Kocher-Langenbeck acetabular approach

Posterior approach acetabulum. fixation tricks , tips

1. Kocker-Langenbeck approach Ihab El-Desouky (M.D.) Asst. Prof. Pelvis and joints Reconstruction unit Member of A.A.H.K.S.

2. Kocker-Langenbeck approach Learning outcomes: Historical Development of the approach Indications: Preoperative precautions Surgical Anatomy Classic steps Modifications: Complications

3. Kocher- Langebeck Approach Working horse! Equally with ilioinguinal approach (40 % ) Single column Many modifications were added -Trochanteric osteotomy -Gluteus maximus dissection plane -External rotators preservation

4. Historical Development 1-Von Langenbeck In 1874 described his “longitudinal incision for hip infections“ "from above the sciatic notch to the middle of the greater trochanter passing between the bundles of the gluteal maximus muscle“ Von Langenbeck (1810-1887)

5. 2-Theodor Kocher (1841-1917) In 1911 described the caudal extension of Langenbeck’s approach "The incision is curved, over femoral shaft, the base of the great trochanter upwards obliquely and backwards in the direction of the gluteus maximus" Theodor Kocher (1841-1917)

6. 3-Judet et al (1958) have combined these two classical posterior incisions, gaining the advantages offered by each. Since 1960,Letournel et al called it the Kocher-Langenbeck approach.

7. Indications: FRACTURE PATTERN DETERMINES APPROACH - Posterior wall -Posterior column -Posterior wall &column -Transverse with posterior wall -Transverse with major displacement at the posterior column ( juxtatectal and infratectal ). - Posterior elements in T-type

8. at the level of the roof (Transtectal) of the acetabulum (therefore involving the weightbearing area ) Either sequential ilioinguinal then Kocher-Langenbeck Or Kocher Langenbeck with trochanteric osteotomy

9. Access: Visible (including released Q femoris Palpable After Trochanteric osteotomy 360 ° acetabulum (Ganz)

10. Preoperative preparation: Surgery 3 to 5 days after injury. • Review the patient ’ s general condition, limb N/V status • blood transfusion. • Review the imaging studies (anteroposterior pelvic and Judet views and CT. • Operating table, instruments, and implants. Retractors, Clamps , Forceps, Pusher. 3.5-mm screws and 3.5-mm reconstruction plates 1/3 tubular , mini-screws (2mm

11. Soft tissue Retractors Hohmann Sciatic nerve (or Deever ) Cobra Taylor (gluteal muscles) Schanz pins Sciatic n. retractor in the lesser notch

12. Reduction tools: Jaw clamps of Matta (ball tipped- pointed) (standard & offset) Schanz pins Weber pointed clamp . Jungbluth reduction clamp. Large King Tong forceps ball-tipped; Ball-spiked pusher; spiked disc Farabeuf reduction forceps ; and Serrated reduction forceps

13. Jungbluth clamp with 2 screws technique Ball spike pusher with spiked disc for comminuted bone

14. Positioning : Prone or lateral Prone: -Femoral head in reduced position (gravity helps reduction of transerve fracture) -90 o knee flexion places the sciatic nerve in a relaxed position -allows digital access to the quadrilateral surface (transverse or T type fractures)

15. Prone Position: Disadvantages -Un-scrubbed assistant is required for intraoperative adjustment of the table -Not allowing extension by trochanteric osteotomy -Muscular or high BMI --- heavy posterior flap -Disorientation of the surgeon --Special padding fo the chest and bony prominence

16. So Lateral positioning Easy maneuverability of the limb Allow trochanteric flip osteotomy Muscular and high BMI But: Femoral head displaces fragments Folded sterile towels allow for femoral head subluxation -Incomplete hip extension and knee flexion—higher sciatic palsy

17. In Both positions Keep the hip slightly extended and knee flexed 90 ° Sciatic palsy reduced from 18% to 5% c a d a v e r

18. No advantage to either position for the posterior approach could be found With equivalent radiologic outcomes between both groups, a significantly higher rate of infection (p 0.017) were found in the prone group

19. Residual fracture displacement with transverse fractures reduced and stabilized in the lateral position compared with those positioned prone .

20. Transverse with posterior wall fracture

21. Kocher- Langenbeck Approach (prone) Steps Surface landmarks and incision planning Skin incision Fascia lata & gluteal fascia Gluteus maximus dissection Trochanteric bursa Gluteus maximus insertion release Identification of the sciatic nerve Gluteus medius retraction Pyriformis muscle identification & release Re-identification of the sciatic nerve course Obturator internus and gemelli release Lesser notch retractor Fracture reduction and fixation Muscle debridement and closure

22. Kocher- Langenbeck Approach(prone) Prone with flexed knee on a radiolucent table C-ram opposite side of the surgeon Imaging of A/P and Judet views Inlet and outlet views freely

23. Surface Landmarks: PSIS (posterior superior iliac spine) G. Trochanter F. Shaft Skin incision: -6-8 cm form PSIS -Tip of GT -Centre of GT -Centre of femoral shaft

24. Fascial incision -Start the dissection of gluteal maximus and its fascia using scissors then separate the muscle fibers with fingers -Iliotibial tract is dissected using scalpel

25. Gluteus maximum splitting - posterior 2/3 muscle belly (inferior gluteal artery), - anterior 1/3 belly (superior gluteal Artery Inferior gluteal bundle is the limit

26. Trochanteric bursa: Free the covering layer over the rotators Visualization of the sciatic nerve carefully

27. Gluteus maximus insertion release Detach the gluteus maximus 1.5 cm from its insertion into the gluteal tuberosity of the femur. less tension and easier mobilization A constant perforator should be cauterized

28. Identification of the sciatic nerve Rotators damage in posterior dislocation Identified at the quadratus femoris No tension or compression is applied Define the upper border of Q femoris Quadratus

29. Identification of the pyriformis muscle Retract the gluteus Medius tendon at the G trochanter limited by Superior gluteal bundle Beneath it lie both the G minimus (HO) , and rounded pyriformis tendon. G Medius G minimus Pyriformis

30. Pyriformis tendon should be tagged and incised 1.5 cm from its insertion Avoid injury of Medial Circumflex femoral Artery (MCFA)

31. Blood supply of the femoral head Deep branch of MCFA Can be injured : -Detachment of the Q femoris (femoral side) -Detachment of pyriformis or Obturator Int less than 1.5 cm

32. Re-Identification of the sciatic nerve (SN) course: (relation to Pyriformis ) 84% deep to the muscle (anterior) Trace the nerve till the G notch

33. Variation of S nerve course (Common Peroneal CPN-Tibial TN) 84% 12% 3% 1%

34. Sciatic nerve variation: 12% CPN pierces 3% CPN superficial very rare

35. Release of obturator internus and gemelli: Double tag of the muscles and release 1.5 cm form attachment

36. Sciatic nerve retractor (lesser notch) Reflect the obturator internus till the lesser notch and insert the retractor Feel Q plate

37. Posterior column exposure Clear the obturator internus fascia

38. Tips for fractures reduction and Fixation: -Subperiosteal elevation of Obturator internus fascia, Quadrilateral plate , Gluteus minimus (HO) -Carefully debride the fragment edges.(reduction) -Never devitalize the soft tissue attachment (capsular attachment)– AVN of the posterior wall

39. Kocher- Langenbeck Approach Prone Tips for fractures reduction and Fixation:

40. 2cm

41. O bturator O utlet I liac I nlet

42. Apply interfragmentary wall screws Double plates for the column Check intra-articular position in all views

43. Wound closure Meticulous debridement Remove necrotic tissue (G minimus) and irrigate the entire wound suction drains Reinsert all tendons and approximate the split parts of the gluteus maximus closure of the iliotibial tract

44. Modifications: 1-Trochanteric flip osteotomy: -Supraacetabular region with superior wall fragment -Femoral head fracture with surgical dislocation -Anterior column screw – transtectal transverse Lateral approach Single sheath including V lateralis, G Medius 1.5 cm

45. Kocher- Langenbeck Approach

46. For superior wall segment (extended posterior wall) screws :parallel to joint , plate , spring

47. Transtectal transverse fractures

48. Anterior column screw after trochanteric osteotomy: 4 cm above the acetabulum just posterior to anterior gluteal line In line with center of reduced hip (12 O’clock) ( Ob Outlet, IL Inlet)

49. Complications: 1-Sciatic Nerve Palsy; 3-5% -Always flex knee 90 ° -Proper identification -Expect variations -Intermittent retraction -Never two retractors in both notches

50. 2- Infection 2-5% 3-Heterotopic ossification: necrotic G minimus 10% 4-Superior gluteal artery bleeding: 4- Post-traumatic OA : 17% 5-AVN: 7.5%

51. Take Home Message Kocher –Langenbeck -Non extensile (use trochanteric osteotomy) -Posterior fractures -Prone is better except in some situations -Special instruments -Meticulous exposure and identification -Tips for reduction and fixation

52. FURTHER READING