The pararectus approach in acetabular fracture fixation: evidence of reproducibility and learnability.

Abstract

<h4>Purpose</h4>The Pararectus approach is an anterior intrapelvic exposure introduced by Keel et al. for the management of anterior acetabular fractures. While its safety and effectiveness have been demonstrated, evidence regarding the learnability of this technically demanding method remains under discussion. This study compares the first fifty consecutive eligible cases treated by the approach's inventor (group A) with the first fifty independent cases performed by a surgeon without prior acetabular subspecialization (group B).<h4>Methods</h4>Consecutive patients representing the first 50 Pararectus cases for displaced acetabular fractures in group A (2009-2013) and group B (2017-2021) were included. Baseline demographics were comparable except for age (64 vs. 73 years, p = 0.001) and trauma mechanism (high-energy trauma more frequent in group A, 46% vs. 12%; p < 0.001). Group A was treated using manually contoured reconstruction and buttress plates, whereas group B was managed with a standardized traction-table setup and a precontoured suprapectineal plate system (p < 0.001). Operative time, intraoperative blood loss, intra- and postoperative complications, CT-based reduction quality, reoperations ≤ 30 days, and conversion to total hip arthroplasty (THA) ≤ 24 months were analyzed.<h4>Results</h4>The analyzed outcomes demonstrated comparable operative parameters between both groups: (i) Operative time averaged 172 min (range 50-339) in group A and 165 min (90-266) in group B (p = 0.19), (ii) intraoperative blood loss was 1000 ml (250-6000) in group A and 900 ml (200-4500) in group B (p = 0.09), (iii) intraoperative complications occurred in 5/50 (10%) in group A compared with 3/50 (6%) in group B (p = 0.71), (iv) CT-based reduction quality was anatomical in 36/50 (72%) in group A and 31/50 (62%) in group B, imperfect in 14/50 (28%) vs. 16/50 (32%), and poor in 0/50 (0%) vs. 3/50 (6%) (overall p = 0.17), (v) postoperative complications occurred in 7/50 (14%) in group A and 5/50 (10%) in group B (p = 0.75), (vi) of these, reoperations ≤ 30 days were required in 7/50 (14%) in group A and 1/50 (2%) in group B (p = 0.066), (vii) conversion to THA ≤ 24 months was required in 5/50 (10%) in group A and 2/50 (6%) in group B (p = 0.70), with a mean time to THA of 13.8 months vs. 5.8 months (p = 0.22).<h4>Conclusion</h4>Operative parameters, reduction quality, postoperative complications, and conversion to THA ≤ 24 months were comparable between the two surgeons. These findings indicate that, within a standardized workflow and instrumentation, the Pararectus approach can be applied safely and reproducibly even during the early phase of independent practice.