the kocher-langenbeck approach · theodor kocher (1841-1917) in 1911 described the caudal extension...
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The Kocher-Langenbeck Approach
Andreas Panagopoulos, MD, PhD
Lecturer in Orthopaedics
University Hospital of Patras
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Bernhard von Langenbeck (1810-1887)
Hyphenated-History
1st description in 1867
In 1874 described his “longitudinalincision for hip infections"
"from above the ischiadic notch to themiddle of the greater trochanterpassing between the bundles of thegluteal muscles“
"hip joint resections"
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Theodor Kocher (1841-1917)
In 1911 described the caudal extensionof Langenbeck’s approach
"The incision is an angular (or curved)one, extending from the base of theouter surface of the great trochanterupwards to its anterior superior angle,and from thence obliquely upwards andbackwards in the direction of thegluteus maximus"
Hyphenated-History
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Kocher's depiction of the incision from his 1911 textbook
Hyphenated-History
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In 1954, Judet et al combined thesetwo to create the so called Kocher-Langenbeck approach, named so in1980 for surgical procedures, whichthey performed with the patientprone on an orthopedic table.
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most commonly used surgical exposure forthe stabilization of displaced posterior wallfractures of the acetabulum
Definition
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Indications Direct visualization
Indirect visualization
Visualization after quadratusfemoris origin release
posterior wallposterior columnposterior column & wall
transverse,transverse & posterior wallT-shaped
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If the transverse component is locatedat (juxta-) or below (infra-) the level ofthe roof (tectum) of the acetabulum(therefore not involving the weight-bearing area of the acetabulum)
Indications
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Preparation & Positioning
Special instruments
Surgeon familiarity and preference
Pelvic fracture table
Femoral traction
C-arm control
Lateral or Prone
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Prone Positioning
femoral head in reduced position(gravity helps reduction)
90o knee flexion places the sciatic nervein a relaxed position
allows digital access to the quadrilateralsurface (transverse or T type fractures)
avoid excessive abdominal pressure
Unscrubbed assistant is required forintraoperative adjustment of the table
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easy maneuverability of the limb
facilitates the approach to the greatersciatic notch and, therefore, to theinner side of the pelvis
femoral head would tend to keep thefracture surfaces apart because ofgravity
sciatic nerve at risk
Lateral Positioning
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No advantage to either position for the posteriorapproach could be found
With equivalent radiologic outcomes between bothgroups, a significantly higher rate of infection (p 0.017)and need for revision surgery (p 0.009) were found inthe prone group
For severe fractures (11 B2 vs 4) longer inpatient wait fordefinitive fixation, leading to a higher risk of nosocomialcolonization
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residual fracture displacement in patients with transversefractures reduced and stabilized in the lateral positioncompared with those positioned prone.
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bony landmarks :(1) posterior superior iliac spine(2) greater trochanter(3) shaft of femur
Skin incision
A more proximal extension may improveexposure in obese or muscular patients.
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Superficial fascial dissection
the gluteus maximus muscle(using scissors)
the tractus iliotibialis (using a scalpel)
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Gluteus maximum splitting
- posterior muscle belly (inferiorgluteal artery),- anterior belly (superior gluteal
artery)that includes one third of the gluteusmaximus and the muscle of the tensorfasciae latae.
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Deep dissection
Free the layer of fat covering the shortexternal rotators, exposing the insertionof the piriformis tendon, the gemelli,and the internal obturator muscle.
Carefully visualize the sciatic nerve.
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Deep dissection (option)
Detach the gluteus maximus 1 cm fromits insertion into the gluteal tuberosityof the femur.
Detachment can be done partially orcompletely
This allows a decrease of tension andeasier mobilization of the gluteusmaximus muscle.
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External rotators dissection
Isolate the piriformis tendon and theconjoined tendons of the obturatorinternus and superior and inferiorgemelli muscles.
They are tagged and incised 1 cmlateral from their femoral insertions.
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Exposure of posterior wall
Release and reflect each of the short external rotator muscles
Expose the greater sciatic notch, the ischial spine, and the lesser sciatic notch.
Insert two retractors in the greater and the lesser sciatic notches.
Protect the sciatic nerve
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Optional: T-capsulotomy
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Reduction-internal fixation
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Wound closure
meticulous debridement
Remove necrotic tissue and irrigate the entire wound
two suction drains
Reinsert all tendons and approximate the split parts of the gluteus maximus
closure of the iliotibial tract
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sciatic nerve injury,
infection,
severe bleeding,
heterotopic bone formation,
thromboembolic disease
Complications
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Modifications
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two windows: between the gluteusmedius and piriformis superiorly andbetween the external rotators andischial tuberosity inferiorly.
The approach spares the division ofexternal rotators and of the abductorsof the hip, thus preventing iatrogenicdamage to the vascularity of the headof the femur and of the fracturefragments.
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19 pt - 8 in each group
the gait analysis, and the shortmusculoskeletal function assessmenttest showed no statistical difference
the operation time was even lower inthe modified group
The fracture reduction was good anddid not seem to have additionalapproach-related complications
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- mobilization of the vastus lateralis- slice of the greater trochanter with
the attached gluteus medius- free access to posterosuperior and
superior acetabular wall area
- better visualization, more accurate reduction, and easier fixation of cranial acetabular fragments.
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With the numbers available, weshowed no benefit to the use of drainsfor acetabular surgery performedthrough a K-L approach.
1,000 patients to show a decrease indrainage time by 1
> 16,000 patients would be needed toshow a decrease in the infection rate
Considerations
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Typically (about 84% of the time), thesciatic nerve runs deep to thepiriformis muscle
One part of the nerve (the peronealdivision) pass through the muscle and theother part (the tibial division) appearbelow the muscle (12%)
The entire nerve also may pass throughthe muscle (1%).
The third variation is passage of theperoneal division above the piriformis andthe tibial division below it (3%).
Considerations
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Conclusions
Non extensile
posterior wall fractures
Prone is better
Special instruments
Fracture table & C-arm
Sciatic nerve (10%)
Bleeding superior gluteal artery (5%)
Heterotopic ossification (10%)