The pararectus approach combined with 3D printing technique was introduced for treatment of acetabular fractures. The main suggested advantage in comparison to conventional approaches was to simplify the treatment of specific fracture patterns with less invasive tissue dissection. The pararectus approach can be used to fix the acetabular anterior and quadrilateral acetabular fractures under direct vision. Additionally, application of 3D printing technique can directly observe the fracture morphology of the acetabulum and pre-bend of the steel plates before surgery.
Due to the special anatomical position of the acetabulum and its relationship with surrounding tissues, the anatomical reduction of the articular surface has become the treatment target for displaced acetabular fractures .Appropriate surgical approach can not only reduce the injury of the patient, shorten the operation time, but also realize the visualization of the fracture, which helps to the reduction and fixation of the fracture.
The pararectus approach, as reported by Keel in 2012, was used to treat acetabular fractures predominantly involving the anterior column and the quadrilateral plate .Compared with the traditional ilioinguinal approach and the modified Stoppa approach,the pararectus approach has the advantages of less trauma, no need to dissect important nerve and blood vessels, and less damage to tissues. At the same time, because the incision is located on the same side of the fracture, it is closer to the acetabulum and can look directly at the front of the acetabulum, which is of great significance for the reduction and fixation of the fracture .
Keel et al. reported that in the treatment of 48 cases of acetabular fractures, the pararectus approach was used to provide clear fracture visualization; the average incision length was 11 cm, which reduced soft tissue damage;Bastian et al.Research shows that, compared with the modified Stoppa approach, the pararectus approach can reveal more false pelvis, and the posterior ring can be fixed without additional surgical approach.Mardian et al. reported that in the comparative study of the pararectus approach and the ilioinguinal approach, the pararectus approach was superior to the ilioinguinal approach in reducing the gap between the fracture blocks.
As the application of 3D printing technology in orthopedics becomes more and more mature, when we understand the classification and displacement of fracture, the process of getting rid of the traditional two-dimensional imaging data obtained only before surgery and constructing a three-dimensional morphology in mind.The 3D printed fracture model can be more convenient to observe the shape of the fracture block, which helps orthopedists to stereoscopically locate the acetabular fracture. At the same time, the application of 3D printing technology can enable orthopedic surgeons to pre-design the fracture reduction sequence, the position of the steel plate and the screwing angle of the screw according to the characteristics of the fracture. In the study by Tack p and Martellini et al. the application of 3D printing technology reduced the patient's operation time, intraoperative blood loss, and also reduced intraoperative and postoperative complications .
When dealing with acetabular fractures, we often need a complete preoperative examination, preoperative evaluation, and choice of surgical approach. Attention should be paid to the treatment of acetabulum fracture by the pararectus approach: ① A single incision cannot be used for fractures of the posterior wall with acetabular joints, and a combined Kocher—Langenbeck approach is often required. For patients who need the Kocher—Langenbeck combined approach, adopt a "floating" position before disinfecting the towels, which is conducive to changing to the supine or lateral position as needed during the operation and reducing the operation time;② For patients with severe extra peritoneal adhesions, consider using this surgical approach as appropriate;③ The surgeon must be familiar with the anatomy of the abdomen, and in patients with peritoneal rupture, suture it in time;"Death crown" blood vessels are the anastomotic arteriovenous system of the inferior abdominal wall or the external iliac arteriovenous system and the obturator artery and vein . This surgical approach can view it directly above the medial obturator of the superior pubic branch, once found, it should be ligated to prevent the tear of the blood vessel caused by traction during fracture reduction, resulting in uncontrollable bleeding .
The main limitation of this study is its small size from a single institution. Owing to the relatively short follow-up time in this study, the mid-to-long-term clinical efficacy requires further follow-up of patients.