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Transcript of V05 acetab surgical_apprch
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Surgical Approaches for Fractures of the Acetabulum
Original Author: Mark Reilly, MDCreated February 2004, Updated February 2007
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Treatment Protocol
• Radiographs Allow Proper Fracture Classification
• Fracture Location and Displacement Determine Need for Surgery
• Fracture Pattern Determines Approach
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Surgical Approach
• Single Approach Preferred– Kocher Langenbeck– Ilioinguinal– Extended Iliofemoral
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Kocher-Langenbeck• Approach to posterior
column and posterior articular surface
• Kocher (1874)• Langenbeck (1904)• Judet, Lagrange
(1958)• Letournel
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Indications for Kocher-Langenbeck
• Posterior Wall Fractures• Posterior Column Fractures• Posterior Column / Posterior Wall Fractures• Juxta-tectal / Infra-tectal Transverse or
Transverse with Posterior Wall Fractures• Some T-shaped Fractures
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Kocher-Langenbeck: Access
• Entire Posterior Column• Greater and Lesser Sciatic Notches• Ischial Spine• Retro-Acetabular Surface• Ischial Tuberosity
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Kocher Langenbeck: Access
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Kocher-Langenbeck: Position
• Prone Position• Radiolucent Table• Knee Flexed, Hip
Extended• Distal Femoral
Traction
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Prone Position
• Aids in Reduction of Transverse Fractures• Improves Quadrilateral Surface Access• Allows Clamp Placement through Greater
Sciatic Notch• Controls Position of Hip, Minimizes Sciatic
Nerve Stretch
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Kocher-Langenbeck: Incision
• 6 to 8 cm from PSIS
• Tip of Greater Trochanter
• Parallel Shaft of Femur 15-20 cm
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Dissection: Kocher-Langenbeck
• Divide Iliotibial Band• Separate Fibers of Gluteus Maximus
– Superior 1/3: Superior Gluteal Artery– Inferior 2/3: Inferior Gluteal Artery
• Split to Inferior Gluteal Nerve Branch
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Dissection: Kocher-Langenbeck
• Release Gluteus Maximus Insertion • Identify Sciatic Nerve on Border of
Quadratus Femoris Muscle
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Dissection: Kocher-Langenbeck
• Release Piriformis Tendon >1cm from trochanter
• Release Conjoint Tendon• Open Obturator Internus Bursa for Sciatic
Nerve Retractor
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Femoral Head Blood Supply
• Deep Branch of Medial Femoral Circumflex
• May be injured by:– Detaching quadratus– Reflecting obturator
internus or piriformis too close to trochanter
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Hollinshead, WH 1982
Sciatic Nerve Anatomy
• 84%: Anterior to Piriformis• 12%: Peroneal Division through Piriformis• 3%: Peroneal Division Posterior to
Piriformis / Tibial Division anterior to Piriformis
• 1%: Entire Nerve through Piriformis
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Dissection: Kocher-Langenbeck
• Subperiosteal Elevation of:– Greater Sciatic Notch– Quadrilateral Surface– Gluteus Minimus
• Debridement of Fracture Edges• Avoid Devascularization of Fx Fragments
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Complications: Kocher-Langenbeck
• Infection 2-5%• Sciatic Nerve palsy 3-5%• Heterotopic Ossification 8-25%
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Trochanteric “Flip”
• Seibenrock, Ganz (Berne)• Improved Cranial, Anterior exposure of
innominate bone• Direct intra-articular evaluation of joint, reduction• Most useful for PW fractures with extension to the
supraacetabular ilium
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Ortho Uni Berne
Trochanteric Flip
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Ilioinguinal Approach• Developed by
Letournel after extensive cadaveric anatomical study
• Approach to the anterior column and anterior articular surface
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Ilioinguinal Approach: Indications
• Anterior Wall• Anterior Column• Transverse with Anterior > Posterior
Displacement• Anterior Column / Posterior Hemitransverse• Associated Both Column
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Ilioinguinal Approach: Access
• SI Joint • Internal Iliac Fossa• Pelvic Brim• Quadrilateral Surface• Superior Pubic Ramus• Limited Access to External Iliac Wing
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Ilioinguinal Approach: Access
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Ilioinguinal: Position
• Supine• Distal Femoral
Traction• Access to Greater
Trochanter (Lateral Traction)
• Hip flexed 20°
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Ilioinguinal: Incision
• 3-4 cm cranial to Symphysis pubis
• Curve to ASIS• Parallel Iliac Crest• Past Most Convex
Portion of Ilium– anterior 2/3
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Symphysispubis
ASIS
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Dissection: Ilioinguinal
• Subperiosteal Dissect Internal Iliac Fossa– Origin of Abdominals and Iliopsoas
• Expose Sacroiliac Joint• Dissect over Pelvic Brim
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Internal IliacFossa
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Dissection: Ilioinguinal
• Incise External Oblique Aponeurosis– From ASIS to midline– 1 cm proximal to External Inguinal Ring
• Expose Floor of Inguinal Canal• Retract Spermatic Cord/Round Ligament• Protect Ilioinguinal Nerve
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External Oblique
Ilioinguinal Nerve
Spermatic Cord
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Dissection: Ilioinguinal
• Incise Inguinal Ligament• Leave 1-2 mm with Internal Oblique and
Transversus Abdominis origin• Protect External Iliac Vessels• Protect Lateral Femoral Cutaneous Nerve
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External Iliac Artery/Vein
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Lateral FemoralCutaneous Nerve
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Dissection: Ilioinguinal
• Separate Lacuna Vasorum and Lacuna Musculorum
• Incise Iliopectineal Fascia to Superior Ramus and from Pelvic Brim
• Connect True and False Pelvis
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Iliopectineal Fascia
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Dissection: Ilioinguinal
• Dissect Lateral to External Iliac Vessels• Transect Ipsilateral Rectus Tendon• Dissect Medial to External Iliac Vessels
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Ilioinguinal: Lateral Window
• Internal Iliac Fossa• Sacroiliac Joint• Pelvic Brim - Upper 1/3
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Ilioinguinal: Middle Window
• Pelvic Brim - SI joint to pectineal eminence• Quadrilateral Surface• Anterior Rim
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Ilioinguinal: Medial Window
• Superior Pubic Ramus• Symphysis Pubis
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Dissection: Ilioinguinal
• Medial window may also be created utilizing Stoppa approach– Midline rectus split– Subperiosteal dissection of quadrilateral surface– Retractor in lesser sciatic notch– Protect obturator nerve/artery
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Ilioinguinal: Corona Mortis
• Vascular Anastamosis– External Iliac– Obturator
• Frequently Venous• Occasionally Arterial
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Complications: Ilioinguinal
• Infection 2-5%• Femoral Nerve palsy 2%• Lateral Femoral Cutaneous
– Dysesthesia common– Sensation returns 80-90% by 1 year
• Heterotopic Ossification 2-10%• Vascular Injury <1%
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Extended Iliofemoral• Developed by
Letournel (1975)• Based on Smith-
Peterson Approach• Maximal
Simultaneous access to both columns of the acetabulum
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Indications for EIF Approach
• Transtectal 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.
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Indications for EIF in Both Column Fractures
• Inability to reduce Posterior Column through Ilioinguinal
• Wide displacement at the rim• Complex posterior column involvement• Associated SI joint disruption• Small posterior wall component
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Extended Iliofemoral: Access
• External Aspect of Ilium• Anterior Column as far medial as
Iliopectineal eminence• Posterior Column to the Upper Ischial
Tuberosity
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EIF Approach: Access
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Extended Iliofemoral: Position
• Lateral Position• Distal Femoral
Traction• Knee flexed 45°
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Extended Iliofemoral: Incision
• Inverted J incision• Parallel Iliac Crest
from PSIS to ASIS• Incise along anterior-
lateral thigh
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Dissection: Extended Iliofemoral
• Release Origins of Gluteals and Tensor Fascia Lata from Iliac Crest
• Dissect Subperiosteal Iliac Wing• Elevate Periosteum from Greater Sciatic
Notch• Incise Fascia Lata to end of muscle belly
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Dissection: Extended Iliofemoral
• Retract Tensor Fascia Lata Muscle Posteriorly
• Incise Sheath of Rectus Femoris• Ligate Lateral Femoral Circumflex Artery
and Vein
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Dissection: Extended Iliofemoral
• Release Gluteus Medius and Minimus Tendons from Greater Trochanter
• Alternatively, Greater Trochanteric Osteotomy
• Reflect Gluteals and Tensor Fascia Lata Posteriorly pedicled on Superior Gluteal
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Dissection: Extended Iliofemoral
• Incise and Retract:– Piriformis Tendon– Obturator Internus Tendon with Gemelli
muscles• Place Sciatic Nerve Retractor in Lesser
Sciatic Notch• Capsulotomy if Required
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Dissection: Extended Iliofemoral
• If Internal Iliac Fossa Exposure Required:– Elevate Abdominal Muscles from Iliac Crest– Elevate Iliacus Subperiosteally– Release Sartorius and Inguinal Ligament from
ASIS– Preserve Anterior Capsule and Direct Head of
Rectus for Blood Supply to Anterior Column
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Complications: Extended Iliofemoral
• Infection 2-5%• Sciatic Nerve palsy 3-5%• Heterotopic Ossification 20-50%
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Other Extensile Approaches
• Triradiate– Anterior Limb added to KL– Trochanteric Osteotomy– Reflect Abductors
• Modified Extensile Lateral– EIF with associated osteotomies
• Greater Trochanter• Iliac Crest• ASIS
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Combined Surgical Approaches
• Kocher-Langenbeck + Ilioinguinal• May be simultaneous or sequential
– Simultaneous may compromise both approaches but can aid in assessment of transverse fracture reduction
– Care with sequential not to block anterior reduction during posterior fixation
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Combined Surgical Approaches
• Rarely necessary– T-shaped fractures if unable to reduce anterior
column from KL– AW+PHT if hemitransverse is segmental or
widely displaced
Return to Pelvis Index
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