- See:
Watson Jones Approach:
- Discussion:
- frx of
anterior column & some anterior column-posterior hemitransverse frx are approached using ilioinguinal approach;
- ilioinguinal approach can give simultaneous access to both anterior & posterior portions of the pelvic ring;
- medial portion of this approach gives access to symphysis pubis and superior pubic ramus;
- if needed,
sacroiliac joint & iliac fossa can be exposed thru this approach;
-
superior ramus frx:
- ilioinguinal approach allows control of iliac vessels and branches, and allows safe access to the superior ramus and symphysis pubis;
-
both column frx:
- may also be used for
both column frx w/ large single posterior fragment, w/ reduction being achieved indirectly
through reduction of the quadrilateral plate;
- in both column frx with displacement of the posterior column and extensile approach is needed;
- consider making a T extension which follows plane of
iliofemoral approach between
tensor fascia lata &
sartorius;
-
disadvantages:
- ilioinginal approach does not allow intra articular visualization of hip;
- if articular visualization is needed make a T extension of incision just medial to ASIS to
allow exposure of hip joint anteriorly;
- T extension follows plane of
iliofemoral approach between
tensor fascia lata &
sartorius;
- PreOp Planning and Positioning:
- a nerve stimualtor may be useful to identify the femoral nerve;
- bladder:
- is separated from pubic bones by a space known as Cave of Retzius
- w/ fracture or prior surgery, there may be adhesions in this area, placing this structure at risk for perforation;
- full bladder will make safe access to this area impossible, and a urinary catheter inserted preoperatively is vital;
- reduction:
- at least two surgical assistants will be required for traction and retraction, otherwise consider
intraoperative traction w/ a
distal femoral pin;
- it is helpful to have a perineal post for countertraction;
- lateral traction can be effected by insertion of a half pin into the greater trochanter;
- for reduction of either
SI joint dislocations or for fixation of
iliac wing frx, it is not necessary to complete middle portion of exposure
unless acetabular reduction & fixation are required;
- references:
Simple intraoperative traction system for acetabular surgery. M Vrahas and JS Reid. Orthop Rev. Vol 23(12) Dec 1994. p 962.
- Incision:
- w/ the standard exposure, the patient is supine w/ a bump under the hip;
- w/ the extended exposure, the patient starts out in the 45 deg oblique position for the ilioinguinal
portion of the exposure, and the table is tilted inorder to expose the posterior crest;
- incision begins along lateral aspect of iliac crest & extends forward over the ASIS, and extends then directly to
symphysis pubis (or just above it);
- note that extended exposure involves a continuation of posterior incision extending from posterior iliac crest inferiorly over PSIS;
- dissection proceeds thru the superficial fascia of the external oblique and the rectus abdominus muscles;
- the inguinal canal is unroofed, which exposes the spermatic cord, which contains the vans deferens (round ligament), and the
ilioinguinal nerve;
- these structures are tagged w/ a rubber penrose drain;
- the femoral neurovascular bundle and the lateral femoral cutaneous nerve are identified;
- a incision is made along the inguinal ligament (in line w/ its fibers), which allows the attached abdominal muscles to be retracted superiorly;
-
lateral window:
- provides access to the iliac fossa and anterior sacroiliac joint;
- identify the demarcation between the abdominal muscles and the
gluteus medius muscle to the iliac crest;
- use cautery to incise thru this demarcation, and then subperiosteally elevate the attachments of the iliacus and abdominal muscles off of the
crest and inner iliac table;
- carry this subperiosteal elevation from the SI joint to the ASIS;
- anterior sacroiliac joint and pelvic brim should be clearly visualized;
- flexing the knee and flexing and externally rotating the hip takes tension off the iliopsoas and improves the exposure;
-
middle window:
- this window allows exposure from ASIS to the pectineal eminence, including quadrilateral plate;
- identify and protect the
psoas muscle,
lateral femoral cutaneous nerve, and the
femoral nerve;
- a penrose drain is passed around all three structures;
- incise the attachements of the inguinal ligament and
sartorius from the ASIS;
- these structures will need to be securely reattached at the end of the case;
- pass a penrose drain around these structures for later indentification;
- by retracting iliopsoas medially, iliac crest can be identified;
- by reflecting the iliopsoas laterally and the vessels medially, quadrilateral plate can be reached;
- iliopectineal fascia:
- iliopectineal fascia separates the middle and medial windows (ie it is the layear of fascia which
divides the iliopsoas and femoral nerve from the
femoral artery and vein;
- lateral wall of the iliopectineal fascia is identified just medial to the iliopsoas muscle;
- this fascia layer needs to be incised down to the iliopectineal eminence;
- prior to incising the fascia, ensure that:
- psoas muscle and femoral nerve are identified and protected with a rubber drain;
- the external iliac artery and vein are identified as a unit and are protected with a rubber drain;
- attempt to locate
obturator nerve and artery (either medial or lateral to
femoral vessels
as they enter the obturator foramen), and attempt to locate an anomalous origin of the
obturator artery (corona mortis) from the external iliac system;
-
medial window
- to reach symphysis pubis, recutus abdominis sheath is divided, & muscles are removed from their insertion onto the symphysis;
- this also gives additional access to the retropubic space and quadrilateral plate.
- exposure of pubic rami stays medial to femoral artery and vein;
- inguinal canal and ligament;
- external ring: the entrance to the inguinal canal is formed by decussating fibers of the external oblique muscle and fascia;
- spermatic cord (or round ligament) is located at the external ring;
- external oblique aponeurosis is incised 1-2 cm superior to the external ring (over the inguinal canal), but the ring itself is left intact;
- lateral femoral cutaneous nerve has already be identified;
- a knife is used to incise the inguinal ligament along its course from the pubis to the ASIS, which gives access to the
the retropubic space and the iliac vessels;
- take care not to injure the obturator nerve as it passes underneath the superior ramus;
- ref:
Transsection of the rectus abdominis muscle in the treatment of acetabular frx: operative technique and outcome in 21 patients.
-
corona mortis
- refers to retropubic vascular communication between either the external iliac (or deep epigastric vessels) and the
obturator artery;
- the medial window is used to identify any possible communication between the
obturator system and the external iliac or
inferior epigastric system (instead of the internal iliac artery);
- these anomalous vessels occur in about 10-30 % of patients;
- it is typically located about 3 cm from the symphysis pubis;
- carefully dissect both lateral and posterior to the external iliac vessels to look for any anomolous vessels prior
to medial vessel retraction (which might avulse any anomalous vessels between these systems);
- if an an anamalous branch is present, then it needs to be ligated to prevent bleeding from this vessel, which
is difficult to control if it retracts into the pelvis;
- references:
-
Corona mortis: incidence and location
-
Retropubic vascular hazards of the ilioinguinal exposure: a cadaveric and clinical study.
-
The incidence and location of corona mortis: a study on 75 cadavers.
-
extended approach:
- may be used for
both column fractures which extend posteriorly to involve the SI joint or the sacral buttress;
- an advantage of the extended exposure is that the anterior circumflex artery is left intact, and inaddition this exposure
may be performed even in the presence of a Morel Lavale lesion;
- the anterior portion of the incision is identical to the standard ilioinguinal approach;
- the extended portion of the incision involves carrying the incision along the iliac crest to the posterior superior iliac spine;
- the incision is then carried straight inferiorly inorder to expose the SI joint;
- posteriorly the incision is carried down to the gluteus fascia, which is then incised in line w/ the incision;
- subperiosteal dissection is then used to elevate the fracture;
- Hazards and Complications:
-
corona mortis
- refers to retropubic vascular communication between either the external iliac (or deep epigastric vessels) and the
obturator
vessels which can occur in 10-15%;
- 73% of patients will have at least one vascular connection along the posterior aspect of the superior ramus which connects the superfical system with the obturator system;
- rectus abdominis necrosis:
- may occur in patients who have undergone previous ipsilateral transrectus abdominal exposure;
-
inguinal hernia: may result from improper repair of the inguinal ligament;
The extended ilioinguinal approach for specific both column fractures.
TG Weber MD, JW Mast MD. CORR No 305. 1994. p 106-111.
The treatment of acetabular fractures through the ilioinguinal approach.
Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective.
Retropubic Vascular Hazards of the Ilioinguinal Exposure: A Cadaveric and Clinical Study.
D.C. Teague, D.O. Graney, and M.L. Chip Routt Jr. Journal of Orthopaedic Trauma Vol. 10, No. 3, pp. 156-159.
Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results.
Cole JD, Bolhofner BR: Clin Orthop 305:112-123, 1994
Necrosis of the rectus abdominis muscle. Complication after ilioinguinal approach.
V Heppert et al. Unfallchirurg. Vol 98(2) 1995 Feb. p 98-101.
Management of acute displaced acetabular fractures using indirect reduction techniques and limited approaches.
DL Helfet and GJ Schmeling. CORR. Vol 305. 1994. p 58-64.
Modification of the ilioinguinal approach.
Complications Following the "T Extensile" Approach: A Modified Extensile Approach for Acetabular Fracture Surgery-Report of Forty-three Patients.
The Modified Ilioinguinal Approach.
Operative Treatment of Acetabular Fractures Through the Ilioinguinal Approach: A 10-Year Perspective.
Internal fracture fixation using the stoppa approach in pelvic ring and acetabular fractures: technical aspects and operative results.
Transsection of the rectus abdominis muscle in the treatment of acetabular fractures: operative technique and outcome in 21 patients.
Minimally invasive ilioinguinal approach to the acetabulum.
