Surgical Approaches to Acetabulum and Pelvis

Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.

1. Surgical APPROACHes TO ACETABULUM and pelvis PRESENTER : DR. BIJAY MEHTA MODERATOR : DR. JANITH SINGH

2. CONTENTS Surgical Anatomy Choice of Approaches Anterior Approaches Posterior Approaches Extensile Approaches Summary

3. SURGICAL ANATOMY Bones Muscles Vessels Iliac Vessels Femoral Artery Superior /Inferior Gluteal Arteries Corona Mortis Inguinal Canal

4. SURGICAL ANATOMY Nerves Sciatic Nerve Femoral nerve Superior /Inferior Gluteal Nerve Obturator Nerve Lateral Femoral Cutaneous nerve of thigh

5. CHOICE OF APPROACH Depends on – Location of fracture Type of Fracture Complexity of Fracture Anterior Approach(usually ilioinguinal approach) used for: Anterior Wall Fracture Anterior Column Fracture Associated Anterior and Posterior Hemitransverse Fracture Associated Both Column Fracture

6. Posterior approach preferred for : Posterior Wall Fracture Posterior Column Fracture Posterior Column and posterior wall Fracture Posterior wall with Transverse Fracture For Transverse Fracture – If high- Iliinguinal Approach If low- posterior approach CHOICE OF APPROACH

7. ANTERIOR APPROACHES Ilioinguinal Approach Stoppa Approach Iliofemoral Approach

8. ILIOINGUINAL APPROACH Developed by Letornel in 1960 Allows exposure to- Entire Internal iliac fossa, and pelvic brim from SI joint to pubic symphysis Quadrilateral surface Anterior column and medial aspect of acetabulum superior and inferior pubic rami

9. ILIOINGUINAL APPROACH :INDICATIONS Anterior Wall Fracture Anterior Column Fracture Associated Anterior Column and Posterior Hemitransverse Fracture Associated Both Column Fracture Some T-type fracture Some transverse type fracture

10. ILIOINGUINAL APPROACH : POSITIONING Supine Foley Catheter Affected leg slightly flexed

11. ILIOINGUINAL APPROACH : INCISION Incision begun 3-4 cm above pubic symphysis Proceeds laterally to ASIS, then along 2/3 rd of iliac crest Extended beyond convex portion of ilium

12. ILIOINGUINAL APPROACH : SUPERFICIAL DISSECTION Dissect through subcutaneous fat in the line of the skin incision- external oblique aponeurosis exposed muscle. The lateral cutaneous nerve of the thigh will appear in the lateral edge of the dissection. In most cases, the nerve will need to be divided.

13. ILIOINGUINAL APPROACH : SUPERFICIAL DISSECTION External oblique aponeurosis divided from the superficial inguinal ring to the ASIS – unroofing of inguinal canal Ilioinguinal nerve isolated/protected spermatic cord/ round ligament isolated

14. ILIOINGUINAL APPROACH : DEEP DISSECTION R ectus abdominis muscle divided 1 cm proximal to its insertion into the symphysis pubis. Using blunt dissection , a plane between the back of the symphysis pubis and the bladder(the Cave of Retzius ) is developed .

15. ILIOINGUINAL APPROACH : DEEP DISSECTION Ligate and divide the inferior epigastric vessels. Complete the division of the muscular structures of the posterior wall of the inguinal canal . The peritoneum covered with extraperitoneal fat is now exposed.

16. ILIOINGUINAL APPROACH : DEEP DISSECTION Using a swab, push the peritoneum upwards to reveal the femoral vessels,femoral nerve and iliopsoas . Isolate the femoral vessels along with sheath and protected in a sling. Strip the iliacus muscle from the inner aspect of the ilium.

17. ILIOINGUINAL APPROACH : DEEP DISSECTION Continue stripping off the iliacus from the inner wall of the ilium to reveal the sacroiliac joint. Incise the iliopectineal fascia upto bone. Retract the iliopsoas and the femoral sheath either medially or laterally to reveal the medial surface of the acetabulum, the superior pubic ramus, and the inner surface of the ilium round to the sacroiliac joint.

18. ILIOINGUINAL APPROACH : DEEP DISSECTION Three windows are created. The lateral window , lateral to the iliopsoas gives access to the inner surface of the ilium The middle window , medial to the iliopsoas but lateral to the femoral artery and vein gives access to the quadrilateral plate. The medial window , medial to the femoral artery and vein gives assess to the superior pubic ramus and symphysis

19. ILIOINGUINAL APPROACH : CLOSURE Drain – placed in Space of Retzius Tendons repaired Transversalis fascia and conjoined tendon of internal oblique and transversus abdominis attached to inguinal ligament External oblique aponeurosis repaired

20. ILIOINGUINAL APPROACH : DANGERS Femoral Nerve Femoral and External iliac arteries Lateral Cutaneous Nerve of thigh Inferior Epigastric vessels Spermatic Cord

21. ANTERIOR APPROACH : MODIFIED STOPPA Anterior Intrapelvic Approach First described by Rene Stoppa for hernia repair in 1975 . Revised for pelvic and acetabular surgery by Hirvensalo et al in 1993. “Modified Stoppa ” was described in 1994 by Cole and Bohofner . Advantages : entire anterior column including quadrilateral plate could be visualized when supplemented with a lateral window

22. STOPPA’S APPROACH :INDICATIONS Anterior Wall Fracture Anterior Column Fracture Associated Anterior Column and Posterior Hemitransverse Fracture Associated Both Column Fracture Fractures involving quadrilateral plate

23. STOPPA’S APPROACH: POSITIONING Patient- Supine , radiolucent table Surgeon – on opposite side Bolster placed beneath the knee Foley catheter placed

24. STOPPA’S APPROACH: SKIN INCISION Pfannensteil Incision placed just above the pubic symphysis . Extended laterally on both sides

25. STOPPA’S APPROACH: SUPERFICIAL DISSECTION Divide the subcutaneous tissues in line with the skin incision in order to expose the fascia overlying both rectus muscles of the abdomen.

26. STOPPA’S APPROACH: DEEP DISSECTION The rectus fascia is incised longitudinally along the linea alba and muscle bellies are retracted laterally. In the proximal part of the incision, care should be taken not to incise the peritoneum.

27. STOPPA’S APPROACH: DEEP DISSECTION The medial part of the rectus muscle is partly detached from symphysis to allow the rectus to retract. The upper border of the superior pubic ramus is identified ( pecten pubis) and blunt dissection using a finger or swab is carried laterally along the pelvic brim without yet incising the fascia.

28. STOPPA’S APPROACH: DEEP DISSECTION Exposing carefully along the medial surface of the superior ramus, the corona mortis vessels are identified and ligated (or clipped) as necessary. The vessels sit above the fascia and are most easily identified if the fascia is not incised prior to ligation.

29. STOPPA’S APPROACH: DEEP DISSECTION Then, the thick periosteum from the superior pubic bone is dissected sharply using diathermy, allowing for deeper blunt dissection. Dissection is continued laterally upto the beginning of the iliopectineal eminence.

30. STOPPA’S APPROACH: DEEP DISSECTION Beginning of the iliopectineal arch should be dissected from the bone and femoral vessels and nerve are elevated. The dissection is continued subperiosteally more laterally following the upper border of the pelvic brim- entire internal surface of the superior pubic ramus is exposed .

31. STOPPA’S APPROACH: DEEP DISSECTION With a Cobb elevator, the periosteum and obturator internus are elevated and the quadrilateral surface can be sufficiently exposed .

32. STOPPA’S APPROACH: ADDITION OF LATERAL WINDDOW An incision is made along the iliac crest. The incision can be extended intraoperatively depending on the necessary exposure. For fractures involving the posterior aspect of the ilium, or the SI joint, the exposure needs to be extended posteriorly almost to the table.

33. Divide the subcutaneous tissues and expose the fascia overlying the external oblique muscle. Identify the border between the gluteus muscles and external oblique muscles. Incise the muscular interval with electrocautery . The external oblique muscle is subperiosteally elevated from the iliac crest. With a small elevator, the iliac muscles are elevated using the same subperiosteal layer. STOPPA’S APPROACH: ADDITION OF LATERAL WINDDOW

34. When elevating the iliacus muscle, bleeding from nutrient vessels can occur and should be stopped with bone wax. Continue with careful blunt dissection to the interior part of the SI joint medially to the pelvic ring. Proceed anteromedially at the pelvic rim as far as to where the iliopectineal eminence begins. STOPPA’S APPROACH: ADDITION OF LATERAL WINDDOW

35. Continue the dissection with an instrument such as a Cobb elevator. The SI joint capsule should be identified. Place a Hohmann retractor into the superior portion of the SI joint . STOPPA’S APPROACH: ADDITION OF LATERAL WINDDOW

36. STOPPA’S APPROACH: WOUND CLOSURE Place drain as needed The midline incision in the rectus abdominis and superficial tissues are closed in layers taking care to protect the underlying bladder and peritoneum. The lateral window is also closed in layers reconstructing the fascial layer preserved in the approach.

37. STOPPA’S APPROACH : DANGERS Obturator Nerve Injury External and Internal iliac arteries Superior Gluteal Vessels Corona Mortis Urinary Bladder

38. POSTERIOR APPROACHES : KOCHER LAGENBECK APPROACH Gives access to posterior wall and posterior column If trochanteric osteotomy, surgical dislocation of hip is used, anterior wall can also be visualized Indications: Posterior Wall Fracture Posterior Column Fracture Posterior Column and posterior wall Fracture Posterior wall with Transverse Fracture Some T-type Fractures

39. KOCHER LAGENBECK APPROACH : POSITIONING Either Prone or Lateral Position Knee Flexed to reduce tension on sciatic nerve

40. Landmarks : Posterior superior iliac spine Greater trochanter Shaft of femur Skin incision started a few centimeters distal and lateral to the PSIS. Continued over the greater trochanter. KOCHER LAGENBECK APPROACH : SKIN INCISION Curved distally along the tip of the greater trochanter towards the lateral aspect of the femoral shaft upto midthigh.

41. Fascia lata is incised in line with the skin incision. Incision extended superiorly along the anterior border of the gluteus maximus muscle for a distance of no more than 7 cm , branch of the inferior gluteal nerve is protected. KOCHER LAGENBECK APPROACH : SUPERFICIAL DISSECTION

42. Split the gluteus maximus in line with its fibers. In the distal half, incise the iliotibial tract in line with its fibers up to the mid third of the thigh. KOCHER LAGENBECK APPROACH : SUPERFICIAL DISSECTION

43. Layer of fat is removed and short external rotators are visualized. The sciatic nerve is visualized. It lies posterior to the gemelli and internal obturator muscles, and anterior to the piriformis muscle, between the greater trochanter and the ischial tuberosity . KOCHER LAGENBECK APPROACH : DEEP DISSECTION

44. Piriformis tendon is isolated and a suture is placed 1 cm lateral to its femoral insertion and tendon is dissected. Reflect the piriformis belly laterally to expose the retroacetabular surface to the greater sciatic notch . Avoid cutting quadratus femoris KOCHER LAGENBECK APPROACH : DEEP DISSECTION

45. Conjoined tendon of the obturator internus and superior and inferior gemelli muscles are isolated and tagged and incised 1 cm lateral from their femoral insertions to protect the medial circumflex femoral artery. Reflect the muscle bellies of the three conjoined muscles laterally to access the lesser sciatic notch . KOCHER LAGENBECK APPROACH : DEEP DISSECTION

46. Greater sciatic notch, the ischial spine, and the lesser sciatic notch are visualized. Insert a retractor in the lesser sciatic notch and one anterosuperiorly in the direction of the anterior inferior spine. Now the posterior column is visible in its whole extent. KOCHER LAGENBECK APPROACH : DEEP DISSECTION

47. KOCHER LAGENBECK APPROACH : DEEP DISSECTION Trochanteric Flip Osteotomy T-shaped Capsulotomy

48. POSTERIOR APPROACH

49. Meticulous debridement done before closure. All tendons are reinserted and split parts of the gluteus maximus are approximated with adaptation sutures. Perform the closure of the iliotibial tract, the subcutis and the skin . KOCHER LAGENBECK APPROACH : CLOSURE

50. Skin and superficial dissection same as Kocher Lagenbeck approach Instead of splitting the fibres of gluteus maximus , interval is made anterior to gluteus maximus b/w Gluteus maximus and medius Others same as KL approach POSTERIOR APPROACHES : MODIFIED GIBSON’S APPROACH

51. Sciatic Nerve Injury Infection Heterotrophic Ossification – debride non viable muscles Superficial Gluteal Artery Injury Medial Circumflex Femoral Artery Injury KOCHER LAGENBECK APPROACH : COMPLICATIONS

52. EXTENSILE APPROACHES EXTENSILE ILIOFEMORAL APPROACH LETOURNEL AND JUDET REINERT ET AL TRIRADIATE EXTENSILE APPROACH MEARS AND RUBASH

53. EXTENSILE ILIOFEMORAL APPROACH Indications : Transtectal transverse fracture with roof impaction      Transverse with posterior wall fractures T-type fractures, especially with posterior wall involvement Both-column fractures with posterior wall or posterior column comminution Delayed fixation of both column, t-type, or transverse + posterior wall fractures (typically > 3 weeks) Malunion /nonunion/deformity correction surgeries

54. EXTENSILE ILIOFEMORAL APPROACH

55. EXTENSILE ILIOFEMORAL APPROACH

56. EXTENSILE ILIOFEMORAL APPROACH

57. EXTENSILE ILIOFEMORAL APPROACH

58. OTHER APPROACHES Ilium Pubic Symphysis - Pfannensteil Sacroiliac Joint- Anterior- Avila Posterior Both SI Joint- Mears and Rubash

59. SUMMARY Complex Injury Anterior, Posterior or Extensile Approaches Knowledge of Anatomy is must Neurovascular structures should be preserved.

60. REFERENCES Campbell’s Operative Orthopaedics , 13 th Edition Surgical Exposures in Orthopaedics , Hoppenfield , 5 th Edition AO Foundation Surgery Reference

61. THANK YOU