Clinical Efficacy Of The Lateral-rectus Approach In The Elderly With Acetabular Fracture

Background:The acetabular fractures may be the most challenging fractures for the orthopedic trauma surgeons because of the special region of anatomy,irregular anatomy morphology,and a variety of fracture types of acetabulum.The difficulty and the risk of surgery are increased by their general condition,bone quality,and their restricted physiological reserves.Accurate anatomic reduction and firm fixation can be obtained easily through a suitable approach providing an adequate operative field for the surgeons.Because the ilioinguinal approach can provide a wide view of the anterior column and the inner surface of the posterior column,it is the standard for the treatment of anterior acetabular fractures which is the major acetabular fractures of older patients.However,the ilioinguinal approach might be suboptimal because of the longer operating time,increased blood loss,and the high rate of soft tissue complications.Modified Stoppa approach has the advantages of minimal trauma and sufficient exposure.It is also widely used in the treatment of acetabular fractures in the elderly.However,it requires combined iliac fossa approach for high acetabular fractures and sacroiliac joint dislocation.The lateral-rectus approach,a novel anterior approach which provides adequate exposure of the anterior columns,the inner surface of posterior column and the quadrilateral plate with the less injury,is used for the complicated acetabular fractures in adults with good functional and radiological outcomes.And it may be a better choice for the elderly patients suffering acetabular fractures.However,the lateral-rectus approach for the treatment of acetabular fractures in the elderly has not been reported.Purpose:This study aims to examine the clinical efficacy and surgical techniques of the lateral-rectus approach for treatment of acetabular factures in elderly patients.Methods:After appropriate exclusion,65 elderly patients with an acetabular fracture who was treated through the lateral-rectus approach from January 2011 and October 2016 were selected retrospectively.By analyzing the medical records retrospectively,the patients,characteristics,fracture type,mechanism of injury,comorbid conditions,ASA class,operative time,intra-operative blood loss,and post-operative complications were assessed.Clinical examination radiographs have been taken,align with the Matta evaluation system.Functional outcomes were evaluated using the modified Merle D' Aubigne-Postel score.Results:All 65 patients had undergone the single lateral-rectus approach successfully.Surgery duration was 101.23 min on average(45-210 min)5 and intra-operative bleeding was 798.46 ml on average(250-1800 ml).According to the Matta radiological evaluation,the quality of reduction evaluated 1 week after surgery was rated as"anatomical"in 41(63.1%)cases,"imperfect"in 12(18.5%)cases,and"poor"in 12(18.5%)cases,with the overall excellent and good rate was 81.5%.The modified Merle D'Aubigne-Postel score performed 18 months after surgery was categorized as excellent in 40(61.5%)cases,good in 10(15.4%)cases,and fair in 15(23.1%)cases,with the overall excellent and good rate was 76.9%.Several complications were found,including screw loosening in 10 cases,fat liquefaction of incision in 2 cases,deep vein thrombosis in 2 cases,and temporary weakness of hip adductors in 5 cases.The injury of the lateral femoral cutaneous nerve and obturator nerve did not occur in any case.At the final follow-up,all the patients gained bone union and none of them had heterotopic ossification.Conclusions:The both-column and quadrilateral plate fractures can be concurrently replaced and rigidly fixed in direct sight via a single lateral-rectus approach.Moreover,the fragility fractures in an older population also can be fixed stably and get good functional and radiological outcomes.The lateral-rectus approach is a valuable alternative to the ilioinguinal and modified Stoppa approach,being the treatment of acetabular fractures in elderly patients.Moreover,the lateral-rectus approach is worth to be further promoted and researched.