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Surgical Approaches for Fractures of the Acetabulum
Original Author: Mark Reilly, MDCreated February 2004, Updated February 2007
Treatment Protocol
• Radiographs Allow Proper Fracture Classification
• Fracture Location and Displacement Determine Need for Surgery
• Fracture Pattern Determines Approach
Surgical Approach
• Single Approach Preferred– Kocher Langenbeck– Ilioinguinal– Extended Iliofemoral
Kocher-Langenbeck• Approach to posterior
column and posterior articular surface
• Kocher (1874)• Langenbeck (1904)• Judet, Lagrange
(1958)• Letournel
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
Kocher-Langenbeck: Access
• Entire Posterior Column• Greater and Lesser Sciatic Notches• Ischial Spine• Retro-Acetabular Surface• Ischial Tuberosity
Kocher Langenbeck: Access
Kocher-Langenbeck: Position
• Prone Position• Radiolucent Table• Knee Flexed, Hip
Extended• Distal Femoral
Traction
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
Kocher-Langenbeck: Incision
• 6 to 8 cm from PSIS
• Tip of Greater Trochanter
• Parallel Shaft of Femur 15-20 cm
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
Dissection: Kocher-Langenbeck
• Release Gluteus Maximus Insertion • Identify Sciatic Nerve on Border of
Quadratus Femoris Muscle
Dissection: Kocher-Langenbeck
• Release Piriformis Tendon >1cm from trochanter
• Release Conjoint Tendon• Open Obturator Internus Bursa for Sciatic
Nerve Retractor
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
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
Dissection: Kocher-Langenbeck
• Subperiosteal Elevation of:– Greater Sciatic Notch– Quadrilateral Surface– Gluteus Minimus
• Debridement of Fracture Edges• Avoid Devascularization of Fx Fragments
Complications: Kocher-Langenbeck
• Infection 2-5%• Sciatic Nerve palsy 3-5%• Heterotopic Ossification 8-25%
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
Ortho Uni Berne
Trochanteric Flip
Ilioinguinal Approach• Developed by
Letournel after extensive cadaveric anatomical study
• Approach to the anterior column and anterior articular surface
Ilioinguinal Approach: Indications
• Anterior Wall• Anterior Column• Transverse with Anterior > Posterior
Displacement• Anterior Column / Posterior Hemitransverse• Associated Both Column
Ilioinguinal Approach: Access
• SI Joint • Internal Iliac Fossa• Pelvic Brim• Quadrilateral Surface• Superior Pubic Ramus• Limited Access to External Iliac Wing
Ilioinguinal Approach: Access
Ilioinguinal: Position
• Supine• Distal Femoral
Traction• Access to Greater
Trochanter (Lateral Traction)
• Hip flexed 20°
Ilioinguinal: Incision
• 3-4 cm cranial to Symphysis pubis
• Curve to ASIS• Parallel Iliac Crest• Past Most Convex
Portion of Ilium– anterior 2/3
Symphysispubis
ASIS
Dissection: Ilioinguinal
• Subperiosteal Dissect Internal Iliac Fossa– Origin of Abdominals and Iliopsoas
• Expose Sacroiliac Joint• Dissect over Pelvic Brim
Internal IliacFossa
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
External Oblique
Ilioinguinal Nerve
Spermatic Cord
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
External Iliac Artery/Vein
Lateral FemoralCutaneous Nerve
Dissection: Ilioinguinal
• Separate Lacuna Vasorum and Lacuna Musculorum
• Incise Iliopectineal Fascia to Superior Ramus and from Pelvic Brim
• Connect True and False Pelvis
Iliopectineal Fascia
Dissection: Ilioinguinal
• Dissect Lateral to External Iliac Vessels• Transect Ipsilateral Rectus Tendon• Dissect Medial to External Iliac Vessels
Ilioinguinal: Lateral Window
• Internal Iliac Fossa• Sacroiliac Joint• Pelvic Brim - Upper 1/3
Ilioinguinal: Middle Window
• Pelvic Brim - SI joint to pectineal eminence• Quadrilateral Surface• Anterior Rim
Ilioinguinal: Medial Window
• Superior Pubic Ramus• Symphysis Pubis
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
Ilioinguinal: Corona Mortis
• Vascular Anastamosis– External Iliac– Obturator
• Frequently Venous• Occasionally Arterial
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%
Extended Iliofemoral• Developed by
Letournel (1975)• Based on Smith-
Peterson Approach• Maximal
Simultaneous access to both columns of the acetabulum
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.
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
Extended Iliofemoral: Access
• External Aspect of Ilium• Anterior Column as far medial as
Iliopectineal eminence• Posterior Column to the Upper Ischial
Tuberosity
EIF Approach: Access
Extended Iliofemoral: Position
• Lateral Position• Distal Femoral
Traction• Knee flexed 45°
Extended Iliofemoral: Incision
• Inverted J incision• Parallel Iliac Crest
from PSIS to ASIS• Incise along anterior-
lateral thigh
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
Dissection: Extended Iliofemoral
• Retract Tensor Fascia Lata Muscle Posteriorly
• Incise Sheath of Rectus Femoris• Ligate Lateral Femoral Circumflex Artery
and Vein
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
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
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
Complications: Extended Iliofemoral
• Infection 2-5%• Sciatic Nerve palsy 3-5%• Heterotopic Ossification 20-50%
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
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
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
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