Surgical Approaches for Fractures of the Acetabulum

Original Author: Mark Reilly, MDCreated February 2004, Updated February 2007

Treatment Protocol

• Radiographs Allow Proper Fracture Classification

• Fracture Location and Displacement Determine Need for Surgery

• Fracture Pattern Determines Approach

Surgical Approach

• Single Approach Preferred– Kocher Langenbeck– Ilioinguinal– Extended Iliofemoral

Kocher-Langenbeck• Approach to posterior

column and posterior articular surface

• Kocher (1874)• Langenbeck (1904)• Judet, Lagrange

(1958)• Letournel

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

Kocher-Langenbeck: Access

• Entire Posterior Column• Greater and Lesser Sciatic Notches• Ischial Spine• Retro-Acetabular Surface• Ischial Tuberosity

Kocher Langenbeck: Access

Kocher-Langenbeck: Position

• Prone Position• Radiolucent Table• Knee Flexed, Hip

Extended• Distal Femoral

Traction

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

Kocher-Langenbeck: Incision

• 6 to 8 cm from PSIS

• Tip of Greater Trochanter

• Parallel Shaft of Femur 15-20 cm

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

Dissection: Kocher-Langenbeck

• Release Gluteus Maximus Insertion • Identify Sciatic Nerve on Border of

Quadratus Femoris Muscle

Dissection: Kocher-Langenbeck

• Release Piriformis Tendon >1cm from trochanter

• Release Conjoint Tendon• Open Obturator Internus Bursa for Sciatic

Nerve Retractor

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

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

Dissection: Kocher-Langenbeck

• Subperiosteal Elevation of:– Greater Sciatic Notch– Quadrilateral Surface– Gluteus Minimus

• Debridement of Fracture Edges• Avoid Devascularization of Fx Fragments

Complications: Kocher-Langenbeck

• Infection 2-5%• Sciatic Nerve palsy 3-5%• Heterotopic Ossification 8-25%

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

Ortho Uni Berne

Trochanteric Flip

Ilioinguinal Approach• Developed by

Letournel after extensive cadaveric anatomical study

• Approach to the anterior column and anterior articular surface

Ilioinguinal Approach: Indications

• Anterior Wall• Anterior Column• Transverse with Anterior > Posterior

Displacement• Anterior Column / Posterior Hemitransverse• Associated Both Column

Ilioinguinal Approach: Access

• SI Joint • Internal Iliac Fossa• Pelvic Brim• Quadrilateral Surface• Superior Pubic Ramus• Limited Access to External Iliac Wing

Ilioinguinal Approach: Access

Ilioinguinal: Position

• Supine• Distal Femoral

Traction• Access to Greater

Trochanter (Lateral Traction)

• Hip flexed 20°

Ilioinguinal: Incision

• 3-4 cm cranial to Symphysis pubis

• Curve to ASIS• Parallel Iliac Crest• Past Most Convex

Portion of Ilium– anterior 2/3

Symphysispubis

ASIS

Dissection: Ilioinguinal

• Subperiosteal Dissect Internal Iliac Fossa– Origin of Abdominals and Iliopsoas

• Expose Sacroiliac Joint• Dissect over Pelvic Brim

Internal IliacFossa

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

External Oblique

Ilioinguinal Nerve

Spermatic Cord

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

External Iliac Artery/Vein

Lateral FemoralCutaneous Nerve

Dissection: Ilioinguinal

• Separate Lacuna Vasorum and Lacuna Musculorum

• Incise Iliopectineal Fascia to Superior Ramus and from Pelvic Brim

• Connect True and False Pelvis

Iliopectineal Fascia

Dissection: Ilioinguinal

• Dissect Lateral to External Iliac Vessels• Transect Ipsilateral Rectus Tendon• Dissect Medial to External Iliac Vessels

Ilioinguinal: Lateral Window

• Internal Iliac Fossa• Sacroiliac Joint• Pelvic Brim - Upper 1/3

Ilioinguinal: Middle Window

• Pelvic Brim - SI joint to pectineal eminence• Quadrilateral Surface• Anterior Rim

Ilioinguinal: Medial Window

• Superior Pubic Ramus• Symphysis Pubis

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

Ilioinguinal: Corona Mortis

• Vascular Anastamosis– External Iliac– Obturator

• Frequently Venous• Occasionally Arterial

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%

Extended Iliofemoral• Developed by

Letournel (1975)• Based on Smith-

Peterson Approach• Maximal

Simultaneous access to both columns of the acetabulum

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.

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

Extended Iliofemoral: Access

• External Aspect of Ilium• Anterior Column as far medial as

Iliopectineal eminence• Posterior Column to the Upper Ischial

Tuberosity

EIF Approach: Access

Extended Iliofemoral: Position

• Lateral Position• Distal Femoral

Traction• Knee flexed 45°

Extended Iliofemoral: Incision

• Inverted J incision• Parallel Iliac Crest

from PSIS to ASIS• Incise along anterior-

lateral thigh

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

Dissection: Extended Iliofemoral

• Retract Tensor Fascia Lata Muscle Posteriorly

• Incise Sheath of Rectus Femoris• Ligate Lateral Femoral Circumflex Artery

and Vein

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

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

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

Complications: Extended Iliofemoral

• Infection 2-5%• Sciatic Nerve palsy 3-5%• Heterotopic Ossification 20-50%

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

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

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

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