Extended iliofemoral approach to the acetabulum

Introduction

Indications

• Exposure of almost all anterior column fractures.
• Exposure of transverse fractures of the acetabulum.
• Exposure of some of the posterior column of the acetabulum.

Advantage

• Useful for double column fractures.

Disadvantages

• Technically demanding approach.
• Large amount of soft-tissue stripping is inherent in this approach and there is a risk of devitalizing the gluteal muscles.
• Two approach techniques utilizing the posterior approach to the acetabulum and the ilioinguinal approach to the acetabulum may be preferable.

Position of patient

• Supine with a small sandbag under the affected buttock to push the affected hemipelvis forward.

Landmarks and incision

Landmarks

• The anterior superior iliac spine is palpated subcutaneously.
• The iliac crest is palpated subcutaneously.

Incision

• Start incision from the anterior half of the iliac crest to the anterior superior iliac spine; extend the skin incision by curving the proximal end posteriorly 5 cm further over the iliac crest.
• Extend the distal end of the incision inferiorly by curving it down so that it runs vertically for 5 cm, heading toward the lateral side of the patella.

Internervous plane

• The superficial plane lies between the sartorius (femoral nerve) and the tensor fasciae latae (superior gluteal nerve).
• The deep plane lies between the rectus femoris (femoral nerve) and the gluteus medius (superior gluteal nerve).

Superficial dissection

• The leg is externally rotated, stretching the sartorius muscle.
• The gap between the tensor fasciae latae and the sartorius is identified by palpation 2 to 3 inches below the anterior superior iliac spine.
• Dissect down through the subcutaneous fat along the intermuscular interval; avoid cutting the lateral femoral cutaneous nerve, which pierces the deep fascia of the thigh close to the intermuscular interval.
• Incise the deep fascia on the medial side of the tensor fascia latae.
• Retract the sartorius upward and medially and the tensor fascia latae downward and laterally.
• The iliac origin of the tensor fasciae latae is detached to develop the internervous plane.
• Ligate the large ascending branch of the lateral femoral circumflex artery, which crosses the gap between the two muscles below the anterior superior iliac spine.

Deep dissection

• Strip the gluteus medius muscle from its origin by blunt dissection
• Elevate the gluteus minimus muscle from the outer wing of the ilium and dissect as far posteriorly as necessary to expose the fracture.
• Perform a trochanteric osteotomy and elevate the gluteal mass from the outer surface of the pelvis to reveal the posterior column.
• The gluteus medius and minimus muscles are suspended by their neurovascular bundle (the superior gluteal nerve and artery), which is emerging through the greater sciatic notch. Be careful with this artery to avoid muscle necrosis: Ensure that the vessels are not put on a stretch for any period of time or thrombosis will occur.
• Expose the inner part of the iliac wing by detaching the origins of the abdominal muscles from the iliac crest and lift off the underlying iliacus muscle by blunt subperiosteal dissection. This allows you to access the area from the inner side of the pelvis to the sacroiliac joint.

Dangers

Lateral femoral cutaneous nerve (lateral cutaneous nerve of the thigh)

• The nerve must be preserved when the fascia between the sartorius and the tensor fasciae latae is incised.

Femoral nerve

• Lies anterior to the hip joint itself, within the femoral triangle. As the nerve is well medial to the rectus femoris, it is not in danger unless the dissection is carried far out of plane to the wrong side of the sartorius and the rectus femoris.
• During deep dissection, locate the femoral pulse by palpation within the femoral triangle; the artery lies medial to the nerve.

Ascending branch of the lateral femoral circumflex artery

• Running proximally in the internervous plane between the tensor fasciae latae and the sartorius. Ligate or coagulate it when separating the two muscles.

Superior gluteal artery and vein

• At risk where they emerge from the greater sciatic notch.

How to enlarge the approach

• Proximally, the approach cannot be extended .
• Distally, the skin incision may be extended along the lateral border of the thigh by splitting the underlying vastus lateralis. This allows access to the anterolateral aspect of the entire shaft of the femur.

Figures