Surgical Approaches to Fractures of the Acetabulum and Pelvis

Joel M. Matta, M.D. Sponsored by

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.

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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.

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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,

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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

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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

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Visual Access. Access by touch.

Figure 7. Access to the bone with the ilioinguinal approach.

Figure 8. Fractures operated through the ilioinguinal approach.

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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

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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). and medially as the sacroiliac joint and pelvic brim. The first abdominal layer The iliopectineal fascia will be found to encountered is the aponeurosis of the divide the femoral vessels and external oblique and the external lymphatics from the iliopsoas muscle sheath of the rectus abdominis in the and femoral nerve (Figure 13). The most medial portion of the incision. vessels and lymphatics should be This layer is incised in line with the dissected away from the muscle and skin incision and then reflected distally nerve away from the fascia laterally. to unroof the iguinal canal. The The iliopectineal fascia is then sharply spermatic cord or round ligament with incised to the pectineal eminence the accompanying ilioinguinal nerve is followed by detachment of the located in the inguinal canal and a iliopectinal fascia from the pelvic brim Penrose drain placed around these proximally to the anterior sacroiliac structures for retraction (Figure 11). An joint (Figures 14, 15, 16). The incision is then made long the entire iliopectineal fascia separates the false length of the inguinal ligament. pelvis from the true pelvis. Detachment Approximately one millimeter of the of the fascia from the pelvic brim allows length of the ligament is split away from access to the true pelvis and thereby the main portion of the ligament. the quadrilateral surface and posterior Medially the transversalis fascia is column. Another Penrose drain is thereby released from the inguinal placed around the iliopsoas and femoral ligament and laterally the common nerve which also includes the lateral origin of the internal oblique and cutaneous nerve of the thigh. A third transverses abdominis are released Penrose drain is then placed around the from the inguinal ligament. Care must femoral vessels and lymphatics. The be taken in this incision as the external vessels should be left within the fatty iliac vessels and lymphatics lie areolar tissue that surrounds them immediately below the medial portion of because this fatty areolar tissue the inguinal ligament and the lateral contains the lymphatics which should cutaneous nerve is found immediately not be disrupted. below the lateral portion of the ligament. It is also usually necessary to In Approximately 10 percent of the incise a portion of the conjoined tendon cases there is either an anastomosis at its insertion to the pubis just medial between the obturator vessels and the to the transversalis fascia and external iliac vessels or an abnormal additionally transect a portion of the origin of the obturator artery from the rectus abdominis tendon at its external iliac vessels. The surgeon insertion on the pubis. After this should inspect posterior to the vessels incision along the inguinal ligament is to check for this possibility.

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Figure 10. Skin incision for the ilioinguinal approach.

Figure 11. Unroofing of the inguinal canal.

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Figure 12. Detachment of the abdominal muscles and transversalis Fascia from the inguinal ligament.

Figure 13. Oblique section of the lacuna musculorum and lacuna vasculorum at the level of the inguinal ligament.

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Figure 14. Division of the iliopectineal fascia.

Figure 15. Oblique section dividing the fascia.

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Figure 16. Proximal division of the fascia from the pelvic brim.

Figure 17. The first window of the ilioinguinal approach.

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Figure 18. The second window of the ilioinguinal approach.

Figure 19. Access to the retropubic space and symphysis.

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If this anastomosis or abnormal origin Following retraction of the vessels, to the obturator artery is present the check the pulse repeatedly to make vessels should be clamped, transsected sure that too great a force has not been and ligated to prevent tearing of the applied. Medial to the vessels, one has vessel during the procedure and access to the superior pubic ramus and bleeding that can be very difficult to the symphysis pubis, if necessary control. A periosteal elevator is used to (Figure19). The spermatic cord may be further expose the superior pubic retracted medially or laterally as ramus and pelvic brim. The periosteal required. The obturator nerve is elevator can also be used on the visualized through either the second or quadrilateral surface for visualization of third window of the ilioinguinal fracture lines. In doing this, take care approach as it passes under the in approaching the greater sciatic notch superior pubic ramus. as it is easy to injure the superior gluteal vessels or branches of the It is often useful to detach the sartorius internal iliac vein. The interior of the and inguinal ligament from the joint can often be visualized through anterior-superior spine and to elevate the fracture lines while the fracture is the tensor fascia lata muscle from the displaced, however cannot be inspected outer portion of the anterior iliac wing. after reduction of the fracture. This access to the external aspect of the bone is often useful for placing The exposure is now complete and the reduction clamps across the anterior operation will be performed through the border of the innominate bone. various windows surrounded by the structures crossing the inguinal At the completion of the procedure ligament. The first window gives access Hemovac drains are placed in the to the internal iliac fossa, the anterior retropubic space of Retzius along the sacroiliac joint and the pelvic brim quadrilateral surface as well as the (Figure 17). Retraction can be internal iliac fossa. If the external performed with lever retractors placed aspect of the bone has been exposed on the anterior sacroiliac joint and the this should also be drained. Full pelvic brim. muscle relaxation should be employed throughout the closure of the incision. The second window, which is obtained The abdominal muscles tend to retract by retracting the iliopsoas and femoral in a proximal and posterior direction nerve laterally and the external iliac and must be restored to their anatomic vessels medially, gives access to the position along the iliac crest in order to pelvic brim from the anterior sacroiliac obtain a sound closure of the floor and joint to the pectineal eminence (Figure roof of the inguinal canal. If the origin 18). It also gives access to the of the sartorius has been detached it is quadrilateral surface for reduction of reattached with a suture placed posterior column fractures. The through a drill hole on the anterior- iliopsoas can be retracted fairly superior spine. The floor of the inguinal vigorously laterally without danger of canal is repaired along the inguinal injury to the femoral nerve. Take care in ligament and the roof of the inguinal the medial retraction of the external canal repaired by closure of the iliac vessels; this is usually done with a aponeurosis of the external oblique. The ribbon retractor with its tip placed iliopectineal fascia is not repaired. against the quadrilateral surface.

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Visual access. Access by touch.

Figure 20. Access to the bone with the extended iliofemoral approach.

EXTENDED ILIOFEMORAL This approach may be thought of as the APPROACH lateral approach to the acetabulum and innominate bone. This exposure follows

a logical neurovascular interval The extended iliofemoral approach was reflecting muscles enervated by the developed by Emile Letournel as a femoral nerve medially. surgical approach to provide maximum simultaneous access to both columns of the acetabulum. It is primarily an The extended iliofemoral approach is approach to the external aspect of the indicated for certain both column, innominate bone giving access to the certain T-shaped and certain associated entire lateral aspect of the iliac wing, transverse plus posterior wall fractures the entire retroacetabular surface and (Figure 21). It is indicated for old the interior of the hip joint following a transverse, transverse plus posterior capsulotomy along the acetabular rim. wall, T-shaped, associated anterior plus A limited exposure to the internal posterior hemitransverse, and both aspect of the bone is possible by column fractures. exposing the internal iliac fossa. The anterior column may be followed Prior to the operation a Foley catheter distally to the pectineal eminence is placed in the bladder. A (Figure 20). Access beyond the pectineal transcondylar Steinmann pin is placed eminence is limited by the tendon of the through the distal femur for iliopsoas. intraoperative traction.

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Figure 21. Fractures operated through the extended iliofemoral approach.

Figure 22. Positioning of the patient on the PROfx® Pelvic Reconstruction Orthopedic Fracture Table for operations through the extended iliofemoral approach.

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Figure 23. Skin incision for the extended iliofemoral approach.

The patient is placed in the lateral distally enough to expose the distal position on the PROfx® Surgery Table. extent of the tensor fascia lata muscle. The knee is kept flexed at least 60 The tensor fascia lata is retracted degrees to relax the sciatic nerve. The posteriorly exposing the fascia layer lateral perineal post may be raised and which separates it from the rectus lowered intraoperatively to provide femoris. This fascia layer is incised lateral traction to the hip (Figure 22). longitudinally. A second fascia layer which separates the rectus femoris The incision starts at the posterior from the vastus lateralis is also incised superior spine and proceeds around the longitudinally. Immediately beneath entire length of the iliac crest to the this fascia layer are found the lateral anterior-superior spine and then femoral circumflex vessels which are anterolaterally down the thigh (Figure clamped, transsected and ligated 23). The periosteum is sharply incised (Figure 24). Strong aponeurotic fibers over the iliac crest. The fascia lata is that cross the anterior portion of the released from the crest. A periosteal greater trochanter are transsected. elevator is used to dissect the gluteal muscles and tensor fascia lata from the The elevation of the gluteal muscles external aspect of the iliac wing. The from the iliac wing is continued in a Most posterior portion of the gluteus posterior and distal direction until the maximus origin is usually left attached greater sciatic notch is reached. The to the iliac wing. The fascia lata is greater sciatic notch must be incised over the anterolateral thigh approached with care to avoid injury to exposing the tensor fascia lata muscle. the superior gluteal nerve or vessels. The incision is usually continued

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Figure 24. Exposure of the lateral femoral circumflex vessels.

Figure 25. Transection of the gluteus minimus and gluteus medius tendons.

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Figure 26. Completed exposure of the external aspect of the bone.

The tendon of the gluteus minimus is transsected at its posterior trochanteric identified at its anterior insertion on the insertion. As it is reflected posteriorly, trochanter. It is tagged with a suture the bursa of the obturator internis and and then transsected in its mid- the lesser sciatic notch are identified as substance. The gluteus minimus also with the Kocher-Langenbeck approach. attaches to the superior hip capsule Retractors can now be placed in the and this insertion is also detached from greater and lesser sciatic notch for the hip capsule. The gluteus medius retraction (Figure 26). tendon is identified as a broad band on the external aspect of the greater Excision of the reflected head of the trochanter about 15 millimeters in rectus femoris muscle gives better length. The tendon is transsected in its access to the superior hip capsule. A mid-substance and tagged with capsulotomy may be performed at the multiple sutures (Figure 25). The rim of the acetabulum and traction surgeon will find the thickest and applied with the PROfx® Surgery Table strongest portion of the tendon to insert will distract the femoral head from the posterior and superior on the greater acetabulum and allow visualization of trochanter. The piriformis tendon is the interior of the joint. The internal identified at its insertion on the iliac fossa may be exposed by superior portion of the trochanter. It is detachment of the abdominal muscles transsected and the muscle reflected from the iliac crest as well as posteriorly further exposing the greater detachment of the sartorius and sciatic notch. The tendon of the inguinal ligament from the anterior- Obturator internis along with the two superior spine. gemellae is tagged with suture and

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Figure 27. Exposure of the internal iliac fossa.

The dissection may be carried out gluteal muscle flap should be protected posteriorly and medially to the anterior against dessication by keeping the sacroiliac joint and pelvic brim. exposed muscle covered with a wet Transection of the direct head of the sponge. rectus femoris at its bony origin will complete the maximum access to the At the completion of the operation anterior column (Figure 27). suction drains are placed along the course of the rectus femoris and vastus In the case of a T-shaped fracture in lateralis. These drains should lead to which no fracture lines transverse the the external iliac fossa and greater iliac wing, both sides of the iliac wing sciatic notch. If the internal aspect of may be exposed without fear of the bone has been exposed this should devascularizing the bone. In the case of be drained as well. If the rectus femoris a both-column fracture, however, the and sartorius origins have been anterior column fracture usually released these muscles should be traverses the anterior portion of the reattached to the bone by suture placed wing to iliac crest. In this case complete through drill holes. The tendons of the exposure of both sides of the iliac wing obturator internis and piriformis are may easily devascularize a large reattached. The tendons of the gluteus segment of the anterior column. In medius and gluteus minimus are order to prevent tins soft tissue pedicles reattached with multiple sutures to the must remain attached to the anterior tendon stumps remaining on the column for vascularity. At a minimum greater trochanter. The fascia lata is the direct head of the rectus femoris reaproximated to the abdominal fascia and anterior hip capsule should be left along the iliac crest and the fascia lata attached to the anterior column. is closed anterolaterally over the thigh. Throughout the operation the large

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Reattachment of the fascia lata to the approach. Radiation can be considered abdominal fascia along the iliac crest if the risk of ectopic bone is considered can be greatly facilitated by abduction to be unusually high. of the hip. Reattachment of the sartorius and rectus femoris origins is facilitated by flexing the hip and SURGICAL APPROACHES extending the knee. FOR PELVIS FRACTURE

POSTOPERATIVE CARE Unstable fractures of the pelvis invariably involve combined lesions to both the anterior and posterior pelvic The postoperative surgical care is ring, and may require staged essentially the same for all three of the approaches. In the great majority of surgical approaches to the acetabulum. cases the posterior lesion is approached Prophylactic antibiotic which is started first, followed by repositioning of the preoperatively is continued for 72 hours patient for operation of the anterior postoperatively. The suction drainage is lesion. In many cases reduction and continued typically for 48 hours internal fixation of the posterior lesion postoperatively though may be will suffice. The approaches used for extended to 72 hours with continued these staged procedures are described drainage. in this section. In a minority of cases it is possible to approach both lesions Passive mobilization of the hip, either simultaneously through the ilioinguinal with physical therapist or with approach. continuous passive motion machine, may be started within the first few days after surgery. Gait training can be started when the patient is comfortable enough, which is usually between five and ten days following the operation. The patient’s weight bearing is limited to 15 kilograms for the first eight weeks following the operation and then weight bearing is progressed as tolerated.

If the fracture is accurately reduced and ectopic bone dose not develop, the range of motion usually returns to 90 percent of normal without problems. Physical therapy is directed primarily toward muscle strengthening of the abductor musculature.

Following the Kocher-Langenbeck and extended iliofemoral approach in domethacin is usually administered 25 milligrams, three times daily for two months after the operation. No prophylaxis against ectopic bone is necessary with the ilioinguinal

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THE APPROACH TO In the case of an acute symphysis THE SYMHHYSIS PUBIS diastasis, one of the heads of the rectus abdominis is commonly torn from its bony attachment. As the linea alba is For the approach to the symphysis split distally, the paramadalis muscle is pubis the patient is placed supine often encountered and this is also split position on the PROfx® Surgery Table. longitudinally at its mid-portion (Figure A Foley catheter is inserted into the 29). Directly beneath the abdominal bladder prior to the operation. The skin wall one finds the peritoneal fat incision may be made either as a proximally and the bladder distally. In transverse incision two centimeters the acute injury, the bladder will fall proximal to the symphysis pubis or as a away from the posterior surface of the vertical mid-line incision. The symphysis as one enters the retropubic transverse incision is more cosmetic space of Retzius; however there may be (Figure 28). The vertical incision may be adherence of the bladder to the bone extended for intra-abdominal access in from an old injury in which case it the case of the multiple injury patient. should be freed carefully with a Regardless of the direction of the skin periosteal elevator from the posterior incision, the deep dissection through aspect of the symphysis. the muscles is always the same. The alba is split longitudinally separating the two heads of the rectus abdominis.

Figure 28. Skin incision for the approach to the symphysis pubis.

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Figure 29. Incision along the linea alba.

Figure 30. Retraction of the two heads of the rectus addominus.

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The two heads of the rectus abdominis THE APPROACH TO THE are left attached to the anterior and POSTERIOR PELVIC RING outer aspect of the symphysis although the insertion is usually freed somewhat by sharp dissection form the superior A single surgical incision can be used to aspect of the symphysis and superior approach fractures of the sacrum, pubis ramus. Hohmann retractors can dislocations of the sacroiliac joint or be placed with their tips over the fracture-dislocations of the sacroiliac superior aspect of the mid-portion of joint. Prior to the operation a Foley the superior pubic ramus on each side catheter is inserted in the bladder. The in order to retract the two heads of the patient is normally operated in the rectus abdominis laterally. Periosteal prone position on the PROfx® Surgery elevation along the superior part of the Table with the auxiliary Radiolucent symphysis as well as the superior Imaging Top attached (Figures 35 & ramus completes the exposure 36).Use of the Radiolucent Imaging Top necessary for reduction and plate allows use of the image intensifier application (Figure 30). intraoperatively for targeting screws that can be placed through the iliac If it is necessary to approach a fracture wing into the sacral ala or the S1 of the superior pubic ramus as well as vertebral body. In order for the oblique the symphysis dislocation this may views to be obtained with the image usually be done simply by retraction of intensifier the pelvis must be positioned the abdominal muscles laterally with over the center of the Radiolucent Hohmann retractors. If this dose not Imaging Top that has no obstacles that give adequate access the tendon of the would impede movement of image rectus abdominis may be transsected intensifier for at least 1.5 meters near its insertion and the exposure (Figure 31). continued laterally as with the ilioinguinal approach by opening the A vertical incision is made 2 roof and floor of the inguinal canal. It is centimeters lateral to the posterior- possible to approach the lateral-most superior spine. The incision starts 5 aspect of the superior ramus while centimeters proximal to the iliac crest staying medial to the external iliac and extends 5 centimeters distal to the vessels. The surgeon should take care superior border of the greater sciatic not to injure the obturator nerve or notch (Figure 32). The thin fascia artery. overlying the gluteus maximus is identified. Subcutaneous tissue is At the completion of the operation, a reflected off the gluteal fascia suction drain is placed in the posteriorly and medially to expose the retropubic space. Closure is normally gluteus maximus origin at the posterior simple with approximation of the two iliac crest and from the sacrum. The heads of the rectus abdominis along the periosteum is sharply incised along the linea alba and closure of the posterior iliac crest to reflect the subcutaneous and skin. If one head of maximus muscle and a portion of the the rectus abdominis has been gluteus medius from the posterior and transsected or the inguinal canal lateral aspect of the iliac wing. The opened, repair these in the anatomic maximus origin is also detached from position. the sacrum. As the gluteus maximus is detached from its origin over the sacrum it is lifted off the multifidus fascia which overlies the multifidus and erector spini muscles overlying the sacrum (Figure 33).

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Figure 31. Prone positioning of the patient on the radiolucent table and use of the image intensifier for operations through the approach to the posterior pelvic ring.

Figure 32. Skin incision for the approach to the posterior pelvic ring.

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Figure 33. Reflection of the gluteus maximus muscle from the posterior crest and multifidus fascia.

Figure 34. Completed exposure of the posterior ilium, sacroiliac joint and sacrolamina.

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With the lateral reflection of the gluteus At the completion of the operation, maximus the greater sciatic notch is Hemovac drains should be placed along exposed. the lateral ilium and into the greater sciatic notch. The internal iliac fossa Further exposure of the notch is should also be drained if it has been obtained by detachment of the exposed. The closure is simple with piriformis origin and careful elevation reapproximation of the gluteal fascia along the border of the greater sciatic overlying the multifidus and erector notch taking care not to injure the spini muscles. superior gluteal vessels or nerve. Exposure of the greater sciatic notch will give a key to the reduction of the ANTERIOR APPROACH TO sacroiliac joint and also allows a finger THE SACROILIAC JOINT to be passed through the notch to palpate the inferior sacroiliac joint anteriorly to the pelvic brim. A sacrum An alternative exposure to the fracture may also be palpated as it sacroiliac joint is anterior. For this traverses the anterior surface of the approach the patient is positioned sacrum. The sacral foramina are supine on the PROfx® Surgery Table palpable as well as the sacral nerve with the auxiliary Radiolucent Imaging roots as they exit the foramina. Top attached and centered over a 1.5 meter radiolucent section that is free from obstacles that would impede If a sacrum fracture is present, it is movement of the image intensifier necessary to expose the fracture line as (Figures 35 & 36) The incision starts it traverses the posterior sacral lamina. just distal to the anterior-superior iliac This is done by elevating the multifidus spine and proceeds posteriorly along muscles from the posterior aspect of the crest about two-thirds of the way the sacrum in a lateral to medial along the crest. The periosteum is direction starting at the lateral edge of sharply incised. The abdominal muscles the sacrum. There are small nerve are released from the crest and the branches that exit through the iliacus dissected subperiosteally from posterior sacral foramina that supply the internal iliac fossa. The iliacus some sensation to the skin overlying should be elevated to the pelvic brim the sacrum, and additionally enervate distally and the sacroiliac joint more the multifidus muscles. These can proximally. It is necessary to dissect usually be preserved even when the subperiosteally along the anterior sacral foramina are exposed posteriorly. aspect of the sacral ala, however one However if they are sacrificed the should be cautious with too vigorous resulting disability is negligible (Figure medial dissection because the L5 nerve 34). Although not necessary in the root crosses the anterior sacral ala and majority of cases, it is possible to obtain can suffer a stretch injury. The tip of a palpation access to the internal iliac thin Hohmann retractor is typically fossa and anterior aspect of the driven into the anterior sacral ala about sacroiliac joint by releasing the erector 15 millimeters medial to the sacroiliac spini muscles and abdominal muscles joint and another Hohmann retractor is from the superior portion of the crest, used for retraction over the proximal and placing a finger over the top of the pelvic brim. The anterior sacroiliac joint crest into the internal iliac fossa. is thereby visualized for reduction.

Mizuho OSI 2018 27 NW0709 Rev C Surgical Approaches to Fractures of the Acetabulum and Pelvis

Figure 35. PROfx® Pelvic Reconstruction Orthopedic Fracture Table shown with the auxiliary Radiolucent Imaging Top attached for positioning patient prone for the Approach to the Posterior Pelvic Ring or supine for the Anterior Approach to the Sacroiliac Joint.

Figure 36. PROfx® Pelvic Reconstruction Orthopedic Fracture Table shown with the auxiliary Radiolucent Imaging Top and Leg Spars attached for positioning patient prone for the Approach to the Posterior Pelvic Ring or supine for the Anterior Approach to the Sacroiliac Joint for when the use of traction is desired.

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THE APPROACH TO THE ILIAC WING

For isolated fractures of the iliac wing the patient may be positioned either THANKS TO EMILE lateral or supine on the PROfx® Surgery Table. The incision parallels the iliac crest. The periosteum is I would like to express my sincerest sharply incised along the superior gratitude and admiration for Professor aspect of the crest and from this point Emile Letournel who contributed to the the external or internal aspect of the development of all of these surgical wing may be exposed by elevation of the approaches and has spent countless gluteal muscles or iliacus or both as is hours teaching surgery of the found necessary for reduction and acetabulum and pelvis to myself and fixation. other surgeons.

POSTOPERATIVE CARE

Prophylactic antibiotic which is started For more information, contact: preoperatively is continued for 72 hours following the operation. Hemovac drains Joel M. Matta, MD, Inc. are normally kept in place for 48 hours though this may be extended to 72 Orthopaedic Surgery Pelvis and Hip Reconstruction hours with continued drainage. The patient is kept at bed rest until he or 2001 Santa Monica Blvd., #1090 she is relatively comfortable, and then Santa Monica, CA 90404 is allowed to ambulate with crutches. Tel: 310-582-7475 Weight bearing is limited to the affected Fax: 310-582-7481 side for eight weeks after the operation www.hipandpelvis.com and then weight bearing as tolerated is www.newhipnews.com instituted. If bilateral injuries requiring Email: [email protected] internal fixation are present, the patient is allowed to do standing pivot transfers from bed to wheelchair initially and gait training with full weight bearing is started at eight weeks after surgery.

Physical therapy is directed toward muscle strengthening at the hips and in particular strengthening of the abductor musculature. No Ectopic bone prophylaxis is necessary.

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NOTES

Surgical Approaches to Fractures of the Acetabulum and Pelvis

For more information, contact: Joel M. Matta, MD, Inc. Orthopaedic Surgery Pelvis and Hip Reconstruction 2001 Santa Monica Blvd., #1090 Santa Monica, CA 90404 Tel: 310-582-7475 Fax: 310-582-7481 www.hipandpelvis.com www.newhipnews.com Email: [email protected]

Mizuho OSI 30031 Ahern Avenue Union City, CA 94587-1234 / USA Telephone: 510-429-1500 Toll Free: 800-777-4674 Outside USA: +1-510-429-1500 Fax: 510-429-8500 www.mizuhosi.com www.newhipnews.com

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