Quick glance of the various approaches for acetabular fracture fixation.

1. Surgical approaches
for
ACETABULAR FRACTURE FIXATION
Dr Sharan Achar, PG- MS Ortho,
Institute of Orthopaedics & Traumatology,
Coimbatore Medical College Hospital.

2.  Kocher Langenback approach
 Ilioinguinal approach
 Iliofemoral approach
 Modified Stoppa’s approach
 Modified Gibson’s approach
SURGICAL EXPOSURES

3. ANATOMIC RELATIONSHIP OF ACETABULUM:

4. POSTERIOR STRUCTURES
Muscular relations:
The outer muscle layer consists of gluteus maximus which inserts into gluteal tuberosity
and iliotibial tract. Gluteus medius is a fan shaped muscle originating from gluteal surface of ilium
and inserts into greater trochanter. Short external rotators form the inner layer. They are pyriformis
superior gemellus , tendon of obturator internus , inferior gemelli , and quadratus femoris.
The critical structures of importance in deep surgical dissection are:
• Superior gluteal nerve and vessels ( above pyriformis)
• Inferior gluteal nerve and vessels
• Sciatic nerve
• Quadratus femoris muscle protecting the ascending branch of medial circumflex femoral artery

6. Vascular relations:
• SUPERIOR GLUTEAL ARTERY: Commonly injured in greater sciatic notch, can be damaged by aggressive
superior or lateral retraction of the abductor muscles during Kocher-Langenbeck exposure
• ASCENDING BRANCH OF MEDIAL FEMORAL CIRCUMFLEX: It is the main blood supply to femoral head. It lies
deep to quadratus, obturator internus, and piriformis, superficial to obturator externus

9. Nerve relations:
SCIATIC NERVE:
Most common traumatic & iatrogenic nerve injury. It exits from greater sciatic notch below the
pyriformis. Sciatic nerve must be isolated and protected through out the procedure. Variations of its coarse
must be kept in mind.

10. Posterior-
KOCHER LANGENBACK
APPROACH

11. INDICATIONS
 Posterior wall fractures
 Posterior column fractures with or without an
associated posterior wall fracture.
 Transverse and T-shaped fractures, treated within
15 days of injury.
 T-shaped fractures, the major displacement
should be posterior, with only minor
displacement occurring anteriorly at the pelvic
brim

12. PATIENT POSITION
Prone position- Most commonly used Lateral position

13. 1. J shaped skin incision was placed lateral
to the posterior superior iliac spine,
extended to the greater trochanter, and
then continued along the axis of the
femur to almost the midpoint of the
thigh.
2. Gluteus maximus muscle is bluntly
divided along the skin incision. Its
insertion to femur is released.
SURGICAL STEPS

14. 3. The sciatic nerve was identified on the posterior surface of
the quadratus femoris and followed proximally until it
disappears beneath the piriformis. The short external
rotators and pyriformis tendon are tagged and divided. The
knee joint is kept in adequate flexion through out the
procedure to prevent iatrogenic sciatic nerve palsy

15. 4. The retractor is positioned is placed in lesser sciatic notch.
5. Subperiosteal elevation was done to exposes the inferior
aspect of the iliac wing. Fracture reduced and fixed with
contoured recon plate and lag screws.

16. Anterior-
ILIOINGUINAL APPROACH

17. ILIOINGUINAL APPROACH
INDICATIONS:
 Anterior wall and Anterior column fractures.
 Anterior column/wall and posterior
hemitransverse fractures
 Both-column fractures.
 Transverse fractures in which the major
displacement is anterior with minimal
posterior displacement
 Both-column fractures having a
noncomminuted posterior column fragment .

18. SURGICAL STEPS
1. The skin incision extends from just posterior to the
gluteus medius tubercle, paralleling the iliac crest to
the anterior superior iliac spine, and then coursing
medially to the midline ending two finger-breadths
above the pubic symphysis

19. 2. Dissect through subcutaneous fat in the
line of the skin incision to expose the
aponeurosis of the external oblique
muscle.
3. The external oblique aponeurosis has been
incised from the anterior superior iliac spine to
the midline, passing at least 1 cm superior to
the superficial inguinal ring, and reflected
distally.

20. 4. The spermatic cord in the male or the
round ligament in the female is bluntly
isolated along with the ilioinguinal nerve
and retracted using a rubber sling.
5. Divide the rectus abdominis muscle 1 cm
proximal to its insertion into the symphysis pubis.
Detach the external, internal oblique and the
transversus abdominis muscles from the inguinal
ligament leaving 2 mm of the ligament attached to
the muscles.

21. 6. Using a swab, push the peritoneum upward to
reveal the femoral vessels. Mobilize the iliacus
muscle from the inner aspect of the ilium. Note
the iliopectineal fascia covering the muscle and
separating it from the femoral sheath.
7. The iliopectineal fascia has been released
and the exposure is complete. Pass the sling
around the femoral sheath. Pass a sling around
the iliopsoas deep to the iliopectineal fascia.

22. WINDOWS OF ILIOINGUINAL APPROACH
1. Lateral window:
Exposes the internal iliac fossa to
the sacroiliac joint and the pelvic
brim.
2. Middle window:
Exposes pelvic brim to pectineal
eminence, quadrilateral surface &
anterior wall.
3. Medial window:
The space of Retzius, superior
ramus, and symphysis pubis are
visualized.

23. WINDOWS OF ILIOINGUINAL APPROACH

24. ILIOFEMORAL APPROACH

25. Indications
(EXTENDED ILIOFEMORAL APPROACH)
 Transverse component with an extended posterior wall
fracture (involving the posterior border of the bone),
 T-shaped and posterior wall fracture, and those
associated with dislocation of the symphysis pubis or
fracture of the contralateral pubis ramus.
 Select T-shaped fractures include those with a transtectal
transverse component, those with a wide separation along
the vertical stem of the T, and those associated with
dislocation of the symphysis pubis or fracture of the
contralateral pubic ramus.
 Select both-column fractures include those having a
complex fracture of the posterior column, a displaced
fracture line crossing the sacroiliac joint, or a wide
separation of the anterior and posterior columns at the rim
of the acetabulum.

26. SURGICAL STEPS
1. The incision extends from just posterior to the gluteus medius tubercle, paralleling the iliac
crest, to the anterior superior iliac spine and then coursing distally for approximately 15 cm along
the lateral aspect of the sartorius muscle.

27. 2. The iliopsoas muscle is elevated off the inner aspect of the iliac crest.
3. The sartorius origin and inguinal ligament are released from the anterior superior iliac spine.
4. The interval between the Sartorius and the tensor fascia lata is developed to allow exposure of the
anterior hip joint capsule, the anteroinferior iliac spine, and the anterior column as far medial as the
iliopectineal eminence

28. EXTENDED ILIOFEMORAL APPROACH
1. The skin incision runs from the
posterior superior iliac spine to the
anterior spine and then curves to lie on
the anterior-lateral thigh.
2. The abductors have been reflected subperiosteally from
the external ilium and reflected posteriorly with the tensor
fascia lata muscle. The fascia separating the tensor from the
rectus is split and the ascending branch of the lateral femoral
circumflex vessels is ligated

29. 3. The abductor tendons are here transected
from the greater trochanter. Alternatively, a
trochanteric osteotomy can be performed.
4. The piriformis and obturator internus
tendons have been transected and the
exposure to the external ilium is completed.

30. MODIFIED STOPPAS APPROACH

31. INDICATIONS
 Anterior column
 Transverse
 T-shaped
 Anterior column/wall and
posterior hemitransverse
 Both-column fractures.
With this approach, it is often necessary to make a second approach through a skin
incision along the iliac crest for fracture reduction or hardware insertion, essentially using
the equivalent of the lateral and medial “windows” of the ilioinguinal approach.

32. SURGICAL STEPS
1. A transverse skin incision is made 2 cm
above the pubic symphysis extending
approximately from one external inguinal ring
to the other.
2. The linea alba is incised at the midline and
split vertically from inferior to superior with care
taken to remain extraperitoneal in the proximal
portion.

33. 3. Protecting the bladder, the rectus
abdominis muscle is then retracted
upward.
4. Sharp dissection is used to elevate the
rectus to expose the symphysis body and
pubic ramus

34. 6. Coronal mortis, anastomotic vessel between major arteries, such as the inferior epigastric and
obturator vessels, is identified and ligated (don’t cauterize).
5. Rectus and neurovascular structures are subsequently retracted laterally and
anteriorly so that they are protected.

35. 7. It is imperative to pay strict attention at
all times to the location of the obturator
neurovascular bundle and lumbosacral
trunk which traverse the operative field.
8. Full access is then developed from anterior to
posterior along the pelvic brim, sharply dividing and
elevating the iliopectineal fascia superiorly and the
obturator fascia inferiorly andexposing the medial wall
of the acetabulum, the fracture, and the pelvic brim.

36. MODIFIED GIBSON APPROACH

37. INDICATIONS
 Differs from the Kocher–Langenbeck
approach in its proximal dissection.

38. 1. The interval between the gluteus
maximus and tensor fasciae lata muscles is
developed,rather than splitting the gluteus
maximus muscle.
2. In this way, the neurovascular supply to the
anterior portion of the gluteus maximus muscle is
not at risk. In addition, anterosuperior visualization
and access are extended

39. OUR EXPERIENCE

40. KOCHER LANGENBECK

41. MODIFIED STOPPA AND ILIOFEMORAL LATERLAL WINDOW

42. MODIFIED STOPPA AND ILIOINGUINAL LATERAL WINDOW

43. THANKYOU