Important surgical approaches to acetabulum and pelvis are described. Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.

1. SURGICAL APPROACHES
TO ACETABULUM AND
PELVIS
PRESENTER : DR. BIJAY MEHTA
MODERATOR : DR. JANITH SINGH

2. CONTENTS
•Surgical Anatomy
•Choice of Approaches
•Anterior Approaches
•Posterior Approaches
•Extensile Approaches
•Summary

3. SURGICAL ANATOMY
•Bones
•Muscles
•Vessels
• Iliac Vessels
• Femoral Artery
• Superior /Inferior Gluteal
Arteries
• Corona Mortis
•Inguinal Canal

4. SURGICAL ANATOMY
•Nerves
• Sciatic Nerve
• Femoral nerve
• Superior /Inferior Gluteal Nerve
• Obturator Nerve
• Lateral Femoral Cutaneous nerve
of thigh

5. CHOICE OF APPROACH
•Depends on –
• Location of fracture
• Type of Fracture
• Complexity of Fracture
•Anterior Approach(usually ilioinguinal approach) used for:
• Anterior Wall Fracture
• Anterior Column Fracture
• Associated Anterior and Posterior Hemitransverse
Fracture
• Associated Both Column Fracture

6. Posterior approach preferred for :
• Posterior Wall Fracture
• Posterior Column Fracture
• Posterior Column and posterior wall Fracture
• Posterior wall with Transverse Fracture
•For Transverse Fracture – If high- Iliinguinal Approach
• If low- posterior approach
CHOICE OF APPROACH

7. ANTERIOR APPROACHES
•Ilioinguinal Approach
•Stoppa Approach
•Iliofemoral Approach

8. ILIOINGUINAL APPROACH
• Developed by Letornel in 1960
•Allows exposure to-
• Entire Internal iliac fossa, and pelvic
brim from SI joint to pubic
symphysis
• Quadrilateral surface
• Anterior column and medial aspect
of acetabulum
• superior and inferior pubic rami

9. ILIOINGUINAL APPROACH :INDICATIONS
• Anterior Wall Fracture
• Anterior Column Fracture
• Associated Anterior Column and Posterior Hemitransverse
Fracture
• Associated Both Column Fracture
• Some T-type fracture
• Some transverse type fracture

10. ILIOINGUINAL APPROACH : POSITIONING
• Supine
• Foley Catheter
• Affected leg slightly flexed

11. ILIOINGUINAL APPROACH : INCISION
• Incision begun 3-4 cm
above pubic symphysis
• Proceeds laterally to ASIS,
then along 2/3rd of iliac
crest
• Extended beyond convex
portion of ilium

12. ILIOINGUINAL APPROACH : SUPERFICIAL DISSECTION
•Dissect through subcutaneous fat
in the line of the skin incision-
external oblique aponeurosis
exposed muscle.
•The lateral cutaneous nerve of
the thigh will appear in the
lateral edge of the dissection.
•In most cases, the nerve will
need to be divided.

13. ILIOINGUINAL APPROACH : SUPERFICIAL DISSECTION
•External oblique aponeurosis
divided from the superficial
inguinal ring to the ASIS –
unroofing of inguinal canal
•Ilioinguinal nerve
isolated/protected
•spermatic cord/ round ligament
isolated

14. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Rectus abdominis muscle divided
1 cm proximal to its insertion into
the symphysis pubis.
•Using blunt dissection, a plane
between the back of the
symphysis pubis and the
bladder(the Cave of Retzius) is
developed .

15. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Ligate and divide the inferior
epigastric vessels. Complete
the division of the muscular
structures of the posterior
wall of the inguinal canal.
• The peritoneum covered
with extraperitoneal fat is
now exposed.
•

16. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Using a swab, push the
peritoneum upwards to
reveal the femoral
vessels,femoral nerve and
iliopsoas.
•Isolate the femoral vessels
along with sheath and
protected in a sling.
• Strip the iliacus muscle
from the inner aspect of
the ilium.

17. ILIOINGUINAL APPROACH : DEEP DISSECTION
•Continue stripping off the iliacus from
the inner wall of the ilium to reveal the
sacroiliac joint.
•Incise the iliopectineal fascia upto
bone.
•Retract the iliopsoas and the femoral
sheath either medially or laterally to
reveal the medial surface of the
acetabulum, the superior pubic ramus,
and the inner surface of the ilium
round to the sacroiliac joint.
•

18. ILIOINGUINAL APPROACH : DEEP DISSECTION
Three windows are created.
◦ The lateral window, lateral to the iliopsoas gives access to the inner
surface of the ilium
◦ The middle window, medial to the iliopsoas but lateral to the
femoral artery and vein gives access to the quadrilateral plate.
◦ The medial window, medial to the femoral artery and vein
gives assess to the superior pubic ramus and symphysis

20. ILIOINGUINAL APPROACH : CLOSURE
•Drain – placed in Space of Retzius
• Tendons repaired
• Transversalis fascia and conjoined tendon of internal
oblique and transversus abdominis attached to inguinal
ligament
• External oblique aponeurosis repaired

21. ILIOINGUINAL APPROACH : DANGERS
•Femoral Nerve
•Femoral and External iliac arteries
•Lateral Cutaneous Nerve of thigh
•Inferior Epigastric vessels
•Spermatic Cord

22. ANTERIOR APPROACH : MODIFIED STOPPA
•Anterior Intrapelvic Approach
•First described by Rene Stoppa for hernia repair in 1975.
• Revised for pelvic and acetabular surgery by Hirvensalo et al in
1993.
• “Modified Stoppa” was described in 1994 by Cole and Bohofner.
•Advantages :
• entire anterior column including quadrilateral plate could be
visualized when supplemented with a lateral window

23. STOPPA’S APPROACH :INDICATIONS
• Anterior Wall Fracture
• Anterior Column Fracture
• Associated Anterior Column and Posterior Hemitransverse
Fracture
• Associated Both Column Fracture
• Fractures involving quadrilateral plate

24. STOPPA’S APPROACH: POSITIONING
•Patient- Supine ,
radiolucent table
•Surgeon – on opposite
side
•Bolster placed beneath
the knee
•Foley catheter placed

25. STOPPA’S APPROACH: SKIN INCISION
•Pfannensteil Incision
•placed just above the
pubic symphysis.
•Extended laterally on
both sides

26. STOPPA’S APPROACH: SUPERFICIAL DISSECTION
•Divide the subcutaneous tissues
in line with the skin incision in
order to expose the fascia
overlying both rectus muscles of
the abdomen.

27. STOPPA’S APPROACH: DEEP DISSECTION
•The rectus fascia is incised
longitudinally along the linea
alba and muscle bellies are
retracted laterally.
•In the proximal part of the
incision, care should be taken
not to incise the peritoneum.

28. STOPPA’S APPROACH: DEEP DISSECTION
•The medial part of the rectus
muscle is partly detached from
symphysis to allow the rectus to
retract.
•The upper border of the superior
pubic ramus is identified (pecten
pubis) and blunt dissection using a
finger or swab is carried laterally
along the pelvic brim without yet
incising the fascia.

29. STOPPA’S APPROACH: DEEP DISSECTION
•Exposing carefully along the
medial surface of the superior
ramus, the corona mortis
vessels are identified and
ligated (or clipped) as
necessary. The vessels sit
above the fascia and are most
easily identified if the fascia is
not incised prior to ligation.

30. STOPPA’S APPROACH: DEEP DISSECTION
•Then, the thick periosteum
from the superior pubic bone
is dissected sharply using
diathermy, allowing for
deeper blunt dissection.
•Dissection is continued
laterally upto the beginning
of the iliopectineal
eminence.

31. STOPPA’S APPROACH: DEEP DISSECTION
•Beginning of the iliopectineal arch
should be dissected from the bone
and femoral vessels and nerve are
elevated.
•The dissection is continued
subperiosteally more laterally
following the upper border of the
pelvic brim- entire internal surface
of the superior pubic ramus is
exposed.

32. STOPPA’S APPROACH: DEEP DISSECTION
•With a Cobb elevator, the periosteum
and obturator internus are elevated and
the quadrilateral surface can be
sufficiently exposed.

33. STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW
•An incision is made along the
iliac crest.
•The incision can be extended
intraoperatively depending on
the necessary exposure.
•For fractures involving the
posterior aspect of the ilium, or
the SI joint, the exposure needs
to be extended posteriorly
almost to the table.

34. •Divide the subcutaneous tissues
and expose the fascia overlying
the external oblique muscle.
•Identify the border between the
gluteus muscles and external
oblique muscles. Incise the
muscular interval with
electrocautery.
•The external oblique muscle is
subperiosteally elevated from the
iliac crest.
•With a small elevator, the iliac
muscles are elevated using the
same subperiosteal layer.
STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW

35. •When elevating the iliacus muscle,
bleeding from nutrient vessels can
occur and should be stopped with
bone wax.
•Continue with careful blunt dissection
to the interior part of the SI joint
medially to the pelvic ring.
•Proceed anteromedially at the pelvic
rim as far as to where the
iliopectineal eminence begins.
STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW

36. •Continue the dissection with an
instrument such as a Cobb elevator.
•The SI joint capsule should be
identified. Place a Hohmann
retractor into the superior portion
of the SI joint.
STOPPA’S APPROACH: ADDITION OF LATERAL
WINDDOW

37. STOPPA’S APPROACH: WOUND CLOSURE
•Place drain as needed
•The midline incision in the rectus
abdominis and superficial tissues
are closed in layers taking care
to protect the underlying
bladder and peritoneum.
•The lateral window is also closed
in layers reconstructing the
fascial layer preserved in the
approach.

38. STOPPA’S APPROACH : DANGERS
•Obturator Nerve Injury
•External and Internal iliac arteries
•Superior Gluteal Vessels
•Corona Mortis
•Urinary Bladder

39. POSTERIOR APPROACHES : KOCHER LAGENBECK
APPROACH
•Gives access to posterior wall and posterior column
•If trochanteric osteotomy, surgical dislocation of hip is used, anterior
wall can also be visualized
•Indications:
• Posterior Wall Fracture
• Posterior Column Fracture
• Posterior Column and posterior wall Fracture
• Posterior wall with Transverse Fracture
• Some T-type Fractures

40. KOCHER LAGENBECK APPROACH : POSITIONING
•Either Prone or Lateral Position
•Knee Flexed to reduce tension on sciatic nerve

41. •Landmarks :
• Posterior superior iliac spine
• Greater trochanter
• Shaft of femur
•Skin incision started a few
centimeters distal and lateral
to the PSIS.
•Continued over the greater
trochanter.
KOCHER LAGENBECK APPROACH : SKIN INCISION
•Curved distally along the tip of the greater trochanter towards the
lateral aspect of the femoral shaft upto midthigh.

42. •Fascia lata is incised in line
with the skin incision.
•Incision extended
superiorly along the
anterior border of the
gluteus maximus muscle for
a distance of no more than
7 cm , branch of the inferior
gluteal nerve is protected.
KOCHER LAGENBECK APPROACH : SUPERFICIAL
DISSECTION

43. •Split the gluteus maximus in
line with its fibers.
•In the distal half, incise the
iliotibial tract in line with its
fibers up to the mid third of
the thigh.
KOCHER LAGENBECK APPROACH : SUPERFICIAL
DISSECTION

44. •Layer of fat is removed and
short external rotators are
visualized.
•The sciatic nerve is visualized.
•It lies posterior to the gemelli
and internal obturator muscles,
and anterior to the piriformis
muscle, between the greater
trochanter and the ischial
tuberosity.
KOCHER LAGENBECK APPROACH : DEEP DISSECTION

45. •Piriformis tendon is isolated and
a suture is placed 1 cm lateral to
its femoral insertion and
tendon is dissected.
•Reflect the piriformis belly
laterally to expose the
retroacetabular surface to the
greater sciatic notch.
•Avoid cutting quadratus femoris
KOCHER LAGENBECK APPROACH : DEEP DISSECTION

46. •Conjoined tendon of the obturator
internus and superior and inferior
gemelli muscles are isolated and
tagged and incised 1 cm lateral
from their femoral insertions to
protect the medial circumflex
femoral artery.
•Reflect the muscle bellies of the
three conjoined muscles laterally
to access the lesser sciatic notch.
KOCHER LAGENBECK APPROACH : DEEP DISSECTION

47. •Greater sciatic notch, the ischial
spine, and the lesser sciatic
notch are visualized.
•Insert a retractor in the lesser
sciatic notch and one
anterosuperiorly in the direction
of the anterior inferior spine.
Now the posterior column is
visible in its whole extent.
KOCHER LAGENBECK APPROACH : DEEP DISSECTION

48. KOCHER LAGENBECK APPROACH : DEEP DISSECTION
•Trochanteric Flip Osteotomy
•T-shaped Capsulotomy

49. POSTERIOR APPROACH

50. •Meticulous debridement done
before closure.
•All tendons are reinserted and
split parts of the gluteus
maximus are approximated with
adaptation sutures.
•Perform the closure of the
iliotibial tract, the subcutis and
the skin.
KOCHER LAGENBECK APPROACH : CLOSURE

51. •Skin and superficial dissection
same as Kocher Lagenbeck
approach
•Instead of splitting the fibres of
gluteus maximus, interval is made
anterior to gluteus maximus b/w
Gluteus maximus and medius
•Others same as KL approach
POSTERIOR APPROACHES : MODIFIED GIBSON’S
APPROACH

52. •Sciatic Nerve Injury
•Infection
•Heterotrophic Ossification – debride non viable muscles
•Superficial Gluteal Artery Injury
•Medial Circumflex Femoral Artery Injury
KOCHER LAGENBECK APPROACH : COMPLICATIONS

53. EXTENSILE APPROACHES
EXTENSILE ILIOFEMORALAPPROACH
• LETOURNEL AND JUDET
• REINERT ET AL
TRIRADIATE EXTENSILE APPROACH
• MEARS AND RUBASH

54. EXTENSILE ILIOFEMORAL APPROACH
Indications :
•Transtectal transverse fracture with roof impaction
•Transverse with posterior wall fractures
•T-type fractures, especially with posterior wall involvement
•Both-column fractures with posterior wall or posterior column
comminution
•Delayed fixation of both column, t-type, or transverse + posterior wall
fractures (typically > 3 weeks)
•Malunion/nonunion/deformity correction surgeries

55. EXTENSILE ILIOFEMORAL APPROACH

56. EXTENSILE ILIOFEMORAL APPROACH

57. EXTENSILE ILIOFEMORAL APPROACH

58. EXTENSILE ILIOFEMORAL APPROACH

59. OTHER APPROACHES
Ilium
Pubic Symphysis- Pfannensteil
Sacroiliac Joint-
◦ Anterior- Avila
◦ Posterior
◦ Both SI Joint- Mears and Rubash

60. SUMMARY
•Complex Injury
•Anterior, Posterior or Extensile Approaches
•Knowledge of Anatomy is must
•Neurovascular structures should be preserved.

61. REFERENCES
•Campbell’s Operative Orthopaedics , 13th Edition
•Surgical Exposures in Orthopaedics, Hoppenfield, 5th
Edition
•AO Foundation Surgery Reference

62. THANK YOU