen.de
                Journal
                Oper Orthop Traumatol
                Oper Orthop Traumatol
                Operative Orthopadie Und Traumatologie
                Springer Medizin (Heidelberg )
                0934-6694
                1439-0981
                16 March 2023
                16 March 2023
                2023
                : 35
                : 2
                : 110-120
                Affiliations
                [1 ]GRID grid.469896.c, ISNI 0000 0000 9109 6845, Abteilung Unfallchirurgie, , BG Unfallklinik Murnau, ; Murnau, Deutschland
                [2 ]GRID grid.21604.31, ISNI 0000 0004 0523 5263, Universitätsinstitut für Biomechanik, , Paracelsus Medizinische Privatuniversität, ; Salzburg, Österreich
                [3 ]GRID grid.5330.5, ISNI 0000 0001 2107 3311, Unfallchirurgische und Orthopädische Klinik, Universitätsklinikum Erlangen, , Friedrich-Alexander Universität Erlangen-Nürnberg (FAU), ; Krankenhausstr. 12, 91054 Erlangen, Deutschland
                Author notes
                [Redaktion]

                Maximilian Rudert, Würzburg

                [Zeichnungen]

                Birgit Brühmüller, Waghäusel

                Article
                800
                10.1007/s00064-023-00800-2
                10076372
                36928712
                887b1518-8b98-4bf3-a4eb-90da7ca9c901
                © The Author(s) 2023

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                History
                : 15 February 2022
                : 9 September 2022
                : 10 September 2022
                Funding
                Funded by: Friedrich-Alexander-Universität Erlangen-Nürnberg (1041)
                Categories
                Originalartikel
                Custom metadata
                © Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2023

                acetabulumfraktur,quadrilaterale fläche,interne osteosynthese,vorderer pfeiler/vordere wand fraktur,ganganalyse,acetabular fracture,internal fracture fixation,quadrilateral surface,anterior column/anterior wall fracture,gait analysis

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