Anterior approach to acetabulum

Aims

LeTournel & Judet iliofemoral approach

Indications

Anterior column fractures
Transverse fractures
Double column
- Good exposure to part of posterior column

Contraindications

Posterior column fractures

Principles

Technically demanding
- Occasional user
  - Predissection of cadaveric material
Large amounts of soft tissue stripping
- Consider use of 2 approach techniques
  - Posterior
  - ilioinguinal

Position

supine

Landmarks

ASIS
Iliac crest

Incision

Curved longitudinal incision
Runs along the anterior half of the iliac crest to the ASIS
Then vertically down anterior thigh for 8 cm

Internervous Plane

Superficial
- Sartorius
  - Femoral nerve
- Tensor fascia latae
  - Superior gluteal nerve
Deep
- Rectus femoris
  - Femoral nerve
- Gluteus medius
  - Superior gluteal nerve

Superficial Dissection

Deep the incision
Being careful to avoid damaging the Lateral Femoral cutaneous nerve of the thigh
ER leg to stretch Sartorius to make it more prominent
Identify the gap between TFL & sartorius
- Develop this plane
- Superiorly near the ASIS
  - Ascending Branch of Lateral femoral circumflex artery must be ligated

Deep Dissection

Identify Rectus femoris & Gluteus medius
Strip gluteus medius from its origin by blunt dissection
Continue on this plane strips the origin of gluteus minimus as well
Contiue as fas posteriorly as necessary
To expose posterior column
- Detach insertion of glutei from greater trochanter
  - Hardinge style
  - Trochanteric osteotomy
- Beware injurying superior gluteal nerv & artery by prolonged stretch
To expose inner part of iliac wing
- Detach origins of abdominal muscles from iliac crest
- Reflect underlying iliacus by blunt subperiosteal dissection

Dangers

Nerves
- Lateral femoral cutaneous nerve
- Femoral nerve
Vessels
- Ascending branch of lateral femoral circumflex artery
- Superior gluteal artery
  - Emerge from greater sciatic notch
  - At high danger because origins & insertion of gluteals are detached