Extended Iliofemoral Approach

Indication

The extended iliofemoral approach is usually only chosen when an anatomical reduction is judged likely to be impossible using either an ilioinguinal or Kocher-Langenbeck approach alone.

• Transtectal transverse or T-shaped fractures with or without involvement of the posterior wall especially in association with comminution of the roof of the acetabulum.

• T-shaped fractures with wide displacement of the vertical fracture line or with associated dislocation of
  the symphysis pubis.

• Both-column fractures with extension into the sacroiliac joint, comminution of the posterior column
  or wide separation of the anterior and posterior columns at the rim of the acetabulum.

• Associated patterns of fracture presenting more than 21 days after injury

Anatomy

Considerations

Prophylactic antibiotics

Positioning

Lateral decubitus position

Consider the use of the Judet table and the lateral traction post to aid reduction

Skin Incision

Incision starts at the posterior superior iliac spine, proceeds around the iliac crest to the anterior superior iliac spine and then continues anterolaterally down the thigh.

Superficial dissection

Incise the periosteum  along the crest,

Dissect and the gluteal muscles and tensor fascia lata from the external aspect of the iliac wing as far as the greater sciatic notch.

Incise fascia lata over the anterolateral thigh exposing tensor fascia lata which is retracted posteriorly.

Deep dissection

The fascial layers separating tensor from the rectus femoris and that separating rectus from vastus lateralis are then carefully incised longitudinally.

Identify and ligate the anterior femoral circumflex vessels.

Continue the dissection further posteriorly by elevating gluteus minimus off the hip capsule and releasing its tendinous insertion from the anterior aspect of the greater trochanter.

At this point identify and transect the tendon of gluteus medius midsubstance.

Alternatively, osteotomize the greater trochanter, taking care to exit posteriorly superficial to the piriformis fossa.

Identify the tendons of piriformis, obturator internus and the gemelli, tag, divide and retracted posteriorly.

Place retractors in the greater and lesser sciatic notches.

At this point, if necessary, the capsule of the hip could be incised circumferentially to allow access to the joint.

Exposure extension

The internal iliac fossa could be exposed by releasing the abdominal muscles from the iliac crest. Access to the anterior column could be obtained by releasing sartorius and the inguinal ligament from the anterior superior iliac spine and the direct head of rectus from the anterior inferior iliac spine.

Consider osteomy of ASIS to release inguinal ligament (pre drill, measure and tap prior to osteotomising ASIS)
 

Closure

Carefully suture the origin of the abductors to the lumbodorsal fascia and abdominal aponeurosis,
with the hip supported in abduction to reduce tension on the suture line.

Place interrupted sutures and after placement of all sutures in the origin of the abductors sequentially tie them.

Consider drains.

Protect the repair with an abduction pillow during transfer of the patient from the operating table to the hospital bed.

Post operatively

Mobilise toe touch/ light PWB weight bearing on the affected limb.
Instruct patient not to undertake active abduction exercises for four to six weeks.

Formal physiotherapy with muscle strengthening can be started at eight weeks after operation or when the fracture was radiologically united.

DVT prophylaxis

• TEDS

• LMWH initially

• Warfarinise post op for 6-12 weeks INR 1.5 - 2

Heteretopic ossification

• Consider Indomethacin

• Consider radiotherapy

Radiographs

• AP pelvis

• Judet views

References

Personal observations

Griffin, D. B.; Beaule, P. E.; Matta, J. M. Safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the acetabulum. Journal of Bone & Joint Surgery - British Volume. 87-B(10):1391-1396, October 2005.

Page created by: Lee Van Rensburg

Last updated 11/09/2015