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Ilioinguinal Approach to the Acetabulum

Author: Joshua Blomberg

Topic updated on 05/04/13 11:34pm

Introduction

Allows exposure to
- entire internal iliac fossa and pelvic brim from the SI joint to the pubic symphysis
- quadrilateral surface of innominate bone and superior/inferior pubic rami (thus allows exposure of anterior column)
- portion of external aspect of ilium
Indications
- anterior wall fx
- anterior column fx
- anterior column plus posterior hemitranverse fx
- majority of associated both-column fractures
  - even in presence of posterior wall fracture
  - posterior-wall fragment attached to ilium can be reduced through lateral ilium exposure
  - not recommended for fractures associated with comminuted post wall fractures or SI joint fractures
- some T-type
  - can used for minimally posteriorly displaced T-type fractures
- some transverse type
  - for transverse fx if displacement is anterior

Positioning

Anesthesia
- patient must be paralyzed throughout case
Position
- supine with greater troch on side of fracture at edge of table
- place bump under ipsilateral buttock
- flex affected leg to relax iliopsoas and neurovascular structures
Imaging
- ensure clear fluoroscopic images can be obtained prior to draping
Catheter
- insert catheter to empty bladder (will obscure vision)

Incision

Incision
- incision begins at midline 3-4cm proximal to symphysis pubis
- proceeds laterally to ASIS, then along anterior 2/3's of iliac crest
- extend incision beyond most convex portion of ilium
Superficial Dissection
- dissect through subcutaneous fat
- start laterally, incise periosteum along iliac crest
- release abdominal and iliacus muscle insertions from ilium
- superiosteally elevate iliacus from internal iliac fossa to SI joint and pelvic brim
- pack internal iliac fossa for hemostasis
- through lower portion of incision expose aponeurosis of external oblique and rectus abdominus
- divide exposed aponeurosis in line with skin incision one cm proximal to external inguinal ring
  - will often have to sacrifice lateral cutaneous nerve of the thigh
- thus unroofs inguinal canal, and exposes inguinal ligament
  - identify and protect ilioinguinal nerve
- isolate spermatic cord/round ligament and place penrose around structures to retract
- sharply incise inguinal ligament, leaving 1-2mm cuff of ligament still attached to divided origin of internal oblique, transversus abdominus, and transversalis fascia
- may need to divide conjoint tendon at its insertion on pubis as well as anterior rectus sheath
Deep Dissection
- bluntly dissect a plane between the symphysis pubis and the bladder (space of Retzius), pack with sponges
- expose anterior aspect of femoral vessels and surrounding lymphatics in midportion of incision (lacuna vasorum)
  - lacuna musculorum is lateral and contains iliopsoas, femoral nerve, and lateral femoral cutaneous nerve
- identify iliopectineal fascia, which seperates the lacuna vasorum and lacuna musculorum
- dissect vessels and lymphatics from medial aspect of fascia, free iliopsoas and femoral nerve from lateral aspcet of fascia
- sharply divide iliopectineal fascia down to pectineal eminence, then detach from pelvic brim; allows access to true pelvis, quadrilateral plate, and posterior column
- place second penrose drain around iliopsoas, femoral nerve, and lateral femoral cutaneous nerve
- place thrid penrose drain around femoral vessels and lymphatics
- identify and ligate corona mortise before retracting vessels
- subperiosteal dissection is used to expose pelvic brim, rami, and quadrilateral surface
- work through 3 Windows to reduce and fix fracture:
  - Medial window
    - medial to external iliac artery & vein
    - access to pubic rami; indirect access to internal iliac fossa and anterior SI joint
  - Middle window
    - between external iliac vessels and the iliopsosas
    - access to pelvic brim, quadrilateral plate, and a portion of the superior pubic ramus
  - Lateral window
    - lateral to iliopsoas (iliopectineal fascia)
    - access to quadrilateral plate, SI joint, and iliac wing
Closure
- drains
  - suction drains are placed in the space of Retzius and along quadrilateral surface
- repair tendon of rectus abdominus
  - transversalis fascia and the conjoined tendon of the internal oblique and transversus abdominus are attached to inguinal ligament
  - roof of inguinal canal is repaired by closure of aponeurosis of external oblique
  - iliopectineal fascia is not repaired

Dangers & Complications

Femoral nerve
Femoral & External Iliac Arteries
- damage can cause thrombosis
- protect by leaving in femoral sheath
Lymphatics
- present in fatty areolar tissue around vessels
- disruption can impair postoperative lymphatic drainage and cause edema
Lateral cutaneous nerve of thigh
- often have to sacrifice leaving numbness on the outer side of the thigh
Inferior epigastic artery
- must sacrifice if has anomoulous origin off obturator artery to allow retraction of iliac vessels
Spermatic cord (contains vas deferens and testicular artery)
- must protect
- damage can cause testicular ischemia, infertility
Heterotopic Ossification
- much more common in the extended iliofemoral and Kocher-Lagenbeck approaches
Obturator nerve
- causes medial thigh numbness when injured

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Qbank (4 Questions)

TAG

(OBQ10.28) While dissecting in the middle window of the ilioinguinal approach a nerve is encountered entering the obturator foramen. Excessive retraction on this structure would result in which of the following? Topic

Review Topic

1. Lateral thigh numbness
2. Weakness in knee extension
3. Anterior thigh numbness
4. Medial thigh numbness
5. Weakness in hip flexion

PREFERRED RESPONSE ▶

DISCUSSION: The obturator nerve is the largest nerve from the anterior divisions of the lumbar plexus, receiving contributions from L2-4. The nerve courses through the psoas major, exiting on its medial aspect and running along the lateral wall of the lesser pelvis until it enters the obturator foramen. It then divides into an anterior and posterior division, supplying branches to the hip joint, adductor longus, adductor brevis, gracilis, adductor magnus and sensory innervation the medial thigh. While in the middle window of the ilioingunal approach, the lateral femoral cutaneous nerve (sensory innervation to lateral thigh) and femoral nerve (sensory innveration to anterior thigh and motor innervation for knee extension) will also be encountered and may be injured. Illustrations A and B demonstrate the course and sensory innervation of the aforementioned nerves, respectively.

Illustrations: A

REFERENCES:

1. Rohen JW, Yokochi C, Lütjen-Drecoll E. Color Atlas of Anatomy, 3rd ed. New York, NY: Ogaku Shoin Publishers; 2002:205-208.

2. Smith WR, Ziran BH, Morgan SJ, eds. Fractures of the Pelvis and Acetabulum, 2nd ed. New York, NY: Informa Healthcare Publishers; 2007:169-282.

Question Authors:

Robert Boykin MD, Patrick McCulloch MD, John Badylak MD,

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TAG

(OBQ08.58) When peforming the ilioinguinal approach, what lies between the external iliac vessels and the lateral muscle compartment? Topic

Review Topic

1. Sartorius muscle
2. Iliopectineal fascia
3. Round ligament
4. Lateral femoral cutaneous nerve
5. Corona mortis

PREFERRED RESPONSE ▶

DISCUSSION: The ilioinguinal approach is typically used for anterior wall and column fracture of the acetabulum. this question is essentially asking what separates the middle from the lateral windows. Mobilization of the external iliac vessels and the iliopsoas (or iliopectineal fascia) create the 3 windows of the ilioinguinal approach: 1) Medial window: medial to external iliac artery & vein. 2) Middle window: between external iliac vessels and the iliopsoas (or iliopectineal fascia) 3) Lateral window: lateral to iliopsoas (or iliopectineal fascia). Note that some sources use the iliospoas as the structure that separates the middle from the lateral windows; other sources use the iliopectineal fascia as the structure that separates the middle from lateral windows.

The corona mortis (answer #5) is a normal variant; it is an anastomotic connection between the external iliac and obturator arteries. If damaged in this approach, massive bleeding & death can result. The lateral femoral cutaneous nerve (answer #4) crosses the inguinal crease close to the ASIS (can be slightly medially to ASIS or, more commonly, 1-2 cm lateral) and, thus, may be seen in the lateral aspect of the ilioinguinal approach. The femoral nerve (answer #3) gives branches that supply muscles in the lateral muscular compartment.

Illustrations: A

REFERENCES:

1. Surgical Exposures in Orthopaedics: The Anatomic Approach (Hoppenfeld, Surgical Exposures in Orthopaedics) . Hoppenfeld. Lippincott Williams and Wilkins, 2009.

2. Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Chapter 37: Surgical treatment of acetabular fractures

Question Authors:

Ben Taylor MD, Derek Moore, Patrick McCulloch MD,

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TAG

(OBQ04.213) During an ilioinguinal approach to the pelvis, the lateral femoral cutaneous nerve is seen. Which nerve roots supply this nerve? Topic

Review Topic

1. L1-2
2. L2-3
3. L3-4
4. L4-5
5. L5-S1

PREFERRED RESPONSE ▶

DISCUSSION: The lateral femoral cutaneous nerve (L2/3) is at risk of transection or traction injury with utilization of the ilioinguinal approach to the acetabulum/pelvis. This structure is most commonly found 10-15mm from the ASIS, passing underneath the inguinal ligament. Injury to this nerve is treated by sharply transecting the nerve and burying the nerve ends to limit the symptoms of the eventual neuroma. The ilioinguinal approach utilizes a Pfannesteil incision continuing laterally along the inguinal ligament and finally along the iliac crest. The lateral window is lateral to the iliopsoas; the middle window is between the iliopsoas and femoral vessels; the medial window is from midline to the femoral vessels.

Illustration A shows a sketch of the ilioinguinal approach, with the lateral femoral cutaneous nerve seen as it exits inferolaterally under the inguinal ligament.

Illustrations: A

REFERENCES:

1. Hoppenfeld, DeBoer: Surgical Exposures in Orthopaedics, ed 2. pp 117-146

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, John Badylak MD,

Please Rate Educational Value!

3.0

Average 3.0 of 10 Ratings

Evidence & References Show References

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Rohen JW, Yokochi C, Elke LD. Color Atlas of Anatomy. 3rd ed. New York, NY: Ogaku Shoin Publishers; 2002:205-208.
Judet JW, Letournel E. Fractures of the Acetabulum. 2nd ed. New York, NY: Springer-Verlag; 1993:363- 398
Rohen JW, Yokochi C, Lütjen-Drecoll E. Color Atlas of Anatomy, 3rd ed. New York, NY: Ogaku Shoin Publishers; 2002:205-208.
Smith WR, Ziran BH, Morgan SJ, eds. Fractures of the Pelvis and Acetabulum, 2nd ed. New York, NY: Informa Healthcare Publishers; 2007:169-282.
Surgical Exposures in Orthopaedics: The Anatomic Approach (Hoppenfeld, Surgical Exposures in Orthopaedics) . Hoppenfeld. Lippincott Williams and Wilkins, 2009.
Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries. Chapter 37: Surgical treatment of acetabular fractures
Hoppenfeld, DeBoer: Surgical Exposures in Orthopaedics, ed 2. pp 117-146

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Ilioinguinal Approach to the Acetabulum

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