Evolving strategies for both-column fractures: From ilioinguinal to pararectus approach with anatomical quadrilateral...

The pararectus approach has emerged as an alternative to the traditional ilioinguinal approach for complex both-column (BC) fractures of the acetabulum. Concurrently, suprapectineal plates have evolved to enhance anatomical fixation of the quadrilateral surface (QLS) and restore joint congruency. This study aimed to answer the following questions: Does the pararectus approach provide comparable articular reduction to the ilioinguinal approach in BC fractures? Does it reduce operative time and blood loss? Are mid-term functional outcomes similar? We hypothesized that the pararectus approach, combined with anatomical QLS plating, would yield similar reduction quality and functional outcomes while decreasing surgical time and blood loss compared to the ilioinguinal approach.

This retrospective, single-center study included 43 patients with BC fractures treated between 2009 and 2022. Patients were divided into two groups: ilioinguinal approach with conventional suprapectineal plate (II, n = 15) and Pararectus approach with anatomical QLS plate (PR, n = 28). Pre- and postoperative CT scans assessed axial, coronal, and sagittal residual gap, step and femoral head displacement. Operative time, blood loss, transfusion needs, and complications were recorded. Functional outcomes were assessed at two years using the Harris Hip Score (HHS) and PMA score.

Articular gap reduction was similar: axial (II: 5.0 ± 2.9 mm vs. PR: 4.6 ± 5.1 mm, p = 0.3), coronal (II: 5.7 ± 2.4 mm vs. PR: 5.6 ± 5.5 mm, p = 0.2), sagittal (II: 5.6 ± 2.8 mm vs. PR: 6.4 ± 6.5 mm, p = 0.6). Residual coronal step was lower in PR (1.9 ± 2.0 mm vs. 3.6 ± 1.9 mm, p = 0.01). Anterior femoral head displacement improved in PR (-1.7 mm vs. + 5.6 mm, p < 0.001). Medial (5.9 mm vs. 3.98 mm, p = 0.4) and proximal displacement (1.1 mm vs. 1.2 mm, p = 0.46) were comparable. Operative time (PR: 125.1 ± 37.9 min vs. II: 309 ± 85.5 min, p < 0.001) and postoperative transfusions (p = 0.01) were significantly reduced in PR. Functional outcomes were comparable (HHS and PMA good-to-excellent: II: 70% vs. PR: 70%, p = 0.9).

The shift from the ilioinguinal to the pararectus approach with QLS plate fixation appears to offer at least equivalent reduction quality while reducing surgical time, transfusion needs, and complications. These findings support evolving strategies in BC fracture management and highlight the key role of implant design. Further prospective studies are needed to confirm these results over the long term.

Level III: comparative cohort study.