Surgical Exposures

Pelvis

By admin

Ovid: Master Techniques in Orthopaedic Surgery: Relevant Surgical Exposures


Editors: Morrey, Bernard F.; Morrey, Matthew C.
Title: Master Techniques in Orthopaedic Surgery: Relevant Surgical Exposures, 1st Edition
> Table of Contents > Section II – Lower Extremity > 6 – Pelvis

6
Pelvis
Andrew S. Sems
POSTERIOR APPROACH TO THE SACRUM AND SACROILIAC JOINT
Indications
  • Open reduction and internal fixation of sacral fractures.
  • Open reduction and internal fixation of sacroiliac fracture-dislocations.
  • Open reduction and internal fixation of sacroiliac dislocations.
  • Open reduction and internal fixation of sacroiliac dislocations with iliac fractures (crescent fracture).
Position
The patient is placed in the prone position with chest rolls positioned to allow the abdomen to hang free (Fig. 6-1).
A completely radiolucent table is utilized to allow imaging in multiple
planes including Judet views and inlet and outlet views. The chest roll
should be placed proximal enough so that the pelvis actually hangs
free, as this is helpful in assisting in obtaining reduction of these
fractures. By supporting the patient’s thorax rather than directly on
the anterior pelvis, the axial skeleton will be stabilized proximally,
allowing the hemipelvis to hang free and reduce anteriorly.
Landmarks
The posterior-superior iliac spine as well as the entire
iliac crest should be palpated. The spinous processes of the sacrum and
lumbar vertebrae should be identified.
Technique
  • Incision: the incision is longitudinal in direction (Fig. 6-2).
    It can be translated medially or laterally as appropriate for the
    particular type of fracture. For sacral fractures, a more medially
    based incision is appropriate, whereas for crescent type fractures or
    pure sacroiliac dislocations, the incision can be made based more
    laterally. For a crescent fracture or sacroiliac dislocation, the
    incision

    P.124


    should
    be just lateral to the posterior-superior iliac spine. It may be curved
    laterally as it can fall in line with the iliac crest as it travels
    anteriorly and laterally. However, a vertical incision also can be
    useful to gain full exposure. In thinner patients, an incision directly
    over the posterior-superior iliac spine should be avoided, as the
    subcutaneous location of the bony prominence may cause difficulty with
    wound healing and breakdown.

    • Note:
      Injection of lidocaine and epinephrine mixtures into the surgical site
      before making the skin incision can assist in controlling bleeding in
      the area. There is often a large amount of subcutaneous adipose in this
      region with significant vascularity that can bleed throughout the case
      and cause exposure and visualization to be difficult, so careful
      attention to gaining hemostasis throughout the subcutaneous dissection
      is important.
  • The gluteus maximus is identified as it
    inserts onto the posterior-superior iliac spine and iliac crest. It is
    incised in the tendinous portion along the posterior-superior iliac
    spine, leaving a cuff of tissue on the posterior-superior iliac spine
    for later repair (Fig. 6-3).
  • As the dissection extends posteriorly,
    the gluteal tendon is incised toward the midline over the sacrum. This
    allows complete retraction of the gluteus maximus and exposure of the
    posterior-superior iliac spine as well as the posterior aspect of the
    ilium. Care should be taken to not disturb the underlying paraspinal
    muscles, particularly the multifidus, unless dissection onto the sacrum
    is necessary. For most sacroiliac dislocations and crescent fractures,
    these paraspinal muscles can be left undisturbed. For sacral fractures,
    the injury and initial displacement of the

    P.125


    fracture
    has often caused severe injury to the paraspinal muscles and some local
    debridement during the approach may be all that is necessary in order
    to fully visualize the fracture.

  • The gluteus maximus is elevated
    subperiosteally along the posterior aspect of the ilium distally to the
    greater sciatic notch, giving access to the entire crescent fracture
    and sacroiliac joint (Fig. 6-4).
  • Finger palpation beneath the greater
    sciatic notch can be utilized to assess anterior reduction of a
    sacroiliac dislocation. Exposure of the greater sciatic notch will
    allow placement of a reduction clamp to correct the vertical
    displacement of the hemipelvis that occurs in posterior pelvic ring
    injuries. Care should be taken during dissection into the greater
    sciatic notch to protect the sciatic nerve as well as the superior
    gluteal vessels and nerve (Fig. 6-5).
  • Once reduction and fixation of the
    posterior ring is completed, care should be taken to repair the gluteus
    maximus insertion in its tendinous portion using a heavy permanent
    suture such as 0-Ethibon. Subcutaneous tissue should be closed in
    multiple layers as well, and drain placement is recommended depending
    on the amount of hemorrhage encountered.
FIGURE 6-1 The prone position allows gravity to assist in reduction of the fracture and hemipelvis.
FIGURE 6-2 The posterior incision can be either curved or vertical in nature depending on the exact location of the fracture.
FIGURE
6-3 The gluteus maximus tendon is identified as it inserts on the
posterior-superior iliac spine and as it inserts towards the midline
distal to the posterior-superior iliac spine. The tendon is incised
leaving a cuff of tendon medially for later repair.
FIGURE
6-4 The gluteus maximus is retracted laterally away from the sacroiliac
joint and can be retracted as far as the greater sciatic notch.
FIGURE 6-5 The superior gluteal neurovascular bundle prevents further lateral retraction of the gluteus maximus.

P.126


Pearls and Pitfalls
  • Avoid making an incision directly over
    the most prominent portion of the posterior-superior iliac spine,
    particularly in thinner patients as this may be very prominent and may
    break down as the patient lies on their back recovering.
  • Subperiosteal dissection along the
    lateral aspect of the ilium can identify the proximal extent of
    crescent fractures. Blunt retractors or malleable retractors along the
    lateral aspect of the ilium can be utilized to visualize these
    fractures and gain anatomic reduction. Additionally, sacroiliac screws
    may provide a large amount of stability to a fixation construct for
    sacroiliac dislocations and crescent fractures. These screws should be
    placed away from the iliac fracture line so they will not fail by
    breaking through into the fracture site, and this can be visualized
    through this approach. However, percutaneous incisions will need to be
    made over the lateral aspect of the gluteal region in order to place
    the screws, as the necessary trajectory cannot be obtained through the
    posterior approach to the sacroiliac joint.
APPROACH TO THE ACETABULUM THROUGH THE ILIOINGUINAL APPROACH
Indications
  • Both column fractures of the acetabulum.
  • Anterior column posterior hemi-transverse fractures of the acetabulum.
  • Anterior column fractures.
  • In conjunction with the Kocher-Langenbeck approach for treatment and fixation of transverse, and T-type acetabular fractures.
Position
The patient is positioned supine on a radiolucent table (Fig. 6-6).
Traction is often utilized before reduction of these cases and a table
such as a Judet-Tasserit table or Pro FX fracture table which is
radiolucent and allows the use of traction in multiple directions is
optimal.
Landmarks
One should palpate the entire iliac crest as well as
paying attention to the anterior-superior iliac spine. The pubic
tubercles and symphysis should be identified.
Technique
  • Incision: the incision follows the
    contour of the iliac crest from posterior to anterior, and then is
    directed over the inguinal ligament to a point approximately 2 cm
    proximal to the pubic symphysis (Fig. 6-7).

    • P.127


  • The abdominal musculature is identified
    as it inserts on the iliac crest. The aponeurosis of the abdominal
    muscles terminates just proximal to an avascular zone between the hip
    abductors and abdominal musculature. This zone is identified and this
    interval should be split directly down to the iliac crest (Fig. 6-8).
  • Subperiosteal dissection along the iliac
    crest with elevation of the abdominal musculature insertion is
    performed to gain access to the inner table of the pelvis, exposing the
    lateral window. Once the lateral window has been exposed and the
    iliopsoas has been elevated off the inner fossa, this area of the wound
    should be packed with lap sponges and the exposure should continue
    distally.
  • The skin incision is then extended from
    the anterior-superior iliac spine to an area approximately 2 cm
    proximal to the pubic symphysis.
  • The external abdominal oblique
    musculature and fascia is identified as the fibers course in a
    direction from superolateral to inferomedial towards the superficial
    inguinal ring. The spermatic cord should be identified and a Penrose
    drain should be placed around it to protect it and allow retraction
    medially and laterally (Fig. 6-9).

    • P.128


  • The external abdominal oblique is split in line with its fibers just proximal to its insertion on the inguinal ligament (Fig. 6-10).
    Dissection should be continued down towards the inferior aspect of the
    superficial inguinal ring. If possible the superficial ring should be
    kept in place so that a later repair is not necessary.
  • At this point the combined tendon of the
    internal abdominal oblique and transverse abdominus muscle is
    identified as it inserts on the inguinal ligament. This conjoined
    tendon should be incised in line with its fibers near its insertion on
    the inguinal ligament giving ample amount of tendon on both sides of
    the incision to repair at the end of the case (Fig. 6-11).
  • The lateral femoral cutaneous nerve is
    identified crossing over the psoas muscle near the anterior-superior
    iliac spine. This nerve may need to be sacrificed for complete exposure
    of the acetabulum; however, initial attempts should be made to protect
    and save this nerve.
  • The psoas muscle and femoral nerve should
    be identified. These structures should be kept together and a Penrose
    drain should be placed around them in their entirety (Fig. 6-12).
    Care should be taken to elevate the psoas off of the internal fossa of
    the ilium in its entirety so that trauma to the muscle is minimized.
  • Once the entire psoas muscle and femoral
    nerve are protected with a Penrose drain, they can be retracted
    laterally. The iliopectineal fascia is identified and very careful
    dissection just medial

    P.129


    to
    this should be performed to separate it from the external iliac
    vessels. Once the iliopectineal fascia is separated from the external
    iliac vessels, a finger should be placed between the fascia and the
    vessels to palpate the pulse and confirm the vessels are medial to the
    finger.

  • Once the external iliac vessels are
    confirmed to be medial and the fascia is isolated, scissors are used to
    split the iliopectineal fascia all the way to the pelvic brim (Fig. 6-13).
  • With the combined tendon of the
    transversalis abdominus and internal abdominal oblique incised near its
    insertion, dissection should now proceed medially. A small portion of
    the rectus abdominus muscle will need to be incised transversely as it
    inserts on the pubic tubercle just medial to the spermatic cord or
    round ligament (Fig. 6-14). This will allow for exposure of the medial side of the external iliac vessels.
  • Circumferential access to the external
    iliac vessels can now be gained by placing a Penrose drain around the
    bundle and it can now be retracted medially and laterally (Fig. 6-15).
  • Once this is performed, all three windows
    of the ilioinguinal approach have been exposed and reduction and
    fixation of the acetabular fracture can be performed.
  • Following fixation, care should be taken
    to tightly repair the structures in the inguinal region to prevent
    postoperative hernia development. After thorough irritation of the
    wound, the portion of the transected rectus abdominus is reapproximated
    using interrupted 0-Ethibon sutures. Next, the internal abdominal
    oblique and transversalis abdominus conjoined tendon is repaired back
    to the inguinal ligament using multiple 0-Ethibon sutures.
    • Note: Multiple single sutures are preferred in case one should break or rupture, the remainder of the repair will stay intact.
  • A layered closure is preferred and the
    external abdominal oblique is then closed using 0-Ethibon sutures. If
    care has been taken during the dissection to preserve the superficial
    inguinal ring, the fascia can typically be closed just below this and
    the ring will be intact.
  • A drain can be placed in the lateral
    aspect of the wound, resting in the internal iliac fossa. The abdominal
    aponeurosis can then be reapproximated using multiple 0-Ethibon
    sutures. The subcutaneous tissue is closed in layers and the skin is
    closed with either a nonabsorbable monofilament suture or a staple.
FIGURE
6-6 Patient is positioned supine on a radiolucent fracture table
allowing bilateral skin traction with a perineal post in place.
FIGURE 6-7 Incision is made over the iliac crest, anterior-superior iliac spine, and pubic symphysis.
FIGURE 6-8 The abdominal muscles are incised at their aponeurosis and elevated from the iliac crest.
FIGURE
6-9 The external abdominal oblique and spermatic cord are identified
and circumferential control of the spermatic cord is gained.
FIGURE
6-10 The external abdominal oblique fascia is identified and split in
line with its fibers proximal to the inguinal ligament.
FIGURE
6-11 The combined tendon of the internal abdominal oblique and
tranversalis abdominus is identified and incised near its insertion on
the inguinal ligament.
FIGURE
6-12 Circumferential control of the psoas muscle and femoral nerve are
obtained with a Penrose drain placed around the structures.
Pearls and Pitfalls
  • Exposure can be very difficult in obese
    patients and consideration should be given to adjusting the incision
    slightly proximal in order to gain the appropriate trajectory for screw
    and hardware placement. By moving the incision just proximal a few
    centimeters this amount of soft tissue will not need to be retracted as
    much during the case and appropriate trajectory of the screw can be
    obtained.

    • P.130


  • The femoral nerve should be clearly
    identified as it sits on the psoas muscle prior to placing a Penrose
    drain around this neuromuscular group. The femoral nerve may
    occasionally have multiple branches and care should be taken not to
    divide them or retract ones without having control of all of them.
  • Retraction of the external iliac vessel
    should be performed carefully. Malleable retractors can be placed in
    the middle window to retract the vessels medially; however, care should
    be taken so that the sharp edges of the malleable retractors do not
    impinge on the external vessels. In patients who are older or who have
    known atherosclerotic disease, care should be taken to avoid excessive
    or aggressive retraction of these vessels as plaques may dislodge or
    intimal damage may occur.
FIGURE 6-13 The iliopectineal fascia is identified and split down to the pelvic rim.
FIGURE 6-14 The rectus abdominus is transected just medial to the spermatic cord.

P.131


FIGURE 6-15 Circumferential control of external iliac neurovascular bundle is obtained.
APPROACH TO THE PUBIC SYMPHYSIS AND STOPPA APPROACH
Indication
  • Open reduction and internal fixation of pubic symphyseal diastasis.
  • Open reduction and internal fixation of pubic rami fractures and parasymphyseal pubic fractures.
  • Open reduction and internal fixation of the quadrilateral surface of the acetabulum and low anterior column fractures.
  • Anterior plate fixation of pelvic discontinuity for total hip reconstruction.
Position
The patient is positioned supine on the radiolucent
table. Skeletal traction is generally not necessary for this approach
and the perineal posts may actually get in the way of exposure and
manipulative procedures.
Landmarks
Identify the pubic tubercles and superior edge of the pubic bodies and superior rami.
Technique
1. Incision: identify the midline of the abdomen over
the pubic symphysis, and make a transverse Pfannenstiel type incision
which is in-line with the skin creases in the suprasymphyseal region (Fig. 6-16).
The incision is made 1 to 2 cm proximal to the pubic symphysis. This
incision may move further proximal in patients who are more obese to
allow appropriate trajectory of screw plates into the pubic bodies.
2. The dissection is carried through the skin and
subcutaneous tissues gaining hemostasis along the way. The rectus
abdominus muscles are identified. They need to be split in the midline
and then elevated off the pubic tubercles leaving a distally based
insertion. The pyramidalis muscle may be identified inferiorly in the
wound, and oblique fibers of the rectus fascia will tend to point to
the midline and can be found crossing in the raphe of the rectus
abdominus.
3. Once the midline of the rectus abdominus is
identified, a small vertical incision is made just over the pubic
symphysis. This incision should go through the rectus fascia and be
approximately 5 mm in length, just long enough to allow placement of
the right angle clamp through this incision aimed proximally.

P.132


FIGURE 6-16 The incision is based just proximal to the superior aspect of the pubic body and superior pubic rami.
4. With anterior retraction and elevation of this clamp,
the rectus is lifted off of the underlying bladder and prevesicular
fat. The fascia can then be incised directly onto the right angle clamp
as it is translated proximally as the fascia and muscle are split (Fig. 6-17).
5. Once the rectus abdominus is split in its midline,
access to the space of Retzius is obtained. The rectus should be
elevated directly off the tubercles by retracting the rectus
anteriorly. The distal insertion of the rectus should be maintained and
transection of the rectus abdominus should be avoided for this approach.
6. Once dissection is carried over the pubic tubercles,
pointed Holman retractors can be placed over the tubercles to retract
the rectus laterally and gain access to the symphysis and anterior
aspect of the pubic bodies.
7. Reduction and fixation of pubic symphysis diastasis or parasymphyseal fractures can then be performed.
FIGURE 6-17 The rectus abdominus is split in line with its fibers and elevated off the pubic tubercles.

P.133


Alternate Exposure
8. A Stoppa approach can be performed through this
incision by dissection along the pubic ramus to the quadrilateral
surface of the acetabulum. Often a headlamp is utilized because of the
relatively deep nature of this wound.
9. Dissection is carried along the desired pubic ramus
towards the quadrilateral surface. Great care should be taken to
observe the corona mortis as it anastomoses between the external iliac
vessels and the obturator vessels, crossing the superior pubic ramus 4
to 6 cm lateral to the pubic symphysis (Fig. 6-18).
10. This anastomosis will need to be identified,
carefully dissected out, and then ligated prior to full exposure of the
quadrilateral surface and pelvic brim. As long as dissection is
maintained along the pelvic brim and quadrilateral surface, the soft
tissues can be retracted superiorly and inferiorly and access to the
spaces can be obtained. Malleable retractors can be utilized to retract
the peritoneal cavity medially.
11. Through this approach, access can be gained along the quadrilateral surface all the way to the sacroiliac joint (Fig. 6-19).
12. Following reduction and fixation of the anterior
pelvic ring, the rectus abdominus is closed with 0-Ethibon sutures. The
subcutaneous tissue is then closed in multiple layers and the skin is
closed with either nylon or staples. Care should be taken during
closure of the rectus to avoid injury to the bladder and prevesicular
fat.
Pearls and Pitfalls
  • The incision may be translated proximally
    in obese patients in order to gain appropriate trajectory for hardware
    placement. Often the abdominal fat will need to be retracted proximally
    and compressed in order to be able to place screws down the pubic
    bodies and into the inferior pubic rami.
  • Transection of the rectus should be
    avoided if at all possible. Dissection can be carried over the pubic
    tubercles to elevate the rectus abdominus leaving a distally based
    insertion.
  • Retractors can be placed over the pubic
    tubercles but should not be placed so far laterally as they enter into
    the obturator foramen due to potential injury to the neurovascular
    structures in the region.
FIGURE
6-18 The exposure is extended along the superior pubic ramus to the
quadrilateral surface. The corona mortis is identified and ligated as
it crosses the pelvic brim.

P.134


FIGURE
6-19 Access to the entire quadrilateral surface and pelvic brim. The
obturator nerve passes across the inferior aspect of the operative
field.
APPROACH TO THE POSTERIOR PELVIS (KOCHER-LANGENBECK APPROACH)
Indications
  • Open reduction and internal fixation of acetabular fractures.
    • Posterior Wall
    • Posterior Column
    • Transverse Posterior Wall
    • Posterior Column-Posterior Wall
    • T-type
    • Transverse
  • Open irrigation and debridement of the hip joint.
Position
The Kocher-Langenbeck approach can be performed either
in a lateral or prone position. The patient should be kept with the
operative knee flexed 90 degrees at all times to remove tension from
the sciatic nerve and to allow for intraoperative retraction. By
placing the patient in a prone position on a specialized fracture
table, knee flexion can be maintained by a special apparatus holding
the traction boot on the operative leg vertically (Fig. 6-20).
A distal femoral traction pin can be attached to the traction device to
allow precise control of the amount of hip joint distraction.
Intraoperative sequential compression devices can also be placed when
the patient is in the prone position to help with the deep vein
thrombosis (DVT) prophylaxis.
Landmarks
The posterior-superior iliac spine as well as the greater trochanter and lateral aspect of the femur are identified.
Technique
  • Incision: the incision is in a line from
    the posterior superior iliac spine toward the center of the greater
    trochanter and then extended distally on the lateral aspect of the
    femur (Fig. 6-21). The incision can be gently curved at the corner or it can be kept at a sharp angle.
  • The posterior incision over the gluteal
    region is made first and dissection is carried through the skin and
    subcutaneous tissue gaining hemostasis through the dissection. The
    fascia over the gluteus maximus and gluteal muscle fibers are
    identified.
    • Note: In
      more obese patients, following this portion of the incision, further
      palpation can be performed to determine the exact location of the
      greater trochanter. If necessary, the incision can then be extended
      more anteriorly to reach the center of the greater trochanter.
  • Once the incision has been made to the center of the greater trochanter, it is extended distally along the line of the femur.

    • P.135


  • The iliotibial band and lateral thigh
    fascia are split in line with their fibers on the lateral aspect of the
    femur. The fascial incision begins distally at a level equal to the
    inferior gluteal fold of the skin, as this is the location of the
    gluteus maximus tendinous sling. This tendon may need to be incised as
    it inserts on the femur to allow sufficient posterior retraction of the
    flap.
  • Once this incision reaches the center of
    the greater trochanter the fascia over gluteus maximus is then split in
    line with the underlying muscle fibers. The muscle fibers of the
    gluteus maximus are then split by blunt finger dissection (Fig. 6-22).
  • Once the gluteus maximus and iliotibial
    band have been split, and the posterior flap is created, it can be held
    in place with large no. 5 Ethibond sutures tacked to the posterior
    skin. The short external rotators are then identified. The piriformis
    muscle is tagged approximately 1 cm from its insertion onto the femur
    and retracted posteriorly.
  • The combined tendon of the gemellae and
    obturator internus are then identified and tagged, again 1 cm from
    their insertion on the femur (Fig. 6-23).
    • Note: Care
      should be taken not to incise these muscles closer than 1 cm from the
      insertion on the femur in order to protect the blood supply to the
      femoral head.
  • Dissection should not be carried into the
    quadratus femoris as the risk of damage to the femoral head blood
    supply is encountered. Once the short external rotators are tagged and
    retracted, subperiosteal dissection along the retroacetabular surface
    is performed.

    • P.136


  • The piriformis muscle is elevated back to
    the greater sciatic notch and the obturator internus and gemellae
    muscles are elevated back to their insertions near the lesser sciatic
    notch (Fig. 6-24).
  • Posterior retraction of the obturator internus will provide a sling around the sciatic nerve and protect it during retraction.
  • Once the lesser sciatic notch is then
    exposed, a retractor may be safely placed into this notch as long as
    tension is kept on the obturator internus to protect the sciatic nerve
    at all times.
  • Dissection can be performed beneath the gluteus minimus and the remainder of hip abductor muscle anteriorly.
  • A Homan retractor can be placed beneath
    the hip abductors to gain access to the superior aspect of the
    acetabulum and more anteriorly for placement of hardware in this region.
  • Following reduction and fixation of the
    acetabular fracture, the short external rotators are reapproximated to
    the greater trochanter. If the patient is in a prone position and the
    fracture table allows for it, the leg may be externally rotated to
    allow for a tension-free repair of the short external rotators.
  • Ethibond sutures are utilized through
    either a drill hole in the trochanter or by suturing them into the
    tendinous portion of the hip abductors as they insert on the greater
    trochanter. The posterior flap is then closed using 0-Ethibon sutures
    both laterally and posteriorly over the gluteus maximus. The
    subcutaneous tissue is closed in multiple layers and the skin is then
    closed with either sutures or staples.
FIGURE
6-20 Prone position of the patient on the fracture table with the
distal femoral traction pin, knee flexed in 90 degrees, and sequential
compression device on the calf to assist in DVT prophylaxis.
FIGURE
6-21 The incision is based on line from the posterior-superior iliac
spine to the center of the greater trochanter and then extending
distally in line with the femur.
FIGURE
6-22 The posterior muscular flap is made by incising the iliotibial
band fascia in line with its fibers and the gluteus maximus in line
with its fibers. The gluteus maximus tendon insertion on the femur may
need to be incised for further posterior retraction of the flap.
Pearls and Pitfalls
  • If performed in the prone position,
    initial internal rotation of the leg during exposure will place the
    short external rotators in a stretched position and allow easier
    identification and exposure of the tendinous portions of these muscles.
  • Incision of a portion of the gluteus
    maximus tendinous sling that inserts on the femur may be required if in
    extremely muscular patients or obese patients in which further
    posterior retraction of the muscle flap is necessary.
  • Placing the patient in a prone position
    with distal femoral traction pin and peroneal post-traction may
    facilitate exposure of the hip. Traction can be applied using the
    table’s traction mechanism and the hip joint can be distracted to allow
    debridement any intra-articular fragments and to assess the femoral
    head for articular cartilage injuries.

P.137


FIGURE
6-23 The piriformis and obturator internus muscles are identified and
tagged and incised 1 cm away from their insertion into the femur.
FIGURE
6-24 Dissection underneath the piriformis and obturator internus to the
greater and lesser sciatic notches, respectively, with continual
traction on the obturator internus to protect the sciatic nerve.

P.138


APPROACH TO THE ACETABULUM THROUGH THE EXTENDED ILIOFEMORAL APPROACH
Indications
The extended iliofemoral approach is rarely utilized in
the routine treatment of acetabular fractures. The majority of complex
fractures can be managed through combined ilioinguinal and
Kocher-Langenbeck approaches before an iliofemoral approach would be
necessary. However, certain transtectal transverse or T-type acetabular
fractures with impaction of the acetabular dome or associated posterior
wall fractures are still best treated through the extended iliofemoral
approach. This approach may also be useful for treatment of older or
malunited fractures.
Position
The extended iliofemoral approach requires the patient
to be placed in the lateral position in order to gain access to the
entire outer aspect of the ilium.
Landmarks
The iliac crest from the posterior-superior iliac spine
to the anterior-superior iliac spine should be identified, as well as
the location of the lateral edge of the patella.
Technique
  • Incision: a curvilinear incision from the
    posterior-superior iliac spine to the anterior-superior iliac spine is
    the continued in a line towards the lateral border of the patella. The
    incision will need to be carried to the proximal mid-thigh in order to
    provide adequate exposure (Fig. 6-25).

    • P.139


  • The tendinous interval between the
    abdominal and gluteal musculature is identified along the iliac crest
    and the origins of the gluteal muscles are released and elevated
    subperiostally to the greater sciatic notch (Fig. 6-26). Continue this elevation anteriorly along the crest to release the tensor fascia lata from its origin on the ilium.
  • Next, identify the fascia of the anterior thigh and incise it longitudinally on the lateral border of the sartorius (Fig. 6-27). Develop the interval between the sartorius and tensor fascia lata with blunt dissection.
  • Ascending branches of the lateral femoral
    circumflex artery may be encountered in this interval and can safely be
    ligated to allow further exposure (Fig. 6-28).
  • With the tensor fascia lata retracted
    laterally and the Sartorius retracted medially, dissection is continued
    between the rectus femoris medially and gluteus medius laterally. The
    reflected head of rectus femoris tendon can be released from its origin
    on the supraacetabular ilium.
  • The gluteus minimus is elevated from the
    ilium and hip capsule, and its tendon is incised near the insertion on
    the greater trochanter, leaving a tendinous cuff for later repair.
    Next, the gluteus medius tendon is incised near its insertion on the
    greater trochanter, taking care to leave a tendinous cuff on the
    greater trochanter for later repair (Fig. 6-29).
  • Dissection is now carried posteriorly on
    the greater trochanter to release the insertion of the piriformis,
    gemellae, and obturator internus.
  • These tendons should be released at least
    1 cm from their insertions on the femur in order to protect the
    remaining blood supply to the femoral head. The external rotators can
    now be elevated off the posterior capsule and retroacetabular surface
    of the ilium to the greater and lesser sciatic notches (Fig. 6-30).
  • Continuous retraction of the obturator
    internus posteriorly will provide a protective sling in front of the
    sciatic nerve and retractors may be placed in the greater or lesser
    sciatic notches.
  • If further exposure of the anterior
    column is necessary, the origin of the Sartorius and inguinal ligament
    may be released from the anterior superior iliac spine. The aponeurotic
    insertion of the abdominal muscles can be released posteriorly along
    the iliac crest in a similar fashion to the exposure of the lateral
    window of the ilioinguinal approach.
  • Superiosteal dissection along the inner table of the ilium will elevate the iliopsoas to the pelvic brim.
    • Note: An
      alternative to complete release of all structures from the
      anterior-superior iliac spine and iliac crest is to osteotomize the
      iliac crest while maintaining the inguinal ligament, Sartorius, and
      abdominal musculature insertions and origins on the ilium. Predrilling
      the osteotomy will allow easier reduction and fixation during closure.
  • Following fracture reduction and
    fixation, close attention must be paid to repair of the multiple
    tendons that have been released from their origins and insertions.
    Closure begins at the posterior inferior aspect of the greater
    trochanter. The obturator internus and gemellae common tendon is
    repaired with a permanent suture, size 0 or larger. The piriformis is
    repaired next in the same fashion. Working anteriorly on the greater
    trochanter, the gluteus medius tendon and gluteus minimus tendons are
    repaired next, respectively. Again, large permanent suture is preferred
    for this repair, using size 1 suture or larger. Repair of the reflected
    head of the rectus femoris follows the gluteal tendon repairs.
  • The hip abductors are repaired back to
    the abdominal aponeurosis and lumbodorsal fascia using multiple
    interrupted sutures with the hip held in an abducted position. The
    fascia over the Sartorius is repaired to complete the deep closure.
    Layered closure of the subcutaneous tissues and skin follows to
    complete the procedure.
  • Due to the necessary elevation of the hip
    abductors from both the ilium and greater trochanter, postoperative
    protection of the hip is required.
  • After surgery patients should be
    maintained in a hip abduction pillow in the initial postoperative
    period and should be restricted from active abduction for 6 weeks or
    more.
    • Note: This
      exposure has been associated with a high incidence of heterotopic
      ossification, so consideration of prophylaxis with radiation or
      indomethacin should be given.
FIGURE
6-25 Patient is placed in the lateral position with the entire iliac
crest and thigh prepped into the surgical field. The incision follows
the contour of the iliac crest from the posterior superior iliac spine
to the anterior superior iliac spine and then down the anterior thigh
in a line toward the lateral border of the patella.
FIGURE
6-26 The gluteal muscles are released at their origin near the
aponeurosis of the abdominal musculature and subperiosteal dissection
is carried out towards the greater sciatic notch.
FIGURE
6-27 The fascia over the thigh is split in line with the femur and the
interval between the sartorius (medially) and tensor fascia lata
(laterally) is developed. (i) Avascular white line. (ii) Tensor fascia-lata muscle. (iii) Gluteus medius muscle. (iv) Gluteus minimus muscle. (v) Rectus femoris muscle. (vi) Sartorius muscle. (vii) No-name fascia covering vastus lateralis. (viii) Ascending branch of the lateral, femoral, circumflex artery.

P.140


FIGURE
6-28 The ascending branches of the lateral circumflex femoral artery
are identified in the interval between the Sartorius and tensor fascia
lata and ligated. (i) Tensor fascia-lata muscle. (ii) Gluteus medius muscle. (iii) Gluteus minimus muscle. (iv) Greater trochanter. (v) Piriformis muscle. (vi) Hip joint capsule. (vii) Two heads of the rectus muscle. (vii) Ligated ascending branch of the lateral, femoral, circumflex artery.
FIGURE
6-29 The tendons of the gluteus minimus and medius are tagged and
transected, leaving a cuff of tendon to repair back to the greater
trochanter. (i) Gluteus minimus tendon. (ii) Gluteus medius tendon, (iii) Gluteus maximus tendon. (iv) Superior-gluteal neurovascular bundle. (v) Sciatic nerve. (vi) Piriformis and conjoint tendons. (vii) Hip-joint capsule. (viii) Greater trochanter. (ix) Quadratus femoris.

P.141


FIGURE 6-30 Retractors can be placed in the greater and lesser sciatic notches to complete the exposure. (i) Blunt Homan in lesser sciatic notch. The conjoint tendons have been positioned between the retractor and the sciatic nerve. (ii) Gluteus minimus tendon. (iii) Gluteus medius tendon. (iv) Partial release of gluteus maximus tendon. (v) Anterior-superior iliac spine and sartorius muscle origin. (vi) Piriformis muscle. (vii) Sciatic nerve. (viii) Anterior-inferior iliac spine and relected head of rectus femoris muscle.

P.142


Pearls and Pitfalls
  • Multiple tendons need to be released in
    order to perform this approach appropriately. In order to repair the
    tendons to the correct place, the tendon cuffs should be tagged as well
    as the mobile end so the tendons can be put back to the matching
    location.
  • Begin the dissection posteriorly along
    the ilium and work anteriorly to release the gluteus medius. The
    interval between the Sartorius and tensor fascia lata can be difficult
    to determine if the anterior superior iliac spine has not already been
    identified and exposed. If the interval cannot be determined, follow
    the Sartorius from the anterior superior iliac spine distally to
    develop this interval.
  • Predrilling the iliac crest osteotomy will allow easier and more accurate reduction and fixation at the end of the case.
RECOMMENDED READING
Cole
JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa
limited intrapelvic approach. Description of operative technique and
preliminary treatment results. Clin Orthop Relat Res 1994;305:112-123.
Griffin
DB, Beaule PE, Matta JM. Safety and efficacy of the extended
iliofemoral approach in the treatment of complex fractures of the
acetabulum. J Bone Joint Surg Br 2005;87(10):1391-1396.
Jimenez ML, Vrahas MS. Surgical approaches to the acetabulum. Orthop Clin North Am 1997;28(3):419-434.
Letournel E. The treatment of acetabular fractures through the ilioinguinal approach. Clin Orthop Relat Res 1993;292:62-76.
Matta
JM. Fractures of the acetabulum: accuracy of reduction and clinical
results in patients managed operatively within three weeks after the
injury. J Bone Joint Surg Am 1996;78(11):1632-1645.
Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. Clin Orthop Relat Res 1994;305:10-19.
Moed BR, Karges DE. Techniques for reduction and fixation of pelvic ring disruptions through the posterior approach. Clin Orthop Relat Res 1996;329:102-114.
Qureshi
AA, Archdeacon MT, Jenkins MA, et al. Infrapectineal plating for
acetabular fractures: a technical adjunct to internal fixation. J Orthop Trauma 2004;18(3):175-178.

Continue Reading
You might also like More from author

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read More