Clinical Application Of The Lateral-rectus Approach For The Treatment Of Old Pelvic Fractures Complicated With Nerve Injuries

Background:Pelvic fractures are often associated with severe combined injuries that require early treatment.It is difficult to treat the fracture at the early stage of injury and the treatment time is long,the fractures often develop into old fractures.Because old pelvic fracture is often associated with pelvic bone structure abnormalities,the level of the surrounding tissue is not clear,nerve injuries causing by the pulling of displaced bone or compression of the sacral foramen fractures are not diagnosed definitely,so its treatment has been a difficult point of orthopedic trauma doctors.At present,no matter what kind of treatment is used,there are some perioperative problems such as large trauma,long operation time,large amount of bleeding,difficult reduction,and nerve and blood vessel injury.Therefore,the objective of this study was to investigate the treatment of old pelvic fracture complicated with nerve injuries through the Lateralrectus Approach(LRA),in order to achieve osteotomy and correcting pelvic deformity,reduction and fixation of fracture,and neurolysis of lumbosacral plexus through single anterior surgical approach,so as to reduce surgical trauma and complications,and finally achieve relatively satisfactory clinical results.Purpose:we retrospectively analyzed and evaluated the clinical outcomes of old pelvic fractures complicated with nerve injury treated by using osteotomy and correcting pelvic deformity,reduction and fixation,and neurolysis of lumbosacral plexus via LRA.Methods:1.Data of 10 patients with old pelvic fractures and nerve injuries treated by LRA from June 2015 to June 2019 were retrospectively analyzed to collect intraoperative data,and the quality of fracture reduction was evaluated by imageology criteria of Mears and Velyvis,the clinical outcome was assessed at the end of the follow-up using the Majeed pelvic score,and the recovery of nerve function was assessed using the criteria developed by the Nerve Injuries Committee of the British Medical Research Council(BMRC).2.The data of 12 patients with old sacral fractures complicated with sacral plexus injury treated by LRA from January 2013 to June 2019 were retrospectively analyzed to collect intraoperative data.The enlargement of sacral foramen and decompression of sacral plexus were evaluated by X-ray and CT,and the recovery of nerve function was evaluated by the criteria of BMRC at the last follow-up.Results:1.The operation time of 10 patients was 80～240 min,with an average of 133.5 min.The bleeding volume was 200～2400 mL,with an average of 1030.0 mL.The quality of reduction was evaluated after operation:anatomical reduction in 6 cases,satisfactory reduction in 3 case,unsatisfactory reduction in 1 case,and the satisfactory rate was 90.0%.The average follow-up was 19.2 months and the average healing time was 8.2 weeks.The Majeed clinical efficacy score of the latest follow-up was improved from the average 51 points preoperative to 85 points postoperative.Among them,the results were excellent in 6 cases,good in 2 case and fair in 2 case,the excellent and good rate was 80.0%.The recovery of nerve function was evaluated by the criteria of BMRC:6 cases recovered completely,4 cases recovered partially,and the effective rate was 100.0%.2.Of the 12 patients,11 successfully completed the operation,and 1 patient was terminated because of the complete occlusion of S1 foramen and the failure to complete sacral foramen.The operation time was 75～140 min,with an average of 95.8 min.The bleeding volume was 200～1100 mL,with an average of 615.0 mL.X-ray film and CT showed enlargement of sacral foramen after operation.The mean follow-up time was 21.3 months.The Majeed clinical efficacy score of the latest follow-up was improved from the average 59 points preoperative to 88 points postoperative.Among them,the results were excellent in 8 cases,good in 3 case and fair in 1 case,the excellent and good rate was 91.7%.The nerve function recovery was evaluated according to the criteria of BMRC:complete recovery in 6 cases,partial recovery in 5 cases,no recovery in 1 case,and the effective rate was 91.7%.Conclusions:The LRA can fully expose the anterior ring of pelvis,the periphery of the sacroiliac joint and the presacral structures.For the nerve injuries with different injury mechanism,the nerves can be further decompressed by osteotomy,fracture reduction and internal fixation,presacral decompression,enlargement of sacral foramen and so on via the LRA,which can create the conditions for the recovery of nerves function,and finally achieved relatively satisfactory clinical results.So it is a feasible surgical method for the treatment of old pelvic fracture complicated with nerve injury.