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SYMPOSIUM Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 1  |  Page : 17-19
Surgical approaches to the acetabulum


MIOT Hospitals, Chennai, India

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How to cite this article:
Suryanarayan P, Kesavan A R. Surgical approaches to the acetabulum. Indian J Orthop 2002;36:17-9

How to cite this URL:
Suryanarayan P, Kesavan A R. Surgical approaches to the acetabulum. Indian J Orthop [serial online] 2002 [cited 2019 Dec 10];36:17-9. Available from: http://www.ijoonline.com/text.asp?2002/36/1/17/35917
Acetabular fractures illustrate best; the critical influence of the surgical approach on the treatment outcome. [1],[2],[3],[4],[5] The choice of approach is influenced by so many factors, unique to this location. [2],[4],[5],[6],[7]

Choice of surgical approach

The approaches to the acetabulum are classified as either limited (basic) or extensile depending on the degree of exposure accomplished and as anterior or posterior depending on the particular region they expose.

Standard posterior approach Kocher-Langenbeck approach Ideal indication:

Isolated fractures of the posterior wall &/or column with or without dislocation (Types A1, A2 - AO classification). It can also be used in Types B1, B2 (AO) fractures. This approach can be used where the major rotation and displacement are posterior.

Salient features:

  • The hip should be kept extended and the knee flexed to avoid any tension on the sciatic nerve.
  • Quadratus femoris is not cut, to protect the ascending branch of the medial circumflex femoral artery.
  • The gluteus medius & minimus are subperiosteally raised from the ilium & retracted with 1 or 2 Steinmann pins inserted above the greater sciatic notch. The superior gluteal vessels & nerve, which emerge from the inner pelvis in this area, have to be protected.
  • To increase the exposure of the roof of the acetabulum a trochanteric osteotomy or a trochanteric flip is helpful
  • Soft tissue release of the inner surface of the quadrilateral plate can be done through the sciatic notches subperiosteally, if necessary after osteotomising the ischial spine, if need be (in late fractures).
Caution:

There is a constant vessel within the gluteus muscle 1-2 cm from the sciatic notch, which if not taken proper care of while retracting or dissecting tends to produce troublesome bleeding.

Ilioinguinal approach Indications:

  1. Anterior wall.
  2. Anterior column.
  3. Combined anterior column with posterior hemi- transverse extension.
  4. Types A3 and B3 fractures (AO) where the major rotation and displacement are anterior.
  5. Both column fractures.


This approach provides exposure of the entire inner table of the innominate bone from the symphysis pubis to the anterior aspect of the sacroiliac joint, including the quadrilateral surface & the pubic rami.

The exposure is done through 3 windows.

  1. Retracting the psoas medially allows exposure of the internal iliac fossa, the pelvic brim and the anterior sacro- iliac joint. This is aided by flexing and internal rotating the hip to relax the iliopsoas.
  2. The middle window is created by retracting the psoas laterally and the vessels medially. This allows the superior pubic ramus, the quadrilateral plate to be visualized.
  3. The medial window is seen by retracting the vessels laterally and the spermatic cord medially. This gives access to the remainder of the pubic ramus, the pubic symphysis and the quadrilateral surface. The most medial part can be visualized well by retracting the spermatic cord laterally.
Salient features:

  • Protect the lateral cutaneous femoral nerve.
  • Protect the inferior epigastric artery.
  • Dissecting the iliac vessels with the associated lymphatics as a single unit along with the areolar tissue around them (to protect the lymphatics & prevent post operative swelling of the limb)
  • Identify the obturator vessels & nerve.
Useful access to the posterior column can be obtained through the second (middle) window by manipulating the quadrilateral plate.

The interior of the joint can be visualised by distracting the fracture fragments.

Before closure, drains are left in the retropubic space & internal iliac fossa. All structures are repaired.

Dangers: Injury to the iliac vessels, lymphatics, femoral nerve, lateral cutaneous femoral nerve.

Iliofemoral approach

Indications:
Anterior column fractures, where fracture line does not extend medial to the iliopectineal eminence.

Advantage: Easy access. No dissection of the femoral vessels required, as in the ilioinguinal approach.

Disadvantage: Limited anterior column access. Medial to the iliopectineal eminence the exposure is to be done with the ilioinguinal approach. This usually limits fixation options to screws or short plates in this approach. Injury to the lateral cutaneous nerve of thigh is difficult to prevent in this approach.

Combined approach Indications

Where access to both columns is required, this approach is used. This involves the combination of one anterior and one posterior approach (described above), under the same anaesthesia. [8],[9],[10]

Advantage: The entire posterior wall and column (with or without trochanteric osteotomy), the entire anterior wall and column, sacro iliac joint, pubic symphysis can be visualized.

Extensile approaches Extended iliofemoral approach

Letournel developed an extended iliofemoral approach that provides complete exposure of the inner and outer tables of the ilium and the acetabulum.

Indications:

This is an extended approach for difficult transtectal transverse, T type, both column fractures with posterior wall involvement.

Advantages:

This approach is a lateral approach to the innominate bone, which allows excellent simultaneous exposure of both columns.

Disadvantages:

The extensive stripping of muscles impairs the vascularity of the abductors. Heterotopic ossification is much more common in this approach. Injury to the femoral nerve is also documented.

Modifications:

Reinert et al [11] have modified the extended iliofemoral approach to allow later reconstructive procedures (Maryland approach)

Triradiate approach

Mears and Rubash have described an extensile approach to the lateral aspect of the ilium, the entire anterior column and wall, the entire posterior column and wall, the anterior aspect of the sacro iliac joint, the inner iliac wall. [12]

Indications: Transtectal transverse fractures, T type, both column fractures with posterior wall involvement. In other words this is an alternative to the extended iliofemoral approach.

Summary

Standard approaches give adequate exposure for most acetabular fractures. Though the extended approaches give much wider exposure, they require a tremendous amount of experience to avoid secondary complications. As far as possible the muscles around the acetabulum like the gluteus medius need gentle handling to avoid heterotopic ossification [2] , [13],[14] and other such complications. The retraction should be gentle to avoid traction injury to the short vascular pedicle.

The position and the approach should also take into consideration, the feasibility of intra operative radiology.

Authors' preferred surgical approaches:

1) Posterior injuries - Kocher Langenbeck approach

High posterior column injuries, transverse fractures - Trochanteric flip with screw re­attachment.

2) Anterior injuries - Ilio-inguinal approach.

3) Complex / combined, T fractures - - Combined anterior and posterior approach with the patient in floppy lateral position.

 
   References Top

1.Letournel E. Les fractures du cotyle. Etude d'une serie de 75 cas. J Chir (Paris) 1994; 82:47.   Back to cited text no. 1    
2.Letournel E. Fractures of the acetabulum. Elson RA (ed). Berlin; Springer-Verlag. 1993.  Back to cited text no. 2    
3.Matta JM. Operative indications and choice of surgical approach for fractures of the acetabulum. Tech Orthop 1986; 1:13.  Back to cited text no. 3    
4.Matta JM, Anderson LM, Epstein HC, Hendricks P. Fractures of the acetabulum: a retrospective analysis. Clin Orthop 1986; 205:230.  Back to cited text no. 4    
5.Matta JM, Mehne DK, Roffi R. Fractures of the acetabulum: Early results of a prospective study. Clin Orthop 1986; 205:241.  Back to cited text no. 5    
6.Jimenez ML, Vrahas MS. Surgical approaches to the Acetabulum. Orthop Clin North Am 1997; 28(3): 419.  Back to cited text no. 6    
7.Judet R, Judet J, Letournel E. Fractures of the acetabulum - Classification and surgical approaches for open reduction: A preliminary report. J Bone Joint Surg [Am] 1964; 46-A: 1615-1646.  Back to cited text no. 7    
8.Routt ML, Swiontkowski MF. Operative treatment of complex acetabular fractures: Combined anterior and posterior exposures during the same procedure. J Bone Joint Surg [Am] 1990; 72-A: 897.  Back to cited text no. 8    
9.Rowe CR, Lowell JD. Prognosis of fractures of the acetabulum. J Bone Joint Surg [Am] 1990; 43-A: 30.  Back to cited text no. 9    
10.Helfet DL, Schmeling GJ. Management of complex acetabular fractures through single non-extensile exposures. Clin Orthop 1994; 305:58-68.  Back to cited text no. 10    
11.Reinert CM, Bosse MJ, Poka A, et al. A modified extensile exposure for the treatment of complex or malunited acetabular fractures. J Bone Joint Surg [Am] 1988; 70-A: 329.  Back to cited text no. 11    
12.Mears DC, Rubash HE: Extensile exposure of the pelvis. Contemp Orthop 1986; 6:21.  Back to cited text no. 12    
13.Bosse MJ, Poka A, Reinert CM, Slawson R, McDevitt ER. Heterotopic ossification as a complication of acetabular fractures. J Bone Joint Surg [Am] 1988; 70-A: 1231.  Back to cited text no. 13    
14.Brooker AF, Bowerman JW, Robinson RA, Riley Jr LH. Ectopic ossification following total hip replacement: Incidence and a method of classification. J Bone Joint Surg [Am] 1973; 55-A: 1029.  Back to cited text no. 14    

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Correspondence Address:
P Suryanarayan
MIOT Hospitals, Chennai
India
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Source of Support: None, Conflict of Interest: None


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