The Kocher–Langenbeck surgical approach has been credited to the original efforts of Bernhard von Langenbeck (1810–1887) with a subsequent modification by one of his students, Theodor Kocher (1841–1917). Langenbeck's original approach used an incision from the greater trochanter and extending toward the greater sciatic notch1; to increase the exposure, Kocher added an extension down the femoral shaft with the release of the gluteus maximus and detachment of the short external rotators from the femur.2 Judet and LeGrange3 then modified this surgical approach for the treatment of acetabular fractures in 1958. The Kocher–Langenbeck approach allows direct vision of the posterior column and wall of the acetabulum, as well as palpation of the quadrilateral plate through the greater sciatic notch.
The case presented is that of a 43-year-old man who fell approximately 15 feet and suffered a posterior wall fracture-dislocation. On initial presentation, the patient had a grossly shortened and internally rotated lower extremity. The hip was reduced urgently and a computed tomography scan was obtained. Because of the size and location of the wall fragment, the presence of marginal impaction and intraarticular fracture fragments, the patient was indicated for open reduction and internal fixation through a Kocher–Langenbeck approach to the posterior acetabulum. Before surgery, skeletal traction was placed to alleviate pressure generated by the intraarticular fragments.
This approach can be performed in both the prone and lateral positions. Although some surgeons advocate for lateral positioning, others suggest that prone positioning helps facilitate reduction in certain acetabular fracture patterns. For this case, a radiolucent flattop table was used and the patient was positioned prone on gel rolls, with attention paid to supporting the anterior superior iliac spine, keeping the abdomen and axillae free. Care was taken to pad all bony prominences and to position the shoulders in slight abduction and gentle flexion to avoid any stretch on the brachial plexus intraoperatively. The operative leg is prepped into the field so that it can be flexed at the knee and extended at the hip to reduce tension on the sciatic nerve.
The surgical landmarks are the femoral shaft, greater trochanter, posterior superior iliac spine, and posterior ilium. The skin incision has 2 limbs. The caudal limb is created first along the femoral shaft up to the level of the greater trochanter. The cranial limb is then extended toward the posterior superior iliac spine. The gluteus maximus is then split bluntly through a natural raphe at the upper two-third and lower one-third muscle junction, corresponding to the dual vascular contributions from the superior and inferior gluteal arteries, respectively. This split extends upward cranially until the vascular pedicle is reached.
Bursal and fatty tissue overlying the quadratus femoris and short external rotators are identified and debrided. The sciatic nerve is most reliably found superficial to the quadratus femoris. The tendon of the piriformis is identified, tagged, and divided approximately 1 cm from its insertion. The superior and inferior gemelli muscles are debrided, and the obturator internus tendon within them is identified, tagged, and divided similarly. The gluteus medius is then retracted and the gluteus minimus muscle caudal to the superior gluteal artery can either be retracted or debrided to gain exposure to the portions of the posterior column and wall and hip capsule that are necessary for fracture reduction and fixation. The obturator internus tendon can be used as a guide to the lesser sciatic notch, which has a characteristically smooth surface. This anatomical landmark is important in both identification and protection of the sciatic nerve with subsequent retractor placement into the lesser notch, as the sciatic nerve consistently lies posterior to the obturator internus.
In this patient, the reduction sequence was as follows: (1) fracture delineation with debridement of hematoma and soft tissue, (2) removal of intraarticular free fragments, (3) reduction of marginal impaction, (4) reduction and provisional stabilization of the posterior wall fragment, and (5) definitive fixation of the posterior wall. When elevating marginal impaction, it is important to use an osteotome to lever a sufficient amount of subchondral bone with the impacted articular surface for structural support. Congruency with the femoral head and adjacent acetabular articular surfaces can be used to assess the reduction. This reduction can be augmented with the use of intraosseous mini-fragment screws, cancellous allograft or autograft bone, or bone substitutes in the void left behind by the elevation. Ball spike pushers are often helpful reduction aids and Kirschner wires for provisional stabilization, which can later be replaced with independent lag screws in the wall piece, if desired.
Plate stabilization is generally performed with a 3.5-mm pelvic reconstruction plate. The plate is positioned peripherally along the wall such that it serves as an adequate buttress to prevent displacement and is first secured caudally into the ischium. The plate is undercontoured in this setting to allow for uniform compression and controlled buttressing of the fracture surface as the more cranial screws are placed and the plate contours down to the intact ilium. A secondary coronal bend is also necessary to allow the plate to curve along the periphery of the wall as the plate extends more cranial and anterior.
On closure, the short external rotators that were previously divided are then repaired back to their respective tendinous insertions. A deep drain can also be placed at this time at the discretion of the surgeon. Perioperative antibiotics are continued for 24 hours, and the patient is immediately started on chemoprophylaxis for deep venous thrombosis (DVT), barring any contraindications. Mechanical DVT prophylaxis is continuous during and after surgery. Postoperatively, the patient is kept toe-touch weight-bearing for approximately 6 weeks, then advanced to weight-bearing as tolerated. During that time, surgeons may elect to maintain posterior hip precautions. Routine radiographs, including AP and Judet obliques, are obtained at the 6-week and 12-week postoperative visits.
Outcomes of posterior wall acetabular fractures are noted to be good to excellent in several large series in more than 80% of patients. However, these results are directly related to anatomical reduction and avoidance of postoperative complications, such as avascular necrosis, heterotopic ossification, posttraumatic osteoarthritis, infection, and sciatic nerve injury.4–6 Anatomical reduction may be challenging in the presence of marginal impaction and wall comminution that, along with fracture patterns extending into the subchondral arc at the level of the acetabular roof, are notable radiographic predictors of early failure in some series.7,8 Older age and delayed reduction of an associated fracture-dislocation also portend an unfavorable prognosis in this fracture pattern.
1. Langenbeck B. Ueber die Schussfracturen der Gelenke und ihre Behandlung. Berlin, Germany: A. Hirschwald; 1868.
2. Kocher T. Siles HJ, Paul CB, eds. Operative Surgery. 3rd English Ed. London, United Kingdom: Black; 1911.
3. Judet R, LeGrange J. La voie postero-externe de Gibson. France:Press Med; 1958:263–264.
4. Moed BR, Willson Carr SE, Watson JT. Results of operative treatment of fractures of the posterior wall of the acetabulum. J Bone Joint Surg. 2002;84:752–758.
5. Letournel E, Judet R. Fractures of the Acetabulum. Berlin, Germany: Springer-Verlag; 1993.
6. Pantazopoulos T, Nicolopoulos CS, Babis GC, et al. Surgical treatment of acetabular posterior wall fractures. Injury. 1993;24:319–323.
7. Brumback RJ, Holt ES, McBride MS, et al. Acetabular depression fracture accompanying posterior fracture dislocation of the hip. J Orthop Trauma. 1990;4:42–48.
8. Saterbak AM, Marsh JL, Nepola JV, et al. Clinical failure after posterior wall acetabular fractures: the influence of initial fracture patterns. J Orthop Trauma. 2000;14:230–237.