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Surgical Approaches to Fractures of the Acetabulum and Pelvis

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Surgical Approaches to Fractures of the Acetabulum and Pelvis Surgical Approaches to Fractures of the Acetabulum and Pelvis Joel M. Matta, M.D. Sponsored by Surgical Approaches to Fractures of the Acetabulum and Pelvis APPROACHES TO THE The table will also stably position the limb in a number of different positions. ACETABULUM No one surgical approach is applicable KOCHER-LANGENBECK for all acetabulum fractures. After APPROACH examination of the plain films as well as the CT scan the surgeon should be knowledgeable of the precise anatomy The Kocher-Langenbeck approach is of the fracture he or she is dealing with. primarily an approach to the posterior A surgical approach will be selected column of the Acetabulum. There is with the expectation that the entire excellent exposure of the reduction and fixation can be retroacetabular surface from the ischial performed through the surgical tuberosity to the inferior portion of the approach. A precise knowledge of the iliac wing. The quadrilateral surface is capabilities of each surgical approach is accessible by palpation through the also necessary. In order to maximize greater or lesser sciatic notch. A less the capabilities of each surgical effective though often very useful approach it is advantageous to operate approach to the anterior column is the patient on the PROfx® Pelvic available by manipulation through the Reconstruction Orthopedic Fracture greater sciatic notch or by intra- Table which can apply traction in a articular manipulation through the distal and/or lateral direction during Acetabulum (Figure 1). the operation. Mizuho OSI 2018 1 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis Figure 2. Fractures operated through the Kocher-Langenbeck approach. Figure 3. Positioning of the patient on the PROfx® Pelvic Reconstruction Orthopedic Fracture Table for operations through the Kocher-Langenbeck approach. Mizuho OSI 2018 2 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis Figure 4. Skin Incision for the Kocher-Langenbeck approach. The Kocher-Langenbeck approach is indicated for Posterior wall, Posterior The gluteal fascia and fascia lata are column, transverse, transverse plus incised in line with the skin incision. posterior wall, and some T-shaped The fibers of the gluteus maximus are fractures (Figure 2). It is indicated for split bluntly. The trochanteric bursa is old fractures of the posterior wall and incised. The gluteus maximus tendon is posterior column. transsected at its insertion on the posterior femur. The gluteus maximus Prior to beginning this approach a Foley should not be split too proximally or the Catheter is placed in the bladder. A fibers of the inferior gluteal nerve which transcondylar Steinmann pin is placed lie within the muscle will be torn. through the distal femur. The patient is the placed in the prone position on the The sciatic nerve is normally located at PROfx® Surgery Table with traction this point at its position on the applied to the transcondylar Steinmann posterior aspect of the quadratus pin and the knee flexed at least 60 femoris. It is followed proximally across degrees (Figure 3). the posterior aspect of the obturator internis and gemellae to the point The Incision starts about 5 centimeters where it disappears beneath the lateral to the posterior-superior spine piriformis muscle. A small vascular and extends anteriorly and distally to pedicle often crosses the posterior the greater trochanter and then distally aspect of the nerve. In order to mobilize along the thigh to approximately the the nerve and see it fully this small mid portion of the thigh (Figure 4). vascular pedicle should be clamped, Mizuho OSI 2018 3 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis Figure 5. Splitting of the gluteus maximus muscle. transsected and cauterized (Figure 5). obturator internis originates from the quadrilateral surface and passes The tendon of the gluteus medius is through the lesser sciatic notch to its identified at its intersection on the insertion on the femur. The lesser trochanter. The gluteus medius muscle sciatic notch acts as a pulley for the is retracted superiorly and anteriorly tendon. A small bursa is present at the exposing the piriformis muscle and point where the tendon pulleys around tendon. The piriformis tendon is tagged the lesser sciatic notch. As this bursa is with suture and transsected near its entered, the tendon of the obturator insertion on the greater trochanter. internis is clearly seen as well as the Reflection of the piriformis muscle smooth cartilaginous border of the posteriorly exposes the greater sciatic lesser notch. The tip of a retractor is notch. Just below the insertion of the placed into the lesser notch to retract piriformis tendon is found the tendon of the obturator internis as well as the the obturator internis. The two gemellae sciatic nerve. A special sciatic nerve lie superior and inferior to this tendon. retractor is very useful in this area. A tag suture is placed through the tendon and the obturator internis A periosteal elevator is used along the tendon is transsected along with the retroacetabular surface from the ischial superior and inferior gemellae. The tuberosity to the inferior portion of the tendon and the gemellae are reflected ilium. The periosteal elevator can also posteriorly and medially, thereby be introduced into the greater sciatic exposing the lesser sciatic notch. The Mizuho OSI 2018 4 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis Figure 6. Completed exposure of the retroacetabular surface. notch to clear periosteum and the Sciatic Notch the nerve tension should obturator internis muscle from the be checked by palpation. Whenever quadrilateral surface. Palpation of the maximal retraction is not necessary the quadrilateral surface will then aid in assistant should relax tension on the fracture reduction. Another retractor retractors retracting the sciatic nerve. It can be placed with its tip in the greater is also possible to injure the superior sciatic notch. A Hohmann retractor is gluteal nerve if the gluteus medius and usually placed with its tip driven into minimus are retracted too vigorously in the inferior portion of the iliac wing to a proximal direction. The tension on the retract the gluteus medius and superior gluteal nerve can also be minimus. A capsulotomy performed checked by palpation of the nerve just along the rim of the acetabulum will anterior to the greater sciatic notch. expose the acetabulum cartilage and femoral head (Figure 6). Further access At the completion of the procedure to the inferior as well as anterior Hemovac drains are placed along the portion of the iliac wing can be obtained external ilium and as well in the greater through a trochanteric osteotomy or a sciatic notch. The tendons of the partial or complete transection of the obturator internis, piriformis as well as gluteus medius tendon. gluteus maximus are reattached to the femur with suture at their anatomic Care must be taken throughout the position. If the tendon of the gluteus procedure to retract only gently on the medius has been transsected, this is sciatic nerve. After the retractors are also repaired. placed in the lesser and/or greater Mizuho OSI 2018 5 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis Visual Access. Access by touch. Figure 7. Access to the bone with the ilioinguinal approach. Figure 8. Fractures operated through the ilioinguinal approach. Mizuho OSI 2018 6 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis Figure 9. Positioning of the patient on the PROfx® Pelvic Reconstruction Orthopedic Fracture Table for operations through the ilioinguinal approach. ILIOINGUINAL APPROACH hemitransverse, most both-column and certain transverse fractures (Figure 8). The ilioinguinal approach is primarily It is indicated for old anterior wall and an approach to the anterior column and anterior column fractures. inner aspect of the innominate bone. The entire internal iliac fossa as well as Prior to procedure a Foley catheter is the pelvic brim are exposed. The inserted into the bladder. The patient is quadrilateral surface is also visualized placed in a supine position on the through this approach. Though it is PROfx® Surgery Table with the lower primarily an approach to the anterior extremities in traction through the column a useful though less effective traction boots attached to traction units approach to the posterior column is on the table. The lateral traction device available through manipulation of the is made available for the possibility of quadrilateral surface (Figure 7). The pulling lateral traction through a final reduction of the articular surface femoral head corkscrew placed into the cannot be directly visualized, however it greater trochanter during the operation is assumed to be correct after the (Figure 9). restoration of the internal contour of the innominate bone. The Incision starts at the mid-line two finger breadths proximal to the The ilioinguinal approach is initiated for symphysis pubis. anterior wall, anterior column, associated anterior and posterior Mizuho OSI 2018 7 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis It proceeds laterally to the anterior- completed, the surgeon has now superior spine of the ilium and then exposed the retropubic space of Retzius follows the iliac crest two-thirds of the in the medial portion of the incision. way posteriorly along the crest. The The external aspect of the femoral incision should extend beyond the vessels and the surrounding lymphatics lateral most convexity of the ilium are exposed in the mid-portion of the (Figure 10). The periosteum is sharply incision and the psoas sheath has been incised along the iliac crest releasing entered in the lateral portion of the the attachment of the abdominal incision with visualization of the lateral muscles and iliacus from the crest. A cutaneous nerve of the thigh and the periosteal elevator is used to expose the femoral nerve within the psoas sheath internal iliac fossa as far posteriorly (Figure 12).
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