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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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