Extended Iliofemoral approach

to the acetabularm
Introduction:-

1. 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 is performed in the lateral position, either on a
flat radiolucent table or a fracture table.
Dangers to this 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,

Additionally, the superior gluteal nerve runs with the

superior gluteal vessels, and is itself at risk of injury
during exposure, retraction, and during efforts to
control bleeding. The sciatic nerve, which usually
exits the notch distal to the piriformis muscle, is also
at risk of injury, typically from retractors or prolonged
stretching.
Skin Incision:-
● 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 ASIS.

● Upon reaching the ASIS, continue along the anterolateral surface of the thigh
for a length of 20-30 cm and halfway down the thigh. Proceed distally, and
then aim posteriorly. This will allow easier posterior retraction of the
musculocutaneous flap.
Superficial Dissection:-
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.
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 fascia latae muscle.
The lateral branches of the lateral femoral cutaneous nerve are severed.
Detach subperiosteally the tensor fascia latae muscle from the ASIS, elevating
towards the hip joint. Retract the muscle laterally.
 Deep Dissection :-
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
Detaching of the fascia latae muscle

Detach subperiosteally the tensor fascia latae

muscle from the ASIS, develop the interval
between sartorius and tensor, and retract the
tensor laterally.

Splitting of the fascia lata

The tensor fascia latae must be retracted and

protected. The dissection is along its anterior
edge and medial surface.

Once the interval between the tensor fascia

latae and the sartorius muscle is developed, a
fatty underlying tissue covered by a thin fascial
layer is revealed.
 Access to the hip Joint:-
Removing the fascia propria over rectus
femoris will expose the direct and
reflected origins of the rectus.

Define the direct head of the rectus

femoris as it inserts on anterior inferior
iliac spine. Identify the reflected head of
the rectus femoris which leads to the hip
capsule.
Next, elevate the gluteus minimus muscle from the
femoral neck.

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.

After retraction of the gluteus minimus muscle, the

trochanteric insertion and the distal part of the
gluteus medius muscle become visible.

The tendon of the piriformis muscle will be found

just proximal and anterior to the medial border of
medius gluteus tendon

The insertion of gluteus medius and minimus can

be prepared by an osteotomy rather than
tenotomies as it is more predictable to bone
healing .
With posterior retraction of the gluteus
medius, the external rotator muscles will
appear.

Continue with careful protection of the

superior gluteal neurovascular bundle.

Detach the piriformis and obturator

internus, and gemelli muscles from the
greater trochanter

Protect the sciatic nerve with care, and

avoid prolonged retraction of the nerve.
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.

Distraction of the femoral head with aid

of the fracture table, femoral distractor,
or manually, allows cleaning of the joint,
and assessment of the articular fracture
lines for later reduction.
Wound closer and drains :-
Reattchment of the hip capsule.
External rotators are reattached.
Reattach the gluteus medius then piriformis and then repair the gl. Minimus
tendon, recreating the original trochanteric insertion.
Then reattach the rectus femoris and proximal origin of glutei. Then repair the
sertorious and then close the fascia , subcutaneous tissue and skin in layers.
Thank you