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.

Background: In elderly patients who have sustained an acetabular fracture involving disruption of the quadrilateral plate (QLP), postoperative loading of the joint beyond the level of partial weight-bearing can result in medial redisplacement of the QLP. The purpose of this biomechanical study was to compare the performances of 4 different fixation constructs intended to prevent medial redisplacement of the QLP. Methods: Anterior column posterior hemitransverse (ACPHT) fractures with disruption of the QLP were created on synthetic hemipelves (fourth-generation Sawbones models) and subsequently stabilized with (1) a 12-hole plate bridging the QLP (Group 1), (2) the plate with added periarticular screws along the QLP (Group 2), (3) the plate combined with an infrapectineal buttress plate (Group 3), or (4) the plate with the added periarticular screws as well as the buttress plate (Group 4). The point of load application on the acetabulum was defined to be the same as the point of application of maximum vertical hip contact force during normal walking. Loads were applied to simulate either partial weight-bearing (20 cycles, from 35 to 350 N) or inadvertent supraphysiologic loads (linearly increasing loads until the onset of failure, defined as fragment displacement of >3 mm). A universal testing machine was synchronized with a digital image correlation system to optically track redisplacement at the QLP. The level of significance was set at p < 0.05. Results: During experimental simulation of partial weight-bearing, maximum fracture step openings never exceeded 2 mm. During simulation of inadvertent supraphysiologic load, the median load to failure was higher (p < 0.05) in Group 2 (962 N; range, 798 to 1,000 N) and Group 4 (985 N; range, 887 to 1,000 N) compared with Group 1 (445 N; range, 377 to 583 N) and Group 3 (671 N; range, 447 to 720 N). Conclusions: All 4 fixation constructs performed in an acceptable manner on testing with simulated partial weight-bearing. Only additional periarticular screws along the QLP increased the fixation strength. Clinical Relevance: Redisplacement of the QLP resulting in an incongruency of the hip joint has been associated with poor long-term outcomes. Within the constraints of this study, periarticular long screws were superior to infrapectineal buttress plates in preventing medial redisplacement of the QLP.

Background: The modified Stoppa approach is performed for safe and efficient management of acetabular fractures involving the anterior column. This approach avoids dissection of the inguinal canal, the femoral nerve, and the external iliac vessels as seen in the “second window” of the ilioinguinal approach and has thus been shown to be less invasive than the ilioinguinal approach ¹ . As an intrapelvic approach, it facilitates the management of medial displacement fracture patterns involving the quadrilateral plate and dome impaction that typically occur in the elderly ^2,3 . The reduced morbidity of this approach is of particular relevance for elderly patients who must respond to the stresses of injury and surgery with diminished physiological reserves. Description: The specific surgical steps include preoperative planning, patient positioning and setup, a Pfannenstiel incision, superficial and deep dissection, development of the Retzius space and retraction of the bladder, exposure of the superior pubic ramus and iliopectineal eminence, dissection and ligation of a potential corona mortis, exposure of the obturator nerve and vessels, subperiosteal preparation of the pubic ramus with retraction of the external iliac vessels, subperiosteal exposure of the quadrilateral plate with detachment of the internal obturator muscle and exposure of the posterior column, assessment of residual displacement by fluoroscopic views, longitudinal soft-tissue or lateral skeletal traction (optional) for reduction of medial displacement of the femoral head, disimpaction of the acetabular dome fragment and grafting of the supra-acetabular void (optional) under fluoroscopic and arthroscopic (optional) control, and reduction and fixation of extra-articular components (iliac wing posteriorly and pubic ramus anteriorly), the posterior column (infra-acetabular screw), and the quadrilateral plate (buttress plate). Before wound closure, the urine output is checked for occurrence of hematuria, an indication of bladder penetration. The anterior lamina of the rectus sheath is then sutured, and a layered closure performed. Alternatives: The ilioinguinal approach might be used instead. Rationale: The modified Stoppa approach avoids dissection within the inguinal canal, the second window of the ilioinguinal approach. Therefore, this approach is less invasive and might be an alternative for joint-preserving surgery, especially in the elderly.