The Pararectus Approach: A New Concept

BACKGROUND: Even 50 years after the introduction of the extrapelvic ilioinguinal approach for open reduction and internal fixation of acetabular fractures involving predominantly the anterior column, this approach is still acknowledged as being the so-called gold standard(1). The pattern of acetabular fractures has changed within the last 10 to 20 years(2,3), with a greater prevalence of quadrilateral plate fractures that is due in part to the increase in elderly trauma. The intrapelvic approach, also called the modified Stoppa approach(4-6), was introduced as a less invasive alternative to the extrapelvic ilioinguinal approach, mostly combined with the first window of the ilioinguinal approach. The Pararectus approach also offers intrapelvic surgical access and has demonstrated safe surgical dissection with enhanced exposure and favorable outcome compared with the Stoppa approach(7-10). DESCRIPTION: The skin incision runs along the lateral border of the rectus abdominis muscle to develop the anterior rectus sheath. The retroperitoneal space lateral to the rectus abdominis muscle is entered and the inferior epigastric vessels and the round ligament in females or the spermatic cord in males are identified. The superior pubic ramus and the iliopectineal eminence are exposed. If the corona mortis vessels (a vascular anastomosis between the obturator vessels and the external iliac artery) are present, they are ligated. The obturator nerve and vessels are exposed. The dissection is then directed posteriorly under retraction of the external iliac vessels with further subperiosteal exposure of the pubic ramus, the quadrilateral plate, and the posterior column. Any nonessential iliolumbar vessels are ligated. Residual displacement is assessed with fluoroscopic views. For reduction of a medially displaced femoral head, longitudinal extremity soft tissue or lateral skeletal traction (optional), with a Schanz pin in the greater trochanter, is used. For disimpaction of acetabular dome fragments and grafting of a supra-acetabular void (optional), a fluoroscopy unit is used to assess reduction and identify the void; in addition, arthroscopy can be used. The scope is introduced through the fracture gap to check for reduction without any water or specific setup. For reduction and fixation of extra-articular components (iliac wing posteriorly and superior pubic ramus anteriorly), the posterior column, and the quadrilateral plate, the fluoroscopy unit is used. The anterior lamina of the rectus sheath is sutured, and a layered closure performed. ALTERNATIVES: The ilioinguinal or modified Stoppa approach might be used instead. RATIONALE: The Pararectus approach combines the advantages of the ilioinguinal approach and the Stoppa approach. The Pararectus approach facilitates surgical access directly above the hip joint, which is comparable with the access obtained through the second window of the ilioinguinal approach, but without dissection of the inguinal canal. Moreover, the Pararectus approach provides intrapelvic visualization that is at least equivalent to that offered by the Stoppa approach but without losing any direct access to the hip joint.