- Extended iliofemoral
The extended iliofemoral 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.
The extended iliofemoral approach involves significant stripping of the bone, is associated with heterotopic bone formation, and an extended recovery period. Prolonged abductor weakness is to be expected. When necessary, this approach may be used to achieve reductions which are otherwise impossible.
- Transtectal associated transverse + posterior wall fractures, or T-shaped fractures, particularly with posterior wall comminution
- Transverse fractures with significant posterior wall involvement
- T-shaped fractures with widely displaced vertical limbs or pubic symphysis dislocation
- Both-column fractures with posterior wall or posterior column comminution, sacroiliac joint involvement, or very high posterior column involvement
- When ORIF of associated or transverse fractures is delayed by three or more weeks
The extended iliofemoral approach should not be used in aged or obese patients, nor in patients who are not committed to a long recovery process.
The extended iliofemoral approach allows simultaneous visualization of both posterior and anterior columns. With this exposure, reduction and fixation are usually straightforward.
- Technically this approach is demanding, and has the highest complication rate.
- Heterotopic bone formation is common. (Prophylaxis should be planned).
- Abductor muscle weakness with prolonged rehabilitation must be expected.
Dangers of the extended iliofemoral approach
This approach risks injury to the vessels and nerves that exit through the greater sciatic notch. The superior gluteal artery and its accompanying veins lie on the deep surface of the gluteal muscles. During elevation and posterior reflection of the glutei, the vessels may be torn, typically where they lie against the ilium at the top of the notch. If torn, they may retract into the pelvis. Bleeding from the superior gluteal vessels may be difficult to control. The surgeon should remember that packing the notch may help, followed by angiographic embolization, or, alternatively, the use of an anterior vascular approach.
The risk of neurovascular injury is increased during exposure of older fractures, and when fracture lines run parallel to the course of vessels and nerves.
The following landmarks are used for orientation:
- Posterior superior iliac spine (PSIS)
- Iliac crest
- Anterior superior iliac spine (ASIS)
- Lateral margin of the knee
Incise the skin in the form of an inverted “J”. Begin at the PSIS and follow the iliac crest to the anterior superior iliac spine.
Reaching the ASIS, continue along the anterolateral surface of the thigh for a length of 20-30 cm and halfway down the thigh. Proceeding distally, aim a bit posteriorly. This will allow easier posterior retraction of the musculocutaneous flap.
Expose the iliac crest from the ASIS towards the PSIS using a standard scalpel.
Develop the interval between the abdominal and the gluteal muscles. They have separate innervation and blood supply. The gluteal muscles will be mobilized, and the abdominal muscles left attached to the iliac crest.
Anteriorly, the interval between the sartorius and the tensor fasciae latae is developed from proximal to distal.
First, incise the fascia over the muscle, and define its anterior edge. Retract the tensor laterally. Continue dissection distally through the full thickness of the fascia lata, approximately 10 cm beyond the distal end of the tensor fasciae latae muscle. The lateral branches of the lateral femoral cutaneous nerve are severed.
Detach subperiosteally the tensor fasciae latae muscle from the anterior superior iliac spine, elevating towards the hip joint. Retract the muscle laterally.
Exposure of the iliac wing
Complete the dissection of gluteal muscles from the top of the iliac crest. Dissect subperiosteally along the external surface of the iliac wing, from anterior to posterior and from proximal to distal.
Proceed further from the lateral aspect of the crest down to the superior border of the greater sciatic notch and posteriorly until the posterior inferior iliac spine are exposed. This last step is better accomplished when the distal part of the incision is completed.
Take care to protect the superior gluteal vessels which emerge from the greater sciatic notch and lie on the deep surface of the muscles.
Detaching of the fasciae latae muscle
Detach subperiosteally the tensor fasciae latae muscle from the anterior superior iliac spine, develop the interval between sartorius and tensor, and retract the tensor laterally.
The lateral branches of the lateral cutaneous nerve are severed.
The deep layer of the fascia lata remains to be divided. This incision is indicated on the illustration.
Do not make a transverse cut in the distal fascia lata. It will complicate the reconstruction.
Splitting of the fascia lata
The tensor fasciae latae must be retracted and protected. The dissection is along its anterior edge and medial surface.
Once the interval between the tensor fasciae latae and the sartorius muscle is developed, a fatty underlying tissue covered by a thin fascial layer is revealed.
Division of circumflex vessels
Once this fascia is incised, the underlying lateral branches of the anterior femoral circumflex vessels appear.
These vessels must be ligated and divided. This allows for the retraction of the flap, and provides access to the fascia propria of the rectus femoris muscle. Removing this will expose the direct and reflected origins of the rectus.
Access to the hip joint
Visualization of the joint capsule
Define the direct origin (1) of the rectus femoris. The reflected origin (2) leads to the hip capsule, just below its inferior or distal border. To gain anterior exposure to the iliopectineal eminence, the direct origin of rectus femoris may be transsected.
Next, elevate the gluteus minimus muscle from the femoral neck.
Release the insertion of gluteus minimus muscle
Following the vastus lateralis towards the greater trochanter, the surgeon will see the insertion of the gluteus minimus on the anterior aspect of the greater trochanter.
This tendon has a triangular shape, and a typical mother-of-pearl color. The insertion typically involves both a superficial and a deep layer.
The minimus tendon must be divided, leaving a stump attached to the trochanter for its repair.
Tag the tendon ends with sutures for easy identification.
Femoral head protrusion into the pelvis may make tendon recognition difficult.
Release the gluteus medius
After retraction of the gluteus minimus muscle, the trochanteric insertion and the distal part of the gluteus medius muscle become visible.
Following the horizontal fibers of the vastus lateralis in cranial direction helps to identify the most distal portion of the gluteus medius tendon.
A curved forceps, placed underneath the gluteus medius tendon will help to define its insertion.
The tendon of the piriformis muscle will be found just proximal and anterior to the medial border of medius gluteus tendon.
Severing the gluteus medius tendon
Once the gluteus medius tendon is prepared, transversally divide the gluteus medius tendon and leave an adequate stump for reattachment on the trochanter.
Release the external rotators
With posterior retraction of the gluteus medius, the external rotator muscles will appear.
Continue with careful protection of the superior gluteal neurovascular bundle.
Cutting of the external rotators
Detach the piriformis and obturator internus, and gemelli muscles from the greater trochanter. Tag them with sutures. Posterior column exposure is improved with a retractor placed in the lesser sciatic notch. Protect the sciatic nerve with care, and avoid prolonged retraction of the nerve.
It is important to preserve the blood supply to the femoral head by leaving the obturator externus tendon and underlying medial femoral circumflex artery. Dividing the short external rotators 1 cm posterior to the greater trochanter helps avoid injury to the artery.
Opening of the joint capsule
Open the joint capsule, if necessary, with a curved incision just distal to the acetabular labrum, which should be protected. If the labrum was torn by the injury, it should be repaired during closure.
Take care not to devascularize the posterior wall fragments. These should be left attached to the joint capsule.
Distraction of the femoral head with fracture table, femoral distractor, or manually, allows cleaning of the joint, and assessment of the articular fracture lines for later reduction.
Exposure of the internal iliac fossa
There are two options:
1. Release the direct tendon of the rectus femoris from the anterior inferior iliac spine. Leave a stump for reconstruction. Flex the hip to relax the iliopsoas muscle and get a better view. Also relax the posterior retractors. This allows you to let the abdominal muscles remain attached to the iliac crest.
In some cases it will be necessary to gain additional exposure of the internal aspect of the innominate bone. This may be required to clean callus from fracture lines of more delayed injuries, to achieve reduction, or for anterior fixation. At best, this exposure is limited to the lateral window of the ilioinguinal approach.
2. Release the abdominal wall muscles and sartorius from the iliac crest. This increases exposure of the internal iliac fossa, and permits introduction of instruments beneath the iliopsoas. The sartorius may be released by an osteotomy that leaves a small fragment of ASIS attached to the muscle. Predrilling for screw fixation can provide a good repair.
Although this step may greatly aid the reduction, its cost is the complete devascularization of the iliac wing and its fracture fragments. Thus, before proceeding, other reduction maneuvers should be considered.
Wound closure and drains
Start wound closure with the reattachment of the hip capsule.
The external rotators are then reattached to the greater trochanter.
Reattach the medius gluteus to the greater trochanter with strong sutures, starting medially, close to the piriformis, with the thickest part of the tendon. The repair must be anatomical and mechanically secure. Next, repair the gluteus minimus tendon, recreating the original trochanteric insertion.
Reattach the rectus femoris origin with transosseous sutures. Knee extension will facilitate this.
Now reattach the proximal origin of the glutei to the iliac crest with the hip abducted. Repair the sartorius and abdominal muscles if they were released. Close the fascia, subcutaneous tissue, and skin in layers.
Typically, 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, if it was exposed.