Advantages of Anterior Retroperitoneal Approach in Osteosynthesis of Pelvic Fractures. Summary of the Doctoral Thesis

Abstract

Scientific and technical progress has conditioned the rise in the number of high energy traumas of the musculoskeletal system. Simultaneously, the number of pelvic fractures has proportionally risen, on average they constitute up to 3% of the total number of bone fractures. The majority of pelvic fractures, i.e. approximately 75%, are considered to be severe and critical musculoskeletal injuries. Pelvic fractures are diagnosed in 18% of cases in the polytrauma patients. Open pelvic fractures constitute 1% of the total number of pelvic fractures, in turn, according to the data provided by different authors, mortality rate in case of open pelvic fractures may reach 50%. Pelvic fractures, intra-articular fractures in particular, relatively often (~10% cases) lead to permanent disability due to the development of posttraumatic osteoarthrosis in hip joints and the following endoprosthetic replacement of the hip joint. Although the application of ilioinguinal approach has yielded good practical results, treatment results necessitate that new approaches in surgical treatment are sought. For example, extraperitoneal approach performed through a lower midline incision was first described by E. Hirvensalo in 1992 and L.D. Cole in 1994. This surgical treatment approach in case of pelvic ring and acetabular fractures is relatively widely used in the USA and Finland. In Latvia, this approach to the treatment of pelvic ring and acetabular fractures was introduced in 2008 by the author of the present Thesis at RAKUS Clinic of Traumatology and Orthopaedics (The Head of the Department and scientific supervisor of the Doctoral Thesis professor A. Jumtiņš, the Head of the Clinic Dr. med. G. Lācis). Using this surgical approach, 48 patients were operated in the period from October 2008 to May 2012. The treatment results of 35 patients out of 48 have been analysed in the present study. 34 patients from the control group were operated using conventional anterior ilioinguinal approach. The present study provides a comprehensive review of the opportunities offered by the application of the surgical treatment approach under discussion, its complications, results and advantages over other surgical approaches, using this approach in the treatment of the patients with unstable pelvic ring and acetabular fractures. Having summarised and analysed research results, the author has developed an algorithm for the application of various surgical approaches to be used in the treatment of pelvic fractures depending on the type of fracture. The study was conducted in the period of four years. On average, about 12 pelvic surgical operations were performed annually on the previously systematised patients. Based on the exclusion and inclusion criteria, out of 48 patients treated using anterior retroperitoneal method, treatment results of only 35 patients were analysed. In the control group, the data of 34 patients were systematised and their treatment results were analysed. Processing of radiological examination data and the measurements were performed in the digital form using Centricity PACS-IW software and local intranet. Mathematical measuring and Majeed functional scoring scales were used in further processing of the obtained data. The work hypothesis nominated – front extraperitoneal approach compared to ilioingvinal approach in cases of complex pelvic fracture allows shorter operative time, less intraoperative blood loss, smaller perioperative hemotransfusion amount, better postoperative radiological parameters of the pelvic bone fragments and late postoperative functional results. The aim of the study – to explore the anterior retroperitoneal and ilioingvinal surgical approach of operative and postoperative period of the clinical and radiological parameters as well as differences in postoperative functional outcomes in patients with complex pelvic fractures, and based on the results obtained, to elaborate and develop recommendations for implementation in practical traumatology surgery. Conclusions. The analysis of surgical parameters (duration of surgery, blood loss during surgery, hemotransfusion amount), surgical correction of postoperative radiological parameters and late postoperative functional results in patients with complex pelvic fractures, in cases of the anterior retroperitoneal approach are statistically significantly better than in cases of ilioingvinal approach. Anterior retroperitoneal approach in cases of complex pelvic fracture is safe and provides qualitative pelvic bone fragments for osteosynthesis.