Functional Outcome of Resection versus Reconstruction in Mason II-III Radial Head Fractures; A Short-Term Prospective Study

The anterior transmuscular intrapelvic approach for the treatment of acetabular fractures-a new anterior surgical strategy

The anterior ilioinguinal and the posterior Kocher-Langenbeck approach have long been the standard surgical approaches to the acetabulum. The last decade has witnessed the development of so-called intrapelvic approaches for anterior pathologies because they provide better exposure of the quadrilateral plate. Currently, the modified Stoppa approach and the pararectus approach are frequently used by surgeons for the treatment of acetabular fractures. We investigated an even more direct access to the entire anterior column and the quadrilateral plate via the abdominal wall muscles, between the incisions for the ilioinguinal and the pararectus approach.After intensive study of anatomic specimens, a cadaver dissection was performed prior to clinical application. The approach was then used in 20 patients who were assessed retrospectively.Postoperative CT scans showed that, according to the Matta scoring system, the quality of fracture reduction was "anatomical" (≤ 1 mm) in 12 (60%), "imperfect" (2-3 mm) in four (20%), and "poor" (> 3 mm) in four (20%) patients. Numerous minor complications were observed; the majority of these had resolved at the time of discharge.In conclusion, the anterior transmuscular intrapelvic approach (ATI) is a safe and effective alternative to the ilioinguinal and pararectal approaches, and may be regarded as an evolutionary advancement of traditional procedures.

Ilioinguinal versus modified Stoppa approach for open reduction and internal fixation of displaced acetabular fractures: a systematic review and meta-analysis of 717 patients across ten studies

BACKGROUND

Acetabulum fracture is one of the most challenging fractures to manage and operate for orthopaedic surgeons; anatomical reduction of fractures and reconstruction of the joint is of utmost importance. These factors in turn are dependent on the appropriate surgical approach used to improve the clinical outcomes and reduce associated complications. Hence, this meta-analysis aims to compare the outcomes of ilioinguinal versus modified Stoppa approach for open reduction and internal fixation (ORIF) of displaced acetabular fractures.

METHODS

Medline (PubMed), Embase, Scopus, and Cochrane Library databases were searched from their inception to 10th of June 2021 for both randomized clinical trials (RCTs) and or non-randomized studies comparing the outcomes of ilioinguinal approach and modified Stoppa approach for the ORIF of acetabular fractures. The estimates of treatment effects were described by mean difference (MD) for continuous variables and odds ratio (OR) for dichotomous variables with corresponding 95% confidence (95% CI) intervals. The risk of bias was assessed by MINORS tool for the non-randomized, and the Cochrane Collaboration's risk of bias tool for RCTs.

RESULT

A total of ten studies (717 patients), three RCTs and seven retrospective studies, were included. Modified Stoppa approach showed shorter mean duration of surgery (MD 47.13, 95% CI: 27.30-66.96), lesser number of overall complications (OR 2.14, 95% CI: 1.46-3.13), less intraoperative blood loss (MD 259.65, 95% CI: 152.66-366.64), and lower rates of infection (OR 2.17, 95% CI: 1.14-4.15). However, ilioinguinal approach showed a better quality of fracture reduction (OR 0.59, 95% CI: 0.42-0.82). Results were equivocal in terms of vascular injuries (OR 1.88 (95% CI: 0.86-4.09), nerve injuries (OR 1.77, 95% CI: 0.99-3.17), heterotopic ossification (OR1.74, 95% CI: 0.63-4.82), and clinical outcome (OR 0.81, 95% CI: 0.45-1.47) between the two groups.

CONCLUSION

Modified Stoppa approach carries a lesser duration of surgery, lesser intraoperative blood loss, fewer overall complications, and lesser postoperative infection rates compared to ilioinguinal approach. Although a better anatomical reduction is achieved by ilioinguinal approach, however, this does not translate into better clinic functional outcomes which remain comparable between the two approaches. So overall, modified Stoppa approach seems a better alternative for managing these fractures.

A new modified pararectus approach and visualization: an anatomical study

INTRODUCTION

The aim of our study was to visualize all the windows used in the pararectus approach with detailed cadaver images to facilitate better understanding of orthopedic surgeons and, in addition, was to modify the incision used in the pararectus approach to a more cosmetic bikini incision.

MATERIALS AND METHODS

In total, 20 cadavers fixed in 10% formalin were used in this study. Of these cadavers, 14 were male and six were female, with a mean age at death of 57 (42-82 years). The four windows were defined as follows in all the cadavers: pubic, quadrilateral, sacroiliac, and iliac windows.

RESULTS

The most important structure at risk in the pubic window was the corona mortis, as it was observed in 12 (60%) cadavers. In men, the spermatic cord was an important structure at risk in the pubic window. The obturator vessels and nerves were the structures at most risk in the quadrilateral window due to their close location with the quadrilateral surface. The obturator nerve on the medial side and at the entrance of the pelvis through the linea terminalis and lumbosacral truncus were the structures at most risk close to the sacroiliac joint in the sacroiliac window.

CONCLUSION

This anatomical study includes highly instructive visual shapes and cadaver images for the acetabulum and pelvis, whose anatomical structures are quite complex. We have found that this modified pararectus approach provides excellent access to the internal pelvic rim.

CLINICAL RELEVANCE

The anatomical data regarding the modified pararectus approach in this study will assist orthopedic surgeons in the surgical management of acetabular and pelvic fractures.

Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum: an anatomical feasibility study

Pelvic ring injuries or acetabular fractures present a challenge to trauma surgeons. Recently, endoscopic dissection techniques for visualization of the anterior pelvic ring and acetabulum have been presented. Robotic-assisted surgical systems offer advantages in terms of improved visualization and easier instrument handling. The aim of this pilot anatomic study was to verify the feasibility of robotic-assisted plate osteosynthesis on the anterior pelvic ring and acetabulum. The experiment was performed on a human whole body specimen. The DaVinci system with standard instruments as used in RARP was used. After docking the system, the anterior pelvic ring was first prepared as previously described for the endoscopic techniques. This was followed by dissection of both acetabula analogous to pelvic lymphadenectomy as performed during RARP. After the dissection was performed along the pelvic brim up to the iliosacral joint, the complete anterior column of the acetabulum including quadrilateral surface and incisura ischiadica major could be visualized. Finally, robotic-assisted endoscopic plate osteosynthesis was performed on the symphysis and anterior acetabular column as previously described in the endoscopic techniques. Robotic-assisted plate osteosynthesis of the anterior pelvic ring and acetabulum is feasible with the available robotic-assisted systems. Due to the excellent freedom of movement of the robotic arms, combined with the magnifying 3D visualization of the system, highly accurate preparation of the situs in preparation for plate osteosynthesis can be performed. The question of reduction of dislocated fractures remains open and is the subject of further investigation. Compared with conventional laparoscopy, robotic-assisted preparation nevertheless appears to offer an advantage in view of the complexity of the operation.

The influence of bone quality on radiological outcome in 50 consecutive acetabular fractures treated with a pre-contoured anatomic suprapectineal plate

PURPOSE

To investigate the range of indications of an anatomical-preshaped three-dimensional suprapectineal plate and to assess the impact of the bone mass density on radiologic outcomes in different types of acetabular fractures.

PATIENTS AND METHODS

A consecutive case series of 50 acetabular fractures (patient age 69 ± 23 years) treated with suprapectineal anatomic plates were analyzed in a retrospective study. The analysis included: Mechanism of injury, fracture pattern, surgical approach, need for additional total hip arthroplasty, intra- or postoperative complications, as well as bone mass density and radiological outcome on postoperative computed tomography.

RESULTS

Most frequently, anterior column fracture patterns with and without hemitransverse components as well as associated two column fractures were encountered. The anterior intrapelvic approach (AIP) was used in 98% (49/50) of the cases as primary approach with additional utilization of the first window of the ilioinguinal approach in 13/50 cases (26%). Determination of bone density revealed impaired bone quality in 70% (31/44). Postoperative steps and gaps were significantly greater in this subgroup (p < 0.05). Fracture reduction quality for postoperative steps revealed anatomic results in 92% if the bone quality was normal and in 46% if impaired (p < 0.05). In seven cases (14%), the plate was utilized in combination with acute primary arthroplasty.

CONCLUSION

A preshaped suprapectineal plate provides good radiological outcomes in a variety of indications in a predominantly geriatric cohort. Impaired bone quality has a significantly higher risk of poor reduction results. In cases with extensive joint destruction, the combination with total hip arthroplasty was a valuable option.

Fractures of the acetabulum: from yesterday to tomorrow

Purpose

The aim of this article is to present history, state of the art, and future trends in the treatment of acetabular fractures.

Methods

Review of recent and historical literature.

Results

Acetabular fractures are difficult to treat. The first descriptions of this injury already appeared in ancient Greek history, but intensive development started in the second half of the twentieth century after Judet and Letournel’s seminal work. Their classification is still the gold standard today. It is actually a pre-operative planning system and is used to determine the most appropriate surgical approach. The therapy of choice for dislocated fractures is open reduction and internal fixation. Recent modern techniques based on high-tech computerized planning systems and 3D printing have been successfully integrated into orthopaedic trauma practice.

Conclusion

There is no ideal surgical approach for acetabulum fracture treatment, so new approaches have been developed in recent decades. The best outcome series have shown good or excellent results, between 70 and 80%.

Use of surgical glue for Mason type III radial head fractures: A case report

RATIONALE

A Mason type III radial head fracture, which is characterized by comminuted fragments of the radial head, is a severe injury. Open reduction and internal fixation (ORIF) is an alternative treatment method; however, the technique of using an on-table reduction in combination with surgical glue is rarely reported.

PATIENT CONCERNS

A 48-year-old man was admitted to our department with complaints of elbow pain after falling down. Elbow radiography and computed tomography (CT) demonstrated characteristics of fractures before the operation.

DIAGNOSIS

Radiographic images showed a Mason type III radial head fracture.

INTERVENTIONS

The patient underwent ORIF at our hospital. During the operation, the technique of on-table reconstruction combined with surgical glue was used.

OUTCOMES

The patient recovered well and was able to participate in his usual work.

LESSONS

Mason type III radial head fractures could be treated with ORIF, and a satisfactory result could be anticipated, thus avoiding a radial head replacement or resection. Anatomical reduction of a comminuted radial head could be obtained via an on-table reconstruction and application of surgical glue.