Extensile (extended iliofemoral) Approach to Acetabulum - Approaches

Introduction

The extended iliofemoral approach exposes the entire lateral innominate bone
Indications
- Transtectal transverse fracture with roof impaction
- Transverse with posterior wall fractures
- T-type fractures, especially with posterior wall involvement
- T-type fractures with pubic symphysis dislocation
- Both-column fractures with posterior wall or posterior column comminution, sacroiliac joint involvement, or very high posterior column involvement
- Delayed fixation of both column, T-type, or transverse + posterior wall fractures (typically > 3 weeks)
- Malunion/nonunion/deformity correction surgeries

Preparation

Position
- lateral decubitus positioning is utilized in this approach.

Approach

Incision
- the incision is carried along the iliac crest
  - starting from the PSIS and running anteriorly to the ASIS
  - it is then continued down from the ASIS in line with the posterior femur
Superficial dissection
- separate the abdominal musculature from the gluteal musculature at the iliac crest.
- develop the interval between the sartorius and tensor fasciae latae.
- retract the tensor laterally and dissect through the fascia lata distal to the muscle (longitudinally).
- elevate the tensor fasciae latae from the ASIS.
Deep dissection
- dissect gluteal muscles off iliac crest
- subperiosteally dissect the gluteal muscles off the iliac crest from anterior to posterior and cephalad to caudad.
- continue the elevation until the PSIS and greater sciatic notch are encountered.
- the lateral branches of the anterior femoral circumflex vessels must be ligated to further retract the tensor and fascia lata laterally.
- elevate the direct head of the rectus femoris from the pelvis as well as the gluteus minimus (off the proximal femur).
- sequentially tag and resect the insertions of the
  - gluteus medius/minimus
  - piriformis
  - conjoint tendon (superior and inferior gemelli/obturator internus)
  - Take care to protect the superior gluteal artery and nerve as well as the sciatic nerve.
- release hip capsule, if not injured.
- access to the internal iliac fossa may be obtained inferiorly by releasing the indirect head of the rectus femorus and superiorly by releasing the abdominal musculature off the iliac wing and elevating the iliacus from the internal fossa.
  - elevating the abdominal musculature from the iliac crest and iliacus from the internal fossa in this approach will completely devitalize the wing. This aspect of the approach should be used on a very limited basis.
Wound closure
- 3 drains are placed before closure, one along the posterior column, another in the distal portion of the incision, and a third in the internal iliac fossa
- order of wound closure/repair:
  - hip capsule, external rotators
  - gluteus medius, must be fixed anatomically and with strong sutures
  - gluteus minimus
  - rectus femoris origin with transosseous sutures, knee extension facilitates this repair
  - sartorius and abdominal muscles if taken down
  - fascia, subcutaneous layers, and skin

Dangers & Complications

Heterotopic Ossification
- highest rate of heterotopic bone formation of all pelvic approaches
Extended patient recovery period
Permanent hip abductor weakness is expected
Iatrogenic injury
- structures at risk
  - superior gluteal artery and vein
  - sciatic nerve
  - lateral femoral cutaneous nerve (lateral branches always transected)
  - perforating branches of the femoral artery