Skip to main content

Advertisement

SpringerLink
Log in

A new modified pararectus approach and visualization: an anatomical study

  • Trauma Surgery
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Hauschild O, Strohm PC, Culemann U, Pohlemann T, Suedkamp NP, Koestler W, Schmal H (2008) Mortality in patients with pelvic fractures: results from the German pelvic injury register. J Trauma 64:449–455. https://doi.org/10.1097/TA.0b013e31815982b1

    Article  PubMed  Google Scholar 

  2. Bastian JD, Tannast M, Siebenrock KA, Keel MJ (2013) Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach. Injury 44:1793–1798. https://doi.org/10.1016/j.injury.2013.08.009

    Article  CAS  PubMed  Google Scholar 

  3. Meena S, Sharma PK, Mittal S, Sharma J, Chowdhury B (2017) Modified stoppa approach versus ilioinguinal approach for anterior acetabular fractures; a systematic review and meta-analysis. Bull Emerg Trauma 5:6–12

    CAS  PubMed  PubMed Central  Google Scholar 

  4. Keel MJ, Bastian JD, Büchler L, Siebenrock KA (2013) Anteriore Zugänge zum Acetabulum [Anterior approaches to the acetabulum]. Unfallchirurg 116:213–220. https://doi.org/10.1007/s00113-012-2332-7

    Article  CAS  PubMed  Google Scholar 

  5. Keel MJ, Ecker TM, Cullmann JL, Bergmann M, Bonel HM, Büchler L, Siebenrock KA, Bastian JD (2012) The Pararectus approach for anterior intrapelvic management of acetabular fractures: an anatomical study and clinical evaluation. J Bone Joint Surg Br 94:405–411. https://doi.org/10.1302/0301-620X.94B3.27801

    Article  CAS  PubMed  Google Scholar 

  6. Keel MJB, Siebenrock KA, Tannast M, Bastian JD (2018) The pararectus approach: a new concept. JBJS Essent Surg Tech 8:e21. https://doi.org/10.2106/JBJS.ST.17.00060

    Article  PubMed  PubMed Central  Google Scholar 

  7. Von Rüden C, Wenzel L, Becker J, Thannheimer A, Augat P, Woltmann A, Bühren V, Perl M (2019) The pararectus approach for internal fixation of acetabular fractures involving the anterior column: evaluating the functional outcome. Int Orthop 43:1487–1493. https://doi.org/10.1007/s00264-018-4148-8

    Article  Google Scholar 

  8. Xia G, Yang X, Xiong R, Zhang X, Shao Y, Du G, Li T, Mai Q, Wang H, Fan S (2015) Pararectus approach for treatment of acetabular both-column fracture combined with translocation of quadrilateral surface. Zhonghua Wai Ke Za Zhi 53:700–703

    PubMed  Google Scholar 

  9. Wenzel L, von Rüden C, Thannheimer A, Becker J, Brand A, Augat P, Perl M (2020) The pararectus approach in acetabular surgery: radiological and clinical outcome. J Orthop Trauma 34:82–88. https://doi.org/10.1097/BOT.0000000000001636

    Article  PubMed  Google Scholar 

  10. Bastian JD, Savic M, Cullmann JL, Zech WD, Djonov V, Keel MJ (2016) Surgical exposures and options for instrumentation in acetabular fracture fixation: pararectus approach versus the modified Stoppa. Injury 47:695–701. https://doi.org/10.1016/j.injury.2016.01.025

    Article  CAS  PubMed  Google Scholar 

  11. Reinert CM, Bosse MJ, Poka A, Schacherer T, Brumback RJ, Burgess AR (1998) A modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg Am 70:329–337

    Article  Google Scholar 

  12. Routt ML, Swiontkowski MF (1990) Operative treatment of complex acetabular fractures. Combined anterior and posterior exposures during the same procedure. J Bone Joint Surg Am 72:897–904

    Article  PubMed  Google Scholar 

  13. Pohlemann T, Herath SC, Braun BJ, Rollmann MF, Histing T, Pizanis A (2020) Anterior approaches to the acetabulum: which one to choose? EFORT Open Rev 5:707–712. https://doi.org/10.1302/2058-5241.5.190061

    Article  PubMed  PubMed Central  Google Scholar 

  14. Letournel E (1993) The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 292:62–76

    Article  Google Scholar 

  15. Archdeacon MT (2015) Comparison of the ilioinguinal approach and the anterior intrapelvic approaches for open reduction and in- ternal fixation of the acetabulum. J Orthop Trauma 29:S6–S9. https://doi.org/10.1097/BOT.0000000000000270

    Article  PubMed  Google Scholar 

  16. Hirvensalo E, Lindahl J, Kiljunen V (2007) Modified and new approaches for pelvic and acetabular surgery. Injury 38:431–441. https://doi.org/10.1016/j.injury.2007.01.020

    Article  PubMed  Google Scholar 

  17. Guo HZ, He YF, He WQ (2019) Modified Stoppa approach for pelvic and acetabular fracture treatment. Acta Ortop Bras 27:216–219. https://doi.org/10.1590/1413-785220192704188933

    Article  PubMed  PubMed Central  Google Scholar 

  18. Becker CA, Linhart C, Bruder J, Zeckey C, Greiner A, Cavalcanti Kußmaul A, Weidert S, Suero EM, Böcker W, Kammerlander C (2021) Cementless hip revision cup for the primary fixation of osteoporotic acetabular fractures in geriatric patients. Orthop Traumatol Surg Res 107:102745. https://doi.org/10.1016/j.otsr.2020.102745

    Article  PubMed  Google Scholar 

  19. Märdian S, Schaser KD, Hinz P, Wittenberg S, Haas NP, Schwabe P (2015) Fixation of acetabular fractures via the ilioinguinal versus pararectus approach: a direct comparison. Bone Joint J 97:1271–1278. https://doi.org/10.1302/0301-620X.97B9.35403

    Article  PubMed  Google Scholar 

  20. Manrique J, Paskey T, Tarabichi M, Restrepo C, Foltz C, Hozack WJ (2019) Total hip arthroplasty through the direct anterior approach using a bikini incision can be safely performed in obese patients. J Arthroplasty 34:1723–1730. https://doi.org/10.1016/j.arth.2019.03.060

    Article  PubMed  Google Scholar 

  21. Kacra BK, Arazi M, Cicekcibasi AE, Büyükmumcu M, Demirci S (2011) Modified medial Stoppa approach for acetabular fractures: an anatomic study. J Trauma 71:1340–1344. https://doi.org/10.1097/TA.0b013e3182092e8b

    Article  PubMed  Google Scholar 

  22. Okcu G, Erkan S, Yercan HS, Ozic U (2004) The incidence and location of corona mortis: a study on 75 cadavers. Acta Orthop Scand 75:53–55. https://doi.org/10.1080/00016470410001708100

    Article  PubMed  Google Scholar 

  23. Tornetta P, Hochwald N, Levine R (1996) Corona mortis. Incidence and location. Clin Orthop Relat Res 329:97–101

    Article  Google Scholar 

  24. Ponsen KJ, Joosse P, Schigt A, Goslings JC, Luitse JS (2006) Internal fracture fixation using the Stoppa approach in pelvic ring and acetabular fractures: technical aspects and operative results. J Trauma 61:662–667. https://doi.org/10.1097/01.ta.0000219693.95873.24

    Article  PubMed  Google Scholar 

  25. Atlihan D, Tekdemir I, Ates Y, Elhan A (2000) Anatomy of the anterior sacroiliac joint with reference to lumbosacral nerves. Clin Orthop Relat Res 376:236–241. https://doi.org/10.1097/00003086-200007000-00032

    Article  Google Scholar 

  26. Becker CA, Kammerlander C, Cavalcanti Kußmaul A, Dotzauer F, Woiczinski M, Rubenbauer B, Sommer F, Linhart C, Weidert S, Zeckey C, Greiner A (2018) Minimally invasive screw fixation is as stable as anterior plating in acetabular T-Type fractures—a biomechanical study. Orthop Traumatol Surg Res 104:1055–1061. https://doi.org/10.1016/j.otsr.2018.06.013

    Article  PubMed  Google Scholar 

Download references

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Orthopedics and Traumatology, Haseki Training and Research Hospital, Istanbul, Turkey

    Dogan Atlihan & Mahmud Aydin

  2. Department of Orthopedics and Traumatology, Aksaray University Education Research Hospital, Aksaray, Turkey

    Sercan Capkin

  3. Department of Orthopedics and Traumatology, University of Missouri Kansas City, Kansas City, USA

    Serkan Surucu

  4. Mersin City Training and Research Hospital, Mersin, Turkey

    Fatih Gunaydin

  5. Department of Anatomy, Faculty of Medicine, Ankara University, Ankara, Turkey

    Halil Ibrahim Acar

Authors
  1. Dogan Atlihan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mahmud Aydin
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sercan Capkin
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Serkan Surucu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Fatih Gunaydin
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Halil Ibrahim Acar
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Dogan Atlihan.

Ethics declarations

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

Ethical approval

Ethics committee approval was obtained (Approval number: i8-565-21).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (MP4 310529 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Atlihan, D., Aydin, M., Capkin, S. et al. A new modified pararectus approach and visualization: an anatomical study. Arch Orthop Trauma Surg 143, 2493–2501 (2023). https://doi.org/10.1007/s00402-022-04478-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00402-022-04478-2

Keywords

Search

Navigation