Posterior approach to hip - Kocher Langenbeck

Indication

Posterior column pelvic fracture, Transverse and some T  fractures.

Posterior wall acetabular fracture.

Anatomy

Beware of:

• Sciatic nerve

• Superior gluteal nerve and vessels

Considerations

Keep knee flexed to keep tension off sciatic nerve

Consider Cell saver

Positioning

Lateral position (or prone)

(When draping expose more of buttocks than would for total hip replacement, extend wound more proximal.)

Skin Incision

Posterior superior iliac spine to tip of greater trochanter then down in line of femoral shaft.

Superficial dissection

In the same direction as the skin incision, split fascia lata and gluteus maximus in line of their fibres.

Partially release the fibres of gluteus maximus inserting distally into the femur

(Try avoid the underlying vessel, always bleeds)

Deep dissection

Identify posteriorly

• Sciatic nerve (May enter anteriorly, split or enter posterior to piriformis)

• Piriformis

• Short external rotators

• Quadratus femoris

Place stay sutures on and divide Piriformis and short external rotators, reflect to protect sciatic nerve.

(Leave a small cuff on the trochanter side to avoid interfering with the femoral head blood supply)

Elevate obturator internis to reveal posterior column down to Ischium.

Expose Ischium (Hamstrings insert onto ischium)

Beware superior gluteal nerve and artery at apex of incision exiting greater sciatic notch.

Insert Schantz screw into proximal lateral femur to control head. Allow distraction, inspection of hip and removal of loose fragments where indicated.

Insert Schantz screw into ischium to aid reduction of posterior column fractures when needed.

Reduce fractures and hold.

Posterior wall fragment, reduce and hold with lag screws (very oblique lag screws, easy to penetrate joint)

Support posterior wall with contoured recon plate across fracture at least 3 screws on either side.

(Beware putting screws in middle holes of plate viz hip joint penetration)

For posterior column fracture reduce and hold with 4.5 mm recon plate again at least three screws either side

Exposure extension

Consider trochanteric osteotomy.

Either:

• Simple trochanteric osteotomy

• Gantz sliding osteotomy

Closure

Post operatively

Consider Heterotopic ossification prophylaxis

• Indomethacin

• Radiotherapy

References

Fractures of the pelvis and acetabulum 2nd edition; Tile M

Personal observations

Page created by: Lee Van Rensburg

Last updated 11/09/2015