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A 32-year-old male sustains a complex both-column acetabular fracture and the operating surgeon decides to utilize an extended iliofemoral approach. The patient should be counseled that as compared with other surgical approaches to the acetabulum, the extended iliofemoral approach has the highest rate of which of the following?
Pudendal nerve palsy
Corona mortis injury
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The extended iliofemoral approach has the highest rate of heterotopic ossification as compared to other acetabular approaches, which is thought to be due to the extensive muscle release from the outer table of the pelvis.
The extended iliofemoral approach to the acetabulum is a large, extensile exposure that allows access to a large area of the pelvis and acetabulum, including the entire lateral aspect of the innominate bone. This approach is most commonly utilized for complex fractures involving both columns, or for malunion/nonunion surgeries of the acetabulum. In addition to the risk of heterotopic ossification, this exposure is also associated with a prolonged patient recovery period and permanent hip abductor weakness, also secondary to the nature of the exposure.
Griffin et al. reviewed 106 patients operated on using an extended iliofemoral approach with a minimum follow-up of two years. Fracture reduction was anatomical in 76%, and 64% of patients reported good or excellent functional outcomes; reduction was correlated with outcome in this analysis. Significant heterotopic ossification was seen in 30%.
Illustration A shows the approach, with the amount of innominate bone exposure shown in detail.
1) Fracture union has not been shown to be increased with this particular approach.
2) Return to work is typically delayed in this patient population due to a long recovery period.
3) Pudendal nerve palsy has not been shown to be increased in this approach as compared to the other acetabular approaches.
4) The corona mortis is not typically injured with this approach, and is usually noted during the Stoppa approach, where it can be inadvertently injured.
Griffin DB, BeaulÃ© PE, Matta JM
J Bone Joint Surg Br. 2005 Oct;87(10):1391-6. PMID: 16189314 (Link to Abstract)
Griffin, BJJ 2005
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The approach shown in Figure A is most indicated for which of the following acute fracture patterns?
Comminuted posterior wall fracture
Posterior wall and posterior column fracture
Transtectal transverse fracture with impacted roof
Anterior column and posterior hemitransverse fracture
Simple posterior wall fracture
Figure A outlines the surgical incision for the extended iliofemoral approach. This approach was developed by Emile Letournel as a simultaneous approach to both columns of the acetabulum. This approach exposes the entire lateral innominate bone by posterior reflection of the abductors and reflection of short external rotators. It can be extended anteriorly into the first iliac window of the ilioinguinal incision if needed. Indications for this approach include: transverse and T-type fractures with posterior wall involvement or an impacted roof, both-column fractures with posterior wall or posterior column comminution, sacroiliac joint involvement, and transverse fractures more than three weeks old. Disadvantages of this approach include: significant stripping of the bone which can lead to heterotopic bone formation, and prolonged abductor weakness and recovery period. The incision starts at the posterosuperior iliac spine, follows the iliac crest to the anterosuperior spine, and then turns slightly lateral to parallel the femur on the anterolateral aspect of the thigh.
Judet et al review 129 surgically treated acetabular fractures and describe mechanism of injury, radiographic findings, and options for treatment.
Answer choices 1,2, and 5 are typically treated through a Kocher-Langenbeck approach. Answer choice 4 is usually treated through an ilioinguinal approach.
JUDET R, JUDET J, LETOURNEL E.
J Bone Joint Surg Am. 1964 Dec;46:1615-46. PMID: 14239854 (Link to Abstract)
JUDET, JBJS 1964
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Transtectal T shaped fracture through the extended iliofemoral approach