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V05 acetab surgical_apprch

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V05 acetab surgical_apprch

  1. 1. Surgical Approaches for Fractures of the Acetabulum Original Author: Mark Reilly, MD Created February 2004, Updated February 2007
  2. 2. Treatment Protocol • Radiographs Allow Proper Fracture Classification • Fracture Location and Displacement Determine Need for Surgery • Fracture Pattern Determines Approach
  3. 3. Surgical Approach • Single Approach Preferred – Kocher Langenbeck – Ilioinguinal – Extended Iliofemoral
  4. 4. Kocher-Langenbeck • Approach to posterior column and posterior articular surface • Kocher (1874) • Langenbeck (1904) • Judet, Lagrange (1958) • Letournel
  5. 5. 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
  6. 6. Kocher-Langenbeck: Access • Entire Posterior Column • Greater and Lesser Sciatic Notches • Ischial Spine • Retro-Acetabular Surface • Ischial Tuberosity
  7. 7. Kocher Langenbeck: Access
  8. 8. Kocher-Langenbeck: Position • Prone Position • Radiolucent Table • Knee Flexed, Hip Extended • Distal Femoral Traction
  9. 9. 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
  10. 10. Kocher-Langenbeck: Incision • 6 to 8 cm from PSIS • Tip of Greater Trochanter • Parallel Shaft of Femur 15-20 cm
  11. 11. 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
  12. 12. Dissection: Kocher-Langenbeck • Release Gluteus Maximus Insertion • Identify Sciatic Nerve on Border of Quadratus Femoris Muscle
  13. 13. Dissection: Kocher-Langenbeck • Release Piriformis Tendon >1cm from trochanter • Release Conjoint Tendon • Open Obturator Internus Bursa for Sciatic Nerve Retractor
  14. 14. 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
  15. 15. 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
  16. 16. Dissection: Kocher-Langenbeck • Subperiosteal Elevation of: – Greater Sciatic Notch – Quadrilateral Surface – Gluteus Minimus • Debridement of Fracture Edges • Avoid Devascularization of Fx Fragments
  17. 17. Complications: Kocher- Langenbeck • Infection 2-5% • Sciatic Nerve palsy 3-5% • Heterotopic Ossification 8-25%
  18. 18. 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
  19. 19. Ortho Uni Berne Trochanteric Flip
  20. 20. Ilioinguinal Approach • Developed by Letournel after extensive cadaveric anatomical study • Approach to the anterior column and anterior articular surface
  21. 21. Ilioinguinal Approach: Indications • Anterior Wall • Anterior Column • Transverse with Anterior > Posterior Displacement • Anterior Column / Posterior Hemitransverse • Associated Both Column
  22. 22. Ilioinguinal Approach: Access • SI Joint • Internal Iliac Fossa • Pelvic Brim • Quadrilateral Surface • Superior Pubic Ramus • Limited Access to External Iliac Wing
  23. 23. Ilioinguinal Approach: Access
  24. 24. Ilioinguinal: Position • Supine • Distal Femoral Traction • Access to Greater Trochanter (Lateral Traction) • Hip flexed 20°
  25. 25. Ilioinguinal: Incision • 3-4 cm cranial to Symphysis pubis • Curve to ASIS • Parallel Iliac Crest • Past Most Convex Portion of Ilium – anterior 2/3
  26. 26. Symphysis pubis ASIS
  27. 27. Dissection: Ilioinguinal • Subperiosteal Dissect Internal Iliac Fossa – Origin of Abdominals and Iliopsoas • Expose Sacroiliac Joint • Dissect over Pelvic Brim
  28. 28. Internal Iliac Fossa
  29. 29. 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
  30. 30. External Oblique Ilioinguinal Nerve Spermatic Cord
  31. 31. 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
  32. 32. External Iliac Artery/Vein
  33. 33. Lateral Femoral Cutaneous Nerve
  34. 34. Dissection: Ilioinguinal • Separate Lacuna Vasorum and Lacuna Musculorum • Incise Iliopectineal Fascia to Superior Ramus and from Pelvic Brim • Connect True and False Pelvis
  35. 35. Iliopectineal Fascia
  36. 36. Dissection: Ilioinguinal • Dissect Lateral to External Iliac Vessels • Transect Ipsilateral Rectus Tendon • Dissect Medial to External Iliac Vessels
  37. 37. Ilioinguinal: Lateral Window • Internal Iliac Fossa • Sacroiliac Joint • Pelvic Brim - Upper 1/3
  38. 38. Ilioinguinal: Middle Window • Pelvic Brim - SI joint to pectineal eminence • Quadrilateral Surface • Anterior Rim
  39. 39. Ilioinguinal: Medial Window • Superior Pubic Ramus • Symphysis Pubis
  40. 40. 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
  41. 41. Ilioinguinal: Corona Mortis • Vascular Anastamosis – External Iliac – Obturator • Frequently Venous • Occasionally Arterial
  42. 42. 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%
  43. 43. Extended Iliofemoral • Developed by Letournel (1975) • Based on Smith- Peterson Approach • Maximal Simultaneous access to both columns of the acetabulum
  44. 44. 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.
  45. 45. 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
  46. 46. Extended Iliofemoral: Access • External Aspect of Ilium • Anterior Column as far medial as Iliopectineal eminence • Posterior Column to the Upper Ischial Tuberosity
  47. 47. EIF Approach: Access
  48. 48. Extended Iliofemoral: Position • Lateral Position • Distal Femoral Traction • Knee flexed 45°
  49. 49. Extended Iliofemoral: Incision • Inverted J incision • Parallel Iliac Crest from PSIS to ASIS • Incise along anterior- lateral thigh
  50. 50. 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
  51. 51. Dissection: Extended Iliofemoral • Retract Tensor Fascia Lata Muscle Posteriorly • Incise Sheath of Rectus Femoris • Ligate Lateral Femoral Circumflex Artery and Vein
  52. 52. 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
  53. 53. 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
  54. 54. 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
  55. 55. Complications: Extended Iliofemoral • Infection 2-5% • Sciatic Nerve palsy 3-5% • Heterotopic Ossification 20-50%
  56. 56. 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
  57. 57. 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
  58. 58. 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 E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e- mail to ota@aaos.org

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