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Introduction
  • Indications
    • acetabular fractures
    • pelvic ring injuries
  • Approach provides access to 
    • pubic body
    • superior pubic ramus
    • pubic root
    • ilium above and below the pectineal line
    • quadrilateral plate 
    • medial aspect of the posterior column
    • sciatic buttress
    • anterior sacroiliac joint
    • upper ilium and iliac crest
Preparation & Positioning
  • Preparation
    • a radiolucent table is required
    • Foley catheter is required to improve visualization
  • Position
    • supine 
    • ipsilateral limb is draped free into the field
    • hip and knee are flexed to relax the ilipsoas/femoral neurovascular bundle
    • operating surgeon is on the opposite side of the table
Approach
  • Incision
    • a transverse incision is made approximately 2 cm above the symphysis
      • this is carried short of each external inguinal ring
    • for the "lateral window", an incision is made along the iliac crest, starting ~2 cm posterior to the ASIS, following the iliac crest posteriorly
  • Superficial dissection
    • subcutaneous tissue and rectus fascia are incised transversely 
    • the pyrimidalis muscle is released and tagged for later repair 
    • the rectus abdominus fascia is split along the linea alba 
    • the transversalis fascia is opened superior to the pubic symphysis
      • this opens the potential space of Retzius (space behind the symphysis and anterior to the bladder) 
    • for the "lateral window", the insertion of the external oblique is released, permitting dissection into the internal iliac crest fossa (requires elevation of the iliacus muscle)
  • Deep dissection
    • the origin of the rectus abdominus muscle is released off the posterior pubic rami but maintained anteriorly
      •  a Hohmann retractor is used to retract the rectus anteriorly
    • the iliopectineal fascia is released to enter the true pelvis
    • anastamoses between the external iliac and obturator vessels (corona mortis) should be identified along the superior pubic ramus and ligated 
    • the iliopsoas can now be subperiosteally elevated, and a retractor is used to retract the iliopsoas and external iliac vessels
      • the entire pelvic brim should be visualized at this time 
    • the obturator neurovascular bundle is exposed and protected as the quadrilateral surface and posterior column are dissected
Dangers & Complications
  • Obturator nerve and vessels
    • retracted carefully during exposure of the quadrilateral plate and posterior column
  •  Corona mortis
    • these anastamoses must be ligated as they appear on the lateral 1/3 of the superior pubic ramus
    • they are nearly universally present but vary significantly in size
  • External iliac vessels
    • exposed and retracted early in the exposure; must be mobilized to expose the iliac fossa and false pelvis
  • Bladder
    • Foley catheter limits injury; placement of a malleable retractor anterior to bladder also helps protect

 

 

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Questions (2)

(OBQ13.112) When performing an anterior intrapelvic approach to the acetabulum, ligation of the anastamoses between the obturator vessels and which of the following vessels should be performed to gain appropriate access to the true pelvis? Review Topic

QID: 4747
1

External iliac vessels

70%

(2239/3209)

2

Internal iliac vessels

20%

(643/3209)

3

Superior gluteal vessels

5%

(147/3209)

4

Femoral vessels

3%

(89/3209)

5

Femoral cutaneous vessels

2%

(68/3209)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(OBQ10.53) A 55-year-old male involved in a motor vehicle collision sustains an acetabular fracture. Which of the following approaches would provide the best exposure for open reduction internal fixation of the displaced fragments seen on the 3-D CT image in Figure A? Review Topic

QID: 3141
FIGURES:
1

Modified Stoppa approach

53%

(1015/1916)

2

Extended Iliofemoral

16%

(312/1916)

3

Kocher-Langenbeck

12%

(228/1916)

4

Medial window of the ilioinguinal

13%

(244/1916)

5

Simultaneous anterior and posterior exposure

6%

(107/1916)

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PREFERRED RESPONSE 1
EVIDENCE & REFERENCES (5)
Topic COMMENTS (1)
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