Review Question - QID 213094

The extended iliofemoral approach to the acetabulum is associated with the highest risk of heterotopic ossification (HO) compared to the other pelvic approaches.

Heterotopic ossification (HO) is a common complication after the surgical management of acetabular fractures, occurring in approximately 7-100% of patients. Significant discomfort, stiffness, and poor functional outcomes are seen in some patients with HO. The etiology is multifactorial, and the surgical approach is an important factor. The incidence of HO has been found to be low with the ilioinguinal and anterior intrapelvic (Stoppa) approaches, intermediate with the Kocher-Langenbeck approach, and high with the extended iliofemoral approach. Debridement of a contused gluteus minimus may help to prevent the formation of HO.

Firoozabadi et al. performed a review to determine risk factors for the development of HO after acetabular fracture fixation through an isolated Kocher-Langenbeck approach. They found that the only predictor for the development of HO was the need for prolonged mechanical ventilation. ISS, sex, presence of comminution, femoral head impaction, dislocation, degloving injury, debris in the joint, number of other fractures, and a head and chest Abbreviated Injury Score >2 did not correlate with severe HO. They, therefore, state that patients with prolonged mechanical ventilation might benefit from HO prophylaxis given the increased risk of developing severe HO in this patient population.

Rath et al. performed a study to determine the impact of necrotic gluteus minimus muscle (GMM) debridement on the formation of HO after operative treatment of acetabular fractures through a Kocher-Langenbeck approach. They found that necrotic GMM resection diminishes HO formation comparably to other reported series in which NSAIDs were used. They, therefore, concluded that resection of the necrotic GMM from the zone of injury is an efficient and safe method of preventing significant HO in patients after operative fixation of acetabular fractures treated through a Kocher-Langenbeck approach.

Stöckle et al. performed a prospective study to assess the rate of anatomic reconstructions as well as approach-related morbidity and complications in the treatment of complex acetabular fractures through a modified extended iliofemoral approach. They found that 80% of patients had an anatomic reduction with a remaining displacement of less than or equal to 1mm. The reported complications to include a loss of reduction (8%), grade 3 heterotopic ossification (13%), and AVN (4%).

Griffin et al. performed a study to determine the safety and efficacy of the extended iliofemoral approach in the treatment of complex fractures of the acetabulum. They found that significant heterotopic ossification developed in 30% of patients and was associated with worse functional outcomes. They therefore recommended that effective prophylaxis against heterotopic ossification should be strongly considered.

Incorrect Answers:
Answer 2: The extended iliofemoral approach is performed through the interval between the tensor fascia lata (TFL) and sartorius.
Answer 3: The extended iliofemoral approach is performed with the patient in a lateral decubitus position.
Answer 4: Permanent hip abductor weakness is an expected, not a rare, complication of the extended iliofemoral approach.
Answer 5: Neurovascular structures that are at risk during an extended iliofemoral approach include the superior gluteal artery and vein, sciatic nerve, lateral femoral cutaneous nerve, and perforating branches of the femoral artery.