1. ORIF of the posterior wall—surgical approach
Reviewed: 2018
Reviewer: Jorge Barla
AO Trauma Advanced Principles Course

2. Learning objectives Classify the acetabular fracture
Establish a preoperative plan
Understand the structures at risk
Teaching points:
Focus only on the approach!

3. AO classification 62A1 Posterior wall fracture 62A2
Posterior column fracture

4. Preoperative plan Decide on patient position (lateral-prone) C-arm
Digastric osteotomy needed?
If so, then saw necessary
Bone graft for marginal impaction
Proper implant selection

5. Kocher-Langenbeck approach
The Kocher-Langenbeck approach can be carried out in the prone or lateral positions, with or without a traction table.
Advantages of the prone approach include ease of reduction of an associated transverse fracture.
While the traction table may aid in joint distraction, it may also limit mobility of the limb during surgery and may present a risk of pressure or traction injury. An alternative is to use the distractor

6. The area shaded in purple can be accessed by using the Kocher-Langenbeck approach
The red area can be accessed by adding a digastric osteotomy of the greater trochanter

7. Kocher-Langenbeck approach landmarks
PSIS
Greater
trochanter
Femoral
shaft

8. The fascia lata is incised in line with skin incision
Proximally the gluteus maximus muscle’s fibers are split apart

9. Neural anatomy—inferior gluteal nerve
Innervates the superior third of the gluteus maximus muscle and is located at half way between the greater trochanter and the PSIS
Kocher-Langenbech Approach

10. Deep branch of the MCA

11. Superior gluteal artery
Deep branch (4 branches)
Superior
Inferior (transverse)
Supra acetabular
Acetabular
Beck M. Radiol Surg Anat 2003

12. Neural anatomy—sciatic nerve
Keep the hip extended and the knee flexed

13. Insertion of external rotators
Distal
Greater trochanter
Insertion of external rotators
The piriformis tendon is identified just caudal to the gluteus minimis. It is cut, tagged with a suture, and retracted.
More caudally, the gemelli muscle bellies are identified and dissected in order to expose the obturator internus tendon.
Sciatic nerve
Proximal

14. Obturator internus tendon
Lesser sciatic notch
The obturator internus is cut, tagged, and retracted to expose the lesser sciatic notch.
Retraction of the obturator internus tendon helps to protect the sciatic nerve. Whenever the sciatic nerve is retracted, the hip should be extended and the knee flexed, to prevent tension.
Sciatic nerve

15. Gautier et al (J Bone Joint Surg Br. 2000;82:679–683)
Piriformis
tendon
Quadratus
femoris
MCA:
deep branch
Dissection should not be carried out distal to the obturator internus near the femoral insertion of the external rotators. This ensures that the branches of the medial femoral circumflex artery continue to perfuse the femoral head.
References:
Gautier E, Ganz K, Krugel N, et al. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br Jul;82(5):679–683.
Gautier et al (J Bone Joint Surg Br. 2000;82:679–683)

16. Piriformis muscle Posterior wall Sciatic nerve Posterior capsule
Obturator internus
gemelli
Retraction of the external rotator tendons exposes the posterior hip capsule and the posterior aspect of the ilium and ischium near the hip.
Presenter, please note: if the talk is too long this one slide can substitute for the proceeding 4 slides.

17. Distal
Posterior wall
Gemelli and
obturator internus
Proximal
Piriformis

18. Femoral head Displaced posterior wall fragments Impaction of the
The posterior wall fragment is retracted to expose the hip joint.
Sciatic nerve

19. The impaction is reduced and grafted
Impacted segments are elevated and grafted.

20. Superior fragments and/or impaction are difficult to address threw the conventional Kocher-Langenbeck approach

21. Trochanteric flip osteotomy
Cranial extension and muscle protection in acetabular fracture fixation using a Kocher-Langenbeck approach
Improves visualization
Improves fracture reduction
Improves ability for fragment fixation
Reference:
Siebenrock KA, Gautier E, Ziran BH, et al. Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using a Kocher-Langenbeck approach. J Orthop Trauma Jan; Suppl:52–56.
Siebenrock et al (J Orthop Trauma. 2006; Suppl:52–56)

22. Kocher-Langenbeck exposure (line ADE)
Gibson, more anterior interval (without violation of the gluteus maximus muscle fibers - angled line BDE)
“Modified” Gibson approach (straight line CDE) is the incision most commonly utilized in contemporary practice

23. Greater trochanter
Piriformis tendon
insertion

24. Vastus lateralis
Greater trochanter
Gluteus medius
Gluteus medius and vastus lateralis muscles remain attached to the greater trochanter

25. Bone fragment can now be mobilized anteriorly
Cranial aspect of the posterior acetabulum can be addressed

26. A hemi circumferential view of the acetabular rim and capsule
Starts posterior and inferior to the retracted piriformis tendon extends anteriorly around the acetabulum to the level of the reflected head of the rectus

27. Take-home messages
Posterior wall fractures can affect joint congruity and stability
Posterior wall fractures, alone or in combination, typically require a posterior surgical approach
Remember structures at risk:
Sciatic nerve
Vascular supply to the femoral head (MCA)
Digastric trochanteric osteotomy can expand the approach to address the superior aspect of the acetabulum and the femoral head
Perfect anatomical reduction is mandatory to improve patient's outcome

28. Take-home messages
Posterior wall fractures can affect joint congruity and stability
Posterior wall fractures, alone or in combination, typically require a posterior surgical approach
Remember structures at risk:
Sciatic nerve
Vascular supply to the femoral head (MCA)
Digastric trochanteric osteotomy can expand the approach to address the superior aspect of the acetabulum and the femoral head
Perfect anatomical reduction is mandatory to improve patient's outcome