This document describes several surgical approaches for treating fractures of the acetabulum, including the Kocher-Langenbeck, ilioinguinal, and extended iliofemoral approaches. The Kocher-Langenbeck approach is used for posterior column and wall fractures via a posterior incision. The ilioinguinal approach is used for anterior column and wall fractures through an anterior incision. The extended iliofemoral approach provides access to both columns through a lateral incision. Each approach has specific indications, positioning, incisions, dissections, exposures, and potential complications described. Combined approaches may be needed in some complex fracture patterns.

1. Surgical Approaches for
Fractures of the Acetabulum
Original Author: Mark Reilly, MD
Created February 2004, Updated February 2007

2. Treatment Protocol
• Radiographs Allow Proper Fracture
Classification
• Fracture Location and Displacement
Determine Need for Surgery
• Fracture Pattern Determines Approach

3. Surgical Approach
• Single Approach Preferred
– Kocher Langenbeck
– Ilioinguinal
– Extended Iliofemoral

4. Kocher-Langenbeck
• Approach to posterior
column and posterior
articular surface
• Kocher (1874)
• Langenbeck (1904)
• Judet, Lagrange
(1958)
• Letournel

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

7. Kocher-Langenbeck: Access
• Entire Posterior Column
• Greater and Lesser Sciatic Notches
• Ischial Spine
• Retro-Acetabular Surface
• Ischial Tuberosity

8. Kocher Langenbeck: Access

9. Kocher-Langenbeck: Position
• Prone Position
• Radiolucent Table
• Knee Flexed, Hip
Extended
• Distal Femoral
Traction

10. 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

11. Kocher-Langenbeck: Incision
• 6 to 8 cm from
PSIS
• Tip of Greater
Trochanter
• Parallel Shaft of
Femur 15-20 cm

13. 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

15. Dissection: Kocher-Langenbeck
• Release Gluteus Maximus Insertion
• Identify Sciatic Nerve on Border of
Quadratus Femoris Muscle

18. Dissection: Kocher-Langenbeck
• Release Piriformis Tendon >1cm from
trochanter
• Release Conjoint Tendon
• Open Obturator Internus Bursa for Sciatic
Nerve Retractor

19. 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

21. 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

24. Dissection: Kocher-Langenbeck
• Subperiosteal Elevation of:
– Greater Sciatic Notch
– Quadrilateral Surface
– Gluteus Minimus
• Debridement of Fracture Edges
• Avoid Devascularization of Fx Fragments

26. Complications: Kocher-
Langenbeck
• Infection 2-5%
• Sciatic Nerve palsy 3-5%
• Heterotopic Ossification 8-25%

27. 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

28. Ortho Uni Berne
Trochanteric Flip

30. Ilioinguinal Approach
• Developed by
Letournel after
extensive cadaveric
anatomical study
• Approach to the
anterior column and
anterior articular
surface

31. Ilioinguinal Approach:
Indications
• Anterior Wall
• Anterior Column
• Transverse with Anterior > Posterior
Displacement
• Anterior Column / Posterior Hemitransverse
• Associated Both Column

33. Ilioinguinal Approach: Access
• SI Joint
• Internal Iliac Fossa
• Pelvic Brim
• Quadrilateral Surface
• Superior Pubic Ramus
• Limited Access to External Iliac Wing

34. Ilioinguinal Approach: Access

35. Ilioinguinal: Position
• Supine
• Distal Femoral
Traction
• Access to Greater
Trochanter (Lateral
Traction)
• Hip flexed 20°

36. Ilioinguinal: Incision
• 3-4 cm cranial to
Symphysis pubis
• Curve to ASIS
• Parallel Iliac Crest
• Past Most Convex
Portion of Ilium
– anterior 2/3

37. Symphysis
pubis
ASIS

38. Dissection: Ilioinguinal
• Subperiosteal Dissect Internal Iliac Fossa
– Origin of Abdominals and Iliopsoas
• Expose Sacroiliac Joint
• Dissect over Pelvic Brim

39. Internal Iliac
Fossa

40. 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

42. External Oblique
Ilioinguinal Nerve
Spermatic Cord

43. 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

44. External Iliac Artery/Vein

45. Lateral Femoral
Cutaneous Nerve

46. Dissection: Ilioinguinal
• Separate Lacuna Vasorum and Lacuna
Musculorum
• Incise Iliopectineal Fascia to Superior
Ramus and from Pelvic Brim
• Connect True and False Pelvis

48. Iliopectineal Fascia

49. Dissection: Ilioinguinal
• Dissect Lateral to External Iliac Vessels
• Transect Ipsilateral Rectus Tendon
• Dissect Medial to External Iliac Vessels

51. Ilioinguinal: Lateral Window
• Internal Iliac Fossa
• Sacroiliac Joint
• Pelvic Brim - Upper 1/3

53. Ilioinguinal: Middle Window
• Pelvic Brim - SI joint to pectineal eminence
• Quadrilateral Surface
• Anterior Rim

55. Ilioinguinal: Medial Window
• Superior Pubic Ramus
• Symphysis Pubis

57. 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

58. Ilioinguinal: Corona Mortis
• Vascular Anastamosis
– External Iliac
– Obturator
• Frequently Venous
• Occasionally Arterial

59. 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%

60. Extended Iliofemoral
• Developed by
Letournel (1975)
• Based on Smith-
Peterson Approach
• Maximal
Simultaneous access
to both columns of the
acetabulum

61. 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.

62. 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

64. Extended Iliofemoral: Access
• External Aspect of Ilium
• Anterior Column as far medial as
Iliopectineal eminence
• Posterior Column to the Upper Ischial
Tuberosity

65. EIF Approach: Access

66. Extended Iliofemoral: Position
• Lateral Position
• Distal Femoral
Traction
• Knee flexed 45°

68. Extended Iliofemoral: Incision
• Inverted J incision
• Parallel Iliac Crest
from PSIS to ASIS
• Incise along anterior-
lateral thigh

69. 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

71. Dissection: Extended Iliofemoral
• Retract Tensor Fascia Lata Muscle
Posteriorly
• Incise Sheath of Rectus Femoris
• Ligate Lateral Femoral Circumflex Artery
and Vein

74. 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

77. 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

80. 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

81. Complications: Extended
Iliofemoral
• Infection 2-5%
• Sciatic Nerve palsy 3-5%
• Heterotopic Ossification 20-50%

82. 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

83. 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

84. 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