Surgical Approaches for Fractures of the Acetabulum Original Author: Mark C. Reilly, MD Created February 2004, Updated 2007 Philip Kregor, MD 2011

Treatment ProtocolRadiographs Allow Proper Fracture ClassificationFracture Location and Displacement Determine Need for SurgeryFracture Pattern Determines Approach

Surgical ApproachSingle Approach PreferredKocher LangenbeckIlioinguinalExtended iliofemoral

Kocher-LangenbeckApproach to posterior column and posterior articular surfaceKocher (1874)Langenbeck (1904)Judet, Lagrange (1958)Letournel

Indications for Kocher-LangenbeckPosterior Wall FracturesPosterior Column FracturesPosterior Column / Posterior Wall FracturesJuxta-tectal / Infra-tectal Transverse or Transverse with Posterior Wall FracturesSome T-shaped Fractures

Kocher-Langenbeck: AccessEntire Posterior ColumnGreater and Lesser Sciatic NotchesIschial SpineRetro-Acetabular SurfaceIschial Tuberosity

Kocher Langenbeck: Access

Position: Kocher-LangenbeckLateral or Prone PositionRadiolucent TableHip Extended, Knee FlexedDistal Femoral Traction if prone

Prone PositionAids in Reduction of Transverse FracturesImproves Quadrilateral Surface AccessAllows Clamp Placement through Greater Sciatic NotchControls Position of Hip, Minimizes Sciatic Nerve Stretch

Kocher-Langenbeck: Incision6 to 8 cm from PSISTip of Greater TrochanterParallel Shaft of Femur 15-20 cm

Dissection: Kocher-LangenbeckDivide Iliotibial BandSeparate Fibers of Gluteus MaximusSuperior 1/3: Superior Gluteal ArteryInferior 2/3: Inferior Gluteal ArterySplit to Inferior Gluteal Nerve Branch

Dissection: Kocher-LangenbeckRelease Gluteus Maximus Insertion Identify Sciatic Nerve on Border of Quadratus Femoris Muscle

Dissection: Kocher-LangenbeckRelease Piriformis Tendon >1cm from trochanterRelease Conjoint TendonOpen Obturator Internus Bursa for Sciatic Nerve Retractor

Femoral Head Blood SupplyDeep Branch of Medial Femoral CircumflexMay be injured by:Detaching quadratusReflecting obturator internus or piriformis too close to trochanter

Sciatic Nerve Anatomy84%: Anterior to Piriformis12%: Peroneal Division through Piriformis3%: Peroneal Division Posterior to Piriformis / Tibial Division anterior to Piriformis1%: Entire Nerve through Piriformis Hollinshead, WH 1982

Hollinshead, WH 1982

Dissection: Kocher-LangenbeckSubperiosteal Elevation of: Greater Sciatic NotchQuadrilateral SurfaceGluteus MinimusDebridement of Fracture EdgesAvoid Devascularization of Fx Fragments

Complications: Kocher-LangenbeckInfection 2-5%Sciatic Nerve palsy 3-5%Heterotopic Ossification 8-25%

Trochanteric FlipSeibenrock, Ganz (Berne)Improved Cranial, Anterior exposure of innominate boneDirect intra-articular evaluation of joint, reductionMost useful for PW fractures with extension to the supraacetabular ilium

Ortho Uni BerneTrochanteric Flip

Ilioinguinal ApproachDeveloped by Letournel after extensive cadaveric anatomical studyApproach to the anterior column and anterior articular surface

Ilioinguinal Approach: IndicationsAnterior WallAnterior ColumnTransverse with Anterior > Posterior DisplacementAnterior Column / Posterior HemitransverseAssociated Both Column

Ilioinguinal Approach: AccessSI Joint Internal Iliac FossaPelvic BrimQuadrilateral SurfaceSuperior Pubic RamusLimited Access to External Iliac Wing

Ilioinguinal Approach: Access

Ilioinguinal: PositionSupineDistal Femoral TractionAccess to Greater Trochanter (Lateral Traction)Hip flexed 20

Ilioinguinal: Incision3-4 cm cranial to Symphysis pubisCurve to ASISParallel Iliac CrestPast Most Convex Portion of Iliumanterior 2/3

SymphysispubisASIS

Dissection: IlioinguinalSubperiosteal Dissect Internal Iliac FossaOrigin of Abdominals and IliopsoasExpose Sacroiliac JointDissect over Pelvic Brim

Internal IliacFossa

Dissection: IlioinguinalIncise External Oblique AponeurosisFrom ASIS to midline1 cm proximal to External Inguinal RingExpose Floor of Inguinal CanalRetract Spermatic Cord/Round LigamentProtect Ilioinguinal Nerve

External ObliqueIlioinguinal NerveSpermatic Cord

Dissection: IlioinguinalIncise Inguinal LigamentLeave 1-2 mm with Internal Oblique and Transversus Abdominis originProtect External Iliac VesselsProtect Lateral Femoral Cutaneous Nerve

External Iliac Artery/Vein

Lateral FemoralCutaneous Nerve

Dissection: IlioinguinalSeparate Lacuna Vasorum and Lacuna MusculorumIncise Iliopectineal Fascia to Superior Ramus and from Pelvic BrimConnect True and False Pelvis

Iliopectineal Fascia

Dissection: Ilioinguinal (Classic Description)Dissect Lateral to External Iliac VesselsTransect Ipsilateral Rectus TendonDissect Medial to External Iliac Vessels

Dissection: Ilioinguinal (Stoppa extension)Surgeon moves to contralateral side of tableCross midline with skin incisionSplit linea albaRetract ipsilateral rectus

Dissection: Ilioinguinal (Stoppa extension)Mobilize bladder and prevesicular fat from quadrilateral surfaceIdentify and protect obturator nv bundle

Dissection: Ilioinguinal (Modified Stoppa extension)Retractor over pelvic brimRetractor in lesser sciatic notch

Ilioinguinal: Lateral WindowInternal Iliac FossaSacroiliac JointPelvic Brim - Upper 1/3

Ilioinguinal: Middle WindowPelvic Brim - SI joint to pectineal eminenceQuadrilateral SurfaceAnterior Rim

Ilioinguinal: Medial Window (Classic Description)Superior Pubic RamusSymphysis Pubis

Ilioinguinal: Medial Window (Modified Stoppa extension)Superior Pubic RamusPelvic BrimSymphysis PubisQuadrilateral surfaceInner border of greater and lesser sciatic notches

Ilioinguinal: Corona MortisVascular AnastamosisExternal IliacObturatorFrequently VenousOccasionally Arterial

Complications: IlioinguinalInfection 2-5%Femoral Nerve palsy 2%Lateral Femoral CutaneousDysesthesia commonSensation returns 80-90% by 1 yearHeterotopic Ossification 2-10%Vascular Injury

Extended IliofemoralDeveloped by Letournel (1975)Based on Smith-Peterson ApproachMaximal Simultaneous access to both columns of the acetabulum

Indications for EIF ApproachTranstectal Tr+PW or T-shaped fractures Transverse fractures with extended posterior wall T-shaped fractures with wide separations of the vertical stem of the "T" or those with associated pubic symphysis dislocations.Certain Associated Both Column Fractures.Associated fracture patterns or transverse fractures which are operated greater than 21 days following injury.

Indications for EIF in Both Column FracturesInability to reduce Posterior Column through IlioinguinalWide displacement at the rimComplex posterior column involvementAssociated SI joint disruptionSmall posterior wall component

Extended Iliofemoral: AccessExternal Aspect of IliumAnterior Column as far medial as Iliopectineal eminencePosterior Column to the Upper Ischial Tuberosity

EIF Approach: Access

Extended Iliofemoral: PositionLateral PositionDistal Femoral TractionKnee flexed 45

Extended Iliofemoral: IncisionInverted J incisionParallel Iliac Crest from PSIS to ASISIncise along anterior-lateral thigh

Dissection: Extended IliofemoralRelease Origins of Gluteals and Tensor Fascia Lata from Iliac CrestDissect Subperiosteal Iliac WingElevate Periosteum from Greater Sciatic NotchIncise Fascia Lata to end of muscle belly

Dissection: Extended IliofemoralRetract Tensor Fascia Lata Muscle PosteriorlyIncise Sheath of Rectus FemorisLigate Lateral Femoral Circumflex Artery and Vein

Dissection: Extended IliofemoralRelease Gluteus Medius and Minimus Tendons from Greater TrochanterAlternatively, Greater Trochanteric OsteotomyReflect Gluteals and Tensor Fascia Lata Posteriorly pedicled on Superior Gluteal

Gluteus Minimis tendon

Gluteus Medius tendon

Dissection: Extended IliofemoralIncise and Retract:Piriformis TendonObturator Internus Tendon with Gemelli musclesPlace Sciatic Nerve Retractor in Lesser Sciatic NotchCapsulotomy if Required

Dissection: Extended IliofemoralIf Internal Iliac Fossa Exposure Required:Elevate Abdominal Muscles from Iliac CrestElevate Iliacus SubperiosteallyRelease Sartorius and Inguinal Ligament from ASISPreserve Anterior Capsule and Direct Head of Rectus for Blood Supply to Anterior Column

Complications: Extended IliofemoralInfection 2-5%Sciatic Nerve palsy 3-5%Heterotopic Ossification 20-50%

Other Extensile ApproachesTriradiateAnterior Limb added to KLTrochanteric OsteotomyReflect Abductors Modified Extensile LateralEIF with associated osteotomiesGreater TrochanterIliac CrestASIS

Combined Surgical ApproachesKocher-Langenbeck + IlioinguinalMay be simultaneous or sequentialSimultaneous may compromise both approaches but can aid in assessment of transverse fracture reductionCare with sequential not to block anterior reduction during posterior fixation

Combined Surgical Approaches Rarely necessaryT-shaped fractures if unable to reduce anterior column from KLAW+PHT if hemitransverse is segmental or widely displaced

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