The Kocher-Langenbeck approach is a nonextensile approach to the posterior acetabular column.
It allows direct visualization of the dorsocranial part of the acetabulum either through the fracture gap or after capsulotomy.
ORIF of fractures of the posterior wall/ column
Transverse juxta- and infratectal fractures
Combined fracture types in which the posterior column or wall needs to be reduced under direct vision
This image shows
in dark brown color - visual and direct access
in light brown color - access by touch only
Outline all bony landmarks with a sterile marking pen:
(1) posterior superior iliac spine
(2) greater trochanter
(3) shaft of femur
Start the skin incision a few centimeters distal and lateral to the posterior superior iliac spine. A more proximal extension (indicated by dashed line) may improve exposure in obese or muscular patients.
Carry the incision anteriorly over the greater trochanter. Curve it distally along the tip of the greater trochanter towards the lateral aspect of the femoral shaft.
End the incision at the mid third of the thigh (just distal to the insertion of the gluteus maximus tendon).
Superficial surgical dissection
After dividing the subcutaneous tissues, sharply incise the subcutaneous tissues along
the gluteus maximus muscle (using scissors)
the tractus iliotibialis (using a scalpel)
Split the gluteus maximus
Split the gluteus maximus in line with its fibers, starting at the greater trochanter in a proximal direction up to the crossing of the first neurovascular bundle.
This creates a posterior muscle belly (inferior gluteal artery), and an anterior belly (superior gluteal artery) that includes one third of the gluteus maximus and the muscle of the tensor fasciae latae.
Incise the tractus iliotibialis
In the distal half of the incision, incise the iliotibial tract in line with its fibers up to the mid third of the thigh.
Free the layer of fat covering the short external rotators, exposing the insertion of the piriformis tendon, the gemelli, and the internal obturator muscle.
The sciatic nerve (see figure) lies posterior to the gemelli and internal
obturator muscles, and anterior to the piriformis muscle, between the greater
trochanter and the ischial tuberosity.
Carefully visualize the sciatic nerve.
Ensure at all times that no direct pressure or stretching is exerted on the nerve.
Option: Detach the gluteus maximus muscle
Detach the gluteus maximus 1 cm from its insertion into the gluteal tuberosity of the femur.
Detachment can be done partially or completely.
This allows a decrease of tension and easier mobilization of the gluteus maximus muscle.
Detach the external rotator muscles
Isolate the piriformis tendon and the conjoined tendons of the obturator internus and superior and inferior gemelli muscles. They are tagged and incised 1 cm lateral from their femoral insertions.
Avoid damage to the medial circumflex femoral artery which is running in proximity (at the upper border of the quadratus femoris muscle).
Exposure of the posterior wall/column
Release and reflect each of the short external rotator muscles, freeing the muscle bellies from the posterior joint capsule.
Expose the greater sciatic notch, the ischial spine, and the lesser sciatic notch.
Insert two retractors in the greater and the lesser sciatic notches. Now the posterior column is visible in its whole extent.
Protect the sciatic nerve, which lies behind the retractor, with abdominal sponges. Use the short external rotator muscles as a cushion.
Option: perform a capsulotomy
If the posterior capsule is intact and direct inspection of the joint is required, a T-shaped capsulotomy is made.
Incise the joint capsule 0.5 cm lateral to the edge of the posterior wall, avoiding damage to the limbus.
Place the vertical leg of the incision parallel to the femoral neck.
With the help of a Schanz screw placed in the femoral neck, distraction of the hip joint can be achieved. In this way, the inner aspect of the acetabulum is directly visible.
Alternatively, distraction is achieved by enhancing skeletal traction on the femoral shaft with the extension table.
Inspect the weight-bearing dome and the femoral head.
Detect if there is any marginal impaction or damage to the cartilage of the acetabulum and femoral head. Localize, remove, and/or clean and reinsert any free intraarticular fracture fragment(s).
If no capsulotomy has been performed, the hip joint cannot be inspected after reduction (fixation) of the fragments.
Perform a meticulous debridement of all soft tissues before starting wound closure.
Remove necrotic tissue and irrigate the entire wound to decrease the risk of periarticular ossification. Insert at least two suction drains. Reinsert all tendons and approximate the split parts of the gluteus maximus with adaptation sutures. Perform the closure of the iliotibial tract, the subcutis and the skin.
The repair of these tendons at the time of closure represents additional risk to the femoral head circulation. This is particularly true for the conjoint tendon where passage of a needle into the tendon stump may injure the medial femoral circumflex artery.