Historical Development

Historically, open reduction and internal fixation of displaced acetabular fractures was performed using a few standard approaches:

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  Kocher-Langenbeck approach

  
  
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  Ilioinguinal approach

  
  
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  Extended iliofemoral approach

Several modifications were developed for special fracture situations. During the last two decades one relevant additional approach was introduced by the Helsinki group. Hirvensalo et al introduced the intrapelvic approach, which has been increasing in favor—with several modifications—since 1993.¹

For long time, the posterior Kocher-Langenbeck approach as well as the anterior ilioinguinal approach were used in the majority of patients.² These single-column approaches allow visualization of one acetabular column and their use is still favored.^3,​4

For more complex situations, in the 1980s and 1990s, extended approaches (extended iliofemoral approach according to Letournel,² its modification to Reinert⁵ [Baltimore approach], and the triradiate approach according to Mears⁶) were introduced. These approaches are presently rarely chosen due to the extensive soft tissue dissection and higher complication rates.⁷ Alternatively, the combination of an anterior and posterior standard approach was recommended,^8,​9,​10 having the disadvantage of longer operating time and increased blood loss without superior results compared to a single approach.

The Kocher-Langenbeck approach was the most frequently used approach for decades and was therefore regarded as the working horse.

A meta-analysis by Giannoudis et al stated that 48.7% of patients were treated using the Kocher-Langenbeck approach, followed by 21.9% treated with ilioinguinal approaches, and 12.4% were treated using extended approaches.¹¹ The main disadvantage of this analysis is that some fracture types were overrepresented, as an especially high number of reports included isolated posterior wall fractures and associated fracture types.

Analyzing only data from consecutive analyses^{2,​12,​13,​14,​15,​16,​17,​18,​19,​20,​21,​22,​23,​24,​25,​26,​27,​28,​29,​30,​31,​32,​33} the frequency shown in ▶ Table 7.1 represents are more realistic data set. A total of 3457 cases were evaluated. Posterior approaches were used in 52%, followed by anterior approaches in 25.9%, extended approaches in 14.7%, and combined anterior/posterior approaches in 5.5%.

More recent data from 2005–2007 showed that anterior approaches are now predominantly used according to a higher number of acetabular fractures with anterior column involvement, taking the large group of older patients into account. Data from the first German Multicenter Pelvis Study Group found a modified approach distribution (▶ Fig. 7.1), indicating that more than 40% of all patients with acetabular fractures are still treated via the Kocher-Langenbeck approach.³⁴ Thus, the Kocher-Langenbeck approach is still the working horse in approaching displaced acetabular fractures.

Recently, a more fracture type–dependent individual approach for stabilization of acetabular fractures is increasingly recommended.^3,​4 Various modifications of the Letournel approaches were developed together with several modifications of the intrapelvic approach.

The following modifications of the Kocher-Langenbeck approach were described:

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  Surgical hip dislocation with trochanteric flip osteotomy³⁵

  
  
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  Gluteus maximus split approach³⁶

  
  
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  Modified Gibson approach^37,​38

  
  
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  Modified Kocher-Langenbeck approach^39,​40

  
  
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  Modified two-portal Kocher-Langenbeck approach⁴¹

  
  
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  Modified Kocher-Langenbeck approach without detachment of the short external rotators^42,​43

In the modification of the Kocher-Langenbeck approach according to Magu, as well as with the two-portal variant according to Josten, the short external rotators were not detached from their insertion, allowing less muscular dissection.^{39,​40,​41}

The modified Gibson approach, reintroduced by Moed et al, allows for more extended access to the superior acetabular region,^37,​38 which is also easily achieved with surgical hip dislocation.^{35,​44,​45} The latter approach allows additional access to the anterior acetabulum and, therefore, the variant of surgical hip dislocation with trochanteric flip osteotomy as an extended Kocher-Langenbeck variant is a developing option.³⁵

Early anterior approaches to the acetabulum were the Smith-Peterson approach^46,​47 and the iliofemoral approach. Since the 1960s, the ilioinguinal approach and the extended iliofemoral approach were developed based on the work by Emile Letournel and Robert Judet.²

These approaches are primarily extrapelvic approaches with preparation and reduction from outside the acetabulum. The ilioinguinal was used as the standard anterior approach for the last 40 years.

In the early 1990s, Hirvensalo et al developed the intrapelvic approach in Finland.¹ One year later, a comparable approach was described in North America and named the Stoppa approach.⁴⁸ These approaches became increasingly popular in the last decade and various modifications have been described.

In order to reduce the invasiveness of the approach, the two-incision approach according to Ruchholtz^49,​50 and the pararectus approach according to Keel⁵¹ were introduced in the last years.

Ultimately, all of these approach the acetabulum, especially the region of the quadrilateral surface, from an intrapelvic view (true pelvis).

7.2 Choice of Approach

The choice of approach is primarily based on the fracture type, the time of osteosynthesis in relation to injury date, the extent of necessary exposure, and the reduction possibility.

In order to achieve optimal results, displaced acetabular fractures should be stabilized within 3 weeks after injury,² optimally within 1 week after trauma or as early as possible.

The detailed technique of operative approaches for acetabular fractures is sufficiently reported in various textbooks and publications.^{1,​2,​3,​4,​35,​44,​45,​48,​52,​53,​54,​55,​56,​57}

Thus, a brief summary of the standard approaches with discussion of their modifications as well as a description of their direct (visualization) and indirect (palpation) intraoperative exposures are described in this chapter.

7.2.1 Kocher-Langenbeck Approach

The Kocher-Langenbeck approach is still the working horse in many displaced acetabular fractures.⁵⁸

The Kocher-Langenbeck approach consists of two parts. In 1874 von Langenbeck described a longitudinal incision starting from above the greater sciatic notch to the greater trochanter, dissecting the gluteal muscles for treating hip joint infections.⁵⁹ Theodor Kocher in 1911 described a curved incision starting from the posteroinferior corner of the greater trochanter, running across the posterosuperior tip of the greater trochanter, passing oblique in line with the fibers of the gluteus maximus muscle in the direction of the posterior superior iliac spine.⁶⁰

The combination of these approaches, based on Letournel’s work, allow reduction of fractures in the posterior region of the acetabulum under direct visualization, but show an increased approach morbidity compared to the ilioinguinal approach.

Indications

Fractures with a predominant involvement of the posterior column area and many fractures with transverse fracture components are the most important fracture types for which the Kocher-Langenbeck approach is suitable⁵⁸:

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  Isolated fractures of the posterior wall

  
  
• 
  

  Isolated fractures of the posterior column

  
  
• 
  

  Associated fractures of the posterior column and wall

  
  
• 
  

  Fractures with additional posterior wall fragment(s) (transverse + posterior wall, T + posterior wall, both column + posterior wall)

  
  
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  Both-column fractures with multifragmentary posterior column involvement

  
  
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  Certain pure transverse and T-type fractures

Contraindications

According to the presented indications, this approach cannot be used in fractures with predominant anterior column/wall pathology. Therefore, the following fracture types are considered contraindications⁵⁸:

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  Isolated anterior wall fractures

  
  
• 
  

  Isolated anterior column fractures

  
  
• 
  

  Associated fractures with multifragmentary anterior column fractures

  
  
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  Certain acetabular fracture with a transverse fracture component

Exposure

The classical Kocher-Langenbeck approach allows direct visualization of the entire posterior column and wall and part of the supraacetabular region. Additionally, part of the inner surface of the true pelvis (quadrilateral surface) can be palpated through the suprapiriform foramen (▶ Fig. 7.2).

Additional surgical hip dislocation with a bigastric trochanteric osteotomy allows a near total exposure of the acetabular roof and near total direct visualization of the articular surface^{35,​44,​45} (see later).

Patient Positioning

The Kocher-Langenbeck approach can be performed in the prone position, usually using a fracture table, and in the standard lateral decubitus position (▶ Fig. 7.3) on a radiolucent table. Both positions should allow all necessary intraoperative views of the pelvis and acetabulum: anteroposterior (AP) view of the hip, iliac and obturator oblique views, lateral view, and combined oblique views.

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  Prone position: There are several advantages to using the prone position on a traction table. The femoral head is somehow reduced due to gravity and additional 90-degree knee flexion releases tension to the sciatic nerve. Additionally, in fractures with a transverse component, digital access to the quadrilateral surface is more easily achieved compared to the lateral position and interference by excessive abdominal pressure is avoided. The main disadvantage is the necessity of an unscrubbed assistant for intraoperative manipulation of the table and hip position.^58,​62

  
  
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  Standard lateral position: The main advantage to using the standard lateral position is the possibility of intraoperative change to surgical hip dislocation with trochanteric flip osteotomy, and easier mobilization of the entire leg. The reported possible disadvantages are that the femoral head pushes the fracture in a displaced position due to gravity, often requiring lateral traction of the femoral head and neck by using a Schanz screw, and a potential risk of sciatic nerve damage due to an incomplete extension of the hip joint together with only a slight flexion of the knee.^58,​62

In both the analyses, comparing these different patient positions, no advantages or disadvantages could be identified regarding quality of reduction.^62,​63 The prone position lead to a higher rate of postoperative infections and revision surgeries and, due to longer positioning times, a potential risk of nosocomial infection was proposed.⁶³

In our experience, the standard lateral position is preferred, as the main advantage is allowing a plan B to perform a surgical dislocation of the hip in selected fractures, which is impossible in the prone position.

Skin Incision

The skin incision in the fully extended hip starts just anterior to the posterior superior iliac spine in the direction of the tip of the greater trochanter and then following along the axis of the femur ending at the transition between the proximal and middle third of the thigh (▶ Fig. 7.3). The incision line is therefore a curved incision with anterior convexity. For surgical dislocation of the hip according to Ganz, no change of this incision is necessary.⁴⁴ When performing the skin incision in 45-degree hip flexion, a straighter incision is seen.

Superficial Dissection

After dissecting the subcutaneous tissue in line with the skin incision, the iliotibial tract distally and the fascia of the gluteus maximus muscle proximally are identified and split in line with the skin incision (▶ Fig. 7.4). Although the lateral thigh fascia is sharply incised, a blunt digital splitting of the gluteus maximus fascia is recommended. At the distal situs, the tendon of the gluteus maximus muscle is almost ever visible.

Deep Dissection

The aim of the first step during deep dissection is identification of the short external rotator muscles (piriformis, superior and inferior gemellus, obturatorius externus and internus, quadratus femoris muscles) and the course of the sciatic nerve.

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  The trochanteric area is often covered by parts of the trochanteric bursae. An area of hematoma is visible within this bursa and a partial bursectomy has to be performed in several cases.

  
  
• 
  

  The quadratus femoris muscle is easily identified at the lower wound area, as its muscle fibers typically run perpendicular to the axis of the femoral shaft. By palpating the muscle belly, the sciatic nerve can be identified or even visualized, as significant traumatic hematoma formation is not normally present in this area. During further dissection, the course of the sciatic nerve must always be known but a complete mobilization/dissection of the nerve is not recommended. Additionally, the hip should always be extended and knee flexion is recommended during the entire surgery to release tension to the sciatic nerve⁶⁴!

  
  
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  The most relevant step is now to identify the superior border of the quadratus femoris muscle. The terminal branch of the medial circumflex femoral artery (MCFA) must be identified. Its terminal anastomosis to anterior arterial vessels, the ramus trochantericus, is almost always visible^44,​65 and can be identified in the interval between the distal triceps coxae and the quadratus femoris muscle running to the tip of the greater trochanter (▶ Fig. 7.5). In the triangle between the triceps coxae and the quadratus femoris muscle, the obturatorius internus tendon is visualized on which the deep branch of the MCFA runs toward the capsular insertion of the femoral head–neck junction (▶ Fig. 7.6).

  
  
• 
  

  The third step is the identification of the triceps coxae muscle–tendon unit and piriformis tendon. After subtendinous and submuscular mobilization, about 1 cm away from their insertions, a sharp transection is performed (▶ Fig. 7.7) with blunt mobilization of these muscles from the underlying capsule in the direction of the posterior border of the posterior column. An anatomical landmark can often be prepared, where the obturator internus tendon enters the true pelvis just superior to the sciatic spine. Here, often a bursa is present and a blunt Hohman retractor can be inserted to protect the sciatic nerve together with the muscle bellies of the triceps coxae. Care has to be taken during this procedure not to violate the deep branch of the MCFA at the upper margin of the quadratus femoris muscle, as it is crucial for the femoral head vascularity. Thereafter, the piriformis muscle/tendon is dissected from the capsule and the complete posterior column and wall is now visible (▶ Fig. 7.8).

  
  
• 
  

  If required, a capsulotomy is performed and the fracture is visualized. The acetabular labrum should be protected.

  
  
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  Depending on the fracture type, in a fourth step, an extended dissection can be performed to the superior acetabular area with blunt dissection of parts of the gluteus medius and minimus muscle from the superior capsule and the supraacetabular periosteum.⁵⁸ Inserting a blunt Hohman retractor retracts these structures. Avoiding damage to these muscles can lead to a reduced rate of heterotopic ossifications.

  
  
  
  

  

  
  

  Fig. 7.5 Anatomy of deep exposure of the Kocher-Langenbeck approach. Ramus trochantericus at the posterior greater trochanter and at the upper margin of the quadratus femoris muscle (a), triceps coxae (b), sciatic nerve (c) and tendon of the obturator internus muscle (d).

  
  
  
  

  

  
  

  Fig. 7.6 Identification of the ramus profundus of the medial circumflex femoris artery on the obturator externus muscle tendon.

  
  
  
  

  

  
  

  Fig. 7.7 Dissection of the triceps coxae (a) and the piriformis (b), taking care of the ramus profundus of the medial circumflex femoral artery.

  
  
  
  

  

  
  

  Fig. 7.8 Exposure of the posterior hip joint capsule and the posterior column and submuscular preparation to the superior acetabulum region below the gluteus minimus muscle.

Surgical Hip Dislocation with Trochanteric Flip Osteotomy

Ganz and Siebenrock described the safe surgical hip dislocation technique based on the trochanteric flip osteotomy described by Mercati⁶⁶ as an enlargement of this approach to the superior, intraarticular, and anterior region of the acetabulum.^{35,​44,​45,​65} This enlargement can be performed after performing the Kocher-Langenbeck approach or, depending on the fracture type, using the Gibson approach, while protecting the short external rotator muscles.⁶⁷

Thus, the articular surface can be visualized completely and the supraacetabular region can be better exposed. Furthermore, fractures with a transverse component can more safely be reduced and fixed with an anterior column screw under direct visualization of the reduction and the implant position.

The first part of the approach of surgical hip dislocation is identical to the Kocher-Langenbeck approach in regard to the preparation and dissection of the greater trochanter, the short external rotators, the quadratus femoris muscle, and the sciatic nerve.

• 
  

  Originally, a straight trochanteric osteotomy was favored with a trochanteric bone chip (flip fragment) of a maximum width of 1.5 cm, starting just anterior to the origin of the vastus lateralis muscle and posterior to the fibers of the gluteus medius muscle (▶ Fig. 7.9). For easier and better reattachment, a Z-shaped osteotomy is now favored. It has to be noted that only few fibers of the piriformis tendon should be attached to the trochanteric flip fragment.

  
  
• 
  

  The vastus lateralis is mobilized together with the gluteus medius and the flip fragment anteriorly for visualization of the anterior and superior capsule (▶ Fig. 7.10). Now the interval between the upper border of the piriformis muscle and the dorsal-caudal edge of the gluteus minimus muscle has to be identified. Depending on the fracture type, the tendons of the triceps coxae and the piriformis muscle can be left intact. In acetabular fractures, dissection of these tendons is often necessary for better exposure of the posterior column. Mobilization of the gluteus minimus away from the capsule allows for a sufficient superior acetabular view. The anastomosis between the deep branch of the MCFA and the inferior gluteal artery at the lower border of the piriformis has to be protected.⁶⁵

  
  
• 
  

  By flexion and external rotation of the hip joint, the anterior capsule can be sufficiently exposed.⁴⁴ Capsular incision starts anterior at the femoral shaft, runs along the femoral neck axis to the acetabular rim, and then in a posterior direction parallel to the acetabular labrum under protection of the labrum (▶ Fig. 7.11, ▶ Fig. 7.12).

  
  
• 
  

  With external rotation of the hip, the femoral head can be dislocated posteriorly using a bone hook and the leg is positioned anteriorly in a prepared sterile bag (▶ Fig. 7.13). Insertion of appropriate retractors at the anterior and posterior acetabular rim and into the obturator foramen allows for complete visualization of the articular surface (▶ Fig. 7.14). Additional posterior traction of the femoral head and neck with a hook retractor increases articular visualization.

In contrast to the standard Kocher-Langenbeck approach, surgical hip dislocation with trochanteric osteotomy enables a significant enlargement of visualization and palpation of the entire hip joint (▶ Fig. 7.15).

Results

Approach-related results are rarely reported in the literature. The main disadvantages are inhomogeneous patient groups and different acetabular fracture populations. Some early results dealing with the Kocher-Langenbeck approach are reported by Letournel² and some recent results exist.^{55,​68,​69}

• 
  

  Detailed results on Kocher-Langenbeck–related complications were reported by Letournel.² He observed eight and six violations of superior gluteal artery and vein, respectively, and 20 postoperative hematomas (4.3%). Iatrogenic sciatic nerve injuries were found in 9.9% and the rate of deep infection after open reduction and internal fixation was reported to be 3.2%.

  
  
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  Rommens analyzed 60 consecutive patients with fractures of the posterior wall who were treated using the Kocher-Langenbeck approach.⁵⁵ The rate of postoperative sciatic nerve damage was 8.3%. A deep hematoma was observed in 3.3%, and an infection occurred in one patient (1.7%). Anatomical reduction was observed in 96.7%.

  
  
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  Briffa et al reported on results in 71 patients with different acetabular fractures treated using the Kocher-Langenbeck approach.⁶⁸ The rate of exact anatomical reconstructions was 70.4%, whereas 14.1% had near anatomical reductions and 15.5% had an imperfect reduction.

  
  
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  Tannast et al reported on Matta’s data in 352 patients with acetabular fractures using the Kocher-Langenbeck approach.⁶⁹ The average blood loss was 800 mL and the average operating time was 150 minutes. A total of 82% of these fractures had anatomical reconstructions, 15% near anatomical, and 3% imperfect reconstruction of their joint.

Current analyses compared the results using the Kocher-Langenbeck approach in the lateral decubitus position and the prone position.^62,​63

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  After osteosynthesis of 66 pure transverse fractures, five complications (7.6%) occurred.⁶² There were four infections (6.1%) and one temporary sciatic nerve lesion (1.5%). No difference in terms of type of positioning was noted. Anatomical reductions were observed in 60% performing surgery in the prone position in contrast to 40% in the lateral position. Duration of surgery and the estimated blood loss were comparable with approximately 260 minutes and 580 mL, respectively.

  
  
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  In contrast, another study showed no effect of type of positioning on the rate of anatomical reconstructions.⁶³ Overall, using the prone position, infections and the need of secondary surgical interventions were more frequent.

Results after using the technique of surgical hip dislocation with bigastric trochanteric osteotomy are increasingly reported.^{67,​70,​71,​72}

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  In an analysis of 18 patients with different fracture types, the overall operation time was 216 minutes and an estimated blood loss of 900 mL was reported.⁷⁰ In 77.8% an anatomical joint reconstruction was achieved, and an imperfect reduction did not occur in any case.

  
  
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  Results of the Bernese group in 60 patients with different fracture types showed a surgical time of 204 minutes at an estimated blood loss of 1556 mL.⁷¹ Four complications occurred (6.7%): one iatrogenic superior gluteal nerve damage, one loss of reduction, one fracture nonunion, and one nonunion of the trochanteric osteotomy. Overall, an anatomical joint reconstruction was achieved in 92.6% and in the remaining patients near anatomical reconstructions were observed.

  
  
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  Results focusing on specific fracture types (T-type fractures, pure transverse fractures, and associated transverse posterior wall fractures) showed minor anatomical reconstructions rates with 65% anatomical, 16% near anatomical, and 19% imperfect reconstructions.⁶⁷ The average operative time was 150 minutes and the mean blood loss was 1334 mL.

  
  
  
  

  
  

  Clinical Relevance

  
  

  
  

  Surgical hip luxation can optimize the rate of anatomical joint reconstructions in special fracture situations.

7.2.2 Ilioinguinal Approach

The ilioinguinal approach was one of the most commonly used standard approaches in the treatment of displaced acetabular fractures during the last decades.^2,​73

The main advantage is the reduced soft tissue detachment of periarticular muscles with only a small risk of developing heterotopic bone formation. In contrast, indirect joint visualization and therefore indirect fracture reconstruction makes this approach demanding.⁷⁴

Indications

Indications for this approach have been described in detail by Letournel.^2,​73 Fractures with major injury at the anterior column and wall area and fractures with a transverse component can be sufficiently treated using this approach. Accordingly, the following fractures types are accepted indications for using the ilioinguinal approach:

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  Isolated fractures of the anterior wall

  
  
• 
  

  Isolated fractures of the anterior column

  
  
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  Associated fractures of the anterior column posterior hemitransverse fractures

  
  
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  Both-column fractures with a single, large minor displaced posterior column fragment

  
  
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  Certain transverse and T-type fractures

Contraindications

In analogy to the mentioned indications, fractures with a main posterior pathology as well as intraarticular concomitant injuries that cannot be addressed indirectly (e.g., posterior marginal impactions) are better indications for a posterior approach. Therefore, the following fracture types are considered contraindications for the single use of the ilioinguinal approach²:

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  Isolated fractures of the posterior wall

  
  
• 
  

  Isolated fractures of the posterior column

  
  
• 
  

  Associated posterior column and posterior wall fractures

  
  
• 
  

  Associated fractures with an additional displaced posterior wall fragment

  
  
• 
  

  Fractures with significant posterior displacement, which cannot be reduced anteriorly

  
  
• 
  

  Fractures with posterior marginal impactions

Exposure

The classical ilioinguinal approach allows direct visualization of the iliac fossa, the more or less complete area of the terminal line/innominate line from the pubic symphysis to the sacroiliac (SI) joint, and includes parts of the quadrilateral surface. By palpation, parts of the posterior column can be indirectly felt in the area of the greater sciatic notch and at the quadrilateral surface. The outer side of the iliac wing is not routinely dissected (▶ Fig. 7.16). By modifying the classical approach, additional parts of the hemipelvis can be visualized^{48,​75,​76,​77,​78} (see later).

Patient Positioning

The standard position of the patient is the supine position on a radiolucent table thus allowing for standard X-rays (pelvic AP, Judet views, combined oblique pelvic ring and Judet views). Rotation of the patient around their long axis on the table should be possible.

Skin Incision

The landmarks for this incision are the iliac crest, the anterior superior iliac spine (ASIS), the inguinal ligament, and the pubic symphysis.

The classical skin incision starts slightly posterior to the apex of the iliac crest, then runs along the iliac crest, and turns anteriorly at the ASIS in line with the inguinal ligament up to the pubic symphysis about two fingers superior to the symphysis. Further preparation is going down to the fascia (▶ Fig. 7.17).

Modifications of this incision were reported by Ganz⁷⁷ with anterior preparation of the hip capsule. Here, a more L-shaped skin incision is selected (▶ Fig. 7.18).

Dissection

Deep dissection of the ilioinguinal approach is based on surgical development of three windows.

First Window

Dissection starts with the first window, which is identical to the anterolateral approach to the SI joint. Subcutaneous dissection is performed until identification of the junction between the external oblique muscle and the fascia of the gluteus maximus muscle, which is slightly lateral to the top of the iliac crest. Therefore, the fascial dissection starts from lateral to avoid transmuscular dissection.

The abdominal muscles are sharply separated from the iliac crest to get subperiosteal access to the iliac fossa. The iliopsoas muscle is subperiosteally detached from the iliac bone up to the terminal line and to the SI joint (▶ Fig. 7.19).

After evacuation of the fracture hematoma, dissection can be extended subperiosteally to the lateral shoulder of the sacrum thereby protecting the lumbosacral trunk. The iliopsoas muscle and the abdominal organs are held medially using long Langenbeck retractors. Blunt Hohmann retractors can be inserted medial to the terminal line and anterior to the SI joint to get digital and visible access to the anterior SI joint and parts of the posterior column. Sharp Hohmann retractors or K-wires can be inserted subperiosteally on the sacral shoulder for visualization of the SI joint, if necessary. Before performing further anterior dissection (second and third window), a tamponade of the iliac fossa is done with an abdominal cloth.⁷⁴

Clinically, the first window is necessary to address fracture lines reaching the iliac fossa and the iliac crest to perform stabilization of these fractures, mostly high extending anterior column fractures, according to the proximal-to-distal rule.⁷⁴

Second Window

The main principle of dissecting the second window of the ilioinguinal approach is opening the floor of the inguinal canal and its anterior and posterior walls. Subcutaneous dissection is performed until identification of the abdominal external oblique muscle.

The incision of the fascia of the external oblique muscle (anterior wall) is performed parallel to the inguinal ligament while sparing the superficial inguinal ring. Blunt dissection of the soft tissues from the inguinal ligament allows identification of the spermatic cord/teres uteri ligament together with the inguinal nerve. These latter structures are secured by mobilization and holding with a vessel loop (▶ Fig. 7.20).

Opening the floor and posterior wall of the inguinal canal is performed by incising the fascia of the transversus abdominis muscle and, after identification of the inguinal ligament, dissection of the ligament is performed leaving a small portion of the inguinal ligament intact to allow for easier later reattachment (▶ Fig. 7.20).

Now the muscular and vascular lacunae are presented. At the most lateral part of this part of incision, the lateral cutaneous femoral nerve can be identified and looped in the fatty tissue, typically medial to the anterior superior iliac spine. The arcus iliopectineus is identified at the medial border of the muscular lacuna. Directly lateral of the arcus iliopectineus, the femoral nerve can be visualized. In approximately 30-degree hip joint flexion, tension of the iliopsoas muscle and the femoral nerve is released and the arcus iliopectineus is easily visible.

Medial to the arcus iliopectineus, the iliac external vessels can be palpated and the vascular lacuna is opened by superficial incision. Blunt medial mobilization of the vessels is performed to identify the medial margin of the arcus iliopectineus, followed by dissection until reaching bone contact at the iliopectineal eminence.

By inserting two small Langenbeck retractors, the arcus iliopectineus is fully exposed. With a scissor, the arcus is then cut up to the iliopectineal eminence (▶ Fig. 7.21). The posterior fascia of the iliopsoas muscle is often already, at least partially, disrupted. Thus, further dissection of this fascia is not necessary. Sharp incision of the iliopectineal fascia on the superior ramus and the anterior acetabular wall is performed with a scalpel to reach the quadrilateral surface (▶ Fig. 7.22). With retraction of the iliopsoas laterally and the vessels medially, while flexing the hip, exposure to the superior and medial parts of the quadrilateral surface and anterosuperior parts of the acetabulum is achieved (▶ Fig. 7.23).

Overall, the second window allows for reduction of fractures of the quadrilateral surface and intermediate anterior column fracture lines. Reduction of the main anterior column displacement with the possibility of “pushing down” this fracture part is then possible. The main dissection of the second window is extrapelvic.

Third Window

If necessary, the third window medial to the vessels is opened. The interval between the lateral border of the rectus abdominis muscle and the vessels is bluntly dissected. Dissecting the rectus abdominis muscle is usually not necessary (▶ Fig. 7.24). The third window is useful to fix the often-used inguinal plate lateral to the pubic symphysis.

Modifications

Some modifications of the ilioinguinal approach allow for extended dissection and visualization of parts of the iliac bone, the superior pubic ramus, and the anterior hip joint. A total of three relevant extensions are reported in the literature.^{75,​76,​77}

Lateral Modification

Gorczyca et al and Weber et al reported a lateral extension to visualize parts of the outer ilium.^75,​79 A limited dissection of parts of the gluteus medius and minimus muscles is performed on the outer side of the ilium. This allows for a simpler reduction of high extending anterior column fractures by inserting long reduction forceps or if placement of a periacetabular cerclage osteosynthesis in high extending fractures of the posterior column is possible. With a more extended dissection it is possible to even stabilize fractures in the area of the acetabular roof by dorsomedial lag screws.

Pohlemann et al developed a cannulated instrument, based on a Cobb raspatory, for cerclage osteosynthesis to minimize the risk of damage to the gluteal neurovascular bundle.⁷⁸

Anterior Modification

In order to enable visualization of the entire anterior wall with additional possibility of intraarticular reduction control, the Bernese group of Ganz et al reported an anterior modification of the ilioinguinal approach.⁷⁷

Anterior dissection is performed according to the Smith-Petersen approach⁴⁶using a more L-shaped incision (see ▶ Fig. 7.18). After osteotomy of the anterior superior iliac spine, the pars directa of the rectus femoris muscle is detached at the anterior inferior iliac spine and retracted inferiorly and medially. Thus, the hip joint capsule can be fully exposed from anterior and the joint can be opened, if necessary (▶ Fig. 7.25). Typical fracture types for this modification are intermediate anterior column fractures and fractures of the anterior or anterosuperior wall. A similar modification was also reported by Pape et al.⁷⁸

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