Anatomical Study And Clinical Application Of Pararectus Approach In Acetabular Fractures

Part Ⅰ Anatomical study of pararectus approach in acetabular fracturesObjective: Through the anatomical study of the pararectus approach on pelvic specimens,the positional relationship between the important tissue structures of this surgical approach is clarified,and it provides an anatomical basis for the clinical use of the pararectus surgical approach in the treatment of acetabular fractures.Methods: Five adult cadavers with the complete pelvic structure were selected for dissection(10 sides in total),including 2 females and 3 males.Incision mark: The outer1/3 point connecting the anterior superior iliac spine and the navel is the starting point of the incision,and the inner 1/3 of the anterior superior iliac spine and the symphysis pubis is the ending point of the incision.Dissect layer by layer along the incision line,mainly observe the exposed parts of the 5 windows during the operation and important tissue structures at each level.Results: Cut the skin to the parietal peritoneum in turn along the incision line,and pay attention to avoid damaging the important tissues and blood vessels.Window 1 is located between the iliac crest and the iliopsoas muscle.Take the iliac crest and the iliopsoas muscle space,retract the skin to the outside,and retract the iliopsoas muscle to the inside to reveal the iliac crest and the medial iliac fossa;Window 2 is located between the iliopsoas muscle and the external iliac vascular bundle.Retracting the vascular bundle to the inside can reveal the sacroiliac joint at the back,and retracting the iliopsoas muscle to reveal the starting point of the suprapubic ramus and the iliac pubis;Window 3 is located between the external iliac vascular bundle and the spermatic cord(or round ligament of the uterus).After retraction of the two,the pubic ramus,iliac pubic bulge and pelvic edge can be exposed;Window 4 is located on the inner side of the spermatic cord(or round ligament of the uterus),which can reveal the pubic body and symphysis after being retracted outward;The position of window 5 is similar to window 3,but it is located on the deep surface of the true pelvis,and the quadrilateral and ischial spines can be exposed after retraction.By using the 5 windows of the incision,the approach can directly expose the anterior pelvic rim from the pubic symphysis to the sacroiliac joint,the inner part of the quadrilateral and the posterior column,the iliac fossa,and the iliac crest.Conclusion: Before using the pararectus surgical approach to treat acetabular fractures clinically,anatomical exploration can effectively reduce the risks in real surgery.Through the experiments of this study,the pararectus surgical approach can clearly reveal the acetabulum,especially the deep structures such as the quadrilateral,and at the same time realize the visualization of important neurovascular structures,which provides an anatomical basis for the clinical application of pararectus surgical approach to treat acetabular fractures.Part Ⅱ Clinical application of pararectus approach combined with 3D printing technology in acetabular fracturesObjective: Based on the anatomical study of the pararectus surgical approach in acetabular fractures,the therapeutic effect and clinical experience of the pararectus surgical approach combined with 3D printing technology in acetabular fractures were explored.Methods: A retrospective analysis of the data of 27 patients with acetabular fractures treated with pararectus surgical approach from October 2018 to August 2020.There were 21 males and 6 females;ages were 30-69 years old,with an average of 48.8 years old.According to the Judet-letournel classification,there were 9 cases of anterior column fractures,5 cases of anterior wall fractures,10 cases of double column fractures,and 3 cases of anterior column with posterior half transverse fractures.Before surgery,3D printing technology was used to print a model of the affected pelvis,and the model was used to simulate the sequence of fracture reduction,plate placement and pre-bending.Routine follow-up for 1,3,6 and 12 months after the operation,pelvic anteroposterior,closed oblique position,iliac oblique position and CT were taken to evaluate the fracture reduction,and the hip joint function was evaluated according to the modified Merle d’Aubigne and Postel scoring system.Results: In this group of 27 patients,the length of the surgical incision was 9-14 cm,with an average of 11cm;the operation time of the patients was 135-215 min,with an average of 153min;the intraoperative blood loss was 340-1050 ml,with an average of645 ml.The patient’s postoperative pelvic CT + three-dimensional reconstruction showed that the fracture was well reduced and the screw did not enter the articular surface;the fracture healing time was 12-16 weeks,with an average of 13 weeks.One patient developed postoperative wound infection,and the wound was completely healed through enhanced dressing change and effective antibiotics applied 28 days after the operation;A 61-year-old patient developed postoperative myositis ossificans,traumatic femoral head necrosis,collapsed and flat hip joint surface,and narrow joint space(ARCO Ⅳ)at 16 months after surgery.After that,a total hip replacement was performed in the joint surgery department of our hospital,and the postoperative recovery was good without other.There were no internal fixation loosening,fracture and other related complications in all follow-up patients.According to the modified Merle d’Aubigne and Postel scoring system,14 cases were excellent,8 cases were good,3 cases were fair,and 2 cases were poor.Conclusion: The pararectus approach can reduce and fix acetabular fractures in front of the acetabulum,especially the tetragonal acetabulum under direct vision.The 3D printed three-dimensional model can simulate the realistic operation environment before the operation,and design the order of fracture reduction,the position of the steel plate and the angle of the screw in,so as to make the operation scheme safer,more accurate and more individualized.The application of pararectus approach combined with 3D printing in the treatment of acetabular fractures is conducive to the treatment of acetabular fractures with small incisions and provides new ideas for the clinical treatment of acetabular fractures.