This cadaver video (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A402) on the ilioinguinal approach presents its indications and techniques for the operative treatment of acetabular fractures. The principle is to work through 3 different windows. Excellent indications for the ilioinguinal approach are all fractures that involve the anterior column from the sacroiliac joint to the symphysis pubis and all additional fracture types where a possible fracture of the posterior column can be reduced and fixed through the middle window. Indications, according to the Letournel classification, are fractures of the anterior wall, the anterior column, anterior column plus posterior hemitransverse, some t types, and most of the associated both-column fractures.1
We present a 28-year-old patient with an associated both-column fracture. For surgery, the patient is positioned supine on a radiolucent carbon table or a special table, such as the ProFx traction table. The patient is positioned and draped on the table such that pelvic anterior–posterior (AP) as well as 45-degree oblique, inlet and outlet films can be taken during surgery. Draping on the carbon table leaves the injured leg mobile. The symphysis pubis, the umbilicus, the anterior superior iliac spine (ASIS), and the iliac crest are draped into the surgical field.
The skin is incised 2 cm superior to the symphysis pubis toward the ASIS, slightly curved, and along to the iliac crest posteriorly. For exposure of the lateral window, the fascia of the abdominals has to be incised along the iliac crest. Then, a Cobb elevator can be used for the subperiosteal mobilization of the iliacus muscle. To develop the middle window, the fascia of the obliquus externus muscle must be incised from the ASIS to the pubic tubercle, crossing and incising the top portion of the outer annulus of the spermatic cord or rotund ligament. The next step is to split the inguinal ligament carefully one-third proximal to two-third distal. The ligament is divided from lateral toward the pubic tubercle, being very careful on top of the medially lying femoral artery and vein. After the iliopectineal arch is identified and incised toward the innominate tubercle, on top of the acetabulum, and posteriorly along the pelvic brim toward the sacroiliac joint, the abdominals can be split away from the pelvic brim to open the true pelvis. Laterally, close to the ASIS, it is important not to lacerate the lateral femoral cutaneous nerve. Medially, the dissection of the inguinal ligament should stop just lateral from the palpable femoral artery. The medial window, medial to the vessels, has to be opened through the split inguinal ligament. The following careful and blunt dissection medial and lateral of the femoral vessels is the only difficult and potentially dangerous part during this approach and has to be performed slowly and diligently.
Finally, the lateral window gives access from the sacroiliac joint to the lateral border of the iliopsoas muscle. The middle window gives access from the medial border of the iliopsoas muscle to the femoral artery. And the medial window allows the approach to the anterior pelvic ring medially from the femoral vein up to the symphysis pubis.
Anatomical reduction of a distracted posterior column from the anterior column can be received using a colinear clamp in the middle window after cleaning the fracture. Rotational displacement can be controlled with an additional Matta clamp. Then, 1 or 2 anterior to posterior column screws can be introduced, to secure the reduction. The screws have to run parallel to the anterior border of the greater sciatic notch and parallel to the quadrilateral plate. Thereafter, a contoured plate is inserted from medial to posterolateral, underneath the vessels and the iliopsoas muscle. Plate final position at the pelvic brim has to be controlled digitally before plate screws are inserted. Intraoperative x-rays of the reduction with AP and oblique films are mandatory.
Closure is anatomical with the reconstruction of the inguinal ligament, the fascia of the abdominals, recreation of the external annulus, and the secure refixation of the abdominal muscles to the iliac crest.
Postoperatively, x-rays using standard AP and oblique views or computed tomography are performed for quality control (in our patient, we show a gap and stepless anatomical reconstruction of the acetabulum). Immediate physiotherapy and mobilization is initiated with partial weight bearing 10–20 kg on the afflicted side for 6 weeks. Afterward, weight bearing is increased stepwise until full mechanical loading is reached 10–12 weeks postoperatively.
In summary, the ilioinguinal approach is a standard anatomical approach. It is very soft-tissue sparing and indicated in all acetabular fracture types, according to the Letournel classification, where the posterior column is reducible through the middle window and when there is no posterior column or wall involvement that would necessitate a direct approach. The ilioinguinal approach gives an excellent visual and palpatory exposure of the anterior column up to the symphysis pubis. It allows for palpatory control of the quadrilateral plate but allows only for indirect control of the posterior column within the middle window. A downside of the ilioinguinal approach is that in surgery, the mobilization of femoral artery and vein can be tasking and demanding.
1. Matta JM. Operative treatment of acetabular fractures through the ilioinguinal approach. A 10-year perspective. Clin Orthop Relat Res. 1994;305:10–19.