Updated: 2/6/2017

Posterior Approach to the Acetabulum (Kocher-Langenbeck)

Topic
Review Topic
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Questions
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Evidence
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Introduction
  • Southern/Moore approach and the Kocher-Langenbeck approach both use the same interval
    • Kocher-Langenbeck is used to refer to an approach used to address the acetabulum which is more extensile
    • Southern/Moore approach more commonly refers to a more limited hip arthroplasty approach
      • incision is identical to Kocher-Langenbeck, except localized posterior to greater trochanter
  • Provides exposure to
    • posterior wall of acetabulum
    • lateral aspect of the posterior column of acetabulum
    • indirect access to true pelvis and anterior aspect of posterior column through palpation
    • proximal femur
  • Indications
    • THA
    • hip hemiarthroplasty
    • removal of loose bodies
    • dependant drainage of septic hip
    • pedicle bone grafting
    • posterior wall fx
    • posterior column fx
    • posterior wall and posterior column fx
    • simple transverse fx (patient prone)
      • fx must be less than 15 days old
      • fx line located at or below acetabular roof
      • no major anterior displacement
Intermuscular plane
  • No internervous plane
    • gluteus maximus innervated by inferior gluteal nerve
    • nerve branches of upper 1/3 of muscle cross intended interval of dissection halfway between level of greater trochanter and PSIS
      • muscle split is stopped when first nerve branch to upper part of muscle is encountered
  • Vascular plane
    • upper 1/3 of muscle
      • supplied by superior gluteal artery 
    • lower 2/3 of muscles
      • supplied by inferior gluteal artery 
    • line of fat on surface marks interval
Preparation
  • Anesthesia
    • patient must be relaxed
  • Position
    • lateral position 
      • posterior wall and lip fxs (can use skeletal traction when using lateral position)
      • allows for femoral head dislocation
      • position of choice for joint arthroplasty
      • allows buttock tissue to "fall away" from the field
    • prone position 
      • for transverse fx (flex the knee to prevent stretching of sciatic nerve)
      • femoral head is maintained in  reduced position throughout procedure
      • improves quadrilateral surface access
      • improved access to cranial and anterior aspect of posterior wall fractures
  • Imaging
    • ensure appropriate imaging can be obtained prior to formal prepping and draping
Approach
  • Incision
    • longitudinal incision centered over greater trochanter
      • start just below iliac crest, lateral to PSIS
        • mini-incision approach shows no longterm benefits to hip function 
      • extend to 10 cm below tip of greater trochanter
  • Superficial dissection
    • through subcutaneous fat
    • incise fascia lata in lower half of incision
    • extend proximally along anterior border of gluteus maximus
      • split gluteus maximus muscle along avascular plane
      • release portion of gluteal sling to aide in anterior retraction of muscle belly
    • detach short external rotators after tagging
      • the piriformis should be tagged and released approximately 1.5cm from the tip of the greater trochanter to avoid damaging the blood supply to the femoral head
        • the piriformis will provide a landmark leading to the greater sciatic notch  
          • the contents of the greater sciatic notch include:  
            • piriformis
            • superior and inferior gluteal vessels and nerves
            • sciatic and posterior femoral cutaneous nerves
            • internal pudendal vessels
            • nerves to the obturator internus and quadratus femoris
      • the obturator internus should be tagged 1.5 cm from the greater trochanter and blunt dissection should be used to follow its origin to the lesser sciatic notch
        • posterior retraction will protect the sciatic nerve
    • clear abductors and soft tissue to visualize posterior capsule and posterior wall region
  • Deep dissection
    • no further dissection is needed in setting of isolated posterior wall fracture
    • palpable exposure of quadrilateral plate to assess reduction of posterior column accomplished by elevation of obturator internus elevation
      • access can be enlarged by release of sacrospinous ligament
    • hip joint exposure
      • perform marginal capsulotomy
      • capsular attachments to posterior wall fragments need to be kept intact to prevent devascularization
      • femoral traction can allow visualization of intra-articular surface of hip joint
    • osteotomy of greater trochanter
      • extends access along external surface of anterior column
Dangers
  • Sciatic nerve
    • initially located along posterior surface of quadratus femoris muscle
      • quadratus femorus anatomy is constant; rarely damaged in setting of fracture
    • extend hip and flex knee to prevent injury
    • minimize chance of injury by using proper gentle retraction and releasing your short external rotators (obturator internus) posteriorly to protect the sciatic nerve from traction
    • treat injury with observation and use of ankle-foot orthosis
      • prognosis for recovery of tibial division is good despite severe initial damage
      • prognosis for recovery of peroneal division is dependant on severity of initial injury
  • Inferior gluteal artery
    • leaves pelvis beneath piriformis
    • if it is cut and retracts into the pelvis, then treat by flipping patient, open abdomen, and tie off internal iliac artery
  • First perforating branch of profunda femoris
    • at risk of injury with release of gluteus maximus insertion
  • Femoral vessels
    • at risk with failure to protect anterior aspect of the acetabulum, or with placement of retractors anterior to the iliopsoas muscle
  • Superior gluteal artery and nerve
    • leaves the pelvis above the piriformis and enters the deep surface of the gluteus medius.
    • this tethering limits upward retraction of gluteus medius and blocks you from reaching the iliac crest
    • injury can cause excessive bleeding
  • Quadratus femoris
    • excessive retraction and injury must be avoided to prevent damage to medial circumflex artery
  • Heterotopic Ossification
    • debride necrotic gluteus minimus muscle to decrease incidence of HO
 

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Questions (5)
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(OBQ11.266) Figure A is a cadaver specimen where a posterior approach to the hip has been performed after removal of part of the Gluteus maximus muscle. Which of the following choices correctly identifies structures A, B, and C in Figure A? Review Topic

QID: 3689
FIGURES:
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1

A: Gluteus minimus, B: Piriformis tendon, C: Sacrospinous ligament

35%

(1024/2956)

2

A: Piriformis tendon, B: Superior gemellus tendon, C: Sacrospinous ligament

2%

(45/2956)

3

A: Gluteus minimus, B: Piriformis tendon, C: Sacrotuberous ligament

60%

(1772/2956)

4

A: Piriformis tendon, B: Quadratus femorus tendon, C: Sacrotuberous ligament

2%

(58/2956)

5

A: Gluteus minimus, B: Superior gemellus tendon, C: Sacrotuberous ligament

2%

(45/2956)

L 3

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(OBQ10.48) Which of the following structures exits distal to the anatomic landmark identified in Figure A Review Topic

QID: 3136
FIGURES:
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1

Sciatic nerve

12%

(337/2912)

2

Superior gluteal artery

3%

(94/2912)

3

Piriformis tendon

4%

(124/2912)

4

Inferior gluteal artery

27%

(790/2912)

5

Obturator internus

53%

(1551/2912)

L 3

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SUBMIT RESPONSE 5
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(OBQ06.257) All of the following structures pass below the piriformis through the greater sciatic foramen EXCEPT: Review Topic

QID: 268
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1

pudendal nerve

19%

(220/1173)

2

sciatic nerve

7%

(81/1173)

3

inferior gluteal nerve

3%

(36/1173)

4

obturator nerve

64%

(752/1173)

5

inferior gluteal artery

6%

(75/1173)

L 3

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SUBMIT RESPONSE 4
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