Posterior approach acetabulum. fixation tricks , tips

1. Kocker-Langenbeck approach
Ihab El-Desouky (M.D.)
Asst. Prof. Pelvis and joints Reconstruction unit
Member of A.A.H.K.S.

2. Kocker-Langenbeck approach
• Learning outcomes:
Historical Development of the approach
Indications:
Preoperative precautions
Surgical Anatomy
Classic steps
Modifications:
Complications

3. Kocher- Langebeck Approach
Working horse!
Equally with ilioinguinal approach (40 % )
Single column
Many modifications were added
-Trochanteric osteotomy
-Gluteus maximus dissection plane
-External rotators preservation

4. Historical Development
1-Von Langenbeck
In 1874 described his “longitudinal
incision for hip infections“
"from above the sciatic notch to the
middle of the greater trochanter
passing between the bundles of the
gluteal maximus muscle“
Von Langenbeck
(1810-1887)

5. 2-Theodor Kocher (1841-1917)
In 1911 described the caudal extension
of Langenbeck’s approach
"The incision is curved, over femoral shaft,
the base of the great trochanter
upwards obliquely and
backwards in the direction of the
gluteus maximus"
Theodor Kocher
(1841-1917)

6. 3-Judet et al (1958)
have combined these
two classical posterior incisions,
gaining the advantages offered by each.
Since 1960,Letournel et al called it the
Kocher-Langenbeck approach.

7. •Indications:
FRACTURE PATTERN
DETERMINES APPROACH
-Posterior wall
-Posterior column
-Posterior wall &column
-Transverse with posterior wall
-Transverse with major
displacement at the posterior
column (juxtatectal and
infratectal).
- Posterior elements in T-type

8. at the level of the roof (Transtectal)
of the acetabulum
(therefore involving the weightbearing area )
Either sequential ilioinguinal then Kocher-Langenbeck
Or Kocher Langenbeck with trochanteric osteotomy

9. • Access:
Visible (including released Q femoris
Palpable
After Trochanteric osteotomy
360 ° acetabulum (Ganz)

10. •Preoperative preparation:
• Surgery 3 to 5 days after injury.
• Review the patient’s general condition, limb N/V status
• blood transfusion.
• Review the imaging studies (anteroposterior pelvic and Judet
views and CT.
• Operating table, instruments, and implants.
• Retractors, Clamps , Forceps, Pusher.
• 3.5-mm screws and 3.5-mm reconstruction plates
• 1/3 tubular , mini-screws (2mm

11. • Soft tissue Retractors
Hohmann
Sciatic nerve (or Deever)
Cobra
Taylor (gluteal muscles)
Schanz pins
Sciatic n. retractor in the lesser notch

12. • Reduction tools:
• Jaw clamps of Matta (ball tipped- pointed)
(standard & offset)
• Schanz pins
• Weber pointed clamp .
• Jungbluth reduction clamp.
• Large King Tong forceps ball-tipped;
• Ball-spiked pusher; spiked disc
• Farabeuf reduction forceps; and
• Serrated reduction forceps

13. • Jungbluth clamp with 2 screws technique
Ball spike pusher with spiked disc for
comminuted bone

14. Positioning :Prone or lateral
Prone:
-Femoral head in reduced position
(gravity helps reduction of transerve fracture)
-90o knee flexion places the sciatic nerve
in a relaxed position
-allows digital access to the quadrilateral
surface (transverse or T type fractures)

15. Prone Position:
Disadvantages
-Un-scrubbed assistant is required
for intraoperative adjustment of the table
-Not allowing extension by
trochanteric osteotomy
-Muscular or high BMI --- heavy posterior flap
-Disorientation of the surgeon
--Special padding fo the chest and bony prominence

16. • So Lateral positioning
• Easy maneuverability of the limb
• Allow trochanteric flip osteotomy
• Muscular and high BMI
But:
Femoral head displaces fragments
Folded sterile towels allow for
femoral head subluxation
-Incomplete hip extension and knee
flexion—higher sciatic palsy

17. • In Both positions
Keep the hip slightly extended and knee flexed
90 °
Sciatic palsy reduced from 18% to 5%
c
a
d
a
v
e
r

18. No advantage to either position for the posterior
approach could be found
With equivalent radiologic outcomes between both
groups, a significantly higher rate of infection (p 0.017) were found in
the prone group

19. Residual fracture displacement with transverse
fractures reduced and stabilized in the lateral position
compared with those positioned prone.

20. Transverse with posterior wall fracture

21. Kocher- Langenbeck
Approach (prone)
• Steps
Surface landmarks and incision planning
Skin incision
Fascia lata & gluteal fascia
Gluteus maximus dissection
Trochanteric bursa
Gluteus maximus insertion release
Identification of the sciatic nerve
Gluteus medius retraction
Pyriformis muscle identification & release
Re-identification of the sciatic nerve course
Obturator internus and gemelli release
Lesser notch retractor
Fracture reduction and fixation
Muscle debridement and closure

22. Kocher- Langenbeck
Approach(prone)
• Prone with flexed knee on a
radiolucent table
• C-ram opposite side of the
surgeon
• Imaging of A/P and Judet
views
Inlet and outlet views freely

23. • Surface Landmarks:
PSIS (posterior superior iliac spine)
G. Trochanter
F. Shaft
• Skin incision:
-6-8 cm form PSIS
-Tip of GT
-Centre of GT
-Centre of femoral shaft

24. Fascial incision
-Start the dissection of gluteal maximus and its
fascia using scissors then separate the muscle fibers with fingers
-Iliotibial tract is dissected using scalpel

25. • Gluteus maximum splitting
• - posterior 2/3 muscle belly (inferior
• gluteal artery),
• - anterior 1/3 belly (superior gluteal
Artery
Inferior gluteal bundle is the limit

26. • Trochanteric bursa:
Free the covering layer over the rotators
• Visualization of the sciatic nerve carefully

27. • Gluteus maximus insertion release
• Detach the gluteus maximus 1.5 cm
from its insertion into the
gluteal tuberosity of the femur.
• less tension and easier mobilization
• A constant perforator
should be cauterized

28. • Identification of the sciatic nerve
Rotators damage in posterior dislocation
Identified at the quadratus femoris
No tension or compression is applied
Define the upper border of Q femoris
Quadratus

29. • Identification of the pyriformis muscle
Retract the gluteus Medius tendon
at the G trochanter limited by
Superior gluteal bundle
Beneath it lie both the G minimus (HO)
, and rounded pyriformis tendon.
G Medius
G
minimus
Pyriformis

30. • Pyriformis tendon should be
tagged and incised
1.5 cm from its insertion
Avoid injury of Medial Circumflex
femoral Artery (MCFA)

31. • Blood supply of the femoral head
Deep branch of MCFA
• Can be injured :
-Detachment of the Q femoris
(femoral side)
-Detachment of pyriformis or
Obturator Int less than 1.5 cm

32. Re-Identification of the sciatic nerve (SN) course:
(relation to Pyriformis)
84% deep to the muscle
(anterior)
Trace the nerve till the
G notch

33. Variation of S nerve course (Common Peroneal CPN-Tibial TN)
84% 12% 3%
1%

34. • Sciatic nerve variation:
12% CPN pierces 3% CPN superficial very rare

35. • Release of obturator internus and gemelli:
Double tag of the muscles and release 1.5 cm form attachment

36. • Sciatic nerve retractor (lesser notch)
Reflect the obturator internus till the lesser notch and insert the
retractor
Feel Q plate

37. • Posterior column exposure
Clear the obturator internus fascia

38. • Tips for fractures reduction and Fixation:
-Subperiosteal elevation of
Obturator internus fascia,
Quadrilateral plate ,
Gluteus minimus (HO)
-Carefully debride the fragment edges.(reduction)
-Never devitalize the soft tissue attachment (capsular attachment)– AVN
of the posterior wall

39. Kocher- Langenbeck
Approach Prone
• Tips for fractures reduction and Fixation:

41. 2cm

42. Obturator Outlet Iliac Inlet

43. • Apply interfragmentary wall screws
• Double plates for the column
• Check intra-articular position in all views

44. Wound closure
• Meticulous debridement Remove necrotic tissue (G minimus) and
irrigate the entire wound
• suction drains
• Reinsert all tendons and approximate the split parts of the gluteus
maximus
• closure of the iliotibial tract

45. • Modifications:
1-Trochanteric flip osteotomy:
-Supraacetabular region with superior wall fragment
-Femoral head fracture with surgical dislocation
-Anterior column screw –transtectal transverse
Lateral approach
Single sheath including
V lateralis, G Medius
1.5 cm

47. Kocher- Langenbeck Approach

49. • For superior wall segment (extended posterior wall)
screws :parallel to joint , plate , spring

51. • Transtectal transverse fractures

52. • Anterior column screw after trochanteric osteotomy:
4 cm above the acetabulum just posterior to anterior gluteal line
In line with center of reduced hip (12 O’clock) ( Ob Outlet, IL Inlet)

54. Complications:
1-Sciatic Nerve Palsy; 3-5%
-Always flex knee 90 °
-Proper identification
-Expect variations
-Intermittent retraction
-Never two retractors in both notches

55. 2- Infection 2-5%
3-Heterotopic ossification: necrotic G minimus 10%
4-Superior gluteal artery bleeding:
4- Post-traumatic OA : 17%
5-AVN: 7.5%

56. Take Home Message
Kocher –Langenbeck
-Non extensile (use trochanteric osteotomy)
-Posterior fractures
-Prone is better except in some situations
-Special instruments
-Meticulous exposure and identification
-Tips for reduction and fixation

57. FURTHER READING