The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest.

BACKGROUND: The feasibility of harvesting a vascularized iliac crest utilizing the Pararectus approach was assessed in cadavers and then this new technique was implemented in a clinical case. METHODS: Bilaterally in five cadavers the branches of both external iliac arteries were injected with colored silicone to assess their position to each other and to harvest a bone graft vascularized by the deep circumflex iliac artery (DCIA) through the Pararectus approach. This technique was implemented in a 68-years-old female patient, initially admitted to a level-I-trauma center after sustaining multiple injuries by falling from great height. For definitive treatment of a severely contaminated medially open (Gustilo-Anderson Type 3A) calcaneal luxation fracture (Sanders type IIIBC) in this patient a vascularized iliac crest autograft harvest by the Pararectus approach was used for reconstructive surgery. RESULTS: The DCIA and the deep inferior epigastric vessels (DIEV: vascularizing the rectus abdominis muscle and main pedicle of the inferiorly based rectus abdominis myocutaneous flap) are very close on the lateral and medial border of the external iliac artery, respectively. As a consequence, the retrograde dissection of the DIEV towards the DCIA through the Pararectus approach made the dissection of the vascularized iliac crest more amenable, preserving both the lateral femoral cutaneous and the genitofemoral nerves. Four months after the surgery the patient was able to fully weight-bear in orthopedic shoes. Radiographs and CT scans showed correct hind foot alignment and bony integration of the vascularized iliac crest graft into the residual calcaneal body. CONCLUSION: The Pararectus approach allowed for secure collection of large vascularized iliac grafts. The presented technique was successful as a salvage procedure in a clinical case with substantial bone loss after an open calcaneal fracture.

Secure Screw Placement in Management of Acetabular Fractures Using the Suprapectineal Quadrilateral Buttress Plate.

Acetabular fractures involving predominantly the anterior column associated with a disruption of the quadrilateral surface can be treated with instrumentation implementing the stabilization of the quadrilateral surface. The recently introduced suprapectineal quadrilateral buttress plate is specifically designed to prevent secondary medial subluxation of the femoral head, especially in elderly patients with reduced ability for partial weight bearing. Whereas there are guidelines available for safe screw fixation for the anterior and posterior columns, there might be a concern for intra-articular placement of screws placed through the infrapectineal part of the quadrilateral buttress plate. Within this report we analyzed retrospectively screw placement in 30 plates in postoperative CT scans using algorithms for metal artifact reduction. None of the screws of the buttress plate penetrated the hip joint. We describe the placement, length, and spatial orientation of the screws used for fracture fixation and suggest that the use of intraoperative image intensifiers with a combined inlet-obturator view of 30-45° best projects the screws and the hip joint. Preoperative knowledge of approximate screw placement and information for accurate intraoperative imaging may contribute to safe acetabular fracture fixation and may reduce operating time and limit radiation exposure to the patient and the personnel. This trial is registered with KEK-BE: 266/2014.

Percutaneous screw fixation of the iliosacral joint: A case-based preoperative planning approach reduces operating time and radiation exposure.

INTRODUCTION: A preoperative planning approach for percutaneous screw fixation of the iliosacral joint provides specific entry points (EPs) and aiming points (APs) of intraosseous screw pathways (as defined by CT scans) for lateral fluoroscopic projections used intraoperatively. The potential to achieve the recommended EPs and APs, to obtain an ideal screw position (perpendicular to the iliosacral joint), to avoid occurrence of extraosseous screw misplacement, to reduce the operating time and the radiation exposure by utilizing this planning approach have not been described yet. METHODS: On preoperative CT scans of eight human cadaveric specimen individual EPs and APs were identified and transferred to the lateral fluoroscopic projection using a coordinate system with the zero-point in the center of the posterior cortex of the S1 vertebral body (x-axis parallel to upper S1 endplate). Distances were expressed in relation to the anteroposterior distance of the S1 upper endplate (in%). In each specimen on one side a screw was placed with provided EP and AP (New Technique) whereas at the contralateral side a screw was placed without given EP and AP (Conventional Technique). Both techniques were compared using postoperative CT scans to assess distances between predefined EPs and APs and the actually obtained EPs and APs, screw angulations in relation to the iliosacral joint in coronal and axial planes and the occurrence of any extraosseous screw misplacement. The "operating time (OT)" and the "time under fluoroscopy (TUF)" were recorded. Statistical analysis was performed by the Wilcoxon signed-rank test. RESULTS: EPs were realized significantly more accurate using the new technique in vertical direction. The screw positions in relation to the iliosacral joint showed no significant difference between both techniques. Both techniques had one aberrantly placed screw outside the safe corridor. The (mean±SD) "OT" and the (mean±SD) "TUF" were significantly decreased using the new technique compared to the conventional technique (OT: 7.6±2min versus 13.1±5.8min, p=0.012; TUF: 1.5±0.8min versus 2.2±1.1min). CONCLUSION: The presented preoperative planning approach increases the accuracy in percutaneous screw fixation of the iliosacral joint, reduces operating time and minimizes radiation exposure to patient and staff.

Prevention of cement leakage into the hip joint by a standard cement plug during PFN-A cement augmentation: a technical note.

Medial penetration of the helical blade into the hip joint after fixation of trochanteric fractures using the proximal femur nail antirotation (PFN-A) is a potential failure mode. In low demand patients a blade exchange with cement augmentation may be an option if conversion to total hip arthroplasty is unfeasible to salvage the cut-through. This article describes a technique to avoid intraarticular cement leakage using a cement plug to close the defect in the femoral head caused by the cut-through.

Anterior fixation of unstable pelvic ring fractures using the modified Stoppa approach: mid-term results are independent on patients' age.

PURPOSE: Open surgical management of unstable pelvic ring injuries has been discussed controversially compared to percutaneous techniques in terms of surgical site morbidity especially in older patients. Thus, we assessed the impact of age on the outcome following fixation of unstable pelvic ring injuries through the modified Stoppa approach. METHODS: Out of a consecutive series of 92 patients eligible for the study, 63 patients (mean age 50 years, range 19-78) were evaluated [accuracy of reduction, complications, failures, Majeed-Score, Oswestry Disability Questionnaire (ODI), Mainz Pain Staging System (MPSS)] at a mean follow-up of 3.3 years (range 1.0-7.9). Logistic multivariate regression analysis was performed to assess the outcome in relation to increasing patient age and/or Injury Severity Score (ISS). RESULTS: Out of 63 patients, in 36 an "anatomic" reduction was achieved. Ten postoperative complications occurred in eight patients. In five patients, failure of fixation was noted at the anterior and/or posterior pelvic ring. In 49 patients, an "excellent" or "good" Majeed-Score was obtained; the mean ODI was 14 % (range 0-76 %); 50 patients reported either no or only minor chronic pelvic pain (MPSS). Only an increasing ISS conferred an increased likelihood of the occurrence of a non-anatomical reduction, a "poor" or "fair" Majeed-Score, or an ODI >20 %. CONCLUSIONS: Increasing age did not impact the analysed parameters. Open reduction and internal fixation of the anterior pelvic ring through a modified Stoppa approach in unstable pelvic ring injuries did not result in an unfavourable outcome with increasing age of patients.

Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach.

INTRODUCTION: Data concerning outcome after management of acetabular fractures by anterior approaches with focus on age and fractures associated with roof impaction, central dislocation and/or quadrilateral plate displacement are rare. METHODS: Between October 2005 and April 2009 a series of 59 patients (mean age 57 years, range 13-91) with fractures involving the anterior column was treated using the modified Stoppa approach alone or for reduction of displaced iliac wing or low anterior column fractures in combination with the 1st window of the ilioinguinal approach or the modified Smith-Petersen approach, respectively. Surgical data, accuracy of reduction, clinical and radiographic outcome at mid-term and the need for endoprosthetic replacement in the postoperative course (defined as failure) were assessed; uni- and multivariate regression analysis were performed to identify independent predictive factors (e.g. age, nonanatomical reduction, acetabular roof impaction, central dislocation, quadrilateral plate displacement) for a failure. Outcome was assessed for all patients in general and in accordance to age in particular; patients were subdivided into two groups according to their age (group "<60yrs", group "≥60yrs"). RESULTS: Forty-three of 59 patients (mean age 54yrs, 13-89) were available for evaluation. Of these, anatomic reduction was achieved in 72% of cases. Nonanatomical reduction was identified as being the only multivariate predictor for subsequent total hip replacement (Adjusted Hazard Ratio 23.5; p<0.01). A statistically significant higher rate of nonanatomical reduction was observed in the presence of acetabular roof impaction (p=0.01). In 16% of all patients, total hip replacement was performed and in 69% of patients with preserved hips the clinical results were excellent or good at a mean follow up of 35±10 months (range: 24-55). No statistical significant differences were observed between both groups. CONCLUSION: Nonanatomical reconstruction of the articular surfaces is at risk for failure of joint-preserving management of acetabular fractures through an isolated or combined modified Stoppa approach resulting in total joint replacement at mid-term. In the elderly, joint-preserving surgery is worth considering as promising clinical and radiographic results might be obtained at mid-term.

[Anterior approaches to the acetabulum]. / Anteriore Zugänge zum Acetabulum.

Since the 1960s the ilioinguinal approach by Letournel with the three anatomic windows has been successfully established for the treatment of acetabular fractures involving predominantly the anterior column. The previous standard approach, the iliofemoral approach by Smith-Petersen, is still used for the therapy of anterior wall or isolated femoral head fractures. The increase in acetabular fractures in the elderly with lateral compression fractures after lateral falls, characterized by medial displacement of the quadrilateral plate and superomedial dome impaction, led to the use of the intrapelvic modified Stoppa approach with or without the first window of the ilioinguinal approach in the 1990s. To combine the advantages of the second and third windows of the ilioinguinal approach and the medial view of the modified Stoppa approach the Berne research group recently introduced the pararectus approach in acetabular surgery, which can be used as a less invasive acetabular surgical (LIAS) technique especially in the elderly.

[Posterior approaches to the acetabulum]. / Posteriore Zugänge zum Acetabulum.

Posterior approaches to the hip joint were developed by Langenbeck and Kocher in the nineteenth century. Letournel created the term Kocher-Langenbeck approach which became one of the most important approaches to the hip joint. The further extension of this approach by digastric trochanteric osteotomy and subsequently by surgical hip dislocation enables visualization of the entire hip joint which allows complete evaluation of articular joint damage, quality of reduction and confirmation of extra-articular hardware. With the increasing incidence of acetabular fractures in the elderly there is a concomitant increase of complicating factors, such as multifragmentary posterior wall fractures, dome impaction, marginal impaction and femoral head damage. These factors are negative predictors and compromise a favorable outcome after acetabular surgery. With direct joint visualization these factors can be reliably recognized and corrected as adequately as possible. Surgical hip dislocation thus offers advantages in complex posterior wall, transverse and T-shaped fractures with or without posterior wall involvement. For these fracture types surgical hip dislocation represents a standard approach in our hands.

Rationales for the Bernese approaches in acetabular surgery.

PURPOSE: To present two new approaches to acetabular surgery that were established in Berne, and which aim at enhanced visualization and anatomical reconstruction of acetabular fractures. METHOD: The trochanteric flip osteotomy allows for surgical hip dislocation, and was introduced as a posterior approach for acetabular fracture management involving the posterior column and wall. For acetabular fractures predominantly involving the anterior column and the quadrilateral plate, the Pararectus approach is described. RESULTS: Full exposure of the hip joint, as provided by the trochanteric flip osteotomy, facilitates anatomical reduction of acetabular or femoral head fractures and safe positioning of the anterior column screw in transverse or T-shaped fractures. Additionally, the approach enables osteochondral transplantation as a salvage procedure for severe chondral femoral head damage and osteoplasty of an associated inadequate offset at the femoral head-neck junction. The Pararectus approach allows anatomical restoration with minimal access morbidity, and combines advantages of the ilioinguinal and modified Stoppa approaches. CONCLUSIONS: Utilization of the trochanteric flip osteotomy eases visualization of the superior aspect of the acetabulum, and enables the evaluation and treatment of chondral lesions of the femoral head or acetabulum and labral tears. Displaced fractures of the anterior column with a medialized quadrilateral plate can be addressed successfully through the Pararectus approach, in which surgical access is associated with minimal morbidity. However, long-term results following the two presented Bernese approaches are needed to confirm that in the treatment of complex acetabular fractures the rate of poor results in almost one-third of all cases (as currently yielded using traditional approaches) might be reduced by the utilization of the presented novel approaches.

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.

Surgical dislocation of the hip for a locked traumatic posterior dislocation with associated femoral neck and acetabular fractures.

Traumatic posterior dislocation of the hip associated with a fracture of the posterior acetabular wall and of the neck of the femur is a rare injury. A 29-year-old man presented at a level 1 trauma centre with a locked posterior dislocation of the right hip, with fractures of the femoral neck and the posterior wall of the acetabulum after a bicycle accident. An attempted closed reduction had failed. This case report describes in detail the surgical management and the clinical and radiological outcome. Open reduction and fixation with preservation of the intact retinaculum was undertaken within five hours of injury with surgical dislocation of the hip and a trochanteric osteotomy. Two years after operation the function of the injured hip was good. Plain radiographs and MR scans showed early signs of osteoarthritis with some loss of joint space but no evidence of avascular necrosis. The patient had begun skiing and hiking again. The combination of fractures of the neck of the femur and of the posterior wall of the acetabulum hampers closed reduction of a posterior dislocation of the hip. Surgical dislocation of the hip with trochanteric flip osteotomy allows controlled open reduction of the fractures, with inspection of the hip joint and preservation of the vascular supply.