review article surgical approaches to the acetabulum and...

Review Article

Surgical Approaches to theAcetabulum and Modifications inTechnique

Abstract

Acetabular injuries are often difficult to treat because the acetabulumis surrounded by many important structures, making access difficultand sometimes dangerous. Surgical exposures of the acetabulumarecomplex and require significant skill and in-depth knowledge of pelvicanatomy. Each approach has its limitations, and the potentialmorbidity associated with these exposures can be daunting. Recentmodifications to traditional acetabular approaches have beendeveloped to address these issues. Knowledge of the ilioinguinal,Kocher-Langenbeck, and extended iliofemoral surgical exposuresand the potential drawbacks associated with each approach areessential to optimize treatment and minimize morbidity.

Surgical approaches to the acetab-ulumcanbe challenging.Although

classic approaches are familiar tomostorthopaedic surgeons, they are pri-marily used by traumatologists totreat acetabular fractures. Choosingthe correct approach requires a thor-ough understanding of the fracturepattern because no single approachallowsaccess to the entire acetabulum.The ilioinguinal, Kocher-Langenbeck,and extended iliofemoral exposuresare the three main approaches tothe acetabulum. The ilioinguinalapproach allows direct access to theanterior column, whereas the Kocher-Langenbeck approach primarily ex-poses posterior structures. Theextended iliofemoral approach isreserved for delayed fixation and forfractures that are not amenable totreatment by less extensile exposures.Modifications have been developed

to broaden traditional approaches tothe acetabulum and mitigate compli-cations. An understanding of the ad-vantages and limitations of eachtechnique can enable surgeons to

choose the proper exposure for ana-tomic reduction and fracture fixation.

Ilioinguinal Approach

The ilioinguinal approach to theacetabulum was developed to accessthe anterior column, quadrilateralsurface, and upper posterior columnthrough the creation of three ana-tomic “windows” into the pelvis1

(Figure 1). This approach is used tomanage fractures that involve theanterior column and/or the anteriorwall, anterior column-posteriorhemitransverse fractures, and manyboth-column and transverse frac-tures.2-4

The patient is positioned supine ona radiolucent operating table orfracture table. The leg is draped freeto control position and aid visuali-zation. Traction is applied to theinjured limb to anatomically positionthe femoral head, allowing the sur-geon to build the acetabulum aroundit. However, traction places tensionon the surrounding musculature and

592 Journal of the American Academy of Orthopaedic Surgeons

Norele Jean Cutrera, MD

Daphne Pinkas, MD

Jose Bernardo Toro, MD

From the Department of OrthopaedicSurgery, Jacobi Medical Center,Bronx, NY (Dr. Cutrera), the KayalOrthopaedic Center PC, FranklinLakes, NJ (Dr. Pinkas), and theDepartment of Orthopedics, PeconicBay Medical Center, KraussMusculoskeletal Institute, Riverhead,NY (Dr. Toro).

None of the following authors or anyimmediate family member hasreceived anything of value from or hasstock or stock options held ina commercial company or institutionrelated directly or indirectly to thesubject of this article: Dr. Cutrera, Dr.Pinkas, and Dr. Toro.

J Am Acad Orthop Surg 2015;23:592-603

http://dx.doi.org/10.5435/JAAOS-D-14-00307

Copyright 2015 by the AmericanAcademy of Orthopaedic Surgeons.

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.

can limit exposure. On a standardtable, the surgeon can place a radio-lucent triangle or bump under theknee to relieve tension on the musclesand the neurovascular bundle,thereby improving visualization.An incision is made along the iliac

crest, extending approximately 5 cmsuperior to the anterior superior iliacspine (ASIS) and medially toward thepubic symphysis (Figure 1). The at-tachments of the abdominal andiliacus muscles are released from thecrest, allowing access to the innertable of the ilium. Blunt dissectionalong the iliac fossa directly exposesthe sacroiliac joint and pelvic brim.The ilioinguinal exposure requires

incision of the inguinal canal. Theaponeurosis of the external abdomi-nal oblique muscle is incised from theASIS toward the midline, where itsfibers blend with the external sheathof the rectus abdominis muscle. Therectus is similarly dissected in linewith the skin incision, unroofingthe inguinal canal to expose the

spermatic cord, or round ligament,and the accompanying inguinalnerve. Retraction of these structuresexposes the inguinal ligament, whichis flanked laterally by the lateralfemoral cutaneous nerve (LFCN) andmedially by the external iliac vesselsand lymphatics. Dividing this liga-ment along its length allows fordevelopment of the retropubic spacebetween the bladder and the poste-rior aspect of the pubic symphysis,which permits access to the pubicramus.The ilioinguinal approach requires

the creation of three important win-dows that allow access to the entireanterior column and the quadrilateralsurface.1 The lateral, middle, andmedial windows are framed by twocurtains: the lacuna vasorum and thelacuna musculorum. The lacunavasorum consists of the femoral ves-sels and lymphatics within a commonsheath. The iliopsoas muscle andfemoral nerve sit lateral to these ves-sels, forming the lacuna musculorum.

The iliopectineal fascia lies betweenthese curtains and must be divideddown to the level of the pectinealeminence, which separates the truepelvis from the false pelvis. This stepallows access to the three windows.The lateral window, which is lateralto the iliopsoas muscle, exposes theinner table of the ilium, anteriorsacroiliac joint, and pelvic brim. Themiddle window, which is locatedbetween the iliopsoas muscle andfemoral vessels, allows access to thequadrilateral plate and pelvic brimfrom the anterior sacroiliac joint tothe pectineal eminence. The medialwindow, which is medial to the fem-oral vessels, exposes the superiorpubic ramus and pubic symphysis.Fracture reduction and fixation canbe accomplished by navigating withinthese three windows.

RisksNerve injury, vascular injury, hypo-perfusion, and thrombosis are among

Figure 1

A through C, Illustrations demonstrating the ilioinguinal approach. A, The incision and associated bony access.B, Acetabular exposure with access via the medial and middle windows. C, Exposure via a lateral window provides accessto the inner table of the ilium. Inset, Illustration of the anterior and posterior aspects of the hip demonstrating areas of directaccess (blue) and secondary access by touch (yellow).

Norele Jean Cutrera, MD, et al

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the potential dangers encounteredduring the ilioinguinal approach. TheLFCN is encountered during super-ficial dissection, and the incidence ofinjury to this nerve is as high as 18%,making it the most frequently injurednerve during the ilioinguinalapproach.1 The LFCN lies from 3 to46 mmmedial to the ASIS.5 It coursesunder the inguinal ligament anteriorto the iliacus muscle, where it dividesinto anterior and posterior brancheson the surface of the sartorius muscle.In 26.7% of cases, the LFCNbranches proximal to the inguinalligament.6 Historical studies on mer-algia paresthetica have describedanecdotal variations of the LFCNcourse, including lateral to the ASISor through the inguinal ligament;however, these variations have beendisputed by recent studies.5-7

Corona mortis is a vascular anas-tomosis located between the obtura-tor and external iliac arteries or theinferior epigastric artery—vesselsthat are encountered posterior to thesuperior pubic ramus. This anasto-mosis has been found at an averageof 68 mm from the pubic symphysis(range, 40 to 96 mm).8 The coronamortis can be venous (60%), arterial(36%), or both (4%). The estimatedincidence of this anatomic variant is10% to 40%.1 Although this vas-cular connection was present in 83%of 80 cadaver specimens, Darmaniset al8 encountered it in only 5 of 492anterior acetabular approaches. Theauthors concluded that the coronamortis may not be as commona threat as once believed. Nonethe-less, the corona mortis is an impor-tant potential source of bleeding thatmay be encountered during anterioracetabular exposures.Case reports have described

thrombosis or injury to the externaliliac or femoral vessels during theilioinguinal approach.9 Iliac or fem-oral artery thrombosis can occur ifprolonged retraction of vessels isneeded for exposure in the middle

window.9 Signs of hypoperfusioncaused by artery compromise can besubtle, such as diminished pulses onthe side of injury. Any suspicion ofthrombosis or vessel injury shouldtrigger vascular evaluation becauseprolonged hypoperfusion can resultin compartment syndrome, limb loss,or even death.3

ModificationsNumerous modifications to theilioinguinal approach have beendescribed. Minimally invasive surgi-cal (MIS) approaches have gainedpopularity due to shorter surgicaltimes and decreased neurovascularrisk. Ruchholz et al10 describeda MIS approach in which the middleand medial windows were accessedthrough two 3- to 4-cm incisions.This technique requires the use ofspecialized retractors. At the pubicsymphysis, the rectus abdominusmuscle is split to access the medialwindow. An incision created over thelinea terminalis allows access to theiliopectineal fascia and the middlewindow. This modified approach wasused in a study of 26 older patients(mean age, 67 years) with anteriorcolumn and anterior column–posterior hemitransverse fractures.10

Compared with traditional ilioingui-nal approaches, less surgical time wasrequired with the modified approach(mean, 109 minutes versus 175 mi-nutes), but the amount of bleedingwas similar (1,000 mL versus 1,500mL).3,10 Although the authors re-ported no wound complications, 23%of patients had a 2- to 3-mm articularincongruity on initial postoperativeradiographs, and two had loss ofreduction at short-term follow-up.Wolf et al11 described a MIS

approach performedwith a “median”lower abdomen incision, which isa midline vertical incision locatedsuperior to the pubic symphysiscombined with a lateral incision at theiliac crest, similar to a traditional

lateral window exposure. This lessextensive approach seeks to decreasemorbidity and broaden the use of theilioinguinal approach. The use ofa median window improves access tothe quadrilateral surface and can beconsidered for management of frac-tures with medial femoral head dis-placement and minimal displacementof the posterior column.Other studies have examined the

use of the ilioinguinal approach incombination with other exposures.Kloen et al12 combined the classicilioinguinal approach with a modi-fied Smith-Petersen approach. Theincision begins over the iliac crestand continues toward the ASIS. Atthe level of the ASIS, however, theapproach continues distally as theSmith-Petersen approach, improvingaccess to the anterior hip and ace-tabulum. A third arm of the incisionis made medially toward the pubicsymphysis, completing access to allthree windows (Figure 2, A). Os-teotomy of the ASIS minimizestraction on the LFCN duringretraction of the sartorius muscleand inguinal ligament. A second os-teotomy performed along the iliaccrest may allow detachment of theabductor muscles from the iliacwing, exposing the outer table of theilium13 (Figure 2, B). In the setting oflow anterior column fractures andcomminuted fractures of the anteriorwall, the Smith-Petersen modifica-tion is ideal for providing access tostructures that are often obscured bythe iliopsoas muscle in the standarddissection. This technique may alsoimprove exposure of the quadrilat-eral surface. The modified approachalso enables subluxation or disloca-tion of the hip for intra-articularvisualization, whereas the tradi-tional ilioinguinal approach relies onanatomic reduction of extra-articular structures for joint con-gruity. Finally, this modification maybe associated with a decreased inci-dence of injury to the LFCN, with

Surgical Approaches to the Acetabulum and Modifications in Technique



only 2 of 15 patients sustaining anincomplete LFCN palsy in oneseries.12

The ilioinguinal approach offerslimited visualization of posteriorcolumn structures. Although manyboth-column fractures are amenableto treatment with this traditionalapproach, fractures with extensioninto the sacroiliac joint or sciaticnotch make choosing the correctexposure difficult. Some surgeonselect tomanage these fractures throughthe invasive extended iliofemoralapproach.Weber andMast14 describean alternative extended ilioinguinalapproach, combining the classicilioinguinal approach with a posteriorapproach to the sacroiliac joint(Figure 3). The patient is placed ina semilateral position, with the tabletilted to maintain access to theposterior sacrum. The ilioinguinalexposure is continued posteriorly tothe posterior superior iliac spine(PSIS) and inferiorly along the sacro-iliac joint. Exposing the posteriorcolumn requires release of the gluteus

maximus from the lateral sacrum andPSIS. Weber and Mast14 reportedexcellent reductions in six patientstreated using this approach, with onlyone case of asymptomatic heterotopicossification (HO). Although posteriorapproaches to the sacroiliac joint areassociated with wound complications,only two patients in this series hadwound issues at the ilioinguinal por-tion of the incision. Potential draw-backs of this approach includelengthy surgical times (mean, 10hours) and significant blood loss(mean, 2.45 L).The ilioinguinal approach provides

incomplete access to the quadrilateralsurface. Direct visualization is limitedto the ischial spine, and placement ofhardware along the quadrilateral sur-face is difficult. Karunakar et al15

described the use of a modified ilioin-guinal approach in which the modifiedStoppa approach was used to cir-cumvent this issue. A midline Pfan-nenstiel incision is incorporated intothe medial aspect of the ilioinguinalapproach to more extensively develop

the medial window, exposing theentire quadrilateral plate. Unlike thetraditional ilioinguinal approach, mostsurgical work is done through thisexpanded medial window. This mod-ified approach is ideal for fractures

Figure 2

Illustrations of the incision for a combined ilioinguinal and Smith-Petersen approach (A) and the modified ilioinguinal andSmith-Petersen exposure with osteotomies of the anterior superior iliac spine and iliac crest (B). Inset, Illustration of theanterior and posterior aspects of the hip demonstrating areas of direct access (blue) and secondary access by touch(yellow).

Figure 3

Illustration demonstrating theextended ilioinguinal incision, whichprovides additional access to thesacroiliac joint.


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with concomitant anterior pelvic ringinjuries and fractures involving medialdisplacement of the quadrilateral plate.

Kocher-LangenbeckApproach

Bernhard von Langenbeck firstdescribed the posterior acetabularapproach in 1874; it was primarilyused to treat infections andwar-relatedhip injuries.16 Theodor Kochermodified Langenbeck’s approach byextending the incision caudally todivide the gluteus maximus muscleand reflect the gluteus mediusand minimus muscles. The Kocher-Langenbeck approach has been usedsince 1892, and it allows access to theentire posterior column, retro-acetabular surface, ischial spine, andthe greater and lesser sciatic notches.16

It is ideal for fractures involving theposterior column and posterior wall.Many transverse and T-type fracturescan also be managed with thisapproach, depending on fracture

obliquity and which column hasgreater displacement. Infratectorialand juxtatectorial transverse fracturesgenerally involve major displacementof the posterior column, and theKocher-Langenbeck approach is idealfor management of these fractures. Inthe setting of major displacement ofthe anterior column, the ilioinguinalapproach is preferred.Patients can be placed in the lateral

decubitus or prone position, de-pending on the fracture pattern. Lat-eral positioning allows gravity to pullthe soft tissue and musculature of thebuttock away from the surgical field.A trochanteric osteotomy and surgi-cal hip dislocation, as described bySiebenrock et al,17 can be performedwith the patient in the lateral posi-tion but not in the prone position.Lateral positioning is preferred in thesetting of concomitant pubic ramifractures or bladder injuries. Pronepositioning allows for easier palpa-tion of the quadrilateral surface andfacilitates clamp placement throughthe greater sciatic notch. This position

is generally preferred when treatingtransverse and T-type fracturesbecause they are predisposed tomedial displacement and internalrotation of the caudal segment. Inthese instances, lateral positioningcan cause difficulty in counter-acting gravity and the weight of theinjured limb, resulting in fragmentmedialization by the femoral head.Prone positioning eliminates gravityas a potential deforming force andallows for easier hip extension andknee flexion, relieving tension on thesciatic nerve. In a retrospective studyof patients with transverse fracturestreated using the Kocher-Langenbeckapproach with the patient positionedprone or lateral, Collinge et al18

found no significant difference inbleeding, surgical time, or perioper-ative complications. The authors didfind a trend toward increased malre-ductions in the lateral versus pronegroups (P = 0.08), although this trendwas not statistically significant. Ulti-mately, patient positioning is deter-mined by surgeon preference.

Figure 4

Illustrations of the incision and bony access (A) for the Kocher-Langenbeck approach and the exposure (B) via thisapproach. The short external rotators are resected 1.5 cm from their insertion onto the greater trochanter to preserve thefemoral blood supply. Inset, Illustration of the hips demonstrating areas of direct access (blue) and secondary access bytouch (yellow).




The Kocher-Langenbeck incision iscentered over the posterior half of thegreater trochanter. The incision con-tinues proximally toward the PSISand distally along the femoral shaftfor approximately 10 cm (Figure 4,A). Distally, the fascia lata is incisedin line with the skin incision. Proxi-mally, the gluteus maximus muscle isbluntly dissected in line with its fi-bers. The short external rotators(SERs) are detached 1.5 cm fromtheir trochanteric insertion to protectthe blood supply to the femoral head(Figure 4, B). The gluteus mediusand minimus tendons can be dividedat the greater trochanter if visuali-zation of the acetabular dome isrequired. Elevation of the piriformismuscle and conjoint tendons to theirretroacetabular origins allows accessto the greater and lesser sciaticnotches, respectively. The innerwall ofthe ilium can be accessed through thelesser sciatic notch. Dissection throughthe greater sciatic notch allows pal-pation of the quadrilateral surface.Retractors can be carefully placed intothe sciatic notches to expose the pos-terior column.1 A T-shaped capsu-lotomy can be performed, althoughthe capsule often is already disrupted.

RisksThe Kocher-Langenbeck approach re-quires an understanding of two keyneurovascular structures: the medialfemoral circumflex artery (MFCA)and the sciatic nerve. The MFCAoriginates from the profunda femorisartery or, less frequently, from thecommon femoral artery and windsposteriorly around the femur betweenthe iliopsoas and pectineus muscles. Itcan be found posteriorly between theinferior gemellus and quadratus fem-oris muscles. The deep branch of theMFCA (dbMFCA) is the primarysource for the blood supply to thefemoral head.19 At the proximal bor-der of the quadratus femoris, thedbMFCA lies directly posterior to the

obturator externus tendon, where itgives off a greater trochanteric branch.It then continues anterior to the con-joint tendon, perforating the hip cap-sule between the piriformis andsuperior gemellus tendons. Once in-tracapsular, the artery continuesproximally along the posterosuperiorfemoral neck, giving off terminalbranches that perforate the bone 2 to4 mm lateral to the bone-cartilagejunction. In a cadaver study, Gautieret al19 established the relationshipbetween the dbMFCA and the land-marks encountered during posterioracetabular exposure. On average, theartery is 18.2 mm from the top of thelesser trochanter, 8.8 mm from theobturator externus insertion, and 12.4mm from the obturator internusinsertion. The authors sequentiallytenotomized muscle insertions on theproximal femur, performed a circum-ferential capsulotomy, and dislocatedthe femoral head. The dbMFCA waspreserved if the obturator externustendon remained intact. This promp-

ted an alternative approach to theexternal rotators during the Kocher-Langenbeck approach, conserving theobturator externus tendon at itsinsertion on the femur. Instead oftransecting the piriformis and conjointtendons at their insertions, a 1.5-cmcuff is preserved to protect theMFCA.Care is also taken to preserve thequadratus femoris tendon because theobturator externus and dbMFCA lieimmediately anterior to it.Iatrogenic injury to the sciatic nerve

is another potential complicationassociated with the Kocher-Langenbeck approach. The sciaticnerve is intimately associated with thepiriformis tendon, but its course canvary, as described by Beaton andAnson20 in a study of 120 cadavers.The sciatic nerve most commonlyemerges from the pelvis anterior to thepiriformis tendon (84.5%), but mayalso divide into its common peronealand tibial branches before exiting thepelvis (14.7%). The piriformis canalso have two distinct muscle bellies

Figure 5

A and B, Illustrations demonstrating the trochanteric flip osteotomy. The bone isretracted anteriorly along with the attached abductor and vastus lateralismuscles.


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(11.7%), a so-called bipennate varia-tion that makes the nerve appeartranstendinous. The piriformis ap-pears to split around the nerve. Rarely,the sciatic nerve transects the tendon(0.8%). Knowledge of these anatomicvariants helps ensure adequate pro-tection of the sciatic nerve during theKocher-Langenbeck approach. Properleg positioning may also prevent iat-rogenic injury. The surgical limbshould be held in hip extension andknee flexion to relieve tension on thenerve throughout the procedure.

ModificationsModifications to the Kocher-Langenbeck approach seek to

improve visualization and preservethe normal anatomy of the posteriorhip. The greater trochanteric flip os-teotomy is perhaps the best-knownmodification; it was popularized bySiebenrock et al17 and improvesaccess to the superior hip joint andsupracetabular region. Theoretically,it may also limit HO because lessforceful abductor retraction isrequired to achieve exposure. Aplane osteotomy (approximately1.5-cm thick) is performed betweenthe posterior gluteus medius muscleinsertion and the vastus lateralis(Figure 5, A). The trochantericfragment is retracted anteriorlyalong with the attached gluteusmedius and minimus muscles and thevastus lateralis muscle (Figure 5, B).By retaining the muscle attachmentsto the fragment, the postoperativecranial migration that can occur intraditional greater trochanteric os-teotomies can be prevented. Theosteotomy also facilitates posteriordislocation of the femoral head ifjoint inspection is required. Thegreater trochanter is later repairedwith screw fixation. In a study of 10acetabular fractures treated using theKocher-Langenbeck approach witha trochanteric flip osteotomy, nocases of osteotomy nonunion, mal-union, or HO were reported.17

The modified Gibson (mG)approach is an alternative to tro-chanteric osteotomy; it also improvesaccess to the supracetabular region.21

Instead of splitting the gluteus max-imus muscle, as in the Kocher-Langenbeck approach, the proximalmG incision is directed anteriorly intothe interval between the gluteusmaximus muscle and the tensor fascialata (TFL). The entire gluteus max-imus muscle is retracted posteriorlyand deep dissection continues as inthe Kocher-Langenbeck approach.Anterosuperior acetabular access isimproved because the gluteus mediusmuscle, which is unencumbered bythe overlying gluteus maximus mus-

cle fibers, can be retracted anteriorly(Figure 6). In addition to theimproved cosmesis provided bythe vertical nature of the incision,the risk of injury to the neuro-vascular supply of the anteriorportion of the gluteus maximusmuscle is decreased.Several authors have described SER-

sparing modifications to the Kocher-Langenbeck approach.22-24 Theoreti-cally, these modifications decrease therisk of iatrogenic injury to the MFCA,thus preventing femoral head necrosis.Limited dissection may also decreaseHO formation. SER-sparing mod-ifications use viewing portals proximaland distal to the rotators. The superiorportal lies between the gluteus mediusand piriformis tendons, whereas theinferior portal lies between the SERsand the ischial tuberosity.Magu et al22

used this technique to manage acute,isolated, noncomminuted posteriorwall fractures. Josten and Trabold23

applied the same MIS approach morebroadly to treat posterior columnfractures. Acceptable reductions wereachieved, but no differences in activerotation or abductor strength werefound with SER-sparing techniques.Sarlak et al24 described a moreextensive approach that exploits theinterval used in the mG approach toaccess the superior acetabular region,working deeply through SER-sparingportals. The authors reporteddecreased blood loss and surgicaltimes. Larger studies are needed todetermine which patients may ben-efit from these modified approaches.SER-sparing techniques are notcurrently indicated for comminutedposterior wall fractures or whenvisualization of the articular surfaceis required.

Extended IliofemoralApproach

The extended iliofemoral (EIF)approachwas developed by Letournel

Figure 6

Illustration demonstrating themodified Gibson incision andassociated bony access. Inset,Illustration of the hip demonstratingareas of direct access (blue) andsecondary access by touch (yellow).




andJudet25 in 1974 to access both theanterior and posterior columns; it isreserved for complex fractures thatinvolve displacement of both columnsand those treated subacutely (.3weeks). The lateral decubitus positionallows access to the entire ilium. Thelateral aspect of the EIF approach issimilar to that of the ilioinguinalapproach. The incision runs parallelto the iliac crest but begins moreposteriorly at the PSIS. The incisioncontinues anteriorly to the ASIS,where the EIF approach curves dis-tally along the lateral border of thesartorius (Figure 7, A). The glutealmuscles and TFL are dissected sub-periosteally from the outer ilium(Figure 7, B). Abdominal musculatureand the iliacus may be dissected off

the ilium to gain access to the innertable. The sartorius muscle andilioinguinal ligament can be releasedapproximately 2 cm from their ori-gins on the ASIS, or an ASIS osteot-omy can be performed. Detachmentof these structures allows exposure ofthe entire iliac crest, iliac fossa,superior pubic ramus, and sacroiliacjoint.Anteriorly, the interval is developed

superficially between the sartoriusmuscle and the TFL and deeplybetween the gluteus medius and rec-tus femoris muscles, as in the Smith-Petersen approach. Release of thereflected head of the rectus femorisfrom its supra-acetabular origin aidsvisualization of the hip joint. Thelateral femoral circumflex artery

(LFCA) is found between the rectusfemoris and vastus lateralis musclesand is routinely ligated. Thegluteus minimus and medius tendonsare released from the greater tro-chanter, tagged for later repair, andsuperiorly reflected. Similar to theKocher-Langenbeck approach, theSERs are released from the greatertrochanter to aid visualization of thehip joint. Capsulotomy may also beperformed.

RisksAnatomic structures at risk of injuryduring the EIF approach are similarto those at risk in both the ilioinguinalandKocher-Langenbeck approaches.Of unique concern is the superior

Figure 7

A, Illustration demonstrating the incision for the extended iliofemoral approach and associated bony access. B, Illustrationdemonstrating the exposure, which provides access to the entire iliac crest, iliac fossa, superior pubic ramus, and sacroiliacjoint. Inset, Illustration of the anterior and posterior aspects of the hip demonstrating areas of direct access (blue) andsecondary access by touch (yellow).


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gluteal artery (SGA), the main vas-cular pedicle to the large abductorflap created in the EIF approach.26

The LFCA provides the collateralblood supply to this flap, but isroutinely ligated to gain exposure.The SGA can be severed at the timeof injury, particularly with signifi-cant fracture displacement into thesciatic notch. Preoperative angiog-raphy can be performed if injury tothe SGA is suspected.27 If injury tothe artery is confirmed or an SGAembolization is required, a combinedilioinguinal and Kocher-Langenbeckapproach may be the preferredoption to avoid ligation of the LFCA.Injury to the SGA may be a theo-

retical concern. Reilly et al28 exam-ined the incidence of SGA laceration

associated with the EIF approach. In39 patients with fractures that weredisplaced into the sciatic notch andtreated using the EIF approach, theauthors reported no SGA lacerationsand only one SGA thrombosis, withno incidents of flap necrosis. Moreresearch is needed to clarify whichpatients may benefit from pre-operative angiography before an EIFapproach.

ModificationsModifications to the EIF approachattempt to limit its extensile nature.The Maryland modification usesa stepwise method to tailor the extentof dissection.29 Unlike the J-shapedincision of the EIF approach, this

modification uses a T-shaped inci-sion (Figure 8, A). The proximalincision extends from the PSIS to theASIS. Distally, however, the incisionruns parallel to the lateral femoralshaft. An anterior flap is created tothe ASIS, with care taken to preservethe LFCN, and deep dissection con-tinues through the Smith-Peterseninterval between the gluteus mediusand rectus femoris muscles. Dissec-tion in the posterior flap exposes thehip with release of the SERs.The main modification to the

Maryland approach lies in the use ofosteotomies (Figure 8, B). An os-teotomy of the greater trochanter isperformed instead of gluteal muscledetachment. The ilium is exposedwith an iliac crest osteotomy, and the

Figure 8

A, Illustration demonstrating the incision for the Maryland modification of the extended iliofemoral approach. B, Illustrationdemonstrating osteotomies of the greater trochanter, iliac crest, and anterior superior iliac spine. Inset, Illustration of theanterior and posterior aspects of the hip demonstrating areas of direct access (blue) and secondary access by touch(yellow).




attached abductor flap is retractedposteriorly. An ASIS osteotomy alsoaids anterior exposure. All osteoto-mies undergo screw fixation to allowearly postoperative rehabilitation.This modification may decrease thehip abductor weakness associatedwith the standard EIF approach.

Dual Approaches

For management of complex acetab-ular fractures, combined anterior andposterior approaches have becomeincreasingly popular as an alternativeto the EIF and other extensile ap-proaches. Prior to the development ofthe EIF approach, Letournel et al30

used dual approaches for fractureswhen complete reduction was unat-tainable through a single exposure.Combined approaches are oftenperformed in a staged fashion duringone or more procedures. Staging canprove disadvantageous if rigid fixa-tion is employed during the initialprocedure because any displacementencountered during the second sur-gery will be difficult to correct.Harris et al31 advocated the use ofdual exposures performed simulta-neously by two surgical teams todiminish surgical time and blood losswhile maintaining the intraoperativeflexibility to reduce and repair frac-tures from both anterior and poste-rior aspects. The indications fora combined approach are similar tothose for the EIF approach, includingT-type fractures, posterior column-posterior wall fractures with signifi-cant displacement, comminutedtranstectal transverse fractures, andmany both-column fractures.

Complications

The risk of complications (eg, infec-tion, thromboembolism, HO, nerveinjury) exists with all acetabular ap-proaches. Therefore, surgeons must

counsel patients regarding the preva-lence of such complications.The overall infection rate after open

acetabular fixation ranges from3%to5%.32 A retrospective review foundthat body mass index, intensive careunit stay, and Morel-Lavallée lesionswere independent risk factors forsurgical site infections.32 Anotherretrospective review found that pre-operative embolization, obesity (bodymass index .30 kg/m2), and pre-operative leukocytosis were associ-ated with surgical site infection.33

Patients with one or more of thesefactors should be warned of theincreased risk of infection.Patients with acetabular fractures

also have an increased risk ofthromboembolic complications.34

The incidence of deep vein throm-bosis ranges from 9% to 58%, andthe incidence of symptomatic pul-monary embolism is approximately2%.35 Mechanical compression,low-molecular-weight heparin andprophylactic inferior vena cava fil-ters have been used to decrease therisk of thromboembolic complica-tions. However, there are currentlyno clear guidelines on standardizedprophylaxis in this population. Arecent systematic review on the pre-vention of thromboembolic events inpatients with pelvic and acetabularfractures was unable to yield specificrecommendations.34 Well-designedclinical trials are needed to developclear protocols.HO is a well-known complication

associated with acetabular fracturefixation. In a study of 9 acetabularfractures, Letournel36 reported anoverall HO rate of 24%, with clini-cally significant HO occurring in35%, 10%, and 2% of patientsundergoing surgery with the EIF,Kocher-Langenbeck, and ilioingui-nal approaches, respectively. The useof HO prophylaxis is not uncommonin patients undergoing surgery withthe EIF approach and in those withrisk factors for HO (eg, head

injuries, burns). Indications for theuse of HO prophylaxis in patientsundergoing surgery with the Kocher-Langenbeck approach are morecontroversial. Two randomizedcontrolled trials showed no benefitassociated with the prophylactic useof indomethacin to prevent HO inpatients undergoing surgery with theKocher-Langenbeck approach.37,38

In addition, the use of indomethacinhas been linked to nonunion of pos-terior wall and long bone fractures aswell as adverse gastroenterologic ef-fects.39 In a randomized controlledtrial that included 68 patients, thosein group 1 received a placebo andthose in groups 2, 3, and 4 receivedindomethacin prophylaxis for 3 days,1 week, and 6 weeks, respectively.40

Sagi et al40 found that 62% of pa-tients who received a 6-week courseof indomethacin for HO prophylaxiswent on to develop nonunions, pre-dominantly of the posterior wall. Theauthors reported that a 1-weekcourse of indomethacin may be suf-ficient to reduce HO formationwithout increasing the rate of fracturenonunion. Routine prophylaxis withthe ilioinguinal approach is not cur-rently recommended.38

Iatrogenic nerve palsy after ace-tabular surgery occurs in 1% to 18%of cases.41 The most common iatro-genic injury involves the peronealdivision of the sciatic nerve. Sciaticnerve palsy is most commonlyencountered in patients undergoingsurgery with a Kocher-Langenbeckapproach, particularly in patientswith posterior wall fractures sec-ondary to a hip dislocation. Thesciatic nerve can also be injuredduring an ilioinguinal approach. Inone study, the ilioinguinal approachwas associated with more sciaticnerve palsies than the Kocher-Langenbeck or EIF approaches.41

This may be the result of heightenedvigilance regarding limb positioningand retractor placement during pos-terior approaches. The ilioinguinal


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approach uses hip flexion to relax theiliopsoas muscle. This position, cou-pled with retractors placed near thesciatic notch, places the sciatic nerveat risk of injury.The use of intraoperative neuro-

monitoring to mitigate nerve injury iscontroversial. Decreased nerve injuryhas been reported with the use of in-traoperative somatosensory evokedpotentials and electromyography.42

However, Haidukewych et al41

found no improvement in the inci-dence of nerve injury with intra-operative monitoring and estimatedthat the cost was.$60,000 per case.

Summary

The selection of a surgical approachto the acetabulum is predicated onseveral factors. The approach shouldbe determined after the fracture hasbeen classified and assessed for dis-placement. Knowledge of the tradi-tional and modified acetabularapproaches is essential to tailortreatment to specific patient needs, toavoid complications, and tominimizesurgical morbidity. Although frac-ture characteristics play a pre-dominant role in choice of approach,other factors should be considered,including the presence of concomi-tant fractures or neurologic injuryand whether the patient is obese.Future studies may determine whichtreatments are optimal for certainfracture types and patient groups.

References

Evidence-based Medicine: Levels ofevidence are described in the table ofcontents. In this article, reference 37is a level I study. References 2, 28,34, 35, and 42 are level II studies.References 10, 11, 18, 27, 32, 33,and 38-41 are level III studies. Ref-erences 1, 3, 4, 8, 21-24, 29, and 36are level IV studies. References 5-7,

9, 12-17, 19, 20, 26, and 31 are levelV expert opinion.

References printed in bold type arethose published within the past 5years.

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2. Matta JM: Fractures of the acetabulum:Accuracy of reduction and clinical results inpatients managed operatively within threeweeks after the injury. J Bone Joint Surg Am1996;78(11):1632-1645.

3. Letournel E: The treatment of acetabularfractures through the ilioinguinalapproach. Clin Orthop Relat Res 1993;292:62-76.

4. Matta JM: Operative treatment ofacetabular fractures through theilioinguinal approach: A 10-yearperspective. Clin Orthop Relat Res 1994;305:10-19.

5. Hospodar PP, Ashman ES, Traub JA:Anatomic study of the lateral femoralcutaneous nerve with respect to theilioinguinal surgical dissection. J OrthopTrauma 1999;13(1):17-19.

6. Grothaus MC, Holt M, Mekhail AO,Ebraheim NA, Yeasting RA: Lateral femoralcutaneous nerve: An anatomic study. ClinOrthop Relat Res 2005;437:164-168.

7. Ghent WR: Meralgia paraesthetica. CanMed Assoc J 1959;81:631-633.

8. Darmanis S, Lewis A, Mansoor A,Bircher M: Corona mortis: An anatomicalstudy with clinical implications inapproaches to the pelvis and acetabulum.Clin Anat 2007;20(4):433-439.

9. Langford JR, Trokhan S, Strauss E:External iliac artery thrombosis after openreduction of an acetabular fracture: A casereport. J Orthop Trauma 2008;22(1):59-62.

10. Ruchholtz S, Buecking B, Delschen A, et al:The two-incision, minimally invasiveapproach in the treatment of acetabularfractures. J Orthop Trauma 2013;27(5):248-255.

11. Wolf H, Wieland T, Pajenda G, Vécsei V,Mousavi M: Minimally invasiveilioinguinal approach to the acetabulum.Injury 2007;38(10):1170-1176.

12. Kloen P, Siebenrock KA, Ganz R:Modification of the ilioinguinal approach.J Orthop Trauma 2002;16(8):586-593.

13. Lefaivre KA, Starr AJ, Reinert CM: Amodified anterior exposure to theacetabulum for treatment of difficultanterior acetabular fractures. J OrthopTrauma 2009;23(5):370-378.

14. Weber TG, Mast JW: The extendedilioinguinal approach for specific bothcolumn fractures. Clin Orthop Relat Res1994;305:106-111.

15. Karunakar MA, Le TT, Bosse MJ: Themodified ilioinguinal approach. J OrthopTrauma 2004;18(6):379-383.

16. Mehlman CT, Meiss L, DiPasquale TG:Hyphenated-history: The Kocher-Langenbeck surgical approach. J OrthopTrauma 2000;14(1):60-64.

17. Siebenrock KA, Gautier E, Ziran BH,Ganz R: Trochanteric flip osteotomy forcranial extension and muscle protection inacetabular fracture fixation using a Kocher-Langenbeck approach. J Orthop Trauma1998;12(6):387-391.

18. Collinge C, ArchdeaconM, Sagi HC:Qualityof radiographic reduction and perioperativecomplications for transverse acetabularfractures treated by the Kocher-Langenbeckapproach: Prone versus lateral position.J Orthop Trauma 2011;25(9):538-542.

19. Gautier E, Ganz K, Krügel N, Gill T,Ganz R: Anatomy of the medial femoralcircumflex artery and its surgicalimplications. J Bone Joint Surg Br 2000;82(5):679-683.

20. Beaton LE, Anson BJ: The relation of thesciatic nerve and of its subdivisions to thepiriformis muscle. Anat Rec 1937;70:1-5.

21. Moed BR: The modified gibson posteriorsurgical approach to the acetabulum.J Orthop Trauma 2010;24(5):315-322.

22. Magu NK, Rohilla R, Arora S, More H:Modified Kocher-Langenbeck approach forthe stabilization of posterior wall fracturesof the acetabulum. J Orthop Trauma 2011;25(4):243-249.

23. Josten C, Trabold O: Modified “2-portal”kocher-langenbeck approach: A minimally-invasive procedure protecting the shortexternal rotator muscles. J Orthop Trauma2011;25(4):250-257.

24. Sarlak AY, Selek O, Inanir M,Musaoglu R,Baran T: Management of acetabularfractures with modified posterior approachto spare external hip rotators. Injury 2014;45(4):732-737.

25. Letournel E, Judet R: Les fractures ducotyle. Paris, France, Masson et Cie, 1974.

26. Juliano PJ, Bosse MJ, Edwards KJ: Thesuperior gluteal artery in complexacetabular procedures: A cadavericangiographic study. J Bone Joint Surg Am1994;76(2):244-248.

27. Bosse MJ, Poka A, Reinert CM,Brumback RJ, Bathon H, Burgess AR:Preoperative angiographic assessment of thesuperior gluteal artery in acetabular fracturesrequiring extensile surgical exposures.J Orthop Trauma 1988;2(4):303-307.

28. Reilly MC, Olson SA, Tornetta P III,Matta JM: Superior gluteal artery in the




extended iliofemoral approach. J OrthopTrauma 2000;14(4):259-263.

29. Reinert CM, Bosse MJ, Poka A,Schacherer T, Brumback RJ, Burgess AR: Amodified extensile exposure for thetreatment of complex or malunitedacetabular fractures. J Bone Joint Surg Am1988;70(3):329-337.

30. Letournel E, Judet R, Elson R: Fractures ofthe Acetabulum, ed 2. New York, NY,Springer-Verlag, 1993, xxiii, p.733.

31. Harris AM, Althausen P, Kellam JF,Bosse MJ: Simultaneous anterior andposterior approaches for complexacetabular fractures. J Orthop Trauma2008;22(7):494-497.

32. Suzuki T, Morgan SJ, Smith WR, Stahel PF,Gillani SA, Hak DJ: Postoperative surgicalsite infection following acetabular fracturefixation. Injury 2010;41(4):396-399.

33. Sagi HC, Dziadosz D, Mir H, Virani N,Olson C: Obesity, leukocytosis,embolization, and injury severity increasethe risk for deep postoperative woundinfection after pelvic and acetabular

surgery. J Orthop Trauma 2013;27(1):6-10.

34. Slobogean GP, Lefaivre KA, Nicolaou S,O’Brien PJ: A systematic review ofthromboprophylaxis for pelvic andacetabular fractures. J Orthop Trauma2009;23(5):379-384.

35. Borer DS, Starr AJ, Reinert CM, et al: Theeffect of screening for deep vein thrombosison the prevalence of pulmonary embolismin patients with fractures of the pelvis oracetabulum: A review of 973 patients.J Orthop Trauma 2005;19(2):92-95.

36. Letournel E: Acetabulum fractures:Classification and management. ClinOrthop Relat Res 1980;151:81-106.

37. Matta JM, Siebenrock KA: Doesindomethacin reduce heterotopic boneformation after operations for acetabularfractures? A prospective randomisedstudy. J Bone Joint Surg Br 1997;79(6):959-963.

38. Griffin SM, Sims SH, Karunakar MA,Seymour R, Haines N: Heterotopicossification rates after acetabular fracture

surgery are unchanged withoutindomethacin prophylaxis. Clin OrthopRelat Res 2013;471(9):2776-2782.

39. Burd TA, Hughes MS, Anglen JO:Heterotopic ossification prophylaxis withindomethacin increases the risk of long-bone nonunion. J Bone Joint Surg Br 2003;85(5):700-705.

40. Sagi HC, Jordan CJ, Barei DP, Serrano-Riera R, Steverson B: Indomethacinprophylaxis for heterotopic ossificationafter acetabular fracture surgery increasesthe risk for nonunion of the posteriorwall. J Orthop Trauma 2014;28(7):377-383.

41. Haidukewych GJ, Scaduto J, Herscovici DJr, Sanders RW, DiPasquale T: Iatrogenicnerve injury in acetabular fracture surgery:A comparison of monitored andunmonitored procedures. J Orthop Trauma2002;16(5):297-301.

42. Helfet DL, Anand N, Malkani AL, et al:Intraoperative monitoring of motorpathways during operative fixation of acuteacetabular fractures. J Orthop Trauma1997;11(1):2-6.


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